Orthopaedic Surgery

This clinic is a weekly multidisciplinary clinic that runs with participation from orthopaedics, endocrinology and clinical genetics, with a focus on genetic bone diseases. We look after patients with osteogenesis imperfecta, inherited rickets and skeletal dysplasias. 

The Baby Hip Clinic at SickKids is an inter-professional clinic that includes an orthopaedic surgeon, a physiotherapist practitioner, a senior secretary, fellows, residents, orthotists, clinic nurses and administrators. The clinic is designed to assess and treat babies with Developmental Dysplasia of the Hip (DDH). Babies with dislocated hips are ideally seen at the earliest available clinic date. 

All other babies are ideally seen around six weeks of age. Patients requiring treatment in a Pavlik Harness will be seen every one to four weeks to check progress and adjust the harness for growth. An orthotist will apply the harness and full treatment in the harness usually lasts 12-16 weeks. Patients requiring operative management will be followed in a surgeon’s elective clinic. 

Upon completion of treatment, children are monitored and return to clinic in intervals of six months to four years (see Hip Follow-up clinic below). For location and more see the Baby Hip Clinic's directory information. 

The Clubfoot Clinic at SickKids is a multidisciplinary clinic designed to assess and treat children with congenital idiopathic talipes equino varus (club foot) foot deformity. Children are ideally seen within four to six weeks of birth, and commence treatment with serial casting immediately. The treatment procedure requires weekly visits and full correction is often achieved within 10 to 12 weeks. 

Children are monitored closely in clinic for the first year following correction, then approximately every 6 months until approximately five years of age.  

For more about this clinic, location and other important details, visit the SickKids Clubfoot Clinic in our Directory. 

What is Clubfoot?

Clubfoot is a condition that causes the lower leg, ankle and foot to be turned inward and pointed down. The deformity occurs during early development of the fetus and is present at birth. It affects 1-2 children for every 1000 live births. Clubfoot can run in families. The cause is multifactorial, including genetic, though the responsible gene(s) has not yet been found. Other names for idiopathic clubfoot include congenital clubfoot and Talipes Equinovarus. 

The deformity can occur in one or both feet and is twice as common in boys as it is in girls. Because the muscles, tendons and bones have been growing in an abnormal position, the foot is often quite rigid and requires several stages of treatment. 

The standard of care treatment globally, and our practice in the SickKids Clubfoot Clinic, is the Ponseti Method of casting, a minor surgical procedure and bracing. Ideally, treatment should begin in the weeks soon after birth, after you and your baby are comfortably settled at home.  

Broadly, there are three stages:

1) Weekly Ponseti stretching and casting of the foot and leg 
2) A minor surgical procedure to the Achilles tendon 
3) Bracing to hold the corrected position 

Stages of Clubfoot treatment

Stage 1: Casting

The first part of treatment involves a specific series of gentle stretching and casting of the affected foot/feet to gradually correct the alignment. This is often referred to as manipulation and casting. The treatment is performed by a physical therapist or orthopaedic surgeon trained in the Ponseti Method. 

Casting ideally starts within 4 weeks of birth and repeated every 1-2 weeks, for an average of 
4-7 weeks. The number of casts can depend on the stiffness of the foot, age of the infant or child, and skin condition and response to casting. 

The stretching and casts do not hurt the baby as they are done gently. Each infant will respond differently to the casting, but as the babies get used to their casts, they may be a little fussy for 1-2 days after casting. 

Stage 2: Achilles Tendon Tenotomy (Release)

The casting corrects the foot alignment, but in the majority of infants the Achilles tendon (where the calf muscle attaches to the heel) is too strong and prevents full upward motion of ankle. As the Achilles tendon is very tight, it is recommended to surgically release/cut it, rather than continuing to put force on the foot with casting. Over 90% of babies will require this. 

