HISTORY OF CLUBFOOT MANAGEMENT

Over the years approaches to the management of clubfoot have changed and evolved. Numerous surgical, conservative and mixed treatment techniques have been utilised with varying levels of success. In the past decade the Ponseti method has become widely recognised as the gold standard for clubfoot treatment. 

Early non-operative management

As early as 400 BC, Hippocrates described clubfoot and recommended non-operative treatment using manipulations and bandages – remarkably similar to the treatment techniques commonly in use today:

‘manipulate the foot as if holding a wax model, not by force, but gently’ 

Clubfoot treatment brace used in 1806- Source: Wellcome images

Later, forceful manipulations were used to correct the deformity. One of the most infamous of these was a wrench devised by Thomas (1834-1891) which was used to forcibly change the position of the foot. Not surprisingly, these techniques resulted in injuries to many patients and poor outcomes. 

Thomas Wrench - Source: RCPSG archives 

Surgical management

Surgical management of clubfoot became popular in the 1970’s, 80’s and 90’s. There are many different types of surgical technique described for treating clubfoot. Two of the most widely used are the postero-medial release (PMR), an extensive release of the tight and contracted soft tissues of the clubfoot and the ‘a la carte’ approach which aims to correct various components of the deformity depending on the presentation of the individual. 

Surgical management of clubfoot can correct the deformity and give the patient a foot which looks more normal and functions well at first. However, several long-term follow up studies have demonstrated that the outcomes of surgical management are not as good as initially thought. Over time surgically treated feet become painful, stiff and show weakness and early arthritic changes. These symptoms all cause limitation of activity which one study that followed up patients treated with soft tissue release at 30 years found to be comparable to the disability caused by Parkinson’s disease and chronic heart failure. Surgical treatment can also be expensive and result in higher numbers of complications, such as infection compared to other techniques.

Illustration showing early surgical management of clubfoot in the 1800's - Source: Wellcome images

Conservative management

Conservative techniques primarily achieve correction of clubfoot by slowly stretching tight structures, allowing time for soft tissue remodelling and for the position of the bones in the foot to be corrected.

The Kite method is a conservative technique for treating clubfoot developed by Dr Kite in the USA in the 1930s. Kite sought to find a non-invasive treatment strategy for clubfoot after he became dissatisfied with the poor results of surgical treatment. Kite’s method of treatment consists of a series of manipulations and castings followed by night splinting with the feet held in dorsiflexion and slight abduction.

Kite reported good outcomes with non-invasive treatment in 800 cases of clubfoot. These outcomes were not reproducible in further studies, however and up to 90% of children treated using the Kite method needed additional surgical, soft tissue releases. These unsatisfactory outcomes were attributed to two main factors: anatomically inaccurate method of manipulation of the foot which prevents the deformity from resolving and the use of short leg (below knee) casts which are inadequate to hold the corrected position of the foot . The Kite method also requires high numbers of castings and it may be up to two years before the deformity is corrected.

The ‘French’ or ‘functional’ method of clubfoot treatment is another conservative technique used in different parts of the world. This method uses daily manipulation and stretching of the foot, stimulation of underactive muscles and strapping of the foot to hold it in position, all carried out by a physiotherapist. In high income settings this method has been found to significantly reduce the need for clubfoot surgery and, in one study, to have comparable outcomes to the Ponseti method. However, possibly due to the higher level of input required by the French method parents in the USA were twice more likely to select the Ponseti method of treatment than the French method for their children.

The Ponseti technique

The Ponseti technique combines conservative techniques of manipulation and casting and a small surgery in the form of an Achilles tenotomy. The Ponseti technique was developed in the 1960s by Dr Ignacio Ponseti at the University of Iowa in the USA. He devised the technique after observing poor outcomes of clubfoot surgery and extensive study of the anatomy of the foot and ankle.

