What causes clubfoot?
Clubfoot is the commonest musculoskeletal pathology diagnosed in babies and children.
It is a developmental disorder that affects the normally developing foot. These changes tend to occur in the 2nd trimester of pregnancy.
Clubfoot occurs as a result of imbalances of several muscles in the leg that pull foot the foot into an improper position. These impaired muscles are smaller and shorter than they should be, and there is a direct correlation between smaller calf muscles and increased severity of clubfoot.
A newborn with bilateral (both feet) clubfoot.
Who gets clubfoot?
Clubfoot sometimes runs in families and certain communities. If one parent is affected, the risk is as low as 3 – 4%. Where both parents are affected, the risk rises to 30%.
However, 80% of the time, clubfoot is an isolated diagnosis with no obvious cause. This is called idiopathic clubfoot.
Boys are affected more often than girls, and babies of moms who smoke during pregnancy seem more likely to be affected.
Half the time, both feet are affected.
A small number of babies/children may suffer from nerve diseases or medical syndromes and present with clubfoot. In these individuals, clubfoot is only one of the several conditions that may need treatment.
A baby undergoing Ponseti casting for her right clubfoot.
What exactly causes the appearance of clubfoot?
The ligaments connecting the bones in the back and inside of the foot are excessively thick and tight.
The bones in the front part of the foot are turned in and flexed toward the midline by the tight muscles, ligaments and tendons. This, in turn, malpositions their joints.
Clubfoot presents clinically as a high arched sole, a ‘C’-shaped foot, with the heel pulled upward into a more vertical and in-turned position.
The ligaments, tendons and muscles also have an increased amount of collagen. This collagen content remains high until the child is about four years old. For this reason, previously treated clubfoot often recurs in approximately 70% of children by that age.
An older boy walking with relapsed bilateral clubfoot.
What is the current standard of treatment for clubfoot?
Clubfoot does not resolve on its own without treatment. Babies and children with clubfoot must receive care to avoid long-term disability and loss of function.
Dr Ignacio Ponseti, an American orthopaedist, introduced his casting technique in the late 1940’s. It proved successful, spread globally, and is now the most widespread method used to treat clubfoot worldwide.
Ponseti Casting is a gentle, gradual manipulation of the leg, ankle and foot to correct the deformities caused by clubfoot. These manipulations are done weekly, and the improved position is held in a Plaster of Paris (POP) cast.
The Ponseti technique works because, although the collagen content is increased in volume in clubfoot, it remains stretchable. Due to their young age, babies and childrens’ bones and joints also respond well, resulting in improved alignment.
The Ponseti technique is particularly successful because it reduces long-term complications, helps avoid aggressive and invasive surgery and reduces the rate of recurrence.
The end goal of treatment is to achieve a supple foot that has turned away from the midline, that is painfree and strong.
An adult with untreated clubfoot.
Tell me more about the treatment?
Therapy is divided into two phases: the Treatment Phase and the Maintenance Phase.
During the Treatment Phase, weekly POP casts are applied to the affected extremity, over approximately six weeks. This results in gradual stretching and progressive correction of the deformities.
Once maximum correction has been achieved, the heel cord (achilles tendon/tendo achilles) is sometimes cut in a minor surgical procedure called a ‘tendo achilles tenotomy’. This is often done as an outpatient under local anaesthetic, and a cast is applied thereafter for three weeks. [Take note that a tenotomy may be done more than once should the heel cord become tight again over time.]
It is important to ensure that maximum correction has been attained to ensure that your little one will not struggle fitting the foot abduction brace (FAB) during the next phase of treatment.
The Maintenance Phase follows on after Treatment Phase casting is complete.
This stage of therapy consists of the daily use of a FAB. The FAB is a pair of boots connected to each another by a rigid metal bar. These boots prevent in-turning of the forefoot (by keeping the foot apart and out turned by 70° from the midline). FABs also prevent re-tightening of the heel cord by keeping the toes pointing slightly upward.
These boots must be worn correctly in order to be effective in preventing the return of the deformities seen in clubfoot. A FAB must be sized and fitted by an orthotist, and is worn daily up to the age of 4 years.
Dr Maina holding a used pair of Mitchell Ponsetti FAB boots donated by a patient.
A pair of Markell FAB boots. (Image kindly provided by Jan-Hendrik van Niekerk, Orthotist.)
Steenbeek FAB boots are cost effective and readily produced globally. While there are many variations on this design, FAB boots are used during the Maintenance Phase of treatment. Regardless of their design FABs share common, important design elements highlighted in the images below:
Front view of FAB boots: FAB boots keep the feet apart (shoulder width), and prevent tightening of the heel cord by keeping the toes pointed slightly upwards (by about 20°).
