Club Foot

  • Club foot

    Clubfoot is defined as a group of foot deformities in the new born child's foot often presenting dramatically in the shape or position.

    Clubfoot is a common birth defect occurring in about one in every 1,000 live births. Approximately 50% of cases of clubfoot are bilateral. This occurs in males more often than in females by a ratio of 2:1.

    Clubfoot can be mild or severe, affecting one or both feet. Clubfoot will hinder your child's development once it's time for your child to walk, so treating clubfoot soon after birth is recommended.

    Presentation

    In most instances, parents of the affected child will seek attention to the abnormal foot. Clubfoot twists the top of a child's foot downward and inward, increasing the arch and turning the heel inward. Also, the calf muscles in the affected child's foot are usually underdeveloped, and the affected foot may be shorter than the other foot. Despite its look, however, clubfoot itself doesn't cause any discomfort or pain.

    club foot
    Comparison between club and normal foot
    club foot
    Club foot before treatment

    When to see a podiatrist ?

    Your obstetrician or pediatrician are likely to notice clubfoot soon after the birth of your child and probably advise you to see an orthopaedic surgeon specialising in podiatry problems including clubfoot.

    Causes

    There is still no certainty why it happens, though it can occur in some families with previous clubfeet. In some cases, clubfoot can be associated with other congenital abnormalities of the skeleton, such as spina bifida, a serious birth defect that occurs when the tissue surrounding the developing spinal cord of a fetus doesn't close properly.

    Environmental factors play a role in causing clubfoot. Studies have strongly linked clubfoot to cigarette smoking during pregnancy.

    Risk factors include

    • Sex. Clubfoot is more common in males.
    • Family history. If you, your spouse or your other siblings have had clubfoot, your baby is more likely to have it as well.
    • Smoking during pregnancy. If a woman with a family history of clubfoot smokes during pregnancy, her baby's risk of having this condition is much greater.

    Problems with clubfoot

    Clubfoot does not cause a problem till the child starts to stand and walk. Left untreated, however, clubfoot shows as a twisted, deformed and generally a smaller foot. The twist of the ankle may not allow the child to walk on the soles of the feet. To compensate, the child may walk on the outside of the feet. These adjustments may prevent natural growth of the calf muscles. Into teenage and adulthood, neglected clubfoot can cause arthritis in the joints around the ankle.

    Left untreated, however, clubfoot can become a burden. Not only is your child likely to have arthritis, but the unusual appearance of the foot may make body image a concern during the teen years. The twist of the ankle may not allow your child to walk on the soles of the feet. To compensate, he or she may walk on the balls of the feet, the outside of the feet or even the top of the feet in severe cases. These adjustments may inhibit natural growth of the calf muscles, cause large sores or calluses on the feet, and result in an awkward gait.

    What you need to tell your child's clubfoot specialist?

    Here are some questions to consider asking your foot specialist:

    • What types of corrective treatment are available for my child's condition?
    • Will my child need surgery?
    • What kind of follow-up care will my child need?

    In addition, tell your doctor:

    • If you have family members — including extended family — who've had clubfoot
    • If you had any medical issues or problems during your pregnancy

    Tests and diagnosis

    Most commonly, a doctor recognizes clubfoot after birth just from looking at the shape and positioning of the newborn's feet. The doctor may request X-rays to fully understand the severity of the deformity.

    It's possible to clearly see some cases of clubfoot before birth during a baby's ultrasound examination. If clubfoot affects both feet, it's more likely to be apparent in an ultrasound. While nothing can be done before birth to solve the problem, knowing about the defect may give you time to learn more about clubfoot and get in touch with appropriate health experts, such as a genetic counsellor or an orthopaedic surgeon.

    Treatment

    Because your newborn's bones and joints are extremely flexible, treatment for clubfoot usually begins 7 to 10 days after birth.

    The goal of treatment is to restore the look and function of the foot before your child learns to walk, in hopes of preventing long-term disabilities.

