Pediatric ortho problems in India: tenotomy

CLUBFOOT / CTEV

Introduction

This is a very common deformity noticed immediately at birth and can be diagnosed in pregnancy time through repeat ultrasound examination. It might inadvertently be a cause for parents worry, if diagnosed during pregnancy. It is a surprise that many such parents come to me for advice on termination of pregnancy. I want to make it very clear that it is a 100% treatable condition and such dramatic decisions are not warranted. In India and other developing countries this perfectly treatable condition is commonly neglected, especially in rural setups. Over a period it becomes less amenable to conservative treatments and may result in a rigid foot, whereon surgery becomes a must.

Etiology and Incidence

Prevalence is 1 in 1000 in Indian population, with male child more commonly affected and in approximately 50% cases it is bilateral. Intrauterine overcrowding due to less amniotic fluid, twins, large baby, associated uterine fibroid can cause clubfoot due to mechanical pressure. There is no true reason for this deformity but there is an association with hip and spine disorders. It can also be found with multiple joint contractures or constriction band syndrome. Family history is also a predisposing factor. All babies born with CTEV must be screened on day 1 for Developmental hip dysplasia, spinal disorders or other syndromic associations.


USG study of a clubfoot baby

Management

Initial treatment is conservative with plaster casts. It must be started as early as possible preferably on day 1. These casts are above the knee level to prevent slipping out of plaster while the baby kicks and to control rotations. Parents have to be cautious regarding care of casts. They must keep them clean and dry by avoiding spilling of water or urine over the cast. These casts are put after gentle passive manipulation of foot and ankle to a corrected position, gradually the correction is achieved and sometimes even exaggerated to achieve slight over correction. It is important that weekly casts are changed for 4-6 weeks till only equinus deformity is remaining, which can be corrected by a percutaneous tenotomy followed by again casting, this last cast is continued for a total of 3 weeks. Later after removing the cast baby is put on a foot abduction orthosis for 23hrs a day till 3 months after which the splints are worn only at night times. Initially it is important to ensure compliance with braces and their fitting, so your doctor may advise you to come frequently for a month, once all is well followup once in every 3 months is sufficient. These shoes may need change frequently as the baby grows. Followup is necessary till 3-4 years of age to check compliance and detect recurrence early. For residual deformity various surgical procedures are available which can be done at appropriate age. In neglected and rigid clubfoot surgery is required. It can be done before walking age at around 9 months. Surgery involves soft tissue procedures to release the tight medial and posterior structures. Bony surgery may be needed at later age for residual deformities. Sometimes a tendon transfer is needed to correct a flexible adduction deformity. For more resistant and delayed cases an external fixator in the form of Rings or small rods are applied to slowly correct the deformity by gradual distraction.