Genetic Factors
The incidence of clubfoot varies widely with respect to race
and gender and increases with the number of affected relatives, suggesting
that the etiology is at least partly influenced by genetic factors1. The incidence among different races
ranges from 0.39 per 1000 among the Chinese population to 1.2 per
1000 among Caucasians to 6.8 per 1000 among Polynesians2,3p. Lochmiller et al. recently reported
a male-to-female ratio of 2.5:14.
Siblings of affected individuals have up to a thirtyfold increase
in the risk of clubfoot deformity. Clubfoot affects both siblings
in 32.5% of monozygotic twins but in only 2.9% of
dizygotic twins5. Lochmiller et
al. reported that 24.4% of affected individuals have a
family history of idiopathic talipes equinovarus4.
Histologic Anomalies
Almost every tissue in the clubfoot has been described as being abnormal6.
Ultrastructural muscle abnormalities were identified by Isaacs et
al.7. Handelsman and Badalamente demonstrated an increase in type I:II
muscle-fiber ratio from the normal 1:2 to 7:1, suggesting a possible
link to a primary nerve abnormality8.
Conversely, Bill and Versfeld were unable to demonstrate neuropathic
or myopathic changes in untreated clubfeet with electromyographic
studies9.
A primary germ plasm defect of bone resulting in deformity of the
talus and navicular was suggested by Irani and Sherman in 196310. Defects in the cartilage of clubfeet
were demonstrated by Shapiro and Glimcher11.
Ionasescu et al. identified increased collagen synthesis in clubfeet12.
Ippolito demonstrated deformity of the talus, with medial angulation
of the neck and medial tilting and rotation of the body of the talus13. Together with medial tilting and rotation
of the calcaneus, these deformities accounted for the varus deformity
of the hindfoot, which in turn accounted for the supination of the
forefoot. In a study by Davidson et al., magnetic resonance imaging
studies demonstrated plantar flexion and varus angular deformity
of the talus, calcaneus, and cuboid in the infant’s clubfoot14.
Ippolito and Ponseti proposed a theory of retraction fibrosis
of the distal muscles of the calf and the supporting connective
tissues6. In a more recent anatomic
and histologic study, Ippolito demonstrated increased fibrosis of
muscle tissue in four aborted fetuses with clubfoot13.
Deitz et al. identified a reduction in cell number and cytoplasm
in the posterior tibial tendon sheath compared with that in the
anterior tibial tendon sheath, suggesting a regional growth disturbance15.
Zimny et al., in an electron microscopic study of the fascia from
the medial and lateral sides of clubfeet, suggested that myofibroblasts
might contribute to contracture and deformity16.
Sano et al. performed immunohistochemical analyses and electron
microscopic studies of forty-one biopsy specimens from the clubfeet
of patients who were six to thirty months old17.
Contractile proteins and a gradation of cells from fibroblasts to myofibroblasts
were observed. The authors suggested that this pattern showed similarities
to a healing process and that the presence of the proteins and cells indicated
a cause both for the clubfoot deformity and for the common recurrence
of the deformity after surgery.
Vascular Anomalies
Hootnick et al.18, as well
as Sodre et al.19, observed that
the majority of clubfoot deformities were associated with hypoplasia
or absence of the anterior tibial artery. Hootnick et al. suggested that
vascular dysplasia might have a causal relationship to the clubfoot
deformity18. Muir et al. found
a substantially greater prevalence of the absence of the dorsalis
pedis pulse in the parents of children with clubfoot20.
Anomalous Muscles
Turco identified anomalous muscles in about 15% of his
patients with clubfoot3. Porter
recently described an anomalous flexor muscle in the calf of five
children with clubfoot21. He also
observed that patients with this anomalous muscle had a greater
frequency of first-degree relatives with clubfoot. Chotigavanichaya
et al. reported the case of a patient in whom clubfoot could be
corrected only after release of an accessory soleus muscle22.
Intrauterine Factors
Hippocrates suggested that the foot is held in a position of equinovarus
by external uterine compression and oligohydramnios3. However, Turco suggested that it
is unlikely that such increased pressure would repeatedly produce
the same deformity, especially when there is plenty of room in the
uterus at the time that a clubfoot forms (in the first trimester).
In a review of the literature and of the cases of his own patients,
Turco observed that there were as many left as right clubfeet, despite
the asymmetrical positioning of the fetus in the womb. This finding
suggests that positioning is not a factor.
Bohm described four stages of fetal development of the foot23. He suggested the possibility that
clubfoot represented an interruption in the development of the normal
foot. However, medial displacement of the navicular, which is common
in clubfoot, is not seen at any stage in the normally developing
foot. Kawashima and Uhthoff studied the anatomy of the human foot from
the eighth to the twenty-first intrauterine week in 147 specimens24. Their results suggested that the normal
foot appears to be similar to a clubfoot during the ninth week of
gestation. They suggested that an interruption in development might
be responsible for the deformity.
In recent studies of the complications of amniocentesis, an association
has been observed between clubfoot and early amniocentesis (prior
to the eleventh week). Farrell et al. reported that the rate of
clubfoot after amniocentesis was 1.1%, approximately ten
times higher than the rate of 0.1% associated with all
live births25. The risk of bilateral
deformity was noted to be about the same as that in the general
population of patients with clubfoot. When early amniocentesis was
associated with an amniotic fluid leak, the risk of clubfoot deformity increased
to 15% from 1.1% when leakage did not occur. Farrell
et al. postulated that some event during early amniocentesis with
fluid leakage stops the development of the foot at a time when the
foot is in the clubfoot position. They observed that persistent
oligohydramnios was not seen on subsequent ultrasound studies. Farrell
et al. also postulated that altered pressure from the leak could
alter the developmental process. The CEMAT (Canadian Early and Mid-Trimester
Amniocentesis Trial) Group25 did
not find the same association with clubfoot and suggested that the
amount of fluid removed at the time of amniocentesis might be responsible
for the difference between their findings and those of Farrell et
al.
