Child Orthopedics

Frequently Asked Questions

I'm a grandmother now and my two-year-old granddaughter has clubfeet (both sides). I'm trying not to interfere but my daughter and her husband don't seem to be taking the treatment seriously. The little girl is supposed to wear a special splint at night. When we visited last week, I never saw them put it on her. They say she doesn't like it and screams all night. Do you have any suggestions?

Clubfoot is a congenital (present at birth) deformity that causes the feet to point down and turn inwards. Left untreated, this condition prevents normal foot and ankle motion needed for walking and running. The Ponseti method developed by Dr. I. Ponseti 50 years ago has become the standard of care for clubfoot deformity. It is used around the world. The method involves gentle manipulations of the feet and casting. Manipulation and casting refers to moving the bones through the full available motion and then putting a cast on the foot, ankle, and lower leg to hold them in place. Once the soft tissues and bones get used to that position, the cast is removed and the foot and ankle are manipulated (moved) a little further, again putting a cast on to maintain the new position. This process is repeated each week until the deformity is overcome. After casting and/or tenotomy, the next step is to place the child in a Denis-Browne splint. This orthotic has a pair of open-toed shoes attached to a bar. The shoes are placed at an angle to hold the correction. The shoe on the corrected side is placed at 70-degrees of external rotation. If the child had bilateral clubfeet (both sides involved), then both shoes were set at this angle. If only one foot was affected, the uninvolved shoe was placed at a 45-degree angle. Parent/family education is a key element of the Ponseti method. Once the child is in a removable brace of this type, compliance is very important. For best results, the child must wear the Denis-Browne brace everyday (full-time, day and night) for three months. After that, it can be removed during the day and just put on during naps and nighttime. But this schedule must be kept up until the child is four years old. The family must also bring the child to the clinic on a regular basis for follow-up. This is especially important as the bones of the foot (and the child) grow larger. The examiner can make any adjustments needed or resize the brace as the child grows and changes. Sometimes children just can't tolerate wearing the foot brace at night. It's not really a matter of parental compliance. Early communication with the surgeon is advised in order to head off any problems early and make the treatment more tolerable for the child. Sometimes modifications can be made to the brace to improve the child's comfort. If it is a matter of behavior and the temper tantrums of a two-year old, it may be possible to let her go to bed and put the brace on after she falls asleep. She won't have the brace on as long as the protocol suggests, but it's certainly better than not at all. There is a risk of recurrence without proper follow-through. In that case, casting is used again and the process is repeated. Either way, it comes back down to getting the child to wear the splint in order to assure good results in the long-run.

Joseph A. Janicki, MD, et al. Comparison of Surgeon and Physiotherapist-Directed Ponseti Treatment of Idiopathic Clubfoot. In The Journal of Bone and Joint Surgery. May 2009. Vol. 91. No. 5. Pp. 1101-1108.

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