Clubfoot in a birth defect in which the feet are turned inwards and appear like golf clubs. Although clubfoot is diagnosed at birth, many cases are first detected during a prenatal ultrasound. In about half of the children with clubfoot, both feet are affected. Boys are twice more likely than girls to have the deformity.

Appearance

The foot is turned inward and there is often a deep crease on the bottom of the foot.
In clubfoot, the tendons that connect the leg muscles to the foot bones are short and tight, causing the foot to twist inward.

In limbs affected by clubfoot, the foot and leg are slightly shorter than normal, and the calf is thinner due to underdeveloped muscles. These differences are more obvious in children with clubfoot on only one side.

Classification

Clubfoot is often broadly classified into two major groups:

• Isolated (idiopathic) clubfoot is the most common form of the deformity and occurs in children who have no other medical problems.
• Nonisolated clubfoot occurs in combination with various health conditions or neuromuscular disorders, such as arthrogryposis and spina bifida. If your child's clubfoot is associated with a neuromuscular condition, the clubfoot may be more resistant to treatment, require a longer course of nonsurgical treatment, or even multiple surgeries.

Regardless of the type or severity, clubfoot will not improve without treatment

Parents of infants born with clubfeet and no other significant medical problems should remain reassured that with proper treatment done by us their child will have feet that permit a normal, active life.

Cause

Researchers are still uncertain about the cause of clubfoot. The most widely accepted theory is that clubfoot is caused by a combination of genetic and environmental factors. What is known, however, is that there is an increased risk in families with a history of clubfeet.

Treatment

The goal of treatment is to obtain a functional, pain-free foot that enables standing and walking with the sole of the foot flat on the ground.

Nonsurgical Treatment

The initial treatment of clubfoot is nonsurgical, regardless of how severe the deformity is. The most widely used technique throughout the world is the Ponseti method, which uses gentle stretching and casting to gradually correct the deformity.

In the Ponseti method, long-leg casts are applied after the feet are correctly positioned.

Treatment should ideally begin shortly after birth, but older babies have also been treated successfully with the Ponseti method. Elements of the method include:

• Manipulation and casting. Your baby's foot is gently stretched and manipulated into a corrected position and held in place with a long-leg cast (toes to thigh). Each week this process of stretching, re-positioning, and casting is repeated until the foot is largely improved. For most infants, this improvement takes about 6 to 8 weeks.
• Achilles tenotomy. After the manipulation and casting period, approximately 90 percent of babies will require a minor procedure to release continued tightness in the Achilles tendon (heel cord). During this quick procedure (called a tenotomy), we will use a very thin instrument to cut the tendon. The cut is very small and does not require stitches. A new cast will be applied to the leg to protect the tendon as it heals. This usually takes about 3 weeks. By the time the cast is removed, the Achilles tendon has regrown to a proper, longer length, and the clubfoot has been fully corrected.
• Bracing. Even after successful correction with casting, clubfeet have a natural tendency to recur. To ensure that the foot will permanently stay in the correct position, your baby will need to wear a brace (commonly called "boots and bar") for a few years. The brace keeps the foot at the proper angle to maintain the correction. This bracing program can be demanding for parents and families, but is essential to prevent relapses.

For the first 3 months, your baby will wear the brace essentially full-time (23 hours a day). We will gradually decrease the time in the brace to just overnight and nap time (about 12 to 14 hours per day). Most children will follow this bracing regimen for 3 to 4 years.

A small percentage of children develop relapses despite proper bracing. If the child's foot slips out of the boot on a regular basis, it may be the first sign of a mild recurrence of the deformity. If addressed promptly, this can usually be corrected with a few serial casts and possibly a minor surgery.

Surgical Treatment

Although many cases of clubfoot are successfully corrected with nonsurgical methods, sometimes the deformity cannot be fully corrected or it returns, often because parents have difficulty following the treatment program. In addition, some infants have very severe deformities that do not respond to stretching. When this happens, surgery may be needed to adjust the tendons, ligaments, and joints in the foot and ankle.

Because surgery typically results in a stiffer foot, particularly as a child grows, every effort is made to correct the deformity as much as possible through nonsurgical methods. Even an infant with severe deformities or clubfeet associated with neuromuscular conditions can improve without surgery. If a child's foot has been partially corrected with stretching and casting, then the surgery required to fully correct the clubfoot will be less extensive.

• A postromedial soft tissue release procedure involves loosening up (lengthening) of all tight muscles and ligaments on planter and medial (inner) side of the foot. This is done under general anaesthesia. Small wires are passed through the joints to keep them in desired position and an above knee cast is applied.

After 4 to 6 weeks, we will remove the pins and cast, and typically apply a short-leg cast, which is worn for an additional 4 weeks. After the last cast is removed, it is still possible for the muscles in your child's foot to try to return to the clubfoot position, so special shoes or braces will likely be used for up to a year or more after surgery.

• In rare neglected or resistant cases an external fixator (Ilizarov or JESS) is applied to slowly correct the deformity. This technique also has promising results.
• If bones remain deformed and do not allow the joints to get reduced then these bones are cut (osteotomy) and put in right position and fixed with wires till they heal. These procedures are usually done in older children with neglected CTEV.

Your baby's clubfoot will not get better on its own. With treatment, your child should have a nearly normal foot, and he or she can run and play and wear normal shoes.

If treatment is started early (within 1 week of life) with casting and manipulation techniques, usually the results are exceptional and there is no physical challenge faced by the child in future. Our team regularly treats such cases with good outcome and have treated nearly 125 such children in last 5 years.