Robertson and Corbett retrospectively reviewed the medical records
of 330 children who were born with an uncomplicated clubfoot deformity
and found that the mean month of conception of these children was June,
a finding at variance with the peak months of conception for the
overall population of the United States for the same period26. They theorized that an intrauterine
enterovirus infection with peak rates in the summer and fall could
cause anterior horn-cell lesions at the appropriate stage of fetal
development, leading to a deformity such as congenital clubfoot.
It is important to examine the entire body of a patient with clubfoot.
Associated anomalies of the upper extremities, back, and legs as
well as abnormal reflexes can provide information about the etiology
of the deformity and the likelihood of successful treatment.
A standardized examination of the clubfoot should be performed initially
and after each interval of treatment with manipulation and a cast.
A reference point, usually the knee in 90° of flexion, must be chosen
for the examination of the foot. Torsional alignment, varus and
valgus, and the overall size and shape of the leg, ankle, and foot
should be assessed. Torsion is difficult to assess clinically in
a patient with clubfoot because the medial malleolus is obscured
by the navicular. The congenital clubfoot is generally shorter and
wider than the normal foot. Transverse plantar creases or clefts
at the midfoot and at the posterior part of the ankle should be
noted27. Atrophy of the calf is
an expected component of clubfoot, particularly in an older child
with severe or residual deformity.
Equinus must be assessed with the knee both in extension and
in flexion. The true contracture of the gastrocnemius-soleus muscle
complex, which crosses the knee, is indicated by the equinus measured
with the knee extended. The difference between the equinus measured with
the knee flexed and that measured with it extended indicates the
amount of stiffness in the ankle joint. The posterior aspect of
the calcaneus must be palpated carefully when the equinus is measured
because the bone may be pulled proximally away from the heel pad
(Fig. 1).
The varus or valgus position of the heel at rest and in the position
of best correction should be measured. Flexibility of the subtalar
joint is difficult to measure but may give an indication about stiffness.
The lateral border of the foot should be held in the position
of maximum correction and measured. Persistent varus, particularly
after a trial of cast immobilization, may indicate varus deformity
at the calcaneocuboid joint (medialization of the ossification center
of the cuboid as described by Simons28)
or varus deformity of the metatarsals.
The talar head should be palpated dorsolaterally at the midfoot.
The talar head usually is lined up with the patella, although in
plantar flexion. Manipulation to reduce the forefoot onto the talar
head indicates the amount of midfoot stiffness.
Forefoot supination should be noted. All deformities should be assessed
in relation to the next most proximal segment—i.e., the forefoot
on the midfoot, the midfoot on the hindfoot, and the hindfoot on
the ankle. If the hindfoot is in 30° of varus and the forefoot (the
line of the toes) is angulated 30° in relation to the tibia (Fig. 2), then the deformity
is hindfoot varus and there is no forefoot supination. Errors in
this assessment may lead the surgeon to overcorrect the forefoot
in a cast or to surgically create a pronation deformity29.
Palpation of the lateral column with the foot in dorsiflexion
can demonstrate overcorrection of the midfoot (iatrogenic rocker-bottom
foot).
Although radiographic examination has been used to demonstrate
the deformities of the tarsal bones in clubfeet, the images are
hard to reproduce, evaluate, and measure. There are several reasons
for this: (1) it is difficult to position the foot, particularly
when it is very stiff and deformed, in a standard fashion in the
x-ray beam; (2) the ossific nuclei do not represent the true shape
of the mostly cartilaginous tarsal bones14;
(3) in the first year of life, only the talus, calcaneus, and metatarsals
may be ossified (the cuboid is ossified at six months; the cuneiforms,
after one year; and the navicular, after three years and even later)30; (4) rotation distorts the measured
angles and makes the talar dome appear flattened (Fig. 3); and (5) failure
to hold the foot in the position of best correction makes the foot
look worse than it is on the radiograph.
To optimize the radiographic studies, the foot should be held in
the position of best correction, with weight-bearing, or, if an infant
is being examined, with simulated weight-bearing. Since the anteroposterior
and lateral talocalcaneal angles (Kite’s angles31) are the most commonly measured
angles, the x-ray beam should be focused on the hindfoot (about
30° from the vertical for the anteroposterior radiograph, and the
lateral radiograph should be transmalleolar with the fibula overlapping
the posterior half of the tibia, to avoid rotational distortion)
(Fig. 3).
For an older child, it may be useful to focus the x-ray beam
on the midfoot as this view allows assessment of dorsolateral subluxation
and narrowing of the talonavicular joint. Lateral dorsiflexion and
plantar flexion radiographs may be useful to assess ankle motion
and hypermobility in the midfoot.
Common Radiographic Measurements
Three measurements should be made on the anteroposterior radiograph31-33: (1) the anteroposterior talocalcaneal
angle (usually <20° in a clubfoot), (2) the talar-first
metatarsal angle (up to about 30° of valgus in a normal foot and
mild-to-severe varus in a clubfoot), and (3) medial displacement
of the cuboid ossification center on the axis of the calcaneus34-36. This apparent displacement may
represent angular deformity of the calcaneus or medial subluxation
of the cuboid on the calcaneus.
To make the lateral radiograph, the foot should be held in maximum
dorsiflexion with lateral rotation but without pronation. The x-ray
beam should be focused on the hindfoot. The foot should be positioned
with the radiographic plate placed laterally against the posterior
half of the foot. The clubfoot is bean-shaped, and placement of
the radiographic plate medially forces the foot to be rotated laterally
in the x-ray beam (Figs. 4-A and 4-B). Two measurements should be made:
(1) the talocalcaneal angle (typically <25° in a clubfoot), and
(2) the talar-first metatarsal angle. Plantar flexion of the forefoot
on the hindfoot indicates contracted plantar soft tissues or midtarsal
bone deformity (a triangular navicular).
Simons distinguishes classification from evaluation28,33. Classification involves typing the
foot by etiology, such as neurologic, teratologic, or idiopathic.
Evaluation involves measuring the foot—i.e., the size,
shape, range of motion of the joints, and radiographic angles. Both
classification and evaluation are important to the understanding
of comparative outcome studies and to the successful treatment of
each clubfoot.
