About one baby in every 1,000 in the United States is born with clubfoot. Almost half of those babies have bilateral clubfoot where both feet have the deformity. The wonderful news is that there is a non-surgical treatment that, with rare exceptions, can correct clubfoot and help children live normal lives.
Clubfoot requires a proper medical evaluation and will not resolve on its own.
In this segment, Dr. Matthew Dobbs joins the show to discuss treatment options for club foot available at St. Louis Children's Hospital and when to refer to a specialist.
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Treatment Options for Clubfoot
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Learn more about Matthew Dobbs, MD
Matthew Dobbs, MD
Matthew Dobbs, MD, is a Washington University pediatric orthopedic surgeon at St. Louis Children’s Hospital.Learn more about Matthew Dobbs, MD
Transcription:
Treatment Options for Clubfoot
Melanie Cole (Host): About one baby in every 1,000 in the United States is born with clubfoot. The good news is that there's a nonsurgical treatment that with rare exceptions can current clubfoot and help children live normal lives. My guest today is Dr. Matthew Dobbs. He’s a Washington University pediatric orthopedic surgeon at St. Louis Children’s Hospital. Welcome to the show. First of all, what is clubfoot and are certain children at risk for it?
Dr. Matthew Dobbs (Guest): Thanks for having me. Clubfoot is the most common musculoskeletal birth defect. As you said, it’s one in 1,000 live births that have this problem. It does tend to run in families. You asked who’s most at risk, but it doesn’t always. Roughly, in 35% of situations, we will find a positive family history – meaning one or more relatives with them, several generations a pedigree will be affected.
Melanie: Do we know what causes it?
Dr. Dobbs: We don’t. In the vast majority of cases, we do not know the cause. There are some cases that are associated with known medical problems – neurological problems, muscular problems – but the vast majority occur in otherwise isolated cases – in other words, children with no other medical issues whatsoever. If you wanted to imagine what a clubfoot is or looks like, if you simulated weight bearing – if you took a baby up and had clubfoot and tried to put them on their feet, they would be walking or standing on the top and outside of their feet. The name “clubfoot” comes from the end of a golf club. That’s really what the foot looks like – it’s turn over and in.
Melanie: At what point is the condition detected? Is it something you would see in utero or would it be the obstetrician delivering that first notices this?
Dr. Dobbs: It is absolutely diagnosable on ultrasound, so in utero. Many times today, we get couples that will come in before a delivery because they’ve had that diagnosis on ultrasound. We actually like it when that’s the case because we can actually educate them early and alleviate fears and really get them in tune with what the treatment is going to be.
Melanie: Let’s talk about treatment for a few minutes. Is this something that is surgically necessary? It’s not going to go away on its own, so it does require some intervention.
Dr. Dobbs: That is correct. Clubfoot does not go away on its own. It is not a positional foot problem – it is congenital. It does require treatment, but luckily we have a wonderful method called the ‘Ponseti method’ that has avoided the need for surgery in a vast majority of patients. It has turned treatments into a casting protocol rather than a very expensive surgery that used to be used commonly.
Melanie: Speak about the Ponseti method. Also, you invested your own device to treat clubfoot called the Dobbs Dynamic Clubfoot Bar. Tell us about that.
Dr. Dobbs: The treatment method involved serial casting, so we see the child and parents in the clinical once a week. We undergo a very brief manipulation of the foot to stretch it out and that takes about 30 seconds, followed by the application of the cast, and then they are seen weekly for that same procedure and each week we’re able to stretch the foot out a little bit more. Before the very last cast goes on, most patients require a small procedure to link the heel cord, and that’s done in the office under local anesthetics, so no trip to the operating room. Following all of that casting – that’s about two months in all – we go into a brace and I did develop a brace that’s used. This is used to maintain correction and the reason it’s necessary is after successful casting of the clubfoot, there's a tendency towards relapse or recurring, and so the brace prevents that from happening.
Melanie: What do you tell parents about how long this would take and even other pediatricians that are continuing care with this child when they're wearing the brace?
Dr. Dobbs: The brace theme is something that is used for up to four years after the cast correction. We talk to the families about this in great detail at every visit and starting with visit #1, so I always tell them this is a partnership and they are playing the leading role in this because the casting part, which I'm applying myself, that goes on for a couple of months, and afterwards comes the bracing protocol, and that goes on for several years. It’s really a team effort in the old phrase “it really takes a village,” it’s very true for clubfoot management. But when the families hear this early and initiate this protocol, it’s extremely successful.
