Club foot repair

Definition

Club foot repair, also known as foot tendon release or club foot release, is the surgical repair of a birth defect of the foot and ankle called club foot.

Purpose

Club foot or talipes equinovarus is the most common birth defect of the lower extremity, characterized by the foot turning both downward and inward. The defect can range from mild to severe and the purpose of club foot repair is to provide the child with a functional foot that looks as normal as possible and that is painless, plantigrade, and flexible. Plantigrade means that the child is able to stand with the sole of the foot on the ground, and not on his heels or the outside of his foot.

Demographics

In the United States, club foot is a common birth defect, and occurs at a rate of one to four cases per 1,000 live births among whites. Severe forms of clubfoot affect some 5,000 babies (about one in 735) born in the United States each year. Boys are affected with severe forms of clubfoot twice as often as girls. The risk increases 30-fold in individuals who have a relative of the first-degree affected by the defects.

Description

A newborn baby's club foot is first treated with applying a cast because the tendons, ligaments, and bones are quite flexible and easy to reposition. The procedure involves stretching the foot into a more normal position and using a cast to maintain the corrected position. The cast is removed every week or two, so as to stretch the foot gradually into a correct position. Serial casting goes on for approximately three months.

In 30% of cases, manipulation and casting is successful, and the foot can be placed in a brace to maintain the correction. In about 70% of cases, manipulation and castings alone do not correct the deformity completely and a decision will be made concerning surgery.

The type of surgery depends on how severe the club foot is. The deformity features tight and short tendons around the foot and ankle. Surgery consists of releasing all the tight tendons and ligaments in the posterior (back) and medial (inside) aspects of the foot and repairing them in a lengthened position. Metal pins may also be used to maintain the bones in place for some six weeks. Surgery usually involves an overnight stay in hospital. After surgery, the foot is casted for some three months, followed by the use of a brace to hold the correction. The brace is worn for approximately six to 12 months after surgery.

Diagnosis/Preparation

Presurgical diagnosis requires radiography. The evaluation usually includes only the acquisition of weight-bearing images because the stress involved is reproducible. In babies, weight-bearing is simulated by the application of dorsal flexion stress.

Some surgeons prefer to wait until the child is about one year old before performing surgery, so that the foot may grow a little larger to facilitate surgery. Other surgeons operate as early as three months of age when it becomes clear that further castings will not achieve any more correction.

Aftercare

The patient usually stays in the hospital for two days after club foot repair. The foot is casted and kept elevated, with application of ice packs to reduce swelling and pain. Painkillers may also be prescribed to relieve pain. During the 48 hours following surgery, the skin near the cast and the toes are examined carefully to ensure that blood circulation, movement, and feeling are maintained. After leaving the hospital, the cast is usually left on for about three months. Skin irritations due to the cast or infections may occur. A course of physical therapy may be indicated after removal of the cast to help keep the foot in good position and improve its flexibility and to strengthen the muscles in the repaired foot. The well-treated clubfoot is no handicap and is fully compatible with a normal, active life. Most children who have undergone club foot repair develop normally and participate fully in any athletic or recreational activity that they choose.

Risks

The risks involved in club foot repair are the general risks associated with anesthesia and surgery.

Risks associated with anesthesia

• adverse reactions to medications
• breathing problems

Risks associated with surgery

• excessive bleeding
• infections

Normal results

If club foot repair is required, the foot usually becomes quite functional after surgery. In some cases, the foot and calf may remain smaller throughout the patient's life.

Morbidity and mortality rates

If left untreated, club foot will result in an abnormal gait, and further deformity may occur on side of the foot due to preferential weight bearing.

Alternatives

The Ponseti non-surgical treatment

Dr. Ignacio Ponseti developed this method which consists of a weekly series of gentle manipulations followed by the application of casts which are placed from the toes to the upper thigh. Five to seven casts are applied every week. Before applying the last cast, which is worn for three weeks, the heel-cord is cut to finalize the correction of the foot. By the time the cast is removed the heel-cord has healed. After this two-month period of casting, a splint is worn full-time by the patient for a few months and is then worn only at night for two to four years. Special shoes also maintain the foot in the corrected position.

The French treatment

This method consists of daily physical therapy, featuring gentle and painless stretching of the foot. The foot is then taped to maintain the corrected position until just the next day's visit. At night, the taped foot is inserted into a continuous passive motion machine at home to maximize the amount of stretching. The tape is removed for a few hours each day to wash the foot, air the skin, and to perform exercises. Removable splints are also used to support the taped foot. The one-hour physical therapy sessions are conducted five days each week for approximately three months. Taping is stopped when the child starts walking.

Resources

BOOKS

Lehman, W. B. The Clubfoot. Philadelphia: Lippincott, Williams and Wilikins, 1980.

Ponseti, I. V. Congenital Clubfoot. Fundamentals of Treatment. Oxford: Oxford University Press, 1996.

Simons, G. W. The Clubfoot: The Present and a View of the Future New York: Springer Verlag, 1994.

PERIODICALS

Aronson, J. and C. L. Puskarich. "Deformity and Disability from Treated Clubfoot." Journal of Pediatrics and Orthopedics 10 (1990): 109–112.

Cooper, D. M. and F. R. Dietz. "Treatment of Idiopathic Clubfoot. A Thirty Year Follow-up." Journal of Bone and Joint Surgery 77A (1995): 1477–1479.

Herzenberg, J. E., C. Radler, and N. Bor. "Ponseti Versus Traditional Methods of Casting for Idiopathic Clubfoot." Journal of Pediatrics and Orthopedics 22 (July-August 2002): 517–521.

Ideka, K. "Conservative Treatment of Idiopathic Clubfoot." Journal of Pediatrics and Orthopedics 12 (March-April 1992): 217–223.

ORGANIZATIONS

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. (847) 434-4000. http://www.aap.org .

Shrine and Shriner's Hospitals. 2900 Rocky Point Dr., Tampa, FL 33607-1460. (813) 281-0300. http://www.shrinershq.org/index.html

OTHER

American Academy of Pediatrics. "Club Foot." Essentials of Musculoskeletal Care [cited April 2003]. http://www.aap.org/pubserv/essenexp.htm .

The Club Foot Club [cited April 2003]. http://home.ica.net/~maudefamily .

"Help for Patients with Club Foot." Shrine and Shriners Hospitals. March 28, 2003 [cited April 2003]. http://www.shrinershq.org/patientedu/clubfoot2.html .

"List of Physicians Qualified in the Ponseti Method." Virtual Children's Hospital [cited April 2003]. <http://www.vh.org/pediatric/patient/orthopaedics/clubfeet/physic ans.html> .

"Patient Guide to Club Foot." John Hopkins Department of Orthopedic Surgery [cited April 2003]. <http://www.hopkins medicine.org/orthopedicsurgery/peds/clubfoot_new.htm> .

Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Club foot repair is performed in a hospital. Club foot surgery is difficult and requires meticulous attention to details. It is accordingly performed by experienced pediatric orthopedic surgeons who are specialists in the field.

QUESTIONS TO ASK THE DOCTOR

• Is there any treatment needed to prevent the club foot from coming back after surgery?
• What are the chances that my child's club foot will get corrected?
• How long will it take to recover from the surgery?
• What procedures do you follow?
• How much club foot surgery do you perform each year?