The Integration of Contemporary Orthopedic and Orthotic Management of Clubfoot

Since 1944, Dr. Ignacio Ponseti has treated clubfoot using a manipulative, casting, and minimal surgical method. Once reduced and corrected, a foot abduction orthosis (FAO) is fitted to continue to hold the foot in the corrected position at infancy until four years of age. This method has become popular with the orthopedic surgeons due to the positive outcomes published by Ponseti, as early as his initial paper in 1963 (1). The purpose of this presentation is to describe the role of the Orthotist in the treatment. The orthotic regimen will be discussed and problem solving will include descriptions of the most common difficulties encountered. The presentation will conclude with a case study and an actual patient model, which will allow discussion on orthotic treatment from a parent’s perspective.

Talipes equinovarus, or clubfoot, is a combination of forefoot adduction, supination and adduction of the foot, varus at the heel, and equinus at the ankle. It develops late during pregnancy, usually during the 16-18th week, and is detectable in sonograms. It may occur in otherwise healthy fetuses. Annually over 100,000 babies are born with idiopathic clubfoot worldwide (2). It is estimated that in the U.S. it occurs in 0.6-1.0 per 1000 live births (3). Half of the cases tend to be bilaterally afflicted and boys are twice as likely as girls to have clubfoot (4).

The clubfoot is manipulated through a series of steps. First, the forefoot is supinated and the first metatarsal dorsiflexed to correct the cavus. Next, while the forefoot remains in supination, the forefoot is abducted while counter pressure is applied to the head of the talus. This corrects the varus and medial deviation of the foot. Finally, dorsiflexion of the fully abducted foot corrects the equinus.

The treatment consists of the application of serial casts to the manipulated foot, followed by orthotic management with the FAO. Treatment should begin immediately after birth. The clubfoot typically corrects after the application of four to five long leg plaster casts that are applied to the manipulated foot with the knee at 90° (Fig. 1). These casts are changed every four to five days. The final cast should be in a position of 70° of abduction and 20° of dorsiflexion. A percutaneous tenotomy of the Achilles tendon is necessary in 80% of the cases (3). If a tenotomy is performed, the last cast is worn for three weeks. After the removal of the final cast, a FAO is worn to prevent relapses. The FAO should be worn for 23 hours per day for the first three months and at nap and nighttime only until three to four years of age. Relapses are correctable with the Ponseti method if caught early enough.

A FAO is used to prevent relapses after the removal of the last cast (Fig. 2). The FAO consists of a Fillauer adjustable night splint [*Night Splint 9-15” #012204 from Fillauer, Inc., Chattanooga, TN.], Markell straight last shoes [*Tarso Medius straight last shoes #1644 or #2644 from M.J. Markell Shoe Co., Inc., Yonkers, NY 10701.], and “Iowa Heel Counter” (Fig. 3) [*Iowa Heel Counter (1/4” plastazote), Sizes 1 or 2, from Wrymark, Inc., St. Louis, MO 63146.]. The FAO should be setup with 10° of dorsiflexion and 70° of abduction for the clubfoot or 30° of abduction for the unaffected foot (Fig.4). Although the shoes are straight last they should be attached to the night splint with the buckles on the medial aspect, so that the parents do not have to turn the child prone to tighten the straps. The width of the bar, heel center to heel center, should equal the child’s outside shoulder width. Finally, the Iowa Heel Counter is glued into the posterior proximal aspect of the shoe as a heel counter to allow normal development of the calcaneus. To don the FAO, place the child’s foot firmly into the shoe while keeping the knee at 90°. Keep a thumb over the dorsum of the foot and shoe, while pulling the strap snug. Secure the strap with the buckle. Check that the heel is down by gently pulling up and down on the child’s calf. If the toes move proximally while applying a gentle upward pull on the calf, the heel is not securely down in the shoe, so the strap should be tightened by one more hole. Once the foot is securely in the shoe, the laces may be tightened. If the child is of poor temperament, it is recommended that the FAO be donned first to the good foot because the child will likely kick his/her way into the other shoe. It is the responsibility of the Orthotist to fit the orthosis and explain its use to the parents.

Parents find the following advice useful. The child may be irritable for the first two days after application of the FAO. Playing with the child with the FAO may reduce this irritability. Parents must teach the child to simultaneously kick and swing his/her legs while wearing the FAO. If redness is observed on the heel, it indicates that the child’s heel is not secure in the shoe. The child should be checked to ensure that a relapse has not occurred. If a child continually escapes from the FAO these steps should be followed until the foot remains secure within the shoe: 1. Tighten the strap by one more hole, 2. Tighten the laces, 3. Remove the shoe tongue. In order to protect the child, family, and furniture it is recommended that the FAO bar be padded. A bicycle handle bar pad or pads from a car seat strap work well for this. These tips should help parents successfully use the FAO.

The FAO is used after full correction (70° abduction and 10° dorsiflexion) of the clubfoot is achieved through the Ponseti Method. It is the only device proven to reduce relapses (3, 5). It is the responsibility of the Orthotist to fit the FAO to the child and to explain its use to the parents.

This presentation would not be possible without the generosity of Dr. Ignacio Ponseti who has spent numerous hours mentoring me in clinic on this technique. Special thanks also to Donald Shurr, C.P.O., P.T. without whose encouragement I never would have pursued a career in orthotics and prosthetics or had the opportunity to work with Dr. Ponseti and the babies with clubfeet.

Figures:

Figure 1: Left to right illustrates the progression serial casting with the Ponseti Method of clubfoot	Figure 2: A plastazote heel counter is used in the shoe.

Figure 3: The FAO is used upon completion of the serial casting to prevent relapses.	Figure 4: This FAO is setup for a left clubfoot, as observed by the 70° of abduction on the left and 30° of abduction on the right.

References

1. Ponseti IV, Smoley EN. Congenital Club Foot: The Results of Treatment. Journal of Bone and Joint Surgery. March 1963; 45A(2): 261-276.

2. Staheli L, Ed. Ponseti Management of Clubfeet. Seattle: Global-HELP.org. 2003.

3. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical Reduction in the Rate of Extensive Corrective Surgery for Clubfoot Using the Ponseti Method. Pediatrics. February 2004; 113(2): 376-380.

4. Ponseti IV. Congenital Clubfoot: Fundamentals of Treatment. New York: Oxford University Press, 1996.

5. Cooper DM, Dietz Fr. Treatment of Idiopathic Clubfoot: A Thirty-Year Follow-up Note. Journal of Bone and Joint Surgery. October 1995; 77A(10): 1477-1489.