Foot

Many problems of the feet in newborns result from the position of the fetus during pregnancy. Sometimes a foot is turned up or the child sits on the foot and molds it into a turned-in position. Later on, in childhood, foot problems, such as flatfoot, often occur and can be hereditary (can run in the family). However, additional factors such as obesity, lack of activity, and inappropriate footwear can increase the problem.

Although foot problems in newborns that result from intra-uterine molding (such as calcaneovalgus foot or metatarsus adductus) are benign and often resolve spontaneously, other deformities that present abnormal conditions of the soft tissue and bones need early treatment to achieve good functional outcome and prevent problems and pain later in life.

Metatarsus Adductus

Metatarsus adductus is usually seen right after birth. The forefoot is adducted (turned in) in relation to the hindfoot, giving the foot a banana-shaped or C-shaped appearance. This is a typical molding deformity and usually responds well to gentle massage performed by the parents. Occasionally, the deformity is more rigid and a cast and/or small orthopedic shoe is necessary for a limited time.

Calcaneovalgus Foot

With this molding deformity, the foot is turned up toward the shin bone and can even touch the shin. This can look dramatic; however, the deformity corrects spontaneously and rarely needs one or two casts to stretch out the foot more quickly. Physical therapy and bandaging the foot can also speed up correction.

Equinus Foot

An equinus foot points down from the ankle joint and cannot or can hardly be flexed upward. During walking, the heel cannot touch the ground and children walk on tiptoes. If this is only on one side, it usually results in a limp. In almost all cases, equinus foot results from a shortening or contracture of the Achilles tendon or calf muscles.

Physical therapy can be helpful in some cases, but others might require night-time bracing, medication, or casts. In resistant cases, surgical correction might be necessary.

Flatfoot

Flatfoot is the most common postural foot deformity in children. The inner arch of the foot is flattened, and the heel is more angled. Sometimes flatfeet are combined with knock-knees. Furthermore, we often see a combination of hereditary factors (such as increased flexibility of joints) and a weakness of the foot muscles.

Toddlers regularly present with flatfoot that improves or corrects spontaneously up to the age of 5 to 6 years. If spontaneous improvement does not occur, special activating (podological) insoles can strengthen the muscles and thus improve the arch of the foot.

If no improvement is achieved despite therapy and if the extent of the deformity and malposition of the foot create pain and problems later in life, surgical options should be discussed.

Clubfoot

Clubfoot is the most common congenital deformity at birth. The foot is stiff and turned inward. The shapes of some of the bones are different compared with those of normal feet, and the muscles and tendons are shortened.

Klumpfuß Kinderfuß Neugeborenes Baby Füße Fehlstellung

Clubfoot can be diagnosed before birth based on ultrasonographic findings, making prenatal counseling and planning of treatment possible. Treatment is usually started within the first 3 weeks of life. Almost all clubfeet can be corrected with the Ponseti method including a percutaneous minimally invasive sectioning of the Achilles tendon.

More invasive surgery is rarely necessary. Only some clubfeet that present as part of a neurological problem or a syndromic disorder might require open joint surgery.

An important part of treatment is night-time bracing and regular follow-up because relapse (recurrence) can occur during growth. If relapse is detected early, it can be easily treated and corrected.

In Austria, approximately one of 900 babies is born with a clubfoot. Clubfoot is seen more commonly in boys than in girls, and in approximately 40% of cases, the deformity occurs in both feet.

Etiology

The true etiology (cause) of clubfoot is still unknown; however, it seems to be multifactorial. Foot development occurs during the first trimester of pregnancy; therefore, clubfoot can be observed with prenatal ultrasound as early as the 16th to 22nd week of pregnancy. Sometimes a relative has clubfoot, and the condition is termed familial clubfoot. If a parent had a clubfoot at birth, the risk of clubfoot in an offspring is between 3% and 4%.

Patho-anatomy

Clubfoot is a complex deformity consisting of multiple components. Pathologic changes include those to the joints, bones, muscles, tendons, and ligaments to various degrees. In most cases, a so-called idiopathic (of unknown cause) or isolated clubfoot is found. This means that there are no other findings and that the child is developing normally.

