Management of Clubfoot

Ernesto Ippolito, Pasquale Farsetti

and Matteo Benedetti Valentini

Contents Abstract
History of Clubfoot Management . . . . . . . . . . . . . . . 4484 Congenital clubfoot is charaterized by a
malalignement of talocalcaneal, talonavicular
Treatment of Virgin Clubfoot . . . . . . . . . . . . . . . . . . . . 4485
Ponseti Conservative Treatment . . . . . . . . . . . . . . . . . . . 4485
and calcaneocuboid joints, the cause of which
Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4493 is still unknown. Its management must begin
shortly after birth. During the last years, The
Treatment of Recurrent Cubfoot . . . . . . . . . . . . . . . . 4495
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4496 Ponseti method has been spreading throughout
the world, and its protocol of management
Treatment of Mal-Treated Clubfoot . . . . . . . . . . . . 4500
Triple Arthrodesis-Technique . . . . . . . . . . . . . . . . . . . . . . 4501
followed almost everywhere. It consists of
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4503 manipulation followed by a toe-to-groin plas-
ter cast application every 57 days (usually,
Treatment of Neglected Clubfoot . . . . . . . . . . . . . . . . 4505
Consevative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4506 45 casts). A percutaneous tenotomy of the
Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4507 Achilles tendon is required in about 85% of
Ilizarov Correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4509 the cases. A modified Danis-Browne splint is
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4509 thereafter applied up to 3-4 years of age.
Relapse is the re-appearance of clubfoot
deformity after full correction, the highest
incidence occurring between 1.5 and 4 years
of age. Tibialis anterior tendon transfer to the
third cuneiform is indicated in relapsing cases.
Relapse must be differentiated from
mal-treated clubfeet in which the original
deformity has never been fully corrected.
Mal-treated cases are difficult to treat, and
their management depends on the age at
diagnosis.

Keywords
Clubfoot  History  Ilizarov technique 

Mal-treated clubfoot  Neglected clubfoot 

Ponseti technique  Recurrent clubfoot 

E. Ippolito (*)  P. Farsetti  M.B. Valentini
Surgical Technique  Virgin clubfoot
Department of Orthopaedic Surgery, University of Rome
Tor Vergata, Rome, Italy
e-mail: ippolito@med.uniroma2.it

