Clubfoot: Why it happens and how doctors treat it

Clubfoot is a condition in which a newborn's foot or feet appear to be rotated internally at the ankle. PHOTO/FILE. 

Every Thursday, a group of mothers travel to Mulago National Referral Hospital. These are mothers of children born with clubfoot hoping to meet experts who will save their children’s feet from deformation. 

Diriisa Kitemagwa, the principal orthopaedics clinical officer at the hospital, says clubfoot is a range of foot abnormalities usually present at birth (congenital) in which a baby’s foot is twisted out of shape or position. 
Kitemagwa stresses that these congenital abnormalities can be corrected if the operation is carried out shortly after the baby is born.

Successful operations
Anita Namutebi, a resident of Salama Road Village in Munyonyo, is one of the mothers whose baby was born with the defect but it has since been corrected. The 29-year-old mother of three says her other children were born without any defects andshe was traumatised by her youngest child’s condition. 

“However, I am grateful that my husband Dan Kasaga gave me emotional support. I also received advice from my brother that the defect could be easily corrected,” says Namutebi. 

The baby underwent corrective surgery when she was two months old. “After the operation, she was given special shoes to help straighten her legs,” she recounts. The baby girl’s limbs are now free from any deformity.
She urges mothers of children born with such conditions to act urgently and seek medical attention at Mulago National Referral Hospital where services are free of charge. 
Dr Mallon Nyati, a consultant in orthopaedics surgery at Mulago National Referral Hospital, says there are various types of clubfoot with congenital being the most common serious birth defect. 
He notes that in 2008, it was discovered that more than 1,500 children are born with clubfoot in Uganda each year. The number may have dropped given the current awareness about it.
He notes that Clubfoot can occur either in one or both feet and can range from mild to severe. In 1994, there were an estimated 10,000 neglected cases of clubfoot in Uganda.
According to Dr Nyati, in 2008, the ministry of health started Uganda’s sustainable clubfoot project with partners to adopt the Ponseti method. This was in partnership with the Association of surgeons of Uganda, the Uganda nurses and midwives council, the Medical School at Makerere University and Mbarara University, among others. 

Medical students and nurses were taught how to administer treatment in children born with clubfoot and awareness created in communities across the country. This has helped in managing clubfoot. 
Currently, ministry of health statistics reveal that of every 1,000 children born, one will be born with club foot. Most affected are boys and the ratio is two girls to three boys. 

How to correct club foot 
Kitemagwa explains that clubfoot happens because the tendons  which are bands of tissue that connect muscles to bones and muscles in and around the foot are shorter than they should be. The widely accepted method is the Ponsetic treatment method which involves manipulation of the tissue of the baby and casting.

Namutebi says after treatment, her baby’s legs are now straight . PHOTO/LOMINDA AFEDRARU. 

The Ponseti method
The Ponseti method was developed by Dr Ponseti, an orthopaedic surgeon based at the University of Iowa in 1963 following extensive anatomical study of the foot. It has been shown to be safer and more efficient than surgery for the treatment of clubfoot.

This technique, according to Kitemagwa, uses a very specific series of manipulations and castings to correct the foot deformity and complete tenotomy (a surgical act which involves the division of a tendon) of the Achilles’ tendon in most cases to eliminate deformity followed by a further three weeks in a cast. 

The patient must then wear a foot abduction orthosis, a set of boots attached on an immovable bar fulltime for three months. Thereafter, at night at least until the age of four.
If used correctly, results of the Ponseti Method can achieve full correction of the clubfoot deformity in up to 98 per cent of the cases.

About 200 children born with clubfoot are registered at Mulago National Referral Hospital every year but overall, in all government hospitals, about 2,067 are registered per year.
On average, the number of corrections done in all the government hospitals is about 720 per year meaning more than 40 per cent have been corrected.

Case of private hospitals 
Dr Joseph Isanga, an obstetrician and gynecologist at Case Clinic in Kampala, notes that due to a lot of sensitisation for mothers to avoid things such as drug use and tobacco smoking during pregnancy, clubfoot is becoming relatively minimised.

According to Dr Isanga, some cases are complicated and it can take between six months to one year to correct. Usually, if parents cannot manage the charges in private hospitals they are referred to a government hospital where the services are free.

He says it is important for mothers to attend antenatal care because at five months, the babies are screened for any deformities and when identified with clubfoot, the mother is counselled in advance.
He advises mothers to consume foods that contain amino acids, calcium and take tablets which contain iron, folic acid and zinc, which are good for bone formation.

Kitemagwa notes that usually, mothers who come to the clinic come back for consequent visits with a few cases dropping out along the way due to transport challenges especially those who come from far.
For parents who delay to take their babies, correction may be a challenge because of the expenses. It is important for mothers to start treatment at birth. 

Experts say if the child is not treated early enough, the twist of the ankle may not allow them to walk on the sole of the foot. To compensate, they may walk on the ball of the foot, the outside of the foot or even the top of the foot in severe cases.

Walking adjustments may prevent natural growth of the calf muscles, cause large sores or calluses on the foot, and result in an awkward gait.

Risk factors
Family history:
 If either of the parents or their other children have had clubfoot, the baby is more likely to have it as well.

Environment: Smoking during pregnancy can significantly increase the baby’s risk of clubfoot.

Not enough amniotic fluid during pregnancy: Too little of the fluid that surrounds the baby in the womb may increase the risk of clubfoot.

Congenital conditions: In some cases, clubfoot can be associated with other abnormalities of the skeleton that are present at birth (congenital), such as spina bifida, a birth defect that occurs when the spine and spinal cord don’t develop or close properly.