The prevalence of congenital clubfoot is approximately 1 in 1,000 surviving newborns, with the majority of cases being epidemic and a small number of familial cases having dominant inheritance with incomplete ectopic features. The appearance of congenital clubfoot is characterized by bowed feet, pronation, inversion and plantar flexion (ptosis) deformity (Figure 1). The pathological changes are: tibial spur plantar flexion, navicular and dice bones inwardly displaced, and heel bone inversion (Figure 2). Figure 1: Appearance of congenital clubfoot Figure 2: Pathological changes of congenital clubfoot The initial treatment of congenital clubfoot is conservative, and treatment methods include orthopedic splints, bandages and plaster orthosis. One of the most widely accepted and effective treatments is the Ponseti plaster orthosis technique. This technique is also applied in our department for treatment. 1. Why does clubfoot occur? Parents may worry that their child has a clubfoot because they did something bad. Doctors believe that clubfoot has nothing to do with the parents’ behavior. Right now, the cause of clubfoot is not known, but doctors have noticed that the chances of it happening in some families are higher. The incidence of clubfoot is about 1 per 1,000 births, and the chance of having two children with clubfoot in a family is about 1 in 30. In short, there is no need for parents to feel guilty about having a child with clubfoot. 2. What is the future of children with clubfoot? Children with corrected clubfoot are likely to have a near-normal pair of feet with very few effects. Size differences Treated clubfoot is often slightly smaller than a normal foot, and the calf muscles may be slightly reduced; the degree of reduction is related to the severity of the original clubfoot; the leg is usually not significantly shortened. Small differences do not cause any problems and are often unnoticeable to the child; in adolescence, when people are particularly concerned about their body image, minor differences may be noticed, but are usually forgotten after 1 to 2 years. 4. Sports Through the study of patients treated with the Ponseti method, it was found that children and adults with corrected clubfoot could participate in sports like everyone else, and we know that many people become good athletes after their clubfoot is corrected. 5. When should the Ponseti method be done? If possible, it should be started right after birth (7 to 10 days). Most clubfoot can be corrected with the Ponseti cast method before 9 months of age. 6. How many casts are usually required for early use of the Ponseti method? A weekly manipulation followed by a cast is usually corrected in 6 to 8 weeks. 7. How long is the treatment delayed until the Ponseti method is still effective? Treatment is most effective when started before 9 months of age and can still correct all or most deformities when started between 9 and 28 months of age. 8. Does the Ponseti method help with old clubfoot? Clubfoot that is not treated until early childhood can be started with the Ponseti method, but most still require surgery; those treated with the Ponseti method may have a simpler surgery than those cases that do not. 9. What are the precautions to take after putting on a Ponseti cast? ① Place the child’s foot in the cast to begin correcting his or her pronation deformity and to prevent other deformities. The child may be irritable at first, but should soon be comfortable and quiet. After the cast is placed, please note the following: ② Check the circulation: Check the foot circulation once an hour for the first 12 hours after the cast is placed, then 4 times a day. Check by pinching the toe and observe the blood return; if the blood flow is good, the toe will first turn white and then quickly return to pink, which is called whitening reaction; if the toe is black and cold and there is no whitening reaction (from white to pink), the cast may be too tight, in which case, you need to contact your local doctor, emergency department or orthopedic clinic immediately and ask them to check the cast. ③Toes should be exposed: If you cannot see your child’s toes, the cast may have slipped and is not holding the correction; in this case, you need to contact the orthopedic clinic immediately and tell the doctor that you cannot see your child’s toes. Keep the cast dry and clean: When the cast gets dirty, you can wipe it off with a damp rag. ④Plaster is not dry: When the cast is not dry, place it on a pillow or soft cushion. The hard surface will dent the cast and put extra pressure on the limb. When the child sleeps, place a pillow under the cast to elevate the lower limb; the heel just sticks out of the pillow to avoid pressure on the heel, which can cause pain and pressure sores. ⑤ Diapers: change diapers frequently to avoid soiling the cast; diaper to the top of the cast to prevent feces and urine from entering the cast; diapers with elastic leg loops are better. If you notice any of the following, inform the doctor or nurse immediately: – running water from the cast; – any unusual smell from inside the cast; – red, broken or painful skin at the edge of the cast; – child has a fever of 38.5°C or higher, with no other cause such as cold The child has a fever of 38.5℃ or above, no other causes such as cold, infection, etc. can be explained. (7) The cast will be changed every 5-7 days; the nurse will use a special cast knife to remove the cast, so the cast should be softened on the same day by putting the child into a bath or sink and letting warm water enter the cast for 15-20 minutes, then wrap the cast in a wet towel with a plastic bag over it and bring the child to the clinic. After the cast is removed, the child is made to wear an external foot deviation brace (shoe attached to a metal rod) in order to prevent recurrence. The brace is worn for 23 hours a day for the first 3 months, and then it is worn every night and during the day while sleeping for 2 to 4 years. The child may feel uncomfortable during the first 1 to 2 days of wearing the brace, but do not remove the brace at this