The treatment of congenital clubfoot is generally divided into three distinct periods: the first year of life, after the first year of life, and the relapse prevention period.
First Period: Birth to One Year
The initial period begins immediately upon diagnosis, typically soon after birth. During this stage, conservative treatment methods are primarily employed. These include manual correction (redressment), physical therapy (PT), thermal procedures, and the use of corrective devices to maintain the foot in a properly aligned position post-treatment and redressment.
Conservative Treatment Approach
For the first 2–2.5 months, massage and plaster casts are avoided due to the delicate and underdeveloped nature of an infant’s skin. The risk of skin damage and subsequent infection, such as pustular diseases and sepsis, is significantly high during this early phase.
Rationale Against Early Plaster Casting
Plaster casts are also not used initially because the curing process of plaster generates temperatures up to 60°C, which can result in burns and severe skin lesions on the fragile skin of infants.
Enhanced Conservative Measures
Manual Correction (Redressment): Regular, gentle manipulation of the foot to progressively correct its position.
Physical Therapy (PT): Exercises and movements designed to strengthen the muscles and improve flexibility.
Thermal Procedures: Application of heat to improve blood flow and tissue pliability.
Corrective Devices: Braces and splints to maintain foot alignment following corrective procedures.
The emphasis on non-invasive methods during the first year is critical for minimizing complications and preparing the foot for potential surgical intervention if necessary.
This initial phase sets the foundation for successful long-term outcomes in the treatment of congenital clubfoot, focusing on conservative measures to avoid the risks associated with early invasive treatments.
Treatment commences with reduction—systematic correction of deformities and stabilization of the foot using flannel bandages as per the Fink-Ettlingen method. During the reduction process, the primary deformity components are sequentially addressed in a methodical manner: initially, gradual correction of foot supination and forefoot adduction, followed by the final adjustment of plantar flexion (equinus). The priority lies in aligning the calcaneus congruently within the calcaneo-tibial joint "fork," achieved through correction of supination and adduction, facilitating subsequent dorsal flexion at the calcaneo-tibial joint to address equinus. Each reduction session spans a minimum of 5-10 minutes, after which the foot is secured in its corrected position using soft bandaging in accordance with the Fink-Ettlingen technique.
Upon the skin's acquisition of protective function (typically around 2.5 months of age), soft bandage immobilization post-reduction gives way to corrective plaster casts resembling boots. These casts are replaced every 7-9 days, with intervals between changes filled by a comprehensive regimen of conservative measures: physical therapy, massage, further reductions as needed, thermal hydrotherapy, paraffin applications, among others.
For deeper insights into orthopedic techniques and management, consultation of specialized orthopedic literature and journals is recommended to enhance understanding of corrective procedures and their applications in pediatric orthopedics.
During corrective interventions, provided there is positive progression, treatment continues until hypercorrection of deformity is achieved. Complete resolution of all foot deformity components is imperative before the child begins walking, typically by around 1 year of age. In cases where conservative measures fail to achieve complete correction, surgical intervention is indicated. Soft tissue operations following the Zacepin method involve lengthening dysplastic muscle tendons. If necessary, surgical intervention is supplemented by ligament and capsulotomy of the calcaneo-tibial joint to comprehensively eliminate all deformity elements and achieve hypercorrection of foot position. Post-operative care includes a comprehensive conservative treatment regimen aimed at improving hemomicrocirculation in the ankle and foot tissues, stimulating dysplastic muscle growth, securing the foot in the correct position, and preventing deformity recurrence.
For older children who, for various reasons, were not operated on in a timely manner, surgical intervention is complemented by corrective wedge resections and osteotomies along the Chopart joint line to form the arch. Post-surgical management places significant emphasis on preventing recurrence. Orthopedic rehabilitation, orthopedic braces, and specially prescribed footwear, typically used for up to 3 years post-surgery or until growth completion, are extensively employed. It is crucial to note the significant predisposition to deformity recurrence even after surgical treatment. Therefore, post-operative efforts in therapeutic physical culture focus on restoring strength, functionality, and endurance of ankle muscles, along with prolonged use of corrective orthopedic boots, braces, and footwear.
For further exploration of orthopedic techniques and advancements in pediatric orthopedics, referencing specialized orthopedic literature and journals is recommended to deepen understanding and enhance clinical practice.
P.S. From my clinical practice: I am attaching photos of a surgical procedure involving corrective wedge resections and osteotomies along the Chopart joint line to form the foot arch, Achilles tendon lengthening, and skin grafting in a 2-year-old child. Following this surgical intervention, meticulous wound care is crucial. In cases of swelling due to venous stasis, hypertonic solution dressings are recommended. Additional immobilization of the foot with splints or plaster casts may be necessary. Subsequently, collaboration with a physiotherapist is essential for rehabilitation.
This comprehensive approach not only addresses the surgical complexities of pediatric orthopedics but also underscores the importance of post-operative wound management and multidisciplinary care for optimal outcomes.
For further exploration of advanced techniques and evidence-based practices in pediatric orthopedic surgery, continuous education and referencing specialized orthopedic literature and journals are indispensable to refine clinical skills and enhance patient care.
In my clinical practice, I present photographic documentation of a surgical intervention involving a 2-year-old patient. The procedure included corrective wedge resections and osteotomies along the Chopart joint line to reconstruct the foot arch, lengthening of the Achilles tendon, and skin grafting. Post-operative care is crucial, necessitating meticulous wound management. In cases of edema due to venous stasis, hypertonic solution dressings are recommended. Additional immobilization may be achieved using pins or plaster casts. Subsequent rehabilitation with a physiotherapist is essential for ensuring optimal recovery and functionality.
This comprehensive approach underscores the significance of precise surgical techniques and interdisciplinary post-operative care in pediatric orthopedics. Continuous education and referencing specialized orthopedic literature and resources are indispensable for refining clinical skills and enhancing patient outcomes.
Sources:
- Pre- and post-operative intervention examples from my practice.
- "Traumatology and Orthopedics: Textbook for Higher Medical Educational Institutions III-IV Years. National Textbook" by G.G. Holka, O.A. Buryanov, V.G. Klymovytsky.
- Schematic diagrams from The London Orthotic Consultancy (LOC) and L. Reid Nichols, MD, focusing on clubfoot care at Nemours Children’s Health.
Prepared by:
Dr. Vasil M. Shlemko, Orthopedic Surgeon
