Clubfoot Treatment & Management
- Author: Minoo Patel, MBBS, PhD, MS, FRACS; Chief Editor: Jason H Calhoun, MD, FACS more...
Traditionally, surgery for clubfoot is indicated when a plateau has been reached in nonoperative treatment. It is usually performed when the child is of sufficient size to allow recognition of the anatomy. No specific contraindications to surgery exist, though the child's size dictates that surgery is best performed at approximately age 6 months. With greater acceptance of the Ponseti conservative technique, surgery has come to be seen to be a contentious issue. Surgery for clubfeet is no longer the only standard of care.
The aims of medical therapy for clubfoot are to correct the deformity early and fully and to maintain the correction until growth stops.
Traditionally, two categories of clubfeet are identified, as follows:
Easy or correctable clubfeet - These are readily corrected with manipulation, casting, and splintage alone
Resistant clubfeet - These respond poorly to splinting and relapse quickly after seemingly successful manipulative treatment; they require early operative management and are said to be associated with a thin calf and a small high heel.
The Pirani scoring system, devised by Shafiq Pirani, MD, of Vancouver, BC, consists of six categories, three in the hindfoot and three in the midfoot, as follows:
Curvature of the lateral border (CLB) of the foot
Medial crease (MC)
Uncovering of the lateral head of the talus (LHT)
Posterior crease (PC)
Emptiness of the heel (EH)
Degree of dorsiflexion (DF)
The first three (CLB, MC, and LHT) constitute the midfoot score, and the last three (PC, EH, and DF) constitute the hindfoot score.[4, 25] Each category is scored as 0, 0.5, or 1. The lowest possible (ie, best) total score for all categories combined is 0, and the highest possible (ie, worst) total score is 6. The Pirani scoring system can be used to identify the severity of the clubfoot and to monitor the correction.
It is necessary to provide counsel and advice to parents. They should be reassured that they are in no way responsible for the deformity and that it is unlikely to be reproduced in subsequent pregnancies.
Traditional nonoperative treatment
With traditional nonoperative treatment, splintage begins at 2-3 days after birth. The order of correction is as follows:
Attempts to correct equinus first may break the foot, producing a rockerbottom foot (see the image below). Force must never be used. Merely bring the foot to the best position obtainable, and maintain this position either by strapping every few days or by changing casting weekly until either full correction is obtained or correction is halted by some irresistible force.
The corrected position is maintained for several months. Surgery should be used as soon as it is obvious that conservative treatment is failing (persisting deformity, rockerbottom deformity, or rapid relapse after correction has stopped).
By 6 weeks, it is usually apparent whether the foot is easy or resistant; this is confirmed on x-ray due to the orientation of the bones. Reported success rates for these traditional casting methods are 11-58%.
This method was developed by Ignacio Ponseti, MD, of the University of Iowa. The premise of the method is based on Ponseti's cadaveric and clinical observations.[1, 3, 21, 26] A 2014 Cochrane review found this approach to yield signficantly better results than either the Kite method or a traditional approach, though it noted that the quality of the evidence was not high.
The Ponseti method may be divided into seven steps, as follows.
The calcaneal internal rotation (adduction) coupled with plantarflexion is the key deformity. The foot is adducted and plantarflexed at the subtalar joint, and the goal is to abduct the foot and dorsiflex it. In order to achieve correction of the clubfoot, the calcaneum should be allowed to rotate freely under the talus, which also is free to rotate in the ankle mortise.
The correction takes place through the normal arc of the subtalar joint. This is achieved by placing the index finger of the operator on the medial malleolus to stabilize the leg and levering on the thumb placed on the lateral aspect head of the talus while abducting the forefoot in supination. Forcible attempts to correct the heel varus by abducting the forefoot while applying counterpressure at the calcaneocuboid joint prevent the calcaneum from abducting and therefore everting.
Foot cavus increases when the forefoot is pronated. If cavus is present, the first step in the manipulation process is to supinate the forefoot by gently lifting the dropped first metatarsal to correct the cavus. Once the cavus is corrected, the forefoot can be abducted as outlined in step 1.
