About one baby in every 1,000 in the United States is born with clubfoot, a congenital foot deformity where the foot points downward with toes turned inward and the foot bottom twisted inward. Clubfoot is one of the most common congenital foot deformities. Almost half of babies diagnosed with clubfoot have bilateral clubfoot where both feet have the deformity.
Treatment options have evolved through the years and, with early intervention, children with clubfoot have high rates of correction.
Dr. Pooya Hosseinzadeh, Washington University pediatric orthopedic surgeon at St. Louis Children’s Hospital, joins the show to talk more about diagnosing clubfoot and when to consult with a specialist, treatments options including the Ponseti method, what families can expect, and the clubfoot program at St. Louis Children’s.
Clubfoot: Diagnosis, Treatment and Outcomes
Featured Speaker:
Pooya Hosseinzadeh, MD
Dr. Hosseinzadeh is an Assistant Professor of Orthopedic Surgery at Washington University School of Medicine and pediatric orthopedic surgeon at St. Louis Children's Hospital. He has clinical interests in the evaluation and treatment of neuromuscular conditions in children. He specializes in the operative and non-operative treatment of clubfoot and musculoskeletal conditions in children with cerebral palsy and other neuromuscular conditions. Other clinical interests include hip dysplasia, general pediatric orthopedic surgery, lower extremity deformities, and traumatic injuries. Dr. Hosseinzadeh received his medical degree from Isfahan University of Medical Services in Isfahan, Iran. He did a residency training in Orthopedic Surgery at Joan C. Edwards School of Medicine at Marshall University in Huntington, WV and completed a pediatric orthopedic fellowship at Shriners Hospital for Children in Lexington, Kentucky. Additionally, he completed a research fellowship at the University of California Irvine. Transcription:
Clubfoot: Diagnosis, Treatment and Outcomes
Melanie Cole (Host): Treatment options for clubfoot have evolved through the years, and with early intervention, children with club foot have high rates of correction. You're listening to Radio Rounds, the podcast series from Washington University Pediatric Specialists at St. Louis Children's Hospital. I'm Melanie Cole and joining me is Dr. Pooya Hosseinzadeh. He's a Washington University Pediatric Orthopedic Surgeon at St. Louis Children's Hospital. And he's joining the show today to talk more about diagnosing clubfoot, treatment options, and when to consult with a specialist at St. Louis Children's Hospital. Dr. Hosseinzadeh, it's a pleasure to have you join us again. It's been a little while. So, tell us a little bit about clubfoot and the prevalence and what have you been seeing?
Pooya Hosseinzadeh, MD (Guest): Thank you so much for having me again. So, clubfoot is a congenital deformity that is present at birth, and traditionally in the past, if you look at the years before 2000, it used to be treated with extensive surgery around the age of one. Since year 2000, the treatment has changed, all across the world and mostly in the United States and we are now treating most clubfeet very successfully with casting followed by minimally invasive surgery, which is an Achilles tenotomy. They respond really well. I would say close to 95 to 100% of children with clubfeet respond to this initial casting, and minimally invasive surgery, really well.
So, this actually has been a great change in the world of pediatric orthopedics and the treatment of clubfoot deformity. Although it is very successful, the outcome really depends on how well that casting is performed. So, it's very important that it starts at the right time. And actually the right technique is performed to correct the clubfoot deformity. Typically after the casting, the children will be placed in braces, which is usually full-time for about three months and nighttime, up to about three years of age.
Host: Tell us a little bit about diagnosis, doctor. Is this something that you can see in-utero or do we only find out once a child is born?
Dr. Hosseinzadeh: So, actually with the recent advances with intrauterine imaging, a lot of the patients that we see now, the diagnosis has been made in-utero. Typically the diagnosis can be made with the ultrasounds after about 20 weeks of gestation. Of course the diagnosis made in utero is not-as accurate as the diagnosis after birth. So, some of those feet that are called clubfoot, with in-utero ultrasounds may turn out to be kind of normal feet when the child is born, but there's about 70, 80% accuracy in some of the studies, with the diagnosis in-utero. So yes, the diagnosis can be made in utero, but it's confirmed when the child is born.
