CLUBFOOT (CONGENITAL TALIPES EQUINOVARUS)
Written by Francesc Malagelada, Specialty Registrar and supervised by Manoj Ramachandran, Consultant Paediatric Orthopaedic Surgeon, 2014
What is club foot?
Clubfoot is also known as congenital talipes equinovarus (CTEV) or simply talipes. These terms describe a condition involving an unusual position of the foot. Babies are diagnosed when they are born or during antenatal ultrasound.
Talipes can affect both feet in almost half of the affected babies. Most children with clubfoot have no other health problems but in a minority of cases, other conditions can be present like cerebral palsy.
The typical appearance of clubfoot is with the foot pointing downwards (equinus) and the heel turned inwards towards the other foot (varus).
Written by Francesc Malagelada, Specialty Registrar and supervised by Manoj Ramachandran, Consultant Paediatric Orthopaedic Surgeon, 2014
What is club foot?
Clubfoot is also known as congenital talipes equinovarus (CTEV) or simply talipes. These terms describe a condition involving an unusual position of the foot. Babies are diagnosed when they are born or during antenatal ultrasound.
Talipes can affect both feet in almost half of the affected babies. Most children with clubfoot have no other health problems but in a minority of cases, other conditions can be present like cerebral palsy.
The typical appearance of clubfoot is with the foot pointing downwards (equinus) and the heel turned inwards towards the other foot (varus).
The word talipes refers to the foot and ankle. It is a congenital condition meaning that the baby is born with it.
The foot stays in this position and cannot be corrected into a normal foot position without treatment (fixed deformity). If the foot can be moved easily to a normal position, the baby does not have true talipes but positional talipes.
Clubfoot is a painless condition for the baby but if left uncorrected, it causes problems with walking, as the child becomes unable to put the foot flat on the ground. The child may walk on the outer aspect of their feet and they might experience difficulties in wearing shoes and taking part in play.
Early treatment (Ponseti method) is recommended and begins very shortly after birth. With treatment, a vast majority of children recover completely and are able to perform normal activities and sports.
“Clubfoot is an abnormal position of the foot diagnosed at birth and if treated appropriately, the child is able to live a normal life”.
What causes clubfoot?
The deformity occurs because the muscles at the back and inner calves are very tight (Achilles tendon and others). It is still unknown what causes these muscles to be tighter but it seems to be due to a combination of genetic and environmental factors. By applying serial casts and moulding the foot at a young age, these structures can be loosened and the foot deformity corrected.
Clubfoot is one of the commonest deformities that can be seen in babies occurring in about 1 in 1,000 newborns. Chances are having clubfoot are higher if a sibling or one of the parents have clubfoot.
How is clubfoot diagnosed?
The diagnosis is made by a doctor (best done by a specialist paediatric orthopaedic consultant surgeon) examining the foot.
No X-rays are necessary for confirmation. The bones of newborns are not shown well on X-rays as they are mainly formed by cartilage rather than bone.
Treatment for club foot – Ponseti method
In the past, major surgery was used at a very young age for babies as the usual treatment. Current medical research has shown that a method without major surgery, known as the Ponseti method, produces better results. Nowadays this is the gold standard treatment throughout the world.
“The treatment involves weekly visits to the hospital to change plaster casts and the need to wear special boots and bars mainly at night time.”
The Ponseti method is a minimally invasive treatment regimen that involves three phases or stages of treatment:
1. Serial casting. The sooner in the baby’s life the treatment is started, the easier the correction of the foot will be. This is ideally in the first week or two of life when the soft tissues are very elastic.
The treatment begins with weekly manipulations in the hospital by a specially trained physiotherapist or other trained Ponseti professional. A plaster cast is then applied to gradually correct the position of the foot. The casts need to go from the baby’s toes to the groin in order to hold the new position.
The foot stays in this position and cannot be corrected into a normal foot position without treatment (fixed deformity). If the foot can be moved easily to a normal position, the baby does not have true talipes but positional talipes.
