Clubfoot: an orthopaedic surgeon describes clubfoot and current treatment methods.

As an orthopaedic surgeon who has treated numerous cases of clubfoot in my career, I know that it takes exceptional parents to deal with the challenges of a child born with a clubfoot. However, it should be noted that a clubfoot diagnosis does not mean a life of pain, deformity, and disability for your child. Today's treatment options hold out much hope and promise. But what is clubfoot and what treatment methods are most effective?

What Is Clubfoot And How Common Is It?

Clubfoot, which occurs in about one in a thousand births, is the most common musculoskeletal birth defect and is the seventh most common birth defect overall. By a 2 to 1 ratio, boys are more affected than girls. Additionally, about 50 percent of cases are bilateral, affecting both feet.

Most children born with a clubfoot have no other associated medical problems. Still, clubfoot may be part of other disorders such as myelomeningocele (a spinal cord development problem which results in weakness or paralysis of the lower extremities) or arthrogryposis (being born with stiffness and contracture of multiple joints).

There has been extensive research devoted to studying clubfoot, yet the scientific origin remains unknown. The genetic basis of clubfoot is slowly being unraveled, and there is clearly a hereditary aspect to clubfoot.

With modern, hi-tech ultrasound during pregnancy, clubfoot is often detected while the baby is still in the uterus, often by the second semester. The joys of pregnancy and anticipated motherhood can quickly deteriorate into distress and concern: "Will my child have limited mobility and not be able to walk or run properly? Will my child be the object of strangers' stares? Will my child be denied job opportunities or relationships because of the clubfoot condition?" With the practice of abortion accepted among many in today's society, the question of whether to terminate the pregnancy becomes a real issue with some expectant parents.

The good news is that, using modern treatment techniques, most children with a clubfoot do wonderfully. Recent studies indicate that more than 95 percent of children treated with the "Ponseti technique" have an excellent outcome and the large majority are still functioning normally after 35 years.

Parents often play an important role in accomplishing this outcome as they make concerted efforts toward inculcating a positive attitude and building self-confidence within their child. Parents can also assertively nurture their child's physical circumstances with regular, ongoing intervention and advocacy.

Clubfoot is a deformity of the lower limb, characterized by adductus of the forefoot, cavus (increased longitudinal arch), varus of the heel (heel is turned in), and equinus of the foot (foot is in plantar flexion) as well as a small calf muscle. Although the most severe deformity occurs in the hind foot, all components of the deformity are interrelated.

Pathologically, the ligaments of the posterior aspect of the ankle and the medial and plantar aspects of the foot are shortened and thickened. The muscles and tendons of the gastronomies tibialis posterior and toe flexors are shortened and smaller in size.

Physicians do not know the causes of clubfoot and so cannot prevent the condition. Instead, we treat the results of clubfoot. The goal of treatment is to correct all components of the deformity so that the patient has a pain-free, callus-free foot with good mobility and no need to wear modified shoes and inserts.

The Ponseti method

The Ponseti method, developed by Dr. Ignacio V. Ponseti from the University of Iowa, has become the gold standard for treating clubfoot. It is based on specific manipulations and casting and does not require any significant surgery. The Ponseti method has dramatically improved the results of treatment of children born with this condition. Today's Internet savvy parents account, in large part, for the growing use of the Ponseti method in recent years. Traditionally, parents would have relied solely on the advice and treatment options offered by their local health care professionals. Clearly, the movement by parents to mobilize Internet technology in this subject matter combined with the explosion of today's readily available health care information has allowed parents to locate clubfoot support networks, proffer data, share experiences, and provide encouragement.

Noelle

The Ponseti Method was deployed within eight weeks after Noelle Masi was born at Methodist Hospital in Park Slope, Brooklyn. Noelle's parents, Christy and Sean, were very surprised when Noelle was born with a clubfoot as there was no identification of it during sonograms. The joy and exhilaration in the birthing room quickly became subdued with the discovery that the baby's foot was twisted.

Shortly after Christy held the baby, her doctor explained that an orthopedic surgeon was coming to examine the baby. He assured her about the foot condition, and I saw Noelle within hours after her birth. I assured Mrs. Masi that while this clubfoot was serious, it was not an insurmountable challenge and that the odds were that Noelle would have a great result with the Ponseti method of treatment. I wanted Christy to bond with her newborn daughter for several weeks before the initial casting was done.