G. Bentley (ed.), European Surgical Orthopaedics and Traumatology, 4483

DOI 10.1007/978-3-642-34746-7_157, # EFORT 2014
4484
History of Clubfoot Management
From the beginning of the twentieth century to the
present time, clubfoot management has alternated
between conservative and aggressive approaches.
In the early 1900s, treatment was frequently
begun in older children. For that reason, deformi-
ties were often very resistant, and the lack of good
manipulative techniques led Orthopaedic sur-
geons to adopt forceful manipulations with the
aid of aggressive instruments such as forceps
and levers that produced devastating effects on
the growing bones of children with clubfoot. To
avoid those traumatic insults, surgical releases
gradually replaced step-by-step forceful manipu-
lations, thanks also to the advancements in the
field of anaesthetics. In 1906, Codivilla [1]
published a technique of posteromedial release
that stands as a classic. However, his surgical
series included older children aged 1 year and
more because at that time treatment was delayed
for several technical reasons.
In German-speaking countries, the idea of
very early manipulative treatment and plaster
cast immobilization started to develop between
the two world wars [2, 3]. The age when treat-
ment started was lowered to a few days of life,
and the result of conservative treatment improved
greatly. Clubfoot management by manipulation
and casting soon after birth then spread to other
European countries like the United Kingdom [4],
France [5], Italy [6] and to the United States of
America as well, where Kite [7] popularized his
method of staged casting.
However, three basic observations acted
against the advocates of conservative treatment:
(a) Very long duration of manipulation and cast-
ing management protocols;
(b) Severe cases with stiff deformities were
poorly corrected by the manipulation tech-
niques used at the time;
(c) Relapse was particularly frequent in severe
cases.
Surgical treatment was presented as a decisive
method for quick correction and stabilization of a
complex deformity that needed such a long time
E. Ippolito et al.
to be corrected by conservative means. However,
primary surgical treatment was never supported
by long-term result studies, residual deformities
were frequently observed and the operated feet
were often stiff and recurrence was rarely
mentioned!
In the 1950s, the most widely adopted pro-
tocols for clubfoot management in the majority
of institutions all over the world included early
manipulation and casting followed by more or
less extensive soft tissue release operations [8].
Bracing was advised without any precise
indication.
In 1963, Professor Ignacio Ponseti [9]
published the extraordinary results of a series
treated by an original manipulation technique, a
few plaster cast applications, percutaneous
tenotomy of the Achilles tendon and bracing with
a Denis Browne bar and shoes. The recurrence rate
was high in his series but tibialis anterior tendon
transfer to the third cuneiform stabilized the
deformity, thereby avoiding further relapse. The
answers to this provocative simple, quick, and
conservative approach to clubfoot management
were:
(a) The classic paper by Turco [10], who in the
late 1970s published his series treated with a
posteromedial release operation that was a re-
edition of the posteromedial release described
by Codivilla [1] and Brockman [11], at the
beginning of the twentieth century, with
the only innovation being Kirschner wires to
stabilize the corrected deformity, supported
a similar surgical protocol;
(b) The classic papers by Crawford [12] and
McKay [13] published in the early 1980s
which introduced an even more aggressive
pantalar release through a new incision
which he named the Cincinnati incision.
Short-term results were once again reported,
without mentioning recurrence or functional
results.
Just before the publication of the new Cincin-
nati incision for surgical treatment of clubfoot,
Professor Ignacio Ponseti [14] reported very
good long-term functional and radiographic
results of the series published in 1963.
Management of Clubfoot
That paper was almost ignored by the paediatric
Orthopaedic community simply because at that
time the Ponseti management protocol that had
been adopted and refined at the Iowa University
hospital was known and practised by very few
people, even in the United States of America
where the management protocol was born.
In the mid-1980s, the very poor results of
neonatal surgical release proposed by Scandina-
vian [15] and French [16] surgeons some years
previously started to appear in Europe [17, 18],
and Professor Henri Bensahel with Alain
Dimeglio proposed a conservative functional
method of correction based on manipulations
and functional bandages [19]. Again, conserva-
tive treatment gradually started to get the upper
hand over surgical treatment.
During the last few years, Professor Ponsetis
method has been spreading throughout the world,
and nowadays it is the protocol of management
most followed everywhere. Even the last
bastions where strenuous advocates of surgical
treatment still resist are little by little surren-
dering to the blows of young Orthopaedic sur-
geons who learn the Ponseti method and
introduce it through the walls of a consolidated
surgical tradition.
Treatment of Virgin Clubfoot
Ponseti Conservative Treatment
Congenital clubfoot is a structural foot deformity
present at birth as a consequence of in utero mal-
alignment of the talocalcaneal, talonavicular and
calcaneocuboid joints. Articular mal-alignment is
fixed by retracted joint capsules, ligaments and
shortened muscle-tendon units [20]. Every Ortho-
paedic surgeon agrees that congenital clubfoot
management must begin shortly after birth,
based on manipulations and plaster cast applica-
tion. During the first 2 weeks of life ligaments,
joint capsules and tendons are more yielding,
and the surgeon has to take advantage of that
favourable condition. Proper manipulation tech-
nique, followed by application of plaster casts,
4485
provides the best correction of clubfeet in infants.
Failure of manipulative treatment usually occurs
when the surgeon is not familiar with the kinemat-
ics and pathological anatomy of the deformity.
Hindfoot kinematics have been accurately
described by Huson [21]. Tarsal movements
occur simultaneously in the subtalar, talonavicular
and calcaneocuboid joints. If one of them is
blocked, the others are functionally blocked also
(closed kinematic chain). Moreover, in foot inver-
sion and eversion there is no separation between
the movements of the ankle and those of the tarsal
joints (kinematic coupling). In the clubfoot, the
calcaneus, the navicular and the cuboid are rotated
medially in relation to the talus, and are held in
adduction and inversion by tight ligaments and
tendons. Owing to its basic pathology, the club-
foot may be considered a foot blocked in extreme
inversion! Although the whole foot is in extreme
supination, the forefoot is pronated in relation to
the hindfoot and this causes the cavus, because
the first metatarsal is more plantarflexed than the
lateral metatarsals.
Technique
When manipulation is started, the cavus is
corrected first by supinating the forefoot and
dorsiflexing the first metatarsal. The forefoot
must never be pronated. To correct the varus and
adduction, the whole foot must be abducted in
supination under the talus, while counterpressure
is applied with the thumb against the head of the
talus. As the calcaneus abducts, it extends and
everts in the subtalar joint, and thus the heel
varus is corrected (Fig. 1). The improvement
obtained by manipulation is maintained by plaster
cast immobilization of the foot for 1 week. With
immobilization, all the tight fibrous structures
tensioned by manipulation tend to relax. The
deformity may be gradually corrected with fur-
ther manipulation and a weekly plaster cast
change, for a total number of four-to-six casts
depending on the clubfoots stiffness that in turn
varies with the severity of the deformity. The
equinus is corrected last by dorsiflexing the fully
abducted foot [22] (Fig. 2).
4486 E. Ippolito et al.

