CONGENITAL TALIPES

EQUINOVARUS
DR. SAMPATH MARASINGHE
REGISTRAR
SJGH
CONTENTS
1. Introduction
2. Anatomy
3. History
4. Epidemiology
5. Etiology
6. Clinical evaluation
7. Assessment of the severity
8. Management options
INTRODUCTION
Clubfoot is not an embryonic malformation.
Developmental deformation of the foot
Characterized by rotational subluxation of the talocalcaneonavicular
joint complex with
Talus in plantar flexion and
Subtalar complex in medial rotation and inversion
ANATOMY
• In the clubfoot, the ligaments of the
posterior and medial aspect of the
ankle and tarsal joints are very thick
and taut, thereby severely restraining
the foot in equinus and the navicular
and calcaneus in adduction and
inversion.
• Deltoid, tibionavicular ligament, and the
tibialis posterior tendon to be very thick
and to merge with the short plantar
calcaneonavicular ligament.
• A photomicrograph of the
tibionavicular ligament shows the
collagen fibers to be wavy and
densely packed. The cells are very
abundant, and many have spherical
nuclei.
• Excessive collagen synthesis in the
ligaments, tendons, and muscles may
persist until the child is 3 or 4 years of
age and might be a cause of relapses.
• Under the microscope, the bundles of collagen fibers display a wavy
appearance known as crimp.
• This crimp allows the ligaments to be stretched.
• Gentle stretching of the ligaments in the infant causes no harm.
• The crimp reappears a few days later, allowing for further stretching.
• That is why manual correction of the deformity is feasible.
KINEMATICS
• The clubfoot deformity occurs mostly in the tarsus.
• The tarsal bones, which are mostly made of cartilage, are in the most
extreme positions of flexion, adduction, and inversion at birth.
• The talus is in severe plantar flexion, its neck is medially and plantarly
deflected, and its head is wedge-shaped.
• The navicular is severely medially displaced, close to the medial
malleolus, and articulates with the medial surface of the head of the
talus.
• The calcaneus is adducted and inverted under the talus.
• The navicular is medially displaced and
articulates only with the medial aspect
of the head of the talus.
• The cuneiforms are seen to the right of
the navicular, and the cuboid is
underneath it.
• The calcaneocuboid joint is directed
posteromedially.
• The anterior two-thirds of the calcaneus
is seen underneath the talus.
• The tendons of the tibialis anterior,
extensor hallucis longus, and extensor
digitorum longus are medially displaced.
• In the clubfoot, the anterior portion of the calcaneus lies beneath the
head of the talus. This position causes varus and equinus deformity of the
heel.
• Attempts to push the calcaneus into eversion without abducting it will
press the calcaneus against the talus and will not correct the heel varus.
• Lateral displacement (abduction) of the calcaneus to its normal
relationship with the talus will correct the heel varus deformity of the
clubfoot.
• Correction of clubfoot is accomplished by abducting the foot in
supination while counterpressure is applied over the lateral aspect of
the head of the talus to prevent rotation of the talus in the ankle.
• A well-molded plaster cast maintains the foot in an improved
position.
• The ligaments should never be stretched beyond their natural amount
of give.
• After 5 days, the ligaments can be stretched again to further improve
the degree of correction of the deformity.
• The bones and joints remodel with each cast
change because of the inherent properties of
young connective tissue, cartilage, and bone,
which respond to the changes in the direction
of mechanical stimuli.
• This has been beautifully demonstrated by
Pirani, comparing the clinical and magnetic
resonance imaging appearance before, during,
and at the end of cast treatment
• The tendo Achillis, unlike the tarsal ligaments that are stretchable, is
made of non-stretchable, thick, tight collagen bundles with few cells.
• Before applying the last plaster cast, the tendo Achillis may have to be
percutaneously sectioned to achieve complete correction of the
equinus.
• The last cast is left in place for 3 weeks while the severed heel-cord
tendon regenerates in the proper length with minimal scarring.
• At that point, the tarsal joints have remodeled in the corrected
positions.
HISTORY
• Talipes - Talus (astragalus) and pes (foot)
• Literally means to walk on the ankles
• first depicted from archeological studies in ancient Egyptian tombs on
mummies by Smith and Warren reporting clubfoot on the Egyptian
Pharaon Siptah (XII century B.C.).
• This mummy and other drawings from an Egyptian temple indicate
that the deformity known as clubfoot has been recognized for
centuries and that it was possible to reach adulthood without
correction of the deformity.
Drawings of the deformity of Hephaestus’ feet over an Etruscan vase stored at The Kunsthistorisches Museum of
Vienna
• The first research and written description of clubfoot was performed
by Hippocrates from Kos in 400 B.C.
• Clubfoot was considered as curable by Hippocrates for the majority of
cases by manipulative correction remarkably similar to current non-
operative methods.
• He described methods for repeated manipulations of the involved
foot, followed by the application of strong bandages to maintain
correction.
• He explained that treatment should begin as early as possible before
the deformity of the bones is well established
• Ambroise Pare (1510–
1590), almost 2000 years
after Hippocrates,
described essentially the
same technique for the
treatment of varus and
valgus forms of clubfeet.
• He also used some
ingenious slippers and
boots to help maintain the
correction
• The first physician to
approach the
treatment of clubfoot
with attention to their
social as well as their
medical needs in an
institutional setting
was Jean-Andre Venel
(1740–1791)
• The first description of the
pathological anatomy of
clubfeet was given by
Antonio S. Scarpa (1752–
1832).
• he described his methods
of treatment, which relied
on gentle manipulation
and the use of braces
incorporating steel springs
Dr. Ignacio Vives Ponseti (1914- 2009)
• Dr. Ignacio Vives Ponseti was born in Ciutadella de Menorca, Spain, on
June 3, 1914, and died in Iowa City, Iowa on October 18, 2009, at the
age of 95.
• His legacy is the development of a primarily nonoperative method of
clubfoot treatment, which involves serial casting, heel cord tenotomy,
and brace wear.
• This method has become the gold standard of clubfoot treatment and
has benefited tens of thousands patients worldwide.
• It could be easily concluded that Ponseti's paper on clubfoot
management (1963) is one of the few manuscripts in orthopaedic
literature which has changed the practice as we know it now.
EPIDIMIOLOGY
• Demographics
• Most common musculoskeletal birth defect
• Overall incidence 1:1,000, though some populations 1:250
• Highest prevalence in Hawaiians and Maoris
• Male:female ratio approximately 2:1
• Anatomic location
• Half of cases are bilateral
• In 80%, clubfoot is an isolated deformity
AETIOLOGY
• Polygenic inheritance for sensitivity to unknown environmental
factors.
• The inheritance pattern has not been established nor a single gene
identified.
• It has been suggested that these genes activate an arrest in the
normal development of the limb bud at five weeks’ gestation.
• Certain modulating environmental factors (e.g., maternal smoking,
alcohol consumption) have been suggested as a contributing factor, as
has intravenous drug use by the mother during pregnancy.
• Incidence was 17 times higher than in the normal population for f irst-degree
relatives and 6 times higher in second-degree relatives.
• Risk of a second child having clubfoot was 1:35 (to unaffected parents).
 ETIOLOGICAL
FACTORE