time, as the child will quickly adapt. If you do not wear the brace as required, relapse is almost inevitable. After the brace fitting is finished, you can wear normal shoes and follow up every year for 8 to 10 years to prevent recurrence. Figure 3: Ponseti cast for congenital clubfoot Figure 4: Orthopedic brace 10. External foot deviation brace The external foot deviation brace consists of an adjustable-length aluminum rod, two adjustable-size shoe plates, and a straight shoe attached to the plates; the orientation of the plates fixed to the rod is set by the orthopedist, and the straight shoe can be worn on the right or left foot at will, but the buckle is usually located on the inside of the shoe, so that you tie the foot strap and laces so that you do not need to turn the child over. The ankle strap is a key part of the support, and it doesn’t matter if the strap goes through a hole at the top or bottom of the side of the shoe. On the inside of the shoe, above the heel, there is a pink pad which provides room for normal heel development and growth and also helps prevent the heel from coming out of the shoe. 11. Wearing schedule The brace is started immediately after the last cast is removed and the infant wears it for 23 hours a day for the first 3 months, taking it off only for bathing; for the next 3-4 years, the brace is used only at night and during daytime bedtime. The doctor will decide on the duration of wear depending on the severity of the clubfoot. Be sure not to end treatment prematurely and ask your doctor if necessary. Wearing instructions 1. Put cotton socks on the part of the foot and leg that the shoe touches; after the last cast is removed, the child’s skin may be sensitive, so wear 2 pairs of socks for the first 2 days of wearing the brace, and only 1 pair of socks for all subsequent days. 2. When putting on the brace, if the child does not refuse, you can put on the worse foot first and then the better foot; if the child kicks and stirs a lot, you can put on the better foot first, because the child usually kicks off the second shoe. 3. Put the foot into the shoe, tighten the foot strap first, the foot strap will make the heel fit tightly into the shoe. Do not mark the used holes on the foot strap, because with extended use, the leather foot strap may be stretched and the markings will be meaningless. 4. Check whether the heel is worn into the shoe by pulling the calf up and down; if the toe moves back and forth, it means that the heel is not worn in and you must tighten the foot strap again; after wearing in, you can draw a line on the sole of the shoe to mark the position of the toe, and the toe should reach or exceed the position of the line after the heel is worn into the shoe. 5. Tie the laces tightly, but do not interfere with blood circulation. Remember, the laces are the most important. They help hold the foot in the shoe. 6. Make sure your child’s toes are straight and none are bent; to do this, you can cut the toe part of your child’s sock to make it easier to see the toes. 13. Set the brace The brace is set by the orthopedist, but the parent may be responsible for changing the shoe and adjusting the width of the bar, depending on the child’s growth. Replace the shoes only when the child’s toes are completely beyond the edge of the shoe, because the inward deviation (bending inward) of the forefoot usually does not recur, so changing the shoes later will not affect the correction and will save money. If you don’t know the shoe number, measure the length of the shoe and tell the orthotist that the new shoe is usually 2 sizes larger than the old one. You can find a local orthotist to order new straight shoes for the external deviation brace and fix the shoes to the shoe plate on the rod with screws at the bottom of the shoe. Before changing shoes, mark the angle of the shoe on the rod to ensure accurate reset with the buckle facing inward while adjusting the width of the rod; measure the distance between the outside of the two shoulders and the distance between the screws in the middle of the heels of the two shoes should be equal to this. After putting on the shoes for the first time, draw a line to mark the position of the toes after the heel is put into the shoe. 14. Tip Tip ①The child will most likely not like the brace for the first 2 days, not because the brace causes pain, but simply because there is something completely new and different. After putting on the brace, play with your child, which is the key to overcome the discomfort as soon as possible; after putting on the brace, your child cannot move both legs separately, so teach your child to kick and swing both legs at the same time while wearing the brace. You can push and pull the rod of the brace, gently flex and stretch the child’s knee joint, and teach the child to move. ③Make it a habit; if you make brace therapy a routine in your life, your child will adapt better. During the 3-4 years of nighttime and bedtime use, as soon as your child goes to bed, you will put the brace on her and the child will understand when it is time of day to wear the brace. If you make the use of the brace part of your daily life, the child is less likely to refuse. ④Wrap the rod around it. A bicycle handlebar glove is good so that you can protect your child, yourself and your furniture from being touched by the rod. ⑤ Don’t oil the red areas of the skin because the oil will make the problem worse; some redness is normal, and bright red or blisters, especially in the heel area, often indicate that the shoes are not worn tight enough. Be sure to wear the heel down and contact your doctor if you notice redness or blisters on the skin. ⑥If the child always slips out of the support and the heel cannot stay underneath, try the following: a. Tighten the foot strap by one hole; b. Tie the laces tightly; c. Remove the tongue of the shoe (using a support without a tongue will not damage the child); d. Try tying the shoe from top to bottom so that the shoe arches to the toe area. (7) Periodically reinforce the screws on the rod. Tools are provided with the support.