Pronation of the foot also causes the calcaneum to jam under the talus. The calcaneum cannot rotate and stays in varus. The cavus increases as outlined in step 2. This results in a bean-shaped foot. At the end of step 1, the foot is maximally abducted but never pronated.
The manipulation is carried out in the cast room, with the baby having been fed just before, or even during, the treatment. After the foot is manipulated, a long leg cast is applied to hold the correction.
Initially, the short leg component is applied. The cast should be snug with minimal but adequate padding. The authors paint or spray the limb with tincture of benzoin to allow adherence of the padding to the limb. The authors prefer to apply additional padding strips along the medial and lateral borders to facilitate safe removal of the cast with a cast saw. The cast must incorporate the toes right up to the tips but not squeeze the toes or obliterate the transverse arch. The cast is molded to contour around the heel while abducting the forefoot against counter pressure on the lateral aspect of the head of the talus.
The knee is flexed to 90° for the long leg component of the cast. The parents can soak these casts for 30-45 minutes before removal with a plaster knife. The authors' preferred method is to use the oscillating plaster saw for cast removal. The cast is bivalved and removed. The cast then is reconstituted by coapting the two halves. This allows for monitoring of the progress of the forefoot abduction and, in the later stages, the amount of dorsiflexion or equinus correction.
Forcible correction of the equinus (and cavus) by dorsiflexion against a tight Achilles tendon results in a spurious correction through a break in the midfoot, resulting in a rockerbottom foot. The cavus should be separately treated as outlined in step 2, and the equinus should be corrected without causing a midfoot break. It generally takes as many as four to seven casts to achieve maximum foot abduction. The casts are changed weekly. The foot abduction (correction) can be considered adequate when the thigh-foot axis is 60°.
After maximal foot abduction is obtained, most cases require a percutaneous Achilles tenotomy. This is performed in the cast room under aseptic conditions. The local area is anesthetized with a combination of a topical lidocaine preparation (eg, EMLA Cream; AstraZeneca, Wilmington, DE) and minimal local infiltration of lidocaine. The tenotomy is performed through a stab incision with a round-tip (#6400) Beaver blade.
The wound is closed with a single absorbable suture or with adhesive strips.The final cast is applied with the foot in maximum dorsiflexion, and the foot is held in the cast for 2-3 weeks.
After the manipulation and casting phase, the feet are fitted with open-toed straight-laced shoes attached to a Dennis Brown bar. The affected foot is abducted (externally rotated) to 70° with the unaffected foot set at 45° of abduction. The shoes also have a heel counter bumper to prevent the heel from slipping out of the shoe. The shoes are worn for 23 hours a day for 3 months and are worn at night and during naps for up to 3 years.
In 10-30% of cases, a tibialis anterior tendon transfer to the lateral cuneiform is performed when the child is approximately 3 years of age. This gives lasting correction of the forefoot, preventing metatarsus adductus and foot inversion. This procedure is indicated in a child aged 2-2.5 years with dynamic supination of the foot. Before surgery, cast the foot in a long leg cast for a few weeks to regain the correction.
Preparation for operation
The operating room is kept warm, and a general anesthetic is used. The usual position is supine with the foot resting over the contralateral leg in a figure-four position. Some surgeons prefer the lateral decubitus position or even a prone position. A tourniquet generally is used, and the surgical procedure is performed with the help of optical loupe magnification.
Options for incisions include the following:
Turco curvilinear medial or posteromedial incision
The Cincinnati incision is a transverse incision that extends from the anteromedial (region of navicular-cuneiform joint) to the anterolateral (just distal and medial to the sinus tarsi) aspect of the foot and over the back of the ankle at the level of the tibiotalar joint.
The Turco incision can lead to wound breakdowns, especially at the corner of the vertical and medial limbs.[29, 28] To avoid this problem, some surgeons prefer to use either three separate incisions (posterior vertical, medial, and lateral) or two separate incisions (curvilinear medial and posterolateral).