a b

Fig. 1 Sequential steps of the Ponseti manipulation tech- talus with the other hand (a, b). The varus deformity of the
nique. Abduction in supination of the whole foot with heel is corrected to slight valgus by abduction and
dorsiflexion of the first metatarsus to correct the cavus dorsiflexion of the foot (eversion) (c, d)
deformity. Counterpressure is applied on the head of the
Management of Clubfoot
A percutaneous tenotomy of the Achilles ten-
don is necessary in about 85 % of cases to fully
correct the equinus. This is the only surgical step
of the whole corrective procedure. In a 67 week-
old infant, subcutaneous tenotomy of the Achilles
tendon may be performed either in the clinic or in
the operating room, depending on the surgeons
preference and the hospital rules. If the procedure
is done in the clinic, local anaesthesia will
a b
Fig. 2 (continued)
4487
be induced with an insulin needle or with an
anaesthetic ointment applied locally 2 h before
tenotomy. Putting the foot in forced dorsiflexion,
the Achilles tendon is carefully palpated with
a finger tip and marked with a skin marker.
A knife blade is then introduced percutaneously
parallel to the longitudinal axis of the tendon
from the medial side, and it is turned around
90 and pressed against the tendon to cut it.
4488
Fig. 2 Congenital clubfoot in a three-day-old boy (a).
Manipulation of the right foot and plaster cast application
(b, c). At the third plaster cast equinus is still present,
The operation is successful if the acoustic sensa-
tion of the tendon being cut is accompanied by
the abrupt dorsiflexion of the foot no longer held
in equinus by the tight Achilles tendon. A few
drops of blood may come out of the small wound
[22] (Fig. 3). Various types of knife blades may
be used: a number 11 or 15 ordinary blade, an
eye-rounded blade used by ophthalmologists
for cataract excision, and others (Fig. 3).
Complications have been described, such as
injuries to the saphenous vein and other vascular
structures [23], but they are very rare if the
procedure is carefully performed. After
tenotomy, the last plaster cast is applied for 34
more weeks.
E. Ippolito et al.
while the other deformities have been almost fully
corrected (d, e). Sequence of the first four plaster casts
before percutaneous tenotomy of the Achilles tendon (f)
Orthotic management must be considered as
a compulsory part of the conservative treatment
of congenital clubfoot. The brace is applied
immediately after the post-tenotomy plaster is
removed: it consists of open high-top last shoes
attached to a bar with adjustable connections
within a goniometer. In unilateral cases, the
clubfoot shoe is set at 70 of external rotation
and the normal foot shoe at 45 50 . In bilateral
cases, both shoes must be set at 70 of external
rotation (Fig. 4). The brace is applied full-time
until walking age, then at night and during naps
until 4 years of age. Brace wearing is very
important to keep the ligaments and muscle-
tendon units stretched while the foot is growing.
Management of Clubfoot 4489

a b

Fig. 3 Percutaneous tenotomy of the Achilles tendon must be done proximally, close to the myo-tendinous junction (a).
Different types of knives used for tenotomy (b)

By keeping shortened muscle-tendon units and

retracting fibrous structures stretched, the recur-
rence rate may be reduced from almost 45 % to
less than 9 % [22].

Causes of Failure
Failures of conservative treatment, performed
according to the aforesaid protocol invented
and popularized by Professor Ponseti, are
related more often to wrong techniques of
manipulation and plaster cast application than
to severity of the deformity. One exception is
the so-called atypical or complex clubfoot [24].
It represents a small minority of less than 5 % of
typical cases: atypical clubfeet are short and
fat, the metatarsals are severely plantarflexed
with marked cavus, and the ligaments are very
stiff, unyielding to stretching. A plantar crease
often crosses the longitudinal arch of the foot at
90 . In those cases the basic treatment is the
same, but subcutaneous tenotomy of the Achil-
les tendon must be anticipated to allow more
dorsiflexion so as to better stretch the plantar
capsules and ligaments of the Lisfranc joint
(Fig. 5). Before the advent of the Ponseti
Fig. 4 Mitchell-Ponseti abduction brace. The brace
should be worn full time up to one year of age and then
at night up to three-four years of age, to prevent recurrence
technique, those feet were typical candidates
for either posteromedial or pantalar release.
The most common errors [25] made during
conservative treatment are:
(a) Pronation or eversion of the forefoot,
performed with the wrong assumption that
severe supination will be corrected by prona-
tion. The latter will make the deformity worse
by increasing the cavus and locking the
calcaneus in varus under the talus (Fig. 6);
(b) External rotation of the foot to correct
adduction with the calcaneus in varus: this
4490
a a
Fig. 5 Atypical or complex congenital clubfoot in a one-
month-old baby. A deep plantar crease is evident across
the plantar aspect of the foot (a). Cavus correction and full
dorsiflexion of the ankle after percutaneous Achilles ten-
don tenotomy (b)
causes a posterior displacement of the lateral
malleolus by externally rotating the talus
within the ankle mortice;
(c) Abducting the foot at the midtarsal joints with
the thumb pressing on the calcaneocuboid
joint. This manoeuvre, which has been
described by Kite, is a major error because
it does not allow calcaneus eversion under
the talus;
(d) Frequent manipulations not followed by
immobilization. The foot should be
immobilized with the retracted ligaments at
E. Ippolito et al.
Fig. 6 Common errors of the manipulation technique.
The foot is abducted in pronation and the calcaneus,
grasped with the other hand, is fixed under the talus (a).
3-D CT reconstruction of a severe iatrogenic cavus defor-
mity in a three-year-old boy (b)
the maximum stretch obtained after each
manipulation. Lack of immobilization will
allow partial elastic recovery of the original
length of capsules, ligaments and tendons,
thus making treatment much longer as in
physical therapy treatment described by the
French authors;
(e) Application of below-knee instead of
toe-to-groin casts. Since the foot must be
held in abduction under the talus, the
Management of Clubfoot
Fig. 7 Common errors in plaster cast application.
A short-leg plaster cast allows internal rotation of the
foot with consequent loss of correction, and it may be
easily kicked off by the baby
latter must not rotate, in order to avoid loss
of correction. A short-leg cast does not
prevent the ankle and talus from rotating
(Fig. 7);
(f) Attempts to force equinus correction before
heel varus and foot supination are corrected.
This will cause rocker-bottom deformity
(Fig. 8).
Results
Long-term follow-up studies of patients treated
with the Ponseti manipulation and casting tech-
nique have shown excellent, good and satisfac-
tory results in almost 90 % of cases although
treated clubfeet were less supple than normal
feet [14, 26, 27] (Fig. 9). On the contrary, long-
term follow-up of feet treated with posteromedial
release showed worse results [27, 28].
4491
Fig. 8 Common errors of the manipulation technique.
Iatrogenic rocker-bottom deformity due to forced
dorsiflexion of the foot without Achilles tendon tenotomy
(a). X-rays in maximum dorsiflexion may be useful to
show the calcaneus fixed in equinus by a tight Achilles
tendon (b)
Painful clubfeet in adulthood after Ponseti
treatment are observed in a minority of cases.
Pain is mainly caused by a mal-functioning
subtalar joint that is usually already very
abnormal when treatment is started. In those
feet, the hindfoot and forefoot are well-
aligned, the cavus is corrected and only some
residual heel varus is present. The treatment of
choice is either subtalar or triple arthrodesis
depending on the anatomical and functional
conditions of both the calcaneocuboid and the
talonavicular joints.
4492 E. Ippolito et al.

