Clubfoot Research

Clubfoot is a congenital abnormality that affects 1 in every 1,000 newborns. Children born with clubfoot have an inward curved forefoot, high arches, and an inverted heel with a downward pointing ankle. Clubfoot structural malformations delay physical mobility and activity in diagnosed children. They can also have long lasting negative effects on the quality of life of these patients during adulthood, especially in the case of recurrent clubfoot. Unfortunately, up to 50% of treated clubfoot patients have a relapse that requires additional casting and/or surgery. Research regarding the origin, post-relapse outcomes, and prevention of congenital clubfoot is limited. Our goals are to address these understudied areas, provide the best patient care, and improve the quality of life for patients with clubfoot. Our research strives to identify and address some of these common clinical dogmas in treatment and outcomes, in hopes to improve care.

Steven Frick
Chief, Pediatric Orthopaedic Surgery, Stanford University (2016 - Present)

Publications

  • AP Radiographic Assessment of the Pediatric Pelvis for Developmental Dysplasia of the Hip. The Journal of the American Academy of Orthopaedic Surgeons Edmonds, E. W., Hollnagel, K. F., Bomar, J. D., Frick, S. L. 2023; 31 (14): 717-726

    Abstract

    Mastering the art of roentgenographic analysis of the pediatric AP pelvis is paramount in the evaluation of developmental dysplasia of the hip. Understanding the normal radiographic development and the age-dependent changes in normal values allows assessment for pathologic changes. The goal of improving the analysis of the AP pelvis is to increase early detection of disease, assess progress toward normal values, and precisely follow the effects of treatment to improve clinical outcomes.

    View details for DOI 10.5435/JAAOS-D-22-01218

    View details for PubMedID 37410489

  • A Pilot Program: Remote Summer Program to Improve Opportunity and Mentorship Among Underrepresented Students Pursuing Orthopaedic Surgery. JB & JS open access Hastings, K. G., Freiman, H. D., Amanatullah, D. F., Gardner, M. J., Frick, S., Shea, K. G. 2022; 7 (4)

    Abstract

    The purpose of this study was to evaluate the impact of an 8-week remote summer program in supporting underrepresented students interested in orthopaedic surgery.Methods: We received 115 applications, and a total of 17 students participated in the program (14.8%). Nine faculty mentors were matched with 1 or 2 students each. The program delivered a curriculum from June-August 2021 consisting of (1) weekly instructional courses on research-related topics led by a content expert; (2) weekly faculty lectures discussing topics including orthopaedic topics, diversity in medicine, leadership, and work-life balance; and (3) a research experience paired with a faculty mentor and peer mentor. We surveyed students to measure skill progression, satisfaction, and overall program evaluation. Preprogram/postprogram evaluation, midprogram check-in, and student feedback surveys were collected.Results: Program participants represented a range of race and ethnic backgrounds, research experience levels, and various geographic locations across the United States. The cohort included a high rate of female (42%) and Black (35%) participants. On average, postprogram survey scores indicated that participants believed that the summer program improved their research skills (9.6 of 10), improved their orthopaedic interest (8.9 of 10), and improved mentorship and networking (9.1 of 10). For feedback surveys, 14 respondents of 15 total responses (93%) felt they were adequately matched to their faculty mentor. Twelve (80%) felt they had realistic deliverables for research projects within the 8-week program. Thirteen (87%) indicated they contributed to an abstract or manuscript as a coauthor.Conclusion: Our findings indicate that students improved their research skills, interest, and confidence to pursue orthopaedic residency and mentorship/networks in the field. The long-term goal is to improve the accessibility and quality of mentorship for underrepresented students in order to foster an equitable pathway into the field of orthopaedic surgery.

    View details for DOI 10.2106/JBJS.OA.22.00059

    View details for PubMedID 36338797

  • Virtual Reality Reduces Fear and Anxiety During Pediatric Orthopaedic Cast Room Procedures: A Randomized Controlled Trial. Journal of pediatric orthopedics Richey, A. E., Hastings, K. G., Karius, A., Segovia, N. A., Caruso, T. J., Frick, S., Rodriguez, S. 2022

