CLUBFOOT

 CLUBFOOT

There are many causes of the clubfoot deformity, the most common cause is the congenital clubfoot children can be born with. (usually shows up 1 out of every 1,000 live births) This congenital clubfoot is generally treated just after birth with a casting technique called the ponseti clubfoot casting with excellent results. In the 1980s many of these congenital clubfoot infants were treated with a surgical procedure called the Turco release, with the ponseti casting technique used in only a very small handful of infants. Today, the main treatment is the Ponseti casting technique - not the surgery unless there is such a difficult case where the casting cannot provide an acceptable result.  ( to read more about the technique click this link : https://en.wikipedia.org/wiki/Ignacio_Ponseti )

Dr. Gitlin no longer performs infant ponseti casting unless there is the situation where a course of the casting technique was already attempted by a clubfoot specialist and that course has failed. If there is a recurrence after casting or a non functional result we may attempt to revise the casting technique and consider surgical intervention only if absolutely necessary.

Our specialty is fixing clubfoot in the older population by older we mean ages 6 and above. In cases between ages of 6 and 12 we may still try a course of ponseti serial casting even though it is a technique specifically for infants we have found it to be beneficial in some cases in adolescents. In older patients we usually use surgical techniques to create a straight foot. Some of these techniques include tendon lengthening and tendon transfer to balance out the foot. Other techniques involve cutting bone to straighten them or performing fusions ( arthrodesis is medical term for fusion ) and in some cases we use the ilizarov technique which is our main expertise. (to learn more about ilizarov technique click HERE)

Below was a 30 year old male who was born with clubfoot on the left photo you see feet before surgery, on the right photo you see we already fixed the left one. The right one was fixed a year later.

The ilizarov technique uses the external fixation device pictured below to slowly over the course of a few weeks to straighten out the lower limb, ankle and foot. This is reserved for the most difficult cases. We often treat clubfoot patients even as old as 70!!! In those older patients the clubfoot may not have been present at birth. Injuries, nerve damage, stroke, previous surgery can all be possible causes. And in a few cases patients have lived  with a clubfoot they were born with - with great difficulty - those are cases we utilize external fixation for.

Below is a 40 year old male who lived hi whole life with severe clubfoot deformity, on the left You can see on the left photo clubfoot in both feet, in the right photo you can see we have already fixed the left foot.

What is external fixation?

When bone surgery is done, to put bones back together , screws, pins or plates (we call this internal fixation) can be used. All of these are implanted under the skin and left inside the body usually. Sometimes when there is a reason the internal fixation cannot be used - a metallic scaffold is placed on the outside of the body, connected to the bones from the outside with thin wires ( they are 1.8 mm thick in case you are wondering, and sometimes bigger as needed). These fixators can stay attached to the body for up to two months to allow for the foot to heal in the proper position, then the fixator is taken off.

sound painful? usually not, the way the fixator attached to the bone makes in minimally uncomfortable at most. But again this really depends on the patient.

Below is a photograph of an external fixator on the above patients foot.

The photo series above show adult clubfoot before on left, then central picture shows an ilizarov external fixator  on the foot, then the post operative 'fixed' foot on the right photo. It takes about 2-3 months to get from before to after but it can change this persons life competely.

Why is it sometime called an ilizarov fixator or ilizarov frame?

here is why : https://en.wikipedia.org/wiki/Gavriil_Ilizarov

When do you use the external fixators?

If the foot is severely deformed like in the picture below you cannot just take the foot and pull it straight because you will pull the nerves and the blood vessels and this can lead something even as serious as gangrene and amputation. The external fixator allows us to slowly move the foot into its proper position by using a system of nuts and bolts and gears moving simultaneously and very slowly to create a straight foot (by the way we use the word 'rectus' to describe the straight foot)

Doc, Ive already had casting when i was younger, it was straight and now its turning again, what can you do?

That is a question we hear often, sometimes the patient had casting, other times the patient had surgery or even many surgeries over the years and the clubfoot comes back to some degree. This is called a recurrent clubfoot and we deal with this using many of the same techniques i describe briefly above. It is generally easier to deal with these than a full clubfoot correction. Below is a patient who was in an accident and sustained nerve injury. This led to an imbalance of the muscles on the leg that created a mild clubfoot deformity. Preoperative picture on left, post  operative photograph on right showing foot rectus .

Here below is another very bad case the two photos on the left side show before, the one on the right shows both feet fixed about 8 months after we started our treatment. Both were done with external fixation.