Clubfoot

Clubfoot is defined as a congenital foot deformity characterized by a kidney shaped foot that turns inward and points down. The forefoot is curved inward, the heel is bent inward, and the ankle is fixed in planter flexion with the toes pointing down. Shortened tendons on the inside of the lower leg, together with abnormally shaped bones that restrict movement outwards cause the foot to turn inwards. A tightened Achilles tendon causes the foot to point downwards. The medical term for clubfoot is talipes equinovarus. It is the most common congenital disorder of the lower extremity. There are several variations, but talipes equinovarus being the most common. Clubfeet occurs in approximately 1 in every 800-1000 babies, being twice as common in boys as girls. One or both feet may be affected. Clubfoot is most common in children who suffer from spina bifida who have an L4 or L5 motor level. Many orthopedic surgeons instead of serial casting suggest early taping and gentle manipulation followed by an application of a well-padded splint. The reason for this is because serial casting can cause skin irritations and breakdown. Another technique manipulation and casting is a treatment that begins shortly after birth. It involves slowly stretching out the tightened muscles and holding the foot in an improved position with a cast. The casts are made of plaster and extend from the toes to either just above the knee, or just below it. Adduction of the foot is usually corrected first, followed by inversion of the hindfoot, and lastly the plantar flexion. The casts are changed frequently, each time repositioning the foot a little closer to normal. For the first two-three weeks, the casts are changed every second to fourth day. Cast changes are then decreased to once every one-two weeks. This treatment continues until the child is three to six months old. This method of treatment is distressing to the infant for only a short period of time. For this reason parents will be taught cast care before leaving the clinic. If the foot is too stiff to allow for adequate correction, then the tight or shortened tendons may need to be lengthened or released. The type of surgery varies according to how much soft tissue is released. During a surgical correction of a mild case of clubfoot, the surgeon must decide which joints require no, minimal, or moderate incision. In mild clubfoot, the mid and posterior subtalar joints requires minimal or no incision. All medial tendons are lengthened, the anterior and midtarsal joints are released, and the heel chord is lengthened. In treating a moderate case of clubfoot, the surgeon releases the anterior subtalar joint, and all medial tendons are lengthened. Lastly when treating the severe clubfoot, all deformities are attempted to be corrected Once an acceptable correction has been achieved by casting it will need to be maintained with a splint. The most common type of splint is the Dennis Brown boot and bar. Initially the splint must be worn twenty four hours a day. As the child learns to walk, the time in the splint is gradually reduced to nighttime use only. This could continue until the child is four or five years old. Physical therapy is also used to treat a child with clubfoot. It includes stretching, splinting, taping, monitoring casts, and teaching the parents how to help and motivate the child to do everyday life activities. To maintain correction, the child should be followed by the orthopedic surgeon until the bones, in the foot have stopped growing. This is necessary because the growing foot may slowly loose correction. If this happens, surgery on the tendons or abnormal bones may be needed with repeat casting. Most children who have been treated for clubfeet develop normally, and participate in any athletic or recreational activity they choose.