Treating Older Children with Clubfoot

Introduction[edit | edit source]

“Untreated” clubfoot is defined as a clubfoot that has had no treatment before walking age which is usually about 1 year. Once a child starts walking on an untreated clubfoot, the lack of treatment leads to the clubfoot being defined as “neglected”. The neglected clubfoot presents with bony deformity as the bones ossify according to how the child has been weight-bearing on them. Neglected clubfoot deformity is a major cause of disability in low-income countries[1][2]. As many as 50% of children worldwide with clubfeet receive no treatment.[3]

Older children may also have recurrent clubfoot, if they have once been satisfactorily treated but the deformity has recurred and they have continued to walk on it. [4]Major reasons for relapsed/residual clubfoot include incomplete application of the Ponseti principles, inability to adhere to the foot abduction brace protocol, failure to recommend a complete course of bracing and inadequate follow-up. Despite of excellent treatment, there are still relapses, related to intrinsic muscle imbalance.[3]

The Ponseti method can be used successfully as the primary treatment in neglected clubfoot[2], some additional surgery may be required but it minimises the need for extensive corrective surgery[1][5]. Experts agree that the best approach in all ages is to cast in order to gain as much correction as possible for a number of weeks before going to surgery. However, there is not clear consensus on treatment in older children, what is presented here is considered best practice based on the small (but growing) body of evidence around this. 

Specific Problems for Older Children with Clubfoot[edit | edit source]

Older children with neglected clubfeet or recurrent clubfoot deformity have specific problems:

  1. Physical and Social Considerations[4]
    • Stigma
    • Restricted from participating in normal social activities
    • Reduced school attendance
    • Reduced Marriage Prospects
    • Limited Job Opportunities
  2. Pain Due to Abnormal[4]
    • Pressure on Skin
    • Joint Loading
    • Transmission of Load
  3. Skin Problems
  4. Inability to Wear Regular Shoes

Treatment Options[edit | edit source]

Treatment of children less than ten years old may still start with a regular Ponseti protocol, as many of these previously untouched feet can be surprisingly supple. Despite some success achieved with this type of late casting, the majority of patients in this group will need some kind of operative intervention. Success of treatment is inversely proportional to the age at the time of treatment. The first line of treatment should be a course of casting independent of the severity and age.[3]

Surgical Treatment[edit | edit source]

In the past, the standard treatment for neglected clubfoot has been extensive surgical intervention. Extensive operations were performed in older children with fixed deformity to release the tight tissues on the medial and posterior aspects of the foot. If correction could not be achieved then bone resections were also undertaken. This approach is technically demanding, costly, and has a significant rate of complications even in the best hands[1]. Children are often left with a scarred stiff foot, potential for recurrence and pain in adulthood because of damage to joints[4]. But this study conducted by Eidelman et al. has shown that external fixation using a hexapod Miter frame that may simultaneously correct all components of clubfoot deformities might be an effective solution.[3]

Ponseti Principles[edit | edit source]

The older child usually responds to Ponseti casting; however, correction may not be complete and further surgical intervention may be required[4]. Work currently being done in Ethiopia suggests that the midfoot can be corrected well in older children but a limited posterior release is usually needed[1]. Serial cast treatment should therefore always be tried in older children to get as much correction as possible.

Several adaptations to the standard Ponseti manipulations and casting need to be made to adapt the treatment to older children. Treatment should also be undertaken in partnership with a surgeon who is able to do the limited surgery that might be needed to complete the correction.

Modifications to the Ponseti Method for Older Children[edit | edit source]

Assessment[edit | edit source]
  • The Pirani scoring system does not always reflect the true extent of deformity in older children. At present there is not an agreed scoring system for these children but it is important to note and record: equinus deformity, varus deformity and forefoot adduction and uncovering of talar head - especially whether this is flexible or rigid [4]
  • The child should be observed standing and walking, and shoe wear examined.
Manipulation[edit | edit source]
  • Should be done using Ponseti principles of abducting the forefoot using the talus as the fulcrum, but using the ball of the manipulator’s hand on the head of the talus rather than the thumb
  • Manipulations should be done for longer, e.g. 5–10 minutes
  • Abduction is not possible to 50-70 degrees as in infants, and usually only 30–40 degrees is reached
  • Manipulations need to be continued for longer as the foot is not as supple as an infant’s and can take much longer to correct. Our experience is that 10–12 weeks of serial casting is normal to fully correct the forefoot [4]
Casting[edit | edit source]

This should be above the knee, but as the child is bigger and the plaster less likely to slip off, a reduced amount of knee flexion can be allowed: 30–60 degrees is satisfactory. The POP will need to be strong as these children will try to walk. Fibreglass strengthening or car tyre slippers may help protect the cast. Some hospitals set up hostels for accommodation of older children as the length of treatment will be so long. Hostel care may also allow feeding to improve nutrition before surgery and help healing. [4]

Tenotomy or Posterior Release[edit | edit source]

Once the forefoot is abducted and the talar head covered then tenotomy or a more extensive posterior release is needed. Because of the child’s age and size this is done under general anaesthesia. Often the surgeon will progressively release tight posterior structures until the ankle dorsiflexes. After the tenotomy it may be necessary to do weekly cast changes to increase the amount of dorsiflexion. [4]

Bracing[edit | edit source]

It is unlikely that older children will tolerate a night-time FAB, but this is worth trying in those under 4 years. The bracing regime is different to younger children as there is no period of 23-hour use due to the child being active and walking. Older children benefit from an Ankle Foot Orthosis (AFO) for a year if this is available. [4]

Further surgery may be necessary at a later stage. For example[4]:

  • Tibialis Anterior Tendon Transfer (TATT) to balance the foot
  • Soft tissue release, especially of posterior structures
  • Bony procedures to correct deformity.

Key Considerations in Ponseti Treatment in Older Children[edit | edit source]

  • Longer Treatment Period
  • Committed Parents
  • Committed Practitioners
  • Transport Logistics
  • Accommodation
  • Some Posterior Surgery likely to be needed[4]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 Ayana B, Klungsøyr PJ. Good results after Ponseti treatment for neglected congenital clubfoot in Ethiopia: A prospective study of 22 children (32 feet) from 2 to 10 years of age. Acta orthopaedica. 2014 Dec 1;85(6):641-5.
  2. 2.0 2.1 Adegbehingbe OO, Adetiloye AJ, Adewole L, Ajodo DU, Bello N, Esan O, Hoover AC, Ior J, Lasebikan O, Ojo O, Olasinde A. Ponseti method treatment of neglected idiopathic clubfoot: Preliminary results of a multi-center study in Nigeria. World Journal of Orthopedics. 2017 Aug 18;8(8):624.
  3. 3.0 3.1 3.2 3.3 Eidelman M, Kotlarsky P, Herzenberg JE. Treatment of relapsed, residual and neglected clubfoot: adjunctive surgery. Journal of children's orthopaedics. 2019 Jun 1;13(3):293-303.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 Africa Clubfoot Training Project. Chapter 14 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.
  5. Lourenço AF, Morcuende JA. Correction of neglected idiopathic club foot by the Ponseti method. Bone & Joint Journal. 2007 Mar 1;89(3):378-81.