We review the etiology, pathophysiology, diagnosis, and treatment of clubfoot. We are joined by Megan Johnson, MD, Assistant Professor of Pediatric Orthopedic Surgery at the Texas Scottish Rite Hospital for Children in Dallas and UT Southwestern.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host Dr. Neeta Goli, a pediatrician in the UT Southwestern Newborn Nursery. Welcome back to the podcast. In today's episode we will be discussing the evaluation and management of clubfoot. We are recording remotely due to the ongoing COVID pandemic. We are joined today by Dr. Megan Johnson, Assistant Professor of Pediatric Orthopedic Surgery and the Medical Director of Ambulatory Care at Texas Scottish Rite Hospital for Children in Dallas, and UT Southwestern.
Dr. Megan Johnson:
Hello.
Dr. Neeta Goli:
Hi, Dr. Johnson. Thanks for joining us today.
Dr. Megan Johnson:
Sure. It's great to be here. Thanks for inviting me.
Dr. Neeta Goli:
Clubfoot, or a talipes equinovarus, is a congenital foot deformity which involves the forefoot being turned inward and plantarflexed. Dr. Johnson, please, can you tell us more about the anatomy and physiology of this condition and how common it is?
Dr. Megan Johnson:
Sure. So clubfoot is actually really common. It occurs in about one out of every 1000 birth and it's the most common congenital anomaly that we see in newborns. And in about half of the cases it's bilateral, and the rest, it just affects one foot. The pathoanatomy and pathophysiology of it is a little bit complex. And to be honest, we don't completely know everything about it, but what we do know is that there is an abnormal shape to the talus bone, which is one of the bones in the hind foot, and the rest of the foot, the midfoot and the forefoot, are deviated to the inside of the leg, or the medial side of the leg, causing the deformity that you think of when you hear clubfoot. There's also probably a soft tissue component to the disease. We, again, don't quite know exactly what that is, but we do think that there's something abnormal about the muscles and tendons and ligaments in the foot, and also the lower leg, that contribute to the deformity.
Dr. Neeta Goli:
What do we know about the etiology of club foot?
Dr. Megan Johnson:
So we know lots of little things, but I don't think that we totally have the big picture figured out. There is probably a contribution of genetic and environmental factors that lead to clubfoot deformity. We know that many babies with clubfoot have a positive family history of clubfoot. So about 25% of babies who have that diagnosis will have somebody in the family who also had the diagnosis. And we also know that there's an increased risk of having a second child with clubfoot if your first child had a clubfoot, or if there's a sibling in the family that had clubfoot. And we know that in some twin studies, there's an increased prevalence of clubfoot amongst both twins, especially if they're identical. There have been some genes identified that we think probably contribute to clubfoot deformity. This is mostly studies that have been done in animals. And so, there's some things out there that people are investigating.
Dr. Megan Johnson:
There is, in the literature, a link between maternal smoking and clubfoot, which may contribute to an environmental factor that leads to the deformity. But to be honest, we don't really know the cause of it, and that's why we still call it idiopathic clubfoot for now.
Dr. Neeta Goli:
Though clubfoot is usually an isolated finding, it can also be associated with some genetic disorders. What are the most common disorders we should be aware of if we're caring for an infant with clubfoot?
Dr. Megan Johnson:
So, I would say in the vast majority of cases, it's definitely an isolated finding; however, there's definitely an association between lots of different syndromic and genetic conditions that we see associated with clubfoot very frequently. So, a couple of the big ones that are probably more commonly seen would be Down syndrome. We see clubfoot frequently in children with arthrogryposis and Larsen syndrome, which are two disorders that involve multiple joint contractures. We see it in kids who have amniotic bands; it's a fairly frequent association with clubfoot and amniotic bands. You can see it in patients that have tibial or fibular hemimelia, especially tibial, but we definitely see variants of clubfoot in that. It's very common in patients who have spina bifida, and in some patients with cerebral palsy. And then we see it a lot kids who have VATER or VACTERL association, so multiple other deformities, as well as the clubfoot.
