DR SUDHARSHAN REDDY BELLUR
D ORTHO, DNB ORTHO,MNAMS
FELLOW JOINT REPLACEMENT SURGERY
CONSULTANT ORTHOPAEDIC SURGEON
Information for ParentsWhat is clubfoot? Clubfoot is the most common deformity of thefoot bones and joints in newborns. It occurs in about 1 in 1,000 babies.Thecause of clubfoot is not exactly known, but it is most likely a geneticdisorder and not caused by anything the parents did ordid not do. Therefore,there is no reason for parents to feel guilty about having a child withclubfoot. The chances of having a second child with a clubfoot areapproximately 1 in 30.Parents of an otherwise normal infant who isborn with clubfoot can be reassured that their baby, when treated by an expert inthis field, will have a normal-looking foot with essentially normal function.The well-treated clubfoot causes no handicap and the individual is fully ableto live a normal active life. Starting treatment The foot is gentlymanipulated for about 1 minute every week to stretch the short and tightligaments and tendons on the inside, back, and bottom of the foot. A cast thatextends from the toes to the groin is then applied. The cast maintains thecorrection obtained by the manipulation and relaxes the tissues for the nextmanipulation. In this manner, the displaced bones and joints are graduallybrought into correct alignment. Treatment should begin during the first week ortwo of life to take advantage of the favorable elasticity of the tissues atthat age. Cast care at home Check the circulation in the foot every hour for the first 6 hoursafter application and then four times a day. Gently press the toes and watchthe return of blood flow. The toes will turn white and then quickly return topink if the blood flow to the footis good. This is called “blanching.” If thetoes are dark and cold and do not blanch (white to pink), the cast may be tootight. If this occurs, go to your doctor’s office or local emergency departmentand ask them to check the cast. If your child has a soft roll fiberglass cast,remove it. Note the relationship between the tips of the toesand the end of the cast If the toes seem to be shrinking back inside the cast, return toyour doctor’s office or clinic for evaluation. Keep the cast clean and dry The cast may be wiped witha slightly dampened cloth if it becomes soiled. The cast should be placed on a pillow or soft paduntil dry and hard With your child on his/her back, place a pillow under the cast toelevate the leg so that the heel extends just beyond the pillow. This preventspressure on the heel that could cause asore. Prevent cast soiling by frequent diaper changes. Keep the upper endof the cast out of the diaper to prevent urine/stool from getting inside thecast. Disposable diapers and diapers with elasticized legs are ideal ifavailable. Notify your doctor or the clinic nurse if you noticeany of the following • Any foul-smelling odor or drainage coming from insidethe cast.• Red, sore, or irritated skin at the edges of thecast.• Poor circulation in the toes (see #1 above).• Cast slipping off.• Child running a fever of 38.5°C/101.3°F or higherwithout an explainable reason, such as a cold or virus. A new cast will be applied every 5 to 7 days The cast will be removed with a special plasterknife; therefore, the cast must be softened the day you are coming to theclinic.To do this, put your child in a tub or sink,making sure that warm water is getting inside the cast (about 15–20 minutes).After the bath, wrap a soaking wet hand towel around the cast and cover with aplastic bag. A bread sack works well for this. Duration of active treatment Five to seven casts (each extending from thetoes to the upper thigh, with the knee at a right angle), over a period of fourto seven weeks, should be sufficient to correct the clubfoot deformity (seesequence below). Even very stiff feet require no more than eight or nine caststo obtain maximum correction. X-rays of the foot are not necessary, except incomplex cases, because the surgeon can feel the position of the bones and thedegree of correction with his/her fingers. Completion of active treatment A minor office procedure is required to completethe correction in most feet. The back of the ankle is made numb, either with anumbing cream or an injection, after which the heel-cord tendon is divided witha narrow scalpel. A final cast is applied. The tendon regenerates at the properlength and strength by the time the cast is removed 3 weeks later. At the endof the treatment, the foot should appear slightly over-corrected, assuming aflatfoot shape. It will return to normal in a few months. Maintaining correction – the foot abduction brace Clubfoot deformity tends to relapse aftercorrection. To prevent relapses after removal of the last cast, a footabduction brace must be worn, regardless of whether or not the heel-cord tendonwas cut. There are several different types of abduction braces available. Themost commonly used brace consists of straight-bordered, high-top, open-toeshoes that are attached to the ends of an adjustable aluminum bar. The distancebetween the heels of the shoes equals the width of the baby’s shoulders.Modifications to the shoes are made to preventthem from slipping off. The shoe on the clubfoot is outwardly rotated 60 to 70 degreesand on the normal foot (if the child has only one clubfoot), 30 to 40 degrees.The brace is worn 23 hours