Posteromedial and Posterolateral Release for the Treatment of Resistant Clubfoot

 

 

 

 

DEFINITION

Clubfoot, or talipes equinovarus, is a congenital or acquired deformity in which the foot is stiffly positioned in hindfoot equinus and varus and forefoot varus, supination, and plantarflexion.8

When the deformity is not corrected, the patient limps, bearing weight on the lateral forefoot. This can limit ambulation and lead to foot and ankle pain, abnormal calluses, and ulcers and infections.2

The deformity may present as an isolated or syndromic birth defect. Clubfoot has been documented in conjunction with diagnoses of polio, spina bifida, cerebral palsy as well as other disorders.6

 

 

ANATOMY

 

Clubfoot deformity begins as soft tissue imbalance and contractures altering the positions predominantly of the talus, calcaneus, and navicular as well as their corresponding articulations.6

 

The displacement of these bones differs, producing varying amounts of four different positional deformities: cavus, adductus, varus, and equinus.3

 

 

Eventually, the abnormal forces and positions lead to plantarflexion and medialization of the talar neck.6 Weakness and underdevelopment of the foot and calf result to varying degrees.5

 

Although radiographic measurements are hard to reproduce, the anteroposterior (AP) and lateral talocalcaneal

angles are reduced from about 28 degrees to about 5 degrees in children with clubfoot.6

 

PATHOGENESIS

 

The exact cause of clubfoot remains unknown. Many theories can be found in the literature. The cause is probably multifactorial and includes some extent of the following2, 5, 6, 7:

 

Primary germ plasma defect: Initial investigations into multiple cases of clubfoot speculate that the consistent bony deformity is caused by primary bone dysplasia.

 

Uterine restriction: A reduced amount of amniotic fluid causes limited fetal foot movement and, incidentally, clubfoot.

 

Bone-joint hypothesis: The cause of the deformity is abnormalities in the ossification of the bones of the foot.

 

Connective tissue hypothesis: Degeneration in the connective tissues of the skeletally immature foot causes clubfoot.

 

Vascular hypothesis: Muscle wasting has been documented in most children with idiopathic congenital talipes equinovarus. Type 1 fiber predominance and grouping also coincides with most cases of clubfoot.

 

Neurologic complication: Clubfoot is seen in conjunction with a long list of neurologic disorders, including spina bifida, anencephaly, hydrocephaly, and so forth.

 

Developmental arrest hypothesis: Due to a noted similarity between clubfeet and the embryonic foot at the beginning of the second month of fetal development, it has been suggested that the maturation of the fetal foot was arrested while under genetic control.

 

Genetics: This is the most probable cause, as agreed on by many physicians; a family history of talipes equinovarus has been documented in a majority of the reported cases.

 

NATURAL HISTORY

 

The overall incidence of talipes equinovarus is about one per thousand live births but varies with sex and race: It is more commonly seen in boys, and there is a high frequency of affected children in Polynesian

cultures.7

 

Untreated, the deformity leads to limping, abnormal calluses due to weight bearing on the lateral forefoot, atrophy and hypoplasia due to disuse, and pain.

 

Research has been extensive regarding the appropriate approach to treating clubfoot, but few long-term comparative studies exist. Although in the past century extensive surgery predominated, it is now believed that extensive surgical techniques are necessary in fewer than 5% of cases.

 

Currently, the most popular treatment of clubfoot follows Ponseti method, which was not generally accepted until his review article of 1992 in which he demonstrated results similar to those of more extensive surgery with fewer complications. The technique has gained such popularity that most pediatric orthopaedists throughout the world are employing Ponseti basic principles of manipulation, casting, and minimal operative treatment of the clubfoot.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

The deformity of clubfoot is identified at birth as unilateral or bilateral hindfoot equinus and varus and midfoot supination, varus, and equinus.

 

 

To perform the examination, the leg is extended at the knee and the foot is then dorsiflexed. The foot-to-tibia angle is measured to assess the amount of equinus in the frontal plane and the amount of heel varus in the sagittal plane.

