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Prenatal Care for Clubfoot – What Expecting Moms Need to Know

Prenatal Care for Clubfoot – What Expecting Moms Need to Know

by | Oct 19, 2023 | Clubfoot & Foot Disorders

Discovering that your unborn child appears to have a physical difference during an ultrasound can be scary. The news is often unexpected and can lead to thousands of questions about how it will affect your baby. One thing that is commonly identified during the anatomy ultrasound scans is clubfoot, a condition that causes one or both feet to turn inward and downward. While the condition does require treatment, it often can be corrected without surgical intervention.

Our team in the Center for Excellence in Foot led by Anthony I. Riccio, M.D., meets with parents whose babies are diagnosed with clubfoot prenatally and begins treating these children quickly after they are born, beginning interventions within one to two weeks of birth. Learn more about what to expect during the clubfoot treatment process below.

What is clubfoot?

Clubfoot is a congenital (from birth) disorder in which the foot points down instead of straight and turns in, pointing toward the opposite leg. Clubfoot is one of the most common pediatric musculoskeletal conditions that requires treatment by a pediatric orthopedic surgeon.

A clubfoot is not a normal foot that is just twisted and turned into an abnormal position. The outward deformity is created by structural differences inside the foot. The method of treatment for clubfoot cannot alter the structural differences inside the foot. The treatment method takes the structurally abnormal foot that is in an abnormal position and puts it into a series of casts, which slowly turns the foot until it is in a normal position.

If left untreated, clubfoot will make shoe wear problematic and can lead to serious problems, severely limiting activities and even causing difficulty walking.

Prenatal Clubfoot Care: 20 weeks to 40 weeks gestation

Clubfoot can be diagnosed in unborn babies during the mother’s 20-week ultrasound in which the obstetrician or maternal fetal medicine physician reviews anatomy. During this ultrasound, if one or both feet appear to be abnormal, the doctor will refer the mother to visit with an orthopedic specialist to discuss treatment options.

The first appointment with our clubfoot expert Anthony I. Riccio, M.D., consists of a one-on-one conversation about clubfoot and how it is treated. In this appointment, Riccio answers questions that parents have about the condition and educates them on what to expect. This can greatly help a family feel less anxious about the future of their baby and assuage fears about any future disability.

Newborn Clubfoot Care: 1 to 2 weeks old to 2 months old

Riccio encourages families to spend a few days at home enjoying their newborn and then calling Scottish Rite for Children for an evaluation. Ideally, treatment for clubfoot will begin with the first couple of weeks of the baby’s life.

Typical treatment for clubfoot in newborns consists of the Ponseti method, which uses a series of casts and then braces to correct a baby’s clubfoot and prevent its recurrence. In newborns, the first step is to determine the severity of the condition and begin casting.

In serial casting, a cast is applied to the foot or feet once a week for three to five weeks. This brings the foot from upside down and turned inward position to a right side up and turned outward position. In some cases, a simple procedure under local anesthetic is performed to release tightness in the Achilles tendon and bring the foot into a normal position. After three to five weeks of progressive casting, a final cast is applied to hold the foot in the normal position for three weeks.

Infant Clubfoot Care: 2 months old to 7 to 12-months-old

After serial casting is completed, the next phase in clubfoot treatment is bracing to maintain the correction that was achieved through casting. Babies will wear a brace called a boot and bar brace consisting of soft silicone lined shoes with soft suede straps. These shoes are connected to each other by a bar to keep the feet turned outward.

Scottish Rite follows the protocol set by the International Clubfoot Congress of wearing the brace for 23 hours a day until the baby is beginning to pull up to stand, which usually happens between 7 to 12 months of age. Bracing does not interfere with the baby’s ability to reach developmental milestones, such as rolling over, sitting independently or crawling.

Toddler Clubfoot Care: 7 to 12 months old to 4 years old

After the baby begins pulling up to stand, wearing of the boot and bar brace is transitioned to nighttime only until the child reaches age 4. If bracing is not done in its entirety, the risk of clubfoot recurrence approaches 100%.

