True clubfoot is characterized by abnormal bone formation in the foot. There are four variations of clubfoot, including talipes varus, talipes valgus, talipes equines, and talipes calcaneus. In talipes varus, the most common form of clubfoot, the foot generally turns inward so that the leg and foot look somewhat like the letter J. In talipes valgus, the foot rotates outward like the letter L. In talipes equinus, the foot points downward, similar to that of a toe dancer. In talipes calcaneus, the foot points upward, with the heel pointing down.
True clubfoot is usually obvious at birth. The four most common varieties have been described. A clubfoot has a typical appearance of pointing downward and being twisted inwards. Since the condition starts in the first trimester of pregnancy, the abnormality is quite well established at birth, and the foot is often very rigid. Uncorrected clubfoot in an adult causes only part of the foot, usually the outer edge, or the heel or the toes, to touch the ground. For a person with clubfoot, walking becomes difficult or impossible.
There are different types of talipes and all refer to the sometimes alarming angle at which the foot and ankle lie. The four different forms are;
# Talipes equinovarus - the most common form
# Talipes equinovalgus - where the foot points outwards and down
# Talipes calcaneovarus - where the foot points inwards and up
# Talipes calcaneovalgus - where the foot points inwards and down
Surprisingly, study suggested that the women with clubfoot were significantly less likely to have had children than the women without birth defects. This finding is intriguing, since there is nothing intrinsically related to this defect that would explain a reduction in fertility. Clubfoot nowadays is eminently correctable, and it is difficult to believe that clubfoot would carry any stigma that would prevent a woman from marrying or having children. An alternative explanation may be that clubfoot is a visible malformation associated with a number of other defects that are not apparent until later in life and that may influence both survival and fertility.
Clubfoot can be mild or severe, affecting one or both feet. Clubfoot won't hinder your child's development drastically until it's time for your child to walk. At that stage, the awkward positioning of the foot may force your child to walk on the outside edge of his or her feet, causing an odd-looking stride, stiffness and weakened calf muscles.
Study revealed that the estimated relative risks for the most commonly recurring defects in the second infants were 31.4 for cleft lip, 11.3 for limb defects, 7.3 for clubfoot, and 4.9 for defects of the genitalia. The risks of dissimilar defects in second infants after each of these defects in first infants were 1.2, 2.4, 1.4, and 1.5, respectively.
Clubfoot and certain other foot defects generally can be recognized during the newborn examination. These defects usually can be diagnosed with a physical examination alone, though occasionally the doctor may recommend additional tests such as x-rays.
Clubfoot sometimes is diagnosed before birth, during an ultrasound examination. Though the disorder cannot be treated before birth, parents have a chance to locate a good orthopedic surgeon and learn about treatment options.
Many degrees of severity and rigidity of clubfoot are found at birth. Failures in treatment are related more often to faulty techniques of manipulation and application of the cast than to the severity of the deformity. Our experience of 50 years indicates that most clubfeet, when treated shortly after birth, can be easily corrected by manipulation and five or six applications of plaster casts. A small number of infants with very severe, short, fat feet with stiff ligaments unyielding to stretching require special treatment and may need surgical correction.
Treatments vary depending on the severity of the condition. They include :
• Gentle manipulation (stretching of the foot into the correct position)
• Gentle manipulation and maintenance of the corrected position using any or a combination of the following methods: adhesive strapping/splints/plaster casts/splints/Denis Browne bar and booties.
• Surgery
• Ponsetti method
Two goals:
1) To completely correct a club foot
2) To partially correct a club foot so the ensuing surgery will not be so radical
I. Manipulation - Evert heel, abduct forefoot, dorsiflex foot
II. Continuous passive motion - Manipulation repeated regularly; may use a machine
III. Strapping:
- Useful in newborn nursery when casting is difficult to manage
- Positions the foot with adhesive taping
- May re-strap on regular basis
IV. Casting - Manipulate then foot then maintain in plaster casting
Structural talipes needs prompt treatment, while the baby's tissues are still soft, with manipulation of the foot towards the correct position and methods such as strapping or casting to hold it in place.
Manipulation and plastering:
Traditionally in this country treatment tends to be along the lines of using a strapping technique with Elastoplasts for the first few weeks and then casts which are changed frequently in a process called serial casting. Each week you have the opportunity to bring the foot around a little more and then cast it in that position. It would do this for at least the first three months and then decide whether the casting on its own will be enough or whether an operation should be considered.
Gentle manipulation (stretching) and recasting occurs every week to improve the position of the foot. Generally, 5 to 10 casts are needed. The final cast remains in place for 3 weeks. After the foot is in the correct position, a special brace is worn nearly full-time for 3 months. After, it is used at night and during naps for up to 3 years.
