Common Errors in Clubfoot Management

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

Top Contributors - Naomi O'Reilly, Rachael Lowe and Meaghan Rieke  

Introduction

Although the Ponseti method is accepted as the best choice for treatment of clubfoot, the treatment protocol is labor intensive and requires strict attention to details. Deviations in strict use of this method are likely responsible for the variations among centers in reported success rates[1].

Failure to adhere to details, such as manipulation, type of brace, bracing protocol, and relapse management, might affect whether one obtains a good outcome. Here we examine the whole sequence of treatment pointing out the places where common errors occur. This is a useful aid for those involved in supervision and mentoring as it shows the places where mistakes are made and where special emphasis should be made in teaching and demonstrating. Common mistakes are listed in chronological order so you have an overview of the whole treatment process, pointing out where the mistakes are usually made. [2]

Common Errors in Manipulation

Pronating the Foot as a First Procedure

When someone who does not know the Ponseti procedure first sees a clubfoot, they instinctively want to pronate it as that seems to them to be the way to correct the deformity. The foot may look a little better after pronating, but in fact the deformity is made worse and the cavus is increased. [2]

Pressure over Calcaneum when Abducting the Foot

Blocks movement of the calcaneum. [2]

Abducting the Foot by Holding the Leg at the Ankle or Above

This is an error as it puts a rotation force on the talus and this can cause the fibula to be forced backwards. This error can be corrected by making sure that the thumb is on the head of the talus. [2]

Failure to Fully Abduct the Foot

This is an error, because only when the foot is fully abducted is the calcaneum properly corrected, and only then is the foot ready for dorsiflexion. Abduction should be to at least 50 degrees. [2]

Pushing the Foot into Dorsiflexion Too Early

If the foot is pushed into dorsiflexion before the midfoot is corrected, or too much force is used, then the foot can “bend” in the middle which results in a “rocker bottom” foot. It can also result in a lot of pressure on the talus which can then flatten and form a “flat top talus”. The key to avoiding these problems is to make sure that before starting to dorsiflex the talar head is fully covered, there is at least 50 degrees of abduction of the foot, and the heel is in neutral to valgus. [2]

Errors in Casting

Trying to Apply Cast Alone

This is very difficult as it is not possible to control the leg and also apply the cast on one’s own. The ideal team is a parent to comfort the child, the manipulator to hold the leg, and the caster to apply the POP. [2]
Remember: “TWO People to Cast” [2]

Not Holding the Foot in the Corrected Position during Cast Application

If the foot is not held in the corrected position while the cast is applied then this can result in incomplete correction. If the correction is then done after the POP is applied it can cause folding up or wrinkling up of the POP, which can cause pressure sores. [2]

Early Removal of Cast

If casts are taken off at home then there is a possibility that the foot position will deteriorate. It is therefore important that casts are removed at the clinic. Parents should bring their children early in good time for this. Observing the condition of the cast before it is removed is useful for you to see where the cast may need to be reinforced and how well it is maintaining position. [2]

Below-Knee Casts

These are a mistake as they cannot keep the foot abducted. They can also slip off more easily. Casts should be from the toes to the top of the thigh. [2]
Remember: “Toe to Groin Casts”. [2]

Poor Casting Technique

If too much padding is used, or not enough moulding, then the child’s foot can slip up inside the cast and the deformity can worsen. It is important to use a thin layer of padding and to make the casts well-fitting. Also parents should be told to come back immediately if the foot disappears inside the cast. [2]

Applying Too Much Pressure

Too much pressure on the lateral head of talus can result in indentation of the plaster of Paris and blisters or pressure sores. The pressure over the head of the talus should be gentle and hands should keep moving while applying and moulding the casts. [2]

Common Errors During Tenotomy

Injecting Too Much Local Anaesthetic Solution

This can make palpation of the tendon very difficult because the tissues swell, and therefore it is difficult to find the tendon and to cut it. Only inject 0.5 - 1ml in babies. [2]

Performing a Tenotomy That is Too Low

The incision in the picture below is too low and can risk damage to the calcaneum. Make the tenotomy at 1 - 1.5cm above the insertion of the tendo achilles. [2]

Incomplete Tenotomy

There should be a “pop” or “snap” as the tendon gives way, and the foot should immediately move into dorsiflexion. If this does not happen then it is likely that the tendon was not properly divided and you should consider repeating the procedure if necessary. [2]

Common Errors During Bracing

Failure to Use the Foot Abduction Brace

This is not a very common error, but it does happen, especially when parents are really delighted with the correction of the initial deformity. It has to be made clear to them at the beginning that the brace is crucial for 4–5 years after correction. [2]

Attempting to Fit a Brace Before the Foot is Fully Corrected

If the feet are not fully corrected then bracing is seldom useful. Feet that are still in equinus often slip out of braces. It is important to review the correction phase and get feet well-corrected and in dorsiflexion before bracing. [2]

Poor Brace Design

The bar may not be wide enough, the affected foot may not be abducted to 70 degrees, and the shoe may have a high back, which helps lever the foot out of the shoe. There should be a low back to the heel to stop this happening. [2]

Communication Errors

Misunderstandings about the treatment process are common and it is important to communicate clearly to parents about how long the process will take, and what to expect. It is especially important to emphasize the risk of recurrence if the treatment is not followed carefully and the bracing is stopped early. It is also important for parents to know that, if the deformity does recur, they should come back to clinic as this can be dealt with. [2]
Remember: “Talk to Parents from the Start, especially about Braces!” [2]
Remember: “Keep Talking to Parents” [2]

References

  1. Zhao D, Li H, Zhao L, Liu J, Wu Z, Jin F. Results of clubfoot management using the Ponseti method: do the details matter? A systematic review. Clinical Orthopaedics and Related Research®. 2014 Apr 1;472(4):1329-36.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 Africa Clubfoot Training Project. Chapter 11 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.