a b

Fig. 9 Severe bilateral congenital clubfoot treated with alignment of the hindfoot with the forefoot in both views,
the Ponseti technique and bilateral anterior tibial tendon although some residual irregularity can be observed in the
transfer at four years of age. The feet are fully corrected tarsal bones (df)
and mobile at 19 years of age (ac). X-rays show good
Management of Clubfoot
Fig. 10 Scheme of the
posteromedial release
(Codivilla operation). tA
tendo Achillis, TP tibialis
posterior, FDL flexor
digitorum longus, FHL
flexor hallucis longus
FDL
FHL
Surgical Treatment
During the last few years, Ponsetis conservative
treatment has been gaining approval throughout
the world, while surgical treatment is losing advo-
cates. Strict indications are gradually decreasing as
soon as the skill of surgeons who do manipulation
and casting increases [29, 30]. However, surgical
treatment may still be indicated for some particular
cases. In our institution, since we learned the
Ponseti method in the late 1970s, only two
posteromedial releases have been performed dur-
ing the last 30 years in infants not responsive to the
conservative method, and one of the two cases was
a syndromic clubfoot. Surgical treatment of resis-
tant clubfoot in infants may be accomplished by
two main techniques:
(a) Posteromedial release and (b) Pantalar
release.
Posteromedial Release-Technique
This was described by Codivilla [1] in 1906 and
then re-described with minor modifications by
4493
TP
tA
others [10, 11]. A single medial incision is made
from the medial border of the Achilles tendon
down to the navicular-first cuneiform joint. The
tibialis posterior neuro-vascular bundle is iso-
lated first, then the Achilles tendon, tibialis pos-
terior, flexor hallucis longus and flexor digitorum
communis tendons are lengthened. Capsulotomy
of the tibiotarsal, subtalar, and talonavicular
joints is performed as well as release of the medial
ligaments of the tibiotalar, subtalar and
talonavicular joints (Fig. 10). After surgery, a
toe-to-groin plaster cast is applied for 4 weeks.
In our cases, long-term follow-up of
posteromedial release gave less than 50 % of
satisfactory results, with many stiff and cavus
feet (Fig. 11). We also had 9 % of iatrogenic flat
feet (Fig. 12). Surgical treatment did not prevent
recurrence.
Pantalar Release-Technique
This was first described by Crawford in 1983
[12]. A horseshoe incision is made starting
medially at the navicular-first cuneiform joint,
continuing posterior to cross the Achilles tendon,
4494 E. Ippolito et al.