    Abstract

    BACKGROUND: Virtual Reality (VR) has been used as a distraction tool in various medical settings to reduce pain and anxiety associated with procedures. This study evaluates the effectiveness of VR as a distraction tool for decreasing fear, anxiety, and pain in pediatric patients undergoing common outpatient orthopaedic procedures.METHODS: A total of 210 patients were recruited from a single orthopaedic clinic between October 2017 and July 2019. Patients were randomized to the VR group or to the control group (standard of care). Outpatient procedures included cast and/or pin removals. Primary outcome measures were collected preprocedure and postprocedure using validated surveys, and included: fear (Children's Fear Scale), anxiety (Children's Anxiety Meter-State), and pain (Numerical Rating Scale). Patients and caregivers in the VR group completed a satisfaction survey at the end of their appointment. Fear, anxiety, and pain scores between the 2 groups were analyzed using multivariable linear regression models, and the satisfaction survey was analyzed using descriptive statistics.RESULTS: One hundred twenty nine patients were included in the final analysis, with 85 patients in the VR group and 44 patients in the control group. During the procedure, patients in the VR group reported significantly lower average fear scores (P<0.001) and anxiety scores (P=0.003) as compared with controls. There were no differences between the groups in fear and anxiety scores before and after the procedure, or pain scores before, during, or after the procedure. Overall, patients and caregivers in the VR group reported high satisfaction scores, with 97% of patients and 95% of caregivers recommending this intervention to others.CONCLUSION: VR technology was found to be an effective distraction tool to improve fear and anxiety during cast removal procedures. Findings build on a body of evidence that supports the use of distraction tools in clinics, specifically pediatric orthopaedics, to improve fear and anxiety. The distraction tools can be easily translated into current practices.LEVEL OF EVIDENCE: Level I.

    View details for DOI 10.1097/BPO.0000000000002250

    View details for PubMedID 36040069

  • What is New in Pediatric Orthopaedic Foot and Ankle. Journal of pediatric orthopedics Tileston, K., Baskar, D., Frick, S. L. 2022; 42 (5): e448-e452

    Abstract

    BACKGROUND: This paper aims to report on the last 5 years of relevant research on pediatric foot and ankle pathology with specific focus on clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans.METHODS: The Browzine platform was used to review the table of contents for all papers published in the following target journals related to the treatment of pediatric foot and ankle conditions. Search results were further refined to include clinical trials and randomized controlled trials published from March 1, 2015 to November 15, 2021.RESULTS: A total of 73 papers were selected for review based on new findings and significant contributions in treatment of clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans. Also included were several papers that did not fit into any of these categories but provided new insight into specific foot and ankle pathologies.CONCLUSIONS: Treatment strategies for children with foot and ankle pathology are continually evolving. We review many of the most recent publications with the goal of improving understanding of these pathologies and highlighting current best practices.LEVEL OF EVIDENCE: Level III.

    View details for DOI 10.1097/BPO.0000000000002134

    View details for PubMedID 35405728

  • The Axillary Nerve Danger Zone in Percutaneous Fixation in the Pediatric Shoulder: The "1-Mountain-3-Valleys" Principle. The Journal of bone and joint surgery. American volume Stavinoha, T. J., Randhawa, S. D., Trivedi, S., Dingel, A., Shea, K. G., Frick, S. L. 2022

    Abstract

    Adult literature cites an axillary nerve danger zone of 5 to 7 cm distal to the acromion tip for open or percutaneous shoulder surgery, but that may not be valid for younger patients. This study sought to quantify the course of the axillary nerve in adolescent patients with reference to easily identifiable intraoperative anatomic and radiographic parameters.A single-institution hospital database was reviewed for shoulder magnetic resonance images (MRIs) in patients 10 to 17 years old. One hundred and one MRIs from patients with a mean age of 15.6 ± 1.2 years (range, 10 to 17 years) were included. Axillary nerve branches were identified in the coronal plane as they passed lateral to the proximal humerus and were measured in relation to identifiable intraoperative surface and radiographic landmarks, including the acromion tip, apex of the humeral head, lateral physis, and central apex of the physis. The physeal apex height (i.e., 1 "mountain") was defined as the vertical distance between the most lateral point of the humeral physis (LPHP) and the central intraosseous apex of the physis.Axillary nerve branches were found in all specimens, adjacent to the lateral cortex of the proximal humerus. A mean of 3.7 branches (range, 2 to 6) were found. The mean distance from the most proximal branch (BR1) to the most distal branch (BR2) was 11.7 mm. The pediatric danger zone for the axillary nerve branches ranged from 6.6 mm proximal to 33.1 mm distal to the LPHP. The danger zone in relation to percent of physeal apex height included from 62% proximal to 242% distal to the LPHP.All branches were found distal to the apex of the physis (1 "mountain" height proximal to the LPHP). Distal to the LPHP, no branches were found beyond a distance of 3 times the physeal apex height (3 "valleys"). In children and adolescents, percutaneous fixation of the proximal humerus should be performed with cortical penetration outside of this range. These parameters serve as readily identifiable intraoperative radiographic landmarks to minimize iatrogenic nerve injury.This study provides valuable landmarks for percutaneous approaches to the proximal humerus. The surgical approach for the placement of percutaneous implants should be adjusted accordingly (i.e., performed at least 1 mountain proximal or 3 valleys distal to the LPHP) in order to prevent iatrogenic injury to the axillary nerve.