a day for at least 3 months and, thereafter, at nightand during naps for 3 to 4 years. During the first and second nights of wearingthe brace, the baby may be uncomfortable as he/she adjusts to the legs being tetheredtogether. It is very important that the brace not be removed, becauserecurrence of the clubfoot deformity will almostinvariably occur if the brace is not worn asprescribed. After the second night, the baby will have adapted to the brace.When not required to wear the brace, ordinary shoes can be worn. The footabduction brace is used only after the clubfoot has been completely correctedby manipulation, serial casting and, possibly, heel-cord tendon release. Evenwhen well corrected, the clubfoot has a tendency to relapse until the child isapproximately 4 years old. The foot abduction brace, which is the onlysuccessful method of preventing a relapse, is effective in 95%of the patients when used consistently asdescribed above. Use of the brace will not delay the child’s development withregard to sitting, crawling, or walking. Wearing instructions for the foot abduction brace Always use cotton socks that cover the foot everywhere the shoe touches the baby’s foot andleg. Your baby’s ski n may be sensitive after the last casting, so you may wantto use two pairs of socks for the first 2 days only. After the second day, use onlyone pair of socks. If your child does not fuss when you put the braceon, you may want to focus on getting the worst foot in first and the better one insecond. However, if your baby tends to kick a lot when putting on the brace,focus on the better foot first,because the baby will tend to kick into the second shoe. Hold the foot into the shoe and tighten the ankle strap first. Thestrap helps keep the heel firmly down into the shoe. Do not mark the hole onthe strap that you use because, with use, the leather strap will stretch andyour mark will become meaningless. Check that the child’s heel is down in the shoe by pulling upand down on the lower leg. If the toes move backward and forward, the heel isnot down, so you must retighten the strap. A line should be marked on the topof the insole of the shoe indicating the location of the tips of the child’stoes; the toes will be at or beyond this line if the heel is in properposition. Lace the shoes tightly but do not cut off circulation. Remember: thestrap is the most important part. The laces are used to help hold the foot inthe shoe. Be sure that all of the baby’s toes are out straight and that none of them arebent under. Until you are certain of this, you may want to cut the toe portionout of a pair of socks so you can clearly see all the toes. Helpful tips for the foot abduction brace Expect your child to fuss in the brace for the first 2 days.This is not because the brace is painful but because it is something new anddifferent. Play with your child in the brace. This is key to getting over theirritability that is often due to the inability of the child to move his/herlegs independently of each other. You must teach your child that he/she can kickand swing the legs simultaneously with the brace on. You can gently push andpull on the bar of the brace to teach your child to flex and extend his/her kneessimultaneously.Make it routine Children do better if you make this treatment aroutine in your life. During the 3 to 4 years of night and naptime wear, putthe brace on any time your child goes to the “sleeping spot.” The child willknow that when it is that time of day, the brace needs to be worn. Your childis less likely to fuss if you make the use of this brace a part of the dailyroutine. Pad the bar Bicycle handlebar tape works well for this. Bypadding the bar, you will protect your child, yourself, and your furniture frombeing hit by the bar when the child is wearing it. Never use lotion on any red spot on the skin. Lotion makesthe problem worse. Some redness is normal with use. Bright red spots orblisters, especially on the back of the heel, usually indicate that the shoewas not worn tightly enough. Make sure that the heel stays down in the shoe. Ifyou notice any bright red spots or blistering, contact your physician. If your child continues to escape from the brace, and theheel is not down in the shoe, try the following.a. Tighten the strap by onemore hole.b. Tighten the laces.c. Remove the tongue of theshoe (use of the brace without the tongue will not harm your child).d. Try lacing the shoes fromtop to bottom, so that the bow is by the toes. Periodically tighten the screw on the bar. Long term monitoring Following full correction of the clubfoot,clinic visits will be scheduled every 3–4 months for 2 years, and then lessfrequently.Your physician will decide on the duration ofbracing depending upon the severity of the clubfoot and the tendency for the deformityto relapse. Do not end treatment early. Yearly visits will be scheduled for 8to 10 years to check for possible longterm relapses. Relapses If the deformity relapses during the first 2–3years, weekly manipulations and casts are reinstituted. Occasionally, a secondheel-cord tendon release is needed. In somecases, despite proper bracing, a minor operation is needed when the child isolderthan 3 years to prevent further relapses. Theoperation consists of transferring a tendon (the tibialis anterior) from theinsideborder of the foot to the center of the foot.