Childhood Orthopedic Problems: Clubfoot
Guest: Dr. Jennifer Hooker – Pediatric Orthopedic Surgery
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Jenny Hooker who is Assistant Professor of Pediatric Orthopedics at the Children’s Hospital at MUSC. Dr. Hooker, let’s talk about a common pediatric orthopedic problem, clubfoot. Just what is a clubfoot?
Dr. Jenny Hooker: A clubfoot is something that children can be born with. It is not very common but happens to about one in a thousand children when they’re born. It’s really a position of the foot where the back portion of the foot is pointed down. The middle portion of the foot is turned inward, towards the middle of the body. Then, there’s also some rotation of the forward part of the foot in the region of the toes.
Dr. Linda Austin: So, it’s really sort of a twisting around? I’m picturing it almost like a woman’s foot in a high heel, except turned in, pigeon-toed. Is that kind of what it’s like?
Dr. Jenny Hooker: Yes, that’ similar. There’s a significant component though of the turning in and there’s also that rotational component.
Dr. Linda Austin: What happens, uncorrected, as a child grows older with this, as in the old days, before there were orthopedic surgeons? What would happen?
Dr. Jenny Hooker: This is actually something that we see in patients who live in other countries in the world, who don’t have access to medical care even today. Children will learn to walk. They can bear weight on the foot but they bear weight in an extremely poor position, and long-term, if they continue to walk on the foot in this rotated and tipped position, it causes lots of problems with arthritis down the road and they really are unable to wear shoes because of the shape of the foot.
Dr. Linda Austin: So is it typically then just one foot that is clubbed and the other one is normal, or do you sometimes have both feet clubbed?
Dr. Jenny Hooker: Commonly it’s just one foot that’s affected but it can be both. Club foot is something that we see in association with some syndromes. So, for patients who have an associated syndrome, such as spina bifida, it’s actually more frequently seen in both feet.
Dr. Linda Austin: How do you treat it? What do you do?
Dr. Jenny Hooker: There is an operation but the interesting thing about this disorder is that our thinking about it has radically changed in the last 20 to 30 years. A doctor by the name of Ignacio Ponseti, who is still in practice at the University of Iowa, has really radically changed the way we treat clubfoot. And although most patients used to have a large open surgical procedure performed, 20 to 30 years ago, nowadays, most clubfoot can be successfully treated with a course of casting and a small simple surgery that really consists only of the release of a single tendon.
Dr. Linda Austin: What a dramatic difference. So, at what age does the casting start?
Dr. Jenny Hooker: Really, in the newborn period. So, we like to see the patients within a week or two following their hospital discharge, after they come home with Mom. And we begin casting right away. The casts are placed from the tip of the toes all the way up onto the thigh and they’re actually changed about once a week. With each casting, we manipulate the foot and help to turn it into a more normal and more natural position.
Dr. Linda Austin: Why does the cast have to go all the up to the thigh?
Dr. Jenny Hooker: Part of the component that we talked about with this deformity is a rotational problem. If you stop below the knee, some rotation occurs through the knee so that instead of getting rotation correction in the foot, you actually get some rotation through the knee. So we take the cast onto the thigh to make sure that we prevent rotation at the knee, thereby getting all of our rotational correction through the foot.
Dr. Linda Austin: Is it painful for the baby?
Dr. Jenny Hooker: That’s a great question. The answer to that is, no. Although what we do see is, because the foot has been encased in a cast, when they finally come off at the very end, parents may notice the kid’s foot seems to be a little hypersensitive for a day or two, not anything that causes continual crying but they may notice that they’re a little fussy with clothing changes.
Dr. Linda Austin: So, how many weeks or months, does a child have to be casted?
Dr. Jenny Hooker: Generally speaking, for a typical clubfoot that’s not associated with any type of syndrome, we’re looking at somewhere in the neighborhood of four to seven casts. So, it’s a process that takes about a month to two months to get the foot into a good position.
What we really try to do is rotate the foot so that, instead of pointing inward, by the end of our casting, it’s actually pointed significantly outward. At that point in time, generally speaking, we can’t bring the foot up as far as we would like to. So, it’s still like the toe is pointed downward somewhat, as if you were trying to point your toe to put on a pair of slacks, or a pair of jeans. What we do at that point then is a small operative procedure where we make a little cut in the tendon, the Achilles tendon in the back of the heel, to allow that tendon to lengthen. Lengthening that tendon allows us to then bring the foot up into a much better position.
Dr. Linda Austin: Boy, that must be a rewarding procedure for you, especially compared to the old days where it sounds like it was a pretty difficult operation to do.
Dr. Jenny Hooker: Absolutely! There’s no question that it’s very gratifying to take a newborn who has what really can be quite a scary deformity when the parents first see it and, without the need for any significantly invasive surgery, really give the child a foot that’s going to function well for them for the rest of their life.
Dr. Linda Austin: Does this tend to run in families?
Dr. Jenny Hooker: It can. There can be a genetic component. Although we do think that most of them are just a spontaneous thing that happens to children.
Dr. Linda Austin: Dr. Hooker, thank you so much for talking with us.
Dr. Jenny Hooker: No problem. You’re welcome.
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