 

The dorsolateral aspect of the midfoot is palpated to locate the talar head. The forefoot is then manipulated to determine if the forefoot can be reduced onto the talar head.

 

The lateral rotation of the foot-thigh angle can be assessed by flexing the knee and ankle to 90 degrees and gently laterally rotating the foot. The angle is measured.

 

These examinations do not determine a classification but rather the stiffness of the foot and the amount of improvement attained with serial casting and surgical intervention.

 

 

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The clinician should investigate associated anomalies, such as spina bifida, spasticity, muscular dystrophy, arthrogryposis, and so forth. By understanding the cause, the likelihood of treatment success can be predicted.

 

The clinician should observe the shape and size of the foot. The clubfoot is generally shorter and wider than a normal foot.

 

Examination reveals equinus and varus of the ankle and midfoot. Creases or clefts are seen at the midfoot and ankle. Calf atrophy is expected, particularly in the older child (FIG 1A-C).

 

Treatment may be altered depending on the presentation of the clubfoot.

 

Range of motion: equinus

 

 

Ankle motion (dorsiflexion and plantarflexion) is assessed in both knee extension and flexion. The os calcis may remain in equinus (by palpation) even though the heel pad appears to come out of equinus (by observation) (FIG 1D,E). This is the so-called empty heel pad sign.

 

Therefore, the foot may “look” as if the equinus is corrected, but the physician must palpate it to know for sure.

 

Range of motion: subtalar joint

 

 

Range of motion is difficult to measure. The resting alignment of the heel to the talus is usually varus in the untreated clubfoot and 5 to 10 degrees of valgus in the corrected foot. The clinician looks at the sole of the foot to observe midfoot varus. The sole is manipulated to see how flexible it is (FIG 1F,G).

 

 

 

 

FIG 1 • Physical examination for clubfoot. A-C. Appearance. D,E. Equinus range of motion (ROM). F,G. Subtalar ROM. H. Forefoot ROM. I,J. Forefoot supination. K. Forefoot plantarflexion. (Copyright .)

 

Overcorrection of the heel into valgus can lead to painful pronation. Residual varus of the lateral border of the foot may be due to subtalar rotation, varus of the calcaneus, medialization of the cuboid on the calcaneus, or varus deformity of the metatarsals. Correction may be required at the site of deformity.

 

Range of motion: forefoot on the talar head

 

 

The foot is palpated dorsolaterally at the lateral midfoot. It usually is lined up with the patella, although plantarflexed. Manipulation is used to reduce the forefoot (FIG 1H).

 

 

The more difficult it is to reduce the forefoot onto the talar head, the stiffer the deformity. Forefoot supination

 

The clinician observes that the forefoot of the clubfoot appears supinated with respect to the tibia. However, supination relates to the position of the forefoot to the hindfoot (FIG 1I,J).

 

If the forefoot appears 30 degrees supinated to the tibia and there is 30 degrees varus to the hindfoot varus, then

 

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the deformity is hindfoot varus and not supination, that is, the forefoot is properly aligned to the hindfoot and there is no supination.

 

It is important to know where this deformity is. Errors in this assessment may lead the surgeon to overcorrect the midfoot or surgically create a pronation deformity.

 

Forefoot plantarflexion

 

 

The physician begins with palpation of the medial column from the first metatarsal to the talar head. Plantarflexion of the forefoot on the hindfoot is measured.

 

In the operated foot, the physician checks for dorsolateral subluxation or dislocation of the navicular on the talar head (FIG 1K).

 

Deformity must be corrected where it is. This assessment, in conjunction with radiographs, will help to assess its location in the soft tissues, the ankle, the bone, or the joints (such as subluxation of the talonavicular joint).

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Sonograms may be used to diagnose clubfoot prenatally.5 Although no prenatal treatment is available, many parents want to know the diagnosis of clubfoot so they can learn about the natural history and treatment options available to them.

