{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T15:57:26Z","timestamp":1782230246193,"version":"3.54.5"},"reference-count":31,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2022,10,27]],"date-time":"2022-10-27T00:00:00Z","timestamp":1666828800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Ministry of Health, Rome\u2014Italy","award":["RC. 11\/15"],"award-info":[{"award-number":["RC. 11\/15"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Genes"],"abstract":"<jats:p>Congenital clubfoot is a common pediatric malformation that affects approximately 0.1% of all births. 80% of the cases appear isolated, while 20% can be secondary or associated with complex syndromes. To date, two genes that appear to play an important role are PTIX1 and TBX4, but their actual impact is still unclear. Our study aimed to evaluate the prevalence of pathogenic variants in PITX1 and TBX4 in Italian patients with idiopathic clubfoot. PITX1 and TBX4 genes were analyzed by sequence and SNP array in 162 patients. We detected only four nucleotide variants in TBX4, predicted to be benign or likely benign. CNV analysis did not reveal duplications or deletions involving both genes and intragenic structural variants. Our data proved that the idiopathic form of congenital clubfoot was rarely associated with mutations and CNVs on PITX1 and TBX4. Although in some patients, the disease was caused by mutations in both genes; they were responsible for only a tiny minority of cases, at least in the Italian population. It was not excluded that other genes belonging to the same TBX4-PITX1 axis were involved, even if genetic complexity at the origin of clubfoot required the involvement of other factors.<\/jats:p>","DOI":"10.3390\/genes13111958","type":"journal-article","created":{"date-parts":[[2022,10,27]],"date-time":"2022-10-27T04:35:17Z","timestamp":1666845317000},"page":"1958","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["What Is the Exact Contribution of PITX1 and TBX4 Genes in Clubfoot Development? An Italian Study"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8101-9659","authenticated-orcid":false,"given":"Anna Monica","family":"Bianco","sequence":"first","affiliation":[{"name":"Genetics Unit, Institute for Maternal and Child Health, IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3703-5576","authenticated-orcid":false,"given":"Giulia","family":"Ragusa","sequence":"additional","affiliation":[{"name":"Genetics Unit, Institute for Maternal and Child Health, IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Valentina","family":"Di Carlo","sequence":"additional","affiliation":[{"name":"Unit of Paediatric Orthopaedic and Traumatology, Institute for Maternal and Child Health, IRCCS \u201cBurlo Garofolo\u201d, 34147 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1483-3612","authenticated-orcid":false,"given":"Flavio","family":"Faletra","sequence":"additional","affiliation":[{"name":"Genetics Unit, Institute for Maternal and Child Health, IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mariateresa","family":"Di Stazio","sequence":"additional","affiliation":[{"name":"Genetics Unit, Institute for Maternal and Child Health, IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Costantina","family":"Racano","sequence":"additional","affiliation":[{"name":"Unit of Pediatric Orthopaedics and Traumatology, Istituto Ortopedico Rizzoli (IRCCS), 40136 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0361-9920","authenticated-orcid":false,"given":"Giovanni","family":"Trisolino","sequence":"additional","affiliation":[{"name":"Unit of Pediatric Orthopaedics and Traumatology, Istituto Ortopedico Rizzoli (IRCCS), 40136 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefania","family":"Cappellani","sequence":"additional","affiliation":[{"name":"Genetics Unit, Institute for Maternal and Child Health, IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maurizio","family":"De Pellegrin","sequence":"additional","affiliation":[{"name":"Pediatric Orthopedic San Raffaele Hospital of Milano, 20132 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ignazio","family":"d\u2019Addetta","sequence":"additional","affiliation":[{"name":"Unit of Pediatric Orthopaedics and Traumatology Giovanni XXIII Children\u2019s Hospital, Via Giovanni Amendola, 70126 Bari, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Carluccio","sequence":"additional","affiliation":[{"name":"Unit of Pediatric Orthopaedics and Traumatology Giovanni XXIII Children\u2019s Hospital, Via Giovanni Amendola, 70126 Bari, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sergio","family":"Monforte","sequence":"additional","affiliation":[{"name":"Pediatric Orthopedic of Buzzi Children Hospital of Milano, 20154 