Clubfoot

Clubfoot, also known as congenital talipes equinovarus , is a fairly common birth defect. It occurs in about 1 out of every 750 to 1,000 live births. This defect can occur in one or both feet.

About twice as many boys are affected than girls are. 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. Only about 10 percent of babies with clubfeet have any other associated birth defect. There are two general categories of clubfoot – intrinsic and extrinsic. 

• Intrinsic clubfoot is described as:
  
  • Rigid at birth with atrophy (not as well developed)
  • Fibrosis (stiffness)
  • Abnormal bone position
• Extrinsic clubfoot means 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

As more and more women have ultrasounds during their pregnancies, doctors are diagnosing clubfoot before birth more often. Improved ultrasound images are also helping with prenatal diagnosis. 

Is clubfoot genetic or heritable? 

This defect does seem to have an increased incidence in families with a history of clubfoot or other orthopedic problems. 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) or a blood relative with similar defects.

If your child has clubfoot, your obstetrician likely will refer you to a maternal-fetal medicine specialist (a doctor who handles high-risk pregnancies). Your maternal-fetal medicine specialist will do a more extensive ultrasound to confirm the diagnosis and look for any other anomalies your child may have.

How does clubfoot affect my baby?

Clubfoot is not painful for your baby. It really has no effects on your newborn. However, it does need to be corrected, as it will not resolve on its own. Your child will not be able to walk normally with untreated clubfoot because he or she will not be able to place the affected foot (or feet) flat on the floor.

How does the diagnosis clubfoot affect my pregnancy?

There is no prenatal treatment for clubfeet. But, if you know about the diagnosis prior to delivery, you will have a chance to locate an orthopedic surgeon who is familiar with treating clubfeet and learn about treatment options. 

The majority of babies who have clubfoot will not have other problems. There are a few birth defects that can be accompanied by clubfeet, so we recommend a thorough exam of your baby using a level II ultrasound. 

Isolated clubfeet will not affect your pregnancy. However, if your child has another birth defect that accompanies clubfeet, you may need more frequent monitoring to evaluate your child’s well-being during the pregnancy.

How do you treat clubfoot?

Until very recently, the routine treatment for clubfoot was serial casting and surgery. However, a nonsurgical technique has proved to provide even better results without the risk of surgery complications. This method is called the Ponseti Method, after the doctor who first used it in the 1950s. 

The Ponseti Method

This method did not gain popularity until the babies who were first treated grew up and proved that this method provides better results than the traditional surgical method does.
The Ponseti Method is a multi-step, multi-visit process that begins shortly after birth, when the tendons are more flexible. 

Steps in the Ponseti Method

1. At first, doctors gently massage and manipulate the clubfoot. This stretches and contracts the tissue. 
2. Following the massage and manipulation, doctors place a thin plaster cast (or casts), with the foot (or feet) positioned in the more stretched position. The cast extends from the toe to the groin. 
3. Doctors change the cast(s) every five to seven days. With each casting, doctors repeat the massage and manipulation and apply a new cast to the stretched foot. This process typically continues for five or six casting sessions. 
4. Before doctors apply the last cast, 90 to 95 percent of these babies will require a tenotomy. This procedure releases or cuts the Achilles tendon to help correct the clubfoot deformity. Some surgeons will do the tenotomy in the clinic if the clubfoot is only on one side, but most of the time, the tenotomy is done in the hospital under general anesthesia for the comfort of the patient. It is outpatient surgery and the child will go home the same day. 
5. Once doctors have removed the final cast, they fit the children with a special type of 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. The child must wear the splint for 23 hours a day for three months and then at night and during naps (10-12 hours per day) for the next two to four years.

What happens if this treatment doesn’t work?

If non-operative treatment, like the Ponseti Method, is not effective, children may have to have surgery. Historically, surgical correction was the standard of care and all clubfeet were treated the same way. More recently, surgical correction is more individualized and aimed at treating only those areas that require surgical intervention for correction.

How successful is the Ponseti Method?

Reported success rates with the Ponseti Method vary greatly. Doctors successfully correct approximately 50 to 90 percent of children with clubfeet without surgery. However, some babies have short, fat feet with stiff ligaments that will not yield to stretching and may require some type of surgery. If surgery becomes necessary for your child, his or her orthopedic surgeon will explain what type of procedure should be performed.

Meeting with an orthopedic specialist during pregnancy

The Fetal Concerns Center can schedule a meeting with the orthopedic doctor before your baby is born. Meeting with an orthopedic surgeon will help you get a better idea of how your baby's clubfoot can 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 birth.

Will I be able to care for my baby in the hospital after birth?

Yes. If your baby is born with clubfoot and no other problems, he or she will likely go to the newborn nursery. In most cases, you can visit the nursery and have your baby brought to your room. 

Will my baby need to see a specialist?

If you deliver at Froedtert & The Medical College of Wisconsin Froedtert Hospital Campus, an orthopedist may see your child in the hospital. 

If you do not deliver here, or the orthopedist does not see your baby before he or she goes home, please call to set up the first casting appointment as soon as possible after you take your baby home. For best results, we will need to do the casting as soon after birth as possible.

Will I be able to breastfeed?

Yes, you should be able to breastfeed your baby. If you do plan to breastfeed, a lactation consultant can answer any questions you may have. You may want to discuss how to position your baby for feeding if he or she has long leg casts. 

When can my baby go home?

More than likely, your baby will go home when you leave the hospital unless he or she has other issues that require more intensive treatment or more assessment.

What is my baby's long-term prognosis?

The long-term prognosis for babies with clubfoot who are treated with the Ponseti Method is excellent. Historically, they have had almost no difference in function or pain in their feet than people who were born without clubfoot. The only known issues that can cause increased pain are related to excessive weight gain and working jobs that require a lot of time standing.

Learn more about the Orthopedics Program  at Children's Wisconsin.