The Ponseti technique was slow to catch on at first and has only been accepted widely within the last decade. However, in recent years studies have shown that when applied correctly, the Ponseti technique can achieve correction of the clubfoot deformity in up to 98% of cases. A long term follow up study 30 years after treatment found very favourable treatment results, with ‘excellent or good’ foot function demonstrated in 78% of individuals with clubfoot compared with 85% of matched individuals without congenital foot deformities. These outcomes have led to the current situation in most high-income countries and many LMIC where the Ponseti method is the treatment of choice for clubfoot by most orthopaedic surgeons.

SOURCE: GLOBAL CLUBFOOT INITIATIVE

IMPORTANT INFORMATION ABOUT CLUBFOOT

WHAT IS CLUBFOOT

Clubfoot is a complex, congenital deformity of the foot also known as ‘congenital talipes equinovarus’ (CTEV) caused by the abnormal development of a baby’s bones, ligaments and muscles whilst in the womb1.

Visually, the foot affected by clubfoot appears to be twisted inwards and downwards.  The foot will be shorter than a normal foot and the calf muscles of the affected limb will be smaller2. The deformity will feel ‘fixed’ – not able to be corrected manually and will not resolve on its own3.

Clubfoot

Around the world, 150,000 – 200,000 babies with clubfoot are born each year.  Approximately 80% of these will be in low and middle income countries. The incidence of clubfoot varies around the world.

The exact causes of clubfoot are not known. Scientific studies have found that familial inheritance, genetics and environment are all likely to be factors which interact to cause clubfoot but how this happens is not well understood. Clubfoot can occur in either one or both feet – bilateral cases of clubfoot account for around 50% of cases. It is almost twice as common in males as in females.  

Source: Global Clubfoot Initiative

JENNIFER WAMBUI: OVERCOMING ALL PHYSICAL CHALLENGES TO BECOME A GOSPEL ARTIST!

This song serves as a true testimony in my life. God has fought all the battles for me and I no longer have fear in my life. You may be undergoing some difficult steps in your life right now but don't you worry because God is under control. MPay the song be an inspiration and a motivator in your life to reach greater heights. Bless you all!

Jennifer Wambui is the President and Executive Director, Clubfoot Correction Awareness Initiative, CaCAI. She is a TV actress (NASWA, CITIZEN TV), a gospel artist (goes by the stage name Jenny Msanii) and a photography model.

THE POWER OF GOING BEYOND PHYSICAL LIMITS

Jessica Cox: Pilot born without arms on flying with her feet

Jessica Cox was born without arms as a result of a rare birth defect.

That has not stopped her from living her life to the fullest. In fact, Ms Cox has experienced and achieved more than most people do in a lifetime.

She can drive a car, fly a plane and play piano - all with her feet.

In 2012 she married Patrick, her former Taekwondo instructor (she has two black belts). They live in Tucson in the US state of Arizona.

Ms Cox, 30, travels around the world as a motivational speaker, using her own life as an example of what one can achieve if one wants it enough. This month she will visit Ethiopia to help promote disability rights.

Source; BBC

CLUBFOOT DEFORMITY IN KENYA

Children with physical disabilities are quite often socially and economically disadvantaged. Educational opportunities are reduced through selection bias and because of transportation difficulties, employment opportunities are reduced for similar reasons. In addition, mothers of children with physical disabilities have to spend more time looking after them and therefore have less time for other children or for domestic and other economic activities. This often results in a reduced standard of living for the entire family.

Like many developing countries, Kenya has a considerable number of children with physical disabilities and one out of three of these children have a clubfoot.The incidence of clubfeet is 1 per 1000 live births. Around 1400 children with idiopathic clubfoot are born every year in Kenya  Many of these children are receiving little or no treatment for their foot deformity for reasons such as;

a) Clubfoot deformity is not recognized at birth: Many birth attendants particularly in rural areas are unaware of the clubfoot deformity and the need for early treatment

b) When recognized there is no treatment available: Even when identified, lack of trained (para) medical personnel result in treatment being unavailable

c) Inadequate treatment: Many (para) medical personnel have not had an opportunity to upgrade their skills over the years and are therefore unaware of the Ponseti method of managing the congenital clubfoot. The Ponseti Method has been shown to be the most effective method of correction)

WHAT IS CLUBFOOT

What is Clubfoot?