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio","family":"Andreacchio","sequence":"additional","affiliation":[{"name":"Pediatric Orthopedic of Buzzi Children Hospital of Milano, 20154 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniela","family":"Dibello","sequence":"additional","affiliation":[{"name":"Unit of Pediatric Orthopaedics and Traumatology Giovanni XXIII Children\u2019s Hospital, Via Giovanni Amendola, 70126 Bari, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9367-4909","authenticated-orcid":false,"given":"Adamo P.","family":"d\u2019Adamo","sequence":"additional","affiliation":[{"name":"Genetics Unit, Institute for Maternal and Child Health, IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"},{"name":"Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,10,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1097\/00003086-197205000-00003","article-title":"Genetic and environmental factors in the etiology of talipes equinovarus","volume":"84","year":"1972","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_2","unstructured":"PubMed (2022, April 26). Muscle Imbalance in the Aetiology of Idiopathic Club Foot. An Electromyographic Study, Available online: https:\/\/pubmed.ncbi.nlm.nih.gov\/7615605\/."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1097\/01202412-199504010-00003","article-title":"Update on pathologic anatomy of clubfoot","volume":"4","author":"Ippolito","year":"1995","journal-title":"J. Pediatr. Orthop. B"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1097\/01202412-199907000-00009","article-title":"Confirmation of arterial deficiencies in a limb with necrosis following clubfoot surgery","volume":"8","author":"Hootnick","year":"1999","journal-title":"J. Pediatr. Orthop. B"},{"key":"ref_5","unstructured":"PubMed (2022, April 26). Development of the Foot in Prenatal Life in Relation to Idiopathic Club Foot, Available online: https:\/\/pubmed.ncbi.nlm.nih.gov\/2312708\/."},{"key":"ref_6","unstructured":"PubMed (2022, April 26). Family Studies and the Cause of Congenital Club Foot. Talipes Equinovarus, Talipes Calcaneo-Valgus and Metatarsus Varus, Available online: https:\/\/pubmed.ncbi.nlm.nih.gov\/14216453\/."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"548","DOI":"10.1136\/adc.40.213.548","article-title":"The causes of congenital club foot","volume":"40","author":"Alberman","year":"1965","journal-title":"Arch. Dis. Child."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1515\/folmed-2017-0030","article-title":"Prenatal Diagnosis of Clubfoot: A Review of Current Available Methodology","volume":"59","author":"Faldini","year":"2017","journal-title":"Folia Med."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Singer, N.G., and Ravelli, A. (2015). Evaluation of musculoskeletal complaints in children: Clinical evaluation. Rheumatology, Elsevier Inc.. [6th ed.].","DOI":"10.1016\/B978-0-323-09138-1.00099-1"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"433","DOI":"10.1007\/s11832-012-0444-9","article-title":"An MRI volumetric study for leg muscles in congenital clubfoot","volume":"6","author":"Ippolito","year":"2012","journal-title":"J. Child. Orthop."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1002\/(SICI)1096-8628(19980901)79:2<90::AID-AJMG3>3.0.CO;2-R","article-title":"Genetic epidemiology study of idiopathic talipes equinovarus","volume":"79","author":"Lochmiller","year":"1998","journal-title":"Am. J. Med. Genet."},{"key":"ref_12","unstructured":"PubMed (2022, July 14). An Independent Assessment of Two Clubfoot-Classification Systems, Available online: https:\/\/pubmed.ncbi.nlm.nih.gov\/9600557\/."},{"key":"ref_13","unstructured":"PubMed (2022, July 14). Treatment of Congenital Club-Foot during the 1st Years of Life, Available online: https:\/\/pubmed.ncbi.nlm.nih.gov\/1222603\/."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1097\/01202412-199504020-00002","article-title":"Classification of clubfoot","volume":"4","author":"Souchet","year":"1995","journal-title":"J. Pediatr. Orthop. B"},{"key":"ref_15","unstructured":"(2022, July 15). Pirani Score for Clubfoot Assessment | Epomedicine. Available online: https:\/\/epomedicine.com\/medical-students\/pirani-score-for-clubfoot-assessment\/."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1186\/s13018-018-0913-z","article-title":"The etiology of idiopathic congenital talipes equinovarus: A systematic review","volume":"13","author":"Pavone","year":"2018","journal-title":"J. Orthop. Surg. Res."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1007\/s11832-014-0562-7","article-title":"Heritability of clubfoot: A twin study","volume":"8","author":"Engell","year":"2014","journal-title":"J. Child. Orthop."