Club Foot - Treatment

Treatment

Treatment of clubfoot is evident as early as Egyptian paintings. In early days, the foot was manipulated with a Thomas wrench and casting which caused fracture of several bones in the foot. As medicine evolved, club feet were treated with a complex surgical release, which had many complications. Then a novel idea of serial casting, different from that introduced in the past (such as the Kite method) was introduced by Ponseti with dramatic results. His results were from recognizing how the forefoot and hindfoot interact and lock into position relative to each other. This type of treatment is generally used today for idiopathic cases of clubfoot, while treatment of neuromuscular causes (such as cerebral palsy) differ. Clubfoot is treated with manipulation by podiatrists, physiotherapists, orthopedic surgeons, specialist Ponseti nurses, or orthotists by serial casting and then providing braces to hold the feet in a plantigrade position. After serial casting, bracing using a Dennis-Brown bar with straight last boots, ankle foot orthoses and/or custom foot orthoses (CFO) may be used. In North America, manipulation is followed by serial casting, most often by the Ponseti Method. Foot manipulations usually begin within two weeks of birth. Even with successful treatment, when only one side is affected, that foot may be smaller than the other, and often that calf, as well.

Extensive surgery of the soft tissue or bone is not usually necessary to treat clubfoot; however, there are two minimal surgeries that may be required:

1. Tenotomy (needed in 80% of cases) is a release (clipping) of the Achilles tendon – minor surgery – local anesthesia
2. Anterior Tibial Tendon Transfer (needed in 20% of cases) – where the tendon is moved from the first ray (toe) to the third ray in order to release the inward traction on the foot.

Each case is different, but in most cases extensive surgery is not needed to treat clubfoot. Extensive surgery may lead to scar tissue developing inside the child's foot. The scarring may result in functional, growth and aesthetic problems in the foot because the scarred tissue will interfere with the normal development of the appendage. A child who has extensive surgery may require on average two additional surgeries to correct the issues presented above.

In stretching and casting therapy the doctor changes the cast multiple times over a few weeks, gradually stretching tendons until the foot is in the correct position of external rotation. The heel cord is released (percutaneous tenotomy) and another cast is put on, which is removed after three weeks. To avoid relapse a corrective brace is worn for a gradually reducing time until it is only at night up to four years of age.