Any approach should be able to address the release in all quadrants, as follows:
Plantar - Plantar fascia, abductor hallucis, flexor digitorum brevis, long and short plantar ligaments
Medial - Medial structures, tendon sheaths, talonavicular and subtalar release, tibialis posterior, flexor hallucis longus (FHL), and flexor digitorum longus (FDL) lengthening
Posterior - Ankle and subtalar capsulotomy, especially releasing post talofibular and tibiofibular ligaments and the calcaneofibular ligaments
Lateral - Lateral structures, peroneal sheath, calcaneocuboid joint, and completion of talonavicular and subtalar release
Surgical clubfoot release
In the past, clubfoot surgery was performed in a way that did not differentiate severity. The same procedure was performed for all patients. Bensahel proposed a more individualized approach (ie, addressing only the structures that are required are released). The surgery is tailored to the deformity. For example, if the forefoot is well corrected and externally rotated, if there is no cavus, but if there is still significant equinus, a posterior approach alone should suffice.[30, 31, 7]
Any approach should afford adequate exposure. Structures to be released or lengthened are the following:
Achilles (calcaneal) tendon
Tendon sheaths of the muscles crossing the subtalar joint
Posterior ankle capsule and deltoid ligament
Inferior tibiofibular ligament
Capsules of the talonavicular and subtalar joints
Division of associated ligaments around the subtalar joint
Plantar fascia and intrinsic muscles
The longitudinal axis of the talus and calcaneum should be separated by about 20° in the lateral projection, and the calcaneal angle should be a right angle to the shaft of the tibia.
The correction is held with wires at the talocalcaneal joint, the talonavicular joint, or both, possibly with a plaster cast. The wound should never be forcibly closed. It can be left open to granulate and heal by secondary intention or even grafted with split-thickness skin grafts.
Surgical treatment should take into account the age of the patient, as follows:
In children younger than 5 years, correction can be achieved with soft-tissue procedures
Children older than 5 years require bony reshaping (eg, dorsolateral wedge excision of the calcaneocuboid joint [Dillwyn Evans procedure] or osteotomy of the calcaneum to correct varus)
If the child is older than 10 years, lateral wedge tarsectomy or triple fusion (arthrodesis) is required (salvage procedures)
Posterior release steps, in brief, are as follows:
Identify neurovascular (NV) bundle
Tendon sheaths of FHL, FDL, and tibialis posterior released; tendons not elongated
Ankle joint capsule opened; talofibular, calcaneofibular, and deep portion of deltoid ligaments released (blunt dissection)
Release of distal tibial and fibula ligaments
Posterior release of the subtalar joint
With foot held just above neutral, tendocalcaneum is repaired and skin closed
Plaster-of-Paris cast in corrected position for 4 weeks, followed by splints until maturity
A posteromedial release (Turco procedure[29, 28] ) is performed as follows. (See the images below.)
Make a medial incision 8-9 cm long from the base of the first metatarsal to the tendocalcaneum, curving it just inferior to the medial malleolus without undermining skin. Mobilize and expose the tendons of the tibialis posterior, FDL, FHL, Achilles tendon, and posterior NV bundle.
Continuing the incision in the sheaths of FDL and FHL, divide the master knot of Henry beneath the navicular. Divide the spring ligament, detaching it from the sustentaculum tali and the origin of the abductor hallucis. Release the remaining contractures, starting posteriorly. Lengthen the Achilles tendon (Z-plasty), detaching the medial half of the tendon insertion.
Retract the NV bundle and FHL anteriorly to expose the posterior aspect of the ankle and subtalar joints. Then, incise the posterior capsule of the ankle joint under direct visualization, as well as the posterior talofibular ligament (if necessary at this time). Divide the subtalar capsule and calcaneofibular ligament.