Clubfeet have been evaluated in many ways, yet there is little agreement
on a standard and reproducible method. One of us (R.J.C.) and Lovell
evaluated eighty-five parameters of history, physical examination,
radiographs, and function in an interobserver study and found only twelve
parameters that were reproducible at the 80% level36. Watts noted poor reproducibility
in the interpretation and measurement of clubfoot radiographs37. Flynn et al.38 studied
interobserver reliability in the evaluation of fifty-five feet with
use of two clubfoot grading systems described by Pirani et al. and
by Dimeglio et al. They found very good reliability after an initial
learning curve but observed a lower correlation when therapists’ scores
were included.
Dimeglio et al. divided clubfeet into four groups with use of
a 20-point scale39. Points were
apportioned according to motion, with 4 points each for equinus,
varus of the heel, internal torsion, and adduction. In addition,
1 point each may be added for the presence of a posterior crease,
a medial crease, cavus, and poor muscle condition. The points were
then converted into four grades, each with implications for the
success of treatment. Grade I indicated that the clubfoot was mild
or postural, not requiring surgery; grade II, that there was considerable
reducibility; grade III, that the clubfoot was resistant but partially
reducible; and grade IV, that it was teratologic. They recommended that
grade-I feet be excluded from statistical analysis, as they tended
to improve results artificially. After excluding grade-I feet from
their own series in France, they found that 30% of the
remaining deformities were grade II, 61% were grade III,
and 9% were grade IV.
Other investigators have developed systems, some employing 100-point
scales, for the classification and assessment of function in childhood
and adulthood40-44. The reproducibility
and reliability of these systems have not been established.
The first written record of clubfoot treatment is found in the works
of Hippocrates from around 400 BC. Hippocrates recommended gentle
manipulation of the foot followed by splinting45.
The first advance in nonoperative treatment occurred in 1836, when
Guerin introduced the plaster-of-Paris cast46.
Around the turn of the century, devices such as the Thomas wrench,
which allowed the foot to be "corrected" more
rapidly through forceful manipulation, were introduced47. In 1932, Dr. Hiram Kite, recognizing
that forceful manipulation and extensive surgical releases were
harmful, recommended a return to gentle manipulation and cast immobilization
for the nonoperative treatment of congenital clubfoot48.
Principles of Nonoperative Treatment
Stretching and Manipulation
The basis upon which nonoperative techniques rest is the correction
of deformity through the production of plastic (permanent) deformation
(lengthening) of the shortened ligaments and tendons in the involved
foot. Serial manipulation and cast immobilization relies on the
viscoelastic nature of connective tissue to produce plastic deformation
through a process known as stress relaxation. Deformity is corrected
as much as possible with gentle stretching, which places the shortened
tissues under tension. As the foot is held in the maximally corrected
position by the cast, the tension in the shortened tissues decreases
over time. When the tension decreases sufficiently, more correction
can be obtained by repeating the process.
Most, but not all, advocates of nonoperative treatment of congenital
clubfoot commence manipulative treatment with stretching of the
foot. The specific viscoelastic properties of the tissues of the
congenital clubfoot relative to those of other connective tissues
do not appear to have been studied. Therefore, the duration for
which the foot needs to be stretched, the amount of force that needs
to be applied, and whether the force should be applied continuously
or intermittently are unknown. Consequently, there is controversy regarding
how much preliminary stretching of the foot should occur before
manipulative correction of the deformity is attempted. However,
all authors seem to agree that treatment should be started as early
as possible.
There are almost as many techniques for manipulative treatment
of congenital clubfoot as there are authors who write about congenital
clubfoot. Many authors have reported success rates of <50% for
nonoperative treatment. The two methods that seem to be the most
widely performed and that have the highest reported long-term success
rates are the Kite and Lovell technique49 and
the Ponseti technique50.
The Kite and Lovell technique starts with stretching of the foot through
longitudinal traction applied to the foot. Ponseti did not describe
the use of preliminary stretching.
In both the Kite and Lovell technique and the Ponseti technique, the
manipulation starts with reduction of the talonavicular joint. In
both techniques, a thumb is placed laterally in the sinus tarsi
over the head of the talus. In the Kite and Lovell technique, the
navicular is gently pushed onto the head of the talus with the index
finger of the same hand (Fig. 5). In the Ponseti technique, the other
hand is used to pull the forefoot, and the navicular along with
it, laterally onto the head of the talus. Ponseti considered it very
important to keep the forefoot supinated during this maneuver (in
truth, the forefoot is kept in line with the hindfoot, which is
initially in varus) (Fig. 6). Ponseti believed that failing
to do so, or pronating the forefoot relative to the hindfoot, produces a
cavus deformity. In the Kite and Lovell technique, a slipper cast
is applied after the talonavicular joint is reduced. As the cast
dries, the foot is molded on Plexiglas, with simultaneous pushing
of the heel out of varus and flattening of the foot to prevent cavus.
The lateral pulling of the forefoot relative to the hindfoot
in the Ponseti technique also corrects the forefoot adduction. The Kite
and Lovell technique corrects forefoot adduction by abducting the
forefoot on the hindfoot as the slipper cast dries. In this maneuver,
a finger is placed laterally over the distal end of the calcaneus
to act as a fulcrum. Ponseti termed this maneuver "Kite’s
error," contending that any force applied laterally to
the distal part of the calcaneus to correct forefoot adduction prevents
the distal end of the calcaneus from moving laterally as the calcaneus
is externally rotated out from under the talus (Fig. 7). Kite and Lovell
actually used the slipper cast to externally rotate the calcaneus
and forefoot as a unit from beneath the talus (Fig. 8). In both techniques,
the cast is then extended to the thigh while the foot is held in
external rotation.
In both the Kite and Lovell technique and the Ponseti technique, no
effort is made to correct equinus until forefoot adduction and heel
varus are corrected because an attempt to correct equinus before
correction of the other deformities leads to a rocker-bottom deformity.
According to Ponseti, if equinus persisted after the forefoot and
hindfoot were corrected, a tenotomy of the Achilles tendon was performed percutaneously
with the use of local anesthesia in the cast room and then application
of the cast was continued. Kite and Lovell preferred wedging the
cast when equinus could not be corrected after the forefoot adduction
and heel varus were corrected.
