Clubfoot
A clubfoot is a congenital abnormality of the position of the foot. In the Netherlands, over 200 babies are born with clubfoot each year, and about half of these children have two club feet. It is usually diagnosed during pregnancy.
Symptoms
The name clubfoot often causes confusion; people imagine a shapeless lump. The Dutch name 'klompvoet' is a corruption of the English name 'clubfoot'. It means the foot looks like the blade of a golf club. The deviation starts already below the knee and is therefore not actually a foot deviation, but a lower leg deviation. In the lower leg, tendons and muscles are laid out differently, being shorter and underdeveloped. A clubfoot involves a deviation in the position of the foot in which it shows four characteristic aspects;
- the foot is tilted downwards: the equinus or pointed position
- the foot is tilted inwards: the varus position
- the forefoot is turned inwards: the adduction position, creating a comma shape
- the foot is concave
Cause
A clubfoot has several causes, but usually the exact cause cannot be identified. It may be due to:
- Hereditary determination
- Lying defects in the uterus
- Disruption of the nerve supply to the foot
- Neurological disorder, e.g. spina bifida
- Connective tissue diseases
- Mechanical causes, such as insufficient amniotic fluid
Examination
It is important to start the clubfoot treatment early. Most (expectant) parents have an ultrasound at 20 weeks of pregnancy. This may reveal that a child has one or two clubfoot feet. Therefore, the child is examined by the family doctor, gynaecologist or paediatrician immediately after birth and, if in doubt, referred to the paediatric orthopaedics outpatient clinic where treatment is planned.
The diagnosis is not always immediately clear due to the typical position of the foot, and sometimes a clubfoot is not seen until birth. The (paediatric) orthopaedic surgeon is then called and will make the final diagnosis with physical examination. Only rarely is an X-ray needed for the diagnosis. Further investigation into the cause of the clubfoot consists of an interview with you, physical examination of your baby and possibly, if there are other indications, examination by a paediatric neurologist.
Treatment
Within our practice, we collaborate with the paediatric orthopaedists at Máxima MC Veldhoven. This hospital uses the Ponseti method. Treatment takes place immediately after birth and consists of several steps:
- First, the manipulation is performed. Then the plaster cast is placed where 1 thin layer of padding is applied first. This is done in the maximum possible position to be corrected. Then the plaster follows after which it is waited to release until the plaster is hard.
1. Correction of the cavus The cavus is the hollowing of the foot. The first step is to dissolve this hollow by stretching the foot on the inside. The head of the talus (the ankle bone) is the hub of the correction.
2. Correction of adduction The inward position of the foot is slowly corrected, each time the talus is stabilised after which the foot is manipulated. This is done again at each cast change, and if all goes well, each cast change shows improvement: the adduction of the foot and the varus are eventually gone. After the last plaster cast change, there is a complete correction. If this correction is not sufficient, it may be necessary to go through the heel tendon during a minor surgery. In very special cases, if the foot is very flexible, an additional cast change takes place without surgery.
3. Transecting the heel tendon (tenotomy) Using a bottle of drink as an anaesthetic and some anaesthetic ointment on the skin of the heel bone, the Achilles tendon is transected at the outpatient clinic through a small incision. This is possible because the tendon grows back into place very quickly (usually in 3 weeks) in very small children. Therefore, after the operation, in the presence of the parents, a plaster cast is put back on and left in place for 3 weeks.
4. Brace The brace is a high straight shoe with open toes attached to a bar. The brace is put on immediately after the last plaster cast, which is 3 weeks after the heel tendon is severed. The bar of the brace should be long enough, the heels of the shoes should be shoulder-width apart. During the first 3 months, the brace should be worn for 23 hours. Up to an age of 3 to 4 years, the brace should be worn during 'night and naps'. Nothing then needs to be worn during the day. The most important thing about the brace, is that the brace is actually worn.
Operation
Sometimes surgery is necessary. If the Achilles tendon needs to be lengthened to fix the foot's taper, this is generally done after six to eight weeks. The doctor makes a small incision in the Achilles tendon. The foot is then plastered in the so-called frog position to allow the Achilles tendon to grow to the desired length. This cast remains in place for two to three weeks. After this period, the feet are immobilised until an average of three to four years. In the early days, this is done 23 hours a day. From the time the child starts standing and walking, the feet are only splinted while sleeping, possibly in combination with adapted shoes for the day. During this period, the plasterer and/or the orthopaedist will check your child regularly. Check-ups with the orthopaedist take place until your child is grown. This is usually until around 16 to 17 years of age. There is almost never a need for surgery inside the foot, even in severe clubfoot. However, treatment in severe clubfoot can take longer and there is a greater chance of (partial) relapse. It is therefore very important that your child continues to use the adapted shoes until the age of four.