Host: Tell us a little bit more about complex clubfoot. What is that?
Dr. Hosseinzadeh: So, complex clubfoot, we have actually two forms of complex clubfoot. One of them is a child that is born with a complex clubfoot. The way the deformities in the foot and a complex clubfoot are different than a typical clubfoot, they have more of a rigid what we'll call the cavas and plantar flexion deformity, which is the foot is staying more down than turned in.
And the first ray is shorter and it's hyperextended in the complex clubfoot. So, some children are born with this complex clubfoot. Typically it's seen in the setting of underlying syndromic and neuromuscular conditions typically arthrogryposis that we may see these. And of course the treatment for that, the way we cast them and the way we approach the treatment is different.
The other form of complex clubfoot that we'll see more often is the child that is born with a typical clubfoot. And then the treatment with casting has been started and for some reason, the cast may get loose and the child's foot slips in the cast. And if the foot stays in that slipped position for a while, actually the deformity will change. And the typical clubfoot will turn into a complex clubfoot which is a kind of a challenging problem to treat. You have to change the way you cast the feet in order to address the complex clubfeet.
Host: Well, then tell us a little bit about your program at St. Louis Children's Hospital. What support do you provide families? How long has your team been caring for clubfoot kids? Tell us a little bit about the multidisciplinary approach that's necessary for these kids as they go through the casting and physical therapy and any surgical interventions.
Dr. Hosseinzadeh: So our team at St. Louis Children's actually have been one of the first in the country to adopt that casting method of clubfoot treatment in the country. So, I would say the casting has been done at this hospital for over the past 20 years. So, the parents typically reach out to us or the other physicians reach out to us sometimes when the diagnosis is made in-utero and we get in touch with parents. They are provided with a handout of what to expect as far as the treatment. That usually helps a lot with the parents' anxiety about what they should expect. And we will let them know that with this method of treatment, they should expect really, great results. And their kids will be able to participate in most of the activities that other kids are typically able to participate in. So, that's from before birth.
So, if we give them the handout and they still have questions, we would typically see them, for a prenatal consult to go over the questions and concerns they have. After the child is born, we typically start casting, ideally, we would like to start it within the first month or two, if possible. The younger the child, the more flexible the ligaments and tendons are. And they respond better to stretching with casts. Typically, although I can't say the number of casts that they require. They typically undergo weekly casting. Typically somewhere between four to six casts are required.
Then, about 90% of the children who've had the casting would require lengthening of the Achilles tendon. And as I said afterwards, they go in a braces. The importance of a multidisciplinary approach is having a team of nurses who've been involved with this method for a long period of time. We have the dedicated therapy department who have been involved with this method of treatment and typically see these kids after the casting processes is done because part of a clubfoot is also weakness in some of the muscle groups. So, addressing that with a therapist is an important piece. And of course our orthotics and prosthetics department have been very involved with the brace development and brace care of these kids for a long period of time.
Host: And doctor tell us the most challenging time for families as they go through all of these interventions with their children. Tell us a little bit about that. The role of stretching for kids with clubfoot, and also longterm, as you're telling us these challenges that families face, what can they expect long-term?
Dr. Hosseinzadeh: And so the challenges that we see that most of course, initially, having to come every week for cast changes is challenging for the families with a newborn. But the other challenge that we see pretty often is after the casting is over, compliance with bracing is key because clubfoot is a stubborn deformity and likes to come back. Because there is inherent tendency for contracture in the ligaments and tendons children with clubfeet.
So, the foot has to remain stretched until they're about three years of age. So, compliance with bracing and stretching is key because no matter if you get the foot completely corrected, if you don't keep the foot in the corrected position with the brace and the stretching, the clubfoot will come back soon. And think the challenge with families is to keep the children in braces, because some children will fight and that becomes a challenge for the family. And I think it's very important for them to know that compliance is key in preventing relapse of the deformity.
