What is horseshoe foot? Horseshoe foot is the most common deformity of the bone and joint in newborns. The cause of clubfoot is not known, and the most likely cause is a genetic disorder that is not related to parental behavior. Therefore, parents do not need to consider their child’s horseshoe foot to be their own fault. The chance of a second child having clubfoot is about 1 in 30, and if a child with clubfoot is otherwise normal, parents should be confident that their child’s foot will regain basic function and appearance as long as they are seen by a professional. With a well-treated clubfoot, the child will be able to live a normal life free from the disabilities caused by clubfoot. Beginning Treatment Weekly manipulation is performed on the back and bottom of the foot by stretching the short and tight ligaments and tendons. A cast is then applied from the toes to the groin of the thigh. The cast maintains the position after manipulation and allows the tissue to relax in preparation for the next cast. In this way, the displaced bones and joints are gradually corrected. Because of the good elasticity of the tissues in the first 1-2 weeks after birth, treatment should be started at this time. Home care of the cast 1. Check the blood circulation: Check the blood circulation of the foot once every hour during the first 6 hours of putting on the cast, and then 4 times a day. The way to check is: gently pinch the toe and observe the blood flow back; if the blood flow is good, the toe will first turn white and then quickly return to pink, which is called whitening reaction. If the toe is dark and cold and there is no whitening reaction (white to pink), the cast may be too tight and it is important to contact your doctor or emergency department immediately to have the cast checked. If your child is using a fiber cast, remove it out. If the toe retracts into the cast, the cast may have slipped and is not holding the correction; then contact the orthopedic clinic immediately and tell the doctor that you cannot see your child’s toe. 3.Keep the cast dry and clean: When the cast gets dirty, you can wipe it off with a wet rag. 4. Before the cast is dry: When the cast is not dry, place it on a pillow or soft cushion until the cast is dry and hard. When the child sleeps, place a pillow under the cast to elevate the lower limbs. Keep the heel just out of the pillow to avoid pressure on the heel, which can cause pain and pressure sores. 5. Diapers: Change diapers frequently to avoid soiling the cast; do not put the upper end of the cast close to the diaper to prevent feces and urine from leaking into the cast; it is better to put diapers with elastic leg loops on the baby. Inform the doctor or nurse immediately if you notice any of the following: any putrid smell from the cast or running cast; red, sore and inflamed skin at the edge of the cast; poor circulation in the toes (see point 1 above); slippage of the cast (see point 2 above); fever of 38.5 degrees Celsius (101.3 degrees Fahrenheit) or higher, not caused by other causes such as cold, infection, etc. Change the cast every 5 to 7 days Soft fibrous cast 2 to 3 hours before the next cast, fold the cast over the edge of the fibrous cast, remove the cotton pad, and give the child a bath. Traditional plaster The nurse will use a special plaster knife to remove the cast, so it is important to soften the cast on the same day by putting the child in a bath or tub of water and letting the warm water soak the cast for 15-20 minutes, then wrapping the cast in a wet towel and covering it with a plastic bag; a bread bag works well. Duration of treatment Four to seven casts (each from the toe to the upper thigh, with the knee at 90 degrees) over a period of 4 to 7 weeks should correct the horseshoe deformity (see below for steps). Even in a stiff horseshoe foot, 8 to 9 casts should provide maximum correction. Unless it is a complex case, x-rays of the foot are not necessary because the surgeon is able to feel the position of the bone and the degree of correction with his fingers. Completion of treatment For most clubfoot, a minor procedure is required before completing treatment. The back of the ankle is first anesthetized with a pain relieving cream or an injection of anesthetic, and then the Achilles tendon is severed. When the Achilles tendon is completely severed, a final cast is applied and the Achilles tendon regenerates to sufficient length and strength by 3 weeks, at the end of treatment, the foot will appear slightly overcorrected with a slightly flattened appearance and will be normal after a few months. Maintenance correction – foot abduction brace Horseshoe deformity is prone to recurrence after correction. With or without Achilles tendon severance, an abduction brace must be worn to prevent recurrence after the last cast is removed. There are different types of abduction braces (see examples below). The most common type of brace is a straight, high-sided and toe-opening shoe that is fixed to an adjustable aluminum bar. The distance between the two heels of the shoe is equal to the child’s shoulder width. To prevent slippage, the shoe can be adjusted somewhat. Visually, the affected foot should have the shoe abducted 60-70 degrees, while the normal side (if unilateral horseshoe) is abducted 30-40 degrees. The brace must be worn 23 hours a day for the first 3 months, and then at night and during midday sleep for the next 2 to 4 years. Wearing the brace on the first and second night can be uncomfortable for the child because the two legs are tied together. It is very important not to remove the brace because, if the brace is not worn as prescribed, the horseshoe deformity will inevitably recur. After the second night, the child gets used to the brace. Once the brace was not required, a normal shoe could be worn. The horseshoe foot is completely corrected through manipulation, a series of plaster corrections and possible Achilles tendon severance before an abduction brace can be used. Even if the foot is fully corrected by about 4 years of age, the clubfoot is prone to recurrence. An abduction brace is the only successful method of preventing recurrence and is effective in 90% of children if used