The procedure is done by the orthopaedic surgeon in the clinic under local anaesthetic. It involves a very small incision at the back of the ankle, and does not require stitches. Babies are very comfortable after the procedure and do not need pain medicine. After the tendon is released, the foot will be casted in the fully corrected position for 3 weeks. Infants over 6 months of age typically require the procedure in the operating room under general anaesthetic. 

Stage 3: Bracing

When the infant’s foot is fully corrected, he or she will need to wear a brace to maintain its good position. The bracing phase is essential for preventing the deformity from returning and success is dependent on the parents developing a good routine for brace wear! 

The brace is called Boots and Bar (B&B). It includes two boots attached to a bar that holds the feet shoulder-width apart and turned outward, away from the body. This position is natural and comfortable for the baby and prevents the previously tight muscles from pulling the foot back in a downward and inward position. There are several versions of this brace available on the market and your physical therapist and surgeon will discuss the options available to you and approximate costs. 

Your child will need to wear these 23 hours at a time for the first 3 months. If the foot shape remains well corrected, brace wear is then decreased to nighttime only aiming for 12-15 hours. The casting, tenotomy, and full-time bracing stages are typically completed within 6 months. The child will continue to wear the brace at nighttime only until 5 years of age. Bracing is necessary for all patients and is essential to prevent relapse of the deformity. Most children will not require any special footwear or bracing for daily function. 

The majority of infants with idiopathic clubfoot will experience normal developmental milestones during and following treatment. The average child with idiopathic clubfoot walks by 18 months of age. This is within the normal time frame for all healthy children. 

Response to treatment

The Ponseti Method is considered the most effective treatment of idiopathic clubfoot. As each clubfoot is unique, so will be its response to each phase of treatment. Some clubfeet are more flexible yet others are more rigid, requiring more casts than initially predicted or possibly recasting during later phases of treatment. A small percentage of children may require surgery at some stage in the child’s treatment if the foot is not correcting well with casting. 

Attending all appointments and commitment to keeping casts and braces on as prescribed are important to achieve and maintain correction of the foot deformity.

Regardless of the severity of the clubfoot, the goal and result of treatment is to achieve a functional and painless foot with good alignment. The affected clubfoot is typically a little smaller than the normal foot and the calf muscle may develop slightly smaller. The affected leg may also be slightly shorter and may toe-in slightly. If both feet are involved, they are usually symmetric. None of these differences will cause pain or affect the child’s growth or function. Your child should be able to walk and run normally and to participate in most physical activities. 

Our Clinic and Team

Our clinic team consists of surgeons, physiotherapists and orthopaedic technologists, as well as our front-line staff. Dr. Andrew Howard on Wednesday and Dr. Maryse Bouchard on Thursday. The clinic's physiotherapists are Barb Harvey and Stacy Robitaille. 

AboutKidsHealth resources:

Learn more about Clubfoot Treatment and B&B brace maintenance

This clinic occurs once a month under the direction of the Divisions of Orthopaedic Surgery and Neurosurgery.  

Our inter-professional clinic is devoted to the assessment and treatment of paediatric fractures. Referrals are triaged Monday to Friday, to determine your child’s plan of care. Based on the referral information, you will be given an appointment in our clinic, or instructed to follow up with your family doctor. Typically, we see upper and lower extremity fractures, such as wrist, forearm, elbow, shoulder, thigh, lower leg and feet. We refer forearm buckle fractures to the family doctor for treatment. 

The Fracture Clinic is held four times a week by the residents and a specialty-trained nurse practitioner, with supervision from the orthopaedic staff surgeons.

For more details visit the Fracture Clinic on our Directory. 

The Hip Follow-up Clinic provides conservative management of children with developmental dysplasia of the hip (DDH). The Hip Follow-up Clinic is for graduates of the Baby Hip Clinic or first-time visits of children older than 1 year of age who are not being considered for surgical management.

This clinic is held weekly. Patients are followed by a physiotherapy practitioner who will consult with an orthopaedic surgeon as needed. Patients are required to undergo pelvic x-rays for each appointment that may be held in person at the hospital or virtually through internet access. Patients requiring operative management will be followed in a surgeon’s elective clinic.