EXTRINSIC
INTRINSIC
(INTRAUTERINE
(GENETIC)
)
EXTRINSIC FACTORS
• Cardy et al. found a significant association of clubfoot between paternal smoking family history
during pregnancy
• Hackshaw et al. in a meta-analysis of 172 articles published from 1959 to 2010, confirmed a
significant association of smoking with clubfoot
• Nguyen et al. found . A strong association of clubfoot incidence was found with breech presentation
and younger maternal age
• Werler et  al. investigated the effect of maternal consumption of cigarette smoking, alcohol, and
coffee from 2007 to 2011 with 646 patients and 2,037 controls
• Cigarette smoking is positively associated with increased incidence of clubfoot
• Alcohol and coffee - the risk increased only with a higher level of intake
• Use of antiviral drugs was the most common evidence in isolated clubfoot
• A greater risk was observed for metronidazole
• Slightly higher risks were observed for antinausea treatments - promethazine and ondesetron
EXTRINSIC FACTORS
• Nutritional deficiency
• Karakurt et al. studied the relationship between the plasma total homocysteine level in
blood samples of mothers of children with clubfoot
• Congenital idiopathic clubfoot showed a significant association with a high plasma total homocysteine
level
• Maternal diseases – obesity and / or diabetes
• Amniocentesis and uterine factors
• Farrell et al. analyzed adverse effect of amniocentesis in the etiology of clubfoot in a review
of the largest study by the Canadian Early and Mid-Trimester Amniocentesis Trial group
(CEMAT)
• They were divided into two groups of 2,187 women each: group 1 was the early amniocentesis (EA) group
and group 2 was the midterm amniocentesis (MA) group
• There were 29 (1.3%) cases of clubfoot in 2,172 pregnancies in group 1 but only two (0.1%) in the 2,162
pregnancies of group 2, that is, 10 times more in EA than MA
INTRINSIC FACTORS
• Intrinsic factors
• Neuromuscular or syndromic/dysmorphic etiology
• Arthrogryposis
• Diastrophic dysplasia
• Streeter dysplasia (constriction band syndrome)
• Freeman-Sheldon syndrome
• Möbius syndrome
• Genetic factors
• Limb and muscle morphogenesis - HOXA,HOXD & IGFBP3
• Development of the lower extremity - CAND2 & WNT7a
• Hind limb specific genes - TBX4
• Alvarado et al. screened cases of familial isolated clubfoot to find any genetic etiology and found that
microduplication of chromosome 17q23.1q23.2 is a common cause and provides strong evidence linking it to
clubfoot etiology
• Congenital constriction bands
TYPICAL DEFORMITIES OF THE
CLUBFOOT
1. Cavus
2. Adductus Forefoot
deformities
3. Forefoot supination
4. Hindfoot varus Hindfoot
deformities
5. Equinous
6. Foot is smaller than the normal foot
7. Calf is smaller
PATHOLOGY
• Seven well-established theories of pathology
• Chromosomal theory
• Embryonic theory
• Otogenic theory
• Fetal theory
• Neurogenic theory
• Myogenic theory
• Vascular theory
PATHOLOGY
• Arrest in embryonic development
• The foot in a 6- 8-week-old fetus has many characteristics of a congenital
clubfoot,
• Equinus
• Supination
• Forefoot adduction
• Medial deviation of the talar neck
• The fetal foot becomes normal at 12 to 14 weeks 1 - 111
• Bohm proposed that an arrest in fetal development at this stage was
responsible for the clinical deformities noted at birth 1 – 15
• The characteristic dysmorphic talar head and the medial dislocation of the
navicular have never been observed at any stage of normal fetal development.
PATHOLOGY
• Retractive fibrotic response
• Zimny et.al. identified myofibroblastic retractile tissue in the medial ligaments 1-201
• Ippolito and Ponseti identified an increase in collagen fibers and fibroblastic cells in the
ligaments and tendons of a clubfoot.1 – 94
• Transforming growth factor-β and platelet-derived growth factor are expressed at higher
levels in these contracted tissues.1 -119
• Growth factor blockade with neutralizing antibodies is reported to have the potential to
lessen the severity of the contractures and ultimately positively influence the outcome of
clubfoot treatment.
• The association of clubfeet with syndromes of inherent ligamentous laxity (Down, Larsen)
confounds the hypothesis that fibrotic retractile tissue is a primary etiology
• Recent report using light and transmission electron microscopy failed to reveal any
myofibroblast-like cells in the capsule, fascia, ligaments, or tendon sheaths of nine clubfoot
specimens
PATHOLOGY
• Localized neuromyogenic imbalance
• Imbalance between types I and type II muscle fibers
• Atrophy of type I fibers, has been found in both peroneal and triceps surae
• A recent study on the histologic and histochemical analysis of 431 muscle
specimens in idiopathic clubfeet reported
• 86% showed no evidence of a pathologic diagnosis with normal fiber-type ratios and no
type I fiber grouping indicative of neuromuscular pathology
• Only four specimens (0.9%) showed type I fiber predominance
• 12.8% revealed muscle fiber atrophy 1 – 80
Evaluation of the severity
• Goldner and Fitch
• Carroll
• Pirani
• Dimeglio
• Others
Pirani score
• General Principle of Scoring
• 6 clinical signs of a clubfoot are compared to a normal foot.
• 3 signs evaluate the hind foot contracture.
• 3 signs evaluate the mid foot contracture.
• Each sign is scored with:
• 0 = no abnormality 0.5 = moderate abnormality 1 = severe abnormality
• Higher score indicates a more severe deformity.
• Scoring should be done each visit during treatment.
• Benefits
• Shows the severity of the clubfoot.
• Encourages intensive examination in the beginning.
• Helps to monitor treatment progress.
• Shows, when tenotomy of the Achilles tendon is indicated.
• Tells, when the correction is finished, and the bracing should start.
• Help for research (comparison of results, extraction of subgroups, etc.)
Pirani score
• Hind Foot Contracture Score : 0 - 3
• Posterior Crease
• Empty Heel
• Rigid Equinus
• Mid Foot Contracture Score : 0 - 3
• Medial Crease
• Lateral part of the Head of the Talus
• Curvature of Lateral Border of foot
Hind Foot Contracture Score
• Posterior Crease
• Empty heel
• Easily palpable
• Palpable – deep
• Not palpable