Ponseti reported that 89% of the feet had a good or
excellent result at the time of the thirty-year follow-up. However,
Achilles tenotomies were required in 70% of his patients.
In 1992, Ponseti reported a 50% rate of recurrence requiring
additional cast treatment. Deformities that recurred frequently
required lengthening of the Achilles tendon and transfer of the
anterior tibial tendon to maintain correction50.
Ponseti now reports that the recurrence rate in his patients is far
lower51. Kite and Lovell reported
that up to 95% of feet can be completely corrected without
any surgery. However, the average duration of cast treatment with
their technique is twenty-two months compared with two to four months
with the Ponseti technique52.
While the most common way to maintain the position of the foot after
manipulation is with a plaster cast, other methods have been used.
Shaw, among others, favored the use of adhesive tape and reported
a success rate of 70% with his technique53.
How often the cycle of manipulation and immobilization is repeated
varies. Most physicians change the cast and remanipulate the foot
at weekly intervals. More rapid correction has been achieved with
more frequent (daily) cast changes and manipulation.
After the foot has been corrected (usually as determined on radiographs),
it is held in the corrected position for some period of time. The
initial holding device is usually a cast, and after two to four
weeks of such treatment, the patient is frequently managed with
braces. Kite used a Phelps splint, which was worn until the age
of ten years. Ponseti recommended that a Denis Browne bar be worn
until the age of two to four years. Currently many surgeons discontinue splinting
after the child is able to walk independently.
Newer Methods of Nonoperative Treatment
For some time, there has been an interest in nonoperative methods that
emphasize motion and minimize immobilization. In 1937, Denis Browne54 introduced a technique, which was
modified in 1942 by Thomson55,
in which the child’s own "physiologic motions" were
used to correct the foot through a dynamic mechanism. The technique
consisted of the application of corrective shoes that were then
attached to a bar. The attachment of the shoes to the bar allowed
progressive external rotation of the feet. While the feet were in
this apparatus, the constant kicking by the infant stretched the
contracted tissues, thereby correcting the deformity. Recently,
Yamamoto and Furuya reported on a series of ninety-one clubfeet
treated with a modified Denis Browne splint56.
Sixty feet were corrected without surgery, and good or excellent
correction was maintained at an average of six years and three months
after treatment.
Bensahel et al. developed a nonoperative technique involving manipulation
of the foot by a physical therapist57,58.
Each manipulative session lasts thirty minutes and is followed by taping
of the foot to a wooden splint. This treatment is performed daily
for up to eight months. Bensahel et al. reported that 48% of
their patients had a good result.
Dimeglio et al. described what would seem to be the ultimate stretching
treatment for congenital clubfoot—i.e., continuous passive
motion59. As with the Bensahel
method, the foot is manipulated by a physical therapist for thirty
minutes. After the manipulation, the foot is placed in a machine
that performs stretching (continuous passive motion). Treatment
is usually started at about two weeks of age. The machine is adjusted
each day on the basis of an examination of the foot. The foot is
maintained in the machine for up to eight hours each day. After
each session, a splint is applied to hold the foot in the maximally
corrected position until the next day. Dimeglio et al. reported
that, in a series of 216 feet, forty-five had to be excluded because
the children’s parents were "noncompliant" and
68% of the remaining feet were deemed to have a successful
result59. It is important to note
that "success" did not necessarily mean that no
surgery was required. Treatment was deemed to be successful if the
required surgery proved to be less extensive than that predicted
to be necessary on the basis of the examination of the foot before
treatment was started. It was possible to avoid surgery on the lateral
side of the foot in 32% of the feet that required surgery.
Johnston and Richards recently reported their results with what they
termed the French method60. In
their study, forty-eight feet were treated with a regimen of stretching
exercises. A continuous-passive-motion machine was not utilized.
Thirty-six feet were successfully treated without surgery, nine
required minimal surgery, and three required a comprehensive soft-tissue release.
In a follow-up study, Richards et al. found the French technique
to be more effective than traditional manipulation and immobilization
in a short-leg cast61. Ponseti,
commenting on the later study, noted that short-leg casts, used
by Richards et al., were in his experience less effective than long-leg
casts.
An interesting adjunct to the French technique as described by Johnston
and Richards has recently been reported. Delgado et al. injected
Botox (botulinum toxin type A) into the gastrocnemius-soleus and
posterior tibial muscles of three infants with congenital clubfoot
that had been incompletely corrected by the French method62. After the injections, additional correction
was obtained with continued nonoperative treatment. The rationale
for the use of Botox appears to be that a reduction of tone in the
most contracted muscles might facilitate their lengthening by manipulative
stretching. Determining whether such pharmacologic intervention
is useful will require additional study.
Another process that can be used to produce plastic deformation
of soft tissues is known as creep. Creep occurs when tendons and ligaments
elongate as a result of a continuous stretching. Creep can be produced
by dynamic splinting, which has been found to be helpful when used
in conjunction with serial manipulation and cast treatment63. We have been unable to find reports
on the use of dynamic splinting as a primary nonoperative treatment
modality. Skin irritation and, on occasion, skin breakdown may limit
the usefulness of this technique.
Despite our best efforts, some clubfeet cannot be completely corrected
with nonoperative treatment. In such feet, soft-tissue release is
clearly indicated.
Preoperative Assessment
All clubfeet are not the same. Therefore, it is important to assess
the foot carefully to determine the components of the deformity
that remain. Once that has been done, the surgeon must think about
what anatomical structures contribute to each component of the deformity. Obviously,
those are the structures that need to be addressed at the time of
surgery. A foot in which all components of the deformity are still
present likely requires a full posteromedial plantar lateral release.
If the clinical examination indicates a flexible forefoot and midfoot
with a straight lateral border and a palpable interval between the
tuberosity of the navicular and the medial malleolus but a persistent
equinus, then a posterior release may be all that is needed.
Radiographic assessment of the foot complements the clinical examination.
Radiographs can be used to determine the relationship between the
talus and the calcaneus in both the anteroposterior and lateral
planes. The radiographs reveal whether there is subluxation of the
talonavicular joint and the calcaneocuboid joint and whether the
foot has a cavus component. The lateral radiograph can reveal the
degree of persistent equinus in the ankle.
