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We are headed back to the Shriner's Hospital with our four-year-old son. He had a clubfoot at birth that was treated and seemed to be fine. But he'll be going to kindergarten next year and his pediatrician noticed the foot is starting to collapse. What can they do for this now?
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As you know from personal experience, clubfoot is an unmistakable deformity present at birth. The foot is twisted (turned under and towards the other foot). The medical terminology for this position is equinus and varus.
Equinus means that the toes are pointed down and the ankle flexed forward (like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.
The medical term for clubfoot is Congenital Talipes Equinovarus. Congenital means that the condition is present at birth and occurred during fetal development. Clubfoot mainly affects three bones of the foot: the calcaneus (heel bone), talus (just above the heel bone), and navicular (bone next to the talus).
The standard treatment for a clubfoot deformity in infants and young children is the procedure you are probably most familiar with: the Ponseti Method. Developed by an Italian physician, the Ponseti Method involves manipulating (moving) the bones of the foot and ankle toward a neutral position of alignment. The bones are then held in place by a cast.
Each week the cast is removed, the bones are moved again as close to normal as possible and another cast wrapped around the leg to hold everything in place. This weekly treatment continues for about five to six weeks (or until maximum correction possible is achieved).
The reason this approach works is that manipulation stretches the still very flexible joint capsule ligaments, tendons, and muscles in infants and young children. The Ponseti method also corrects the abnormal relationships of the bones in the foot. By aligning the bones where they belong, this treatment even has the potential to reshape the bones so that they fit together as they should.
A corrective brace is worn after the Ponseti treatment is completed. Many studies over the years have shown that just wearing the brace is not enough to correct the abnormal ankle and foot alignment. Combining manipulation with immobilization followed by corrective bracing has the best results overall.
Relapse can occur and we know that relapses don't recover on their own without intervention. Currently, poor compliance with abduction bracing is the only known risk factor. Changes in the brace angle and wearing schedule have already been implemented, which may account for the decline in relapse rates from even 10 years ago.
Treatment for late-relapses varies and can range from 1) observation only to 2) bracing, or 3) casting followed by bracing, 4) casting to prepare the feet for surgery followed by surgery then bracing, and 5) surgery. Most of the children (no matter how they were treated for the relapse) ended up having surgery to correct the deformity. The most common surgical procedure is a tendon transfer called TATT for tibialis anterior tendon transfer.
Research is needed to determine the best treatment for late relapses and to identify risk factors for relapse. Each case may require a slightly different approach depending on the age of the child, the type of initial treatment, and current symptoms/clinical presentation.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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