According to research at Scottish Rite, 70-80% of children will not require further treatment after the Ponseti method. Unfortunately, because clubfoot is a structural, congenital difference, approximately 20% of children will relapse and need further treatment, despite the medical providers and families doing everything correctly.

While clubfoot care may seem daunting, it is a safe and pain-free process that will give your baby the best outcome and prevent them from having difficulties later in life. Our team in the Center for Excellence in Foot stay with our patients and families every step of the way.

Learn more about clubfoot.

Infantile Clubfoot Deformity

Infantile Clubfoot Deformity

by | May 31, 2023 | Clubfoot & Foot Disorders

Clubfoot deformity occurs in one in 1,000 live births, making it the second most common congenital deformity of the foot (after postaxial polydactyly) and one of the most encountered infantile musculoskeletal congenital differences. In contrast to other common infantile foot deformities, such as metatarsus adductus and calcaneovalgus deformities, a clubfoot is not a normal foot that has been “packaged” into an abnormal position. Rather, a clubfoot is a true congenital deformity. There are structural differences inside the foot that create the outward deformity. The shape of the tarsal bones is not the same as that of a child with a normal foot. The elasticity of the soft tissues is much less than in a child with a normal foot, and arterial vessels are often absent or aberrant. Some of the extensor muscles in the leg have been shown to have an exponentially higher number of contractile elements (actin and myosin filaments) and are thus able to generate force at what is essentially a superhuman level.

Despite our understanding of the underlying anatomic and histologic differences in clubfeet, the exact etiology of the deformity remains unknown. Although genetic aberrancies have been identified that are associated with the clubfoot, these appear to be a result of somatic mutations, and thus, the deformity does not appear to run in families with any identifiable pattern of inheritance.

In approaching the treatment of a clubfoot, it is essential for families and providers to understand the presence of these congenital differences because our method of treating clubfoot cannot alter any of them. We can’t change the shape of the bones. We can’t improve the elasticity of the soft tissues. We can’t change the way the blood vessels move into the foot, and we can’t change the power with which certain muscles fire. Therefore, the goal of clubfoot treatment isn’t to create a normal foot. Rather, the goal of treatment is to take a structurally abnormal foot, which is also in an abnormal position, and through a series of casts applied weekly, slowly convert into an abnormal foot structurally that is ultimately in a near normal or completely normal position. Also, this method limits the need for surgery, which creates scarring and stiffness, thereby preserving as much motion of the foot as possible.

The Ponseti method of treatment is the gold standard of care worldwide for clubfoot deformity. This involves weekly serial casting of the involved foot or feet, with each cast applied in a manner to correct a different component of the clubfoot deformity. These casts are very effective at correcting every component of the clubfoot deformity with great success, save for the contracture of the Achilles tendon, which drives an oftentimes rigid equinus (plantarflexion) deformity of the ankle. Approximately 90% of clubfeet require a percutaneous transection of the Achilles tendon. This is performed in the clinic with topical anesthesia in children aged less than 3 months to overcome this component deformity. Following the heel cord tenotomy, the ankle can be acutely dorsiflexed to at least 10 to 15 degrees, and that position is maintained in a final cast that is kept in place for three weeks.

On average, it takes about four weeks of weekly casting to correct the component deformities of the cavus, hindfoot varus, and metatarsus adductus. That brings the foot from what is essentially an upside down and turned inward position to a right-side-up and turned-out position. At that point, if the ankle remains in equinus, this deformity is corrected with a heel cord tenotomy and a final three-week cast, resulting in a total time to achieve full correction of about seven weeks. As we ideally begin treatment within one or two weeks of life, most deformities are corrected by or before 2 months of age.

It cannot be overstated that deformity correction is just the first part of the treatment of a clubfoot deformity. Maintaining that correction is essential and, in many regards, more difficult. Seven weeks in a cast simply cannot overcome months of intrauterine gestation and the various congenital differences present within these feet. Without a means of maintaining correction, corrected clubfeet will universally and quickly revert to their initial position of deformity.
Maintenance of correction is achieved by keeping the ankles dorsiflexed and the feet externally rotated in what is typically called a “boot and bar” construct. While there are a variety of Ponseti-type braces available, most consist of soft silicone lined shoes with soft suede straps. Regardless of whether the deformity is unilateral or bilateral, these shoes are applied to both feet and connected to each other by a bar. The bar holds the shoes at 60 to 70 degrees of external rotation, and the shoe straps hold the ankles in neutral dorsiflexion.