Dr. Megan Johnson:
And so for that reason, it's really important when we're initially seeing patients with club foot in the office, to do a really thorough physical exam, to look for any other abnormal findings that would be present along with the clubfoot. So, looking at the baby's face, making sure that the face appears to be normal and doesn't have any dysmorphism. Looking at the spine, you can pick up signs of spinal dysraphism or other issues in the spine by doing a really great exam on that. Sacral dimpling and pitting goes along with that as well. And then just looking at the other limbs for other anomalies or deformities is really helpful as well.
Dr. Neeta Goli:
And then you mentioned tibial hemimelia. Would you please remind me what exactly that is?
Dr. Megan Johnson:
Yeah. Tibial hemimelia is when you have abnormally formed tibia, so only partially formed and it comes in on a spectrum of severity, but frequently because the tibia is not there on the medial part of the leg, we'll see that the foot is turned down like in a clubfoot.
Dr. Neeta Goli:
I see. Okay. Thank you. And then, should we expect clubfoot to be diagnosed on the prenatal ultrasounds?
Dr. Megan Johnson:
It's really quite common to pick it up on the prenatal ultrasound, especially on that 20-week anatomy scan. And the positive predictive value of prenatal ultrasound that shows that clubfoot is about 80%. So in 20% of the cases, when the baby's born, there won't be a clubfoot because the foot rests in that plantar flexed and inverted position in utero. And so, while you may see that on ultrasound, sometimes that doesn't mean that the deformity will be there when the baby's born. So, it is definitely very easy to diagnose it that way. It can be missed for sure, so we'll see, frequently children come in and the family did not have a previous notion that there was a diagnosis of clubfoot. But I would say to any parents who are listening that just because the ultrasound shows a possible clubfoot, it doesn't mean that that's for sure the diagnosis, and really, we won't be able to know anything until the baby's born and we have a chance to examine the foot.
Dr. Neeta Goli:
So when the baby is born and we're examining their foot, if we see a baby whose forefoot is turned inwards, how can we tell the difference between a flexible foot deformity versus a true clubfoot?
Dr. Megan Johnson:
This is a really common thing that comes up in the office when we're seeing these babies. So, you can have an intrauterine positioning abnormality of the foot, which just means that the baby was bundled up inside the uterus tightly. And that looks like a clubfoot at rest, but the distinguishing factor is that when you stretch that foot out and you bring it up into dorsiflexion towards the tibia bone and then rotate outward, the foot completely corrects. And the fact that you can dorsiflex the foot past neutral is a really good sign that it's just an positioning abnormality, and it will get better over time with just a little gentle stretching by the parents. And that's different than a true clubfoot, which is more rigid, more difficult to completely correct, and is a foot that you won't be able to dorsiflex past neutral.
Dr. Neeta Goli:
So if we do have an infant with a true clubfoot, what are our initial steps in management?
Dr. Megan Johnson:
So, any baby born with a true clubfoot should see a pediatric orthopedic specialist who is trained specifically in pediatric orthopedics and is knowledgeable about how to treat clubfeet. And it's interesting, the pendulum about treating clubfeet has really swung over the last 30 to 40 years. Back in the '70s, '80s, '90s, patients with clubfoot were treated with an extensive surgical release of all the tight tissues; however, what we realized was that we were creating a lot of scar tissue and a lot of stiff, painful feet later on in life. And so, in the late '90s and early 2000s, Dr. Ponseti came up with a serial casting method to treat the deformity nonsurgically. So, the mainstay of treatment nowadays is casting, and that's initiated, really as soon as we can after the baby's born.
Dr. Megan Johnson:
I like to tell my patients, if we can give families a grace period for the first couple of weeks, just to get everything figured out with the newborn and get the newborn into a good pattern of sleeping and eating, and then if we can start right around the two-week mark, that's a nice time to start because the casting happens every week, and we change those casts out in the office. And it's nice to be able to apply the cast when the baby's just really doing a lot of sleeping and is not really super active and moving a ton; we can get really good correction with the cast that way.
Dr. Neeta Goli:
So it sounds like the Ponseti method is the mainstay of treatment. There's also something called the French functional physical therapy method. What are the differences between these two in terms of logistics and outcomes?
