Clubfoot is a birth defect where one or both legs are turned inward and downward. The affected legs, legs and feet may be smaller than others. In about half of those affected, both legs are involved. Most cases are not related to other issues. Without treatment, people walk on the side of their feet, which causes problems with walking.
The exact cause is usually unclear. Some cases are associated with distal artrogryposis or myelomeningocele. If one identical twin is affected, there is another 33% likely to occur. Diagnosis may occur at birth or before birth during an ultrasound exam.
Initial care is most common with Ponseti methods. This involves moving the foot to an improved position followed by casting, which is repeated at weekly intervals. After bending into the increased, the Achilles tendon is often cut, and braces are worn until the age of four. Initially, the brace is worn almost continuously and then only at night. About 20% of cases, further surgery is required.
Clubfoots occur in about 1 in 1,000 newborns. This condition is less common among Chinese and more common among M? Ori. Men are affected about twice as often as women. Treatment can be done by various health care providers and generally achievable in developing countries with few resources.
Video Clubfoot
Signs and symptoms
In the clubfoot, one or both legs are turned inward and downward. The affected legs, legs, and feet may be smaller than others. In about half of those affected, both legs are involved. Most cases are not related to other issues. Without treatment, people walk on the side of their feet which causes problems with walking.
Maps Clubfoot
Cause
There are many hypotheses about how clubfoot develops. Some hypotheses include: environmental factors, genetics, or a combination of both. Research has not yet pointed out the root cause, but many findings agree that "there may be more than one cause different and at least in some cases phenotypes can occur as a result of the threshold effects of various factors working together."
Some researchers hypothesize, from an early stage of human development, that clubfoot is formed by malfunctions during pregnancy. Early amniocentesis (11-13 weeks) is believed to increase clubfoot rate due to increased potential amniotic leakage from the procedure. Backwardness of the bones and leg muscles of the embryo may be another underlying cause. In the early 1900s it was thought that the narrowing of the legs by the uterus contributed to the occurrence of clubfoot.
Bone retardation also affects the muscles and leg tissues. Abnormalities in connective tissue cause "an increase in fibrous tissue in muscles, fascia, ligaments and tendon sheaths".
Genetics
Mutations in genes involved in muscle development are risk factors for clubfoot, particularly those that encode muscle contractile complexes (MYH3, TPM2, TNNT3, TNNI2, and MYH8). This can cause innate contractures, including clubfoot, in distal arthrogryposis syndrome (DA). Clubfoot can also be present in people with genetic conditions such as Loeys-Dietz syndrome.
Genetic mapping and disease model development have improved the understanding of developmental processes. The inheritance pattern is described as a heterogeneous disorder using a polygenic threshold model. The PITX1-TBX4 transcription route has been the key to this study. PITX1 and TBX4 are uniquely expressed on the back.
Diagnosis
Diagnosis of clubfoot deformity is by physical examination. Typically, newborns are examined immediately after delivery with assessment from head to toe. Examination of the lower extremities and legs reveal deformity, which may affect one or both legs. Foot examination shows four components of deformity.
- Firstly, there is a higher arch on the inside of the foot. This deformity component can occur without the aspect of clubfoot deformity. In isolation, this aspect of deformity is called cavus deformity.
- Second, the forelimbs curved inward or into the medial (toward the big toe). This deformity component can occur without the aspect of clubfoot deformity. In isolation, this aspect of deformity is called metatarsus adductus.
- Third, the heel is rotated inward. It is a natural movement of the heel and subtalar joints, commonly referred to as inversion. In clubfoot deformity, the heel reversal is fixed (not passively confirmed) and is considered a varus deformity.
- Fourth, and finally, the ankle points down. This is a natural movement of the ankle called as plantar flexion. In the clubfoot deformity, this position remains (irreversible) and is called the equinus deformity.
The legs showing all four components were diagnosed with clubfoot deformity. The four components of clubfoot deformity can be remembered with CAVE acronyms (cavus, front foreps, varus, and equinus).
The severity of deformity can also be assessed on physical examination, but is subjective to measure. One way to assess severity is based on the stiffness of deformity or how it can be corrected by manual manipulation of the foot to bring it to a corrected position. Other factors used to assess severity include the presence of skin folds in the arch and in the heels and poor muscle consistency.
