Regarding The Management of Clubfoot Deformity in Children Up To Walking Age

Delphi Method Approved Statements July 21

For the background behind the Delphi method used to reach this consensus please click here.

Referral pathways

1. Regarding the treatment of idiopathic clubfoot deformity in babies and children up to walking age, the Ponseti technique should be the first line treatment.
2. If ante-natal counselling is offered, it should be performed by the practitioners who run the Ponseti clinic.
3. Post-natal referral pathways should allow easy access and early referral.
4. Ponseti casting for the uncomplicated Idiopathic clubfoot should begin between 2 and 6 weeks of age
5. Premature babies can have treatment delayed until they reach birth age, bearing in mind foot size and the size of the smallest available boot

Regarding Initial Assessment

6. A full history (including social history and family set-up) and examination of the child should be done before treatment commences.
7. All babies with a clubfoot deformity should receive a screening US hip scan.
8. The Pirani scoring system should be used at initial assessment, and at each visit/stage of treatment.
9. Practitioners performing the Ponseti technique should be able to recognise an atypical foot, and a neuromuscular/syndromic foot and refer it onwards if it would be more appropriately treated elsewhere.
10. A full neurological examination of the leg should be done to exclude an underlying neurological cause eg dorsiflexion of the big toe at initial assessment and evertor activity after full correction.
11. Radiographs of the foot are not routinely performed

Regarding Ponseti Clinic set up

12. All Ponseti clinics should have a named Consultant overseeing the clinic (either on site or visiting)
13. Ideally, two Ponseti-trained practitioners should be present for each casting; the clinic must have enough staff to be able to run a weekly clinic service and support annual leave.
14. The lead clinician (doctor, physiotherapist, or nurse) should have undergone specific practical Ponseti training on an official Ponseti training course, and have a broad experience of Paediatric Orthopaedics in addition.
15. To ensure competency, all clubfoot clinics should be run by properly trained personnel, regularly audited, exist in networks providing regional support and with clear pathways for onward referral to more experienced practitioners in case of difficulty.
16. In line with the CQC inspection framework, ideally, babies and children should be treated in a child appropriate environment, separately from adults.
17. Results, including the number of casts required, tenotomy and revision tenotomy rates, should be audited at least annually to ensure maintenance of skills and acceptable results.
18. Parent information regarding treatment, cast removal, tenotomy, and boots and bar wear should be made available, both verbally, with leaflets, and on-line.
19. Parents should have clear out of hours contact information for emergency advice, with robust pathways for out of hours clinical care, to address for example, concerns post-tenotomy, plaster slips, including cast removal if necessary.

Regarding the Casting process

20. The Ponseti method of casting should be strictly adhered to.
21. A single thin layer of padding without stockingette should be used under the cast.
22. Plaster of Paris should be used in all cases, quick setting if possible.
23. Ponseti casts are above knee casts, toe to groin
24. A footplate should be left below the toes, and cut out above the toes
25. Casts should be changed every 4-7 days, dependent on the practicalities of clinic set-up.
26. Casts should be removed immediately prior to a casting session, ideally in the clinic and not at home, to allow inspection of quality of the previous cast, and to check for slips and pressure areas.
27. If a cast slips, it must be removed immediately (Babies must not be left in a cast which has slipped).
28. Parents should be taught how to tell if a cast has slipped, how to contact the team out of hours, and told how to remove the cast or where to take the child for it to be removed
29. When necessary, it is possible and practical to apply Ponseti casts to a child who also requires a Pavlik harness
30. The skin condition/presence of pressure sores should be assessed and recorded at every cast change
31. The occurrence of the following in an individual baby should prompt a practitioner to seek help or onward referral:
    • Pressure sores
    • Repeated slips
    • More than 6-7 casts
    • Pirani Score stalling
    • Presentation of Atypical and non-idiopathic feet if they do not have the experience to treat these feet

