Treating Older Children with Clubfoot

Original Editor - Africa Clubfoot Training Team as part of ICRC and GCI Clubfoot Content Development Project

Top Contributors - Naomi O'Reilly, Rachael Lowe, Kim Jackson, Manisha Shrestha, Simisola Ajeyalemi, Tony Lowe, Rucha Gadgil and Meaghan Rieke  

Introduction

“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.

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.

The Ponseti method with some additional surgery can be used successfully as the primary treatment in neglected clubfoot, and that it minimises the need for extensive corrective surgery. 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

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

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

Treatment Options

Surgical Treatment

In the past, 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.

• Often left a scarred stiff foot
• Recurrence could still occur
• Pain in adulthood because of damage to joints

Ponseti Principles

The older child usually responds to Ponseti casting; however, correction may not be complete and further surgical intervention may be required. 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. 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

Assessment

• 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
• The child should be observed standing and walking, and shoe wear examined.

Manipulation

• 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

Casting

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.

Tenotomy or Posterior Release

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.

Bracing

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.

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

• 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

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

References