 

The prenatal ultrasonographic diagnosis of clubfoot may be made if the bones of the lower leg are in the same plane as the plantar surface of the fetal foot. To ensure a correct diagnosis, images in which the leg is

 

extended away from the wall of the uterus should be obtained.5 This deformity may be seen as early as 12 or 13 weeks.5

 

Plain radiographic images in the newborn period add little to the physical examination. Films are not

reproducible and contribute little to the management.

 

With older children, radiographs may be necessary to treat the deformity effectively, as they can identify fixed individual bone deformities such as flat-top talus, varus deformity of the calcaneus, or dorsolateral subluxation

of a triangular navicular on the talar head.6

 

The most common images used are those of the talocalcaneal angle in both the AP and lateral planes. Both must be obtained while bearing weight or simulated weight bearing on the affected foot.6

 

DIFFERENTIAL DIAGNOSIS

Identifying the underlying cause is often helpful. Examination should be complete to identify spinal dysraphisms, syndromes, cerebral palsy, spina bifida, and so forth.

 

 

NONOPERATIVE MANAGEMENT

 

 

Most would claim that extensive surgical techniques are necessary in less than 5% of cases. Two of the major techniques preferred for nonoperative treatment:

 

Optimal for very young patients, the Ponseti method uses weekly manipulations and cast applications to treat the deformity. About 90% of the patients treated with the Ponseti method will need posterior releases, and about 30% will require additional surgical and nonsurgical (repeat casting) management after age 2 years, including repeat posterior release, posteromedial release, and complete subtalar release.

 

Also used predominantly in newborns, the French method incorporates daily manipulation and stimulation of the foot muscles with nonelastic adhesive strapping to correct clubfoot.

 

There will always be the recalcitrant clubfoot that resists methods such as the Ponseti technique. These cases usually fall into the “arthrogrypotic” or “teratologic” category and should be treated with the releases described in the following text. About 1 in 15 idiopathic clubfeet have rigid equinus, midfoot (metatarsal ) plantarflexion, a deep heel crease at the posterior ankle, a transverse midsole or midfoot crease, and a short hyperextended hallux. These feet may not be apparent until after one to three casts. They have been called complex idiopathic clubfoot and are more difficult to treat. Treatment of complex idiopathic clubfoot required up to five additional casts: first to correct the forefoot plantarflexion then to abduct the forefoot at the midfoot, laterally rotating the anterior tuberosity of the calcaneus under the head of the talus. Recurrence of deformity

is more common in this type.4

 

SURGICAL MANAGEMENT

 

All authors agree that the goal of surgical treatment is first to release enough of the tight structures to bring the foot into an anatomically correct position without tension.

 

Many will add that muscles should be balanced to help maintain the anatomic position.

 

Preoperative Planning

 

The age of the child will play an important role in what must be done to restore anatomic alignment. Generally, soft tissue releases are adequate from age 2 months to 4 years and in some cases to age 6 years. By the age of 4 years, many of the clubfeet are beginning to show bony deformity, which will block correction after soft tissue releases alone.

 

The choice of operative procedure depends on not only the age of the patient but also the degree of rigidity, the deformities present, and the extent of correction by previous treatment.7

Positioning

 

The child is placed on the operating table in the prone position.

 

 

The patient is supported using bolsters underneath the shoulders and waist. The legs are kept free and the knee is fully extended.

Approach

 

Surgical release should begin posteriorly and then continue medially. These areas should reveal the tightest structures in an equinovarus foot.

 

As recommended by Henri Bensahel, often, the “à la carte” approach is used in which intraoperative evaluation leads the surgeon to release any and all tight structures. The surgeon must be prepared to do as little or as much as needed to accomplish anatomic realignment.

 

For each of the soft tissue releases described in Techniques section, it is important to evaluate each foot after each step of the surgical release to determine if the anatomy is corrected or if additional release is necessary.