Regarding Tenotomy

32. The foot is ready for tenotomy when the talar head is covered, the heel is in neutral or valgus, and the anterior process of the os calcis has come out from under the talus.
33. The primary tenotomy should be performed under local anaesthesia, however GA may be considered for children over the age of 6 months, at the discretion of the surgeon.
34. Currently in the UK, the tenotomy should be performed by a trained surgeon or under the direct supervision of a trained surgeon.
35. There must be adequate access to a surgeon so that the tenotomy can be performed in a timely fashion, with no long waits in cast for surgeon availability.
36. An environment with facilities allowing for paediatric resuscitation should be available; this would classically be in a clinic environment within a hospital or health centre.
37. The tenotomy should be a complete tenotomy of the Achilles tendon, performed percutaneously, using as small a blade as possible, using a sterile technique.
38. The post-tenotomy cast should stay on for 2-3 weeks, with an option to change the cast within this time frame
39. Boots and bars must be available for fitting as soon as the cast is removed-they may need to be measured prior to the tenotomy
40. It should be expected that a tenotomy will be required- in most settings this will be in 85-95% of cases.

Regarding the Foot Abduction Brace (FAB)

41. The maintenance of a well corrected clubfoot relies on good compliance with the FAB, which requires
    • Education of parents on the importance of bracing starting at the first assessment (or ante-natal counselling stage) and reinforced at each consultation
    • Regular contact and support for families from the Ponseti practitioner
    • Reliable social media sources can also be recommended for information and support eg: STEPS worldwide
42. The boots used should be attached to a fixed bar, shoulder width apart, with an ability to set the angles to 60-70 degrees on the affected side, and 30-40 degrees on the unaffected side.
43. The FAB should be worn for 23 hours a day for the first 3 months then at night-times and naps until 5 years of age (at least 10-12 hours per day in this second phase)
44. There is not yet evidence to support the use of unilateral braces or articulated braces
45. The FAB should be fitted, and regular follow-up should be performed, by a trained and experienced Ponseti Practitioner
46. At the first fitting, the Ponseti practitioner should fit the FAB, teach, and then watch parents fitting the boots.
47. The baby should be settled before sending home; parents should be advised that initial unsettled nights are normal
48. There should be regular follow up with a recommended plan being:
    • 1week after the FAB first fitted, and then 3 monthly until 2 years.
    • 6 monthly until FAB discarded at age 5.
49. If skin issues are encountered during boots wear, we recommend some or all of the following:
    • Using long close-fitting socks
    • Trying another make of boot
    • Trying a short rest out of boots or a period of re-casting
50. At each review appointment the following should be checked:
    • Correction of the foot– eg palpate heel
    • Skin condition
    • Pirani Score
51. There should be easy access to a variety of boot sizes, with a good selection of stock or pre-ordered sizes, to ensure that no baby is ever left out of FAB.
52. After discontinuing FAB wear, follow-up should be for at least 3-5 years or up to skeletal maturity.

Regarding Relapse

53. Relapse implies a re-appearance of any of the elements of the clubfoot deformity in a foot that has previously fitted easily into the FAB
54. If a foot has never settled in the FAB, an assessment of adequate correction of deformity should be made.
55. Early relapse in pre-walkers should be treated with recasting in an above-knee cast, following careful assessment of which components have relapsed.
56. If a revision tenotomy is required, strong consideration should be given to performing this under General Anaesthetic.
57. FAB should be re-introduced when the foot is corrected (Sometimes an alternative boots and bar system may help regain trust and compliance and enable reintroduction of bracing regime with a view to going back to the fixed bar as soon as possible).

Clubfoot Consensus Steering Group

Chair and Point of Contact:
Sally Tennant (email)

Consensus Group Members:
Guy Atherton
Jose Blanco
Rachel Buckingham
Naomi Davis
Vicki Easton
Neeraj Garg
Yael Gelfer
Anna Peek
Rohan Rajan
Amanda Trees
Denise Watson
Elizabeth Wright