1.0

0.5
Hind Foot Contracture Score
• Rigid equinus
Mid Foot Contracture Score
• Lateral part of the Head of the
Talus (palpability)
• None – 0
• Partial – 0.5
• Full - 1
Mid Foot Contracture Score
• Medial Crease
Mid Foot Contracture Score
• Curvature of Lateral Border of
foot
How to remember easily in the exam
• Two points you look for
• Posterior crease
• Medial crease
• Two points you feel for
• Empty heel
• Lateral head of talus
• Two points you measure for
• Equinus
• Curved lateral border
Dimeglio
Dimeglio
Dimeglio
Dimeglio
Dimeglio
Dimeglio
CLUBFOOT ASSESSMENT
• Screening Encourage all healthcare workers to screen all newborns and infants for
foot deformities and other problems.
• Infants with problems can be referred for care at a clubfoot clinic.
• Confirming The diagnosis suggested during screening is made by someone with
experience with musculoskeletal problems who can establish the diagnosis.
• The essential features of a clubfoot include
• cavus,
• varus,
• adductus
• equinus
• During this evaluation, other conditions such as metatarsus adductus
and the presence of some underlying syndrome can be ruled out.
• The clubfoot is classified into categories.
• This classification is made to establish the prognosis and to plan
management.
 POSITIONAL

DELAYED TREATED
TYPICAL
RECURRENT
TYPICAL

CLUBFOOT
ALTERNATIVELY
TREATED TYPICAL

RIGID OR RESISTANT
ATYPICAL

SYNDROMIC

ATYPICAL TERATOLOGIC

NEUROGENIC

AQUIRED
PONSETI CAST CORRECTION
• The setup for casting includes calming the child
with a bottle or breast feeding.
• When possible, have a trained assistant.
• The treatment setup is important.
• The assistant holds the foot while the
manipulator performs the correction
• Start as soon after birth as possible. Make the
infant and family comfortable.
• Allow the infant to feed during the
manipulation and casting processes.
Exactly locate the head of the talus