Though bracing protocols vary to some degree, our protocol mirrors that agreed upon at the International Clubfoot Congress and consists of brace use for 23 hours a day until the child begins to pull to stand and 12 hours a night thereafter until age 4. The braces do not interfere with the achievement of developmental milestones, such as sitting up, rolling over, crawling or standing. The transition from full-time to part-time use is based entirely on the fact that once a child is able to pull to a standing position, they will soon spend more time on their feet. At that time, their own body weight will help to keep their feet flat on the ground. Until that time, babies spend most of their time lying down and sitting, during which the feet are held in a relaxed position. That can result in tightening of the heels cords and a recurrence of equinus.

Bracing is most difficult on parents for the first two weeks after the child comes out of their post-tenotomy cast. After seven weeks of casting, having anything other than cast padding surrounding their feet feels different and can cause fussiness. Parents are counseled extensively about this so they can anticipate and develop strategies to keep the braces in place despite frustration on the part of the child.

As mentioned, the use of the brace and the prescribed protocol is essential to long-term treatment success. If the braces aren’t used as recommended, the risk of recurrence of the deformity approaches 100%. These recurrences can be much more difficult to manage in older children than during infancy. It typically requires repeat casting and general anesthesia for either a repeat heel cord tenotomy or a more invasive surgical intervention.

Unfortunately, even when perfect correction is achieved with casting, and parents are compliant with brace use, a percentage of these deformities still recur and require additional treatment due to the structural congenital differences present. Research has demonstrated that with parental bracing compliance, about 80% of clubfoot patients never need any additional treatment. However, despite everyone’s best efforts, 20% of children still need some additional treatment due to recurrence. These recurrent deformities are most commonly the result of an imbalanced muscle pull across the foot due to a relatively overpowered tibialis anterior tendon. When relatively overpowered, this muscle, due to its insertion along the medial aspect of the foot, supinates the foot during dorsiflexion. That results in the touchdown of the lateral border of the foot during the initial stance phase of gait. This supination, in turn, slowly drives the foot inward and into further supination with weightbearing. Such recurrences are easily managed with a brief period of repeat casting to correct any relapsed deformities. That’s then followed by a transfer of the offending tendon to the dorsum of the foot to remove that supination moment during dorsiflexion.

With an experienced team of providers and parental dedication to brace use, these initially dramatic foot deformities can be corrected beautifully and without any long-term deficits or disabilities. However, it is important to educate parents early regarding certain differences in the foot or feet following treatment. A clubfoot is always smaller than a normal foot, sometimes half to a full shoe size smaller than an unaffected contralateral foot. In addition, the calf musculature of children with clubfoot tends to be smaller, though this size difference does not appear to affect strength. These differences are strictly cosmetic and do not alter function. The goal of clubfoot treatment is to allow a foot or feet to sit flat to the ground, have as much flexibility as possible, allow the child to wear any shoes they want, play any sports they want, have any job they want, and do whatever they want with the foot. In achieving this, their corrected clubfoot will function no differently than a normal foot and will never limit a child in any way in any activity they desire.

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Dr. Anthony I. Riccio is a pediatric orthopedic surgeon and the Director of the Center for Excellence in Foot at Scottish Rite for Children.

Clubfoot: What Parents Need To Know

Clubfoot: What Parents Need To Know

by | Jan 7, 2023 | Clubfoot & Foot Disorders

What is a clubfoot?
A clubfoot is a congenital (present at birth) foot abnormality. It is one of the most common pediatric orthopedic conditions.

  • The heel tilts in and down, and the forefoot is turned in.
  • Without treatment, it is possible for a child with a clubfoot to walk on the outside of the foot which may produce pain and/or difficulty walking.
  • A clubfoot is usually smaller than an unaffected foot.
  • The calf is also usually smaller on the side of the clubfoot.
  • One or both feet may be affected.

