Clubfoot is a congenital anomaly in which one or both feet turn inward. This condition, known in medical terms as pes equinovarus, is commonly known as "clubfoot" or "croup." The cause of this congenital defect, which is usually seen in infants, is generally unknown (idiopathic). Clubfoot is characterized by deformities and functional abnormalities in the foot in newborns and occurs in approximately one in every 1,000 births.

The affected foot is turned inward and downward from the ankle, the arch at the sole of the foot is increased, and the heel and toes are curled forward as if trying to grasp something. The deformity can vary in severity. In some cases, the foot may be so severely rotated that it appears to be upside down. However, it cannot be returned to its normal position by manual intervention.

This condition, which can occur unilaterally or bilaterally in both feet, can sometimes occur in conjunction with other congenital anomalies. If left untreated, it can lead to serious gait problems and visual impairment. Clubfoot generally does not resolve on its own and requires treatment. Throughout history, attempts have been made to treat it with plaster casts or other materials such as beeswax. Today, some successful athletes and players are known to have experienced a mild form of clubfoot during infancy.

Types of Clubfoot (Pes Equinovarus)

Types of clubfoot (Pes Equinovarus) are classified according to the severity of the curvature and deformity in the foot. The most common type of clubfoot is a condition where the toes are bent downward and inward, and the sole of the foot is turned inward and downward. In this case, the soles of the feet are the only affected areas, and no other abnormalities are usually observed.

Additionally, there are cases where the ankle moves closer to the front of the leg. There are many persistent foot and ankle abnormalities associated with pes equinovarus. It is important to have a specialist examine the ankle to make an accurate diagnosis.

The severity of Pes Equinovarus can vary depending on factors such as the presence of other associated anomalies, the degree of curvature, and whether it affects both feet. A specialist doctor can determine the type and severity of the condition through examinations and tests. Therefore, it is important to consult a specialist for accurate diagnosis and appropriate treatment.

Symptoms of Clubfoot (Pes Equinovarus)

The symptoms of clubfoot (Pes Equinovarus) can manifest at different times and in different situations. This condition can be detected during routine ultrasound examinations during pregnancy, usually between 18 and 21 weeks. It is physically evident at birth.

Pes Equinovarus can sometimes be seen in conjunction with other anomalies, such as congenital hip dislocation and spina bifida. In half of these cases, only one foot is affected, while in the other half, both feet are affected. In unilateral cases, it usually occurs slightly more frequently in the right foot than the left.

The affected foot is smaller and less mobile than normal. The skin on the dorsum and sole of the foot may have abnormal folds and striations. Additionally, the calf muscles on the affected side are often underdeveloped.

Because the baby will have become accustomed to the foot deformity at birth, they may not feel any immediate pain. However, they may experience discomfort when trying to stand or walk. They may try to walk by pressing on the outsides or backs of their feet. If treatment is not initiated, calluses, deformities in the foot joints, arthritis, and progressive deformities can develop on the outer side of the foot.

Therefore, if possible, a pediatric orthopedic specialist should evaluate the child's condition and treatment options from birth onward. Early intervention is crucial for better treatment outcomes.

Causes of Clubfoot (Pes Equinovarus)

The exact causes of pes equinovarus (clubfoot) deformity are unknown, but several factors may play a role in its development. Various causes and risk factors are listed below:

• Genetic factors: Genetic predisposition may be important in the development of pes equinovarus. Certain genetic conditions or genetic mutations may increase the likelihood of developing the disease.
• Fetal developmental problems: Certain problems during fetal development can lead to the development of pes equinovarus. This condition can be associated with factors such as low amniotic fluid, limited intrauterine movement, or structural problems within the uterus.
• Congenital anomalies: Certain chromosomal disorders or genetic diseases may increase the risk of pes equinovarus. In particular, chromosomal abnormalities such as trisomy 18 may be associated with this condition.
• Viral infections: Some research suggests that viral infections, such as the Zika virus, during pregnancy can lead to abnormalities in the baby's development, such as clubfoot.
• Other risk factors: Maternal alcohol, tobacco, or drug use during pregnancy, exposure of the baby to invasive procedures such as amniocentesis during birth, or a certain family history may increase the risk of pes equinovarus.

