Clubfoot

Clubfoot is predominantly a hindfoot deformity caused by malalignment of the calcaneo-talo-navicular complex
The components of deformity are
- Plantar flexion of the 1st ray
- Adduction of the forefoot / midfoot on the hindfoot
- Varus and equinus of the hindfoot
- The mnemonic CAVE (cavus, adductus, varus, equinus) is useful in remembering the components of this deformity

Although numerous theories have been proposed, the aetiology is multifactorial and likely involves the effects of environmental factors in a genetically susceptible host
There is abnormal tarsal morphology
- Plantar and medial deviation of the head and neck of the talus
- Abnormal relationships between the tarsal bones in all three planes
- Contracture of the soft tissues on the plantar and medial aspects of the foot

Congenital clubfoot is seen in approximately 1/1,000 births
The risk is approximately 1 in 4, when both a parent and one sibling have clubfeet
It occurs more commonly in males (2 : 1)
Bilateral in 50% of cases

Infant demonstrates
- Forefoot cavus and adductus
- Hindfoot varus and equines
There is a range in the degree of flexibility
All patients will exhibit calf atrophy
Some cases have both internal tibial torsion and shortening of the ipsilateral extremity
A complete physical examination should be performed to rule out coexisting musculoskeletal and neuromuscular problems
The spine should be inspected for signs of occult dysraphism

Many clinicians reserve radiographs for older children with persistent or recurrent deformities
AP and lateral radiographs are most commonly used to obtain radiographic measurements to describe the malalignment between the tarsal bones
Most clinicians will hold the foot in the maximally corrected position
A common radiographic finding is "parallelism" between lines drawn through the axis of the talus and the calcaneus on the lateral radiograph, indicating hindfoot varus

Immediate non operative treatment is recommended for all infants following birth
These include techniques such as manipulation and casting (Ponseti method) or functional treatment (French method)

Ponseti method

The Ponseti method involves a specific technique for manipulation and serial casting
May be best described as minimally invasive rather than non operative
The order of correction follows the mnemonic CAVE (described above)
Weekly cast changes are performed
Overall, 5-10 casts are typically required
The most difficult deformity to correct is the hindfoot equinus
- 90% of patients will require an outpatient percutaneous tenotomy of the heel cord
- A long leg cast with the foot in maximal abduction (70 degrees) and dorsi-flexion is worn for 3 weeks following tenotomy
Then a bracing program begins
- Full time brace for 3 months
- Night-time brace for 3-5 years
A subset of patients will require transfer of the tibialis anterior tendon to the middle cuneiform for recurrence
Compliance with the splinting program is essential, as recurrence is common if the brace is not worn as recommended

French method

Functional treatment or the "French method" is performed while the baby sleeps and involves
- Daily manipulations
- Splinting with elastic tape
- Continuous passive motion (machine required)
While the early results are promising, the method is labor intensive
It remains unclear whether the technique will achieve greater popularity in the United States

Surgery

Surgical realignment has a definite role in the management of clubfeet, especially in
- Congenital clubfeet that have failed non operative or minimally invasive methods
- Neuromuscular and syndromic clubfeet that are characteristically rigid
In resistant cases, non operative methods such as the Ponseti technique may potentially be of value in decreasing the magnitude of surgery required
Common surgical approaches include
- Release of the involved joints (realign the tarsal bones)
- Lengthening of the shortened posteromedial musculotendinous units
- Pinning of the foot in the corrected position
The specific procedure is tailored to the unique characteristics of each deformity
Bony procedures (osteotomies), in addition to soft-tissue surgery, may be required for
- Older children with untreated clubfeet
- Recurrence
- Residual deformity
Triple arthrodesis is reserved as salvage for painful, deformed feet in adolescents and adults