Dr. Megan Johnson:
Like I was mentioning earlier, the Ponseti method is serial casting, and the casts are applied once a week for about four to six weeks on average, but it can take less time or a longer period of time, depending on how severe the deformity is. And then once we're done with the casting and the foot's corrected, most often those children will need to have a little procedure done to correct the last portion of the deformity, which we can't correct with casting, which is the equinus deformity. And that's the part where the foot is plantarflexed down towards the ground. Some people prefer to do it in the office with some local anesthetic, and others prefer to do in the operating room. So it just depends on the person seeing the patient, but this will correct the plantarflexion and allow the foot to come up to a right angle.
Dr. Megan Johnson:
And then one final cast is applied for three weeks. And then the patient goes into a foot abduction orthosis, with the clubfoot side rotated externally about 60 or 70 degrees. And if unilateral, the other foot's only rotated about 40 degrees, and the feet are tethered together with a bar. And then the child wears this for three months full-time, which means 23 out of 24 hours a day. And then at that point, the family can switch to doing night-time and naps. So that's about 12 to 14 hours a day. And the length of time varies a little bit amongst practitioners, but generally we try to get the patients to about age three or four, wearing those braces at night-time. We think by that age, the chance of it reoccurring is a lot less.
Dr. Megan Johnson:
And so, this is in contrast to the French method, which was developed in the '70s. And the French method is a fairly intense program of physical therapy and stretching of the foot in combination with taping that's applied initially by physical therapists who are specially trained to do this method, and then eventually the families take over the treatment and do the stretching and taping. It happens on a daily basis and it's probably an hour or so worth of stretching the foot, gaining some mobilization, and then taping it to hold it there. I am not as familiar with the French method myself because it's not something that's done as commonly as the Ponseti method, but from my understanding, it probably takes around three months to get most of the deformity corrected, and then another couple months to really get the foot where it needs to be. And then it does require that maintenance stretching and taping for quite a while until the child really starts walking. And then you continue therapy and stretching at home after that.
Dr. Megan Johnson:
In terms of outcomes of both of them, there was actually a study done here at Scottish Rite, looking at both methods. And actually, they had very similar outcomes. There was no difference in the way that the foot did after either method. I would say that people who treat clubfoot probably will default to the method that they feel most comfortable with and most trained in, which for most people here would be the Ponseti method. And also, I think in terms of logistics, it's probably a little bit more strain on the families to take on the French method, just because it involves so much stretching and taping every day, whereas with the Ponseti method, you come in once a week to the office, the practitioner takes care of the casting and then for the next week, you really just have to maintain the cast in place. So I think both are reasonable.
Dr. Megan Johnson:
And sometimes if a baby's not tolerating casting very well, or it's not going the way we want it to, sometimes we switch and try something like the French method. So, I think both are options, but in this country, I think you'll more commonly find that the Ponseti method is what people favor.
Dr. Neeta Goli:
Sounds like you'd have to find the right fit for the family. That would have to be a very motivated family to do the French functional method if it's daily, and taping.
Dr. Megan Johnson:
Yes. That is very true.
Dr. Neeta Goli:
And then once these kids grow older, you mentioned for the Ponseti method that they would need to stay in the rigid cast at night-time for naps and overnight, but long-term outcomes, is there anything that we should be aware of for these children once they're older in terms of their walking, their gait?
Dr. Megan Johnson:
Yeah. So fortunately when the Ponseti method is done as Ponseti described it, and the family uses the braces as prescribed for the amount of time prescribed, the success rate and treatment is 90 to 95%. And it's interesting, if all of it's done correctly, and again, the family's compliant with bracing, we do sometimes see some relapse. And in about 20% of cases that we thought were just idiopathic clubfoot, that didn't have an associated neuromuscular condition, we do end up finding that there might be something else going on with the patient, if the foot relapses despite them being compliant with the treatment. But for the most part, patients do really well with treatment. Like I said, about nine out of 10 babies will need that procedure done for the heel cord. And then we watch for a while after we're done with the full-time bracing and the baby goes into night-time and nap bracing, to make sure that there's no evidence of recurrence.