Why does it happen?

  • The exact cause of the clubfoot is unknown.
  • It cannot be prevented, but it is treatable.

How is clubfoot treated?
The goal of treatment of the clubfoot is to have a functional, pain-free foot with good mobility and strength. Two nonsurgical techniques are used in newborns and young infants:

  • Stretching, Taping and Splinting Program
    • Specialized physical therapy program consisting of stretching, stimulation and taping of the foot.
  • Serial (“Ponseti”) Casting Program
    • Involves positioning of the foot followed by application of a cast.
    • The cast extends from the toes to the top of the thigh, with the knee bent.
    • The cast is changed every one to two weeks in clinic.
    • After the casting program is complete, your child will wear a special brace full time for three months, then at night until two or three years of age.
    • Wearing the brace is crucial to prevent the clubfoot from recurring.
  • Surgery – If nonsurgical treatment does not completely correct the foot position or if the foot deformity recurs, surgery may be recommended.

Learn more about the care & treatment of clubfoot. 

Share Your Story: My Favorite People

Share Your Story: My Favorite People

by | Sep 9, 2022 | Clubfoot & Foot Disorders

Meet Addison, a patient who is seen by our team of multidisciplinary experts. Learn more about her journey below.
 
Blog written by Addison.

I have been a patient at Scottish Rite for Children my entire life – more than 15 years! My first appointment was when I was only 5 days old. When I was born, my legs went up toward my head and my knees were backward. I have what is called Larsen’s Syndrome, and this caused me to be born with bilateral knee dislocations, hip dysplasia and club foot.

Dr. Rathjen is my doctor, and he is one of my favorite people. He changed my life by giving me the ability to walk. Throughout the years, I’ve had a bunch of different surgeries and my legs have been casted. Without him, I would not be able to walk, play sports or do any of the other things I love to participate in. My legs don’t really bend, but that does not slow me down! I really love volleyball, and I’m involved in National Charity League and volunteer in my church nursery.

baby sleeping
Scottish Rite will always be a huge part of my life. When I was younger, I was there so often the hospital almost felt like a second home. Everyone is nice, and I always look forward to the different Scottish Rite activities. My mom would bring me to different events, and I always thought it was the most fun place. Throughout the years, I’ve done different things to give back to the organization. I usually do them around the time of my birthday. Scottish Rite changed my life, and I want to give back to the place that gave me so much. I’ve gotten to know Stephanie Brigger, and she is another one of my favorite people!
Doctor with his patient

I’ve never allowed my condition to keep me from living life to the fullest.

I dream of becoming a pediatric physical therapist, so I can help other kids like me. I am so thankful for Scottish Rite.

 

DO YOU HAVE A STORY? WE WANT TO HEAR IT! SHARE YOUR STORY WITH US.

Share Your Story: I Got This

Share Your Story: I Got This

by | Jun 14, 2022 | Clubfoot & Foot Disorders

Meet Ella, a patient who is treated by our experts in the Center for Excellence in Clubfoot and Foot Disorders. Learn more about her journey below. Blog written by Ella’s mother, Lindsay.  I was about halfway through my pregnancy when we found out that our baby, Ella, would be born with a clubfoot. Our standard anatomy scan revealed we were going to have a baby girl, plus indicated there might additional issues going on.  

Our doctor referred us to a specialist, where we learned that Ella most likely had a rare heart condition called Tetralogy of Fallot, in addition to clubfoot. In order to confirm the heart condition, her little heart needed more time to grow and develop. That waiting period was very stressful, but after a couple of weeks and many prayers, we learned that Ella had a healthy heart. She still had clubfoot, so we then went to a different specialist in Oklahoma City.     As soon as she was born, we started her clubfoot treatment. I wanted to be on top of things and give her the very best possible outcome. Immediately following her birth, Ella’s left foot was casted for four weeks. She then had an Achilles tenotomy procedure, where the Achilles tendon was cut so the ankle

During this time, I remember feeling a lot of guilt because our doctor would tell my husband and me that we needed to be doing more. More stretching and more exercises with Ella. My mom intuition kicked in, and I had a bad gut feeling that something just wasn’t right. Her little foot literally wouldn’t stretch anymore, so I consulted with a physical therapist who confirmed my feelings.     Ella underwent another Achilles tenotomy in January of 2019, followed by a tibial osteotomy in December of 2019. During the tibial osteotomy, her tibia was cut and repositioned. This caused Ella to be in extreme pain. We did not have a very good experience at that original hospital, and that was when that I started to research other hospitals and learned about Scottish Rite for Children.  