At their first visit to my office, I applied a specially molded cast, which extended all the way up Noelle's leg. In advance of each follow-up office visit, Noelle's cast had to be softened and removed so that I could evaluate her progress. At first, Christy and Sean found it difficult to gently take off the cast prior to bringing Noelle in for her appointment. It required patience and great care to gently use pliers and scissors. "If there is a new product that should be invented ... it should be a better, more effective casting set-up for infants," Christy exhorts.

Noelle's leg was usually stiff, sore, dry, and red when the cast came off so Christy would spend more time bathing the leg in warm water during the periods that the cast was off. I mentored and encouraged Christy about persevering through the casting challenges and about being patient with Noelle's reactions (crying and kicking) in the interest of accomplishing the long-term goal.

This process of "visiting Dr. Vitale" became almost a weekly ritual for a number of months. Christy notes that as she became a veteran of loosening and softening the cast to take it off, she was able to do it in an hour, down from about three hours the first time. Within the first couple of visits, Noelle's condition improved; at each visit, the progress was evident.

As Noelle grew and developed, she began wearing a foot-leg brace known as boots & bars, prepared by a certified orthotist, Vincent Benenati.

How is Noelle doing today at age four? "My daughter doesn't even remember the cast and the brace. She walks well, runs well and she's such a happy kid," attests Christy. Periodically, Christy plans on bringing Noelle to me for check ups to make sure there are no problems as Noelle matures.

Christopher

Martin and Ramona Peraza of Sheepshead Bay, New York recall the shock when their OBGYN doctor broke the news during a sonogram session that their unborn baby had clubfeet. "For that moment," describes Mr. Peraza, "our hopes and expectations came crashing down, but the doctor assured us that everything would most likely work out. He gave us confidence that there was a medical process in place and that our baby's situation could be effectively handled and managed."

From that point on, Mr. and Mrs. Peraza made it their business to thoroughly read up on all aspects of clubfoot. They researched the Internet and any important sources of information so they would be prepared for what was to come.

Within 24 hours of Christopher Peraza's birth at Lutheran Medical Center in Brooklyn, New York, both of his clubfeet were cast-moved into proper position and wrapped up tightly. Christopher had an operation on his Achilles tendons to release the pressure so his feet would be shaped in the right direction. "Of course, it is a trying time when a three-week-old infant must undergo surgery," Mr. Peraza explains, "but we felt confident and positive about the procedure."

Nearly every week, the Perazas had a follow-up visit with me. Similar to Noelle Masi, a few hours prior to the visit, Martin and Ramona had to position Christopher's feet in warm water and vinegar to soften the cast and delicately remove it. "Needless to say, it is not an easy task holding the legs of an infant still and calm in a bassinet," Martin explained, echoing the complaint of Noelle's mother.

As Christopher began to form and develop, orthotist Vincent Benenati made a pair of the special boots with iron bars at 90 degrees. The bracing is critical in maintaining the shape and growth of the feet in the proper direction. "Clubfeet is something we see practically once or twice a week," describes Benenati, "and the results through The Ponseti method are much superior to what I saw when I first entered the orthotics field about fourteen years ago."

Christopher's dad says, "At fourteen months, Christopher began walking so the boots were then used when he was napping or sleeping overnight. We were told he would probably need these until he was three, but his progress is so positive and his feet look so normal that the doctor says we shouldn't be concerned if he misses some of his time in the boots. Recalling the point at which the news was first given to us about our baby's clubfeet ... this outcome really is a miracle."

Clubfoot and The Future

The only time I perform a "real" clubfoot surgery, in otherwise healthy children, these days is when I travel abroad to third world countries. I see older children who have not had the benefit of The Ponseti Method at an early age. One of my professional pursuits is training caregivers and parents of children with clubfoot in these nations on how to use their local resources to perform casting and treatment. Internationally, neglected clubfoot is the most common cause of physical disability among musculoskeletal birth defects. I am actively working with World Health Organization policymakers to focus on the goal of eradicating untreated clubfoot in children around the globe.

Does clubfoot ever return after a successful treatment?

By the age of three, about 10 percent of children with clubfoot develop a recurrence, characterized by an inward turning of the foot. It happens because the anterior ticial tendon (one of the large tendons on the inside of the foot) is overly active. A transfer of this tendon easily treats this.

By Michael Vitale, MD, MPH, Herbert Irving Assistant Professor of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian