CLUB FOOT IN CHILDREN
Clubfoot is a complex deformity that is readily apparent at birth and in some cases is diagnosed by prenatal ultrasound. The goal of treatment is to obtain and maintain correction of the clubfoot so that the patient has a functional, pain-free, plantigrade foot, with good mobility and without calluses, and does not need modified shoes. Parents of infants born with clubfeet and no other significant medical problems should be reassured that their child, when treated by medical experts, will have feet that are fully compatible with a normal, active life. However, it must always be remembered that a clubfoot will never be a normal foot.
ANATOMY AND PATHOPHYSIOLOGY
All clubfeet are not of the same severity, although all have the same general appearance. The feet are twisted inward so that the top of the foot is where the bottom should be. There is often a deep crease on the bottom of the midfoot.
Left, Note the weightbearing surface of the foot is on the side and top of the foot in this child with bilateral clubfeet. Right, Note the deep crease on the bottom of the midfoot in this child with a unilateral clubfoot.
The foot and calf are smaller in affected limbs, which is more obvious in a child with a clubfoot on only one side
Clubfoot may occur as an isolated disorder (idiopathic) or in combination with various syndromes and other associated anomalies such as arthrogryposis and myelodysplasia. Medical examinations by your doctor or blood tests should be able to determine whether your baby’s clubfoot is idiopathic.
Clubfoot can be mild or severe and all cases require treatment. Clubfoot will not resolve without treatment. The clubfoot is not painful to the infant who does not yet walk.
The incidence of idiopathic clubfoot is estimated to be one to two per 1000 live births. It has a male predominance of 2:1 and occurs in both feet about 50 percent of the time. There is a much higher incidence if the patient has a positive family history for clubfoot.
The etiology of idiopathic clubfoot is unknown. The most widely accepted theory is that clubfoot is caused by a combination of genetic and environmental factors.
IS CLUBFOOT INHERITED?
There is a positive family history of clubfoot in approximately 25 percent of all patients, suggesting a genetic basis for this disorder. If one child in the family has clubfoot, the chance of a second child being born with clubfoot is around 5 percent. When one parent is affected with clubfoot, there is a 3 percent to 4 percent chance that the offspring will also be affected. However, when both parents are affected, their children have a 15 percent chance of being born with clubfoot.
Clubfoot deformity, regardless of etiology or associated clinical problems, results in a severe handicap unless corrected. The surface area for weight-bearing in an untreated clubfoot is the outside of the foot. A child with an untreated clubfoot will walk on the outer edge of the foot instead of the sole, develop painful calluses, be unable to wear shoes and have lifelong painful feet that often severely limit activity and employment.
SURGICAL AND NONSURGICAL OPTIONS
Nonsurgical modalities include serial manipulation and casting, taping, physical therapy and splinting, and continuous passive motion with a machine. Surgical treatment is extensive and requires release of soft tissue and joint contractures, tendon lengthening, and temporary pin fixation of joints in the foot.
NONSURGICAL TREATMENT BENEFITS AND LIMITS
The initial treatment of clubfoot, regardless of severity, is nonsurgical. Manipulation and casting using the Ponseti method is the technique used most frequently in the United States. The majority of clubfeet can be corrected in infancy in about six to eight weeks with the proper gentle manipulations and plaster casts.1 The technique requires training, experience, and practice.
Fewer than 5 percent of infants born with clubfeet may have very severe deformities that are unyielding to stretching. These infants will require surgical correction.
Treatment should be initiated immediately upon diagnosis, preferably within the first week of life. Treatment for the newborn with clubfoot is by manipulation to correct the condition and then casting to maintain the correction. Casting begun at a later age may be more difficult due to the worsening ligamentous contracture and joint deformity. Long-leg plaster casts are used to maintain the corrections obtained through manipulations.
Casts are changed at weekly intervals, and most deformities are corrected in two months to three months. Before applying the last plaster cast, which is to be worn for three weeks, the Achilles tendon is often cut in an office procedure to complete the correction of the foot. By the time the cast is removed the tendon has regenerated to a proper length. After the last cast is removed, the foot should appear overcorrected.
Despite successful initial treatment, clubfeet have a natural tendency to recur. Bracing is necessary for several years to prevent relapses.
