Management of Club foot

Dr. Zammer Ali
Don’t worry if your child is born with deformed foot or club foot
A club foot, also called congenital talipes equinovarus (CTEV), is a congenital deformity  involving one foot or both. The affected foot looks like it has been rotated internally at the ankle. Approximately half of people with clubfoot have either single foot or both feet involved, which is called bilateral club foot. It occurs in males twice as frequently as in females. Prevalence of club foot is about in about one in every 1,000 live births
Without treatment, people with club feet often appear to walk on their ankle or on the sides of their feet.
Over the years approaches to the management of clubfoot have changed and evolved. Numerous surgical, conservative and mixed treatment techniques have been utilized with varying levels of success. In the past decade the Ponseti method has become widely recognized as the gold standard for clubfoot treatment.. There are different causes for clubfoot depending on what classification it is given.
Structural cTEV is caused by  genetic factors. Genetic influences increase dramatically with family history.
It was previously assumed that postural CTEV could be caused by external influences in the final trimester of pregnancy such as intrauterine compression from  olighydramnios  It may be associated with other birth defects, such as spina bifida (defect in spine).
Treatment for clubfoot should begin almost immediately after birth to have the best chance for a successful outcome without the need for surgery. Over the past 10 to 15 years, more and more success has been achieved in correcting clubfeet without the need for surgery. The clubfoot treatment method that is becoming the standard in the U.S. and worldwide is known as the  ponseti  method.
Clubfoot is treated initially with manipulation by orthopaedic surgeons by serial casting and then providing braces to hold the feet in a plantigrade position. After serial casting, bracing using a Denis Browne bar with straight last boots, ankle foot orthoses and/or custom foot orthoses (CFO) may be used. Foot manipulations usually begin within two weeks of birth.
The Ponseti method, if correctly done, is successful  in  95% of cases  in correcting clubfeet using non- or minimal-surgical techniques. Typical clubfoot cases usually require 5- 6 casts over 4-5 weeks. Atypical clubfeet and complex clubfeet may require a larger number of casts. Approximately 80% of infants require an Achilles tenotomy (microscopic incision in the tendon requiring only local anesthetic and no stitches) performed in a clinic toward the end of the serial casting. To avoid relapse of deformity  a corrective brace is worn for a gradually reducing time until it is only at night up to four years of age.
Botox is also being used as an alternative to surgery. Botox is the trade name for Botulinum Toxin type A. a chemical that acts on the nerves that control the muscle. It causes some paralysis (weakening) of the muscle by preventing muscle contractions (tightening). As part of the treatment for clubfoot, Botox is injected into the child’s calf muscle. In about 1 week the Botox weakens the Achilles tendon. This allows the foot to be turned into a normal position, over a period of 4-6 weeks, without surgery.
The weakness from a Botox injection usually lasts from 3-6 months. (Unlike surgery it has no lasting effect). Most club feet can be corrected with just one Botox injection. It is possible to do another if it is needed. There is no scar or lasting damage.
Extensive surgery of the soft tissue or bone is not usually necessary to treat clubfoot; however, there are two minimal surgeries that may be required:
Tenotomy  (needed in 80% of cases) is a release (clipping) of the  Achilles tendon – minor surgery -done under local anaesthesia
Anterior Tibial Tendon Transfer (needed in 20% of cases) – where the tendon is moved from the first ray (toe) to the third ray in order to release the inward traction on the foot.
Each case of club foot  is different, but in most cases extensive surgery is not needed to treat clubfoot. Extensive surgery may lead to scar tissue developing inside the child’s foot. The scarring may result in functional, growth and aesthetic problems in the foot because the scarred tissue will interfere with the normal development of the appendage. A child who has extensive surgery may require on average two additional surgeries to correct the issues presented above.
(The author is Registrar orthopaedics SKIMS medical college.)

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