We believe very strongly in the "à la carte" approach
to the clubfoot as described by Bensahel et al.—i.e., do
only what is necessary to get a good correction of the foot64.
Age
Most surgeons have one of two opinions concerning the optimum
age at which surgery should be performed. Advocates of "early" treatment
perform the surgery when the patient is between three and six months
of age65. They argue that there
is a great deal of growth in the foot, and therefore a lot of remodeling potential,
during the first year of life. In contrast, advocates of "late" treatment
prefer to wait until the child is nine to twelve months of age66. They believe that, because the components
of the foot are larger, the pathoanatomy is more obvious and the
surgery is easier to perform. Also, because the child is old enough
to walk, early weight-bearing may help to prevent recurrence of
deformity. Simons recommended that the size of the foot, rather
than the age of the patient, be used to determine the optimum time
to perform the surgery67. He stated
that the foot should be 8 cm long at the time of surgery.
Incisions
Incisions fall into one of three categories: the Turco oblique
or hockey-stick posteromedial type of incision3;
the circumferential incision, more commonly referred to as the Cincinnati
incision68; and the two-incision
or Carroll approach69. Each has
its own limitations. The Turco incision crosses the skin creases
on the medial side of the foot and ankle. It is certainly more difficult
to reach the posterolateral structures, such as the talofibular
and calcaneofibular ligaments, through this incision. The origin
of the plantar fascia may also be a challenge to expose and release.
The Cincinnati incision has the potential for creating problems
with the skin edges. It has also been criticized for limited exposure
of the Achilles tendon. The criticism of the Carroll approach is
that it can limit the correction of the equinus and/or
varus deformity because of the posteromedial skin tether. We prefer
the Cincinnati incision.
Medial Plantar Release
The abductor hallucis muscle is the guide for the initial part
of the procedure. As long as the surgeon cuts on top of the muscle,
no vital structures will be damaged. It should be followed proximally
to its origin from the calcaneus. As it is exposed proximally, some
thickened fascia that crosses the muscle in a vertical direction
may be encountered. The fascia is divided, and the abductor hallucis
is released from the calcaneus. The part of the origin that passes
between the medial and lateral neurovascular bundles and attaches
to the sustentaculum tali must also be released. The muscle is then reflected
distally. The motor branch from the medial plantar nerve can be
cut without important consequences. Dividing the laciniate ligament
then exposes the medial plantar neurovascular bundle. Careful dissection
is continued distally to the forefoot. An artery and two small veins
cross the nerve in the midfoot. They can be cauterized and divided.
The lateral plantar bundle is then identified. The main calcaneal
branch is the most posterior structure. The bundle is protected
by a 0.25-in (0.64-cm) Penrose drain. The interval between the vein
and the calcaneal branch is a safe area in which to approach the
origin of the plantar fascia and the short toe flexors. Their origins
are divided across the plantar aspect. Obviously, this release is
done only when the deformity is thought to have a cavus component67.
The next structures to be identified are the tendons of the flexor digitorum
longus and flexor hallucis longus. They are followed distally past
the master knot of Henry and proximally above the ankle joint. As
the flexor hallucis longus passes under the sustentaculum tali,
there is a thick retinaculum to be divided. McKay described preservation
of the sheaths of these tendons70.
The dissection continues on the plantar aspect of the foot. The tendon
of the peroneus longus is identified and is carefully released from
its sheath as far as the lateral border of the foot. This tendon
passes around the lateral border at the level of the calcaneocuboid
joint. It must be carefully protected. Many surgeons make the mistake
of looking for the calcaneocuboid joint too distally. Care must
be taken as it is very easy to create a joint by cutting through
cartilage. Once the joint has definitely been identified, it should
be released medially and plantarly. A thin elevator such as a Freer elevator
can then be used to fenestrate the lateral part of the capsule.
The medial part of the capsule and the spring ligament are divided,
which also helps to identify the medial-inferior portion of the
talonavicular joint. By lifting up the tendons and bundle, the medial
portion of the talocalcaneal capsule can be identified and released.
Care must be taken not to start the release too far posteriorly,
where the ankle and subtalar joints are close together, as it is
easy to mistake the subtalar joint for the ankle joint. The risk
is that the deep deltoid ligament could be divided completely. Care
should also be taken not to damage the sustentaculum tali.
The tendon of the tibialis posterior is then identified above
the ankle joint. The sheath is carefully divided longitudinally. Some
of the retinaculum is preserved as a bridge distally. A z-plasty
of the tendon is carried out, and the distal stump is pulled through
the retinacular bridge. Finding the talonavicular joint can be somewhat
challenging. It is critical to remember that the plane of this joint
is paralleling the medial aspect of the talar neck. The inferior
portion may be approached first. Distraction of the joint by pulling
on the insertion of the tibialis posterior helps in the release.
The dorsal structures, such as the tibialis anterior, the extensor
tendons, and the neurovascular structures, must be protected. As
the capsule is released dorsally, care must be taken not to divide
the deep deltoid ligament and to avoid the dorsum of the neck of the
talus. Both of these areas contain important blood supplies to the
talus. The talonavicular joint capsule should be fully divided dorsally,
medially, and plantarly. The Freer elevator can be used to fenestrate
the lateral aspect of the capsule. Carroll also suggested division
of the slips of the tibialis posterior that run forward to attach
to the undersurfaces of the cuneiforms and the bases of the second, third,
and fourth metatarsals71. The
medial plantar release should then be complete (Fig. 9).
Posterior Release
As the posterior part of the skin incision is made, it is important not
to cut too deeply. The Achilles tendon is exposed as far proximally
as possible. A z-plasty is performed, detaching the medial end distally,
to reduce the tendency of the tendon to pull the heel into varus.
McKay stated that he preferred to lengthen the Achilles tendon with
a coronal z-plasty70.
The structures that pass behind the medial malleolus have already
been identified and protected. The lateral structures now need to
be dissected. The sural nerve is found and protected. The peroneal
tendons are exposed, and the sheath is divided distally, beginning
at the tip of the lateral malleolus. The sheath should not be divided proximal
to that level, if possible, to prevent later subluxation of the
tendons anterior to the lateral malleolus. The talocalcaneal joint
is opened first. The release has already been performed medially
and is now continued posteriorly and laterally. With retraction
of the lateral structures, the calcaneofibular ligament is divided.
