• What is clubfoot?
• What causes clubfoot?
• What are the symptoms of clubfoot?
• Risk factors
• Diagnosis
• What does the treatment for clubfoot involve?
• What can be done for children with clubfoot?

What is clubfoot?

Clubfoot is not a congenital malformation, but rather describes a series of developmental abnormalities usually present at birth. The baby's foot is twisted, with the tissues connecting the muscles to the bone (tendons) being shorter than usual. This deformity makes the foot crooked, turned inward, with the tip pointing downward and the toes of one foot pointing toward the other foot. A baby can be born with this developmental abnormality in one or both feet (bilateral).

Clubfoot is a developmental abnormality of the foot classified into three different types:

• idiopathic - unknown cause,
• neurogenic - caused by the condition of the nervous system,
• syndromic  - linked to an underlying syndrome.

Idiopathic clubfoot, known as talipes equinovarus, is the most common type of clubfoot and is present at birth. This congenital abnormality is observed in one out of every 1,000 babies, with half of the cases involving only one foot.

Neurogenic clubfoot is caused by a neurological condition. For example, a baby born with spina bifida may develop clubfoot later in childhood.

Syndromic clubfoot occurs together with a number of other clinical conditions, which relate to an underlying syndrome, such as arthrogryposis, constriction ring syndrome, tibial agenesis (tibial hemimelia), and dwarfism.

Clubfoot is a fairly common condition in newborns and can be treated successfully without surgery, although sometimes babies need surgical treatment after a period of time. Clubfoot can present in mild or complicated forms. About half of children with clubfoot have both feet affected.

A clubfoot will not cause health problems until a child starts sitting up and walking. But untreated clubfoot can lead to serious problems and even the inability to walk. So it is very important that treatment to correct the position of the foot begin immediately, ideally one to two weeks after birth.

What causes clubfoot?

Doctors often don't know what causes clubfoot. Clubfoot tends to occur mostly in:

• Boys - Two-thirds of babies with clubfoot are male.
• Genetic background - Babies with a parent or sibling who had clubfoot are twice as likely to develop the condition.
• Parents' lifestyle - If the pregnant woman smokes or drinks alcohol, it increases the baby's chances of being born with clubfoot.
• Other congenital malformations - In some cases, it is linked to another condition a child is born with, such as spina bifida.
• Too little amniotic fluid during pregnancy - This surrounds the baby in the womb. If there isn't enough, the baby's chances of being born with clubfoot are higher.

What are the symptoms of clubfoot?

In the case of clubfoot, the Achilles tendon is too short, causing the foot to remain arched - known as "fixation of the foot in equinus." The bones of the foot and ankle are misaligned due to differences between the muscles and tendons acting on the foot. Here are some signs that appear in the baby:

• The foot points downward, and the toes may be curled inward.
• The foot appears to be turned sideways or sometimes even upside down.
• The foot may be smaller than a normal foot.
• The muscles of the affected foot may not be fully developed.
• The foot may only be able to perform a limited range of movements.

Risk factors

The main risk factors include:

• Genetic factors,
• Male sex,
• Active or passive exposure to cigarette smoke in women during pregnancy,
• Alcohol consumption in women during pregnancy,
• Avoiding  the use of medications that are not approved by a doctor.

Diagnosis

The foot deformity can be observed during a fetal screening ultrasound as early as the 12th week of gestation, but the diagnosis of clubfoot is confirmed through a physical examination at birth and other investigations specific to orthopedics and rheumatology departments.

What does the treatment for clubfoot involve?

A baby with clubfoot will be treated by a surgeon from the orthopedics department who has been trained in the Ponseti method.

The Ponseti method is done in two phases: the phase of successive correction with casting and the phase of correction with a brace.

• Phase of successive correction with casting

The Ponseti technique of successive correction with casting is a treatment method that involves careful stretching, manipulation of the foot, and immobilization of it in a cast. The first correction is applied one to two weeks after the baby's birth. The cast is changed every seven to 10 days. When a certain degree of correction is reached, the foot is immobilized in that position. At the next correction, the cast is removed, the foot is re-manipulated, and it is immobilized in the next position.  The foot is corrected using four to five successive casts, except for the equinus.

At the fourth or fifth cast correction, the foot can be abducted by 60 - 70 degrees. In 85% of cases, a minor surgical procedure is also required to correct the equinus, namely lengthening of the Achilles tendon. It is a minimal intervention, with a 1 cm scar. The operation involves a small local anesthetic, and the tip of a scalpel blade is used to completely sever the Achilles tendon, after which the foot is immobilized in its final position, where it remains for two to three weeks. The tendon heals on its own within three weeks, at the correct length.

• Phase of correction with a brace

After three weeks, the foot is placed in special braces with a fixed bar between them. The child will remain immobilized with these braces 23 hours out of 24 during the first three weeks after the procedure, after which only at night, for 12 hours, until around the age of 4.

What can be done for children with clubfoot?

Permanent correction of clubfoot can take several years. An uncorrected foot can cause physical and emotional problems.

A well-corrected foot does not look different from a normal foot.

If the foot is treated, the child will most likely walk normally. He or she may have some difficulties with:

• Movement. The affected foot may be less flexible.
• Foot length. The affected foot may be slightly shorter, but this generally does not cause significant mobility problems.
• Shoe size. The affected foot may be up to 1 1/2 sizes smaller than the unaffected foot.
• Muscle size. The muscles of the leg on the affected side may always be smaller than those on the other side.

However, if left untreated, clubfoot can cause more serious problems. These may include:

• Arthritis. The child is likely to develop arthritis.
• Damaged self-image. The unusual appearance of the foot can create social integration problems for the child during adolescence.
• Inability to walk normally. The twisting of the ankle may prevent the child from walking on the sole of the foot.
• Problems arising from gait adjustments. Gait adjustments can prevent the natural development of the foot muscles, cause sores or calluses on the foot, and lead to an awkward walk.

Note! This presentation is for informational purposes only.

Clubfoot can be successfully treated using the Ponseti method, especially if this method is applied to the baby from the first weeks of life and is followed by medical rehabilitation.