a b

Fig. 11 Severe bilateral congenital clubfoot treated with adduction and varus (on the left foot only) are present at
manipulation and casting according to Marino-Zuco, follow-up, 25 years later. The right foot, in which the
posteromedial release with a double incision and anterior anterior tibial tendon transfer was performed, shows
tibial tendon transfer of the right foot. Residual cavus, a better correction (ag)
Management of Clubfoot
a b
Fig. 12 Iatrogenic flatfoot in a 24-year-old patient who had posteromedial release (a, b)
and ending on the lateral aspect of the foot at the
calcaneocuboid joint. All the tendons may
be lengthened, and all talar joints are exposed
for capsular and ligament release (Fig. 13).
Osteocartilaginous anlages are re-aligned and
fixed with K-wires in the corrected position.
A short-leg cast is applied for 4 weeks. Wound
complications have been described, and no
long-term follow-ups have been reported with
this technique.
Treatment of Recurrent Cubfoot
Recurrence (or relapse) is the re-appearance of
clubfoot deformity after full correction [22]
(Fig. 14). It must be differentiated from a mal-
treated clubfoot, in which full correction has
never been achieved and some residual deformity
still persists after the end of treatment [31].
Relapse is common in severe clubfeet, and it is
probably caused by the same pathology that orig-
inated the deformity. Relapse may occur both in
conservatively-treated and in surgically-treated
clubfeet, the latter being usually stiffer and
more difficult to correct. Recurrence has the
highest incidence between 1.5 years and 4 years
of age; it is rare after 5 years of age. Clubfoot
bracing after the end of manipulative treatment is
the best prophylaxis against recurrence. Bracing
must be maintained full-time until walking age
and then at night and during naps until 34 years
of age. If bracing is stopped prematurely by non-
cooperative parents, recurrence is likely to
develop from 24 months after the brace is
4495
discarded, usually when the parents see that the
feet look normal when the child walks [22]. In a
comparative study of clubfeet treated with two
different protocols, one more conservative and
the other more aggressive, the incidence of recur-
rence was about 45 %, and no statistically signif-
icant difference was found between the two series
of patients as concerns recurrence [27]. Both
clubfeet series failed to use a proper brace after
the end of corrective treatment, and brace com-
pliance was low.
In relapsing clubfoot, the heel is in slight
equinus and varus, and the midfoot is in slight
adduction and supination. In the initial phase,
deformities are still correctable with one to three
long-leg plaster casts with 90  knee
flexion, applied using the same technique of
manipulation employed in newborns (Fig. 15).
Sometimes, before manipulation and plaster cast
application, subcutaneous lengthening of the
Achilles tendon might be necessary as well as
subcutaneous plantar fasciotomy [22]. In those
cases in which tibialis anterior exerts a strong
supinatory action and the anteroposterior
talocalcaneal angle is abnormally narrow with
medial subluxation of the tarsal navicular, tibialis
anterior tendon transfer to the third cuneiform is
indicated [22, 32, 33]. Indications for that operation
include:
(a) The presence of the ossification centre of the
third cuneiform that usually appears around
the age of two and a half years;
(b) A mobile foot mainly at the subtalar joint. In
a stiff relapse, the foot must be made flexible
before the tendon transfer.
4496 E. Ippolito et al.

Fig. 13 Scheme of the

pantalar release (Cincinnati
a
6
operation). Calcaneus 1, 9
Talus 2, Distal tibial 7
epiphysis 3, Navicular 4, 8
Abductor hallucis 5, 3
Tibialis posterior tendon 6, 4
Flexor digitorum longus
tendon 7, Flexor hallucis 2
tendon 8, Neurovascular
tibialis posterior bundle 9 1
(a). Lateral malleolus 1,
Talus 2, Calcaneus 3,
Inferior peroneal
retinaculum tendons 4,
Superior peroneal
retinaculum tendons 5,
Achilles tendon 6, Peroneus
longus tendon 7, Peroneus
brevis tendon 8, Extensor
digitorum brevis muscle 9,
Sural nerve 10 (b). (From
Bauer et al.: 5
Orthopadische
Operationslehre Band 2: b 2
Becken und untere 7 8 5
Extremitat. George Thieme 1
Verlag, 1995) 10

3 4

Surgical Technique intact to avoid anterior bowstringing of the trans-

A medial incision is made along the tibialis ante-
rior tendon from the ankle to the first cuneiform.
The tendon is isolated from its sheath and severed
at its distal insertion. The tendon tip is grasped
with a clamp and lifted up to the inferior margin
of the extensor retinaculum that must be left
fer. A Bunnelltype suture is passed with two
Keith needles within the tendon using a no. 2
non-absorbable suture. A second incision is
made at the third cuneiform, identified under
fluoroscopic control, and a tunnel is drilled
through the middle of the bone up to a diameter
of 56 mm, after retracting laterally the tendon of
Management of Clubfoot 4497

a b

Fig. 14 Severe bilateral congenital clubfoot treated with
the Ponseti technique (a, b). The right foot recurred at three
years of age and it was treated by anterior tibial tendon
transfer, while the left foot recurred one year later (c, d).
The radiographs show reconstitution of the AP
talocalcaneal angle and reduction of the medial subluxation
of the tarsal navicular in the right foot treated by anterior
tibial tendon transfer, whereas on the left foot the talus and
the calcaneus are superimposed and the navicular is medi-
ally subluxated on the talar head (e). Pedobarography indi-
cates more pressure on the lateral part of the relapsed left
midfoot and low pressure on the heel (f)
4498
a b
Fig. 15 Recurrence of a right congenital clubfoot treated at 2 years of age, treated by re-manipulation and casting (ac)
the long extensor and the muscular belly of the
short extensor. The tunnel should be drilled with
15 20 of lateral angulation and 10 of posterior
angulation in order to give the transposed tendon
a correct line of pull and to avoid injury to the
neurovascular structures of the plantar aspect of
the foot. The tendon is passed subcutaneously
from the medial to the lateral aspect of the foot
and is passed with the Keith needles through the
tunnel into the plantar aspect of the foot where it
is firmly anchored to a button over a gauze and a
piece of foam rubber (Fig. 16). To obtain a
straight line of pull, sometimes it may be neces-
sary to make a short incision along the lateral
septum of the extensors retinaculum. Residual
equinus must be corrected by percutaneous
lengthening of the tendo Achilles to obtain at
least 90 of ankle dorsiflexion. Lack of equinus
E. Ippolito et al.
correction will compromise the final result of
the transfer. A long-leg plaster cast is then
applied with the foot in eversion and maximum
dorsiflexion and the knee at 90 of flexion for 4
weeks. In older children, a second, short-leg
walking cast may be applied for three more
weeks. When the cast is removed, parents must
be informed that the childs gait might be irregu-
lar for 23 months, until a new central neural
control of the anterior tibial function is acquired,
changing its peripheral action, abnormally
exerted in relapsing clubfoot as a foot invertor,
to a foot evertor. We have been performing this
operation for more than 30 years without any
major complications and with very good clinical
results. A long-term review of relapsed clubfeet
treated with tibialis anterior tendon transfer to the
third cuneiform showed that none of the operated
Management of Clubfoot 4499