Clubfoot, or talipes equinovarus, is a treatable birth defect that affects approximately 150,000-200,000 children each year.  

When clubfoot occurs the foot is twisted inward and down, and this condition occurs during development in the womb.

Physicians have observed that fetuses that develop clubfoot start with a normal foot and then the foot begins to turn inward around the third month. 

Most children born with clubfoot are not missing any bones, muscles, or connective tissue. It is a congenital condition, meaning that when it occurs it is always present at birth.

It is one of the most common congenital deformities. One or both feet may be affected and the affected feet can range from relatively flexible to stiff and rigid.

The condition is not painful for the new born, though when a child gets to walking age, walking with an uncorrected clubfoot can be very painful and difficult, if not impossible.

Source: PONSETI INTERNATIONAL

MESSAGE FROM THE PRESIDENT AND EXECUTIVE DIRECTOR, CaCAI

Jennifer W. Karanja, President and Executive Director, CaCAI

Capped in few words, I am an aesthete. I love and appreciate arts and culture. My involvement in the entertainment industry attests to this. I am a gospel artist, TV actress and a photography model. For people to appreciate what I do, they must be happy. Sometimes happiness is hampered by factors extraneous to us. I am alive to this fact. 

The essence of a human being is humanity. With a humane heart, you can help those bereft of happiness get the almost elusive joy. I have taken cognizance of this noble fact. To achieve this end, I founded CLUBFOOT CORRECTION AND AWARENESS INITIATIVE.

I strive to help children born with Clubfoot as well as raise awareness on the same. This is my duty. I am duty-bound to do this. Why? Because I know what it is to be born clubfooted. My left leg was clubfooted when I was born. The condition was not detected early leading to poor treatments by inexperienced doctors. There is no doubt it was painful and the results were poor. 

My left leg remains weaker, cannot wear heeled shoes  or perform some fitness exercises. If my parents had the information I have today about clubfoot, things would definitely be different. I would have been treated in the right time, through the Ponseti Method, which is pain free, inexpensive and effective. All what am missing today would all be at my disposal. 

I am not alone in this. There are many people out there who missed the opportunity to correct clubfeet the right way. With this knowledge, I am out to ensure no one misses such an opportunity. I have joined hands with like- minded persons to spread all the relevant information about clubfoot to arm people well in case they encounter one.

I am also determined to show people who missed the correct medication that, the world is not over for them. They can still set and achieve goals. Dream and actualize dreams. I have done this personally. I am a gospel artist, a TV actress and a photography model. Everyone can as well. ALL IS WELL.

You are welcome to enable me make children born with clubfoot and their close relatives smile! With your support, no matter how small you feel it is, someday, the once clubfooted individuals will hold their chest close to their heart and say, ALL IS WELL WITH MY FEET!

Thank you and God bless you all.

Jennifer Wambui Karanja

Why ALL IS WELL WITH MY FEET slogan?

The choice of the slogan ALL IS WELL WITH MY FEET was inspired by the 3 IDIOTS, a Bollywood movie, and the "Highest grossing Bollywood movie of all time". The words said by Rancho (Aamir Khan) ,all is well, inspired us to coin a slogan out them. The words are stoic and motivating when life seems to have come to a standstill. 

Individuals born with clubfoot or whose loved ones are clubfooted should wake up and rejoice since clubfeet are treatable. All is well since there is a pain free, inexpensive and effective method to cure clubfeet. All is well with my feet since after the right treatment, the feet are back to their natural state.

All is with my feet since world over, clubfooted men and women have overcome the condition and the attendant stigma to rise to the apex of their careers against all odds. If you have clubfoot or your dear ones are clubfooted, DON'T WORRY. HOLD YOUR CHEST CLOSE TO YOUR HEART AND SAY TO YOURSELF, ALL IS WELL WITH MY FEET!

