Evidence – this leaflet has been produced after

consulting the following documents

REFERENCES
1. Lochmiller C, Johnston D, Scott A, Risman M, Hecht J T 1998 Genetic epidemiology study
of idiopathic talipes equinovarus. American Journal of Medical Genetics 79: 90 – 96
2. M A Honein, L J Paulozzi and C A Moore 2000 Family history, maternal smoking, and
clubfoot: an indication of a gene-environment interaction
3. R. Byron-Scott, P Sharpe, C Hasler, P Cundy, C Hirte, A Chan, H Scott, P Baghurst and E
Haan May 2005 A South Australian population-based study of congenital talipes
equinovarus. Paediatric & Perinatal Epidemiology Volume 19 Issue 3 Page 227
4. L Madrigal, C Tickle, J A Chudeck and Z Miedzybrodzka Rotation of the Mammalian
Hindlimb: Clues to Clubfoot
5. Clubfoot: Ponseti Management. Global Help Publications
6. Michael KD Benson, John A Fixen, Malcolm F Macnicol, Klaus Parsch. Children’s
Orthopaedics and Fractures. Second Edition. Churchill Livingstone.

Your Notes

Externally reviewed August 2006; Published December 2006

Acknowledgements: steps wishes to thank Miss Naomi Davis, Consultant Paediatric Orthopaedic Surgeon, Booth Hall Children’s
Hospital, Manchester and Mr M K D Benson, Consultant Orthopaedic Surgeon, Nuffield Orthopaedic Centre NHS Trust, Oxford
for their help in the preparation of the Clubfoot Leaflets and all parents who provided feedback and photos especially Stella
Morris, Deborah Simpson, Debbie Goodwin and Lauretta Aydinder.

