Treatment of the Complex Idiopathic Clubfoot

Abstract

Treatment with the Ponseti method corrects congenital idiopathic clubfeet in the majority of patients. However, some feet do not respond to the standard treatment protocol. We describe the characteristics and treatment results of these complex idiopathic clubfeet. We identified 50 patients (75 clubfeet) from 762 consecutive patients treated at five institutions. Clinically, complex clubfeet were defined as having rigid equinus, severe plantar flexion of all metatarsals, a deep crease above the heel, a transverse crease in the sole of the foot, and a short and hyperextended first toe. The Achilles' tendon was exceptionally tight and fibrotic up to the middle of the calf. Correction was achieved in all patients by modifying the Ponseti manipulation and casting technique. Correction required an average of five casts (range, 1-10 casts). Two patients (4%) not initially recognized as having complex clubfeet had a posterior release with tendo Achillis lengthening. There were seven relapses that responded to casting. Three patients had a second tenotomy. Modifying the treatment protocol for complex clubfeet successfully corrected the deformity without the need for extensive corrective surgery.

Ponseti Treatment for Idiopathic Clubfoot: Minimum 5-year Followup

“…This was also reported by Haft et al [14] and Lehman et al [21]. Overall, we found that 20.7% of feet required TATT; this is similar to results by Ponseti et al [27], but the need for TATT was statistically lower in patients who followed the Ponseti brace protocol.…”

“…Possible reasons can include the feet either (1) not being fully corrected before being placed in a brace or (2) the development of a relapse despite brace wear making continued brace use impossible. Various authors have suggested modifying the brace to improve brace tolerance [5,15,22,27]. In our study, late presenters were more brace-tolerant.…”

Is it Possible to Treat Recurrent Clubfoot with the Ponseti Technique After Posteromedial Release?: A Preliminary Study

“…Plaster casts were applied with careful molding and holding the talar neck while elevating the first ray and abducting the foot gradually. Long-leg casts were applied and changed every week [24]. Abduction did not always reach 70°, but there was enough abduction to get the feet plantigrade.…”

“…technique was described to treat difficult feet with substantial cavus, complex feet, resulting in fewer number of clubfeet undergoing posteromedial releases [24].…”

“…The Ponseti technique was not originally developed for use in children who had already undergone posteromedial releases [23,24]. As the success of the technique relies on the ability of the foot to move under the talus, it is conceptually difficult to understand how it can work in surgically treated feet, as those surgeries (sometimes multiple procedures) produce considerable fibrosis and the recurrences or incomplete corrections are associated with contractures, stiffness and rigidity [2,3,8].…”