Idiopathic clubfoot is the most common serious musculoskeletal birth defect worldwide. In the United States, about one in 1,000 infants is born with a clubfoot (or clubfeet, as 40% of cases involve both feet).
Here's what parents should know about clubfoot.
What does clubfoot look like?
An idiopathic clubfoot has a very high arch and turns inward toward the other leg, with the toes pointed down and backwards. The foot is quite stiff. The Achilles tendon, located behind the ankle, is tight.
What causes clubfoot?
The cause of idiopathic clubfoot is unknown (idiopathic means cause unknown). Genetic factors likely are involved, though, since there is a tendency for clubfoot to run in families. Idiopathic clubfoot is found in babies who have no other abnormalities.
Very rarely, however, clubfoot occurs as part of a syndrome or neurologic condition such as spina bifida.
How is clubfoot diagnosed?
Clubfoot may be discovered during prenatal ultrasound, usually at around the 20th week of pregnancy.
Occasionally a foot deformity seen during an ultrasound is a harmless positional abnormality, and not a true idiopathic clubfoot. For babies born with positional abnormalities, sometimes caused by crowding in the uterus, the feet are flexible. This kind of positional abnormality is often self-correcting.
Idiopathic clubfoot is diagnosed when the foot is examined at birth and found to be quite rigid. The deformity lasts into adult life unless treated.
How is clubfoot treated?
Fortunately, there is a very effective treatment for clubfoot: the Ponseti method. The treatment is named for Ignatio Ponseti, MD (1914-2009), who developed the technique over a number of years at the University of Iowa. The Ponseti method has three phases, casting, minimal surgery (Achilles tenotomy), and bracing.
Phases of the Ponseti method
Phase one, the casting phase, should start soon (1-3 weeks) after birth. The casting technique is precise and should be performed by a physician (often a pediatric orthopedic surgeon) who is experienced with the Ponseti method. The casts are changed weekly until all elements of the deformity are corrected except a tight Achilles tendon. Usually, the first phase is complete after 5-7 casts.
Phase two is a very minor surgical procedure, an Achilles tenotomy, required in 90% of cases. The tenotomy is generally done under local anesthesia in the office. Following the tenotomy a final cast is applied and left on for three weeks.
Phase three is a prolonged period of bracing, full time for three months following casting and then nighttime only until the child is 4 to 5 years old. The brace is a bar with shoes or splints attached at shoulder width. The shoe or splint is turned out 60-70 degrees on the clubfoot side and 30-40 degrees on the normal side.
Working with your child's doctors during the bracing
It's not easy to keep an infant in a brace every night until age four years old. It is important to work closely with your child's pediatrician and pediatric orthopedic surgeon to identify and solve any barriers to bracing.
In a small percentage of cases, the clubfoot deformity will come back (recur). Stopping the bracing phase too early is the most common cause of recurrence.
If the deformity comes back, the Ponseti casting is repeated and bracing started again. Occasionally, even when the bracing phase of the treatment plan is followed perfectly, the deformity will come back. If this happens, your child's pediatric orthopedic surgeon may recommend a surgical procedure called an anterior tibial tendon transfer.
Beyond joint release surgery
Before the Ponseti method was accepted as the best treatment for babies with idiopathic clubfoot, pediatric orthopedic surgeons often treated clubfeet with extensive joint release surgeries. These surgeries dramatically corrected the clubfoot deformity in the short term. However, many of the children who were treated surgically developed pain and stiffness as they reached adulthood.
The anterior tibial tendon transfer that is occasionally needed to treat recurrent clubfoot deformity is considered part of the Ponseti method. It should not be confused with the joint release surgeries done in the past. It is extremely rare for a child treated with the Ponseti method to need a joint release surgery.
What is the outlook for a child born with a clubfoot?
The outlook for children who are born with a clubfoot and undergo Ponseti treatment, including the complete bracing phase, is excellent. They can be expected to wear normal shoes, participate in sports, and have every opportunity for a happy and productive life.
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