This is an important part of the procedure as this ligament tethers
the calcaneus to the fibula. It would be impossible to rotate the
calcaneus into the corrected position without this release. The
lateral capsular release is continued as far as can be seen from
the posterior perspective. Then the ankle joint is carefully approached.
If the ankle is in substantial equinus, not much of the posterior part
of the talar body is between the calcaneus and the tibial plafond.
Care must be taken not to enter the distal tibial physis while looking
for the ankle joint. The ankle joint capsule is released from the
posteromedial corner of the body of the talus to the posterolateral
corner. It is easy to mistake the lateral surface of the talus for
the posterior surface and therefore carry out an extensive lateral
release rather than a posterior release. The posterior talofibular
ligament should be divided. Some authors have also recommended the
release of the posterior tibiofibular ligament to allow more room
for the body of the talus when it is brought out of equinus49.
Lateral Release
The releases described above allow for excellent correction of the
deformity in many feet. In some feet, however, there will still
be difficulty in rotating the calcaneus outwardly relative to the
talus. In these cases, a more extensive lateral release needs to be
performed (Fig. 10).
During this dissection, the sural nerve and peroneal tendons are
protected. Capsulotomies of the talonavicular and calcaneocuboid
joints should be performed, if necessary. Also, as much of the interosseous
ligament as necessary can be divided to spin the calcaneus on the talus.
We usually try to preserve at least the medial portion of this ligament.
Reduction and Fixation
The talus should be inwardly rotated slightly, and the navicular should
be reduced on the head of the talus. When the navicular is properly
reduced, the medial tuberosity should be prominent. If it is flush
with the medial aspect of the talar head and neck, it is overreduced
laterally. It should, however, be flush with the dorsum of the talar
head. According to Simons, the pin should be placed centrally in
the head and drilled in a retrograde fashion until it emerges at
the posterolateral ridge of the talus. The navicular is reduced,
and the pin is then driven across the joint67.
In the sagittal plane, the pin should be in line with the first metatarsal.
Often this is the only pin necessary to maintain the reduction.
The calcaneus needs to be rotated such that the tuberosity moves
medially away from the fibula. The cuboid needs to be reduced on
the end of the calcaneus, and pinning may be required to stabilize
this reduction. If the interosseous ligament has been completely released,
the subtalar joint needs to be stabilized (Fig. 11). The pin is
placed through the plantar surface of the calcaneus, across the
subtalar joint and into the talus. It should not pass into the ankle
joint. Care should be taken to ensure that the calcaneus is not
tipped into varus or valgus.
Intraoperative Assessment
Once the reduction and pinning have been completed, the degree of
tightness of the toe flexors should be assessed. If the toes cannot
be brought easily to the neutral position, the flexor digitorum
longus and/or the flexor hallucis longus should be lengthened.
The position of the foot should be checked with the knee in 90°
of flexion. It must be plantigrade without a varus, valgus, supination,
or pronation deformity. The thigh-foot axis should be outwardly
rotated 0° to 20°.
There is a difference of opinion about the value of intraoperative radiographs.
Some surgeons use them, and others believe that radiographs are
not necessary if the foot is carefully positioned and clinically
assessed at the end of the procedure49.
If there are any doubts about the quality of the reduction on clinical
examination, radiographs can help to determine the site of the problem.
If the reduction is not satisfactory, the pins must be removed and
the foot, repositioned.
The distal stump of the tibialis posterior tendon is then pulled back
under the bridge of the retinaculum. It is sutured under some tension
to help to prevent the tendency for an overcorrected planovalgus
foot to develop. If the flexor hallucis longus and flexor digitorum
longus tendons have been lengthened, they are repaired without tension.
The Achilles tendon is repaired with the ankle in 10° of plantar
flexion so that there is some tension on it when the foot is in
the neutral position.
Wound Closure
Some surgeons allow the foot to return to an equinovarus position and
close the skin completely. A manipulation is planned for one to
three weeks postoperatively to bring the foot up into the neutral position.
Other surgeons position the foot in the neutral position, approximate
the skin medially and laterally, and leave a skin gap posteriorly.
Gaps as large as 2 to 3 cm have been left with good healing and
minimal scarring72. The wound
is dressed, and some form of immobilization, which varies from a
soft dressing to a full above-the-knee cast, is applied. Some surgeons
bivalve the cast, and others do not.
Postoperative Management
We use either a continuous epidural block, begun after intubation,
or a "one-shot" caudal block at the end of the
procedure. We have been impressed with the comfort provided to the child,
and, as of the time of writing, there have not been any complications
attributable to these blocks.
At one week postoperatively, the child is sedated, the postoperative
dressing is removed, and the wounds are inspected. The foot is held
in the neutral, plantigrade position, and a cast is applied. The
knee is held at 90° of flexion, the foot is outwardly rotated, and
the cast is extended above the knee. The cast is worn for four to
six weeks, after which the child returns to the clinic, the pin or
pins are removed, and an ankle-foot orthosis is fitted. The orthosis
is worn for six months, and the foot is then reevaluated.
The objective of clubfoot surgery is to obtain a complete and
lasting correction with one operation. However, about 25% (range,
13% to 50%) of the feet have a recurrence73,74. The most common persistent deformities
are forefoot adduction and supination. However, varus, equinus,
cavus, and overcorrection of the heel have all been reported following
clubfoot surgery75. Recurrence
of one or more components of the clubfoot deformity may result from
an incomplete correction, failure to maintain correction, tarsal
bone remodeling, abnormal scar formation with tethering of tendons, and
tarsal coalition that was either iatrogenic or missed during the
surgical procedure74.
Preoperative Evaluation
A rating system has been developed to determine the need for revision
surgery. Scores of <60 points (of a possible total of 100 points)
indicate the need for revision (Fig. 12).
