Epidemiology and Pattern of Clubfoot in Enugu, SouthEast Nigeria

Background: clubfoot is a musculoskeletal birth defect of the foot and ankle that affects a lot of children in the world which can pose ambulatory and activity challenges to affected individual when not treated. Aim: To evaluate the epidemiology and pattern of clubfoot at Enugu, Southeast Nigeria. Study Design: A retrospective epidemiological study. Methodology: Ninety-six case notes of patients managed for clubfoot between January 2014 and December 2017. Simple statistical methods like frequency, percentage and mean were used for data presentation and analysis. Results: Idiopathic clubfoot had highest prevalence of 92%, secondary clubfoot 6% and positional clubfoot 2%. Male gender had occurrence rate of 56% and female 44%. Bilateral clubfoot has greater dominance with a prevalence rate of 75% and unilateral clubfoot 25%. 16% responded to plaster cast application without requiring tenotomy, while 84% did not respond to plaster cast application, but required tenotomy. 10% had relapses after correction, while 90% did not have relapses after correction. Conclusion: Clubfoot is a major birth defect in the study area and is more prevalent in male children and in most cases is bilateral, with idiopathic clubfoot dominance.


Introduction
Clubfoot has been defined as a condition in which a newborn's foot or feet appear to be rotated internally at the ankle [1]. It is a condition affecting the position of foot and ankle joint in such a way that when untreated, it can lead to physical impairment and difficulty in ambulation and functions [2]. Clubfoot is a congenital condition (present at birth) that causes a baby's foot to turn inward or downward. It can be mild or severe and occur in one or both feet. In babies who have clubfoot, the tendons (Achilles tendons) that connect their leg muscles to their heels are too short. These tight tendons cause the foot to twist out of shape giving rise to clubfoot [3]. Clubfoot is one of the leading birth defects to children, which they do not outgrow when neglected not attended to [4].
Clubfoot has been investigated in some African countries and other parts of the world with emphasis on etiology and treatment.
Clubfoot presents with soleus muscle atrophy, equinus of the ankle, cavus and adductus of the forefoot, Varus of the heel which can be unilateral or bilateral [4]. In most cases, clubfoot is discovered after the baby is born by physical assessment or visual inspection of the ultrasound, after which nothing can be done to correct until the child is born [5].
Clubfoot can be classified as: positional; resulting from in utero mal positioning, idiopathic; which is when it has no known cause or cannot be linked to any medical cause, secondary; which is when another disease or condition exposed the individual to clubfoot [6].
Some investigations suggest that a good number of adults battle with challenges of untreated/neglected clubfoot in developing countries, especially in some rural places where people do not know that it can be treated [7]. However, some reports had it the etiology of clubfoot cannot be substantiated [4], while some reported habits like smoking and young maternal age (< 23 years old) to have an associated cause [4,8,9]. Some studies maintained that bilateral clubfoot is more prevalent than unilateral clubfoot and some has it that clubfoot has male preponderance than female [7]. It is also widely believed that most clubfoot is idiopathic and present at birth and could be treated with Ponseti method or surgery.

Study Area:
The study is a retrospective study conducted at National Orthopaedic Hospital Enugu, Southeast Nigeria. The hospital is the major government Orthopaedic hospital in southeast region of the country and the catchment areas are mostly Enugu, Abakiliki, Nsukka, Afikpo, Okigwe, owerri and Awaka. Method of Sample Collection: After a due clearance and permission was sort for and obtained from the Chief Medical Director, National Orthopaedic Hospital Enugu, case note of patients who had presented with clubfoot were retrieved from the medical records unit. Relevant information needed for the study like age, gender, feet involved, position of the affected foot and joint were extracted. Patients' privacy was also maintained during the study and folders returned to the medical records after exploring relevant information.

Inclusion Exclusion Criteria:
All patients who presented with clubfoot and were treated at the hospital using Ponseti method or/ and tenotomy within the period under review were included.
Statistical Analysis: simple statistical tools like frequency, percentage and mean were used to analyze the data collected. Table 1 shows the pattern of clubfoot reviewed in the study, with idiopathic clubfoot having highest prevalence of 92%, followed by secondary clubfoot (6%) and positional clubfoot being the least (2%). Table 2 shows gender prevalence of clubfoot, with male preponderance of 56% and female 42%. Table 3 shows unilateral/bilateral distribution of clubfoot in the study area. Bilateral clubfoot dominated with a prevalence rate of 75% and unilateral clubfoot 25%.   Table 5 shows the type treatment that was used to manage the cases presented. 84% responded to Ponseti method without requiring tenotomy, while 16% did not respond to plaster cast application and required tenotomy before correction was achieved. Table 6 shows the cases that had relapses after correction. 10% had relapses after correction, while 90% did not have relapses after correction. From the 10% that had relapses, 7% were managed conservatively, while 3% benefited from surgery (tenotomy). 9% of the relapse cases were bilateral clubfoot patients, while 1% was unilateral clubfoot patient.

Discussion
Idiopathic clubfoot dominated in the study with an occurrence rate of 92%, followed by secondary clubfoot 6%. Positional clubfoot had 2% which could be because the mothers did not go for CTscan during pregnancy or were not informed of the positioning of their babies before delivery. Study carried by Moorthi RN et al. [10] in 2005 reported idiopathic clubfoot as having the highest prevalence [10,11].
The male gender had 56% occurrences and female 44%.
The result also showed that most clubfoot patients present to the hospital between the ages of 29-56 weeks (1-2 months), with the peak at 29-42 weeks (1-1.5 months) and could be perceived as the

Conclusion
Clubfoot is a major birth defect in the study area and is more prevalent in male children and also affected both feet (bilateral clubfoot) in majority of the cases. Idiopathic clubfoot was seen to have greater dominance than positional and secondary clubfoot.
Bilateral clubfoot was seen to have greater relapse tendency and should be given a more serious attention during treatment to avoid

Ethical Approval
Not applicable