• First, palpate the malleoli with the thumb and

index finger of while the toes and metatarsals are
held with other hand.
• Next, slide your thumb and index finger of
hand A forward to palpate the head of the
talus in front of the ankle.
• Because the navicular is medially displaced
and its tuberosity is almost in contact with the
medial malleolus, you can feel the prominent
lateral part of the talar head (red) barely
covered by the skin in front of the lateral
malleolus.
• The anterior part of the calcaneus will be felt
beneath the talar head.
• While moving the forefoot laterally in supination, you will be able to
feel the navicular move ever so slightly in front of the head of the
talus as the calcaneus moves laterally under the talar head.
Manipulation

• The manipulation consists of abduction of the foot beneath the

stabilized talar head.
• Locate the head of the talus.
• All components of clubfoot deformity, except for the ankle equinus,
are corrected simultaneously.
• To gain this correction, you must locate the head of the talus, which is
the fulcrum for correction.
Reduce the cavus
• The first element of management is correction of the cavus deformity
by positioning the forefoot in proper alignment with the hindfoot.
• The cavus, which is the high medial arch [yellow arc] is due to the
pronation of the forefoot in relation to the hindfoot.
• The cavus is always supple in newborns
and requires only elevating the first ray
of the forefoot to achieve a normal
longitudinal arch of the foot.
• The forefoot is supinated to the extent
that visual inspection of the plantar
surface of the foot reveals a normal
appearing arch—neither too high nor too
flat.
• Alignment of the forefoot with the
hindfoot to produce a normal arch is
necessary for effective abduction of the
foot to correct the adductus and varus.
Steps in cast application
• Dr. Ponseti recommends the use of plaster material because it is less
expensive and more precisely molded than fiberglass.
• Preliminary manipulation
• Before each cast is applied, the foot is manipulated.
• The heel is not touched to allow the calcaneus to abduct with the
foot.
• Applying the padding
• Apply only a thin layer of cast padding to allow molding of the foot.
• Maintain the foot in the maximum corrected position by holding the
toes with counterpressure applied against the head of the talus while
the cast is being applied.
• Applying the cast
• First apply the cast below the knee and then
extend the cast to the upper thigh.
• Begin with three to four turns around the
toes [6], and then work proximally up to the
knee [7].
• Apply the plaster smoothly.
• Add a little tension to the turns of plaster
above the heel.
• The foot should be held by the toes and
plaster wrapped over the “holder’s” fingers
to provide ample space for the toes.
• Molding the cast
• Do not try to force correction with the
plaster.
• Use light pressure.
• Do not apply constant pressure with the
thumb over the head of the talus; rather,
press and release repetitively to avoid
pressure sores of the skin.
• Mold the plaster over the head of the talus
while holding the foot in the corrected
position.
• Note that the thumb of the left hand is
molding over the talar head while the right
hand is molding the forefoot in supination.
• The arch is well molded to avoid flatfoot or rocker-bottom deformity.
• The heel is well molded by countering the plaster above the posterior
tuberosity of the calcaneus.
• The malleoli are well molded.
• The calcaneus is never touched during the manipulation or casting.
• Molding should be a dynamic process; constantly move the fingers to
avoid excessive pressure over any single site.
• Continue molding while the plaster hardens.
• Extend cast to thigh
• Use much padding at the proximal
thigh to avoid skin irritation.
• The plaster may be layered back
and forth over the anterior knee
for strength and for avoiding a
large amount of plaster in the
popliteal fossa area, which makes
cast removal more difficult.
• Trim the cast
• Leave the plantar plaster to support the toes,
and trim the cast dorsally to the metatarsal
phalangeal joints, as marked on the cast.
• Use a plaster knife to remove the dorsal plaster
by cutting the center of the plaster first and then
the medial and lateral plaster.
• Leave the dorsum of all the toes free for full
extension.
• Note the appearance of the first cast when
completed.
• The foot is in equinus, and the forefoot is
supinated.
Characteristics of adequate abduction
• Confirm that the foot is sufficiently abducted to safely bring the foot
into 0 to 5 degrees of dorsiflexion before performing tenotomy.
• The best sign of sufficient abduction is the ability to palpate the
anterior process of the calcaneus as it abducts out from beneath the
talus.
• Abduction of approximately 60 degrees in relationship to the frontal
plane of the tibia is possible.
• Neutral or slight valgus of os calcis is present.
• This is determined by palpating the posterior os calcis.
• Remember that this is a three-dimensional deformity and that these
deformities are corrected together.
• The correction is accomplished by abducting the foot under the head
of the talus. The foot is never pronated.
The outcome
• At the completion of casting, the foot appears to be over-corrected
into abduction with respect to normal foot appearance during
walking.
• This is not in fact an overcorrection.
• It is actually a full correction of the foot into maximum normal
abduction. This correction to complete, normal, and full abduction
helps prevent recurrence and does not create an overcorrected or
pronated foot.
Complications of Casting
1. Rocker-bottom deformity is due to poor technique by dorsiflexing
the foot too early against a very tight Achilles tendon.
2. Crowded toes are due to tight casting over the toes.
3. Flat heel pad will occur if, while casting, pressure is applied to the
heel rather than molding the cast above the ankle.
4. Superficial sores are managed by applying a dressing and a new cast
with additional padding.
5. Pressure sores are due to poor technique. Common sites include the
head of the talus, over the heel, under the first metatarsal head, and
popliteal and groin regions.
6. Deep sores are dressed and left out of the cast for one week to allow
healing. Casting is then resumed with special care to avoid relapse.
Cast removal
• Remove each cast in clinic just before a new cast is applied.
• Avoid cast removal before clinic because considerable correction can
be lost from the time the cast is removed until the new one is placed.
• Avoid using a cast saw because it is frightening to the infant and
family and may also cause injury to the skin.
Options for removal
• Cast knife removal