a b

c d

Fig. 16 Sequential steps of tibialis anterior tendon trans-
fer surgical procedure. The tibialis anterior is isolated
through the medial incision, detached from its original
insertion (a), and prepared with a Bunnell nonabsorbable
suture (b, c). A second lateral incision is made at the third
cuneiform (c), a hole is drilled through the third cuneiform
(d), the tendon is transferred subcutaneously to the lateral
side of the foot, passed through the hole (e), and anchored
to the sole of the foot with a button (f)
4500
Fig. 17 3-D CT reconstruction of the whole foot: normal
foot (a), nonrelapsed congenital clubfoot (b) and relapsed
congenital clubfoot treated by anterior tibial tendon trans-
fer to the third cuneiform (c). The navicular-cuneiform
and the calcaneocuboid joints are well aligned in the
patients had a further relapse. Both radiographs
and CT scans of the treated clubfeet after the end
of skeletal growth showed that the transfer had in
time shifted the cuneiforms and the cuboid
more laterally than normal, decreasing the
value of both the calcaneocuboid and the navic-
ular-first cuneiform angles, thus restoring a
normal function of foot dorsiflexion/eversion
[33] (Fig. 17).
E. Ippolito et al.
normal foot (a); the cuboid and the cuneiforms are ori-
ented medially in the nonrelapsed clubfoot (b) and shifted
laterally in the operated clubfoot, in which a hole is visible
in the third cuneiform (c)
Treatment of Mal-Treated Clubfoot
The most common residual deformity of the
poorly treated clubfoot is cavovarus deformity.
Relapsing equinus may be associated when the
foot is left alone without any brace control. The
longitudinal arch of the foot is markedly
increased, the plantar fascia is very tight, and
Management of Clubfoot
the plantar muscles are shortened. This iatrogenic
deformity is usually the result of wrong manipu-
lation and plaster cast immobilization of the fore-
foot in pronation [34], often associated with soft
tissue release operation [35]. As a consequence,
the calcaneus remains in varus since pronation of
the forefoot cannot evert the calcaneus unless the
hindfoot and the midfoot are markedly abducted.
When the child starts walking, the cavovarus
deformity tends to worsen because the first meta-
tarsal has to plantarflex to reach the ground
whereas the lateral metatarsals have to dorsiflex.
Meanwhile, if there is a residual adduction of the
forefoot, the patient will walk with his leg in
external rotation to avoid in-toeing. The lateral
malleolus will move backward in relation to the
medial malleolus, and the external torsion of the
ankle mortice will increase [22, 36] (Fig. 18).
In children under 68 years of age, when the
subtalar joint is still mobile, the cavovarus defor-
mity can be treated by manipulation and applica-
tion of two or three long-leg plaster casts with the
knee flexed at 90 for 34 weeks each. Manipu-
lation and plaster cast application should be
performed under general anaesthesia, after per-
cutaneous fasciotomy and percutaneous Achilles
tendon [37] lengthening in cases of persistent
equinus deformity. In children older than 2.5
years, additional surgical procedures might be:
(a) Tibialis anterior tendon transfer to the third
cuneiform if the muscle exerts a strong
supinatory action and
(b) Transfer of the extensor hallucis longus to the
first metatarsal shaft in cases of very severe
cavus deformity not correctable with manipu-
lation and casting. To avoid plantar drop of the
first toe, the distal end of the extensor hallucis
longus must be sutured to the first tendon of
the extensor digitorum brevis. After surgery, a
toe-to-groin plaster cast with the knee flexed
at 90 will be applied for 56 weeks [22].
In children older than 68 years of age, the
tarsal deformity as well as the cavus become
stiffer. In order to select the most appropriate
surgical procedure, it is important to assess
correctability of the heel varus using the Coleman
lateral block test. If the heel goes to neutral after
a block of wood 23 cm high is placed under the
4501
lateral aspect of the sole of the foot, the cavovarus
deformity is best corrected by the operation
described by Cooper [22], consisting of:
1. Percutaneous sectioning of the plantar fascia;
2. Dorsolateral closing-wedge osteotomy of the
base of the first metatarsal close to the growth
plate;
3. Transfer of the extensor hallucis longus to the
shaft of the first metatarsal to hold the
correction;
4. Sectioning of the peroneus longus to
eliminate its plantar-flexion action on the
first metatarsal, and suturing it to the
peroneous brevis under tension, to maintain
its everting action;
5. Transfer of the tibialis anterior tendon to the
third cuneiform;
6. When necessary, subcutaneous lengthening of
the Achilles tendon must be associated. At the
end of surgery, a toe-to-groin plaster cast is
applied for 4 weeks with the knee flexed at
90 , followed by a weight-bearing plaster boot
for three more weeks.
If the Coleman test is negative, indicating
a rigid deformity, and the foot is still growing, it
is advisable to wait for the end of skeletal growth
before performing a triple arthrodesis operation.
The latter is a very good salvage procedure that
should be done after the end of growth to avoid
excessive foot shortening [22] (Fig. 19). If the
family does not want to wait for the end of growth,
gradual correction by the application of an Ilizarov
apparatus might be a valid alternative (see: section
Treatment of Neglected Clubfoot).
Triple Arthrodesis-Technique
Triple arthrodesis is done through a lateral inci-
sion extending from the tip of the lateral
malleolus to the first cuneiform [22]. The extensor
digitorum brevis is detached from the calcaneus
and reflected forward. The tendons of the extensor
digitorum longus and of the peroneus tertius are
retracted forward while the inferior peroneal ret-
inaculum and the peroneal tendons are retracted
downward. Afer joint capsule stripping, the
calcaneocuboid, the talocalcaneal and the
4502 E. Ippolito et al.

