An Overview of Clubfoot
Clubfoot, also known as congenital talipes equinovarus (CTEV), is a condition that is present at birth and affects the positioning of a baby’s foot. It is characterised by the foot turning inward or downward, making it difficult to walk or perform daily activities. Fortunately, with advancements in medical science, clubfoot can be effectively treated through various treatment approaches that include both non-surgical and surgical clubfoot repair.
This article explores the basics of clubfoot, various surgical approaches to clubfoot repair, what to expect before and after clubfoot repair, possible risks associated with the repair, and the long-term outlook of the surgery.
Understanding Clubfoot
Clubfoot is a condition that occurs during foetal development. The cause of clubfoot is still unclear to researchers. The most accepted view holds that a combination of environmental and genetic factors contributes to clubfoot. What is known, however, is that families with a history of clubfoot have a higher risk.
In clubfoot, the tendons that connect the leg muscles to the heel are shorter than normal, causing the foot to twist and deform due to the tightness of these tendons. Clubfoot can range in severity and can occur in one or both feet. Clubfoot is usually diagnosed shortly after birth by a physical examination, and sometimes an X-ray is ordered to confirm the diagnosis and understand its severity.
Clubfoot does not typically cause pain during infancy; however, if left untreated, the foot remains deformed, and the child has difficulty walking normally.
Fortunately, the majority of cases can be treated effectively with non-surgical methods, such as a combination of stretching, bracing, and casting. Treatment usually commences shortly after birth, and with proper treatment, most children can participate in various physical activities without noticeable signs of the deformity.
While non-surgical methods are effective in most cases of clubfoot, there are cases where complete correction is not possible or the deformity recurs. This may be because it is difficult for families to adhere to the treatment programme. In addition, some children may have severe deformities that do not respond to stretching. In such cases, surgery may be necessary to adjust the tendons, ligaments, and joints in the foot and ankle.
Clubfoot Repair
Clubfoot repair, sometimes called CTEV surgery, is a surgical procedure performed to correct the birth deformity of the ankle and foot.
The type of clubfoot operation performed is determined by:
- Severity of the clubfoot
- Age of the child
- Other treatments the child has received
Common surgical techniques include soft tissue releases, tendon transfers, and bony procedures such as osteotomies. The aim of these procedures is to lengthen the tendons, realign the bones, and achieve a more functional foot position.
Achilles tendon lengthening
If a child’s clubfoot does not respond well to treatment because the Achilles tendon does not stretch enough or is too tight, doctors may suggest Achilles tendon lengthening. This surgery helps the foot stretch and develop properly.
The surgeon makes small incisions on the back of the foot, stretches and cuts the Achilles tendon, and moves it into the right position. The cuts are closed with sutures that dissolve on their own. After the operation, the foot and leg are put in plaster for at least four weeks. After that, a walking cast is used for a fortnight. Sometimes a leg brace is also recommended afterwards.
Tendon transfer surgery
Tendon transfer surgery is recommended for children who have a mild relapse of clubfoot after the Ponseti method (a non-surgical method). This recurrence often results in the foot turning slightly inward or having a high arch. During surgery, a tendon is moved from one side of the foot to the other to improve flexibility and range of motion.
During the procedure, an incision is made to access and cut the anterior tibialis tendon. This tendon is then repositioned and attached to the bone on the other side of the foot using a surgical button. The incision is closed with sutures.
After the operation, a cast is applied from the toe to the thigh for six weeks to allow the tendon to heal in its new position. After that, the plaster is removed and the surgical button is removed in a short procedure. An impression of your child’s leg is used to make a custom-fit splint that is worn 24 hours a day for 6 to 12 months.
Once the foot has completely healed, the brace is removed, and your child can wear normal shoes again.
Bony procedures/Bony Adjustments
For older children who still have foot abnormalities despite earlier treatment, reconstructive surgery may be recommended. This is especially true if there are underlying medical conditions that contribute to musculoskeletal problems. Orthopaedic surgeons assess the child’s anatomy and medical history to determine the most appropriate surgical options.
Reconstructive procedures may include osteotomies, where the bones in the leg or foot are reshaped or repositioned to improve alignment. External fixation, on the other hand, involves the surgical application of braces to the feet using pins and wires. These braces are adjusted daily to gradually reposition the foot.
What to expect before the Clubfoot Surgery?
Before the surgical procedure, the child’s doctor will take a detailed history and perform a comprehensive physical examination. X-rays of the clubfoot may be ordered, and blood tests such as a complete blood count and checking electrolytes or clotting factors.
Provide complete information about any medications the child is currently taking, including any over-the-counter medications, herbs, or vitamins.
In the days leading up to surgery, the healthcare provider may advise stopping the use of aspirin, ibuprofen, or other medications that may affect blood clotting. The carer should carefully follow the healthcare provider’s instructions about which medications the child should continue to take on the day of surgery.
On the day of surgery, the child is usually instructed not to eat or drink anything for 4 to 6 hours before the procedure. Only a small sip of water should be given if medication needs to be taken.
What to expect after the Clubfoot Surgery?
Depending on the type of surgery performed, the child may be discharged the same day or stay in the hospital for 1-3 days immediately after the operation. If the surgery also involves the bones, the hospital stay may be longer.
During the recovery period, it is important to keep the child’s foot elevated. Pain medications may be prescribed to relieve discomfort.
Regular monitoring of the skin around the cast is important to make sure it stays healthy. The child’s toes are also checked to ensure proper blood flow and that they can move and feel.
The child will wear a cast for a duration of 6 to 12 weeks, during which time it may be changed several times. Before the child is discharged from the hospital, they will be given care instructions for the cast.
After the final cast is removed, the child may be prescribed a brace and may be referred for physiotherapy. The physical therapist will assist the carer in performing exercises to strengthen the foot and maintain its flexibility.
Potential risks associated with Clubfoot Surgery
Like any medical procedure, clubfoot repair surgeries carry some risks. Potential complications may include:
- Breathing difficulties
- Medication reactions
- Infection
- Bleeding
Potential problems following clubfoot surgery include:
- Nerve damage in the foot
- Foot swelling
- Blood flow issues in the foot
- Problems with wound healing
- Stiffness
- Weakness
- Arthritis
Recovery and Long-term Outcomes
Clubfoot repair is a gradual process that requires time and commitment from both the medical team and the patient’s family. The duration of treatment depends on the severity of the clubfoot, but it typically ranges from a few months to a few years.
During the correction phase, regular check-ups by the orthopaedic surgeon are essential to monitor progress and make adjustments as needed. Parents or carers play a crucial role in adhering to the treatment plan, including cast changes, bracing, and physical therapy sessions.
Successful clubfoot repair can lead to significant improvements in mobility and overall quality of life. Most patients who are treated can walk and participate in physical activities without major restrictions. However, it is important to note that some patients may have residual foot differences or muscle imbalances that may require ongoing management.(6,7)
Takeaway
Clubfoot correction surgery is an essential surgical intervention for correcting the deformity associated with clubfoot. While nonsurgical methods are effective in many cases, surgery becomes necessary for severe deformities or when conservative treatments fail. Through tendon lengthening, ligament release, and joint adjustments, surgeons aim to realign the foot and ankle, allowing for improved foot function and mobility. Combined with appropriate postoperative care and physical therapy, clubfoot repair surgery offers children the opportunity to live active lives free from the constraints of this congenital condition.