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What is Clubfoot
The term clubfoot describes the physical
appearance of an affected foot as does the
medical term, Congenital Talipes Equino-
varus (you might also hear it just called
talipes or CTEV). The heel is drawn up
and the sole of the foot is turned inwards.
These words describe the position of the
foot at the time of birth.
• Congenital – present at the time of birth
• Talipes – refers to the foot and ankle
• Equino – pointing down (like a horse’s)
• Varus – turning inwards.
We are going to use the term clubfoot in this leaflet as it is the term
used internationally.
Clubfoot can be classified into the following groups: congenital, complex,
atypical, positional, or syndromic.
Congenital clubfoot is by far the most common and most affected
children have no other major abnormalities. It is also sometimes referred
to as isolated clubfoot or idiopathic (means cause unknown) clubfoot.
Complex and atypical refers to feet which are resistant to treatment
Positional clubfoot occurs when an otherwise normal foot is held in
a deformed position in the uterus (the womb), and thus is "moulded"
incorrectly, the foot is very mobile and may correct itself although
sometimes growth and development will be monitored.
The much more unusual, syndromic types are associated with other
abnormalities such as spina bifida or other rare genetic disorders and
these disorders may affect treatment choices and outcomes.
The condition can affect one (unilateral) or both (bilateral) feet.
In the general population idiopathic clubfoot occurs in about 1 per 10003
live births.
What causes Clubfoot?
The subject of this leaflet is Idiopathic Congenital Clubfoot. The causes
of this are not fully known but research has established that:
• There is no single cause
• In about 24% of cases there is a family history of clubfoot. The ratio
of boys to girls with clubfoot is 2.5:11
• About 3 - 4% of children who have a parent or sibling with clubfoot
are also born with the condition1
• The chances of having a second child with clubfoot are approximately
1 in 305
• Research has suggested that smoking during the first three months
of pregnancy is a risk factor and that there is an interaction between
smoking and family history which considerably increases the level of
risk when both factors are present2
• It is also thought that clubfoot may be due to disruption in the
development of the foetus. In a normal foetus the feet are in this
position initially then turn as the pregnancy progresses. In a baby
with clubfoot this turning has not been completed. Research into
this is currently being carried out at the University of Aberdeen3.
When is Clubfoot diagnosed?
Clubfoot is usually diagnosed either during pregnancy by an ultrasound
scan or at birth.
Will there be anything else wrong with my baby?
In most cases clubfoot is an isolated problem but it is also an abnormality
which is present in other, more serious conditions so if your baby has
been diagnosed with clubfoot during a routine scan, more checks may
be offered to find out whether she/he has other problems. The nature
of the tests depend on the policy of the individual healthcare provider
but may include:
• A further ultrasound
• Invasive tests using ultrasound as a guide such as:
• Amniocentesis – amniotic fluid is drawn from the uterus
for analysis
• Chorionic Villus Sampling – the health care provider inserts
a thin tube through the vagina and cervix to take a tiny tissue
sample from outside the sac where the baby develops
• Foetal Blood Sampling – a sample of blood is taken from the
foetus for testing.
Should I have the tests done?
‘…each person should make an informed decision about
screening based upon appreciation of the risks and benefits,
’
National Institute of Clinical Excellence.
The Risks
There is a risk of about 1% of suffering a miscarriage when invasive
testing is carried out.
Uncertainty can still remain after testing as false-positives and
false-negatives are possible.
The Benefits
Knowing about any problems your baby may have allows you to prepare
for the birth and find out about the condition and treatment options.
You can find out about these tests in more detail from our Prenatal
Diagnosis Leaflet.
Can you tell how severe the clubfoot will be?
Not with a prenatal scan, you will have to wait until your baby is born.
Can my baby be treated before the birth?
Not at the time of writing, but treatment usually begins soon afterwards
so it is a good idea to start to find out about the hospital and doctor you
are going to be referred to, make any fact-finding visits you wish to and
seek information and support.
What treatments are available for my baby?
Your doctor will decide on the best type of treatment after examining your
baby. Treatment may start a few days after birth but some doctors like to
give you a week or two to get to know your baby first.
Individual treatments are classified as either conservative or operative.
Your child is most likely to start with conservative treatment and may
experience a range of treatments tailored to the position of the foot.
Stretching (Conservative) treatments
These aim to stretch the soft tissues of the foot and hold it in as normal
a position as possible using methods from the following list: physiotherapy,
gentle manipulation, use of plaster casts, splints/strapping and
special boots.
Methods included in this category are:
The Ponseti Method - an increasingly popular form of conservative
treatment which is becoming more widely practised in the UK now. It
was developed in the USA over 40 years ago and ‘long term follow-up
studies show that feet treated by Ponseti management are strong, flexible
and pain-free’ (Clubfoot: Ponseti Management. Global Help Publications).
The method uses manipulation, gently
rotating the bones and stretching the soft
tissue, then the application of a plaster cast
from the toes to the groin to hold the foot
in position.
This takes place every 5 – 7 days and most
children need 6 – 10 casts, correcting the
position of the foot a little more each time.
After this the surgeon decides whether the tendon at the back of the heel
(the Achilles tendon) needs to be lengthened. Many do but this is only a
small operation, many surgeons only use a local anaesthetic for it. A small
cut is made in the crease of the heel and the tendon is cut. This is called
a tenotomy.
The foot is then put into a final cast for 2 – 3
weeks and when this is removed the child
has to wear boots attached to a bar. These
are worn 23 hours a day for about 3 months
then at night and nap time until the child is
about 4 years old. At this stage the feet are
already fully corrected. Wearing the boots
and bar is essential to prevent a relapse.
steps and Both Feet Forward have also produced a DVD and a separate
leaflet about the Ponseti Treatment.
Traditional methods – these are also based on manipulation, often
by a physiotherapist. Between sessions the foot is held in place by
either strapping or a plaster of paris cast
Operative treatments
During conservative treatment the foot will be monitored and it may
become necessary to perform an operation to correct any remaining
problems. Although the foot has proved too resistant for conservative
treatments alone the skin will have been well prepared for surgery as
it will have been made more supple by the stretching processes.
There are four main types of surgery.
The most common ones are as follows:
Operative treatments
• Soft tissue release – lengthening or cutting the Achilles tendon and
releasing other ligaments and capsules at the back and inside border
of the foot which are preventing the positioning required because
they are too tight.
• Tendon transfers – (e.g. the tibialis anterior transfer) to move
the tendons to a different position, so the function of the foot
can be improved.
Less frequently there may be:
• Surgery on the bones of the foot – bony procedures such as
osteotomies that divide or remove bone to correct deformities, or,
very occasionally, arthrodeses which surgically stabilize joints to enable
the bones to grow solidly together. This is usually carried out after the
child has stopped growing.
• Use of a circular frame such as the Ilizarov – a number of metal
rings held together with rods and fixed to the bone from several
directions by thin wires under tension. By adjusting different
components of the frame over a period of time bones can be
lengthened, thickened or shortened and soft tissue can be stretched.
Occasionally, a combination of these procedures may be necessary.
How long will my child need to see an
orthopaedic surgeon?
Most children need follow-up for a few years after treatment has finished,
some surgeons may prefer to keep you child "on the books" until the feet
have stopped growing.
Sometimes as the child grows there can be a recurrence of the problem,
conservative methods may be tried again or one of the surgical options
may be more suitable.
What is the long term outcome?
Most children do very well with treatment and will be able to go to school
and take part in sporting activities. There has only been one long term
study following children through to adulthood and this was specifically
to look at the results of the Ponseti Method. This study showed that the
use of this method resulted in similar levels of foot pain in mid life to
those experienced by people who were not born with clubfoot5.
How do I decide what treatment to choose
for my child?
This is something you need to discuss with your child’s doctor and other
health professionals but think about:
• What type of treatments are offered at your centre? – remember
to ask them to describe them to you.
• What are the success rates for each type of treatment?
• How is the severity of the condition measured and how does
this relate to the treatment offered?
• What are the skills and experience of people at the centre?
• Are there any complications with the treatment?
• How does your centre measure the results of the treatment?
• How much time will each form of treatment take?
• How involved you will be in the treatment?
• If you choose a centre far from home are you able to travel regularly?
• How will your family and friends respond to the treatment?
Tips – getting the best from your clinic visit ‘ I had a hell of a shock at my 20wk