As far as the outcome, there's several studies actually. We have about 40 year followup of children that were treated with this method out of Iowa. And basically if you compare those adults with the adults who have not had clubfoot deformity, you do not see much change in the daily function that they can perform. So, they will be able to participate in sporting activities and same thing as other kids. Of course, their clubfoot side will always look a bit abnormal. The calf is always smaller, than the other side, if it's a unilateral case. But if they follow with the protocol and they respond well, they should expect good results and similar function to children who did not have a clubfoot it for me.
Host: So, you mentioned that if certain things are changed or don't go the way they should, that it can relapse. What happens when that happens? And while you're telling us about relapse, please give us your best advice for other providers that are seeing children with clubfoot, when you feel it's important, they refer to the specialists at St. Louis Children's Hospital.
Dr. Hosseinzadeh: So, the relapse, as I said, it happens actually throughout the course of treatment in about 40 or 50% of children who were initially treated with casting. So, relapse is something that happens in about 40 to 50%. That the treatment depends on the time of their relapse. Typically, so for example, if it happens early on at age one or two, we typically treat it again with casting.
So, they have to have another round of casting. It typically responds well. If their child is older and there is some muscle imbalance in the foot after the casting, tibialis anterior tendon transfer can be added in order to correct dynamic muscle imbalance that is present. But all of these, as I said, even to clubfeet who have undergone the tibialis anterior transfer and has relapsed, it has been shown in the long-term four year study that they will do really well when you stick with the principles of casting treatment and treat them again with casting and tendon transfer if needed. So, the thing with the relapse is you want to catch a relapse and treat it pretty early on. You don't want the whole clubfoot deformity to recur before starting the treatment.
So, typically, I mean first time we see a child that comes back for treatment that's starting some heelcord tightness or starting walking on the lateral border of the foot. I think that's the time to started the casting again and make sure we get the foot in the corrected position.
And one thing that I always tell patients, if the foot is not corrected, bracing is not going to correct it. So, the job of the brace is to hold the corrected foot in the same position. So, if the foot is turning back into a club foot, treatment, spending more time in the brace is not going to help the foot has to be corrected again with casting and then braces will hold it in that position.
Host: Thank you so much, Dr. Hosseinzadeh. What an informative episode. Thank you again for joining us and sharing your expertise. To speak with Dr. Hosseinzadeh or to refer a patient to St. Louis Children's Hospital, you can call the Children's Direct Physician Access Line at 1-800-678-HELP. Or you can always visit St.Louischildren's.org.
That concludes this episode of Radio Rounds, the podcast series from Washington University Pediatric Specialists at St. Louis Children's Hospital. Please remember to subscribe, rate and review this podcast and all the other St. Louis Children's Hospital podcasts. I'm Melanie Cole.
Clubfoot: Diagnosis, Treatment and Outcomes
Melanie Cole (Host): Treatment options for clubfoot have evolved through the years, and with early intervention, children with club foot have high rates of correction. You're listening to Radio Rounds, the podcast series from Washington University Pediatric Specialists at St. Louis Children's Hospital. I'm Melanie Cole and joining me is Dr. Pooya Hosseinzadeh. He's a Washington University Pediatric Orthopedic Surgeon at St. Louis Children's Hospital. And he's joining the show today to talk more about diagnosing clubfoot, treatment options, and when to consult with a specialist at St. Louis Children's Hospital. Dr. Hosseinzadeh, it's a pleasure to have you join us again. It's been a little while. So, tell us a little bit about clubfoot and the prevalence and what have you been seeing?
Pooya Hosseinzadeh, MD (Guest): Thank you so much for having me again. So, clubfoot is a congenital deformity that is present at birth, and traditionally in the past, if you look at the years before 2000, it used to be treated with extensive surgery around the age of one. Since year 2000, the treatment has changed, all across the world and mostly in the United States and we are now treating most clubfeet very successfully with casting followed by minimally invasive surgery, which is an Achilles tenotomy. They respond really well. I would say close to 95 to 100% of children with clubfeet respond to this initial casting, and minimally invasive surgery, really well.