    Treatment options include:

    • Stretching and casting (ponseti method)

      This treatment entails manipulating the foot into a correct position and then placing it in a cast to maintain that position.

      The cast is applied from the toes to just above or below the knee and is changed every week until the deformity is adequately improved. Frequent release of the Achilles tendon is needed to completely correct the deformity.

      After the shape of the foot is realigned, it's maintained through stretching exercises, special shoes or splinting with braces at night for up to three years. For this method to work effectively, you'll need to apply your child's braces according to your doctor's specifications so that the foot doesn't return to its original position.

      • How often are plasters changed?

        Your child's foot is manipulated every week and plaster is thereafter changed. The plaster is kept for 3 weeks after Achilles tendon release surgery.

      • How many plasters are usually required?

        Depending upon the severity of condition 5 – 8 plasters are normally required. Sometimes your foot specialist may decide to do a tendon release.

    • Ponseti serial clubfoot casting

      Serial casting with visible improvement
      Serial casting with visible improvement
      Correct technique for manipulation on foot
      Correct technique for manipulation of foot

    Surgery

    When clubfoot is severe or doesn't respond to nonsurgical treatments, your child may require surgery.Podiatric surgery if done early can be curative. Dr Padala can lengthen tendons to help ease the foot into a more appropriate position. After surgery, your child will need to wear a brace for a year or so to prevent recurrence of the deformities.

    With a cut on the back of the heel, the tight tendons are lengthened
    With a cut on the back of the heel, the tight tendons are lengthened

    With a cut on the back of the heel, the tight tendons are lengthened

    Follow up after clubfoot treatment

    • Is very important and ensures that there is no recurrence of the problem.
    • First follow up after full correction is 6 weeks to three months.
    • Every four months until age three years (to monitor compliance and check for relapses).
    • Every six months until age 4 years.
    • Every one to two years until skeletal maturity (16 in girls and 18 in boys).

    with a splint for night wear

    After casting is completed, maintaining corrected position with a splint for night wear

    Neglected club foot

    If a clubfoot is not treated by the age of 2 yrs, then the condition is called neglected club foot.

    Problems with a late presentation club foot are:

    • The foot may be severely inturned
    • Due of absence of a normal foot-flat situation, the muscles on the involved side are poorly developed.
    • On the affected side, outer aspect of foot may touch the ground, causing callosity (hard, thick skin formation) or even ulceration.
    • There might be a severe shortening on the involved side.

    Pictures of a deformed, neglected club foot

    Pictures of a deformed, neglected club foot

    Treatment of neglected club foot

    Treatment hinges on identifying all the deforming forces that are keeping the foot in a deformed position.

    The parents should be warned that multiple surgeries may be required.

    Cornerstone of treatment is application of an external fixator frame. Frame fixation at first look seems frightening, but the advantages are:

    • All three deformities namely equinus, cavus and varus can be corrected at the same time.
    • It can correct any involved shortening of the leg as well as the same time.
    • Short side of the foot can also be lengthened using the frame and thereby avoiding bone grafting.
    • Since skin and blood vessels are still tender in the growing child, a frame surgery involves less traumatic surgery.

    Treatment with an external frame fixator for late presentation club foot
    Treatment with an external frame fixator for late presentation club foot

    Treatment with an external frame fixator for late presentation club foot

    Frames need to be in place for 3 months for good correction and preventing recurrences.

    After frame removal continued monitoring is crucial.

    Osteotomy with/without bone graft

    club foot

    Osteotomy Operation

    Even after a frame correction, or in early neglected club foot, there can be hump of bone on the outside of the foot, as shown in the picture below.This is treated by removing a small wedge of bone and fixing the bone with plate and screw or staples.

    Triple fusion

    Triple fusion operation for severe arthritis in club foot

    Triple fusion operation for severe arthritis in club foot

    If there is significant damage to the joints around the ankle, and the ankle is unstable when the child attains skeletal maturity, then a triple fusion: sub-talar (below the talar bone), talo-naviclar and calcaneo-cuboid, is appropriate.