In the Treatment of Clubfoot, the Earlier We Get to the Foot, the Better the Outcome



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Clubfoot is a significant congenital deformity in which the foot is turned inward and upward. For parents of a child diagnosed with clubfoot, the joy of a pregnancy and birth can turn to fear. Dr. Coleen Sabatini specializes in a treatment called the Ponseti Method, popular globally since the early 2000s, which allows children with clubfoot to eventually lead normal lives.

 

What does clubfoot look like?

Imagine that the foot is bent in the middle, rotated in, and turned around on itself. If you were to look from the child’s face down to the foot, you’d be actually be seeing the bottom of the foot instead of the top. It’s a four-part deformity: the foot has an increased arch, which is called cavus; the midfoot and forefoot are rotated inward, which is called adductus; the back of the foot—the heel and ankle– are rotated underneath themselves, which is called varus; and the Achilles tendon is very tight, which restricts movement, and that’s called equinus.

 

What are some of the common misconceptions about clubfoot?

People often come in with fears that their child will not be able to walk or run or play sports. It’s nice to be able to tell parents that clubfoot is a condition that we can correct with treatment. Children with isolated clubfoot deformities will most often be able to walk, run, and be a typical kid.

 

How is treatment different today than it was a generation ago?

A generation ago, all of these kids would have to have a very significant operation to the foot in which multiple tendons would be lengthened, capsules would be cut—a lot of surgery that could cause long-term scarring and stiffness of the foot. With the Ponseti Method, far fewer kids have to have that more extensive operation.

 

How does your practice differ from others?

We have an actual clubfoot program—a clinic every Tuesday morning for babies who are undergoing their initial casting treatment up to teenagers who are coming back for follow-ups. I follow them through maturity, and we have a team of very experienced orthopedic cast technicians, orthotists, and nurses caring for these kids. We take care of not just the deformity, but also all of the concerns and stresses that come along with it for the family and child as the child gets older.

We have a high volume of patients and families coming in, and they’re able to talk with each other and share ideas such as clothing and activities that accommodate the special shoes. It’s an opportunity for them to understand that they’re not alone with this diagnoses. They meet all these other kids in various stages of treatment and see kids who are running around and being able to do sports activities. It’s great for them to make those connections and see what the trajectory might be for their child.

 

What does that trajectory typically look like?

The Ponseti Method, which is used all over the world now for treatment of clubfoot, consists of a series of casts that go from the toes to the upper thigh. You change the cast every week and take specific steps to correct the deformity by rotating it into a more normal position. In the majority of cases, a very small operation is required at the end of the casting in which you cut the Achilles tendon to allow for the final step in the correction of the foot. This process can take from four to eight weeks, and sometimes longer depending on the rigidity of the foot deformity.

After we perform the surgery, the child is in a cast for another few weeks before transitioning to special shoes with a bar that’s worn until age 4, and that’s because the foot wants to pull back into its original position. The child wears this brace full time for about nine months until he or she starts to stand. Then we remove the brace during the daytime, but the child sleeps in it until he or she is about 4 years old.

Some children require additional casting if the foot tries to pull back into a deformed position, and other children require additional surgery as they grow and develop, either from recurrence or because there’s additional problems as they begin walking—the most common being that they have an overpull of one of their tendons and we need to move the positon of that tendon to improve the position of the foot.

 

How do parents know their child has clubfoot?

Clubfoot can either be diagnosed in utero on ultrasound or at the time of delivery. So some families are prepared for the diagnosis and others are anticipating a healthy, normal baby and when the baby is delivered it’s diagnosed with clubfoot. It is a specific, clinical diagnosis that’s made based on evaluations of the foot, and it requires treatment. It is not a condition that will get better on its own.

 

What’s the first thing you do when a child is diagnosed with clubfoot?

I do a thorough physical examination to make sure there aren’t any other abnormalities. I then talk with the family about treatment recommendations and let them know what the expected treatment course is. Then we start treatment right away. The earlier we get to the foot, the better the outcome often is.

 

UCSF Benioff Children’s Hospital Orthopaedics Outpatient Center/Clinic, 744 52nd St., Oakland, 510-428-3238, OrthoSurg.UCSF.edu, ChildrensHospitalOakland.org

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