 

 

 

The goal is to do as little or as much of a release as will place the foot in a corrected position without force. Lengthening tendons and then capsules and ligaments at each location will minimize scarring and stiffness.

 

 

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TECHNIQUES

• Incision

Turco Posteromedial Incision

The Turco incision allows for access to the medial and posterior portions of the foot (TECH FIG 1). The technique begins with a medial incision at the first metatarsal-medial cuneiform joint.

The cut is extended proximally until it is just distal to the tip of the medial malleolus.

Care is taken to curve the incision in a vertical direction, up the calf to expose the Achilles tendon.

To reach the lateral side, the subtalar joint must be opened like a book or a separate lateral incision must be made.

Carroll Medial and Posterolateral Incisions

The Carroll types of incisions allow medial or more posterolateral access (TECH FIG 2).

For the medial incision, a triangle is cut that is demarcated by the center of the os calcis, the front of the medial malleolus, and the base of the first metatarsal.

The incision is made parallel with the base of the triangle, then curved proximal-plantar, and then curved distally over the dorsum of the foot.

For the posterolateral incision, an oblique incision is created that runs from the midline of the distal posterior calf to a point between the tendo Achilles and the lateral malleolus.

A lateral incision may be required to reach the lateral talonavicular joint.

 

 

 

 

TECH FIG 1 • The medial Turco incision.

 

 

 

TECH FIG 2 • The Carroll incision. A. Medial. B. Posterior. C. Lateral.

 

 

 

TECH FIG 3 • The Cincinnati incision. A. Medial. B. Posterior. C. Lateral.

 

Cincinnati Incision (Author's Preferred Incision)

 

The Cincinnati incision provides the most extensive access to the foot, including medial, posterior, and lateral access (TECH FIG 3).

 

The incision begins medially over the talonavicular joint, extending posteriorly at the level of the subtalar joint. It is continued distally to the talonavicular joint laterally and may be extended distally on both the medial and lateral sides.

 

The Cincinnati incision is most easily performed with the patient prone. Flexing the knee provides excellent access to the Achilles tendon for Z-lengthening.

 

 

For severely deformed feet (equinus), closure may be difficult.

 

• Posterior Soft Tissue Release

   

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  In the exsanguinated prone foot, the posterior portion of the Cincinnati incision is made from the distal tip of the medial malleolus around the posterior ankle to the distal tip of the lateral malleolus.

   

  The Achilles tendon sheath is incised to expose the Achilles tendon. In a child younger than 18 months, the tendon can be lengthened by tenotomy, but in the older child, it should be lengthened by Z-lengthening.

   

  To facilitate visualization for a Z-lengthening of the Achilles through the Cincinnati incision, the knee is flexed in the prone patient. With the Cincinnati incision, the surgeon is looking at the plantar aspect of the foot and through the incision and tendon extending up the calf.

   

  The Achilles tendon is lengthened in Z-plasty fashion, releasing the insertion of the distal half of the tendon at the medial side of the calcaneus to reduce the varus force. Fibrotic bands and tendon sheath should also be released.

   

  If the Achilles lengthening is not sufficient to restore the anatomy, the posterior aspects of the subtalar and ankle joints are sequentially released.

   

  The first step is to identify and protect the sural nerve and vessels laterally and the posterior tibial neurovascular bundle medially. The flexor hallucis is then identified posteromedially and protected. The peroneal tendons are also identified and protected (TECH FIG 4).

   

  The ankle capsule is noted and incised from the posteromedial to the posterolateral corners to allow dorsiflexion of the talus in the mortise.

   

  The subtalar joint is found and incised posteriorly, then medially and laterally to the interosseous ligament. The fibulotalar and fibulocalcaneal ligaments can be released as needed.

   

  This release should allow the ankle joint to dorsiflex at least 20 degrees. If the hallux is tightly flexed, the flexor hallucis can be lengthened through this incision by Z-lengthening.

   

   

   

  TECH FIG 4 • Posterior portion of the Cincinnati incision. The Achilles tendon has been cut for lengthening and retracted. (Copyright .)

