Introduction:
Physical abnormality present at the time of birth is called congenital deformity. Clubfoot is a congenital deformity where the muscles and bones of the foot are affected. It is characterized by a change in the shape and position of the normal foot. The diagnosis is made at the time of birth. Recently, most cases of clubfoot have been detected in prenatal scanning during early pregnancy.
What Is Clubfoot?
Clubfoot is a deformity where the foot is turned inwards. In medical terms, it is called talipes. The toes of the foot point towards the opposite leg. It is a prevalent condition affecting one in 1000 children. Clubfoot may affect one or both the feet. About half of the detected cases have it in both feet. The twist may be mild or severe, and the legs are usually shorter. Clubfoot is common in first-born children with a male predilection.
How Is Clubfoot Classified?
Clubfoot can be classified into two major categories. They are;
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Isolated:
Isolated or idiopathic clubfoot is the common type occurring in children at birth and is not associated with other medical conditions.
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Non-Isolated:
Non-isolated clubfoot is rare and occurs with other health problems and neurological disorders.
What Are the Causes of Clubfoot?
The exact cause of clubfoot is not known. It may be a combination of genetic and environmental factors. Some hypotheses suggest clubfoot is formed due to malfunction in gestation. There is a higher risk of clubfoot running in families. If the first child has a clubfoot, the risk of developing this condition is higher in subsequent pregnancies as well. In the case of identical twins, if one baby has the condition, there is a 33 % chance the other one will have the same. Suppose the mother uses tobacco products or drugs during pregnancy, there is a greater chance for the baby acquiring clubfoot. Another reason for clubfoot manifestation is the less fluid in the amniotic sac (a pouch that contains and protects the baby).
What Are the Symptoms of Clubfoot?
Clubfoot is a visible deformity. The symptoms associated with clubfoot are;
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The top of the feet is twisted downward and inward.
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The Achilles tendon (a large tendon at the ankle of the foot) is too short.
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The muscles and the bones of the affected legs are shorter.
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The calf portion is thinner. The heel and the sole are smaller compared with the normal one.
Usually, the condition does not cause any pain by itself. But while the baby is walking, the pressure is applied on the edges of the foot instead of the sole, which can cause callus, infection, or ulcers. Thus, there is pain, inability to wear shoes, and difficulty in walking. In addition, the affected foot has a limited range of movement.
How Is Clubfoot Treated?
Clubfoot cannot get better on its own. They are primarily treated in two ways; non-surgical method and surgical method. The treatment of clubfoot aims to retain the normal function of the feet and restore painless walking with a flat sole. Ideally, treatment should be initiated shortly after birth.
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Non-Surgical:
Using a series of casts, gentle manipulation, stretching movements, and braces will slowly move the foot into the correct position. Non-surgical treatment is usually the combination of the Ponseti method and the French method.
Ponseti method involves casting, Achilles tendon release, and bracing.
Casting - The affected foot is slowly stretched and manipulated in a proper position, and a long cast is applied from the toe to the thigh. The cast is removed after a week, and the outcome is evaluated. Then, the process of stretching, manipulating, repositioning, and casting is done over the course of six to eight weeks until the results are satisfactory.
Achilles Tendon Release - It is also known as Achilles tenotomy. After the series of casting for eight weeks, a small Achilles tendon (heel cord) release procedure is performed. The baby may be kept under sedation, or local anesthesia can also be preferred. A small incision is placed in the area around the heel, and a very thin scalpel is used to cut and remove the tendon. The incision is closed, and the skin is covered with a small dressing. Finally, the long leg cast is applied to the corrected position and left to heal for three weeks. By this time, the clubfoot condition is fully corrected.
Bracing - After successful casting and Achilles tenotomy, the foot must be braced to prevent it from returning to the crooked position. Basically, it is a retaining method. A brace is nothing but the normal shoes or boots connected together with a bar that is bent at ten to 15 degrees. For the first three months, it is recommended to wear the brace for 23 hours a day. Later, the time can be gradually decreased (12 to 14 hours a day). The bracing regimen should be followed for at least three to four years.
The French method is another conservative, non-surgical way of treating clubfoot. It involves stretching, mobilization, and taping the foot in a corrected position. This method requires the direction of a physical therapist. Stretching and manipulation are performed every day. The taping is then stabilized using a plastic splint. This regimen is followed for the first three months, then it is thrice a week for the next four months, and the therapy is gradually weaned over a period of two to three years. Achilles tenotomy is commonly required in the french method also.
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Surgical:
Generally, surgery is preferred when conservative management does not work. However, some cases of clubfoot are so severe that they do not respond to stretches and manipulations. In such conditions, surgery is required to correct the deformity. Usually, the surgery is performed at nine to 12 months of age. The surgery may involve removing or releasing the tendons at the back of the ankle. In most extensive cases, the release of multiple soft tissue structures of the foot is done, and the joints are stabilized with pins which can be removed after four to six weeks. Then, a long leg cast is applied and left to heal for another month, and braces are used for retaining purposes.
Conclusion:
Research shows that all the children with a clubfoot have been treated successfully. A regular active lifestyle is achieved when the treatment is started early. Though the proper management of clubfoot takes several years, it is important that the parents or caregivers are adequately educated about the condition and the importance of the treatment regimen as an uncorrected clubfoot causes lifelong physical and emotional problems.