• Soak the cast in water for about 20 minutes, and then

wrap the cast in wet cloths before removal.
• This can be done by the parents at home just before
their visit. Use the plaster knife and cut obliquely to
avoid cutting the skin.
• Remove the above-knee portion of the cast first.
• Finally, remove the below-knee portion of the cast.
• Soaking and unwrapping

• This is an effective method but requires more

time.
• Soak cast thoroughly in water and when
completely soft unwrap the plaster.
• To make this process easier, leave the end of
the plaster free for identification.
Common Management Errors
• Pronation or eversion of the foot
• This position worsens the deformity by increasing
the cavus.
• Pronation does nothing to abduct the adducted
and inverted calcaneus, which remains locked
under the talus.
• It also creates a new deformity of eversion
through the mid and forefoot, leading to a
beanshaped foot.
• External rotation of foot to correct adduction while
calcaneus remains in varus
• This causes a posterior displacement of the lateral
malleolus by externally rotating the talus in the ankle
mortise.
• This displacement is an iatrogenic deformity.
• Avoid this problem by abducting the foot in flexion
and slight supination to stretch the medial tarsal
ligaments, with counter-pressure applied on the lateral
aspect of the head of the talus [2 thumb position].
• This allows the calcaneus to abduct under the talus
with correction of the heel varus.
• Kite’s method of manipulation
• Kite believed that the heel varus would correct
simply by everting the calcaneus.
• He did not realize that the calcaneus can evert only
when it is abducted (i.e., laterally rotated)under the
talus.
• Abducting the foot at the midtarsal joints with the
thumb pressing on the lateral side of the foot near
the calcaneocuboid joint [2 black dot] blocks
abduction of the calcaneus and interferes with
correction of the heel varus.
• Make certain the foot is abducted around head of
the talus [2 red dot].
• Casting errors
• Failure to manipulate
• The foot should be immobilized with the
contracted ligaments at maximum stretch
obtained after each manipulation.
• In the cast, the ligaments loosen, allowing more
stretching at the next session.
• Short-leg cast
• The cast must extend to the groin. Short-leg
casts do not hold the calcaneus abducted.
• Premature equinus correction
• Attempts to correct the equinus before the heel varus and foot
supination are corrected will result in a rocker-bottom deformity.
• Equinus through the subtalar joint can be corrected by calcaneal
abduction.
• Failure to use appropriate night bracing
• Avoid using a short leg brace as it fails to
hold the foot in abduction.
• The external bar brace should be used full
time for 3 months and at night for 4 years.
• Failure of appropriate bracing is the most
common cause of relapse.
• Attempts to obtain perfect anatomical correction
• It is wrong to assume that early alignment of the displaced skeletal
elements will result in normal anatomy.
• Long-term follow-up radiographs show abnormalities.
• However, good long-term function of the clubfoot can be expected.
• There is no correlation between the radiographic appearance of the
foot and long-term function.
TENOTOMY
• INDICATIONS