These factors may play a role in the development of the disease, but pinpointing the exact cause can be challenging. In any case, further research is needed to identify and understand the specific factors that trigger or influence the disease.

How is Clubfoot (Pes Equinovarus) Diagnosed?

Diagnosis of clubfoot (pes equinovarus) is usually made after a series of evaluations and tests. Steps in the diagnostic process may include:

• Physical Examination: A pediatric orthopedist evaluates foot deformities through a physical examination. This includes examining foot anatomy, including curvature, foot position, range of motion, and other symptoms.
• Imaging tests: Imaging tests such as X-rays, MRIs, or ultrasounds are used to examine the foot bones, muscles, and ligaments in detail. These tests are important for determining the extent of the deformity and determining a treatment plan.
• Differential Diagnosis: Conditions that can be confused with other foot deformities may also occur. Therefore, it is important to perform a differential diagnosis to exclude other conditions that can be confused with clubfoot.
• Family history and pregnancy information: Information about whether there are similar conditions in the family and the pregnancy process are also important to confirm the diagnosis of the disease and determine the treatment plan.

Diagnosis is made after a comprehensive evaluation, and a treatment plan is determined based on this diagnosis. Treatment is tailored to the individual, based on the patient's age, severity of the condition, and other factors.

What are the Treatment Methods for Clubfoot (Pes Equinovarus)?

Treatment for clubfoot (pes equinovarus) generally begins immediately after birth, and the treatment process must be meticulously monitored. Two basic treatment methods are commonly used in this case:

• The Ponseti method: In this method, the baby's foot is placed in a therapeutic position and immobilized with soft casts. Weekly cast changes are performed for approximately two months. Following this, an incision may be made under local anesthesia to lengthen the Achilles tendon. A cast is then applied to maintain the foot in the corrected position. Throughout this process, the foot's condition is regularly checked, and signs of blood circulation are monitored.
• The French method: This method uses more flexible bandages and splints instead of a cast. Under the guidance of a physical therapist , families are trained to position their baby's feet correctly. This method can be considered an alternative for babies who prefer not to wear a cast and are more mobile.

If these methods don't correct the clubfoot, orthopedic surgeons may intervene. Surgery is usually performed when babies are between 6 months and 1 year old. After surgery, special shoes or boots can be used, and exercises prescribed by a physical therapist can be performed.

Side effects of surgical procedures can include increased risk of infection, bleeding, nerve damage, joint stiffness, and limited mobility. Therefore, surgical interventions should be planned with both risks and benefits in mind.

How Long Does Treatment for Clubfoot (Pes Equinovarus) Take?

The duration of treatment for clubfoot (Pes Equinovarus) can vary depending on the severity of the condition and the treatment method. In mild cases, significant correction can be achieved in as little as three months through methods such as casting, stabilizing tape, splinting, and physiotherapy. However, given the possibility of recurrence, treatment may be continued until the child is three or four years old.

In more severe cases requiring surgery, surgery is usually performed when the baby is 6 months or 1 year old. Supportive footwear, such as special boots or splints, may be required after surgery until the child reaches 3-4 years of age. Unfortunately, even in later years, despite treatment, permanent consequences such as walking difficulties, foot deformities, and shortness of the foot can occur. In these cases, individuals may use special devices and appliances to help them walk comfortably.

If treatment is not followed, especially during infancy and childhood, the risk of recurrence may increase. Therefore, when symptoms of clubfoot are observed, it is important to consult a healthcare provider and initiate the diagnosis and treatment process. You can contact our Pediatric Orthopedics department at Private Ankara Magnet Hospital for detailed information about clubfoot treatment and to schedule an appointment.

What is the Risk of Recurrence After Treatment?

After treatment for pes equinovarus, there may be a risk of recurrence if the treatment process is not managed well in accordance with the doctor's recommendations.