Clubfoot, sometimes referred to as club leg, affects roughly 1 out of 1,000 births. Clubfoot involves four primary deformities (midfoot cavus, forefoot adduction, hindfoot varus, and equinus contracture) that result in the ankle being stuck downward, the foot being turned inward or often pointing toward the other foot and hooked onto itself. In about 50% of cases, both feet area affected. Clubfoot management with a pediatric orthopedist gives children with clubfoot the opportunity to treat the deformities, with effective correction being achieved nearly 100% of the time. Norton Children’s Orthopedics of Louisville, affiliated with the UofL School of Medicine, offers a clinic dedicated to clubfoot treatment with a focus on early intervention and decreasing rates of recurrence.

In about 50% of cases, clubfoot is bilateral, meaning both feet are affected. To make a diagnosis of a clubfoot, no special imaging or blood tests are necessary — the diagnosis is made clinically by a thorough physical examination at birth.

“More often than not, clubfoot is being presumptively diagnosed with perinatal ultrasounds,” said James E. Moyer, M.D., nonsurgical pediatric orthopedics physician with Norton Children’s Orthopedics of Louisville. “I offer perinatal consults to expectant parents to go over the potential treatment process and hopefully allay any misconceptions or fears about antepartum orthopedic care.”

Ponseti method for treating clubfoot

Ideally, clubfoot treatment begins in the first month of life. The Ponseti casting method is considered the gold standard of care for children with clubfoot. The method involves a series of long leg plaster casts to passively stretch and slowly correct the deformities in a stepwise fashion. Ideally, the foot is ultimately corrected to a position of external rotation (of about 60 degrees) and dorsiflexion (of 15 to 20 degrees). The Ponseti method essentially has two main phases:

• Correction phase: Casting is typically approximately five to eight weeks. During casting, a child has a cast removed and then reapplied weekly. The initial material is a plaster cast to mold the foot optimally. At Norton Children’s Orthopedics of Louisville, this cast is over-wrapped with fiberglass material. Typically, it takes five to eight casts for the foot to be optimally corrected prior to the heel cord tenotomy. This is a minor procedure, during which the Achilles tendon is cut, effectively lengthening the tendon, which helps release the foot from a stuck-down position. Nearly 100% of clubfoot cases require a heel cord tenotomy. At Norton Children’s Orthopedics of Louisville, this is performed in the operating room using local anesthesia, so the child is not asleep. The incision is typically small enough that no stitches are necessary. Following the tenotomy procedure, a final cast is placed. The child goes home in this final cast, and after three weeks, they return to the clinic where the cast is removed. If appropriate correction has been achieved, Then bracing is started to help maintain the correction.
• Bracing: This part of treatment is critical for maintaining the correction that was obtained. Bracing holds the foot or feet in the optimal position. The standard of care for bracing is full time (23 hours per day) for the first three months, followed by nighttime bracing (typically with a goal of approximately 12 hours). Currently, bracing is recommended to approximately 4 years of age. This minimizes significantly the risk of a clubfoot recurrence.

“Compliance with bracing is crucial for children with clubfoot,” Dr. Moyer said.

Without compliant bracing, recurrence of clubfoot in the first year is close to 90%, according to Dr. Moyer.

“In terms of idiopathic clubfeet, final correction with good flexibility is achieved the overwhelming majority of the time,” Dr. Moyer said. “The biggest challenge with clubfeet is maintaining the correction after it has been obtained. But with regular stretching and good compliance with the bracing protocol, the outcomes are, generally speaking, very good”