Club Foot

Club Foot is the most common name for a congenital foot deformity characterized by a fixed plantarflexion of the hindfoot and forefoot adduction and rotation towards the midline and posterior.

Clubfeet, or "talipes equinovarus," is a condition usually noted shortly after birth in which the infant's foot points downward and inward. Clubfeet occur in approximately 1 in every 1000 births. It is two times more common in boys and half of all cases involve both feet. The soft tissues of the medical (inside) and posterior (hind) aspects of the foot are all shortened, including the blood vessels, nerves and skin. The calf muscle of the involved leg(s) is usually smaller than the normal leg and the affected foot is usually ½ to 1 shoe size smaller than the normal foot as well.

Club feet are also referred to as talipes equinovarus by orthopaedic surgeons. A typical case is illustrated below:

The club foot abnormality is a result of abnormal muscle fibers in the calf, tightened ligaments and tendons in the foot, and malposition of the joints and bones of the foot and ankle. At birth, the deformity is fairly rigid and cannot be actively and passively place in a normal position. This distinguishes a true clubfoot from a "postural clubfoot" which should improve quickly with simple home stretching. A true clubfoot should be thought of as a "manufacturing problem" (in which some of the structural elements of the foot and lower leg are abnormally formed) rather than a positional problem.

The exact cause of a clubfoot is not known. Its occurrence is usually sporadic and is not strictly inherited. The likelihood of having another child with a clubfoot is very small if there are not other members of the family that have had true clubfeet. The diagnosis can usually be accurately made by 24 to 28 weeks gestation by ultrasound. It is important for the parents to know that the presence of a clubfoot is not from anything that they did.

The treatment of clubfoot, if initiated early is likely to result in a painless, very functional foot that needs only regular shoe wear. At our institution approximately 90 % of clubfeet can be treated non-operatively by serial weekly stretching and casting. The purpose of the manipulation is to stretch the tight ligaments and tendons that are holding the bony structure of the foot in malaligment. With skillful technique and a thorough understanding of the abnormal anatomy, the foot can be gradually corrected and then held in a corrected position with a long leg cast. This is done weekly for approximately 4 to 8 weeks depending on how stiff the deformity is. Since clubfeet vary greatly in their resistance to manipulation, some feet respond more quickly than others. Optimally, treatment is begun in the first few weeks of life. This increases the likelihood that the foot can be corrected non-operatively. Often the final correction requires a percutaneous lengthening of the heel cord under a local anesthetic, thus avoiding any risk that might attend a general anesthetic.

After a corrected position is achieved a holding brace is worn for three months full and at night and nap time until the child is walking. The purpose of the brace is to keep the foot in a corrected position while the bones and soft tissues of the foot remodel to make the correction more likely to be permanent.

The above treatment protocol has been shown to achieve the best long-term functional results of all the current methods of treatment for clubfoot. Not every clubfoot will be corrected by this method however. Occasionally, a clubfoot is too rigid to be corrected by this method and the correction needs to be completed surgically. Surgical correction is more likely in children that have other underlying conditions such as arthrogryposis or spina bifida. This is done by lengthening certain tendons, ligaments, and joint capsules. After the realignment, the foot position is held with pins and a cast that are removed in the office after 6 weeks. Some illustrations of this are framed below:

Regardless of the method of correction, the patient should be able to wear regular shoes, walk on time and enjoy play. Follow up by an orthopaedic surgeon is required to ensure that there is no evidence of a recurrence of the abnormal foot position with growth. Occasionally, children will need additional procedures later in childhood to ensure the optimal position of the foot.

Management of Clubfeet
The majority of children born with clubfeet are otherwise healthy. The exact cause of the deformity is unknown. A simple clubfoot may correct with passive exercise or serial casting. There is no bony abnormality present. A complex or "true" clubfoot is more difficult to treat and almost always requires surgery for correction. This foot may have a true bony deformity with shortening of the soft tissues of the foot and has a high incidence of recurrence after correction.

Serial casting—Most clubfeet are treated with serial casting as soon after birth as possible. The foot is gently manipulated, stretched and casted to hold the foot in a more improved position. The foot must be turned out by stretching of the shortened tendons before attempting to bring the foot up to a more normal position.

The casts are made of plaster and extend from the toes to just above or below the knee. The casts are changed every 1-2 weeks for approximately 12 weeks. Following the serial casting, an e-ray will be done to determine the alignment of the bones to each other. Unfortunately not all feet will completely correct-ever after 3-6 months of casting. If physical appearance and x-rays show some deformity remains, surgery may be recommended to obtain final correction.

Cast Care

  1. It will take 24-48 hours for the plaster to dry. DO NOT lean, press or bear weight against the cast during this time. Do not allow the cast to get wet.
  2. Please call if the cast break or becomes soft. If the toes slip up inside of the cast or if you notice swelling, coolness or a blue or purplish color to the toes notify the orthopaedic office. You may be instructed to bring the child to the Emergency Room or to soak the cast off.
  3. You may wish to remove the casts at home the night before your return visit. Mix four tablespoons of vinegar with one quart warm water and soak the casts until you are able to unravel the plaster from the foot (usually about I hour).

The average age for corrective surgery is between 6-12 months of age. Shortened tendons are lengthened and adjustments are made to ligaments and bands on the inside and outside of the foot. (Fig. 3 and 4). Occasionally, an additional incision is made on the bottom of the foot to lengthen a thickened band and muscles. (Fig. 5) The foot is placed in a more normal alignment, and pins are used to secure the correction. The foot is immobilized with many layers of soft, compressive padding and placed in a long leg, bent knee fiberglass cast (Fig. 6).

The child will remain overnight in the hospital for observation of swelling and pain management. It is important that the child not be allowed to stand on the cast(s) until the pins are removed in 6-8 weeks.

Two to three weeks after the initial surgery, your child will return to the operating room or the office for an outpatient cast change. The sutures will be removed at this time and the foot manipulated and placed back into a long leg cast for an additional 4 -5 weeks.

Six to eight weeks after the initial surgery your child will return again to the operating room or the office for another outpatient cast change. The pins will be removed and the foot placed in a short leg cast which will be worn for an additional 4 - 6 weeks.

Treatment Following Surgery
Based of the professional recommendation of the individual orthopaedic surgeon and the degree of bone deformity observed at the time of surgery, additional splinting may be necessary following cast removal. Ankle foot orthosis (AFO) and straight laced, high top shoes are commonly used.

Because the child was immobile for a period of time, walking may be delayed for several months. Walking may also be affected until sufficient strength is regained in the muscles of the affected leg(s).

Because clubfeet represents a congenital deformity, there is the possibility the deformity may recur and require another surgical correction. The pediatric orthopaedic surgeon is committed to following the child with a congenital clubfoot deformity for a number of years, monitoring the development of both the foot and the child.

Having a clubfoot means many months of treatment and years of observation. The goal of treatment is to provide your child with a foot that functions as normally as possible without pain. Although the foot is never entirely normal, long term outcome for the corrected clubfoot is generally good in terms of function. Most people with corrected feet are able to walk and play recreational sports as they desire.