Clubfoot is a painless condition for the baby but if left uncorrected, it causes problems with walking, as the child becomes unable to put the foot flat on the ground. The child may walk on the outer aspect of their feet and they might experience difficulties in wearing shoes and taking part in play.
Early treatment (Ponseti method) is recommended and begins very shortly after birth. With treatment, a vast majority of children recover completely and are able to perform normal activities and sports.
“Clubfoot is an abnormal position of the foot diagnosed at birth and if treated appropriately, the child is able to live a normal life”.
What causes clubfoot?
The deformity occurs because the muscles at the back and inner calves are very tight (Achilles tendon and others). It is still unknown what causes these muscles to be tighter but it seems to be due to a combination of genetic and environmental factors. By applying serial casts and moulding the foot at a young age, these structures can be loosened and the foot deformity corrected.
Clubfoot is one of the commonest deformities that can be seen in babies occurring in about 1 in 1,000 newborns. Chances are having clubfoot are higher if a sibling or one of the parents have clubfoot.
How is clubfoot diagnosed?
The diagnosis is made by a doctor (best done by a specialist paediatric orthopaedic consultant surgeon) examining the foot.
No X-rays are necessary for confirmation. The bones of newborns are not shown well on X-rays as they are mainly formed by cartilage rather than bone.
Treatment for club foot – Ponseti method
In the past, major surgery was used at a very young age for babies as the usual treatment. Current medical research has shown that a method without major surgery, known as the Ponseti method, produces better results. Nowadays this is the gold standard treatment throughout the world.
“The treatment involves weekly visits to the hospital to change plaster casts and the need to wear special boots and bars mainly at night time.”
The Ponseti method is a minimally invasive treatment regimen that involves three phases or stages of treatment:
1. Serial casting. The sooner in the baby’s life the treatment is started, the easier the correction of the foot will be. This is ideally in the first week or two of life when the soft tissues are very elastic.
The treatment begins with weekly manipulations in the hospital by a specially trained physiotherapist or other trained Ponseti professional. A plaster cast is then applied to gradually correct the position of the foot. The casts need to go from the baby’s toes to the groin in order to hold the new position.
The cast or casts (if both feet are involved) will be removed after one week, the foot manipulated again and another cast put on. Usually, after 5 to 7 weeks of repeated manipulation and casting, the foot is corrected into a close to normal foot position.
2. Tenotomy (Tendon release procedure). After the serial casting stage, a minor procedure is suggested for most children in order to achieve the best foot position.
The procedure is called Achilles tenotomy where the tight Achilles tendon at the back of the foot is released. This involves a small cut made in the clinic with just local anaesthetic. After this, the foot is put into a final plaster cast for another 3 weeks to allow complete healing of the cut tendón and to maintain the correction.
The paediatric orthopaedic surgeon will decide whether the baby needs the tenotomy or not. In some mild cases after serial casting, the heel has stretched down fully and there is no need for a tenotomy.
3. Boots and bar. Once the foot is fully corrected, the child has to wear special boots attached to a bar to hold their feet in the most effective position. The boots are worn for 23 hours a day for the first three months and then just at night and nap times (12 to 14 hours) up to the age of 4 years. Regular footwear may be worn at all other times.
2. Tenotomy (Tendon release procedure). After the serial casting stage, a minor procedure is suggested for most children in order to achieve the best foot position.
The procedure is called Achilles tenotomy where the tight Achilles tendon at the back of the foot is released. This involves a small cut made in the clinic with just local anaesthetic. After this, the foot is put into a final plaster cast for another 3 weeks to allow complete healing of the cut tendón and to maintain the correction.
The paediatric orthopaedic surgeon will decide whether the baby needs the tenotomy or not. In some mild cases after serial casting, the heel has stretched down fully and there is no need for a tenotomy.
3. Boots and bar. Once the foot is fully corrected, the child has to wear special boots attached to a bar to hold their feet in the most effective position. The boots are worn for 23 hours a day for the first three months and then just at night and nap times (12 to 14 hours) up to the age of 4 years. Regular footwear may be worn at all other times.