Melanie: Can you tell us something interesting about a particular case or diagnosis that you’ve worked with? You developed this brace so that alone is fascinating, but what lead you to do that?
Dr. Dobbs: I do this because of problems identified in patients, and so the hardest part of clubfoot management is the bracing, and I alluded to it a bit, but it goes on for so much longer than the cast. This is when the child is growing through toddlerhood and so forth. It’s difficult to keep a child in a nighttime brace during that time. The old brace was just a solid bar, so the kids couldn’t move their legs independently and the brace that I developed allows independent leg movement while still holding the foot corrected. My goal was to improve tolerance and I knew that if I could make a brace that was well tolerated by the kid, then the parents would be more able to use it. That was the emphasis towards the development of the new brace.
Melanie: Are there some treatments or research that you're doing at St. Louis Children’s that other physicians may not be aware of and give us a little blueprint for where you see this condition going in the future – any future research or things that you see happening?
Dr. Dobbs: We’ve been very involved, my research team, on researching clubfoot. One of the aspects that we've been heavily involved with is trying to understand genetic factors that cause clubfoot. My team has identified four genes that cause clubfoot in familial cases – those cases that have multiple family members involved. That’s a very interesting part of my research. Another aspect is the clinical side and we right now have a very large multicenter clinical trial going on trying to figure out how long bracing actually needs to be used. I mention we use this as a four to five year protocol, but there are some children that do not need it that long and others that may need it longer. I'm teaching physicians now how to examine the children and be able to pick up on predictive signs that will allow us to personalize clubfoot treatments. In other words, we can see a child at birth and based on exam findings be able to predict their individual risk of relapse and prescribe for them a personalized length of brace treatment. That I think is really advancing the clubfoot treatment to the next level and getting this out throughout the world. The treatment protocol I think is going to be the next big thing for clubfoot management.
Melanie: In summary, tell other pediatricians what you'd like them to know about recognizing clubfoot and when to refer to a specialist.
Dr. Dobbs: I would want to recommend in utero diagnosis ideal. That’s probably more for the obstetrician. If it hasn’t been picked up on ultrasound, then referral in the first month of life after birth is really important because the earlier we start treatment, the easier that treatment process is and it’s easier to get through bracing as the kids are younger, to get them used to that pattern. Early diagnosis, early referral and I would want to express to the pediatrician that it’s very important to find a ponseti certified pediatric orthopedic surgeon to perform this treatment method. It’s not a universal thing for all pediatric surgeons to be able to do or train in, so it’s important to get to the right subspecialist for treatment.
Melanie: Thank you so much for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP. That’s 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to stlouischildrens.org. That’s stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.
Treatment Options for Clubfoot
Melanie Cole (Host): About one baby in every 1,000 in the United States is born with clubfoot. The good news is that there's a nonsurgical treatment that with rare exceptions can current clubfoot and help children live normal lives. My guest today is Dr. Matthew Dobbs. He’s a Washington University pediatric orthopedic surgeon at St. Louis Children’s Hospital. Welcome to the show. First of all, what is clubfoot and are certain children at risk for it?
Dr. Matthew Dobbs (Guest): Thanks for having me. Clubfoot is the most common musculoskeletal birth defect. As you said, it’s one in 1,000 live births that have this problem. It does tend to run in families. You asked who’s most at risk, but it doesn’t always. Roughly, in 35% of situations, we will find a positive family history – meaning one or more relatives with them, several generations a pedigree will be affected.
Melanie: Do we know what causes it?
Dr. Dobbs: We don’t. In the vast majority of cases, we do not know the cause. There are some cases that are associated with known medical problems – neurological problems, muscular problems – but the vast majority occur in otherwise isolated cases – in other words, children with no other medical issues whatsoever. If you wanted to imagine what a clubfoot is or looks like, if you simulated weight bearing – if you took a baby up and had clubfoot and tried to put them on their feet, they would be walking or standing on the top and outside of their feet. The name “clubfoot” comes from the end of a golf club. That’s really what the foot looks like – it’s turn over and in.
Melanie: At what point is the condition detected? Is it something you would see in utero or would it be the obstetrician delivering that first notices this?
Dr. Dobbs: It is absolutely diagnosable on ultrasound, so in utero. Many times today, we get couples that will come in before a delivery because they’ve had that diagnosis on ultrasound. We actually like it when that’s the case because we can actually educate them early and alleviate fears and really get them in tune with what the treatment is going to be.
