Clubfoot is the most common of malformations du pied. It is estimated that it affects, in France, 1 child for 1,000 births. For unknown reasons, this anomaly affects twice as many boys as girls. In 50% of cases, both feet are malformed. We are talking regarding bilateral club foot.
How to recognize a club foot?
The club foot corresponds to a congenital malformation, therefore present from the birth of the child. The baby is born with one or two feet in an unusual position, and it is not possible to straighten them with simple manipulations. “The foot is affected, but also the ankle. The calf is thinner than normal. And there may be a little difference in the length of your foot, which will be shorter than the other, with one or two sizes difference in adulthood”, describes Dr. Alice Fassier, pediatric orthopedic surgeon at the Lyon University Hospital.
Four characteristic abnormalities define what orthopedists call the “equine varus clubfoot” :
The varus foot
The rearfoot is incorrectly positioned and the ankle is turned inwards.
The equine foot
The child positions himself as if standing on tiptoe or tiptoe and his arch of the foot remains in flexion.
The cavus foot
Le pied was brought
The forefoot is turned inwards.
Why do we say clubfoot?
In an article in the specialist journal CME pediatricspublished in 2015, Dr. Fassier gives an explanation and reassures, in passing, the parents: “The term “bot” is defined by the Larousse dictionary as a permanent vicious attitude. This term retains a very pejorative connotation in the general population, despite the considerable progress made in recent decades in conservative treatment, allowing all treated children to have a normal life, wearing commercial shoes. she wrote. The expression is also used in orthopedic language to refer to hand malformations. We then speak of “club hands”.
Club foot: how is the diagnosis made?
The anomaly of the foot is sometimes spotted on ultrasound, during pregnancy. “But it’s not always easy to see, it all depends on the baby’s position,” emphasizes Dr. Fassier. In his department, 60% of the children cared for were diagnosed in utero. But statistics may vary from region to region. In all cases, the diagnosis of clubfoot is made as soon as birth of the child. L’physical examination enough. There is no need to perform x-rays.
How to assess the severity of clubfoot?
“In case of clubfoot, the child’s foot remains characteristically rigid. It is this rigidity that we are going to test and measure on a scale of twenty points, the score of Dimeglio. This is the most widely used quotation in France”, says Dr. Fassier.
- Between 16 and 20 points, clubfoot is considered very severe.
- From 11 to 15 points, it is severe. Dr 6 to 10 points, it is moderate.
- Below 5 points, it is not clubfoot but another foot anomaly.
What causes clubfoot?
Most often, the cause of clubfoot is not identified. We are talking regarding idiopathic clubfoot. The malformation gradually set in during the first trimester of pregnancy, for no known reason. In some very special cases, clubfoot is the consequence of other polymalformative syndromes or of neurological origin affecting the development of the fetus, such as spina bifida.
Is clubfoot hereditary?
“In some cases, clubfoot is of family origin. Families in which a child is born with clubfoot are more likely to give birth to another affected child. There is a hereditary part, but at present, no clubfoot gene has not been identified. The anomaly is likely multifactorial,” answers Dr. Fassier. Statistically, the risk of having a second child with clubfoot is 1 in 30.
How to correct a clubfoot?
Two methods are offered in France, depending on the hospital service taking care of the child: the Ponseti method and the functional method. “Today, the Ponseti method takes precedence over the functional method, because it is less complicated”, says Dr. Fassier.
The Ponsetti method
From its first week of life, the newborn is plastered so that change very gradually the shape of his foot. The plaster goes to the root of the thigh. It is changed every week to adapt to the morphology of the child.
For Dr. Fassier: Five casts are needed on average. But we ask as many as necessary, depending on each case.
Wearing the plaster is not painful, “but the pose can be uncomfortable for the child since it involves putting the foot in a different position”, admits Dr. Fassier. She recommends, to soothe the baby, “coordinate the change of plaster with the taking of a bottle of milk”. Pediatric paracetamol may also be prescribed. The entire care protocol including successive casts is 100% covered by Social Security.
In the Ponseti method, the cast corrects three foot anomalies : le cavus, l’adductus et le varus
To correct the equinusand the characteristic plantar flexion of the clubfoot, it will be necessary lengthen the Achilles tendon. This large tendon located at the back of the foot is too short in 85% of cases of clubfoot. “The operation consists of cutting its sheath to allow it to grow back longer”, explains Alice Fassier. This surgical procedure, called tenotomy, is performed at the age of 1 month, on an outpatient basis (no need to hospitalize the child for more than a day), under general or local anesthesia. The healing of the Achilles tendon then takes three weeks during which the child is once more in plaster.
After the successive casts, the child must wear a special sandal, fitted with a bar that keeps the foot in the correct position. That “derotation” splint is worn 22 hours a day at first. At the age when he begins to walk, the child only wears it at night and it is advisable to continue like this until he is 4-5 years old. This device is not fully reimbursed by Social Security. You have to turn to your mutual insurance company to obtain the supplement.
About 15% of children who have been treated with the Ponseti method require surgery between the ages of 5 and 10 to ” a enhancement surgery », in the words of Dr. Fassier. This consists of lengthening or transferring certain tendons of the foot in order to consolidate its position.
The functional method
In this approach, treatment begins with daily physiotherapy sessions, carried out over several weeks by a specially trained professional. The sessions are then spaced out at the rate of three per week. By manipulating the foot, the physiotherapist gradually corrects the various malformations of the foot.
Between each session, wearing a thermoformed splint and made to measure, taking the knee and the ankle, is essential. As soon as the child reaches the age of 1 year, the splint is kept only at night. It is also at this age that a intervention chirurgicale is carried out “à la carte”, according to Dr. Fassier, depending on the specific problems of the child. In any case, it is a heavier operation than that proposed in the Ponseti method. With this functional method, children can retain some joint stiffness.
At what age will the child walk?
The current management of clubfoot allows children to walk at normal age, that is to say around 18 months.
Parents should know that, except in special cases, their child will walk and ride a bike like all children. He will not be disabled, reassures the orthopedist.
Like all toddlers their age, most children born with clubfoot will be able to play sports. “However, this child will have little chance of being an Olympic champion”, smiles Dr. Fassier who specifies: “As an adult, he will probably have a reduced muscle capacity in the calf, less flexibility than the others and a heel that will not be strictly in the standard alignment. »
Club foot: what shoes to wear?
In France, the treatment of clubfoot makes it possible to dispense with orthopedic shoes which have traumatized previous generations. At the end of the treatment, the child will be able to wear “commercial shoes”assures Dr. Fassier.
The journey is long and particularly stressful for parents. “The more anxious the parents are, the more difficult it is”, observes the orthopedist. In her experience, the situation is better experienced when clubfoot has been detected during pregnancy, during antenatal ultrasounds, and when the parents have been seen for consultation by a specialist, which makes it possible to “de-dramatize the situation and reassure people regarding the very good results obtained by the treatment. »