Rear view of FAB boots: the hole in the heel of the FAB boot is so you can check that there is never a gap between your baby's heel and the insole. Bootstraps/laces/buckles must be adequately adjusted to keep the foot snugly in the boot. A visible gap may imply recurrence of clubfoot and needs medical attention.
Bottom view of FAB boots:The affected foot is turned away from the midline by about 70°. This FAB has been adjusted to treat the baby's right foot in a baby with unilateral (one-sided) clubfoot.
Initially, at completion of the Treatment Phase, FAB boots are worn for 23 hours per day for 3 - 6 months.
This is then followed by wearing the FABs for approximately 16 hours per day (2 - 4 hrs during their daytime nap, 12hrs in the evenings). This is continued for six months further until your baby becomes more mobile and ambulant.
An older child will require a FAB on for between 12-14 hours per day (night time) until they reach the age of 4 or more.
You will be shown how to apply the shoes and how to check for correct fitting on your baby.
Repeat follow ups with Dr Maina during this time (3 - 6 monthly) are essential to keep track of the treatment. The orthotist will also be required to resize/adjust the FAB boots as baby gets bigger.
What kind of future can I expect for my child who has been diagnosed with clubfoot?
Long-term studies have shown good functional outcomes in both children and adults with treated clubfoot.
In people with one foot affected, the treated foot may be slightly shorter and narrower than the unaffected foot. The size of calf muscles on the affected side are also smaller.
While one’s function in adulthood is comparable to that of the unaffected individual, x-rays will still demonstrate evidence of previous pathology.
Often the biggest issues encountered in adulthood are neglected (untreated) clubfoot, osteoarthritic changes (degenerative arthritis typically presenting in one’s 40s and 50s) or overcorrection of clubfoot (associated with aggressive surgical interventions).
The end goal of treatment is to achieve a supple foot that has turned away from the midline, that is painfree and strong.
What can I expect during casting?
Ponseti casts are made of POP and should be removed on the morning of the recasting. This takes approximately an hour or more. In a warm bath, after soaking the cast, removal (by unravelling the loose end of the cast) can be done at home.
At each appointment, Dr Maina will assess your baby’s skin. Casting is rarely abandoned unless your child suffers from broken or damaged skin or sores.
Application of a cast takes approximately 30 to 45 minutes. The cast must be let to cure (harden) over the next day or so while resting on a soft, padded surface.
At no point in the following week should the cast get wet. Should there by any foul smells or redness of skin on the edges of the cast, it may need to be removed.
After casting, your baby’s toes must remain pink. Should the toes remain pale even after applying padding under the knee, you must contact Dr Maina as soon as possible.
Should your baby’s toes ‘disappear’ into the cast, or should the cast break, get loose or get soiled, it may need to be soaked off and reapplied. Please contact Dr Maina’s rooms in the event any untoward events should occur during the week after your new cast has been applied.
An older sister comforting a newborn who has had a cast applied to correct her clubfoot, during the Treatment Phase.
What happens if the clubfoot is resistant to treatment or recurs?
Regardless of your child's age, Ponseti casting is reinitiated for several casts until the deformity is corrected. This is then followed by bracing again.
The commonest reason for recurrence of clubfoot is failure of the maintenance phase.
It is important to maintain consistency when bracing so that your baby/child accepts bracing as part of their daily routine and the risk of recurrence is decreased. Removing the cast or brace when they cry teaches them a problematic pattern of behaviour that is difficult to correct.
Assessing a baby who is undergoing correction of clubfoot.
In others, extensive surgery may be required. This may include soft tissue releases, tendon transfers, osteotomies (breaking and realigning bones), bone resection, Ilizarov frame correction and/or joint fusions (at an older age) to correct malalignment.
Should you have any further queries, kindly contact Dr Maina’s rooms to schedule an appointment.
Dr Anne Maina
Specialist Orthopaedic surgeon
MBBCh (Wits), FC Orth (SA), MMed Ortho (Wits) CIME
Some useful online resources for Parents:
References:
1. John S Blanco, MD; Emily R Dodwell, MD MPH, FRCSC; Shevaun Mackie Doyle, MD; David M Scher, MD. The Ponseti Method for Clubfoot Correction: An Overview for Parents. Accessed 21 Jan 2022. https://www.hss.edu/conditions_the-ponseti-method-for-clubfoot-correction.asp
2. Lynn Staheli, MD. Clubfoot: Ponseti Management. Third Edition. Accessed 25 Jan 2022. https://steps.org.za/wp-content/uploads/2018/04/Clubfoot-Ponseti-Management-Red-Book-V3.pdf