Clubfoot

What is clubfoot?

Clubfoot is a congenital deformity of the foot that occurs once per 1000 live births in the U.S. The foot has a typical appearance of pointing downwards and twisted inwards. Since the condition starts in the first trimester of pregnancy, the deformity is quite established at birth, and is often very rigid.

What causes clubfoot?

No one really knows what causes the deformity. It tends to be more common in boys, although girls are not exempt. There may be a positive family history. In rare instances a child born with myelomeningocele (spina bifida) or arthrogryposis may also have clubfeet. Beyond these observations, no actual cause is known. If your child has clubfoot, it is usually not due to anything you did or did not do during pregnancy.

During development, the posterior and medial tendons and ligaments (in the back and inside) of the foot fail to keep pace with the development of the rest of the foot. As a result, these tendons and ligaments tether the posterior and medial parts of the foot down, causing the foot to point downwards and the twist inwards. The bones of the feet are therefore held in that abnormal position. Over time, if uncorrected, the bones will become mis-shapened.

What are the symptoms of clubfoot?

Clubfoot does not cause pain in the infant. Because it is so obvious, it is usually discovered at birth. If left untreated, the deformity does not go away. It gets worse over time, with secondary bony changes developing over years. An uncorrected clubfoot in the older child or adult is very unsightly, and worse, very crippling. The patient walks on the outside of his foot which is not meant for weight-bearing. The skin breaks down, and develops chronic ulceration and infection.

What does your doctor do about it?

The Ponseti Method of Clubfoot Correction

Ignacio V. Ponseti developed a comprehensive technique for treating congenital clubfoot in the 1940s. He believed that the tissues of a newborn’s foot, including tendons, ligaments, joint capsules, and certain bones, will yield to gentle manipulation and casting of the feet at weekly intervals. By applying this technique to clubfeet within the first few weeks of life, most clubfeet can be successfully corrected without the need for major reconstructive surgery.

The technique evolved from Ponseti’s experiences with the wide variety of treatments being applied at that time and his observations in the clinic and operating room, as well as his anatomic dissections and analysis by using a movie camera to produce radiographic images. Utilizing these principles and his understanding of clubfoot anatomy, Dr. Ponseti began employing this technique in 1948 at the University of Iowa. Recently, his observations have been confirmed using modern techniques, including Magnetic Resonance Imaging (MRI).

The Ponseti technique has become the most widely practiced method for initial treatment of infants born with clubfeet. It is an easy technique to learn and, when applied accurately, it yields excellent results.

The Technique

  • The Correction Phase

Treatment should begin early, optimally within the first few weeks of life. Gentle manipulation and casting is performed on a weekly basis. Each cast holds the foot in the corrected position, allowing it to gradually re-shape. Generally 5 to 6 casts are required to fully correct the alignment of the foot and ankle. At the time of the final cast, the majority of infants (70% or higher) will require a quick, in office, percutaneous procedure (with a small incision through the skin) to gain adequate lengthening of their Achilles tendon.

  • The Maintenance Phase

The final cast remains in place for three weeks, after which the infant’s foot is placed into a removable orthotic device. The orthosis is worn 23 hours per day for three months and then during the night-time till age 4. Failure to use the orthosis correctly may result in recurrence of the clubfoot deformity. Good results have been demonstrated at multiple centers, and long-term results indicate that foot function is comparable with that of normal feet.

Manipulation and Casting                         

First Cast: The forefoot is aligned with the hindfoot.  This reduces the high arch(cavus) and realigns the talus bone with the bones of the midfoot.  This really sets up the whole foot for the remainder of the correction and is the key that Dr. Ponseti discovered.  This first cast makes the foot look more deformed,but not to worry, as the foot will come around in the next few casts.

Second Cast: One week later, the first cast is removed and, after a short period of manipulation a long leg cast is applied.  The correction is downwards and out.  This further straightens the foot, realigning the midfoot bones and stretching tendons.  

Another crucial point in the Ponseti technique which is radically different than other techniques, is that the heel is never directly manipulated. The gradual correction of the hindfoot and midfoot are such that the heel will naturally move into a correct position.

Further Casting: Manipulation and casting is continued on a weekly basis for the next two to three weeks in order to gradually straighten the forefoot, allowing the forefoot to move in line with the heel.  After four or five casts have been applied, normal position of the foot will begin to be observed.

The Achilles tendon: The Achilles tendon is the cord behind the ankle that allows the ankle to move up and down. In children with clubfoot this tendon is shortened, preventing the ankle from bending up properly. In the majority of these children the tendon must be lengthened in order to allow sufficient ankle motion. In the Ponseti technique, this is accomplished with a percutaneous surgical release of the tendon which allows the ankle to be positioned at a right angle with the leg. This percutaneous release is a quick procedure that is typically performed in the office under a local anaesthetic.

 at 18 months of age, the foot remains corrected

Maintenance and Recurrence Prevention

Upon removal of the final cast, the infant is placed into an orthosis or brace which maintains the foot in its corrected position. The purpose of this splinting, after the casting phase in the Ponseti method, is to maintain the foot in the proper position, with the forefeet set apart and pointed upward. This is accomplished with a brace consisting of shoes mounted to a bar.

The brace is worn 23 hours per day for the first 3 months following casting and then while sleeping for several years to follow, usually until around age three or four. Two recent studies have demonstrated the high risk for recurrence if the brace is not worn according to these guidelines. The reasons for recurrence in feet that appear to be fully corrected have not yet been clearly proven, but regardless of the cause, recurrence appears to be close to zero when the bracing regimen is followed accurately.

Management of Recurrence

Recurrences are rare if the technique and aftercare is followed properly.  When they do occur repeat casting can be attempted.  Frequently, the Achilles tendon needs to be lengthened, especially if it has not been done the first time around.  Other times, the recurrence includes inversion or supination of the forefoot.  This type of recurrence would require a surgical transfer of the anterior tibialis tendon to maintain correction.


 

What can be expected after treatment?

Up to the age of one year, there is a 25% chance of recurrence after surgical correction. Close follow-up is therefore needed. By age one, if the foot stays well corrected, standing and walking lessens the chance of recurrence, and the foot usually stays corrected.

The objective of clubfoot treatment is to obtain a plantigrade and flexible foot. “Plantigrade” means the child stands with the sole of the foot on the ground, not on his heels or the outside of his foot. “Flexible” means one can move the foot around freely without pain.

When recurrence occurs, further surgery is needed. In the younger child, soft tissue releases and lengthenings may suffice. In the older child, because of bone changes, surgery involving osteotomy (cutting the bone) is usually needed.

Clubfoot surgery is difficult, and requires meticulous attention to details. Even in the best of hands, failures and recurrences can occur. It is therefore important that the surgery be done by a surgeon experienced in working with children’s feet.