In some cases, it is possible to detect prenatal disease during prenatal ultrasound. A prenatal diagnosis with ultrasound can allow parents to get a chance to get information about the condition and make plans for care after their baby is born.
Other tests and imaging are usually unnecessary. Further testing may be needed if there are concerns for other related conditions.
Treatment
Treatment is usually with some combination of Ponseti or French methods. The Ponseti method includes the following: casting along with manipulation, cutting the Achilles tendon, and amplifying. The Ponseti Method has proven to be effective in fixing problems for those under the age of two. French methods involving rearrangement and footnotes are often effective but require considerable effort by caregivers. Another technique known as Layang does not look good. About 20% of further surgical cases are required.
Ponseti Method
Using the Ponseti method, foot deformities are gradually corrected. These stages are as follows: manipulating the foot to a better position and then holding it with a long leg cast, then removing the cast after a week, and then manipulating the legs again. Foot position usually improves for 4-6 casts. The number of casts varies from person to person to meet the individual characteristics of each individual.
- The starting cast focuses on aligning the forefoot with the hind leg as Ponseti portrays the front leg as relatively pronated compared to hindfoot. Placing the front foot and elevating the first metatarsal enhance this alignment.
- The tailing is subsequently applied after stretching the legs with a focus on front foot abduction with lateral pressure on the talus, to bring the navicula in the lateral direction and increase the alignment of the talonavicular joint. In contrast to the Method of Kite casting, it is important to avoid restricting the calcanocuboid joint. With each additional cast, the abduction increases and this moves the hindfoot from varus to valgus. It is important to leave the ankle in the equinus until the forefoot and the hind legs are corrected.
- The final stage of casting, is to correct the equinus. After fully kidnapping the forefoot with a spontaneous correction of hindfoot, attempts are made to bring the ankle up and into dorsoflection. For most children, the equinus will not be completely correct with the foundry and the procedure is performed to facilitate the final aspect of the deformity correction. The procedure is the release of percutaneous heel rope or tenotomy. Ponseti recommends doing this at a clinic with local anesthesia. For security reasons, many centers perform this procedure with sedation or monitored anesthesia treatments. In this procedure, a numbing medicine is applied, the skin is cleansed, and a small scalpel is used to divide the Achilles tendon. With a small scalpel there is minimal bleeding and no need for stitches. Small dressings are applied and cast the last clubfoot is applied with the foot in a position that is completely corrected. The cast is usually left for 3 weeks.
After correction has been achieved by casting, corrective maintenance begins with full-time use (23 hours per day) of the brace - also known as foot abduction brace (FAB) - on both legs, regardless of whether TEV is on one side or both, usually full time for 3 months. After 3 months, the use of brace is reduced and is used mostly when sleeping for naps and evenings. This part-time binding is recommended until the child is 4 years old.
About 30% of children will experience relapse. Repetition can usually be managed by repeating the casting process. Recurrence is more common when there is poor adherence to the buffer, because the muscles around the leg can pull it back into the abnormal position. Approximately 20% of infants successfully treated with Ponseti casting methods will have an imbalance between the muscles that reverse the ankles (posterior tibialis and anterior tibialis muscle) and the muscles that secrete the ankle (the peroneal muscle). Patients with this imbalance are more susceptible to recurrence. After 18 months of age, this can be resolved by surgery to transfer the anterior tibial tendon from the medial attachment (navicula) to a more lateral position (lateral spiky) to rebalance muscle strength. While this requires general anesthesia and subsequent casting while the tendons heal, it is a relatively small operation that improves persistent muscle imbalance while avoiding disturbances in the foot joints.
French method
The French method for clubfoot treatment is a conservative treatment method for newborns requiring daily physical therapy for the first two months. The purpose of this treatment is to avoid future surgical needs, but success rates vary and after surgery may still be necessary. Treatments include daily manipulation of the legs along with leg stretching, followed by taping to maintain the range of motion achieved at the end of each session. The French method is different from the Ponseti method because the taping technique allows some movement in the legs. Another focus is on strengthening the peroneal muscles that are thought to contribute to long-term correction. After two months of marking physical therapy sessions can be weaned into three times per week, not every day until the child reaches six months. Parents are asked to continue at home and maggot exercises even after the program has reached the correct foot correction to maintain the correction. The Ponseti method is generally preferred.