Casting:
Serial casting is the most frequently used regimen of treatment for these congenital foot deformities because it maximizes the corrective force at the deformity, is reproducible and is cost effective. Ideally, two people should perform the technique for casting, with one wrapping and the other holding the foot and molding the cast. Most casts applied to young infants extend to the upper thigh with the knee flexed. Applying the casts in two parts, the short leg first and the above knee later, allows for more control during molding.
There are many methods of casting; Ponseti's method has been validated by long term follow-up. The initial measures are designed to correct the forefoot cavus, with particular attention to avoiding pronation of the forefoot. Only then is hindfoot correction attempted. A percutaneous heel cord lengthening is done before 3 months of age for persistent hind foot contracture.
Ponseti technique (Non Surgical):
Stretching and putting a cast on the area is a non-surgical method that is often used, especially when it is started at a younger age. Dr. Ignacio V. Ponseti has popularized a casting technique which is more successful than surgery, and it is used throughout the United States with good long term follow-up. After the Ponseti casts, the Foot Abduction Orthosis, or shoes and brace, is the most important way to keep the clubfoot deformity from coming back.
The treatment offered to the parents of children who have talipes is the Ponseti technique. This aims to correct the child’s foot so that the foot is functional, looks as normal as possible and is pain free. There are several stages of treatment:
1. The first stage involves a series of manipulations and casting.
2. Many children will need to have a tenotomy operation, followed by a stage of wearing a cast.
3. The final stage will involve your child wearing boots and a bar until they are about five years old.
Pediatric institutions all around the world are choosing the Ponseti technique over traditional surgery which involves extensive soft tissue release of tendons and joints of the foot. If children have had extensive soft-tissue release, they are often left with a painful stiff foot and limited walking ability.
Once the right position is reached, the infant has to wear a leg brace every day for two years to reinforce the correction. To prevent relapse of this condition, it is imperative the child wears the brace system at night until four years of age.
The rapid spread worldwide of the Ponseti nonoperative approach to treating talipes is the most important factor in reducing the rates of surgery and therefore the complications that may ensue.
Surgical Treatment:
If the manipulation/serial casting treatment fails, surgery may be necessary. The surgical correction is usually not done until the child is between six and nine months of age. The surgical procedure usually consists of releasing and lengthening the tight tendons/joint capsule of the foot.
There are four main types of surgery:
The most common ones are:
* Soft tissue release: lengthening or cutting the Achilles tendon and releasing other ligaments and capsules at the back and inside border of the foot which are preventing the positioning required because they are too tight.
* Tendon transfers: (e.g. the tibialis anterior transfer) to move the tendons to a different position, so the function of the foot can be improved.
* Surgery on the bones of the foot - bony procedures such as osteotomies that divide or remove bone to correct deformities, or, very occasionally, arthrodeses which surgically stabilize joints to enable the bones to grow solidly together. This is usually carried out after the child has stopped growing.
* Use of a circular frame such as the Ilizarov - a number of metal rings held together with rods and fixed to the bone from several directions by thin wires under tension. By adjusting different components of the frame over a period of time bones can be lengthened, thickened or shortened and soft tissue can be stretched.
Many surgeons prefer to make two separate incisions, a posteromedial incision, and a small lateral incision. However, it is also possible to have one circumferential incision. The surgery usually takes 2-3 hours, and involves one or two days in the hospital. The corrections are typically held in place by inserting small pins, which are removed in the office approximately 4-6 weeks after surgery. Following surgery, the foot will need casting for another six to twelve weeks. The leg will be positioned in a bent knee long leg cast. The casting may be followed by full-time or nighttime use of brace for varying periods of time.
Children need regular follow-up for several years after treatment (casting or surgery) to make sure that the clubfoot does not come back. The idiopathic type (i.e. the cause is unknown) clubfoot can come back up to about six or seven years of age. Most, however, if they do return will do so within several years of treatment. Repeat casting or further surgery can be performed.
Washington University orthopaedic surgeon Matthew B. Dobbs, MD, revived a nonsurgical technique to correct talipes equinovarus, or clubfoot, a congenital foot deformity. By combining the venerable procedure with the latest genetic science and translational research, Dobbs aims to drastically improve treatment and perhaps eventually reduce the incidence of the malady. The revived procedure employs weekly stretching of the infant's foot followed by the application of long-leg casts that gently reshape an infant's relatively plastic foot. Dobbs says the procedure serves his patients well, "The casting technique is applicable to all clubfeet from birth to the age of 2 years."
A comparative study shown that Ponseti's manipulation technique and cast immobilization followed by an open heel-cord lengthening and a limited posterior ankle release gave much better long-term results than those obtained in the first group, treated with our manipulation technique and cast immobilization followed by an extensive posteromedial release of the foot.
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