Clubfoot

CLUB FOOT

Clubfoot, medically known as Congenital Talipes Equino Varus (CTEV), is one of the most common congenital anomaly with an incidence of 1 in every 1000 live births. Over the centuries it has been treated by various modalities and has also been described by Hippocrates in 400 BC. Though it has been known since ages, there has been no definite management as it keeps showing tendencies of relapse

NOMENCLATURE

Equinus:

 There is plantar flexion of foot. Derived from equine i.e. horse, which walks on toes.

Calcaneus:

Reverse of Equinus, where the foot is in dorsiflexion

Varus:

The foot is inverted and adducted so that the sole of the foot faces ‘inwards’.

Valgus:

The foot is everted and abducted so that the sole faces ‘outwards’

Usually the foot has a combination of deformities, commonest being Equino-Varus which would be considered as the reference henceforth.

Causes:

A.    Congenital:

1.      Idiopathic i.e. cause is unknown

2.    Non-Idiopathic:

-Genetic Syndromes

-Myopathies like Arthrogryposis multiplex congenita    where there is defective development of muscles

-Neurological Disorders like Spina Bifida

B.    Acquired:

    Neurogenic causes like, meningitis, poliomyelitis, etc 

    Vascular causes like Volkmann’s Ischaemic Paralysis.
Clubfoot is usually detected very early during infancy, though in developing countries, the patient may present late due to various social and economic causes

In 60% cases, there is bilateralism

Secondary changes: These changes occur if the child starts walking on the deformed foot. Weight bearing exaggerates the deformity resulting in the development of callosities and bursae over the lateral side of the foot.

Examination:

1.      The affected foot is smaller in size

2.    Inability to touch the dorsum of the foot to the shin of leg, i.e. inability to bring the foot in the opposite direction which is seen in normal cases

3.    The heel is small in size

4.    Deep skin creases on the back of the heel and on the medial side of the sole.

5.    X-Ray/Radiography

Antenatal Diagnosis

By Ultrasonography (USG), clubfoot can be diagnosed at 18-20 weeks of gestation. But this is only 80% accurate. Clubfoot is also associated with genetic anomalies like congenital heart defects Trisomy18, Larsen’s syndrome, and neural tube defects.
Treatment

In principle, the treatment of clubfoot consists of correction of the deformity by non-operative and operative means, followed by maintenance of the foot in the corrected position. This is to be continued till the foot (and the bones) grows to a reasonable size so that the deformity doesn’t occur.

The treatment should be started as early as possible.

Non-Operative treatment

Hippocrates in 400 BC proposed the first non-operative treatment where he recommended gentle manipulation followed by splinting. 
With the advent of plaster of Paris in 1836, plaster casts were used to treat clubfoot.

Kite   was the first to recommend gentle manipulation and cast immobilization.

There are many techniques to treat Clubfoot; hence the International Clubfoot Study Group has approved Ponseti’s technique, Kite’s technique and Bensahel’s technique as the standardized conservative regimes for the treatment of clubfoot all over the world.
Of these, Ponseti’s method is high successful where the doctor corrects the deformity and applies a plaster cast which is changed every 2 weeks and continued till it is possible to ‘overcorrect’ all the deformities, usually after 6-8 casts. Once this happens, the foot is kept in a suitable maintenance device (discussed subsequently).

One more method is to teach the mother to manipulate the foot after every feed. Minor deformities can be corrected by this method. (Kite’s technique)

Operative Treatment

The list of operative procedures is endless as no single procedure gives a long-lasting correction. Phelps, in 1891 described the first operative procedure.

The optimal age for surgical intervention has always been controversial, with experts settling in the range of 5-6 months to upto 1 year of age. The details of surgery are beyond the context of this post and the reader is advised to refer to specific sites/books.

Maintenance of correction

-         CTEV Splint: made of plastic, hold the foot in overcorrected position

-         Dennis-Brown Splint/ DB Splint: Holds the foot in corrected position. To be worn by the child throughout the day till he starts walking. Once the child starts walking the splint is to be worn during the night and CTEV shoes during the day.

     – CTEV Shoes: These are modified shoes used once the child   starts walking until 5 years of age
Summary

Clubfoot is an enigmatic condition because it can make the best orthopedic surgeons eat humble pie. Clubfoot shows a strong tendency of relapse upto 4 years of age. The incidence is seen to decline after 4 years. One of the main causes of this relapse is patient non-compliance. Though there are many treatment modalities, Ponseti’s Technique holds lot of promise. Clubfoot is definitely curable.
 



Leave a Reply