The preoperative radiographic evaluation includes anteroposterior
and lateral radiographs of the foot in maximum dorsiflexion as previously
described32,33. In addition, when
the previously described radiographic angles are measured, the radiographs
should be reviewed for other changes, including subluxation of the
tarsal navicular, flattening of the trochlear surface of the talus,
and shortening of the calcaneus.
Once the clinical and radiographic evaluations are complete,
attention is turned to correction of the residual deformity. An
algorithm has been developed as a guide for the choice of which
procedure or procedures to perform (Table I)76.
Treatment of Residual Deformity
Residual Forefoot Adduction
Residual adduction is usually found at the midfoot and occasionally
at the forefoot. In patients who are less than two years old, forefoot
adduction is addressed with repeat complete soft-tissue releases77. In patients who are two to four years
old, osteotomies are not recommended because of the immaturity of
the foot. Excision of the calcaneocuboid joint cartilage or cuboid
enucleation are better options. These procedures must be combined
with a medial soft-tissue release. Cuboid decancellation preserves
the articular surface of the cuboid surface proximally and distally, while "crushing" of
the bone shortens the lateral column and corrects adduction3.
For patients who are more than four years of age, many procedures
have been described, including excision of the distal part of the
calcaneus78, fusion of the calcaneocuboid joint79, opening-wedge osteotomy of the
first cuneiform, metatarsal osteotomies, and tarsometatarsal capsulotomies80. Lichtblau, in 1973, described a medial
soft-tissue release and an osteotomy of the distal end of the calcaneus
in which 1 cm of the distal lateral border and 2 mm of the distal
medial border are removed81. He
claimed that the resected calcaneal articular surface was replaced
by fibrocartilage, and he demonstrated mobility at the calcaneocuboid
joint up to six years after surgery.
Evans, in 1961, described a procedure consisting of posteromedial
releases in conjunction with lateral calcaneocuboid wedge resection
and fusion79. The procedure is
not recommended for children under four years of age because of
possible overcorrection. The correction of adduction occurs at the
level of the midfoot, not distal to the navicular79,82,83.
Accurate reduction of the navicular on the talus is essential, as the
position of the navicular is permanently stabilized by the procedure84. Only a narrow wedge from the calcaneocuboid
joint should be removed; otherwise, overcorrection into valgus may
occur79,82,83. The operation decreases
growth of the lateral column of the foot. Satisfactory long-term
functional results have been documented in 60% to 80% of
the patients managed with the procedure79,82.
Fowler et al.85, in 1959, described
an opening-wedge osteotomy of the medial cuneiform, and Hofmann
et al., in 1984, reported on this procedure for the treatment of
residual adduction in clubfoot85.
The Fowler procedure includes an opening-wedge osteotomy of the
medial cuneiform, a radical plantar release, and a transfer of the
tibialis anterior tendon to the dorsum of the first metatarsal. This
procedure is reserved for children who are more than eight years
old because a well-ossified first cuneiform is a prerequisite85. Supination of the midfoot is not addressed,
and the degree of correction is limited by the intact lateral column
complex of the calcaneocuboid joint.
McHale and Lenhart described a procedure for an adducted forefoot
and a supinated midfoot with hindfoot varus86.
The procedure combines an opening-wedge osteotomy of the medial
cuneiform with a closing-wedge osteotomy of the cuboid, addressing
both residual forefoot adduction and midfoot supination. The authors
showed, in a cadaver model, that a cuboid osteotomy is necessary
for correction of midfoot supination. Although hindfoot varus is
not addressed, the procedure has gained popularity and good results
have been reported87.
Köse et al., in 1999, described trans-midtarsal osteotomy88. The procedure involves an opening-wedge
osteotomy of the medial cuneiform and dorsal, truncated wedge osteotomies
of the middle and lateral cuneiforms. Osteotomy of the middle and
lateral cuneiforms allows better correction of rotational and cavus
deformities. Again, the procedure requires well-formed tarsal bones,
and it is most appropriate for patients who are more than six years
old.
Metatarsal osteotomies were described first by Steytler and Van
der Walt89, in 1966, and are indicated
when the adduction deformity originates distal to the navicular.
Care must be taken to avoid injury to the physis of the first metatarsal by
osteotomy or by periosteal stripping; otherwise, shortening of the
first metatarsal will result90.
Heyman et al. described release of the tarsometatarsal joints for correction
of resistant metatarsus adductus or for treating residual clubfoot
adduction deformity80. Through
a dorsal incision, complete capsulotomies and ligament releases
were performed. Because of reports of frequent postoperative stiffness
and pain, this procedure is not recommended.
Residual Cavus
Inadequate plantar release and muscle imbalance are both possible
causes of residual cavus deformity. Soft-tissue release should be
adequate in patients who are less than two years old. Steindler,
in 1920, described release of the plantar fascia from its insertion
at the calcaneus91.
Rigid cavus in children who are more than eight years of age
may require osteotomy of the tarsal bones or the calcaneus92. The Japas V-osteotomy, recommended
for patients who are more than six years old, allows correction
at the midfoot without shortening the foot93.
The Akron midtarsal osteotomy also allows correction at the midfoot
but utilizes a so-called dome-type osteotomy to allow dorsoplantar
and varus-valgus control94. A
more distal osteotomy, at the level of the tarsometatarsal joints,
was proposed by Jahss87. The wedge
osteotomy of the tarsometatarsal joints is not intended for patients
who have not reached skeletal maturity and requires normal vascular
and skin conditions. Arthrodesis at the hindfoot-midfoot region
has also been described92.
Residual Varus or Valgus Angulation of the
Heel
Dwyer described a calcaneal osteotomy with either an opening
or a closing wedge to address varus and cavus angulation of the heel92. Dwyer’s lateral closing-wedge osteotomy
is recommended for children who are more than four years old. The
osteotomy does not correct the deformity at its apex, which is usually
at the level of the midfoot (Fig. 13).
The extra-articular Grice procedure, originally developed for paralytic
or spastic foot deformity, can be used to treat valgus angulation
of the heel in younger patients as it does not interfere with subsequent
growth95-97. It has been successful
for flexible feet in the four-to-ten-year-old age-group. Rigid,
overcorrected feet may require repeat soft-tissue releases as well97.