a b

c
d

Fig. 18 (continued)
Management of Clubfoot
g h
Fig. 18 Bilateral residual equinus-cavovarus-adduction
deformity in a three-year-old boy who was previously
treated with manipulation and plaster casts followed by
calcaneonavicular joints are exposed. The articu-
lar cartilage and a small amount of subchondral
bone are removed with a sharp curved osteotome,
as well as the interosseous talocalcaneal ligament.
Once the calcaneus, the cuboid and the navicular
are fully mobilized, the foot is abducted and the
three joints are fixed in the corrected position with
three Kirschner wires that may serve as a guide to
introduce cannulated screws for internal fixation
of the triple arthrodesis. Sometimes, the presence
of a midfoot cavus may require some dorsal
wedging at the talonavicular and calcaneocuboid
joints. An associated cavus deformity of the
forefoot requires osteotomy of the base of the
first metatarsal, that may be fixed with a small
plate and screws. In the fully grown foot, transfer
of the extensor hallucis longus to the first
metatarsal can be avoided, but the peroneus
longus must be cut and sutured under tension to
the peroneus brevis before the dorsal closing-
wedge osteotomy of the first metatarsal. Even in
feet treated with triple arthrodesis, tibialis anterior
tendon transfer to the third cuneiform should
be associated whenever the muscle exerts a strong
4503
posteromedial release (ag). He was subsequently treated
by re-manipulation and casting and percutaneous length-
ening of the Achilles tendon (h, i)
supinatory action. When the tendon is released
from its distal insertion, a small piece of
bone may be resected with the tendon and
an interference screw may be used to fix it
within the tunnel drilled in the third cuneiform.
After the operation, a plaster boot must be
applied for 46 weeks.
In very, very stiff clubfeet with severe residual
deformity after repeated extensive soft tissue
operations, talectomy might be indicated as a sal-
vage operation [38]. The ideal age for this opera-
tion is between 1 years and 6 years. The primary
indications for talectomy are arthrogrypotic and
myelomeningocele clubfeet with poor or absent
leg muscles.
Technique
A lateral approach is used for talectomy,
extending from the tip of the lateral malleolus to
the talonavicular joint. The head of the talus is
prominent laterally because the navicular and the
calcaneus are in severe adduction. All the
4504 E. Ippolito et al.