Retract the NV bundle posteriorly, and divide the tibiocalcaneal part of the deltoid ligament. Lengthen the tibialis posterior if it is contracted. Open the talonavicular joint and divide its capsule, but avoid damaging the articular surface. Then, release the subtalar ligaments and reduce the navicular onto the head of the talus, which should properly align the other tarsal bones.
Ensure that the relation of the talus to the calcaneus and navicular is correct, and stabilize the foot with Kirschner wires (K-wires). The first K-wire is passed from the dorsum of the foot across the first metatarsal shaft, the medial cuneiform, the navicular, and into the talus. A second wire fixes the subtalar joint, and this should maintain the foot in the corrected position.
Apply an above-the-knee plaster-of-Paris cast, which is changed at 3 weeks and maintained to 6 weeks. The foot is initially held in slight equinus if there is tension on the skin closure, which is corrected at the time of cast change. Splintage is continued for at least 4 months after surgery, and night splints are used for several years.
The Ilizarov correction is used for recurrent clubfeet, especially in conditions such as arthrogryposis.[32, 33, 34, 35] (See the image below.) The calcaneum is held with two opposing olive-tipped wires. The distractor force, in the form of heel-pushing distractors, must be posteriorly directed to prevent anterior subluxation of the talus in the ankle mortise.
Pay meticulous attention to the wound after surgery. If the skin closure is difficult, it is better to leave the wound open and allow it to granulate for a delayed primary or secondary closure or allow it to heal by granulation tissue. Skin grafts also can be used to cover the defect. The plaster splint should be only lightly applied, and the wound should be inspected regularly.
The transfixion pins usually are removed in 3-6 weeks. The foot requires splintage in appropriate footwear for 6-12 months.
Complications of treatment of clubfoot include the following:
Wound breakdown - Release skin retractors every 30 minutes, and release the tourniquet before closing the wound and applying a cast
Stiffness and restricted range of motion - Early stiffness correlates with a poor result
Avascular necrosis (AVN) of the talus - A 40% incidence of avascular necrosis of the talus occurs with combined simultaneous medial and lateral release
Persistent intoeing - This is quite common; it is due not to tibial intorsion but, rather, to insufficient external rotation correction of the subtalar joint
Overcorrection is associated with the following:
Release of the interosseous ligament of the subtalar joint
Excess lateral displacement of the navicular on the talus
Overlengthening of tendon units
For residual deformity following the initial surgery, rule out neurologic causes of recurrence (eg, tethered cord). A residual deformity may be either of the following:
Dynamic - With residual adductus and supination that are fully correctable passively, treat with split anterior tibial tendon transfer 
Fixed - If scarring is not excessive and the patient is younger than 5 years, repeat the release; if the patient is older than 5 years, a bony procedure to straighten the lateral border of the foot is required
Options to correct adductus are as follows:
Metatarsal osteotomy - This operation creates a secondary deformity to compensate for a primary deformity in the tarsus; it rarely is indicated
Calcaneocuboid fusion - The Dillwyn Evans procedure consists of a medial and post release together with excision and fusion of the calcaneocuboid joint  ; it should be reserved for patients older than 4 years; these two procedures aim to shorten the lateral side of the foot
Lengthening the medial side of the foot (eg, talar osteotomy) - This is not widely performed; AVN is a risk
Options to correct residual hindfoot deformity are the following:
Heel varus - Open the medial wedge, or close the lateral wedge; lateral displacement os calcis osteotomy is preferred
Residual cavus and adductus - Perform a wedge tarsectomy
Failed feet - Perform a triple arthrodesis
As small infants with operated clubfeet have grown into heavy adults, they have been prone to painful stiff feet, despite good correction.
Deitz and Cooper published a 30-year follow-up study of patients treated with the Ponseti method. These cases had comparatively pain-free supple feet. The Ponseti method is gaining mainstream acceptance, as evidenced by the emergence of Ponseti clubfeet centers at major teaching hospitals across the United States.
Of the patients who have been monitored over the long term, those who are heavy and those who have jobs involving long periods on their feet (especially performing manual labor) were found to be more likely to have painful feet. This correlated with the trend seen in the general population at large.
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