Despite Early Childhood Surgery, Some Issues Remain in Adults with Clubfoot

Clubfoot, called congenital talipes equinovarus or CTEV in medical language, is a common birth defect, occurring in about one out of every 1,000 births. At first, the foot is treated by trying to manipulate it back into its proper place and shape, but how the manipulation is done depends on the doctor, the facility, and the extent of the defect.

Many studies have been done comparing techniques for managing clubfeet and in most cases, adults who were born with a clubfoot did well with manipulation and casting as children. They have good function for the most part, but many do have limited range of motion and may have pain if they are participating in long activities. Undergoing surgery during adolescence seemed like a good idea, but studies have shown that adolescents who do have surgery on their clubfoot often report problems after the surgery, including pain, weakness, difficulty using the foot properly, and difficulty with their gait. Studies have also reported that adolescents who had the surgery had more difficulty with their ankle and foot motion than did children who had the surgery at a younger age. Adults who undergo clubfoot correction surgery also seem to be at a disadvantage. They reported stiffness in the ankle and foot, arthritis, ankle muscle weakness, pain, and deformity.

The authors of this article reviewed and evaluated the long-term outcomes of the comprehensive surgical release. They collected data from 24 adults (17 males), aged from about 18 years old to 24 years old and a control group (with no clubfoot) of 48 people. Eleven patients had only one clubfoot (unilateral), while the remaining had two clubfeet (bilateral>). As children, none were successful with casting so they underwent surgery before they were 18 months old. Fourteen patients went on to have further repairs.

Each patient was examined and range of motion was assessed of ankles and feet, using the International clubfoot Study Group (ICFSG) rating score. X-rays, with patients standing, were obtained, and the strength of the feet were established. The patients were also assessed for their gait, which provided information not only of the foot and ankle, but of the pelvis, hip, and knee, as well. Assessments were also done suing the American Orhtopaedic Foot and Ankle Society (AOFAS) Ankle/Hindfoot and Midfoot scales, the Foot Function Index (FFI), and the SF-36, as well as a few others.

In the clubfoot group, there were leg length differences of between 0.5 centimeters and 3.5 centimeters in the unilateral group and from 0.91 to 0.77 cm in the bilateral group. Among the unilateral group, the calf circumference on the affected side (the one with the clubfoot) was smaller than the unaffected leg. The range of motion of the affected legs were also lower for the clubfoot group, as was the strength.

In the assessments, only five out of the 37 clubfeet were rated as excellent (according to the ICFSG), 17 were good, 15 were fair to poor, and seven were fair. The Turco score, which classified surgery outcomes, rated six feet as excellent, 24 as good, and seven as fair.

The pain and movement issues lowered the AODFAS scores in both the Ankle/Hindfoot and the Midfoot scales. The Disease Specific Index, another assessment, found that 96 percent of the feet were painful. Results also showed that patient who were on their feet for long periods of time or needed to do stressful activities, such as running, jumping, or stair climbing, to name a few, experienced more problems with their affected foot or feet. In fact, all patients reported some level of pain at the end of the day or after strenuous exercise.

The conclusion seems to be that adults who were treated as children for their clubfoot or feet still have issues with their feet later in adulthood. Although these problems don't cause problems with basic daily living, they do provide limitations in how active the patients can be. The authors suggest that following these patients into their later years to see if any changes occur, particularly as they enter the stages where arthritic changes may occur.

Reference: 

Adam Graf, MS, et al. Long-Term Outcome Evaluation in Young Adults Following Clubfoot Surgical Release. In Journal of Pediatric Orthopaedics. June 2010. Vol. 30, No. 4. Pp. 379-385.

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