In a low percentage of cases (20-30%), children will require further surgery after they have started walking between the age of 2 to 7 years. This may involve moving a tendon in front of the ankle to a different position to improve the foot’s function (tendon transfer).
Clubfoot treatment with the Ponseti method usually produces very good results although the final outcome will depend on the child’s response to treatment (severity of the condition) and the parents’ compliance with the boots and bars regimen.
It is very important that the child continues to wear the boots and bar as the specialist advises. If not worn as advised, there is a high chance that clubfoot can come back (recur) and the position can become abnormal again. If that happens, major surgery may be needed following a small period of casting. If the boots and bars are worn as specified, the likelihood of recurrence is reduced to 5% whereas if parents are not compliant with treatment, it can be up to 80%.
“Excellent outcomes can be achieved with very minimal or no surgery at all, but success highly relies on the compliance in wearing the boots and bar.”
What is the long term outcome?
Even in successfully treated clubfoot, minor differences in foot shape can be expected. The foot usually appears slightly shorter and chubbier, and the calf is thinner compared to au unaffected foot. These are only minor cosmetic differences but the child should have pain free functioning feet and be just as active as any other child.
Picture
Most children do well with treatment and there will be no problems going to school and taking part in a full range of sporting activities. Children followed through adulthood after the Ponseti treatment method experienced no greater severity of foot pain to those experienced by people without clubfoot.
Following treatment, the specialist will monitor the child yearly or biannually until they are fully grown or until the risk of recurrence is minimal.
Treatment for clubfoot - other
Some clubfeet are more difficult to treat such as those that fail Ponseti repeatedly or those associated with syndromes and other medical conditions. These feet are more likely to need surgery and have poorer outcomes in the long-term. Operative procedures for these feet include major soft tissue releases and bony cuts to realign the feet into a more functional position.
Clubfoot at Barts Orthopaedics
Training
Our team undertook personal training with Dr Ignacio Ponseti in Iowa, USA in 2009 – see Walk This Way.
Audit
We have set up a successful hub-and-spoke system for treating clubfoot with the specialists (hub) based at Barts and The London Children’s Hospital and the trained Ponseti physiotherapists (spokes) based at Homerton, Newham and Whipps Cross Hospitals, covering a vast area in Central and East London. The results of our recent audit of this service was completed in 2013:
Outcomes of a hub-and-spoke physiotherapy-led Ponseti service for idiopathic clubfoot (CTEV) in a large urban UK teaching hospital
D Coggings and M Ramachandran
Purpose
To assess the outcomes of idiopathic CTEV treated using the Ponseti method by trained physiotherapists in three spokes (Whipps Cross, Newham and Homerton Hospitals) feeding into one major hub (Barts and The London Children’s Hospital) between 2003 and 2012.
Methods
Ponseti casting carried out by non-surgical trained practitioners has been successfully used in the management of congenital talipes equinovarus (CTEV) in both developed and developing countries. We have employed a hub-and-spoke model with trained physiotherapists at three spokes feeding into a major hub for CTEV patients since 2003. The Ponseti database at Barts and The London Children’s Hospital was interrogated and the following data extracted: number of cases treated, gender, ethnic origin, age at referral to the hub, initial Pirani score, number of casts, need for Achilles tenotomy, rates of recurrence, adherence to the boots and bar regimen and need for further casting or surgery.
Results
227 children (147 boys and 80 girls) with 341 clubfeet were treated between 2003 and 2012. 29% were of British White origin, 50% British Black/Asian/Mixed, 13% European, 7% African/Afro-Caribbean and 1% Australasian. The average age at referral to the hub was 7 weeks, the average initial Pirani score 4 and the average number of casts 5. Achilles tenotomy was performed in 135 feet (39%). Continuity of care was maintained as practitioners in the spokes followed-up the patients locally. Adherence to the bracing regimen was very good at over 90%. 14 children required tibialis anterior tendon transfer at a mean age of 5. There were 40 recurrences (11.7%), of which 7 needed further casting and 33 needed surgical intervention (posteromedial release 20 and posterior release alone in 13).
Conclusion
Our hub-and-spoke physiotherapy-led Ponseti service has been successfully implemented with high success rates and adherence to the protocol.