• To correct equinus when cavus, adductus, and varus are fully

corrected but ankle dorsiflexion remains less than 10 degrees above
neutral.
• Make certain that abduction is adequate for performing the
tenotomy.
Characteristics of adequate abduction
• Confirm that the foot is sufficiently abducted to safely bring the foot
into 0 to 5 degrees of dorsiflexion before performing tenotomy.
• The best sign of sufficient abduction is the ability to palpate the
anterior process of the calcaneus as it abducts out from beneath the
talus.
• Abduction of approximately 60 degrees, in relationship to the frontal
plane of the tibia is possible.
Characteristics of adequate abduction
• Neutral or slight valgus of os calcis is present.
• This is determined by palpating the posterior os calcis.
• Remember that this is a three-dimensional deformity and that these
deformities are corrected together.
• The correction is accomplished by abducting the foot under the head
of the talus.
• The foot is never pronated.
Preparation
• Preparing the family
• Prepare the family by explaining the procedure.
• Explain that tenotomy is a minor procedure
performed under local anesthetic in the outpatient
clinic.
• Equipment
• Prepare all of the material in advance [1].
• Select a tenotomy blade, such as a #11 or #15, or
any other small blade, such as an ophthalmic knife.
• Skin preparation
• Prep the foot thoroughly from midcalf to midfoot
with an antiseptic while the assistant holds the
foot from the toes with the fingers of one hand
and the thigh with the other [1 next page].
• Anesthesia A small amount of local anesthetic
may be infiltrated near the tendon[2 next page].
• Be aware that too much local anesthetic makes
palpation of the tendon difficult and the
procedure more complicated.
Setup for the tenotomy
• With the assistant holding the foot in maximum
dorsiflexion, select a site about 1.5 cm above the calcaneus
for the tenotomy.
• Infiltrate a small amount of local anesthetic just medial to
the tendon at the site selected for the tenotomy.
• Be aware that too much local anesthetic makes palpation of
the tendon difficult and the procedure more complicated.
• Keep in mind the anatomy.
• The neurovascular bundle is anteromedial to the heel cord.
• The heel-cord tendon (light blue) lies within the tendon
sheath (grey).
Tenotomy
• Insert the tip of the scalpel blade from the
medial side, directed immediately anterior
to the tendon.
• Keep the flat part of the blade parellel to
the tendon.
• The initial entry causes a small
longitudinal incision.
• Care must be taken to be gentle so as not
to accidentally make a large skin incision.
• The tendon sheath (grey) is not divided and left
intact.
• The blade is then rotated, so that its sharp edge is
directed posteriorly towards the tendon. The blade is
then moved a little posteriorly.
• A “pop” is felt as the sharp edge releases the tendon.
• The tendon is not cut completely unless a “pop” is
appreciated.
• An additional 15 to 20 degrees of dorsiflexion is
typically gained after the tenotomy.
Post-tenotomy cast
• After correction of equinus by tenotomy, apply the fifth cast [5]
with the foot abducted 60 to 70 degrees with respect to the
frontal plane of the ankle, and 15 degrees dorsiflexion.
• The foot looks over-corrected with respect to the thigh.
• This cast holds the foot for 3 weeks after complete correction.
• It should be replaced if it softens or becomes soiled before 3
weeks.
• The baby and mother may go home immediately.
• Usually, no analgesic is necessary.
• This is usually the last cast required in the treatment program.
CAST REMOVAL
• After 3 weeks, the cast is removed.
• Twenty degrees of dorsiflexion is now possible.
• The tendon is healed.
• The operative scar is minimal.
• The foot is ready for bracing [6ww].
• The foot appears to be over-corrected into abduction.
• This is often a concern to the caregiver.
• Explain that this is not an overcorrection, only full abduction.
Errors during tenotomy
• Premature equinus correction
• Attempts to correct the equinus before the heel varus and foot
supination are corrected will result in a rocker-bottom deformity.
• Equinus through the subtalar joint can be corrected only if the
calcaneus abducts.
• Tenotomy is indicated after cavus, adductus, and varus are fully
corrected.
Errors during tenotomy
• Failure to perform a complete tenotomy
• The sudden lengthening with a “pop” or “snap” signals a complete
tenotomy.
• Failure to achieve this may indicate an incomplete tenotomy.
• Repeat the tenotomy maneuver to ensure a complete tenotomy if
there is no “pop” or “snap.”
 Bracing
• At the end of casting, the foot is abducted to an
exaggerated amount, which should measure 60 to 70
degrees (thigh-foot axis).
• After the tenotomy, the final cast is left in place for 3
weeks.
• Ponseti’s protocol then calls for a brace to maintain the
foot in abduction and dorsiflexion.
• This is a bar attached to straight-last open-toe shoes.
• This degree of foot abduction is required to maintain the
abduction of the calcaneus and forefoot and prevent
relapse.
• The medial soft tissues remain stretched out only if the brace is used
after the casting. In the brace, the knees are left free, so the child can
kick them “straight” to stretch the gastrosoleus tendon.
• The abduction of the feet in the brace, combined with the slight bend
(convexity away from the child), causes the feet to dorsiflex.
• This helps maintain the stretch on the gastrocnemius muscle and heel-
cord tendon.
• Ankle-foot orthoses (AFO’s) are not useful because they only keep the
foot straight with neutral dorsiflexion.
• For unilateral cases, the brace is set at 60 to 70 degrees of external
rotation on the clubfoot side and 30 to 40 degrees of external rotation
on the normal side.
• In bilateral cases, it is set at 70 degrees of external rotation on each
side.
• The bar should be of sufficient length so
that the heels of the shoes are at shoulder
width.
• A common error is to prescribe too short a
bar, that the child finds uncomfortable.
• A narrow brace is a common reason for a
lack of compliance.
• The bar should be bent 5 to 10 degrees
with the convexity away from the child, to
hold the feet in dorsiflexion.
• The brace should be worn full time (day and night) for the first 3
months after the last cast is removed.
