CASE REPORT OF CLUB FOOT CORRECTION IN CHILD WITH SPINA BIFIDA

Anmar A. Habhab and Abdulhadi A. Al-Amoudi ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 17 December 2019 Final Accepted: 20 January 2020 Published: February 2020 Spina bifida is a partially preventable disease, previous studies in many regions of the world showed a decrease in the incidence after using folic acid supplements. However, there are several congenital deformities associated with spina bifida including kyphosis, hip dislocation, and clubfoot. The aim of this case report was to evaluate the deformity correction of the left foot after Taylor's spatial frame with the Ponseti technique in a 5 years old girl with spina bifida.

Moreover,spina bifidais known to have several attributing genetic or environmental factors and many studies showed that the most important factor is the folic acid deficiency during the first month of pregnancy. (5) In addition, theconsanguineous marriage is considered to be another a risk factor, previous studies in Saudi Arabiashowed that the congenital malformations including NTDs correlates with consanguineous marriages. (6,7) Spina bifida is a partially preventable disease, previous studies in many regions of the world showed a decrease in the incidence after using folic acid supplements. (8,9) Currently, there is a recommendation fromthe U.S preventive services task force for all women who are planning or capable of pregnancy have to take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. (10) Furthermore, there are several congenital deformities associated with spina bifida including: kyphosis, hip dislocation and clubfoot. (11,12) The most common deformity associated with spina bifida is clubfootwhich is defined as a foot deformity causing walking difficulty, and it should be treated not only for ambulation but also to avoid complication such as skin irritations, ulcers or fractures. (13) There are many modalities involved in the treatment of the clubfoot. Depending on presentation, treatmentcan vary from non-surgical modalities as casting or bracing to surgical options like posteromedial release. (13) In Some cases of neglected foot deformities can be corrected with PonsetiTaylor method, which is a method of correction using Corresponding Author:-Anmar A. Habhab serial casting and Taylor spatial frame (TSF). (14) Nevertheless, regular follow up should be established to assess the progress and prevent recurrence. (15) However, the TSF is an external fixator used in treating limb pathologies such as deformities or fractures . (14) Whilethe Ponseti technique consist of serial casting. Initial cast aiming to correct cavus by supinating the forefoot and dorsiflexing the first ray. Consequent casting for correction of adduction and various, by applying the pressure on the distal taller head. Followed by Achilles lengthening for hind foot equines. and after casting a brace applied. (16) On the other hand, using Pontsiealone for the purposeof treating clubfoot in spina bifida patients is associated with high recurrence rate . (13) The aim of this case reportwas toevaluate thedeformity correction of the left foot after Taylor spatial frame with Ponseti technique in a 5 years old girl with spina bifida.

Report of the case:
A five years old Saudi girl presented to orthopedic outpatient clinic complaining of walking difficulty. She was born full term, the mother had antenatal follow up during her pregnancy, and she got folic acid supplements before pregnancy. The child had diagnosed during antenatal with spina bifida at L5, and at birth time it was associated with bilateral clubfoot. The deformitywas worsening with time but there is no pain or other associated symptoms. The attempt of treatment was seeking before, she underwent posteromedial soft tissue release and bilateral derotational osteotomy of tibia at age one, but unfortunately the relapse has occurred. There is no history of spina bifida or congenital clubfoot in the family.
Foot examination revealed that she had bilateral foot deformities which werehindfoot in equinus and varus, and midfoot in cavuswith rigid equinus and resistance to passive correction, and forefoot wasadducted. There was bad scar associated with decreased skin elasticity because of multiple previous surgery. There was no foot sensation, and the reflexes was difficult to assessed because the deformity, and no motor function because of low level spina bifida.
Course of treatment has been started in the left foot after taking the informed consent and providing the proper counseling to the patient and her parents about the procedures. The patient underwent soft tissue release surgery for subtalar, talonavicular and calcaneucuboid. Then the frame was applied using olive wire on talar head connected to proximal frame of the tibia (Figure1). After removal of the frame the Achilles tenotomy and dorsal talo tibial capsolutomy were done and below knee cast was applied for six to eight weeks (Figure2).
Although, during the course of correction we faced pin strut collusion that necessitates pin exchange, pin loosening and strut foot impingement at the end of the correction, the plantigrade corrected foot was achieved without reducing foot length. (Figure3) compare the correctedleft foot with the other foot.

Discussion:-
The mainaim of the treatment was to improve the mobility in congenital clubfoot in childwith spina bifida using Taylor spatial frame with Ponseti technique.
However, the public knowledge about clubfoot is low, therefore late seeking of treatment is expected. A cross sectional study in Riyadh in 2018 showed that about 70% of participants had never heard about clubfoot. (15) Additionally, the same study revealed that 58% cases of clubfoot were due to hereditary and genetical causes.
Althoughthe recommended treatment in 5 years old patientsis surgery followed by Ponseti techniques, in our case we added TSFfor the purpose of avoidingbone shortening. Fortunately, the aim was achieved as correction was done without reducing the bone length.
Moreover, the correction is not the only outcome was accomplished, the range of motion had increased as well. In addition, the patient used to walk on lateral aspect which led to more skin complications, so the plantigrade correction will not only improve the mobility but hopefully willdecrease further skin complications. Importantly, the overall satisfaction of the patient and her parents was reached.
Though some cases of spina bifida is due to genetic mutations, we can't underestimate the role of fortification folic acid before pregnancy,a study in King Fahad University Hospital, Khobar 2019 reported 86.6% of 38 mothers who had have spina bifida infants did not receive folic acid before pregnancy . (17) And that alarming us to increase the awareness of the importance of fortification folic acid supplements before pregnancy and other risk factors associated with spina bifida.