I reached out to a respected doctor that I know, and he referred us to Scottish Rite. He told us that the doctors at Scottish Rite were the absolute best! And they are! Ella’s first appointment with Dr. Riccio was in the fall of 2020. At that time, he told us what we didn’t want to hear – another surgery would be necessary for Ella. We had been through so much with our first doctor and hospital that I was very uncertain and had lots of anxiety about what to do.    After much prayer, we decided to schedule a tendon transfer and release surgery with Dr. Riccio.

He could sense that I was afraid, and I was so touched with how he took the time to talk to us and help ease my fears.

The day of her surgery, I was a complete mess. I had stayed up all night, going down a dark rabbit hole on the internet. I will never forget when Dr. Riccio walked in the pre-op area and said, “I got this”. After her surgery, he came to talk with us in recovery and had a huge smile on his face as he walked into the room. He told us that he thought we were going to be very happy with the results. Those memories will be in my mind forever. We are thrilled with the results! We are FOREVER thankful to Dr. Riccio and his entire team. The kindness Ella experienced with the Child Life team was also life changing. Our entire family thanks God for Dr. Riccio and I tell anyone who has a child with clubfoot to go to see him immediately!  

DO YOU HAVE A STORY? WE WANT TO HEAR IT! SHARE YOUR STORY WITH US.

What are Flat Feet?

What are Flat Feet?

by | Feb 3, 2022 | Clubfoot & Foot Disorders

At Scottish Rite for Children, the Center for Excellence in Foot includes a multidisciplinary team of experts who collaborate to determine the best treatment plan for each patient. We know there are a lot of questions if your child begins treatment for their flat feet (Pes Planus). Below are the most commonly asked and the answers from our team. What are flat feet? Flat feet are the flattening of the arches of the feet when standing. What is the cause? Children’s bones and joints are flexible, which can cause their feet to flatten when they stand. Babies are often born with flat feet, and this condition may continue into early childhood. Flat feet can also be hereditary or run-in families. In most children, the feet become less flexible, the arch develops, and flat feet disappear by the age of five or six, but some children continue to have flat feet into adulthood. Do flat feet cause pain? Flat feet are usually painless and do not interfere with walking or participation in sports. In young children, flat feet are not associated with pain to the knees, hips or back. What are the two types of flat feet? 1. Flexible flat feet
  • A flexible flat foot is a variation of a normal foot.
  • Flexible flat feet can be normal in most infants and toddlers, as the arch has not yet developed.
  • The arch is visible when the child is sitting or on their tiptoes, but the arch collapses when the child is standing.
  • This type may be seen in multiple family members.
2. Rigid flat feet
  • A rigid flat foot means that there is no arch in the foot, even when the child is standing on the tiptoes.
  • The motion of the foot and ankle is stiff.
  • X-rays or other imaging may be ordered to determine why your child has a rigid flat foot.
What are treatments for painful flat feet?
  • Most flat feet are not painful and do not require any treatment.
  • For painful flat feet, treatment is focused on comfort and flexibility.
    • Shoe inserts or tennis shoes with a stiff sole and good arch support may be used for painful flat feet, but they will not permanently change the appearance of the foot.
    • Over-the-counter gel and soft shoe inserts are often recommended.
    •  Hard plastic inserts tend to cause discomfort.
    • A referral may be made to an orthotist, for custom shoe inserts.
  • A stretching exercise program may be recommended for flexible flat feet with tight heel cords.
  • Surgery is not recommended in most cases of flat feet.
Learn more about the common foot disorders our experts treat.