consistently as described above. The use of a brace does not hinder the child’s development of sitting, crawling, or walking. Guidelines for wearing an abduction brace 1. Wear cotton socks frequently so that all parts of the foot and leg that are touched by shoes are covered; after the last cast is removed, the child’s skin may be sensitive, so for the first 2 days of wearing the brace, 2 pairs of socks can be worn, and later only 1 pair of socks can be worn. 2.When putting on the brace, if the child does not refuse, you can put on the worse foot first and then the better foot; if the child kicks and stirs a lot, you can put on the better foot first, which is due to the fact that the child usually kicks off the second shoe. 3. Put the foot into the shoe and tighten the foot strap first, the foot strap will make the heel tighten into the shoe. Do not mark the used holes on the ankle strap, because after using it for a long time, the strap will be stretched and the mark will be meaningless. 4.Check whether the heel is worn into the shoe by pulling the calf up and down; if the toe moves back and forth, it means the heel is not worn in and you must tighten the foot strap again; after wearing in, you can draw a line inside the shoe to mark the position of the toe, after the heel is worn into the shoe, the toe should not go beyond the position of the line. 5. Tighten the shoelaces, but do not affect the blood circulation. Remember, the laces are the most important thing, they help hold the foot in the shoe. 6, Make sure your child’s toes are all straight and none are bent; to do this, you can cut the toe part of your child’s sock to make it easier to see the toes. Tips for using an abduction brace 1. The first 2 days your child will probably not like wearing the brace, not because the brace is causing pain, but simply because it is something new and different. 2. Playing with your child after wearing the brace is the key to overcoming the discomfort as soon as possible. When wearing the brace, the child cannot move both legs separately, so teach the child to wear the brace and kick and swing both legs at the same time. You can push and pull the rod of the brace and gently flex and extend the child’s knee to teach the child to move and flex and extend the knee at the same time. 3. Make it a habit; if you make brace therapy a regular part of your life, your child will adapt better. During the 2-4 years of nighttime and bedtime use, as soon as your child goes to bed, you will put the brace on her and she will understand when it is time to wear the brace during the day. If you make the use of the brace part of your daily life, your child will not resist wearing the brace. 4. Wrap the crossbar in a bicycle handlebar glove to protect your child, yourself and your furniture from being broken by the bar. 5. Do not apply emollient oil to the red skin area because it will aggravate the problem. Sometimes red skin is normal, but when bright red spots or blisters appear, especially on the heel area, it means that the shoes are not worn tight enough. Be sure to put the heel inside the shoe and contact your doctor if you notice redness or blisters. 6. If the child keeps slipping out of the support, which means the heel is not inside the shoe, try the following: a. Tighten the foot strap by one hole; b. Tighten the laces; c. Remove the tongue of the shoe (using a support without a tongue will not damage the child); d. Try to tighten the laces from top to bottom so that the shoe arches to the toe area. 7. Periodically reinforce the screws on the rod. Tools are provided with the brace. Long-term follow-up Follow-up visits to the clinic should be made every 3 to 4 months for 2 years after complete correction, and less frequently thereafter. Depending on the severity and ease of recurrence, the doctor will decide how long the brace should be used. Do not end treatment prematurely. To monitor the possibility of relapse, you should visit the clinic every year for 8 to 10 years. Recurrence If a recurrence occurs within the first 2-3 years, weekly manipulation and cast correction should be restarted. A second release of the Achilles tendon may be required. In some children, even with proper bracing, minor surgery is still necessary to prevent recurrence if the child is older than 3 years. The surgery includes a tendon transposition (anterior tibialis) from the medial to the mid-foot. Severe clubfoot The outcome is better if extensive surgery of the bones and joints can be avoided, but 5-10% of congenital clubfoot may be severe, with short, round feet and stiff ligaments that cannot be lengthened by distraction with casts and manipulation. When it is confirmed that the deformity cannot be corrected after a series of plaster corrections, these children may require surgical correction. Finding an Experienced Surgeon When treating clubfoot, an inexperienced surgeon may be able to correct a mild clubfoot deformity. However, many cases require an experienced surgeon for successful treatment. If manipulation and casts are not done properly, treatment can be delayed, making subsequent treatment more difficult, if not impossible. Therefore, before deciding to treat your child surgically, refer your child to an experienced pediatric orthopedic surgeon for non-surgical correction of clubfoot. Frequently Asked Questions What is the future for children with clubfoot? A child with corrected clubfoot is likely to have a near normal foot with only minimal differences. The treated clubfoot will be slightly smaller than a normal foot, and the calf muscles may be slightly reduced. The degree of reduction is related to the severity of the original clubfoot. There is usually no significant shortening of the leg. Small differences do not cause any problems and are often unnoticeable to the child. By adolescence, when people are particularly concerned about their body image, minor differences may be noticed, but are usually forgotten after 1 to 2 years. In studies of patients who have been treated with the Pansetti Method, it has been found that children and adults with corrected clubfoot can participate in sports just like anyone else, and many of the best athletes we know are clubfoot conceivers.