The Case of the Prolific Poet with a Crooked Foot

Albert B. Lowenfels, MD; Shevaun Mackie Doyle, MD

Disclosures

August 22, 2008

Congenital Talipes Equinovarus (Clubfoot)

Congenital talipes equinovarus (CTE), often referred to as clubfoot, is not a recent disease; ancient documents from Egypt, Greece, and India outline various treatment methods. More than 2000 years ago, Hippocrates described a nonsurgical approach that is surprisingly modern: He emphasized early, repeated manipulation, bandaging the deformed extremity, and overcorrection of the defect. Modern treatment of CTE still follows these basic principles. As an infant, Byron did not receive timely, effective treatment, and the painful external braces applied when he was a growing boy failed to correct the deformity.

CTE is a lower-extremity deformity that used to be identified only at the time of birth but now can be detected during the prenatal period using routine obstetrical ultrasound. "Talipes equinovarus" is derived from Latin: talus (ankle bone), pes (foot), equinus (horse), and varus (turned in). "Equinovarus" refers to the foot and ankle position and gait in CTE, which is analogous to that of a horse on tip-toe with heels never touching the ground.[2]

Shorter and wider than normal, the CTE foot is bean-shaped and oriented toward the groin rather than the floor. The leg, ankle, and foot have severely contracted soft tissues and are smaller in size than the unaffected limb. Not only are the bones affected, but the surrounding muscles, tendons, and blood vessels are abnormal as well.

The overall incidence, depending on race, varies from 0.39 to 6.8 per 1000, with prevalence rates lowest in Chinese populations and highest in Polynesians. Up to 50% of cases can be bilateral.[3] Boys are affected 2.5 times more than girls, and siblings have up to a 30-fold increased risk for CTE, suggesting a genetic influence.[4,5] Byron's mother had a waddling gait, although this was most likely caused by her obesity rather than an orthopaedic deformity. Neither of Byron's 2 daughters had CTE.

Theories on the causes of CTE abound: structural defects of the embryonic bone cells; increased scar formation of the calf muscles; inadequate formation or absence of blood vessels; intrauterine limb position; amniotic fluid leakage post amniocentesis; and viral
infection.[6] Smoking has been suggested to increase the risk for this
deformity.[7] Byron always blamed his deformity on his mother's insistence upon wearing a tight corset during her pregnancy -- an unlikely theory.

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