| ||
| Vol. 22, No. 14 |
| August 1, 2000 |
|
Orthopedic Expertise Essential for Treatment of Clubfoot by RONDA WENDLER Shriners Hospitals for Children-Houston (Part 2 of 3)
One in 1,000 children in the United States are born with clubfoot each year. Part one of this three-part series followed the stories of 14-year-old Brandon and 6-year-old Brett Santee, brothers who were both born with talipes equinovarus, or clubfoot. They have completed their treatment for clubfoot and are considered "success stories" at Shriners Hospital.
Clubfoot is one of the most common, yet challenging pediatric foot deformities, says Shriners Hospital pediatric orthopedic surgeon Dr. Allison Scott. How to best treat clubfoot continues to be a controversial subject among orthopedic surgeons, she says. "Over the past several decades, considerable advances have been made toward understanding the cause and treatment of clubfoot. However, there is still no universally accepted method for classifying the severity of the deformity; no consensus on which type of operation is better; and no standardized method for evaluating the results of treatment," Dr. Scott states.
The goal in treating clubfoot is to achieve and maintain as normal a foot as possible. The extent of treatment varies, depending on the severity of each child's condition. Congenital clubfoot is usually mild to moderate, while clubfoot that accompanies other conditions is more severe. Most physicians agree that all infants should be given an initial trial of treatments that do not involve surgery, no matter how rigid the deformity. Nonoperative treatments include physical therapy, taping and splinting, and plaster casting. The earlier these conservative treatments are begun, the more likely they are to be successful, Dr. Scott says. "With the passage of time, untreated clubfoot only becomes more resistant to conservative treatments, so treatment should begin immediately in the newborn," she advises. To begin, doctors or physical therapists slowly "manipulate," or stretch out the tightened muscles and hold the foot in an improved position with a plaster cast. (Plastic splints and tape may be substituted if the child is premature and too small for casting). Casts extend from the toes to either just above or just below the knee. They are changed frequently, each time repositioning the foot a little closer to normal. For the first two to three weeks, the casts are changed every week. Cast changes are then decreased to once every two weeks. This treatment, known as "serial casting," continues until the child is 3 to 6 months old and involves between five and 10 applications of plaster casts. Manipulation and casting may be distressing to the infant for a short period only, Dr. Scott says, but the baby soon settles once rewrapped and cuddled. Complete correction, if it happens, will occur by the time the child is 3 to 6 months of age. Doctors differ widely in their opinions regarding the success rate of serial casting. Some say the procedure works only 5 percent of the time, while some believe almost all cases of clubfoot, when treated early and correctly, can be corrected with conservative therapy. Dr. Douglas Barnes, assistant chief of staff at Shriners, says serial casting works in 20 to 25 percent of cases, but this percentage could increase, he says, if more physicians were trained in proper manipulation and casting techniques. "Physicians with limited experience should not attempt to correct clubfoot with manipulation and casting. They may succeed in correcting mild clubfoot," he says, "but the severe cases require experienced hands." A well-intentioned doctor with inadequate training in serial casting can actually compound the deformity, he says, making further treatment difficult. "Clubfoot patients should be referred to a center with expertise in the management of clubfoot. An orthopedic hospital such as Shriners Hospital for Children, or a university medical school with a pediatric orthopedic practice have such experts on staff," Dr. Barnes explains. If the foot is too resistant to allow for adequate correction, then surgery is performed to lengthen or release the tight or shortened tendons and ligaments, allowing them to be positioned in normal alignment. Although at this point manipulation and serial casting have failed to correct the clubfoot, months of stretching and casting have prepared the skin well for surgery by stretching and making it more supple, Dr. Barnes says. Some surgeons prefer to operate when a child is 6 months old, while others opt to delay until 9 to 12 months of age. Those who prefer early surgery feel that the rapid growth of the foot during the first year of life should occur when the foot has already been corrected, resulting in better alignment. Those desiring to delay surgery say anesthesia is safer when a child is older, a larger sized foot is easier to operate on, and weight bearing on a recently corrected foot helps maintain the correction. Still other physicians believe the size of the foot is more important than the child's age and recommend surgery when the foot is eight centimeters or longer in length. At 4 months of age, Mitch Beito had surgery at Shriners Hospital to correct a left and right clubfoot. Now 6 months old, Mitch is well on his way to recovery. Not surprising, since the expert care Mitch received at Shriners Hospital was supplemented with personalized medical care from his dad Steve, a podiatrist specializing in medical care of the human foot. Mitch, Steve, mom Colleen and sister Allie regularly make the three-hour trip to Houston from their home in New Braunfels, Texas, to monitor Mitch's progress. So far, the prognosis is "excellent," says Steve. "We brought Mitch to Shriners Hospital in Houston because as a doctor, I knew that's where he would receive the ultimate care from specialists who see clubfoot cases every day," he says. Children with clubfoot do well with treatment, develop normally, and participate in most athletic or recreational activities they choose. But it is important for families to understand that a clubfoot will never be a normal foot, Dr. Barnes cautions. There will always be some degree of deformity although the corrected foot may appear nearly normal, and a child with one affected foot may require two different shoe sizes. Usually the calf muscle will be slightly smaller on the affected side. No two cases of clubfoot are identical, Dr. Barnes says. "Each clubfoot behaves differently and each case has its own personality," he says, stressing that a careful and detailed plan of care must be custom made for each child. Patients should be regularly monitored through maturity, he advises, because the growing foot may begin to revert to its uncorrected state. Recurrence is most common within the first two to three years of life, but may happen up to age 7. Relapses are not uncommon in severe clubfoot, and may be corrected by manipulation and two to three plaster casts. However, if the recurrence remains untreated, surgical correction is often required with repeat casting. Subsequent surgeries are much more difficult than the first procedure, Dr. Barnes says. "Having a clubfoot means many months of treatment and years of observation," he says. "It can be tedious and frustrating at times, but the reward is a foot that allows children to participate in all activities without restrictions."
©2006 Texas Medical Center E-Mail: tmcinfo@texmedctr.tmc.edu URL: http://www.tmc.edu/tmcnews/08_01_00/page_02.html |
