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Relapsing Clubfoot: What to Do for the Older Child

Posted on: 06/20/2012
Children born with a clubfoot (medical term: equinovarus deformity) often have corrective treatment called the Ponseti Method. The foot is twisted (turned under and towards the other foot). 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. Failure to wear the brace as directed can result in relapse of this condition. In this study, surgeons at the Ponseti Center for Clubfoot Treatment at the University of Iowa focused on what happens to children after age four if and when the child loses correction of the clubfoot deformity.

Thirty-nine (39) children with relapsing clubfoot were included in the study. Some children had both feet affected so the total number of clubfeet was 60. All the children had been treated at this Ponseti center from early on (some as early as three days after birth, others later but before age two). Everyone was prescribed the required abduction brace, which was supposed to be used up until age four.

There were differences in the timing of relapse among the children. Some lost the initial correction early on while others didn't relapse until much later after treatment. By studying what happened to the children with later relapses, the authors were able to identify some trends that might help guide prevention and treatment for other children affected by this problem in the future.

Treatment for late-relapses also varied and ranged 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 was a tendon transfer called TATT for tibialis anterior tendon transfer.

Continued follow-up of these children showed that almost all of them could wear normal shoes. Some of the children were limited in what they could do as they got older because of their feet. Complaints of pain with activity or aching at the end of the day were reported by 44 per cent of the group.

Different patients reported a variety of problems (e.g., inability to walk a full golf course, difficulty jumping or going up and down stairs, being "clumsy," unable to stand for an eight-hour shift at work). Half of the group still had mild foot deformities that contributed to their functional limitations. A few individuals had further corrective surgery with extended periods of time in braces.

The authors present these findings to help identify the prevalence of late relapse after successful treatment of clubfoot deformities in children using the Ponseti method. Although the Ponseti method seems to be successful early on, children should be followed routinely to recognize early signs of relapse.

We know that relapses don't recover on their own without intervention. Research is needed to determine the best treatment for late relapses and to identify risk factors for relapse. 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 th

References:
Scott D. McKay, MD, et al. Treatment Results of Late-Relapsing Idiopathic Clubfoot Previously Treated with the Ponseti Method. In Journal of Pediatric Orthopaedics. May 2012. Vol. 32. No. 4. Pp. 406-411.

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