Clubfoot also known as Talipes Equinovarus is a birth defect or a deformity of one or both feet. Clubfoot results in the foot being rotated inwards from the ankle such that the sole of the foot cannot be kept on the ground. It can be unilateral or bilateral and at times associated to different syndromes. According to The Global Clubfoot Initiative, “150,000 – 200,000 babies are born with clubfoot worldwide annually. Approximately 80% of these will be in low and middle income countries”.
As per researchers, 2 out of every 1000 children are born with clubfoot in Pakistan.
There are 4 major characteristics defining the presence of clubfoot, these are:
The size of the foot being smaller than normal.
The foot is rotated medially. (In simpler words foot is rotated inwards or towards the other foot.)
The foot is pointed downwards.
Tightening of the Achilles tendon (heel cord).
1. Postural/Positional: This is not true clubfoot and tend to recover without any significant manifestation.
2. Fixed/rigid: This is true club foot and require proper management like tenotomy, casting or braces for complete recovery.
Although the exact cause is still unknown following are known risk factors which can lead to clubfoot in newborns. According to researchers, pathophysiology of club foot is multifactorial and includes both environmental and genetic components.
Family history of club foot surely plays a role in having a child with this deformity. Incidence in first degree relations is approximately 2% while in identical (mono-zygotic) twins is 32%.
Other syndromes and deformities often accompany Clubfoot in some cases e.g. spine bifida, trisomies, down syndrome etc.
Environmental causes may include certain infections during pregnancy, use of certain drugs (sodium aminopterin), smoking etc. Moreover Oligiohydrominos (less amniotic fluid) during pregnancy may also cause clubfoot.
Symptoms of club foot are less evident during the early years of life and become more prominent as the child grows. Although it is a painless condition yet following are some common the clinical features:
Discomfort in the affected foot.
Crippling or limping
Abnormal shape of the foot.
Unable to wear shoes.
It is possible to diagnose Clubfoot either prenatally via ultrasound or right after the birth. The key towards complete recovery is early manifestation and prolong use of foot brace up to the age of 5 years.
1. Non-surgical Management: Ponseti Method, which is a non-surgical method, is the more popular management plan as compared to the surgical. It includes correction of the foot position through regular POP casting or use of splint. Release of harden achilles tendon is also done during this process of manipulation and this technique of releasing of the heel cord is known as Achilles Tenotomy. Once the correction is confirmed, the child is shifted from cast to special footwear or braces, known as foot abduction brace which is continued up to the age of 5 years. If braces are left earlier, there is a great possibility of re-occurrence.
2. Surgical Method: Surgery is done for correcting the positions of bones, muscles and ligaments and is followed by maintenance on POP casts.
Approximately 50% children are recoverable through non-surgical management of club foot and there is an 89% success rate of Ponseti Method including the Achilles tenotomy. Re-occurrence rate of club foot is around 25% but that is mostly because of the non-compliance of the brace.
According to Dr. Anisuddin Bhatti, the focal person of Ponseti International Pakistan and HOD orthopedics JPMC Karachi, “Around 6,000 to 7,000 children are born with clubfoot every year but hardly 5 to 10 percent receive adequate treatment.” Under his supervision, Jinnah Postgraduate medical Centre, Karachi is providing low cost Ponseti management with 95% success rate, more than anywhere in the world. There are 24 major low cost treatment centers in Pakistan including Indus hospital, Abbasi Shaheed and Civil hospitals in Karachi, Civil Hospital Hyderabad and Children’s Hospital Lahore.