Many treatment approaches for those with clubfoot

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  • Thursday, 15 Jan 2015

Set right: Clubfoot after heel cord lengthening.

CLUB foot or clubfoot, also called congenital talipes equinovarus (CTEV), is a congenital deformity involving one foot or both.

The affected foot appears to have been rotated internally at the ankle. Without treatment, people with club feet often appear to walk on their ankles or on the sides of their feet.

However, with treatment, the vast majority of patients recover completely during early childhood and are able to walk and participate in games just like those without CTEV.

It is a relatively common birth defect, occurring in about one in every 1,000 live births. Approximately half of people with clubfoot have both feet affected, which is called bilateral club foot. In most cases it is an isolated disorder of the limbs. It occurs in males twice as frequently as in females.

Hippocrates was the first to make a hypothesis about the cause around 400 B.C. and to this day there are many other hypothesis for clubfoot pathogenesis.

Most of the studies have concluded that clubfoot may be caused by environmental factors, genetics, or a combination of both.

Deformed: Features of club foot.
Deformed: Features of club foot.

“It is likely there is more than one different cause and at least in some cases the phenotype may occur as a result of a threshold effect of different factors acting together”

Clubfoot is usually diagnosed immediately after birth simply by looking at the feet.

It is then up to the doctor whether or not to X-ray the feet to examine how the internal structures are positioned.

In some cases, it may be possible to detect the disease prior to birth during the ultrasound.

It may be more prominent if both feet are affected.

The ability to possibly identify clubfoot before birth can prove beneficial to the child as different treatments can be explored.

Once a child has been diagnosed with clubfoot, there are many different treatment approaches.

Treatment should be given immediately after diagnosis to take full advantage of the flexibility in the baby’s bones and joints.

This allows for improved manipulation to try to achieve a normal foot.

The Ponseti method involved manipulation by people specialised in the technique with serial casting and then providing braces to hold the feet in a plantigrade position.

After serial casting, a foot abduction brace such as a Denis Browne bar with straight lace boots, ankle foot orthoses and/or custom foot orthoses (CFO) may be used.

Extensive surgery of the soft tissue or bone is not usually necessary to treat clubfoot; however, there are two minimal surgeries that may be required:

Tenotomy - clipping of the Achilles tendon - is needed in about 80% of cases.

Anterior tibial tendon transfer, in which the tendon is moved from the first toe to the third in order to release the inward traction on the foot, is needed in about 20% of cases.

In most cases extensive surgery is not needed to treat clubfoot.

Extensive surgery may lead to scar tissue developing inside the child’s foot.

The scarring may result in functional, growth and aesthetic problems in the foot because the scarred tissue will interfere with the normal development of the appendage.

A child who has extensive surgery may require on average two additional surgeries to correct the issues presented above.

In stretching and casting therapy, the doctor changes the cast several times over a few weeks, gradually stretching tendons until the foot is in the correct position of external rotation.

The heel cord is released (percutaneous tenotomy) and another cast is put on, which is removed after three weeks.

To avoid relapse, a corrective brace is worn for a gradually reducing time until it is only at night up to three to four years of age.

This treatment requires stretching and casting, but is better known as the Ponseti method.

The foot is repositioned to the normal position, then a cast (the “Ponseti cast”) is placed on top of it.

The baby’s foot is then continually repositioned and placed back into a cast once a week for several months.

Towards the end of the process after being in a cast, the doctor will then go in and surgically lengthen the heel cord ( Achilles tendon).

After the foot has been realigned, maintenance is kept by doing routine stretching. The child also has to wear special shoes or braces full-time for three months, then just nightly for three years after. This method can be compared to wearing braces on your teeth.

Parents’ have to follow the doctor’s orders for when to wear and not wear the brace to keep the foot corrected.

Failure will occur if parents don’t follow directions and the foot will return to its odd shape.

Treatment for clubfoot should begin almost immediately to have the best chance for a successful outcome without the need for surgery.

Over the past 10 to 15 years, more and more success has been achieved in correcting clubfeet without the need for surgery.

The Ponseti method, if correctly done, is successful in >95% of cases in correcting clubfeet using non- or minimal-surgical techniques.

Typical clubfoot cases usually require five casts over four weeks.

Atypical clubfeet and complex clubfeet may require a larger number of casts.

Approximately 80% of infants require an Achilles tenotomy (microscopic incision in the tendon) performed toward the end of the serial casting.

After correction has been achieved, maintenance of correction may require the full-time (23 hours per day) use of a splint - also known as a foot abduction brace (FAB)-on both feet, regardless of whether the TEV is on one side or both, for several weeks after treatment.

Part-time use of a brace (generally at night, usually 12 hours per day) is frequently prescribed for up to four years.

Without the parents’ participation, the clubfoot will almost certainly recur, because the muscles around the foot can pull it back into the abnormal position.

Approximately 20% of infants successfully treated with the Ponseti casting method may require a surgical tendon transfer after two years of age.

While this requires a general anaesthetic, it is a relatively minor surgery that corrects a persistent muscle imbalance while avoiding disturbance to the joints of the foot.

The long-term outlook for children who experienced the Ponseti method treatment is comparable to that of non-affected children.

In severe cases, surgery may be the only option to correct the foot after trying all other non-invasive methods for treatment.

Surgery does not ensure full recovery, but most babies who underwent the surgery have maintained their normal feet.

A surgeon will go in and lengthen the muscles and tendons to ease the foot into position.

After surgery when the cast is removed, a brace is to be worn to prevent the foot from returning to the old position.

Without any treatment, a child’s clubfoot will result in severe functional disability, however with treatment, the child should have a nearly normal foot.

He or she can run and play without pain and wear normal shoes. The corrected clubfoot will still not be perfect, however, a clubfoot usually stays 1 to 11/2 sizes smaller and somewhat less mobile than a normal foot.

The calf muscles in a leg with a clubfoot will also stay smaller.

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Family & Community , Perak , club foot


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