Clubfoot, also named congenital talipes equinovarus, is one of the most common congenital foot deformities. It is characterized by four primary alterations: midfoot cavus, midfoot adductus, heel/hindfoot varus, and hindfoot equinus. The incidence of clubfoot ranges between 0.5 and 2 cases per 1000 births. While the exact cause of isolated clubfoot is multifactorial, genetic and environmental factors are implicated. The severity of clubfoot varies from mild postural forms to severe rigid deformities. Diagnosis can be made prenatally via intrauterine ultrasound. The Pirani system is commonly used for classification due to its reproducibility and validity, with foot X-rays typically unnecessary for assessment as treatment decisions rely on clinical examination.
The gold standard treatment for clubfoot is the Ponseti technique, developed in the 1940s. It consists of two phases: progressive casting in the early stage to correct the deformity, followed by maintenance of correction in the second phase. While the Ponseti method boasts a low recurrence rate of 2%, around 20% of patients may require Achilles tenotomy, and 80% may need anterior tibialis tendon transfer. This technique is implemented in close collaboration with Dr. Matthew Dobbs. Successful treatment of clubfoot demands meticulous attention to detail, but with proper management, long-term outcomes are excellent, often obviating the need for major surgical intervention.
Treatment for clubfoot at the Paley European Institute emphasizes early intervention, typically within the first week or two of birth. At this critical stage, the Ponseti Method, involving progressive casting, is employed. This approach frequently leads to complete deformity correction with minimal recurrence rates. Unfortunately, a significant number of cases, especially in developing countries, remain untreated or receive inadequate treatment. Individuals with untreated or poorly treated clubfoot often experience severely limited mobility and significant pain. This not only impacts the patient’s quality of life but also imposes substantial social, psychological, and financial burdens on both the individual and their family.
The Ponseti Method involves a comprehensive regimen of serial casting, heel cord tenotomy, brace wear, and stretching exercises. The overarching treatment objective is to achieve a well-functioning foot that is both pain-free and aesthetically normal. The treatment protocol typically unfolds across three distinct phases:
PHASE 1: Casting
Casting commences once the infant reaches a weight of seven pounds and their foot is equivalent in length to the parent’s pinky finger. Cast changes are performed weekly to delicately stretch and reposition the foot. These casts extend from the groin to the toes. An accelerated casting option exists, wherein casting occurs every four days to expedite the correction process, yielding outcomes akin to traditional weekly casting.
PHASE 2: Tenotomy
During this phase, a tenotomy procedure is undertaken to clip the Achilles tendon, thereby elongating the heel. This procedure is typically conducted in the clinic under local anesthesia, particularly for children under one year of age. Parents are encouraged to be present during all casting appointments but are asked to wait in the waiting room during the tenotomy procedure due to its sterile nature. Detailed instructions are provided to parents before the tenotomy appointment.
PHASE 3: Bracing
Following the removal of the final cast, the child is fitted with a foot abduction brace designed to prevent recurrence of the clubfoot deformity. Initially, the brace is worn for 23 hours a day for three months, gradually reducing to 18 hours for the subsequent three months, then 14-16 hours for the subsequent three months, and finally to 12-14 hours a day (during naps and nighttime) until the child reaches four years of age. The ultimate goal is for the child to transition to wearing the brace only during nap and nighttime hours once they begin pulling up. This comprehensive treatment approach at the Paley European Institute ensures optimal outcomes and long-term success in managing clubfoot deformities.
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