Clubfoot

What is clubfoot?
Congenital (present at birth) talipes equinovarus, or clubfoot, is a fairly common birth defect occurring in 1 out of every 750 to 1,000 live births. This defect can occur in one or both feet. Approximately twice as many boys are affected compared to girls. The most severe form of clubfoot is characterized by the foot or feet being turned inward and pointed downward. When both feet are clubbed the toes turn toward each other. Clubfoot is usually an isolated defect with only 10 percent of babies with clubfeet having any other associated anomaly or birth defect. There are two general categories of clubfoot. The first is intrinsic, which is described as rigid at birth with atrophy (not as well developed), fibrosis (stiffness) and abnormal bone position. The second is extrinsic clubfoot. The foot is flexible at birth although the bones are out of position. We do not know what causes clubfoot. We do know it is not related to anything the mother ate or did during pregnancy.

Prenatal diagnosis of clubfoot
Prenatal diagnosis of clubfoot is increasing with increased use of ultrasound and improved ultrasound image quality. This defect does seem to have an increased incidence in families with a history of clubfoot or other orthopedic problems. The family history could include a parent who had clubfoot at birth or a congenital hip dysplasia (which is the underdevelopment of the bones of the pelvis especially the hip joints which can be diagnosed by an examination) or a blood relative with similar defects.

Your obstetrician will most likely refer you to a specialist that handles high-risk pregnancies. These doctors are called perinatologists. The perinatologist will do a more extensive ultrasound to confirm the diagnosis and look for any other anomalies.

How does clubfoot affect my baby?
Clubfoot is not painful for your baby. It really has no effects on your newborn, but does need to be corrected as it will not resolve on its own. Your baby will not be able to walk normally with untreated clubfoot because the feet will not lie flat on the floor.

How does the diagnosis clubfoot affect my pregnancy?
The diagnosis of clubfoot can be made with an ultrasound exam during your pregnancy. There is no prenatal treatment for clubfeet but by knowing this prior to delivery you have a chance to locate an orthopedic surgeon who is familiar with treating clubfeet and learn about treatment options. The majority of these babies will have no other problems. However there are a few birth defects that can be accompanied by clubfeet, therefore a thorough anatomical survey using a Level II ultrasound will be recommended to look at all systems of the baby. Isolated clubfeet has no affect on your pregnancy, but if there is another birth defect that accompanies clubfeet, you may need more frequent monitoring to evaluate the fetus' well-being.

How is clubfoot treated?
The routine treatment until very recently was serial casting and surgery. However, a non-surgical technique has been proven to provide even better results without the risk of complications that can accompany surgery. This method is called the Ponseti Method after the physician who first used it back in the 1950s. It did not gain popularity until those babies initially treated have grown up and proven that this method provides better results than the traditional surgical method. The Ponseti Method begins shortly after birth while the tendons are more elastic, and consists of gentle massage and manipulation (for about 10 minutes) of the clubfoot. This stretches the contracted tissues. Following the massage and manipulation a thin plaster cast is placed, with the foot positioned in the more stretched position. The cast extends from the toe to the groin. The cast(s) is changed every five to seven days. With each casting the massage and manipulation is repeated and a new cast is applied to the stretched foot. This continues for approximately five to six casting sessions. Before the application of the last cast, 90 to 95 percent of these babies require a tenotomy. The Achilles tendon needs to be released or cut to help correct the deformity. This is an office procedure done with local anesthetic. With the removal of the final cast, to prevent relapse, your baby will be fitted with a Dennis-Browne splint. This splint includes a pair of shoes connected to each other by a metal bar attached to the bottom of the shoes. The shoes are rotated away from the body. This splint is worn 23 hours a day for two to three months and then at night and during naps for the next two to four years.

Surgery is indicated as the treatment however, if nonoperative treatment has not been successful. Historically, surgical correction was the standard of care and all clubfeet were treated the same. More recently, surgical correction is more individualized and aimed at treating only those areas that require surgical intervention for correction.

What about surgery?
The statistics vary greatly as to the success rate with the Ponseti Method. Approximately 50 to 90 percent are corrected successfully without surgery. There are, however, some babies who will have short, fat feet with stiff ligaments which will not yield to stretching and may require some type of surgery. If this becomes necessary, your orthopedic surgeon will explain to you what type of surgical procedure is needed.

Will I be able to care for my baby?
Yes. Your baby will more than likely go to the newborn nursery and be treated there if clubfoot is his/her only problem. The orthopedist may see him/her in the hospital if you deliver at Froedtert. If you do not deliver here or the orthopedist does not see your baby before he/she goes home, please call to set up the first casting appointment as soon as possible after you take your baby home. The casting needs to be done as soon after birth as possible for best results. If you had planned on breast-feeding your baby, a lactation consultant can assist in answering any questions you may have. Positioning for breast-feeding with a long leg cast may be an issue you will want to discuss with the lactation consultant.

The Fetal Concerns Program can set up a scheduled meeting with the orthopedic doctor before your baby is born. This helps you get a better idea of how your baby's clubfoot will be treated after delivery. You will meet the doctor and his or her nurse who will be most involved in the care of your baby after he or she is born.

When can my baby go home?
More than likely your baby will go home with you unless there are other anomalies that require more intensive treatment or prolonged assessment.

What is my baby's long-term prognosis?
The long-term prognosis for babies with clubfoot who were treated with the Ponseti Method is excellent. They have had almost no difference in function or pain in their feet when compared to those persons who were born without clubfoot. The only issues that could be potential causes of increased amounts of pain were related to excessive weight gain and those who worked at jobs that required prolonged time on their feet.

Learn more about the Orthopedics Center at Children's Hospital of Wisconsin.