Without normal sensation to the legs, clubfoot (Talipes) can develop before birth. As part of the overall medical care for your child, there will be regular physiotherapy and follow-up from the Orthopaedic Specialists to monitor this condition if it should arise.
Congenital Talipes Equinovarus (CTEV) or Clubfoot is a condition affecting one or both legs. The affected foot and calf are often smaller than usual and the skin and soft tissues of the calf and foot are short and underdeveloped. The heel bone (calcaneus) is held up high by a tight heel cord (achilles tendon) and the ankle bone (talus) is rotated forwards and inwards and can be felt at the front of the ankle.
Congenital – present at birth
Talipes – deformity of the foot
Equino – heel is high
Varus – foot turns in
Most cases of CTEV are idiopathic, this means that there is no known cause for the deformity. In New Zealand there is a high incidence of CTEV, approximately 1-2 per 1000 live births in the European and 6-7 per 1000 live births in the Maori/Polynesian population. CTEV is more common in boys and may be seen running through families (genetic link). For children with Spina Bifida clubfoot is caused by the damaged spinal nerves that affect the legs.
CTEV is a treatable condition. Children can assume normal active lives after treatment and they will have fully functioning feet that will allow them to do anything that other children do. The CTEV foot can be slightly shorter and wider, and the calf will remain slightly smaller regardless of the amount of exercise done. The leg may also be a little shorter. Each baby’s foot is different and treatment duration can vary. Initial treatment of CTEV is non-operative. Treatment should be started preferably before 6 weeks of age, but this may be delayed if other medial problems prevent casting.
There are two methods for used in the treatment of CTEV – the Ponseti method and surgical correction.
The first stage of treatment involves weekly plaster casts applied by your Doctor, Physiotherapist or Nurse. The plaster casts extend from the toes to the top of the thigh with the knee bent at a right angle. A gentle stretch is applied to the foot during cast application, which helps to gradually correct the foot. Usually 4-6 plaster casts are required.
Applying the cast does not hurt your baby, however some babies may protest at having their foot held so it is a good idea to bring something with you to comfort your baby. A bottle or dummy may help. If you are breastfeeding there is plenty of opportunity to feed your baby prior to casting in order to settle them.
The second stage of treatment is a small procedure to release the tendon at the back of the heel. This allows the foot to be brought up so it can sit flat. This procedure is called a Tenotomy and is required for most children with CTEV. This may be done in the Outpatient Clinic or Operating Room. Following the procedure, a new cast is applied. This needs to stay on for 3 WEEKS which allows time for the tendon to grow and repair itself. The plaster cast is then removed in the Orthopaedic Clinic and your baby will be fitted with a pair of shoes connected together with a bar.
Stage three of treatment is the most important part of the treatment for parents. The foot has been corrected and you help to hold it corrected by applying the shoes. The shoes and bar maintain the corrected position of the foot.
If the shoes and bar are not worn there is a very high chance that the muscles and ligaments will tighten and pull the foot back into an abnormal position.
For the first 3 months the shoes and bar must be worn for 22-23 hours per day. After 3 months the shoes and bar are only worn at night and naptimes. This continues through to at least 2 years of age.
Follow-up after your child has had the tenotomy and been fitted with the shoes and bar will be less frequent but it is important that your child continues to be monitored by an Orthopaedic Specialist until they stop growing. As your child grows there is a chance the soft tissues of the leg and foot may tighten up again. Prompt treatment of this minimises any further treatment or surgery.
About 40% of babies will need some form of surgery after having the tenotomy or shoe and bar fitted. This is not a failure but rather part of the Ponseti treatment. Surgery is usually minor and involves lengthening the Achilles tendon again or transferring a tendon (Tibialis Anterior) to balance the muscles in the foot.
If you are concerned about your child at any time while they are undergoing Ponseti treatment contact your Paediatric Orthopaedic Outpaitient Clinic.
Surgical correction of CTEV involves lengthening of the Achilles tendon and release of the ankle joint, multiple joints in the foot, often with re-alignment and pinning of the bones in the foot.
Surgery is usually done at 9 to 12 months of age and will correct all of your child’s CTEV deformities at the same time. After surgery, a cast is applied which holds the foot in the correct position while it heals. Special shoes or braces may be used for up to a year or more after surgery to prevent the muscles in your child’s foot from returning to the original position.
Without treatment, CTEV results in functional disability. With treatment, your child should have a nearly normal foot. If your child is mobile they will be able to walk or run and play without pain and wear normal shoes. Your child’s corrected foot will still not be perfect, and you can expect it to be 1 to 1 1/2 sizes smaller and somewhat less mobile than his/her normal foot. The muscles in your child’s affected leg will also stay smaller.
You may also notice that as the years pass that your child’s corrected foot remains stiffer than his/her normal foot.