Christopher Vara, MD
Shriners Children’s Twin Cities
At Shriners Children’s here in the Twin Cities, we are part of a nationwide group of hospitals and clinics that focus on diagnosing and treating musculoskeletal conditions from birth to adulthood. We are, often, one of the earliest specialty providers that parent(s) and children see, even right after birth.
As with any musculoskeletal condition diagnosed in the perinatal period, parents are often in a state of grief regarding the diagnosis. Our mission, as pediatric orthopedists, is to bring a sense of support and clarity to the diagnosis and treatment and to allay their concerns about their child.
As with any infant, a musculoskeletal diagnosis may be made prenatally or in the immediate postnatal period. Congenital talipes equinovarus (commonly referred to as a clubfoot or clubfeet) are among the diagnoses we are asked to evaluate frequently.
The history of talipes equinovarus dates to antiquity (Hippocrates, ca. 400 BC) and, with such a longstanding history, treatment methods have, thankfully, evolved over time.
In the not so distant past, as a junior resident, I was taught that the infant with talipes equinovarus should return at approximately 1 year of age, around walking age, for extensive posteromedial releases, pinning of joints, and casting of the foot or feet as a “one and done” approach, with the added caveat that “probably something more will be needed later in life.”
Fortunately, after the turn of the millennia, Ignatio Ponseti, MD (1914-2009) of the University of Iowa presented his treatment method which consisted of successive casts over the course of 5-6 (and sometimes more) casts to manipulate the feet sequentially. Initially met with some skepticism, it was soon thereafter adopted and studied further, revolutionizing how we approach clubfeet in children. The principles of treatment involve corrective manipulation and long leg casting, to “bring the feet out of the CAVE” (cavus, forefoot adductus, heel varus, and finally equinus). Typically, once the first 3 (“the CAV”) are corrected by casting, the last procedure (90% of the time), involves a percutaneous tenotomy (either under a local anesthetic in the office or under light sedation in the procedure room), with the final cast in place for 3 weeks.
I am happy to say this Ponseti method has become the standard of care here in the United States and is known worldwide for its successful outcomes and for its simple yet elegant approach. It can be used for any type of talipes equinovarus (regardless of etiology); however, early institution of treatment, even as early as 2 weeks of age, is the key to success. Understandably, the neglected clubfoot at 2, 12 or 20 years of age (rather than 2 weeks) adds layers of rigidity and complexity not found in the infant’s foot or feet. These feet often require extensive bony and soft tissue procedures that cannot rival the traditional Ponseti method for long term outcomes.
As I explain to parents, the critical orthopaedic components of the examination of the infant include an evaluation of the spine (for scoliosis or signs or spinal dysraphism), the hips (for hip dysplasia), and the feet. These are three areas where early diagnosis, and often immediate, intervention can have a positive, long lasting outcome.
Shriners Children’s has immediate openings for evaluation and treatment of children with talipes equinovarus. To refer please email your referral to intaketc@shrinenet.org or fax to 612-596-6102.