A BRIEF HISTORY OF CaCAI

About Clubfoot Correction Awareness Initiative, CaCAI

Virtually in all developing countries, the most pressing human need is the abject lack of unlimited access to good healthcare. Thousands die of treatable illnesses, while those that manage to survive, more often than not become physically debilitated. The largest population in the developing countries is ignorant or has scant information about most illness conditions afflicting them. With this ignorance, people are left to conjure up explanations about the causes of certain diseases, and very often attributing them to witchcraft, curses or other traditional myths. This leads to the stigmatization of the affected members of community leading to their seclusion if not expulsion from the mainstream society. 

It is against this similar background that gave the ground for the founding of CaCAI. Its President and Executive Director, Jennifer Wambui Karanja was born with a clubfoot on her left leg which was a beginning of a series of painful operations, six in total.This condition was unheard of and was taken as any other form of disability. Her parents desperately looked for medical interventions unsuccessfully since there were no specialized clubfoot correction wards in public hospitals.

Jennifer was subjected to painful surgeries that only ended up in exacerbating her condition as well as hampering her studies in school. When everyone had despaired, a knight in shining armor came in form of a family friend, which was a major turnaround in Jennifer’s clubfoot condition. She was referred to AIC CURE Kijabe, known then as Bethany kids where she received a specialized treatment for clubfoot. This gave her the hope of leading a normal life just like her friends in school. She was now able to walk without limping too much as was the case before the treatment, and her shoes could now last longer.

One thing remains clear in her mind today after digesting useful information about clubfoot; that if there was an early specialized clubfoot correction, her condition would have been corrected through a pain free method and her left leg would have been far much better than it is today. Today, she can only wear boots since her left foot cannot walk on heeled shoes. She admires women in heels but she painfully knows that she cannot wear them. A closer look of her walking style will notice a limping. She knows this. Jennifer decided not to let any other person go through what she underwent or miss what she misses today. To achieve this, she founded CaCAI. Against all odds!

CaCAI’s core mission is to raise awareness on the need for early correction of clubfoot. Early intervention is pain- free, inexpensive and effective. CaCAI roots for the Ponseti Method. As the brains behind the Ponseti Method, Ignacio Ponseti, M.D. puts it, "Parents of infants born with clubfeet may be reassured that their baby, if otherwise normal, when treated by expert hands will have normal looking feet with normal function for all practical purposes. The well treated clubfoot is no handicap and is fully compatible with normal, active life."

The majority of clubfeet can be corrected in infancy in about six to eight weeks with the proper gentle manipulations and plaster casts. The treatment is based on a sound understanding of the functional anatomy of the foot and of the biological response of muscles, ligaments and bone to corrective position changes gradually obtained by manipulation and casting.

Our Slogan is;

All is well with my feet!

Our Mission is to;

Raise awareness on the need for early detection and correction of clubfoot through the Ponseti Method of clubfoot intervention.

Our Objectives are;      

  

•      Disseminate all the useful information about clubfoot to people. The information includes clubfoot causes and the best correction methods

•         Sensitize people on the importance of early detection and correction of clubfoot

•  Execute awareness campaigns that will debunk the myth that clubfoot is caused by curses, witchcraft and other traditional beliefs

•       Campaign for the Ponseti Method of clubfoot correction

•   Liaise with organization with similar objectives to raise awareness on the advantages of early clubfoot correction via the Ponseti Method

•     Look for donors to fund the full/partial medication of indentified needy clubfooted individuals

•  Join hands with celebrities that had suffered or had/have a personal experience with clubfoot to raise awareness about clubfoot as well visiting clubfoot victims to motivate them

   

•         Inspire clubfooted individuals by showing them success stories of other clubfooted personalities

 Kindly join us in making  individuals born with clubfoot condtion smile and say, ALL IS WELL WITH MY FEET!