Surgery
If non-operative treatment is unsuccessful or achieves incomplete correction of deformity, surgery is sometimes necessary. Surgery is more common before the wide acceptance of Ponseti Methods. The degree of operation depends on the severity of the deformity. Typically, surgery is performed at the age of 9 to 12 months and the goal is to correct all components of clubfoot deformity at the time of surgery.
For legs with typical components of deformity (cavus, front foreficiency, hindfoot varus, and ankle equinus), a typical procedure is Posteromedial Release (PMR) surgery. This is done through an incision on the medial side of the foot and ankle, which extends to the posterior, and sometimes around the lateral side of the foot. In this procedure, it is usually necessary to release (cut) or extend the plantar fascia, multiple tendons, and joint/ligament capsules. Typically, important structures are exposed and then released sequentially until the feet can be brought to the appropriate plantigrade position. In particular, it is important to bring the ankle to neutral, the heel to be neutral, midfoot parallel to the hindfoot (navicula parallel to the talus, and the cube parallel to the calcaneus). After these connections can be aligned, thin cables are usually placed across these joints to hold them in a corrected position. These wires are temporary and left through the skin for removal after 3-4 weeks. After the joints are aligned, the tendons (usually Achilles, posterior tibialis, and flexor halluces longus) are repaired with appropriate length. The incision (or incision) is covered with a reconstitutable stitch. The foot is then casted in a corrected position for 6-8 weeks. It is common to make cast changes with anesthesia after 3-4 weeks, so pins can be removed and prints can be made to create custom AFO clamps. New cast remains in place until AFO is available. When the cast is removed, AFO is used to prevent the leg from returning to the old position.
For legs with partial deformity correction with nonoperative treatments, surgery may be less extensive and may involve only the posterior part of the foot and ankle. This may be called a posterior release. This is done through a smaller incision and may involve releasing only the posterior capsule of the ankle and subtalar joint, along with extending the Achilles tendon.
Surgery leaves scarring remaining and there is usually more stiffness and weakness compared to non-surgical treatment. As the leg grows, there is the potential for asymmetrical growth that can cause a foot deformity recurrence that may affect the forelegs, middle legs, or hind legs. Many patients do well, but some patients require orthotics or additional surgery. Long-term studies in adults with post-surgical clubfeet, especially those who require multiple surgeries, suggest that they may not do the same in the long run, according to Dobbs, et al. Some patients may require additional surgery as they age, although there are some disputes about the effectiveness of the operation, given the prevalence of scarring present from previous operations.
History
The clubfoot treatment is evident at the beginning of Egyptian paintings. In the early days, the feet were manipulated with Thomas keys and casting which caused fractures of several bones in the legs. Hippocrates about 400 B.C. is the first to offer medical explanations.
Society and culture
Literature
- The main character, Philip Carey, in the novel W. Somerset Maugham Of Human Bondage , has clubfoot, a central theme in the work.
- Hippolyte Tautain, the stableman at Lion D'Or's public home in Gustave Flaubert Madame Bovary's novel was unsuccessfully treated for clubbing by Charles Bovary, which caused the amputation of his legs.
- Charlie Wilcox, the main character in Sharon McKay's novel Charlie Wilcox has clubfoot.
- In the seminal novel of Yukio Mishima Temple of the Golden Pavilion , the character of Kashiwagi has clubfoot parallel to the stutter of the main character, Mizoguchi.
- In David Eddings' series Malloreon , Senji the shaman has clubfoot.
- In the series Caroline Lawrence Roman Mysteries , a character called Vulcan the blacksmith appears in the book "The Secret of Vesuvius". He revealed that he earned his nickname for his clubfoot.
- In The Warlord Chronicles Mordred, King of Dumnonia, has clubfoot which is often used as a symbol for its ugliness and weakness as ruler.
- In Daniel Keyes Flowers for Algernon Gimpy, one of Charlie's co-workers at the bakery, has clubfoot.
- In Perfume: The Story of a Murderer , the main character is born with clubfoot and is described as the person who limps along the novel.
- In Flannery O'Connor's short story "The Lame Shall Enter First", Johnson's character has clubfoot, the main symbol of the story.
References
External links
Source of the article : Wikipedia
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