• Medial Soft Tissue Release

   

  Medial release is undertaken if the posterior release as described earlier does not correct the anatomy.

   

  First, the posterior portion of the Cincinnati incision is extended medially to the medial aspect of the navicular.

   

  The posterior tibial neurovascular bundle is protected while releasing any thickened fascia as well as the flexor hallucis, which may have been lengthened through the posterior part of the incision.

   

  The posterior tibial tendon is located just distal to the flexor digitorum tendon and is lengthened using a Z-plasty as necessary.

   

  The abductor hallucis muscle is lengthened proximally or distally. The flexor digitorum tendon is identified just anterior to the posterior tibial neurovascular bundle and lengthened in notch fashion as necessary (TECH FIG 5).

   

  Deciding whether to lengthen the anterior tibialis tendon can be difficult. If the anterior tibialis tendon appears contracted on anatomic correction, it should be lengthened in a Z-lengthening. Occasionally, the anterior tibialis tendon remains overactive and will need to be lengthened at a future time.

   

  A helpful hint for the lengthening of the tendons on the medial side of the foot: Each of the ends of the lengthened tendons should be tagged with suture, which is then held in a color-coded bulldog clamp. Each group of the proximal and distal sets of clamps can then be held in proper order by a safety pin. This will avoid confusion when it is time to repair the tendons after anatomic realignment of the foot is accomplished.

   

  Release of the plantar fascia has been recommended in the past but is currently avoided because it can contribute to later pes planovalgus. Do not release the plantar fascia in cases of rocker-bottom deformity during the casting.

   

  Care should be taken to avoid injury to the medial plantar vessels and nerve.

   

  If lengthening of these tendons does not permit anatomic alignment, follow this addendum:

   

  Identify and release the talonavicular joint. The navicular is medially displaced on the talar head, making the talonavicular joint obliquely, rather than transversely, oriented.

   

  Follow the distal stump of the Z-plasty-lengthened posterior tibial tendon to its insertion on the navicular.

   

  The capsule is released medially, plantarly, and dorsally and as far laterally as can be reached safely. Be careful not

   

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  to cut the talar neck, as this may lead to avascular necrosis or growth disturbances.

   

   

   

  TECH FIG 5 • Medial portion of Cincinnati incision, superficial. (Copyright .)

   

   

  Release the subtalar capsule from the talonavicular joint to the interosseous ligament medially, including the spring ligament. Be careful not to damage the deep deltoid ligament. A Freer elevator placed into the ankle joint posteriorly can help identify the ankle and subtalar joints.

   

  Reach the medial aspect of the calcaneocuboid joint by carefully dissecting the soft tissues from the plantar aspect of the talar neck. Release of this capsule will allow a wedge opening of the calcaneocuboid joint to straighten the lateral column. Another landmark to the calcaneocuboid joint from the medial side of the foot is the peroneus longus tendon crossing from lateral to plantar.

   

  Many authors have described release of the interosseous ligament through this incision. It is important to preserve this ligament as a pivot axis and to preserve its associated blood supply to the talus.

• Lateral Soft Tissue Release

   

  A problem often occurs when the calcaneus has rotated under the talus on the interosseous membrane and is tethered by a stiff, fibrotic lateral capsule. If the above posterior and medial releases do not permit anatomic alignment, a lateral release may be needed.

   

  The posterior portion of the Cincinnati incision, made for the posterior release, is extended laterally at the level of the subtalar joint to the talonavicular joint.

   

  The extensor digitorum brevis is identified over the sinus tarsi. Its plantar edge is divided from the lateral calcaneus and the muscle is elevated to expose the sinus tarsi and neck and head of the talus.

   

  The lateral capsule of the talonavicular joint is exposed and released. A circumferential release of the talonavicular joint is thus completed (TECH FIG 6).