Dr. Megan Johnson:
And I will say in about 30% of babies, there is a little bit of a slight recurrence due to one of the tendons in the foot being tight and pulling the foot into what we call dynamic supination when the patient walks. This is usually recognized around the age of three. And if that happens, then sometimes we'll need to do a small surgery to tweak the foot, where we move that tendon over to the outside part of the foot to balance the foot better. But even in patients who require that, they do great, they will play sports, they will dance, they really can do all the activities that they want to do without a problem after treatment of clubfoot. There's a lot of professional athletes that have a history of clubfoot. It's a really common thing and there's just a lot of people out there who have had really successful treatment.
Dr. Megan Johnson:
I will say, one thing I point out to families that I see in the office is that the calf muscle on the side of the body that had the clubfoot will always be smaller than the other side that's not affected. And if the clubfoot was bilateral, then it'll be symmetric on both sides. And families always ask, is there some sort of physical therapy that we can do to help bulk up that muscle? And in my experience, I haven't really seen physical therapy to be super helpful for that, but what I do tell them is that despite the calf being a little bit smaller, we don't really see any problems with ability to participate in activities and strength in the muscle in general. So it's just part of the clubfoot deformity, but it doesn't hinder patients moving forward.
Dr. Neeta Goli:
And then are there any special orthotics or anything that these kids might need to use? I'm so happy to hear that you said that they can still be active and participate in sports and everything like that. Any relation to the foot arch, anything else?
Dr. Megan Johnson:
Sometimes we do notice that patients who've undergone casting can have a slight overcorrection of the foot and actually end up with a little bit of a flat foot. And so if those children are having pain or issues with shoewear or something, then sometimes just an orthotic inside the shoe, a shoe insert will be helpful for them. But generally, if the patient is functioning well, they're able to wear shoes, they're doing the activities that they want to do and not complaining of pain or discomfort in their foot, they don't really require any special shoewear or inserts or orthotics once we're done with treatment.
Dr. Neeta Goli:
And then to end the episode today, do you have any advice for our listeners while they take care of newborns?
Dr. Megan Johnson:
Well, I have a two-year-old, so I feel like we were recently in that newborn stage. And so, I would just tell families who have newborns that I think that babies take on what they feel is coming from you. So, I would just say to try to be relaxed and laid back with your baby and just take everything in stride and just know that everyone's doing a great job, and just because you're doing something one way and somebody does something another way, that both ways are probably equally as great. And the best thing that you can do is love your baby, feed your baby, and take care of them and don't worry about the details, it will all fall into place. So, I think just being low-stress and just enjoying the time you have with your child is the most important thing.
Dr. Neeta Goli:
I love that. And then do you have any advice for the clinicians who might be taking care of the babies in the nursery?
Dr. Megan Johnson:
Yeah, I think it's really helpful, one, to provide some counseling when the baby is born. So in that first 24 to 48 hours. I think for the families that had the diagnosis made prenatally on ultrasound, they've had a long time to come to terms with it and think about it. And so they are maybe a little bit more adept at coping with it at that point, but for some families, this is a complete shock to them. And knowing that their baby has clubfoot, I think can take away some of the joy of the whole birth process and having a newborn. And so I think for people that treat newborns in the newborn nursery, I think just try to realize that, and help families deal with those feelings is super helpful.
Dr. Megan Johnson:
And also, I think giving families some reassurance that this is a very treatable condition, it's very common and knowing that there are people out there that are specially trained to take care of this and that in most cases, it doesn't require a huge surgical procedure, can be really reassuring that those first moments when the family is trying to cope with the diagnosis. Lastly, I would just say, although most cases are isolated and idiopathic, I think just making sure if you see a clubfoot, to do a really thorough physical exam and make sure that if there's any other signs of something else going on, that we know about that and include that in workup of a baby.
Dr. Neeta Goli:
Dr. Johnson, thank you so much for joining us today.
Dr. Megan Johnson:
Sure. Thank you for having me.
Dr. Neeta Goli:
Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests and do not necessarily reflect the views of the university.