• Before you go, think about what you want to know. Jot down the
scan, even burst into tears in the room!
’
questions you want to ask.
• ‘ I was really very upset, and it spoiled my
Take your partner, friend or relative with you. If one concentrates
on asking the right questions, the other can take a few notes to
pregnancy, constantly worrying, and blaming myself.
’
help you remember what was said afterwards.
But it usually gets better…
• If you can’t have someone with you, think about taping the
conversation so you can play it back later
• If you don’t understand something, ask the doctor to explain further. ‘ He never stops running and jumping and
is full of energy, he has recently completed
Good ways to ask this include; "This is all very new to me, what do
you mean by……?"
the Ponseti Toddle, and is doing really well’
’
• The doctor may be very busy and if you don’t find out all you need
to know, ask if there is anyone else who can take you through the ‘ with a great doctor her foot
looks brilliant. Only last week
procedure. Often a doctor’s junior colleague will be able to explain
and may have fewer appointments to get through. The nurses at the
clinic or on the ward may be able to tell you more
they said how marvellous it looks.
’
‘ …. has now decided that
he wants to come to every
Is it normal to feel like this? class with me because he
People have all sorts of reactions – these are a few
wants to be a power ranger!!
’
‘ I was really upset on Tuesday afternoon ‘So much for talipes
and yesterday with worry, worrying if
stopping them doing things eh?
’
everything is going wrong?? Is it my fault??? etc!
’
‘ we found out he had clubfeet at our 20 week scan,
and then our minds were completely taken over
and we thought of nothing else until he was born!
’