Finding the permanent solution for clubfoot

It is estimated that 1 in every 1000 live births is affected by clubfoot. These numbers vary amongst different countries. Clubfoot can result in lifelong disability and pain if not treated correctly and on time. In fact, if treated right after birth, this condition does not even require surgery for correction. Lack of awareness is one of the leading causes due to which this easily correctable deformity progresses to permanent disability in so many children. In this article, we will explore this condition in further detail to understand it better.   

What is clubfoot? 

Clubfoot is a congenital deformity (present at birth) of the foot. In this condition, the infant’s foot is twisted out of shape, inward and upward. It is one of the most common deformities that occurs in the bones and joints in new-born.  

This condition can be mild or severe. It can also appear either one or both of the feet. This deformity occurs when the tendons connecting the leg muscles to the foot bones are short and tight. This causes the foot to twist inward.   

What causes clubfoot?  

The exact cause of idiopathic clubfoot is still unclear. Research indicates that it is mostly due to a complex interplay of genetic and environmental factors, and not because of any single gene transmission.  

Risk factors that increase the likelihood of a baby born with clubfoot include factors such as: 

• Maternal and paternal smoking 
• Lack of amniotic fluid in the womb 
• If it is the mother’s first pregnancy 

Another form of clubfoot can be sometimes seen in babies with underlying genetic or neurological problems that cause muscle imbalance. This form of clubfoot is called a “secondary clubfoot”. 

How is clubfoot diagnosed? 

Clubfoot can be diagnosed during pregnancy itself, in the 20-week ultrasound scan. However, most cases are diagnosed at birth after a clinical examination by a paediatrician or a paediatric orthopaedic surgeon.  

Is clubfoot treatable? 

Fortunately, clubfoot is completely correctable, provided it is treated on time. Sequential plasters are used to correct this deformity and prevent any long-term effects. In fact, children with this deformity may not face any functional limitations with the right treatment.  

Starting the treatment as early as possible is key to ensuring maximum results. It is advised that the casting should start as early as 5-7 days after birth. Almost 95-98% of affected children can fully recover without any surgical correction. So, most parents need not be alarmed if they get a diagnosis of clubfoot during pregnancy or after birth.  

It is important to remember that this condition only worsens with age. So early medical intervention is essential for the child to lead a healthy and normal life.  

What is the most preferred treatment protocol for clubfoot? 

Clubfoot is generally treated with non-surgical methods. The treatment protocol is a combination of initial stretching, weekly casting and bracing.  

The treatment is started 5-7 days after birth as long as the baby is otherwise healthy. If the baby is premature or has very or extremely low birth weight, stretching is done till the time the baby is healthy enough for casting.  

This process of gradual correction of the foot using weekly casting is called the “Ponseti technique”. Depending on the severity of the condition, it can span over a few months and also require the use of a special boot and bar.  

The main aim of this treatment protocol is to achieve a functional, pain-free foot that allows standing and walking with the sole of the foot flat on the ground. Starting the treatment early ensures faster and fuller recovery.  

In rare cases, the Ponseti technique might not yield the desired results. This can happen if the condition is extremely complex or caused by underlying conditions (secondary clubfoot). Surgical correction can be used to treat such cases.  

What is the Ponseti technique? 

Named after Ignacio V. Ponseti, a physician recognised for his contribution to the field of orthopaedics, the Ponseti technique is the most widely used technique for treating clubfoot around the world.  

It uses a combination of gentle stretching and sequential casting to correct the deformity over a period of time.  

In this technique, the baby’s foot is stretched gently and manipulated into a corrected position. It is then held in place with the help of a cast (typically covering toes to thigh). This process is repeated every week till the desired results are achieved. It can take 6-8 weeks or more.  

Once the stretching and sequential casting is complete, the surgeon releases the tightness in the Achilles tendon (heel cord) with the help of a minor procedure. The next phase involves a minor procedure. This procedure is called tenotomy and involves using a very thin instrument to cut the tendon. Stitches are not required in this procedure.  

A cast is then applied to protect the tendon, usually for about 3 weeks. Once the tendon regrows to a proper length and heals, the condition (clubfoot) is considered it be completely corrected 

How many plasters are required to correct clubfoot? 

In the Ponseti technique, the cast is changed weekly after gently manipulating the foot. Every time the plaster is cast, the foot is corrected a little more. Hence, the number of casts required depends on the severity of the deformity. However, generally, 4-10 casts are used on average. This may increase if the age of the child is greater, if the deformity is more complex, or left untreated for long. In such cases, biweekly casting might be required as well.  

What comes after sequential casting in clubfoot treatment? 

Once the final casting is complete and removed, the baby will be required to wear special boots connected with a metal bar. This is called the Dennis Brown/Mitchell Ponseti splint. These boots are typically worn for 23 hours a day over a duration of 3 months. Post this, they are recommended while the baby is sleeping and at night, till they are 4 years of age.  

Parents are also required to continue performing the stretching exercises on the baby. Proper usage of the boots is essential in correcting the deformity. 

Does clubfoot ever require surgery? 

In the following cases, a surgical correction might be required to treat clubfoot: 

1. The foot is stiff causing it to relapse 
2. Secondary clubfoot in syndromic children 
3. Children with neuromuscular disorders 
4. Untreated clubfoot 

In such cases, tendon transfer is usually required if the child shows signs of the hyperactive tendon when they start walking. This causes inward movement of the feet while walking.  

Other surgical treatments for clubfoot also include soft tissue release, gradual correction with an external fixator, bone-cutting surgeries or fusion of foot joints.  

Are there any risks involved in clubfoot treatment? 

As long as the right treatment protocol is followed, there are no significant risks involved in this treatment technique. In some cases, if the baby’s skin is more sensitive or if the cast is not proper, the plaster can cause sores on the skin. These are easily treated with antibiotics and forgoing casting for about a week.  

If the Ponseti technique is not done correctly, it can result in complications such as rocker-bottom foot (midfoot break) or an iatrogenic complex clubfoot. The procedure used to cut the heel cord after the casting can also result in bleeding although, this is easily managed.  

Can children born with clubfoot lead normal lives? 

Fortunately, with the right treatment, babies born with this deformity can grow to have a nearly normal foot and be able to run, play and wear regular shoes. The affected foot might become 1 to 1.5 inches smaller than the other foot. The calf muscles might also be smaller causing the child to feel sore or tired easily. However, it rarely causes any significant problem.  

Who treats clubfoot? 

This condition is best treated by a trained paediatric orthopaedic surgeon. Attention to detail is key in avoiding long term complications and for achieving full functionality of the foot by the time the child starts walking.  

Even though the procedure is relatively simple and non-surgical, great precision is required to align the foot correctly. Choose an experienced pediatric orthopaedic surgeon who is well versed in clubfoot treatment.

If your child is diagnosed with clubfoot either during pregnancy or right after birth, the most important thing to do is start treatment right away. Follow the home care instructions such as stretching exercises for the baby provided by the doctor diligently for the best results. 

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