• After that, the child should wear the brace for 12 hours at night and 2
to 4 hours in the middle of the day, for a total of 14 to 16 hours during
each 24-hour period.
• This protocol continues until the child is 3 to 4 years of age.
• The Ponseti manipulations combined with the percutaneous tenotomy regularly achieve an
excellent result.
• However, without a diligent follow-up bracing program, relapse occurs in more than 80% of
cases.
• This is in contrast to a relapse rate of only 6% in compliant families
• How long should the nighttime bracing protocol continue?
• As it is often difficult to determine severity, recommendation is that
all feet should be braced for to 3 to 4 years.
• Most children get used to the bracing, and it becomes part of their
lifestyle.
• If after 3 years of age compliance becomes a problem, it may become
necessary to discontinue the bracing.
• The child is closely followed for evidence of relapse.
• Should early relapse be observed, bracing should be promptly started
again.
Ninety percent of patients required five or fewer casts for correction, and there was no difference between groups (P = 0.85).
Average time from first cast to Achilles tenotomy was 16 days for the 5-day group and 24 days for the 7-day group (P = 0.001).
Types of braces
• Modifications of the original Ponseti brace
provide some advantages.
• To prevent the foot from sliding out of the
shoe, a pad may be placed in the counter
of the shoe.
• New designs make the foot more secure
in the brace, more easily applied to the
infant, and allow the infant to move.
• This flexibility may improve compliance.
• H.M. Steenbeek working for the
Christoffel Blinden Mission in Katalemwa
Cheshire Home in Kampala, Uganda,
developed a brace that can be made from
simple, easily available materials.
• The brace is effective in maintaining
correction, easy to use, easy to fabricate,
inexpensive, and ideally suited for
widespread use
• John Mitchell has designed a brace under Dr. Ponseti’s direction.
• This brace consists of shoes made of a very soft leather and a plastic
sole that is molded to the shape of the child’s foot, making this shoe
very comfortable and easy to use
• Dr. Matthew Dobbs of the Washington
University School of Medicine in St. Louis,
USA developed a new dynamic brace for
clubfoot that allows the foot to move
while maintaining the required rotation of
the foot.
• An ankle-foot orthoses are required as
part of this brace to prevent ankle plantar
flexion.
• M.J. Markel developed a brace that allows the parent to first place
the shoes on the infant and then “click” each shoe onto the bar.
• Dr. Jeffrey Kessler of the Kaiser Hospital in Los Angeles, USA
developed a brace that is flexible and inexpensive.
• The bar is made of 1/8” thick polypropylene.
• The brace may improve compliance because it is well accepted by the
infant
• Dr. Romanus developed this brace in Sweden.
• The shoes are made of malleable plastic that is molded to the shape
of the child’s foot.
• The inside is covered by very smooth leather, which makes the
construct very comfortable.
• The shoes are fixed to the bar with screws.
Follow up
• Schedule a return visit in 10–14 days to monitor the use of the brace.
• If the bracing is going well, schedule the next visit in about 3 months.
• At that time, the bracing may be discontinued during the day.
• The brace must be applied for naps during the day and sleep during
the night.
Relapses
• Recognizing relapses
• Once the cast is removed and the bracing is started, plan to see the
child back at the following schedule to check for compliance and for
evidence of relapse:
• At 2 weeks to check for compliance of full-time bracing.
• At 3 months to graduate to the nights-and-naps schedule.
• Until age 3 check every 4 months to monitor compliance and for
relapses.
• Age 3 to 4 years check every 6 months.
• From 4 years until maturity check every 1 to 2 years.
Reasons for relapses
• Noncompliance of the bracing program.
• Morcuende et al. found that relapses occur in only 6% of compliant
families and in more than 80% of noncompliant families.
• If relapse occurs in infants who are braced, the cause is an underlying
muscle imbalance of the foot that can lead to stiffness and relapse.
Casting for relapses
• Do not ignore relapses!
• At the first sign of relapse, apply one to three casts to stretch the foot
out and regain correction.
• This cast management is the same as the original Ponseti casting
program.
• Once the deformity is corrected by casting, start the bracing program
again.
• Even in the child with a severe recurrence, sometimes casting is very
effective.
Equinus relapse
• Recurrent equinus is a deformity that can complicate management.
• The tibia seems to grow faster then the gastrosoleus tendon unit.
• The muscle is atrophic, and the tendon appears long and fibrotic.
• Correct by applying serial long-leg casts with the foot abducted and
the knee flexed.
• Continue weekly casting until the foot can be brought to about 10˚ of
dorsiflexion.
• If this is not achieved in 4–5 casts in children under 4 years of age
repeat the percutaneous heel-cord tenotomy.
• Once the equinus is corrected, resume the nighttime bracing program.
Varus relapse
• Varus heel relapses are more common
than equinus relapses.
• They can be seen with the child
standing and should be treated by re-
casting in the child between age 12
and 24 months, followed by resuming
of a strict bracing program.
Dynamic supination
• Some children, usually between ages 3 and 4
years, with only a dynamic supination deformity
will benefit from an anterior tibialis tendon
transfer
• This transfer is only effective if the deformity is
dynamic and not fixed.
• Delay the procedure until after 30 months of age
when the lateral cuneiform becomes ossified.
• Normally, bracing is not required after the
transfer.
• Relapses that occur after Ponseti management are much
easier to deal with than relapses that occur after traditional
posteromedial release surgery.
Atypical Clubfoot
• Most typical clubfoot correct with about five well-applied Ponseti
casts.
• Some clubfoot have unique features that prolong treatment making
management more difficult.
• These difficult clubfoot may be classified into several categories.
Untreated typical clubfoot