    View details for DOI 10.2106/JBJS.21.01202

    View details for PubMedID 35344511

  • Idiopathic Toe-Walking in Children and Adolescents: Diagnosis, Natural History, and Treatment Options. JBJS reviews Freiman, H. D., Mensah, C., Codrington, J., Frick, S. L. 2022; 10 (2)

    Abstract

    : Idiopathic toe-walking is a diagnosis of exclusion.: The natural history of idiopathic toe-walking has not been studied in many children; we identified only 1 prospective study. Of children without equinus contractures who were toe-walking before the age of 5.5 years, 59% had spontaneous resolution of toe-walking by 5.5 years of age, and 79%, by the age of 10 years.: Adverse consequences of toe-walking into adulthood have not been reported, but may exist, and further research is needed to define and clarify.: If parents desire treatment to resolve their child's toe-walking, surgical lengthening of the Achilles tendon is the treatment with the highest chance of success and lowest relapse rate, and thus far, no complications have been reported in any surgical series.

    View details for DOI e21.00193

    View details for PubMedID 35180146

  • Dynamic Supination in Congenital Clubfoot: A Modified Delphi Panel Approach to Standardizing Definitions and Indications for Treatment. Journal of pediatric orthopedics Baskar, D., Hosseinzadeh, P., Mosca, V., Bouchard, M., Aroojis, A., Arkader, A., Cidambi, E., Denning, J., Eastwood, D., Gantsoudes, G., Kelly, D. M., Kishta, W., Masquijo, J., May, C., Milbrandt, T., Nichols, L. R., Frick, S. 2022

    Abstract

    BACKGROUND: Dynamic supination is a well-recognized cause of congenital clubfoot deformity relapse. However, there is no consensus on how to diagnose it and there are varied approaches in its management. This study aims to define dynamic supination and indications for treatment by presenting consensus from an international panel of experts using a modified Delphi panel approach.METHODS: An international panel of 15 pediatric orthopaedic surgeons with clinical and research expertise in childhood foot disorders participated in a modified Delphi panel on dynamic supination in congenital clubfoot. Panelists voted on 51 statements using a 4-point Likert scale on dynamic supination, clinical indications for treatment, operative techniques, and postoperative casting and bracing. All panelists participated in 2 voting rounds with an interim meeting for discussion. Responses were classified as unanimous consensus (100%), consensus (80% or above), near-consensus (70% to 79%), and indeterminate (69% or less).RESULTS: Consensus was achieved for 34 of 51 statements. Panelists agreed dynamic supination is present when the forefoot is supinated during swing phase of gait with initial contact on the lateral border of the foot. There was also agreement that dynamic supination results from muscle imbalance between the tibialis anterior and the peroneus longus and brevis. There was no consensus on observation of hindfoot varus in dynamic supination, operative indications for posterior release of the ankle joint, or incisional approach for tibialis anterior tendon transfer. Reference to the calcaneopedal unit concept, planes of movement, and phases of gait were deemed important factors for consideration when evaluating dynamic supination.CONCLUSIONS: Consensus statements from the Delphi panel can guide diagnosis and treatment of dynamic supination in clubfoot deformity relapse, including clinical decision making regarding preoperative casting, surgical approach, and postoperative immobilization. Near-consensus and indeterminate statements may be used to direct future areas of investigation.LEVEL OF EVIDENCE: Level V.

    View details for DOI 10.1097/BPO.0000000000002119

    View details for PubMedID 35180725

Faculty Contact

Dr Steven Frick

Research Contact

Amishi Jobanputra    

amishij@stanford.edu