Club Foot (TEV)

A club foot or clubfoot, also called congenital talipes equinovarus (CTEV), is a congenital deformity involving one foot or both.The affected foot looks like it has been rotated internally at the ankle. Without treatment, people with club feet often appear to walk on their ankles or on the sides of their feet. However with treatment, the vast majority of patients recover completely during early childhood and are able to walk and participate in athletics as well as patients born without CTEV.

Epidemiology 
It is a relatively common birth defect, occurring in about one in every 1,000 live births. Approximately half of people with clubfoot have it affect both feet, which is called bilateral club foot. In most cases it is an isolated dysmelia (disorder of the limbs). It occurs in males twice as frequently as in females.

Classification 
1). Clubfoot is typically identified as 
a). isolated : if it is the only birth defect present, or 
b). complex : if there are additional conditions diagnosed.

2). Clubfoot is classified into two groups,
a). postural TEV and 
b). structural TEV.

CTEV - mnemonic

"InAdEquate" The deformities of the foot in Congenital Talipes Equino Varus(CTEV) are:
• Inversion
• Adduction
• Equinus
Also think: "tAlIpEs", to remember the sequence of correction of deformities:
• Adduction
• Inversion
• Equinus

Joints Affected 
The deformities affecting joints of the foot occur at three joints of the foot to varying degrees. They are

• inversion at subtalar joint, total hindfoot inversion
• adduction at talonavicular joint, and
• equinus and varus at ankle joint, that is, a plantar flexed position, making the foot tend towards toe walking.

Cause Of Clubfoot

Structural cTEV is caused by genetic factors such as Edwards syndrome, a genetic defect with three copies of chromosome 18. Growth arrests at roughly 9 weeks and compartment syndrome of the affected limb are also causes of structural cTEV. Genetic influences increase dramatically with family history. cTEV occurs with some frequency inEhlers–Danlos syndrome and some otherconnective tissue disorders, such as Loeys-Dietz syndrome.

It was previously assumed that postural cTEV could be caused by external influences in the final trimester such as intrauterine compression fromoligohydramnios or from amniotic band syndrome. However, this is countered by findings that cTEV does not occur more frequently than usual when the intrauterine space is restricted.

Treatment of Clubfoot

Clubfoot is treated with manipulation by podiatrists,physiotherapists, orthopedic surgeons, specialistPonseti nurses, or orthotists by serial casting and then providing braces to hold the feet in a plantigrade position. After serial casting, a brace such as a Denis Browne bar with straight last boots, ankle foot orthoses and/or custom foot orthoses (CFO) may be used. In North America, manipulation is followed by serial casting, most often by thePonseti Method. Foot manipulations usually begin within two weeks of birth. Even with successful treatment, when only one side is affected, that foot may be smaller than the other, and often that calf, as well.

Extensive surgery of the soft tissue or bone is not usually necessary to treat clubfoot; however, there are two minimal surgeries that may be required:

1. Tenotomy (needed in 80% of cases) is a release (clipping) of the Achilles tendon – minor surgery –local anesthesia
2. Anterior Tibial Tendon Transfer (needed in 20% of cases) – where the tendon is moved from the first ray (toe) to the third ray in order to release the inward traction on the foot.

Each case is different, but in most cases extensive surgery is not needed to treat clubfoot. Extensive surgery may lead to scar tissue developing inside the child's foot. The scarring may result in functional, growth and aesthetic problems in the foot because the scarred tissue will interfere with the normal development of the appendage. A child who has extensive surgery may require on average two additional surgeries to correct the issues presented above.

In stretching and casting therapy the doctor changes the cast multiple times over a few weeks, gradually stretching tendons until the foot is in the correct position of external rotation. The heel cord is released (percutaneous tenotomy) and another cast is put on, which is removed after three weeks. To avoid relapse a corrective brace is worn for a gradually reducing time until it is only at night up to four years of age.