For location and more, visit our Directory listing: Hip Follow-up Clinic. 

The Limb Reconstruction Clinic is for the planning and monitoring of complex deformity corrections and limb lengthening using state of the art methods of internal and external fixation. 

Read about Limb lengethening and reconstruction on AboutKidsHealth. 

The team that manages musculoskeletal tumours in children includes specialist sarcoma medical oncologists, a clinical oncology nurse practitioner, specialist diagnostic and interventional radiologists, pathologists, a specialist physiotherapist, an oncology social worker, clinic nurses and administrators, a clinical database manager and specialist orthopaedic oncology surgeons. 

We run a multidisciplinary musculoskeletal tumour clinic where we evaluate and expedite work-up of potentially malignant bone and soft tissue tumours. Referrals are quickly processed. 

Following thorough structural and functional imaging, a biopsy is often performed. Those tumours requiring chemotherapy are treated as per a Children’s Oncology Group protocol where possible. Those tumours requiring surgery are treated with intralesional, marginal or wide resection, based on the grade of tumour. Limb-sparing reconstructive procedures are usually possible. We aim to maximize function and undertake biological reconstruction with living tissue where possible, sometimes in collaboration with our plastic microvascular surgery colleagues. 

Reconstruction with state-of-the-art endoprosthetic implants is an alternative approach we utilize. Our group collaborates with the adult musculoskeletal group based at Mount Sinai and Princess Margaret Hospitals across the road. We hold joint conferences and together maintain the tumour bank and collaborate on basic science and clinical outcomes research. This clinic runs every week with orthopaedics, medical oncology, physiotherapy and plastic surgery. The combined Brachial Plexus Palsy Clinic runs once a month with plastic surgery and orthopaedics. 

What is Brachial Plexus Palsy?

The brachial plexus is a group of five nerves that provide movement and sensation to the arm. It may be affected by a difficult childbirth. The usual course is to allow the nerves to heal and repair on their own. This is a gradual process that may take a year or longer. In some cases, surgical exploration of the nerves is required to improve the function of the arm.  

Visit AboutKidsHealth to learn more about the  Brachial Plexus Operation, and the causes, risk factors, diagnosis and treatment of  Brachial Plexus Palsy.  

About The Brachial Plexus Clinic 

Dr. Howard Clarke is the Medical Director of the Brachial Plexus Clinic at SickKids. He has been joined by Dr. Kristen Davidge and Dr. Sevan Hopyan in providing surgical services for these patients.   

The Clinic was started in 1990 and has since developed into a weekly multidisciplinary clinic for the comprehensive care of infants and children with brachial plexus injuries. We see children from newborns to 17-year olds. Approximately 70 children with obstetrical brachial plexus palsy are seen each year through the clinic. Our centre is also dedicated to ongoing research in the field of obstetrical brachial plexus injuries. 

The Brachial Plexus Clinic is a multidisciplinary clinic designed to assess and treat children with brachial plexus problems. Children are seen in the clinic at three-month intervals until one-year of age, then every six months or more thereafter. Children continue to be monitored in the clinic throughout their childhood to measure the effect of growth and development on their ability to function. 

For more information, please email  brachial.plexus@sickkids.ca

The Scoliosis Clinic is a practitioner run clinic, with the support of the orthopaedic surgeons, focusing on the conservative management of scoliosis. This clinic, for non-operative management of spine deformity is run by a specialty-trained physiotherapist practitioner.

Spinal curvatures between 20 degrees and 45 degrees are assessed and managed with monitoring or bracing. Larger curvatures are followed by the orthopaedic surgeons when considering surgery. Monitoring is appropriate for smaller curves in the growing child or when teenagers are nearing the end of growth. Bracing is used for a child who has growth remaining with curves that are between 25 degrees and 45 degrees. The braces are made at SickKids in Orthotics. 

For clinic information and details, visit the Clinic Directory.

For more information on Scoliosis, visit AboutKidsHealth.