Only a small percentage of patients has an additional disorder, such as arthrogryposis, a neurological disorder, or spina bifida. Those cases are summarized in the group of secondary or syndrome-associated clubfeet. Both kinds of clubfoot can be treated with the Ponseti method, with the success rate being higher in cases of idiopathic isolated clubfoot.

Treatment

In almost all cases, the foot can be completely corrected using the Ponseti method. The Ponseti method was developed by Ignacio V. Ponseti over decades and is currently considered the most effective and successful treatment of clubfoot.

The Ponseti method is a primarily nonsurgical form of treatment with which the foot is corrected by weekly delicate manipulation and application of above-the-knee casts for 4 to 6 weeks. This stretches the ligaments and tendons of the foot and gives the bones time to reshape through the corrective forces of the cast.

After the foot has been corrected, more than 90% of children require percutaneous tendo-Achilles tenotomy (pTAT). This is a small procedure during which the Achilles tendon is cut through a 5-mm incision with the patient under short-term general anesthesia. This allows the foot to be moved upward and then again fixed in a postoperative cast for 3 weeks. Because of the great healing potential in newborns and young children, the Achilles tendon heals completely and strongly in an elongated position.

After the last cast has been removed, a foot abduction brace is applied. The brace consists of shoes that are connected to a bar for the purpose of turning the feet outward. A risk after successful clubfoot treatment is recurrence of the deformity or parts of the deformity. Therefore, using the brace is necessary to preserve the corrected position of the foot. The brace must be used 22 hours a day for the first 3 months. After 3 months, the time in the brace is reduced until the brace is worn only at night and during naps.

The brace does not affect your child’s development. The beginning of walking is not or is only minimally (up to 2 months) delayed compared with children without a brace.

Only after the 4th year of life, depending on the foot shape and severity of the original deformity, can use of the brace be discontinued. In some cases, physical therapy can further promote the mobility of the foot.

Klumpfuß Baby Orthopädie
This girl was born with a clubfoot. Treatment began a few days after birth.
Klumpfuss geheilt nach Therapie
Three years after treatment began, the foot shape is completely normal and hardly any difference can be seen between the two sides.

Regular follow-up is necessary, to adapt the bracing protocol to growth and development, and to screen for signs of bracing problems or recurrence. Relapse (recurrence) during the first years of life can occur because of problems with bracing. In most cases, two to three casts and a return to bracing is enough to correct mild relapse at that stage.

Even when bracing is sufficiently accomplished, the foot can start to turn in again. This is usually a result of a muscle disbalance, with the tibialis anterior muscle being stronger in relation to the other muscles, which are generally mildly weaker in clubfoot (especially the peroneal muscles). The relapse is dynamic in the beginning but can be improved over time. In those cases, a tibialis anterior tendon transfer might be necessary, which is most commonly done when the patient is age 4 to 6 years. Depending on the components of relapse, percutaneous Achilles tendon lengthening and/or percutaneous plantar release might be added to the treatment.

The Ponseti method and the described treatment of relapse allow correction of almost all cases of idiopathic clubfoot. In rare cases of secondary or syndromic clubfoot, a residual deformity or relapse might necessitate more extensive surgical release.

For older children, Ponseti casting is still the first line of treatment of relapse and addresses especially the subtalar joint. Tibialis anterior tendon transfer with percutaneous Achilles tendon lengthening and percutaneous plantar release can correct the other components of the deformity. Closing and/or opening wedge osteotomies in the midfoot bones can be added if this part of the deformity is fixed in children older than approximately 10 years.

In extremely rare cases, after multiple surgical attempts to correct the clubfoot and/or in the presence of skin and/or other soft tissue problems, gradual correction using external fixation might be necessary. With a six-axis external fixation frame, it is possible to slowly bring the foot into a plantigrade position. This allows normal footwear and improves walking, but foot function often remains limited.

The most important step toward a functional pain-free foot is applying the Ponseti method, and ensuring that bracing prevents relapse of the deformity.