Non-surgical treatment and the Ponseti Method

Treatment for clubfoot should begin almost immediately to have the best chance for a successful outcome without the need for surgery. Over the past 10 to 15 years, more and more success has been achieved in correcting clubfeet without the need for surgery. The clubfoot treatment method that is becoming the standard in the U.S. and worldwide is known as the Ponseti Method.Foot manipulations differ subtly from the Kite casting method which prevailed during the late 20th century. Although described by Dr. Ignacio Ponsetiin the 1950s, it did not reach a wider audience until it was re-popularized around 2000 by Dr. John Herzenberg in the USA and in Europe and Africa by NHS surgeon Steve Mannion while working in Africa. Parents of children with clubfeet using the Internet also helped the Ponseti gain wider attention. The Ponseti method, if correctly done, is successful in >95% of cases in correcting clubfeet using non- or minimal-surgical techniques. Typical clubfoot cases usually require 5 casts over 4 weeks. Atypical clubfeet and complex clubfeet may require a larger number of casts. Approximately 80% of infants require an Achilles tenotomy (microscopic incision in the tendon requiring only local anesthetic and no stitches) performed in a clinic toward the end of the serial casting.

After correction has been achieved, maintenance of correction may require the full-time (23 hours per day) use of a splint—also known as a foot abduction brace (FAB)—on both feet, regardless of whether the TEV is on one side or both, for several weeks after treatment. Part-time use of a brace (generally at night, usually 12 hours per day) is frequently prescribed for up to 4 years. Without the parents' participation, the clubfoot will almost certainly recur, because the muscles around the foot can pull it back into the abnormal position. Approximately 20% of infants successfully treated with the Ponseti casting method may require a surgical tendon transfer after two years of age. While this requires a general anesthetic, it is a relatively minor surgery that corrects a persistent muscle imbalance while avoiding disturbance to the joints of the foot.

The developer of the Ponseti Method, Dr Ignacio Ponseti, was still treating children with clubfeet (including complex/atypical clubfeet and failed treatment clubfeet) at the University of Iowa Hospitals and Clinics well into his 90s. He was assisted by Dr Jose Morcuende, president of thePonseti International Association.

The long-term outlook for children who experienced the Ponseti Method treatment is comparable to that of non-affected children.

Botox is also being used as an alternative to surgery. Botox is the trade name for Botulinum Toxin type A. a chemical that acts on the nerves that control the muscle. It causes some paralysis(weakening) of the muscle by preventing muscle contractions (tightening). As part of the treatment for clubfoot, Botox is injected into the child’s calf muscle. In about 1 week the Botox weakens the Achilles tendon. This allows the foot to be turned into a normal position, over a period of 4–6 weeks, without surgery.

The weakness from a Botox injection usually lasts from 3–6 months. (Unlike surgery it has no lasting effect). Most club feet can be corrected with just one Botox injection. It is possible to do another if it is needed. There is no scar or lasting damage.

Surgical treatment

On occasion, stretching, casting and bracing are not enough to correct a child's clubfoot. Surgery may be needed to adjust the tendons, ligaments and joints in the foot/ankle. Usually done at 9 to 12 months of age; surgery usually corrects all clubfoot deformities at the same time. After surgery, a cast holds the clubfoot still while it heals. It is still possible for the muscles in the child's foot to try to return to the clubfoot position, and special shoes or braces will likely be used for up to a year or more after surgery. Surgery will likely result in a stiffer foot than nonsurgical treatment, particularly over time.

Without any treatment, a child's clubfoot will result in severe functional disability, however with treatment, the child should have a nearly normal foot. He or she can run and play without pain and wear normal shoes. The corrected clubfoot will still not be perfect, however; a clubfoot usually stays 1 to 1½ sizes smaller and somewhat less mobile than a normal foot. The calf muscles in a leg with a clubfoot will also stay smaller.

Long-term studies of adults with post-club feet, especially those with substantial numbers of surgeries, may not fare as well in the long term, according to Dobbs, et al. A percentage of adults may require additional surgeries as they age, though there is some dispute as to the effectiveness of such surgeries, in light of the prevalence of scar tissue present from earlier surgeries.

In some cases the leg stops developing earlier than the healthy leg and a substantial length difference may occur. In some cases a leg lengthening will be necessary, most commonly by use of the Ilizarov method.