   

  The beak of the calcaneus is then palpated. From the lateral aspect of the talonavicular joint, cut the lateral subtalar capsule, between the beak of the calcaneus and the talar neck, proximally to the interosseous ligament, completing circumferential release of the subtalar capsule.

   

   

   

  TECH FIG 6 • Lateral portion of the Cincinnati incision showing the lateral structures. (Copyright .)

• Realignment of the Bones of the Foot

   

  Once the appropriate soft tissues have been released, the foot can be realigned.

   

  A finger is placed over the talar head dorsolaterally while the foot is laterally rotated in slight supination. This is similar to the Ponseti manipulation.

   

   

   

  TECH FIG 7 • A. Subtalar rotation of the foot. The Freer elevator is in the ankle joint and demonstrates the alignment of the ankle joint. The foot is medially rotated through the subtalar joint. B. The reduced foot is held in place with a pin through the talonavicular joint. Heel is in slight valgus. (Copyright .)

   

   

  A Freer elevator can be placed in the ankle joint in line with the dome of the talus (axis of the talus). The foot should be rotated until the first metatarsal is just lateral to the talar dome axis.

   

   

  This maneuver should correct the lateral border to straight and the heel into slight valgus and reduce the talar head under the navicular (the navicular should be slightly proud to palpation as in normal feet), without wedging open the subtalar joint (TECH FIG 7).

   

• Fixation

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  Holding the foot in the anatomically corrected position until the capsules and tendons heal is best done with a 0.062-inch Kirschner wire, which is passed from the posteromedial talus through the center of the head and into the navicular and the medial cuneiform and out the first web space (TECH FIG 8A).

   

  Intraoperative radiographic images should be obtained at this point to confirm that all components of the reduction have been obtained (TECH FIG 8B,C).

   

   

   

  TECH FIG 8 • A. The foot of a prone patient positioned for posteroanterior (PA) and lateral intraoperative radiographs. B,C. AP and lateral intraoperative radiographs with internal fixation. On the lateral view (B), the talus points into the first metatarsal, and on the AP view (C), the talus points just medial to the first metatarsal. (Copyright .)

   

   

  All of the joints should be congruous. Wedged-open joints may indicate incomplete release of bone deformity, requiring osteotomy.

   

  Proper reduction should result in near-normal motion of the ankle. The fixation pin restricts the foot motion.

   

  If division of the interosseous ligament has been performed (rarely needed in the author's experience), a second pin should be placed from the calcaneus into the talus to maintain the alignment of the subtalar joint.

• Repair of Tendons

   

  Once the foot is anatomically aligned, the tendons are repaired with the foot at 90 degrees to the tibia.

  Bunnell-type stitches are used for end-to-end repair of tendons and four to six simple stitches in a side-

  to-side pattern of 2-0 or 3-0 Vicryl suture for Z-plasty-type lengthening of tendons.

  Do not repair the tendons until the bones have been realigned anatomically. Repairing the tendons at too short a length will result in rapid recurrence.

  Capsules and ligaments should not be repaired surgically. They will heal.

   

   

   

  PEARLS AND PITFALLS

   

  Medial release

  • Failure to lengthen flexor hallucis longus, flexor digitorum longus, and peroneus longus tendon may lead to failure to adequately rotate the subtalar joint or to rapid recurrence of deformity. The preservation or repair of the tendon sheaths is not of value. As long as all the tethers and blocks to motion are removed, a flexible foot and ankle can result.

 

Fixation ▪ The surgeon should not overreduce the talonavicular joint. Lateral overcorrection will cause valgus dorsal overcorrection. This later will cause dorsolateral subluxation with cavus and metatarsus adductus; incomplete medial and plantar reduction will cause incomplete correction of equinovarus. Plantarflexion of the first metatarsal from the axis of the talus can cause permanent forefoot plantarflexion, supination, and hindfoot varus.