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1736","DOI":"10.1126\/science.283.5408.1736","article-title":"Role of Pitx1 upstream of Tbx4 in specification of hindlimb identity","volume":"283","author":"Logan","year":"1999","journal-title":"Science"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"616","DOI":"10.1016\/j.ajhg.2008.10.004","article-title":"Asymmetric Lower-Limb Malformations in Individuals with Homeobox PITX1 Gene Mutation","volume":"83","author":"Gurnett","year":"2008","journal-title":"Am. J. Hum. Genet."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1620","DOI":"10.1002\/ajmg.a.35418","article-title":"Studies of TBX4 and chromosome 17q23.1q23.2: An uncommon cause of nonsyndromic clubfoot","volume":"158","author":"Lu","year":"2012","journal-title":"Am. J. Med. Genet. Part A"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1002\/ajmg.a.36238","article-title":"Familial microduplication of 17q23.1\u2013q23.2 involving TBX4 is associated with congenital clubfoot and reduced penetrance in females","volume":"164","author":"Peterson","year":"2014","journal-title":"Am. J. Med. Genet. Part A"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1038\/ejhg.2012.177","article-title":"Copy number analysis of 413 isolated talipes equinovarus patients suggests role for transcriptional regulators of early limb development","volume":"21","author":"Alvarado","year":"2013","journal-title":"Eur. J. Hum. Genet."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"148","DOI":"10.1016\/j.devcel.2009.11.013","article-title":"Tbx4 and Tbx5 Acting in Connective Tissue Are Required for Limb Muscle and Tendon Patterning","volume":"18","author":"Hasson","year":"2010","journal-title":"Dev. Cell"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"705","DOI":"10.1038\/ejhg.2011.264","article-title":"Deletions in PITX1 cause a spectrum of lower-limb malformations including mirror-image polydactyly","volume":"20","author":"Klopocki","year":"2012","journal-title":"Eur. J. Hum. Genet."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"3943","DOI":"10.1093\/hmg\/ddr313","article-title":"Pitx1 haploinsufficiency causes clubfoot in humans and a clubfoot-like phenotype in mice","volume":"20","author":"Alvarado","year":"2011","journal-title":"Hum. Mol. Genet."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1146\/annurev.genet.39.073003.105925","article-title":"T-box genes in vertebrate development","volume":"39","author":"Naiche","year":"2005","journal-title":"Annu. Rev. Genet."},{"key":"ref_27","unstructured":"Szafranski, P., Coban-Akdemir, Z.H., Rupps, R., Grazioli, S., Wensley, D., Jhangiani, S.N., Popek, E., Lee, A.F., Lupski, J.R., and Boerkoel, C.F. (2022, June 28). Phenotypic Expansion of TBX4 Mutations to Include Acinar Dysplasia of the Lungs. Available online: http:\/\/wileyonlinelibrary.com\/journal\/ajmga."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1016\/j.ajhg.2010.06.010","article-title":"Familial Isolated Clubfoot Is Associated with Recurrent Chromosome 17q23.1q23.2 Microduplications Containing TBX4","volume":"87","author":"Alvarado","year":"2010","journal-title":"Am. J. Hum. Genet."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1592","DOI":"10.1016\/j.joca.2010.09.008","article-title":"Association of a single nucleotide polymorphism in Tbx4 with developmental dysplasia of the hip: A case-control study","volume":"18","author":"Wang","year":"2010","journal-title":"Osteoarthr. Cartil."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"226","DOI":"10.2337\/db18-0857","article-title":"DNA sequence variation in ACVR1C encoding the activin receptor-like kinase 7 influences body fat distribution and protects against type 2 diabetes","volume":"68","author":"Emdin","year":"2019","journal-title":"Diabetes"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"P454","DOI":"10.1016\/j.ajhg.2010.01.038","article-title":"Identification of a Recurrent Microdeletion at 17q23.1q23.2 Flanked by Segmental Duplications Associated with Heart Defects and Limb Abnormalities","volume":"86","author":"Ballif","year":"2010","journal-title":"Am. J. Hum. Genet."}],"container-title":["Genes"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2073-4425\/13\/11\/1958\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T01:03:46Z","timestamp":1760144626000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2073-4425\/13\/11\/1958"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,10,27]]},"references-count":31,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2022,11]]}},"alternative-id":["genes13111958"],"URL":"https:\/\/doi.org\/10.3390\/genes13111958","relation":{},"ISSN":["2073-4425"],"issn-type":[{"value":"2073-4425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,10,27]]}}}