a b

Fig. 19 Right residual equinus-cavovarus-adduction
deformity in a 19-year-old boy who was previously treated
with manipulation and plaster casts followed by posterior
release (ad). He was treated the second time by triple
arthrodesis associated with the Cooper procedure and
tibialis anterior tendon transfer to the third cuneiform.
In this case, the tendon was detached with a little piece
of bone and fixed into the third cuneiform hole with an
interferential screw. At follow-up, the deformities are well
corrected and the foot is well aligned (eg)
Management of Clubfoot
a b
Fig. 20 Neglected left clubfoot in a 25-year-old man, wearing custom-made shoes (ac)
ligaments and joint capsules inserting into the
talus are severed while the foot is forced
into equinus and supination so that the
posteromedial ligaments can be better identified.
After excision of the talus, the ankle mortise
should fit into the anterior upper surface of the
calcaneus. A Steinmanns pin is inserted upward
through the calcaneus into the tibia to maintain
the foot in the proper position with respect to the
tibia. The foot is immobilized in a short-leg plas-
ter cast. The cast and the Steinmanns pin are
removed after 4 weeks, and a walking plaster
boot is then applied for 6 more weeks. A well-
moulded leg brace is worn for 6 more months to
prevent recurrence of the deformity.
Treatment of Neglected Clubfoot
Neglected clubfeet are exceptionally observed
nowadays in Western developed countries. Club-
foot is defined as neglected when the deformity is
left untreated up to childhood, adolescence
4505
or adulthood. However, in underdeveloped
countries, poor social conditions and inadequate
health care service leave many children with
completely untreated congenital clubfeet.
Owing to the total inversion of the plantar aspect
of the foot, these patients walk on the dorsum of
the foot where huge callosities develop over the
years (Fig. 20). These complex and very severe
deformities involve not only soft tissues that are
shortened and tight but also compensatory bony
deformity, with alteration of the normal shape of
the foot bones that becomes irreversible after the
end of growth. Retracted ligaments, capsules and
muscle tendon units act as tethers on the medial
and plantar aspect of the foot, causing
wedge-shaped deformity of the tarsal bones that
become wider superolaterally and narrower
inferomedially. Moreover, the anterior part of
the talar trochlea, that is anteriorly subluxated
due to the foot equinus, becomes wider than
the width of the ankle mortise and the
metatarsals mostly the first become more
and more plantarflexed.
4506
Consevative Treatment
Up to 1012 years of age, many
clubfeet may still have some residual
that allows manipulative treatment
In our experience, manipulative
a b
c
Fig. 21 (continued)
E. Ippolito et al.
is best performed under general anesthesia
after subcutaneous lengthening of the Achil-
neglected les tendon and sectioning of the tibialis pos-
flexibility terior through a mini-incision. Manipulation
[35, 39]. is performed according to Ponsetis tech-
treatment nique, and a long-leg plaster cast with the
d
Management of Clubfoot
e f
Fig. 21 Neglected right clubfoot in a 9-year-old
girl treated by percutaneous lengthening of the
Achilles tendon, tibialis posterior tenotomy through
a mini-incision and manipulation and casting according
to Ponseti, followed by tibialis anterior tendon
knee flexed is maintained for 4 weeks. After
four or five plaster casts, when the foot will
become plantigrade, a short-leg plaster cast
is applied to start weight-bearing, in order
to improve mineralization of the osteopaenic
bones following such a long non-weight-
bearing time. After 23 months, anterior tib-
ial tendon transfer to the third cuneiform is
performed to balance muscular forces acting
on the foot (Fig. 21).
4507
transfer (ac). At follow-up, nine months later, the foot
was plantigrade and well aligned, although it was shorter
than the normal foot. Dorsiflexion of the ankle was
normal (dg)
Surgical Techniques
After the end of skeletal growth, bony structural
deformities are the main obstacle to manipulative
correction, as well as the capsules and ligaments
that become very stiff. Several corrective opera-
tions have been described for neglected clubfeet,
mainly based on shortening osteotomy of the lat-
eral column of the foot, metatarsal and midtarsal
closing -wedge osteotomies for cavus correction
4508 E. Ippolito et al.

a b

Fig. 22 Neglected left clubfoot in a 39-year-old man treated by the Ilizarov technique after percutaneous lengthening of
the Achilles tendon and midtarsal osteotomy through the cuneiforms (ad)

associated with medial soft tissue release and complications like skin necrosis, pseudoarthrosis,
either triple or more extended foot arthrodesis infection, and vascular damage. The final result of
[40]. All of these procedures are very demanding acute surgical correction of a neglected clubfoot is
from the technical point of view and prone to the creation of a much shortened foot.
Management of Clubfoot
Ilizarov Correction
To avoid all the above-mentioned complications,
the Ilizarov technique has been employed
[41, 42]. This technique is much less invasive
than open surgery and allows simultaneous cor-
rection of all the components of the deformity
without bone resection or foot shortening. In
adult feet with very stiff deformities, a midfoot
osteotomy either percutaneous or through a short
skin incision can be done before distraction to
obtain a better and easier correction of the
cavovarus deformity. Subcutaneous lengthening
of the Achilles tendon must also be performed,
associated if necessary with division of the
tibialis posterior tendon through a small incision.
A two-ring pre-constructed Ilizarov frame is
applied to the mid and distal tibia using either
1.8 mm thick Kirschner wires or 56 mm thick
half-pins. The foot apparatus is constructed using
a half-ring for the hindfoot and a half-ring for the
forefoot. The hindfoot ring is parallel to the leg
rings, whereas the dorsal forefoot half-ring is 90
angulated in relation to the hindfoot half-ring.
The hinges and threaded rods are then assembled
to obtain simultaneous correction of the basic
deformities (Fig. 22). Equinus and varus are
corrected by distraction of the rods connecting
the tibia to the calcaneus. The forefoot adduction
is corrected by distraction of the medial rod
connecting the half-ring of the hindfoot to the
half-ring of the forefoot, while the mid-forefoot
cavus is corrected by shortening the two rods
connecting the forefoot half-ring to the upper leg
ring. At the end of the correcting procedure,
tibialis anterior tendon transfer may be added
to improve muscular foot balance and to avoid
relapse. A non-weight-bearing short-leg plaster
cast is then applied for 4 weeks, followed by
a weight-bearing short-leg cast for 6 more
weeks. The limited range of motion of foot
joints, characteristic of neglected clubfoot, can-
not be improved by this method and it is not
possible to recover a normal anatomy. However,
a painless plantigrade foot can be obtained with-
out too much shortening of the foot and with few
complications.
4509
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