So, this actually has been a great change in the world of pediatric orthopedics and the treatment of clubfoot deformity. Although it is very successful, the outcome really depends on how well that casting is performed. So, it's very important that it starts at the right time. And actually the right technique is performed to correct the clubfoot deformity. Typically after the casting, the children will be placed in braces, which is usually full-time for about three months and nighttime, up to about three years of age.
Host: Tell us a little bit about diagnosis, doctor. Is this something that you can see in-utero or do we only find out once a child is born?
Dr. Hosseinzadeh: So, actually with the recent advances with intrauterine imaging, a lot of the patients that we see now, the diagnosis has been made in-utero. Typically the diagnosis can be made with the ultrasounds after about 20 weeks of gestation. Of course the diagnosis made in utero is not-as accurate as the diagnosis after birth. So, some of those feet that are called clubfoot, with in-utero ultrasounds may turn out to be kind of normal feet when the child is born, but there's about 70, 80% accuracy in some of the studies, with the diagnosis in-utero. So yes, the diagnosis can be made in utero, but it's confirmed when the child is born.
Host: Tell us a little bit more about complex clubfoot. What is that?
Dr. Hosseinzadeh: So, complex clubfoot, we have actually two forms of complex clubfoot. One of them is a child that is born with a complex clubfoot. The way the deformities in the foot and a complex clubfoot are different than a typical clubfoot, they have more of a rigid what we'll call the cavas and plantar flexion deformity, which is the foot is staying more down than turned in.
And the first ray is shorter and it's hyperextended in the complex clubfoot. So, some children are born with this complex clubfoot. Typically it's seen in the setting of underlying syndromic and neuromuscular conditions typically arthrogryposis that we may see these. And of course the treatment for that, the way we cast them and the way we approach the treatment is different.
The other form of complex clubfoot that we'll see more often is the child that is born with a typical clubfoot. And then the treatment with casting has been started and for some reason, the cast may get loose and the child's foot slips in the cast. And if the foot stays in that slipped position for a while, actually the deformity will change. And the typical clubfoot will turn into a complex clubfoot which is a kind of a challenging problem to treat. You have to change the way you cast the feet in order to address the complex clubfeet.
Host: Well, then tell us a little bit about your program at St. Louis Children's Hospital. What support do you provide families? How long has your team been caring for clubfoot kids? Tell us a little bit about the multidisciplinary approach that's necessary for these kids as they go through the casting and physical therapy and any surgical interventions.
Dr. Hosseinzadeh: So our team at St. Louis Children's actually have been one of the first in the country to adopt that casting method of clubfoot treatment in the country. So, I would say the casting has been done at this hospital for over the past 20 years. So, the parents typically reach out to us or the other physicians reach out to us sometimes when the diagnosis is made in-utero and we get in touch with parents. They are provided with a handout of what to expect as far as the treatment. That usually helps a lot with the parents' anxiety about what they should expect. And we will let them know that with this method of treatment, they should expect really, great results. And their kids will be able to participate in most of the activities that other kids are typically able to participate in. So, that's from before birth.
So, if we give them the handout and they still have questions, we would typically see them, for a prenatal consult to go over the questions and concerns they have. After the child is born, we typically start casting, ideally, we would like to start it within the first month or two, if possible. The younger the child, the more flexible the ligaments and tendons are. And they respond better to stretching with casts. Typically, although I can't say the number of casts that they require. They typically undergo weekly casting. Typically somewhere between four to six casts are required.
Then, about 90% of the children who've had the casting would require lengthening of the Achilles tendon. And as I said afterwards, they go in a braces. The importance of a multidisciplinary approach is having a team of nurses who've been involved with this method for a long period of time. We have the dedicated therapy department who have been involved with this method of treatment and typically see these kids after the casting processes is done because part of a clubfoot is also weakness in some of the muscle groups. So, addressing that with a therapist is an important piece. And of course our orthotics and prosthetics department have been very involved with the brace development and brace care of these kids for a long period of time.
