What is complex clubfoot?
A complex clubfoot is essentially any clubfoot that does not respond to proper manipulation and casting or bracing in the normal way because one or more parts of the foot are different - more complex - than in an average clubfoot. At times it has been referred to as plantaris or cavus, which refer specifically to a clubfoot that has dynamic differences in the midfoot from a normal clubfoot; however these terms were discarded in favor of the broader term atypical clubfoot. This is likely because not all of these clubfeet are plantaris-type clubfeet, and new information shows that even plantaris-type clubfoot is rooted in more than just the cavus deformity.More recently, this was changed to the more accurate complex clubfoot, which reflects the more difficult nature of these feet.
Several doctors from all over the world have come together to research this condition, and they are making leaps and bounds with identification and treatment. In late 2005 they began presenting papers at symposiums and meetings about complex clubfoot, and it is expected that something will be published about it in the very near future.
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What are the symptoms of complex clubfoot?
As in any other clubfoot, complex clubfoot comes in varying degrees of severity and not all components are always there. The following symptoms are a general guideline.
In a “virgin clubfoot“ that is, one that has never been manipulated and casted, the symptoms include the foot being short and stubby - that is, it’s heel-to-toe length is significantly shorter than a normal foot and the foot looks fat and thick, as if it were bunched up in the middle - and has a deep crease on the sole going from side to side (transverse crease) and usually another crease on the back of the foot above the heel. As manipulation and casting begins more symptoms can begin to appear.
An atypical clubfoot that has been manipulated to the point of abducting, or turning it out in external rotation that you see in the brace, will frequently acquire a secondary deformity in which the long toe bones (metatarsals) become partially dislocated at the midfoot joint (Lisfranc or tarsometatarsal joint) and there appears a crease on the outside of the foot called a lateral crease.
An atypical clubfoot will often slip in even the most well applied cast, and may come completely out of a cast. This can cause a variety of secondary deformities and in general makes correction very difficult. The same is true of the Markell shoes attached to the DBB/FAB. Many parents say that no matter how well or tight the shoes are put on, the feet just slip right out. Sometimes the large toe appears to be either out of alignment with or shorter than the other toes. The outside toes may appear to roll under the side of the foot so that it looks like the whole foot is curling in on itself. The arch of the foot will usually be very high and because of this the foot will remain significantly shorter than normal.
Because of the nature of an atypical clubfoot, a doctor inexperienced with correcting them may think that the foot is corrected when it is not. When compared to photos other corrected clubfeet, it will continue to look different. This is what usually leads parents to seek a second opinion even when their doctor says everything is fine.
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What causes complex clubfoot?
In the normal clubfoot, the main deformity is the in-turning of the heel (adduction). This is not a big problem in the atypical clubfoot. In an atypical clubfoot the main parts of the deformity are the severely short Achilles tendon (equinus) and general toe-down position of the foot (plantarflexion) and the “scrunching up” of the midfoot causing an extremely high arch (cavus or plantaris). The ankle bone (talus) is tilted down and forward severely almost to the point of dislocation under the shin bone (tibia). The toe-down tilt is unyielding.
All of this is thought to be caused by a tightening and shortening of the ligaments in the ankle/heel area and the sole of the foot (the posterior hindfoot and plantar facia respectively). All clubfeet have tendons, ligaments and muscles effected by shortening and tightening, however these ligaments are usually not involved, or at least not to the same extent that they are in an atypical clubfoot. The long toe flexors, which are the muscles that attach to the toes and allow them to move, also seem to be effected. This is what causes the large toe misalignment and the curling under of the outside toes that is sometimes seen in an atypical clubfoot.
An atypical clubfoot also tends to have a serious muscle imbalance of the midfoot, where some of the muscles, ligaments, and tendons are very tight and short and others are of normal length or even abnormally long. This causes the midfoot to be generally unstable and makes correction somewhat difficult. The instability also causes the foot to be prone to relapse for some time.
In most children with atypical clubfoot the affected ligaments loosen and the foot stabilizes by 12-14 months of age and the child is able to walk well. This is not always the case, however. My own son can walk well and has been walking for several months; however his midfoot still seems to be very unstable and prone to relapse easily and quickly. He experience a relapse 2 months after being corrected by Dr. Ponseti during the time he was learning to walk and had to be re-casted 1 month after he started walking well. To date, there are only two known cases where the foot will not stabilize and continues to relapse long after the time when other cases have become stable. Unfortunately for us, Kai is one of these cases.
How common is complex clubfoot?
This is the answer to the question.
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How is complex clubfoot treated?
Complex clubfoot is treated with slight modification to the manipulation normally used in the Ponseti Method. A full description can be found at Google Books in Drennan's "The Child's Foot and Ankle" page 71:
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What is the long-term outlook for complex clubfoot?
Look soon for updated information here! Current studies show the outlook at 2 years post-correction to be excellent, with the foot or feet developing normally. There is anecdotal evidence of relapse past this age that I will be adding to the site shortly. There is also a follow-up study being done at the University of Iowa by Dr. Morcuende that is expected out within the next year.
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