What is clubfoot?
Clubfoot (also spelt club foot) or talipes equinovarus, is a treatable deformity of the foot and ankle that is present at birth (i.e. it’s congenital). In a baby born with club foot, the foot is twisted inward and down with deep inner and heel creases, and the soles of the feet face backwards. The condition occurs during development in the womb. Physicians have observed that fetuses that develop clubfoot start with a normal foot and then the foot begins to turn inward around the third month.
Most children born with clubfoot are not missing any bones, muscles, or connective tissue. It is a congenital condition, meaning that when it occurs it is always present at birth. It is one of the most common congenital deformities. One or both feet may be affected and the affected feet can range from relatively flexible to stiff and rigid. The condition is not painful for the new born, though when a child gets to walking age, walking with an uncorrected clubfoot can be very painful and difficult, if not impossible.
Researchers do not know exactly what causes clubfoot. There is evidence of a genetic link - if either of the parents were born with clubfoot, their children are more likely to have it - but no other causes have been confirmed.
If you have one child with club foot then your risk of having a second child affected is one in 35. Boys are twice as likely to be affected as girls and around half of the children born with club foot will have both feet affected.
80% of the 200,000 children born each year with clubfoot around the world are born in low and middle income countries. Many will never receive treatment and face the rest of their lives with a severe disability which causes pain, difficulty in walking and exclusion from society.
Sad fate of clubfeet sufferers in poorer nations
Main form of treatment: Ponseti Method
If clubfoot is treated early, the position and function of the foot can be greatly improved. One of the most effective, inexpensive, and permanent treatment alternative for young children is the Ponseti method, the main treatment for club foot.
What is it?
The Ponseti Method was developed over 50 years ago by Dr. Ignacio Ponseti at the University of Iowa in USA. He devised the technique after observing poor outcomes of clubfoot surgery and extensive study of the anatomy of the foot and ankle.
The method involves weekly sessions with a specialist or trained healthcare professional who will gently manipulate one or both of the afflicted feet into closer-to-normal foot position and put in a cast from the toes to thigh to hold the foot in its new position. The gentle manipulation involves gradually stretching out the ligaments and reshaping the bones of the foot, until the foot is in a normal position.
The casts will be changed weekly at each session and the feet will be altered a little more each time. On average, 5 or 6 casts are usually used, but you may need to have a few more or a few less, depending on the severity of the condition.
Since the feet is manipulated gently it shouldn’t hurt. However, babies will often cry during manipulation and casting although it is not usually due to pain.
- Ignacio Ponseti (3 Jun 1914 – 18 Oct 2009) Spanish physician, specialising in orthopedics.
Achilles tendon surgery
Following the series of casts, your specialist will decide whether your baby needs to have a small operation to release the tight tendon at the back of their heel (the Achilles tendon). This is a very minor operation called 'Achilles tendon tenotomy' that most babies with club foot will need to have. This allows the foot a more normal range of movement. The tendon takes 2-3 weeks to heal in a plaster.
Achilles tendon surgery is often recommended after the front of the foot has been manipulated (usually after the fourth or fifth cast) but when the ankle cannot be fully altered.
The procedure is usually carried out under a local anaesthetic on an outpatient basis, which means that your baby will not have to stay in hospital over night. In some cases, a general anaesthetic may be used so that your baby will be unconscious during the operation.
During the procedure, the surgeon will make a small cut in your baby’s heelcord to release their foot into a more natural position. Your baby’s foot and leg will be put in a plaster cast for about 3 weeks.
A small number of children will require further surgery when they are between 2-7 years of age. This may involve moving a tendon in front of the ankle to a different position to improve the foot’s function.
The Ponseti Method is most successful while the child is still young and the tissues are soft and pliable. Therefore treatment should ideally start within a week or two of the baby being born, but can still be effective if started much later.
Bracing via special boots
When the final cast is removed the child is fitted with foot abduction braces, special boots attached to a bar. Bracing is critical to the success of treatment as it holds their feet in the most effective position. The boots have straps to attach them firmly to your child’s feet and the bar will keep their feet about shoulder distance apart. The children wear a brace for 1 or 3 months full time after the casting is completed. They then wear the brace at night time for 2-3 years. During the day, the child can wear normal footwear and should start to walk and run at the same time as any other child.