Host: And doctor tell us the most challenging time for families as they go through all of these interventions with their children. Tell us a little bit about that. The role of stretching for kids with clubfoot, and also longterm, as you're telling us these challenges that families face, what can they expect long-term?
Dr. Hosseinzadeh: And so the challenges that we see that most of course, initially, having to come every week for cast changes is challenging for the families with a newborn. But the other challenge that we see pretty often is after the casting is over, compliance with bracing is key because clubfoot is a stubborn deformity and likes to come back. Because there is inherent tendency for contracture in the ligaments and tendons children with clubfeet.
So, the foot has to remain stretched until they're about three years of age. So, compliance with bracing and stretching is key because no matter if you get the foot completely corrected, if you don't keep the foot in the corrected position with the brace and the stretching, the clubfoot will come back soon. And think the challenge with families is to keep the children in braces, because some children will fight and that becomes a challenge for the family. And I think it's very important for them to know that compliance is key in preventing relapse of the deformity.
As far as the outcome, there's several studies actually. We have about 40 year followup of children that were treated with this method out of Iowa. And basically if you compare those adults with the adults who have not had clubfoot deformity, you do not see much change in the daily function that they can perform. So, they will be able to participate in sporting activities and same thing as other kids. Of course, their clubfoot side will always look a bit abnormal. The calf is always smaller, than the other side, if it's a unilateral case. But if they follow with the protocol and they respond well, they should expect good results and similar function to children who did not have a clubfoot it for me.
Host: So, you mentioned that if certain things are changed or don't go the way they should, that it can relapse. What happens when that happens? And while you're telling us about relapse, please give us your best advice for other providers that are seeing children with clubfoot, when you feel it's important, they refer to the specialists at St. Louis Children's Hospital.
Dr. Hosseinzadeh: So, the relapse, as I said, it happens actually throughout the course of treatment in about 40 or 50% of children who were initially treated with casting. So, relapse is something that happens in about 40 to 50%. That the treatment depends on the time of their relapse. Typically, so for example, if it happens early on at age one or two, we typically treat it again with casting.
So, they have to have another round of casting. It typically responds well. If their child is older and there is some muscle imbalance in the foot after the casting, tibialis anterior tendon transfer can be added in order to correct dynamic muscle imbalance that is present. But all of these, as I said, even to clubfeet who have undergone the tibialis anterior transfer and has relapsed, it has been shown in the long-term four year study that they will do really well when you stick with the principles of casting treatment and treat them again with casting and tendon transfer if needed. So, the thing with the relapse is you want to catch a relapse and treat it pretty early on. You don't want the whole clubfoot deformity to recur before starting the treatment.
So, typically, I mean first time we see a child that comes back for treatment that's starting some heelcord tightness or starting walking on the lateral border of the foot. I think that's the time to started the casting again and make sure we get the foot in the corrected position.
And one thing that I always tell patients, if the foot is not corrected, bracing is not going to correct it. So, the job of the brace is to hold the corrected foot in the same position. So, if the foot is turning back into a club foot, treatment, spending more time in the brace is not going to help the foot has to be corrected again with casting and then braces will hold it in that position.
Host: Thank you so much, Dr. Hosseinzadeh. What an informative episode. Thank you again for joining us and sharing your expertise. To speak with Dr. Hosseinzadeh or to refer a patient to St. Louis Children's Hospital, you can call the Children's Direct Physician Access Line at 1-800-678-HELP. Or you can always visit St.Louischildren's.org.
That concludes this episode of Radio Rounds, the podcast series from Washington University Pediatric Specialists at St. Louis Children's Hospital. Please remember to subscribe, rate and review this podcast and all the other St. Louis Children's Hospital podcasts. I'm Melanie Cole.