There are several different braces that are commonly prescribed. All braces consist of a bar (the length of which is the distance between the child’s shoulders) with either shoes, sandals, or custom-made orthoses attached at the ends of the bar in about 70 degrees of external rotation. The bar can be either solid (both legs move together) or dynamic (each leg can move independently). The brace is worn 23 hours a day for three months and then at nighttime for three to four years. The brace consists of a bar (the length of which is the distance between the child’s shoulders) with high top open-toed shoes attached at the ends of the bar in about 70 degrees of external rotation.
In children with only one clubfoot, the shoe for the normal foot is fixed on the bar in 40 degrees of external rotation. Bracing is critical in maintaining the correction of the clubfeet. If the brace is not worn as prescribed there is a near 100 percent recurrence rate.
Babies might get fussy for the first few days after receiving a brace, and will require time to adjust. It is important to check your child’s feet several times a day after initiating the bracing to ensure no blisters are developing on the heel.
HELPFUL TIPS FOR BRACEWEAR
Play with your child in the brace. This is the key to getting over the irritability quickly. If your child is using the solid bar, you must teach your child that he/she can kick and swing the legs simultaneously with the brace on. You can do this by gently flexing and extending the knees by pushing and pulling on the bar of the brace. If your child is using the dynamic bar, it is also helpful to gently move the legs up and down as your child gets used to the brace.
Make it a routine. Children do better if you develop a fixed routine for the bracewear. During the three to four years of night/naptime wear, put the brace on anytime your child goes to the “sleeping spot.” They will figure out that when it is “that time of day” they need to wear the brace. Your child is less likely to fuss if this is a consistent routine.
Pad the bar. A bicycle handle bar pad works well for this. By padding the bar you will protect your child, yourself and your furniture from the metal bar when the child is wearing the brace.
Never use lotion on any red spots on the skin. Lotion will make the problem worse. Some redness is normal with use. Bright red spots or blisters, especially on the back of the heel, usually indicate that the heel is slipping. Ensure that the heel stays down in the shoe by securing the straps and/or buckles.
If your child continues to escape from the brace try the following steps. (Check after each step to see if the heel is down; if not, proceed to the next step):
- Tighten the middle strap first using your thumb to hold the foot and the tongue piece in place (Dobbs brace) or tighten the strap by one more hole (sandals or shoes).
- Try double-socking or place one sock under the insert and one on top to help pad and take up excess room in the Dobbs brace.
- Remove the tongue of the shoe (using the orthosis without the tongue will not harm your child).
- Try lacing the shoes from the top to bottom, so that the bow is by the toes.
- Use 40-inch round shoelaces.
- Try thinner or thicker cotton socks, or the ones with letters on the sole.
A small percentage of children develop relapses despite proper bracing. The more severe and rigid the initial deformity was, the greater the risk of recurrence. Recurrences may be treated a series of manipulations and casting followed by occasional tendon transfers to maintain correction.
Poor technique in manipulation and/or casting can result in unnecessary failure of nonsurgical treatment. Without a thorough understanding of the anatomy and kinematics of the normal foot and of the deviation of the bones in the clubfoot, the deformity is difficult to correct. Poorly conducted manipulations and casting will further compound the clubfoot deformity rather than correct it, making treatment difficult or impossible.
Surgeons with limited experience in the treatment of clubfoot should not attempt to correct the deformity. They may succeed in correcting mild clubfeet, but severe cases require experienced doctors. Ask your doctor for a referral to a center with expertise in the nonsurgical correction of clubfoot before you consider surgery.
SURGICAL INTERVENTION AND CONSIDERATIONS
Surgery is indicated if there is failure to achieve satisfactory clinical and radiographic evidence of deformity correction by nonsurgical methods, for residual deformities, and for recurrent deformities unresponsive to nonsurgical measures. Controversy surrounds the age at which clubfoot surgery should be performed. Most surgeons operate on the child between six months and one year of age.3, 4
Though there is some variation in surgical technique, all of the major reconstructive clubfoot surgeries involve extensive soft-tissue release of the posterior, medial, and lateral structures of the foot. The correction, once achieved, is usually held temporarily (six weeks) with wire fixation across the joints of the foot. More surgery is required to remove the wire.
The need for additional surgery after the first operation is reported to range from five percent to 50 percent.