Recovery and prognosis
A clubfoot does not 'cure', but it can be corrected. In over 90% of children, Ponseti's method results in:
- the position of their foot(s) is neutral, flat on the ground
- they can put full and painless weight on their foot(s)
- they can wear normal shoes
- they have no restrictions in their daily life.
Result
The most common reason for relapse is not wearing the brace. Research shows that there is only 6% relapse in families who adhere to brace protocol. In families that do not, relapse is 80%. Causes of relapse when brace protocol is followed are often muscle instability or stiffness of the foot. A child with a clubfoot corrected by the Ponseti method as described can expect to have an almost normal foot. Some minor differences may be noticed. The treated clubfoot is slightly smaller than the normal foot and lower leg muscles are slightly smaller. The size of the difference depends on the original severity of the clubfoot. A slight shortening of the leg may be noticed. These differences do not cause any problems and are often not noticed by the child until he/she reaches puberty when body image becomes important. The differences are usually forgotten or ignored within a year or two.
Paediatric physiotherapy
Within our practice, we treat children if there is a specific need for help. In principle, the guideline states that paediatric physiotherapy is not necessary. However, if there is pain and/or functional impairment, child physiotherapy may be indicated. Treatment is functionally focused on improving muscle strength, stability, gait pattern, fundamental skills, sports and play, and advice and homework support.
Hip dysplasia
Hip dysplasia is an abnormality of the hip joint. In hip dysplasia, your baby's hip joint has not developed properly. The developmental disorder is not painful but, if left untreated, can cause osteoarthritis later on. Hip dysplasia occurs in about two per cent of all babies. A normal hip joint consists of a hip head and a hip socket. The head rotates in the socket like a ball. In hip dysplasia, the hip socket is not deep enough and does not surround the hip head properly. As a result, the head can easily slip out of the shallow socket. It is even possible for the head to no longer enter the socket at all, in which case there is hip luxation.
Cause
The cause is not entirely clear. However, we do know that some factors increase the risk of hip dysplasia:
- Baby's breech presentation
- Heredity (the occurrence of hip defects in the family)
Examination
It is important to detect hip dysplasia at an early stage. The earlier treatment can be provided, the better the outcome will be. That is why babies are examined immediately after birth and during their visit to the consultation centre. If the doctor suspects a hip defect, additional examination is necessary at the outpatient paediatric orthopaedics clinic. At the age of three months, ultrasound provides reliable information about the defect. Treatment can then also be started.
Treatment
Below the age of three months, hip dysplasia sometimes heals spontaneously. If it does not, treatment consists of properly positioning the hip head in the hip socket by means of spread breeches.
Spread breeches
Your child's legs will be kept in the spread position, using a spreader panty. These are flexible harnesses and not plaster casts. If the child's legs kick a lot, the intensified pressure of the hip head in the hip socket creates a growth stimulus. This causes the hip socket to deepen. The sling stays on for 23 hours a day, for at least three months. Such spreader shorts are also called the Pavlik bandage.
Hip luxation
In case of a hip luxation, a pavlik bandage is usually started to get the hip head back into the socket. When the pavlik bandage fails to get the hip back into the socket, a plaster cast is chosen. In the operating theatre, the hip head will then be placed back into the socket. After this, your child will be given a plaster cast. A plaster cast will stay on for about three months.
Possible complications with spreader shorts
- Crying: Your child may be a little weepy in the first few days (nights). This is because it can't move as much and has to get used to the sling.
- Pain
- Bleeding disorder: A well-known and annoying complication is the disruption of blood flow to the femoral head. This can occur while wearing a spread or plaster cast, but also after hip surgery. The disruption in blood flow can stop the growth of the head. One of the first signs of circulatory disorder is pain, causing your baby to cry loudly incessantly.
- Delay in motor development and later achievement of early motor milestones: this delay usually catches up quickly
Recovery and prognosis
A new hip ultrasound is done six weeks after starting the spreading treatment. There is no point in doing this earlier, as growing a proper hip head and socket takes time. If the treatment is successful, the spreading treatment can usually be phased out after 3 to 6 months. Around the first year, a pelvic radiograph is taken to see how the head and socket are developing. The later the hip deformity is discovered, the longer the treatment will take. The spreader shorts may cause your child to lag behind in the development of movement. Fortunately, this delay usually catches up quickly once the spread treatment is discontinued.
Paediatric physiotherapy
In our practice, we treat children with hip dysplasia and guide parents through handling and positioning advice and exercises for at home.
See also heading 'orthopaedic complaints'