Clubfoot

Clubfoot


clubfoot, or Giles Smith syndrome (TEV), is a birth defect. TEV is classified into 2 groups Postural TEV or Structural TEV. Without treatment, persons afflicted often appear to walk on their ankles, or on the sides of their feet. It is a common birth defect, occurring in about one in every 1,000 live births. Approximately 50% of cases of clubfoot are bilateral. In most cases it is an isolated dysmelia. This occurs in males more often than in females by a ratio of 2:1.
There are different causes for clubfoot depending on what classification it is given. Structural TEV is caused by: genetic factors, such as Edwards syndrome, a genetic defect with three copies of chromosome 18. Growth arrests at roughly 9 weeks and compartment syndrome of the affect limb are also causes of Structural TEV. Genetic influences increase dramatically with family history. It was previously assumed that postural TEV could be caused by external influences in the final trimester such as intrauterine compression from oligohydramnios or from amniotic band syndrome. However, this is countered by findings that TEV does not occur more frequently than usual when the intrauterine space is restricted. Breach Birth presentation is also another known cause. TEV may be associated with other birth defects such as spina bifida cystica. Use of MDMA (Ecstasy) and smoking while pregnant has been linked with this congenital abnormality.

Treatments
Clubfoot is treated with manipulation by podiatrists, physiotherapists, orthopedic surgeons, specialist nurses, or orthotists by providing braces to hold the feet in orthodox positions, serial casting, or splints called knee ankle foot orthoses (KAFO). Other orthotic options include Dennis-Brown bars with straight last boots, ankle foot orthoses and/or custom foot orthoses (CFO). In North America, manipulation is followed by serial casting, most often by the Ponseti Method. Foot manipulations usually begin within two weeks of birth. Even with successful treatment, when only one side is affected, that foot may be smaller than the other, and often that calf, as well.
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:
1. Tenotomy (needed in 80% of cases) is a release (clipping) of the Achilles tendon – minor surgery- local anesthesia
2. 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.
Of course, each case is different but the main idea is that 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 child’s foot because the scarred tissue will interfere with the normal development of the foot. A child who has extensive surgery may require on average 2 additional surgeries to correct the issues presented above.
In stretching and casting therapy the doctor changes the cast multiple times over a few weeks, gradually stretching tendons until the foot is in the correct position of external rotation. The heel cord is released (percutaneous tenotomy) and another cast is put on, which is removed after three weeks. To avoid relapse a corrective brace is worn for a gradually reducing time until it is only at night up to four years of age.

Ponseti Method
The clubfoot treatment method that is becoming the standard in the U.S. and worldwide is known as the Ponseti Method [5]. Foot manipulations differ subtly from the Kite casting method which prevailed during the late 20th century. Although described by Dr. Ignacio Ponseti in the 1950s, it did not reach a wider audience until it was re-popularized around 2000 by Dr. John Herzenberg in the USA and in Europe and Africa by NHS surgeon Steve Mannionwhile working in Africa. Parents of children with clubfeet using the Internet also helped the Ponseti gain wider attention. 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 casts over 4 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.
After correction has been achieved, maintenance of correction may require the full-time (23 hours per day) use of a splint—also known as a foot abduction brace (FAB)—on both feet, regardless or whether the TEV is on one side or both, for several weeks after treatment. Part-time use of a brace (generally at night, usually 12 hours per day) is frequently prescribed for up to 4 years. Approximately 20% of infants successfully treated with the Ponseti casting method may require a surgical tendon transfer after two years of age. While this requires a general anesthetic, it is a relatively minor surgery that corrects a persistent muscle imbalance while avoiding disturbance to the joints of the foot.
The developer of the Ponseti Method, Dr Ignacio Ponseti, at 93 years of age is still treating children with clubfeet (including complex/atypical clubfeet and failed treatment clubfeet) at the University of Iowa Hospitals and Clinics. He is assisted by Dr Jose Morcuende, president of the Ponseti International Association.
The long-term outlook for children who experienced the Ponseti Method treatment is comparable to that of non-affected children.