Clubfoot treatment with the Ponseti method usually produces very good results although the final outcome will depend on the child’s response to treatment (severity of the condition) and the parents’ compliance with the boots and bars regimen.
It is very important that the child continues to wear the boots and bar as the specialist advises. If not worn as advised, there is a high chance that clubfoot can come back (recur) and the position can become abnormal again. If that happens, major surgery may be needed following a small period of casting. If the boots and bars are worn as specified, the likelihood of recurrence is reduced to 5% whereas if parents are not compliant with treatment, it can be up to 80%.
“Excellent outcomes can be achieved with very minimal or no surgery at all, but success highly relies on the compliance in wearing the boots and bar.”
What is the long term outcome?
Even in successfully treated clubfoot, minor differences in foot shape can be expected. The foot usually appears slightly shorter and chubbier, and the calf is thinner compared to au unaffected foot. These are only minor cosmetic differences but the child should have pain free functioning feet and be just as active as any other child.
Picture
Most children do well with treatment and there will be no problems going to school and taking part in a full range of sporting activities. Children followed through adulthood after the Ponseti treatment method experienced no greater severity of foot pain to those experienced by people without clubfoot.
Following treatment, the specialist will monitor the child yearly or biannually until they are fully grown or until the risk of recurrence is minimal.
Treatment for clubfoot - other
Some clubfeet are more difficult to treat such as those that fail Ponseti repeatedly or those associated with syndromes and other medical conditions. These feet are more likely to need surgery and have poorer outcomes in the long-term. Operative procedures for these feet include major soft tissue releases and bony cuts to realign the feet into a more functional position.
Clubfoot at Barts Orthopaedics
Training
Our team undertook personal training with Dr Ignacio Ponseti in Iowa, USA in 2009 – see Walk This Way.
Audit
We have set up a successful hub-and-spoke system for treating clubfoot with the specialists (hub) based at Barts and The London Children’s Hospital and the trained Ponseti physiotherapists (spokes) based at Homerton, Newham and Whipps Cross Hospitals, covering a vast area in Central and East London. The results of our recent audit of this service was completed in 2013:
Outcomes of a hub-and-spoke physiotherapy-led Ponseti service for idiopathic clubfoot (CTEV) in a large urban UK teaching hospital
D Coggings and M Ramachandran
Purpose
To assess the outcomes of idiopathic CTEV treated using the Ponseti method by trained physiotherapists in three spokes (Whipps Cross, Newham and Homerton Hospitals) feeding into one major hub (Barts and The London Children’s Hospital) between 2003 and 2012.
Methods
Ponseti casting carried out by non-surgical trained practitioners has been successfully used in the management of congenital talipes equinovarus (CTEV) in both developed and developing countries. We have employed a hub-and-spoke model with trained physiotherapists at three spokes feeding into a major hub for CTEV patients since 2003. The Ponseti database at Barts and The London Children’s Hospital was interrogated and the following data extracted: number of cases treated, gender, ethnic origin, age at referral to the hub, initial Pirani score, number of casts, need for Achilles tenotomy, rates of recurrence, adherence to the boots and bar regimen and need for further casting or surgery.
Results
227 children (147 boys and 80 girls) with 341 clubfeet were treated between 2003 and 2012. 29% were of British White origin, 50% British Black/Asian/Mixed, 13% European, 7% African/Afro-Caribbean and 1% Australasian. The average age at referral to the hub was 7 weeks, the average initial Pirani score 4 and the average number of casts 5. Achilles tenotomy was performed in 135 feet (39%). Continuity of care was maintained as practitioners in the spokes followed-up the patients locally. Adherence to the bracing regimen was very good at over 90%. 14 children required tibialis anterior tendon transfer at a mean age of 5. There were 40 recurrences (11.7%), of which 7 needed further casting and 33 needed surgical intervention (posteromedial release 20 and posterior release alone in 13).
Conclusion
Our hub-and-spoke physiotherapy-led Ponseti service has been successfully implemented with high success rates and adherence to the protocol.
