Saturday, 23 July 2011

What is Clubfoot?

Treating Clubfoot

Clubfoot, medically termed Talipes equinovarus is a relatively common foot deformity, affecting one in 1,000 children in any general population each year. The condition affects twice as many boys as girls and it has a genetic component to it, reveals Dr.Salman Hameed, Specialist Orthopedic Surgeon, Welcare Hospital, Dubai. If a family has one or more persons who have clubfoot, then the chances are higher that the baby may have one also. If a couple has one child with clubfoot, the chances are 1 in 50 of a sibling being born with the condition. However, since clubfoot is readily identifiable at birth, it is easy to diagnose and begin treatment promptly.

What is clubfoot and does it occur in one foot or both feet?
In 99% of instances, children are born with club foot which in 50% of cases affects both feet. Clubfoot refers to a foot that points downward, the toes turn inward and the bottom of the foot faces inwards. It looks like as if the top part of the foot is facing sideways on the outside, and the underside of the foot seems to be inwards, giving the appearance of a club. In 1% of cases, clubfoot may occur for other reasons including trauma and fractures to the foot. Clubfoot sometimes occurs along with other birth defects, but usually it is the only problem the child has.

What causes clubfoot?
While the causes are multifactorial, in majority of instance, the cause is unknown or idiopathic. The condition may be due to problems with circulation or some nerve or tendon problems or due to formation of some fibrous tissues in the region. The second most important cause of clubfoot, is postural or positional while the baby is in the mother’s womb. The foot may have assumed the shape in the womb itself. Few children have clubfoot in its most severe and least common form, associated with certain systemic conditions or syndromes.

Is there any racial bias to the condition?
It is more common in the Western society, with almost 5% of babies being born with it in Hawaii, Florida and such other countries. The incidence is slightly higher among Caucasians. The incidence amongst Asian is rather low, being about 0.05%. However, no matter how low the incidence may be, the condition needs prompt treatment since it can be debilitating if left untreated.

Since the condition is physical visible at birth, is there need for any other investigative measures except clinical examination?
In some instances, we may do an X Ray of the hips and spine to exclude problems in these regions. This is so because in 5% - 10% of kids with clubfoot, they can have dislocated hips, etc. Also, the X-ray is taken to see how the bones in the foot are shaped. Sometimes a baby's foot is turned inward but the bones are shaped normally, and the foot can be gently pulled into a normal position.

How is clubfoot treated?
Treatment should ideally start at birth. A child with clubfoot should be referred to a pediatric orthopaedic surgeon specializing in the treatment of clubfoot. The first step in treatment involves identifying any underlying problem that may be associated with clubfoot, like spina bifida, neurological conditions, etc. Secondly, we need to find out if the clubfoot is of the rigid or flexible type and the extent of the deformity. This is important since clubfoot associated with certain syndromes, may not be correctible easily. Whatever the cause, treatment begins with the conservative modality of manipulating the foot. This involves stretching the ligaments, tendons and joints of the affected foot, soon after birth. Following this, an above-the-knee plaster is done which is changed biweekly for the first couple of weeks, followed by weekly changes once the condition improves. The plaster casting is done for 3 – 4 months.

When is surgery undertaken?
More than 75% of children with clubfoot require surgery. This is particularly so in cases where the cause of the condition is idiopathic. However, in these cases, we can reduce the level or extent of surgery by doing some partial correction by manipulation and plaster technique till the child grows to an age where surgery can be performed.

Does this imply, surgery is not undertaken at birth or soon thereafter?
Yes. The child should be at least six months old and the foot should be 6cm – 7cm long for surgery to be effective. The foot is so small at birth, and its various structures including the tendons and nerves are so small and have not developed at all. So if surgery is done at this time, there’s a big danger of damage to the nerves and blood vessels. Ideally, surgery should be done about 2 – 3 months before the child is expected to walk so that when it’s been corrected, the child will be able to walk at the time he is expected to walk, as a normal course.

What is the success associated with surgery and will these children be able to pursue normal activities including sports?
Success of surgery depends upon the severity of the condition and whether it is correctible or not. Clubfoot on account of postural causes are 100% correctible even with conservative treatment because there is no bony abnormality or joint disorders. Some of the conditions, especially those associated with certain syndromes are not correctible because the foot can be very rigid. Those due to idiopathic causes are less correctible.

The foot will never be normal in the sense that the calf of the foot will be small and the big toe will also be a bit smaller. The range of movements of the foot will also be a bit small. So these children may not be able to participate in very serious, competitive sports. However, in more than 90% of children, once they are corrected properly, though the foot is not completely normal, they can participate effectively in daily activities of school and a lot of sporting activities. The idea behind any treatment is to have a foot which is flat on the ground, is painless and has good joint mobility and strength and the bones are developing normally.

Also, the corrected foot will be about 1 cm smaller than the other foot in most cases where clubfoot is idiopathic in nature. And this will always be like that. These children may use footwear of the same size, using fillers in them for the shorter foot.

Is there a possibility of recurrence of the condition following treatment? Would any child require surgery more than once?
If the condition recurs, it will definitely need surgery. There is possibility of recurrence, even in the postural cases of clubfoot. This may happen if there is neglect with respect to the plaster casting, if the shoes are not appropriate or are not worn properly. Recurrence can happen any time after treatment, usually from the time of treatment till the child reaches to about 6 – 7 years of age. Therefore it is very important that the child be keenly observed up to this age. The recurrence rate in the idiopathic type of clubfoot is 20% - 25%. In these cases, the second surgery may be done at any age, but before the child turns 10.

Additionally, in some instances, the severity of the condition is so great that a few surgeries rather than one surgery, may need to be done to effect correction. These surgeries are done gradually over a period of time.

What are the possible complications of surgery?
Since we are working around nerves and blood vessels, these can be damaged, if not done by experienced hands. There can be skin problems sometimes, following surgery. In some cases, we may prefer to leave the incised skin open to heal on its own rather than using tight stitches to close it. When this happens, the parents need to keep a very close watch on the children so that the open skin does not get infected.

What are the complications of untreated clubfoot?
If not treated early, the treatment becomes bigger, more elaborate, difficult and results are poor. The foot becomes stiffer because bones start developing in an abnormal position; joints start curving in abnormal positions; ligaments and muscles get permanently lengthened or stretched out or contracted and tightened up.

Also, if the treatment is not done properly, the child ends up being handicapped and will be walking on the top of the foot rather than the bottom of the foot, or from the side of the foot. This in turn can cause pressure points, pressure ulcers and skin breakdowns.
However, even those children in whom the clubfoot has been neglected, which is quite common in this part of the world, a different kind of surgery is now performed (Illizarov Ring Fixator Technique) to correct the deformities thus caused.


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