It is very important that your child wears the boots for the required amount of time otherwise their foot may return to how it was previously and treatment may have to begin again.
The children return for regular check ups and new braces are fitted as their feet grow. Regular reviews also ensure that if they suffer a relapse further treatment are provided where applicable.
The Ponseti Method is successful in treating more than 8 out of 10 (i.e. over 80%) cases of club foot. Long-term results are also very promising compared to previous surgical treatment methods. It’s the most cost effective treatment with no side effects.
Although the Ponseti method can be a time-consuming process to go through, it is not painful and in around 95% of cases it is an effective method of treating babies with club foot. It is important to stick to the treatment, particularly the use of the boots and bar, to prevent club foot re-occurring.
Evidence shows that effective treatment with the Ponseti method can ensure a child with clubfoot will have pain-free, normal looking feet that function well.
...However, there are a small number of children with clubfoot that cannot be fully treated with the Ponseti Method. This can be due to other underlying conditions which make treatment more challenging. Some children will require further surgery which have a less successful outcome.
The Ponseti technique was slow to catch on at first and has only been accepted widely within the last decade. However, in recent years studies have shown that when applied correctly, the Ponseti technique can achieve correction of the clubfoot deformity in up to 98% of cases. A long term follow up study 30 years after treatment found very favourable treatment results, with ‘excellent or good’ foot function demonstrated in 78% of individuals with clubfoot compared with 85% of matched individuals without congenital foot deformities. These outcomes have led to the current situation in most high-income countries and many LMIC where the Ponseti method is the treatment of choice for clubfoot by most orthopaedic surgeons.
Global Clubfoot Initiative
Sometimes, club foot can reoccur. This is known as a relapse and it is estimated to occur in one or two out of every 10 cases. Relapses are more likely if the treatment method described above is not followed exactly.
If club foot reoccurs, it may be necessary for some of the treatment stages to be repeated - for example, your child may need to have their foot manipulated again and put in a cast.
In some cases, ensuring that your child continues to wear the boots and bar may be enough to improve their club foot significantly. However, in other cases where there has been a relapse, surgery may be required.
Can adults be treated using Ponseti Method?
At present, older children and adults cannot be treated by the Ponseti Method. They'll require corrective orthopedic (bone) surgery to avoid life-long disability. Treatments of clubfoot should start soon after birth.
Left untreated a club foot becomes known as a "neglected club foot". Surgery is necessary. The cost of surgery means many thousands of club feet remain untreated.
It is very important to locate and treat the children with clubfeet before they become "neglected".
Walk for Life (Bangladesh)
Clubfoot problem in Bangladesh
Clubfoot is a serious problem in many developing countries. Approximately 80% of cases of clubfoot occur in these countries.
Every year in Bangladesh an estimated 5,000-6,000 children are born with clubfoot deformity. That’s approximately 1 of every 1,000 children born in the country. Left untreated, the condition leads to lifelong deformity causing individual disability and potential unproductively. This causes the children to grow up as burdens of the family, limiting their prospect to finding job and ultimately leads to significant poverty. Their living condition is also affected as they are unable to walk without great pain and are unable to carry out many daily tasks comfortably. The sad fate of these 'neglected clubfeet' sufferers is evident in the streets of Bangladesh were many of the beggars have clubfeet.
Only a small fraction of these children receive corrective Ponseti management or orthopedic surgery in their lifetime. Undoubtedly, number of these untreated children will definitely rise in future with increasing number of population, if our health system cannot keep pace with it.
Regrettably, in Bangladesh as well as in many other developing countries, there is little public awareness about clubfoot as a medical condition, or the Ponseti Method as a proven treatment option. Consequently, the gradual limb deformation is typically ignored until it becomes a truly disabling condition. We are confident that with quality trained medical staff and a public awareness campaign to identify clubfoot, treatment for all clubfoot children is achievable in Bangladesh as well as in Chittagong division.
Zero Clubfoot (Bangladesh)