Melanie: Let’s talk about treatment for a few minutes. Is this something that is surgically necessary? It’s not going to go away on its own, so it does require some intervention.
Dr. Dobbs: That is correct. Clubfoot does not go away on its own. It is not a positional foot problem – it is congenital. It does require treatment, but luckily we have a wonderful method called the ‘Ponseti method’ that has avoided the need for surgery in a vast majority of patients. It has turned treatments into a casting protocol rather than a very expensive surgery that used to be used commonly.
Melanie: Speak about the Ponseti method. Also, you invested your own device to treat clubfoot called the Dobbs Dynamic Clubfoot Bar. Tell us about that.
Dr. Dobbs: The treatment method involved serial casting, so we see the child and parents in the clinical once a week. We undergo a very brief manipulation of the foot to stretch it out and that takes about 30 seconds, followed by the application of the cast, and then they are seen weekly for that same procedure and each week we’re able to stretch the foot out a little bit more. Before the very last cast goes on, most patients require a small procedure to link the heel cord, and that’s done in the office under local anesthetics, so no trip to the operating room. Following all of that casting – that’s about two months in all – we go into a brace and I did develop a brace that’s used. This is used to maintain correction and the reason it’s necessary is after successful casting of the clubfoot, there's a tendency towards relapse or recurring, and so the brace prevents that from happening.
Melanie: What do you tell parents about how long this would take and even other pediatricians that are continuing care with this child when they're wearing the brace?
Dr. Dobbs: The brace theme is something that is used for up to four years after the cast correction. We talk to the families about this in great detail at every visit and starting with visit #1, so I always tell them this is a partnership and they are playing the leading role in this because the casting part, which I'm applying myself, that goes on for a couple of months, and afterwards comes the bracing protocol, and that goes on for several years. It’s really a team effort in the old phrase “it really takes a village,” it’s very true for clubfoot management. But when the families hear this early and initiate this protocol, it’s extremely successful.
Melanie: Can you tell us something interesting about a particular case or diagnosis that you’ve worked with? You developed this brace so that alone is fascinating, but what lead you to do that?
Dr. Dobbs: I do this because of problems identified in patients, and so the hardest part of clubfoot management is the bracing, and I alluded to it a bit, but it goes on for so much longer than the cast. This is when the child is growing through toddlerhood and so forth. It’s difficult to keep a child in a nighttime brace during that time. The old brace was just a solid bar, so the kids couldn’t move their legs independently and the brace that I developed allows independent leg movement while still holding the foot corrected. My goal was to improve tolerance and I knew that if I could make a brace that was well tolerated by the kid, then the parents would be more able to use it. That was the emphasis towards the development of the new brace.
Melanie: Are there some treatments or research that you're doing at St. Louis Children’s that other physicians may not be aware of and give us a little blueprint for where you see this condition going in the future – any future research or things that you see happening?
Dr. Dobbs: We’ve been very involved, my research team, on researching clubfoot. One of the aspects that we've been heavily involved with is trying to understand genetic factors that cause clubfoot. My team has identified four genes that cause clubfoot in familial cases – those cases that have multiple family members involved. That’s a very interesting part of my research. Another aspect is the clinical side and we right now have a very large multicenter clinical trial going on trying to figure out how long bracing actually needs to be used. I mention we use this as a four to five year protocol, but there are some children that do not need it that long and others that may need it longer. I'm teaching physicians now how to examine the children and be able to pick up on predictive signs that will allow us to personalize clubfoot treatments. In other words, we can see a child at birth and based on exam findings be able to predict their individual risk of relapse and prescribe for them a personalized length of brace treatment. That I think is really advancing the clubfoot treatment to the next level and getting this out throughout the world. The treatment protocol I think is going to be the next big thing for clubfoot management.
Melanie: In summary, tell other pediatricians what you'd like them to know about recognizing clubfoot and when to refer to a specialist.
Dr. Dobbs: I would want to recommend in utero diagnosis ideal. That’s probably more for the obstetrician. If it hasn’t been picked up on ultrasound, then referral in the first month of life after birth is really important because the earlier we start treatment, the easier that treatment process is and it’s easier to get through bracing as the kids are younger, to get them used to that pattern. Early diagnosis, early referral and I would want to express to the pediatrician that it’s very important to find a ponseti certified pediatric orthopedic surgeon to perform this treatment method. It’s not a universal thing for all pediatric surgeons to be able to do or train in, so it’s important to get to the right subspecialist for treatment.
Melanie: Thank you so much for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP. That’s 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to stlouischildrens.org. That’s stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.