Salvage Procedures
Triple arthrodesis has been used in children who are more than ten
years old and is considered a salvage procedure (Fig. 14)98. In a study of fifteen patients with
clubfoot deformity who were treated with this procedure, Adelaar
et al. noted that eleven had a good result and two each had a fair
and a poor result99. Angus and
Cowell noted that 65% of twenty-six feet with a rigid equinus
foot deformity had a poor result at an average of thirteen years
after triple arthrodesis100.
Wei et al.101 and Fogel et
al.102 reported on limited talonavicular
arthrodesis in patients who had had previous clubfoot surgery and
had talonavicular osteoarthritis with dorsolateral subluxation and
pain. The patients in the study by Wei et al.101 were
an average of eleven years old at the time of the surgery. Unlike
adults who have undergone talonavicular arthrodesis, children have
been noted to retain some subtalar motion. Fifteen of sixteen patients
reported satisfaction with the procedure after an average follow-up
of four years.
The Ilizarov apparatus has been combined with various osteotomies
to provide distraction osteogenesis for the correction of residual
deformity in the clubfoot and other foot deformities103,104. Equinus, varus angulation
of the hindfoot, midfoot adductus, and cavus may all be addressed with
the use of a circular frame and Kirschner wires. However, the potential
complications are numerous103,104.
Paley reported that treatment of twenty-five various foot deformities
with the Ilizarov apparatus resulted in twenty minor and major complications
in eighteen feet104. The patient
must understand that the final functional outcome will be a stiff
but cosmetically improved plantigrade foot.
Dynamic Forefoot Supination
Transfer of the tibialis anterior tendon has a role in the treatment of
a supple recurrent clubfoot (Fig. 15). Garceau and Palmer mentioned
several prerequisites for successful transfer of the tibialis anterior
tendon for the treatment of recurrent varus and adductus105,106. The patient must be less than six
years old and have a passively correctable deformity, weak peroneals
confirmed by electromyography, and no active abduction or eversion.
Stiff joints or strong peroneals are contraindications. Gartland
and Surgent noted that recurrence after primary correction is more
likely to respond to tibialis posterior transfer107.
Residual Toeing-in
Two alternatives for a patient who has a recurrent clubfoot with
residual toeing-in are supramalleolar tibial osteotomy and talocalcaneal
osteotomy. Hjelmstedt and Sahlstedt recommended talocalcaneal wedge osteotomy
through the talar neck and reported that 60% of the thirty-six
feet managed with the procedure had a good result, 20% had
a fair result, and 20% had a poor result108-110.
Lloyd-Roberts et al. and Swann et al. reported on a supramalleolar
tibial osteotomy with apex posterior angulation and medial rotation111,112 to correct equinus and adductus primarily.
Neither of these osteotomy procedures are in wide use.
Dorsal Bunion
Dorsal bunion refers to a plantar flexion contracture of the
first metatarsophalangeal joint with a dorsiflexion contracture
of the first tarsometatarsal joint. It can be the result of imbalance between
weak Achilles and peroneus longus tendons and strong flexor hallucis
longus and tibialis anterior tendons. One procedure described for
its correction is the "reverse Jones" procedure113, which involves transfer of the flexor
hallucis longus to the head of the first metatarsal. If necessary,
a plantar flexion first metatarsal osteotomy and capsulorrhaphy
can be included.
The Overcorrected Foot
Valgus position of the hindfoot and pronation of the forefoot characterize
the overcorrected clubfoot deformity. Multiple factors may produce
this deformity, including the release of the interosseous ligament
at the subtalar joint and division of the deep deltoid ligament.
The forefoot may be corrected nonoperatively by stretching and bracing and
operatively by metatarsal and midfoot osteotomies. Treatment of
the overcorrected clubfoot includes the use of orthoses for flexible
deformity in children who are less than four years of age and repeat
soft-tissue release for rigid deformity. Subtalar or triple arthrodesis
is recommended for a child who is more than ten years old. Combination medial
and lateral column osteotomies of the calcaneus, cuboid, and cuneiforms
have also been described114-117.
Skin Problems
Frequently, severe recurrent clubfoot deformities are associated
with difficulty in skin closure. This problem is especially true
of posteromedial wounds. Options to address the problem include
tissue expanders118-120; free
muscle flaps121; and partial wound
closure, which allows secondary healing to close a wound in order
to decrease the risk of necrosis122.
Free muscle flaps such as gracilis flaps require microvascular techniques,
but no debulking is required as shrinkage is expected. Other techniques
that may assist in wound closure are lateral skin release and z-plasty of
the skin119.
Although the etiology of congenital clubfoot remains unknown, reproducible
pretreatment grading now seems possible. However, the lack of an
agreed upon and reproducible posttreatment evaluation system still
hinders outcome studies of the treatment of clubfoot.
The literature from about 1970 to 1990 contains enthusiastic reports
on the correction of congenital clubfoot through extensive surgical
release procedures3,70,123. Over
time, we have come to recognize the complications of such surgery,
including recurrence, overcorrection, stiffness, and pain124. Perhaps because of these findings,
there seems to be a renewed interest in nonoperative techniques
for the correction of congenital clubfoot. Recent studies have documented
the effectiveness of the two leading techniques involving serial manipulation
and cast treatment. The Ponseti technique appears to be effective
and requires only a reasonable amount of time out of the lives of
the patient and his or her parents. The technique frequently includes
some minimal invasive surgery. The Kite and Lovell technique requires
minimally invasive surgery less often but is more time-consuming.
French investigators and others have introduced new ideas that may
reduce the need to immobilize the foot. The French approach requires
fairly extensive physical therapy and demands substantial parental time
and attention59. It is not yet
clear that the French technique is more successful in obviating
the need for surgery than is expertly applied serial manipulation
and cast immobilization. It also has not been proved that the long-term results
of the French technique are better than those of serial manipulation
and cast immobilization. It is probable that unless the French technique
is found to substantially decrease the need for surgery, it will
prove to be less cost-effective than serial manipulation and cast
immobilization.
It is likely that a small number of clubfeet will require surgery even
after expertly applied nonoperative treatment. However, it is hoped
that such surgery will be less extensive than procedures commonly
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