June 3, 2020 12:52:12 pm
Globally, June 3 is observed as World Clubfoot Day, believed to have been designated by the Ponseti International Association or the PIA, in commemoration of the birthday of Dr Ignacio Ponseti (1914-2009), the developer of the Ponseti Method for treating clubfoot. And while it is celebrated, there is still little awareness about what clubfoot disability is, and how it affects children around the world.
According to Ponseti International, clubfoot is the most common “musculoskeletal birth deformity, affecting 2,00,000 newborn children each year, 80 per cent in the developing countries”. To understand it better, indianexpress.com reached out to Dr Ratnav Ratan, Paediatric Orthopaedic Specialist at the CK Birla Hospital in Gurugram, who answered some frequently asked questions. Read on.
What is clubfoot?
Clubfoot is a congenital deformity in which an infant’s foot is twisted out of shape inward, upward. It is the most common deformity of the bones and joints in newborns. It can be mild or severe and occur in one or both feet. Approximately one newborn in every 1,000 live births will have clubfoot, in which the tendons that connect the leg muscles to the foot bones are short and tight, causing the foot to twist inward.
The cause of clubfoot is not exactly known, but it is most likely multifactorial, and no single gene transmission has been identified. Risk factors include maternal and paternal smoking, lack of amniotic fluid in the womb and first pregnancy. There is another type of clubfoot which occurs in babies with genetic or neurological problems causing muscle imbalance. These are called secondary clubfoot.
What should parents know?
Clubfoot can be detected in-utero by 20 weeks of pregnancy, by ultrasound. Most are, however, detected at birth on clinical examination. A trained paediatric orthopaedic surgeon is the best specialist to treat the condition. It is a completely correctable deformity with timely intervention at birth.
Is there a reason to be alarmed?
Clubfoot is a completely correctable deformity. With timely intervention at birth with sequential plasters, the child ends up having a normal foot without any functional limitations. The key here is early casting, starting five to seven days after birth. It is successful in 95-98 per cent of kids and doesn’t require any extensive surgical correction. The condition does not resolve without treatment and will only worsen with progressing age, if left untreated. In most cases, the parents need not be alarmed if their baby is detected with clubfeet at or before birth.
What is the remedy or treatment?
Most cases of clubfoot are successfully treated with nonsurgical methods that may include a combination of initial stretching, weekly casting and finally bracing. Treatment usually begins shortly after birth within five to seven days, provided the baby is healthy and mature enough. In case of pre-term or extreme low birth weight babies, the casting is deferred and only stretching is done till the casting is safe for the baby.
The standard of care is gradual correction using weekly casting of the foot by the Ponseti technique. It is successful in 95-98 per cent of kids, and avoids any extensive surgeries, as mentioned earlier. This may be done over a span of few months, followed by prolonged usage of special boot and bar. The goal of treatment is to obtain a functional, pain-free foot that enables standing and walking with the sole of the foot flat on the ground. The younger the age at which the treatment is initiated, sooner and better the cure. Rarely do cases of complex clubfoot or those with underlying genetic disorders causing muscle imbalance, fail to respond to the Ponseti technique and may require surgical release.
Is surgery a must?
Surgery may rarely be required in cases where either the foot is stiff which predisposes it to relapse, secondary clubfoot in syndromic kids, neuromuscular disorders or in untreated clubfoot. Mostly, a tendon transfer is required after walking age in kids showing signs of a hyperactive tendon causing inward movement of the feet while walking. Other surgical options include soft tissue release, gradual correction using an external fixator, bone cutting surgeries or fusion of foot joints.
What is the Ponseti technique?
The Ponseti technique is the most widely used technique throughout the world for the treatment of clubfoot. It uses gentle stretching and casting to gradually correct the deformity. It is the gold standard for all types of clubfeet as the initial non-surgical treatment.
In the technique, the baby’s foot is gently stretched and manipulated into a corrected position and held in place with a long-leg cast (toes to thigh). Each week this process of stretching, re-positioning, and casting is repeated until the foot is largely improved. For most infants, this improvement takes about six to eight weeks. The next phase involves a minor procedure to release continued tightness in the Achilles tendon (heel cord) in 90 per cent of babies. During this procedure (called a tenotomy), we use a very thin instrument to cut the tendon. The cut is very small and does not require stitches. A new cast will be applied to the leg to protect the tendon as it heals. This usually takes about three weeks. By the time the cast is removed, the Achilles tendon has regrown to a proper, longer length, and the clubfoot has been fully corrected.
What else has to be kept in mind?
The long leg cast is changed weekly following gentle manipulation. At each session, the plaster cast is changed, and each time the foot is corrected a little more. The whole process may require four to 10 casts. Older kids, stiff foot, complex clubfoot, untreated clubfoot needs biweekly casts and more number of casts.
Once the final cast is off, the baby will need to wear special boots connected with a metal bar for three months; the boots are worn 23 hours a day. After this, they are only worn at night and during daytime naps, until the age of around four years. Parents will also need to continue doing stretching exercises with their baby. Babies might be fussy during the first few days of wearing a brace and will need time to adjust. Adhering to the prescribed usage guidelines for the special boots is extremely important; not following the guidelines correctly is the most common cause of failure of this treatment method.
The technique is absolutely safe, provided the critical steps are diligently followed by your paediatric orthopaedic doctor. Sometimes, plaster sores can happen in babies with sensitive skin or with overzealous correction in stiff foot. It is easily managed with antibiotics and by giving a cast holiday for a week or so. Non-adherence to the critical steps in Ponseti technique may lead to rocker bottom foot (midfoot break) or an iatrogenic complex clubfoot. Bleeding sometimes happens after the heel cord cutting procedure, and can be easily managed.
Can these children go on to have regular lives?
With appropriate treatment, the child should have a nearly normal foot, and he or she can run and play and wear normal shoes. The affected foot is usually 1 to 1-1/2 sizes smaller and somewhat less mobile than the normal foot. The calf muscles in the child’s clubfoot leg will also stay smaller, so your child may complain of sore legs or getting tired sooner than peers. The affected leg may also be slightly shorter than the unaffected leg, but this is rarely a significant problem.
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