 

Additional bone issues

• Severe, stiffly deformed clubfeet may develop bone deformity, which can prevent adequate anatomic correction with soft tissue release alone. Posterior soft tissue release will do little for ankle stiffness due to flat-top talus. The surgeon should always obtain radiographs preoperatively for these severely deformed stiff feet. Metatarsal and talar neck osteotomies are rarely indicated in the young child.

   

  Turco incision

  • Scar contracture may cause recurrence of equinovarus deformity.

     

    Problems with correction

• Overcorrection can lead to valgus deformity; failure to correct the deformity after such releases is likely due to scarring of the lateral structures, which blocks derotation of the subtalar joint.

 

 

 

POSTOPERATIVE CARE

 

During the first postoperative week, a Jones-type dressing is preferred to allow for swelling in children

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younger than 6 months of age. Bulky dressings and casts are recommended for children older than 6 months. Non-weight-bearing casts protect the tendon repair for 6 weeks.

 

Ponseti-type casting will help maintain the alignment. Casts should be changed at 1 week and continue for 3 months.

 

Braces are helpful for prolonged periods, if recurrence occurs or underlying neuromuscular disease has been identified.

 

After incisions, wound closure and positioning in equinus for 2 weeks allows healing and can be followed by serial casting to stretch the soft tissues to dorsiflex the ankle.

 

Pins may be removed after 4 to 6 weeks.

 

Muscle balancing is better left for a later time, after rehabilitation from extensive surgical release.

OUTCOMES

As noted previously, surgery is usually necessary only with the most resistant forms of clubfoot. Successful results can be obtained in 52% to 91% of cases, enabling most children to participate in normal activities.5

Stiffness, recurrence, and weakness are common, and no treatment known today can correct the underlying neuromuscular causes.

The incidence of a poor outcome is higher in children who have surgery before 6 months of age. Waiting to treat young patients may be beneficial because it allows for growth of the anatomy as well as time to

fully evaluate the case.1

These children should be referred to centers with the most experience.

 

 

COMPLICATIONS

The challenges that this deformity presents ultimately may lead to a variety of complications1: Skin slough and wound dehiscence

Neurovascular complication

Physeal damage Osteonecrosis of the talus

Aseptic necrosis of the navicular Failure to achieve or loss of correction Overcorrection or undercorrection Hindfoot valgus

Forefoot abduction or adduction Calcaneus deformity

Pes planus Persistent equinus Heel varus

Dorsal forefoot subluxation with apparent cavus Skew foot

Dorsal bunion Claw toes

 

Anesthetic foot Sinus tarsi syndrome Restricted motion

Reduced calf girth and foot size Recurrence of the deformity

Neuromuscular abnormalities, growth disturbances, and simple muscular or mechanical imbalance can lead to recurrence or overcorrection throughout the growth period. Stretching, bracing, casting, and even additional surgery may be needed.

 

 

REFERENCES

1. Crawford AH, Gupta AK. Clubfoot controversies: complications and causes for failure. Instr Course Lect 1996;45:339-346.

    

    

2. Miedzybrodzka Z. Congenital talipes equinovarus (clubfoot): a disorder of the foot but not the hand. J Anat 2003;202:37-42.

    

    

3. Noonan KJ, Richards BS. Nonsurgical management of idiopathic clubfoot. J Am Acad Orthop Surg 2003;11:392-402.

    

    

4. Ponseti IV, Zhivkov M, Davis N, et al. Treatment of the complex idiopathic clubfoot. Clin Orthop Relat Res 2006;451:171-176.

    

    

5. Rochon M, Eddleman K. Controversial ultrasound findings. Obstet Gynecol Clin North Am 2004;31:61-99.

    

    

6. Roye DP Jr, Roye BD. Idiopathic congenital talipes equinovarus. J Am Acad Orthop Surg 2002;10(4):239-248.

    

    

7. Tachdjian MO. The Child's Foot. Philadelphia: WB Saunders, 1985:139-239.

    

    

8. Turco VJ. Current Problems in Orthopaedics: Clubfoot. Hartford, CT: Churchill Livingstone, 1981:xi-xii.