- Children’s Orthopaedic & Spine Care Clinic
Fig – Our patient 7 days old with club foot
Fig2 – Same child at 4 years age – fully active, normal feet
Club foot is a birth defect that causes a malformation of the bones, joints and muscles. The foot is twisted inwards and downwards (See Pic C1 C2). The condition occurs in about 1-4 out of every 1,000 newborns. It is treated shortly after birth with cast correction using the Ponseti method. We at The Childrens Orthopedic & Spine Care Clinic (COSCC) have been pioneers in the use of this technique in India. Since year 2001, Dr Sanjay Sarup has treated over 1400 children with this condition. All children with club foot treated in our clinic have made full recovery. They have no restriction and can play all games, participate in sports activities and dancing. In short, they lead happy, normal lives.
We use the PONSETI method for correcting clubfeet.
We advise all parents to bring the child for cast correction in the first week of life. At this stage, the bones of the foot are soft and the correction is faster and easier. After one month of age, the foot is stiffer. The correction takes a longer time and more plasters have to be applied.
In order to commence casting, we need the following items to be bought by the parents:
The plasters are applied from the toes to upper thigh.
Fig – Casting in progress
The plasters are applied as frequently as once in 4 or 5 days. Most babies at this age are corrected in 1 month, and usually require 5 to 6 cast changes.
We teach parents how to remove plasters at home in a quick and safe manner.
Do not let the cast be soaked with urine.
A plaster that gets wet accidentally must be dried by blowing COLD air by a hair drier onto the wet area. (DO NOT BLOW HOT AIR AS THAT CAN DAMAGE THE SKIN OF THE BABY).
A wet cast causes a rash. Sometimes the rash can become so severe that casting has to be abandoned.
Persistent Blue or white discoloration, or marked swelling of the toes, indicates that there is internal swelling of the leg, or that the cast is too tight. Usually, this is accompanied by excessive crying. If this happens, you will need to inform our staff and then remove the plaster at home. You can always bring the baby in next day for a new cast.
Take a medium sized basin and fill up to halfway with warm water. The water should be at the same temperature as used for bathing a baby).
Add 2 cups of white vinegar to the water.
Hold the baby in your lap with legs sticking out over the basin. Keep pouring the basin water over the casts for 10 minutes. The cast will get soft. Pluck off the cast end and unwrap like a bandage, pouring more water over drier inside portions as they get exposed.
Wash the legs with soap and water and dry.
At the end of the casting period, most babies will require a tendon release surgery. This is done at the hospital. The baby is admitted for 4 hours to day care. A local anesthesia or a short general anesthesia is administered. If a general anaesthesia is required, it is given with utmost precautions by our highly experienced Anaesthesia team. The surgery is done carefully by a 4mm incision. At the end of surgery, a cast is applied. The cast will be maintained for 1 month.
The baby experiences no pain from the surgery.
In the postoperative period, sometimes a bloodstain will appear on the cast around the heel area. At times, this will increase over the first day. This is normal and is not a cause for concern.
Fig. Picture shows the scar of surgery – it is hardly visible.
The cast is maintained for a month. At the end of this period, parents remove the cast at home. There is a small adhesive dressing at the back of the heel that must be removed. The leg is bathed with soap and water. The leg is dried by patting down the skin with a clean towel. Moisturizer is liberally applied. The child is taken for measurements for fitting a Dennis Browne Splint. Once the splint is ready, an appointment is made to see the doctor at the clinic. At this stage, exercises are taught to the parents.
Fig 4 – COSCC modified Dennis Browne splint
coscc
Fig 4a - Baby wearing Dennis Browne Splint. Children adjust easily to splints. Counselling and parental behavior must be positive and encouraging.
The Dennis Browne Splint (DBS) is a boot on both feet connected by a bar. (See Pic). The angle on the boot is preset and depends upon the type of clubfoot. In normal feet and in Atypical Club foot, the angle is set to 50 degrees. In normal clubfoot, the angle is set to 70 degrees. This device is essential for maintaining the correction of your child’s foot.
The Dennis Browne splint is worn day and night for the first 3 months. It is removed for exercises 6 times a day. It is also removed for bathing. After 3 months, it is worn only while sleeping (Both day and night).
Dobb’s Splints – These can also be used instead of Dennis Browne Splints.
The Dennis Browne Splint is essential for maintaining correction of your child’s foot. There are studies that have shown that Club foot relapses in all cases whose parents abandon the use of this splint. We know that it is restricting for children to wear this splint as they get older. Therefore, it is essential to train the child in such a manner that they accept the splint as a part of their normal routine. The DBS is worn for the first 4 years of life.
When wearing a DBS, the feet need frequent careful inspection at the time of exercise. Make sure that the skin is healthy and has no areas of breakdown or pressure. If this happens, please get in touch with us at the clinic.
You will generally have to visit our clinic once in 3 months for the 1st two years, and then once in 4 months in the 3rd year, and then once in 6 months till the child is 12 years of age.
Follow-up is important as it allows us to monitor the feet for any early recurrence.
Fig. Club foot at Birth
Fig. The same child after correction at our clinic at age 2 years
With regular exercises, and the use of a Dennis Browne Splint – the relapse rate is very low (around 10% in our clinic).
When we detect an early relapse, we usually review the exercises, or correct a faulty habit (such as noncompliance with wearing a DBS). We may then choose to apply serial casts again. In some children, repeat surgery is required (a tenotomy, or a tendon transfer or both).
Club foot can be corrected at any age. The correction is best when the child comes to us at 7 days of age. With increasing age, the correction becomes more difficult,
When a child presents to us in the first month of life, the treatment is completed within 30 to 45 days.
This is called a relapse. Relapse is seen in approximately 10% cases. The cause often is abandoning the use of a Dennis Browne Splint. Sometimes the club foot is very severe and may come back in-spite of the best possible efforts. However, relapses can be treated very successfully by cast applications, and surgery. The highest chance of relapse is in the first 4 years of life.
The club foot does not affect the length of the limb of the height of a person. In severe CTEV, the affected foot is smaller than the opposite side, and remains so. However, the smaller foot does not cause any physical limitation to the child.
CTEV or Club foot is a common birth defect. It is present in 1 in every 1000 children. The defect is more common in boys. The cause is multifactorial.
Genetic defect that develops spontaneously may produce a club foot deformity.
A genetic anomaly causing club foot deformity when present in a parent or a sibling may cause a CTEV to develop.
No. Club foot is a rarely seen in Down’s syndrome.
Club foot may be associated with other genetic defects such as Trisomy 18. It may be associated with intraspinal pathology such as a meningo-myelocoele. It may be associated with arthrogryposis, or amniotic band syndrome.
In most cases, the cause is not known.