• If treatment is delayed, the idiopathic clubfoot
management becomes progressively more
difficult and prolonged.
• Full correction is still possible into late
childhood.
• For example, this 3-year-old boy with
untreated clubfoot was managed with six casts
followed by a tenotomy and a holding cast for
6 weeks.
• The foot was fully corrected.
• Regardless of age, start with standard Ponseti management,
recognizing that additional treatment may be required.
• If correction is incomplete and residual deformity is unacceptable, soft
tissue or bony surgery may be required to complete the correction.
Atypical clubfoot
• Evaluation
• Examination often demonstrates
• Severe plantarflexion of all
metatarsals,
• A deep crease just above the heel and
across the sole of the midfoot [yellow
arrows], and a
• Short hyperextended big toe.
Treatment by Ponseti method
• Start with manipulation and casting.
• Be aware that treatment will be prolonged, and the risk of relapse is
increased.
• Manipulation
• Carefully identify the talar head laterally.
• It is not as prominent as the anterior process of the calcaneus.
• When manipulating, the index finger should rest over the posterior
aspect of the lateral malleolus while the thumb of the same hand
applies counterpressure over the lateral aspect of the talar head
• Do not abduct more than 30 degrees.
• After 30 degrees abduction is achieved,
change emphasis to correction of the
cavus and equinus.
• All metatarsals are extended
simultaneously with both thumbs
• Casting
• Always apply casts with the above-knee portion in 110 degrees flexion to prevent
slippage.
• Up to 6–8 casts can be needed to correct deformity.
• Tenotomy
• A tenotomy is necessary in most cases.
• Perform the tenotomy when equinus is not corrected.
• At least 10 degrees dorsiflexion is necessary.
• Sometimes it is necessary to change casts at weekly intervals after the tenotomy
to gain more dorsiflexion, if sufficient dorsiflexion is not achieved immediately
after the tenotomy.
• Bracing
• Reduce abduction on the affected side to 30 degrees in the foot abduction brace.
• The follow-up management remains the same.
Other atypical clubfoot
• Clubfoot often coexists with other congenital
abnormalities, such as arthrogryposis,
myelomeningocele, and other syndromes.
• Often the syndrome causes abnormal
collagen, creating stiff ligaments, capsules,
and other soft tissues.
• Syndromic clubfoot are more difficult to treat
and sometimes require surgery.
• Arthrogryposis
• Start with standard Ponseti casting.
• Nine to 15 casts are often required.
• If correction is not achieved, surgery may be
required.
• The magnitude of the surgery will be less as a
result of the Ponseti casting.
• Less extensive procedures such as percutaneous
releases of the tendons of the posterior tibialis,
heel cord and the great toe flexor may suffice.
• The post correction bracing is essential and may
require continuing until mid childhood or longer.
• Myelodysplasia
• Because of sensory loss, casting requires great care
to prevent skin ulceration.
• Apply more padding and avoid excessive pressure in
molding.
• Other syndromes
• Clubfoot is often seen in many other syndromes such
as dystrophic dysplasia, Möbius syndrome, Larsen
syndrome, Wiedemann-Beckwith syndrome, and
Pierre Robin syndrome.
• The long-term functional outcome usually depends
more on the underlying syndrome than the clubfoot.
Management of residual deformity
• If cast correction is incomplete and residual deformity unacceptable,
operative correction may be required.
• Start with Ponseti casting.
• Even if cast correction is incomplete, the severity of the deformity is
reduced, and less surgery will be required to complete the correction.
• Less surgery means less stiffness, weakness, and pain in adult life.
• Select the procedure based on the age of the child and severity and
type of deformity.
• Be aware that clubfoot requiring operative correction are prone to
recur throughout childhood (25–50%)
• Soft tissue release is indicated in infancy and early childhood.
• The procedure depends upon the severity and location of the
deformity.
• Bony procedures are indicated and may be used in later childhood.
• The options include resection and fusions.
• Ilizarov frame correction is becoming more commonly performed for
older children.
• Correction is achieved by gradual distraction and repositioning.
• Reduce the risk of recurrence by over-distraction before correction.
Pitfalls of Ponseti’s technique
• The Ponseti method is highly laborious with a very strict regimen. More failure
will be present if these principles are neglected
• Azarpira et al. commented on the factors responsible for recurrence with
Ponseti’s treatment. They reviewed the results of 196 clubfeet in 115 children
• Male:female ratio of 2.6:1
• Mean age at start of treatment of 5.4 days after birth (1–60 days)
• An average number of casts of 4.2
• Follow up of 11–60 months
• 39 feet had recurrence (30%)
• More recurrences with high statistical significance were observed with
• Nonidiopathic clubfeet
• Noncompliance with bracing
• Low educational level
• More number of casts
Pitfalls of Ponseti’s technique
• Zhao et al. reported from a comprehensive review of well-considered inclusion
criteria from 19 eligible articles out of 519 recorded reports of the Ponseti
method of treatment
• Good correction has been reported in all reports in the initial phase of casting, with
around 90% in all
• Recurrence has been very common in the maintenance phase of prolonged bracing and
noncompliance
• The rate of noncompliance was up to 61%
• The relapse rate was up to 62%
• The most common reason for noncompliance is discomfort and its long-term use
• Four reasons have been analyzed by the authors for noncompliance
1. Variation in bracing protocol
2. Varied definition of noncompliance
3. Calculation of time period of daily bracing
4. Inadequate follow-up or tracking methods
Pitfalls of Ponseti’s technique
• There will be recurrence in more than 80% of cases if the bracing
protocol is neglected
• Important reasons for failures
• Illiteracy
• Poverty
• Lack of training and family support due to culture barriers
• Lack of communication in remote areas
• Reasons for relapses
• Equinus – more rapid tibial growth than growth of gastrocsoleus
• Varus or dynamic supination – overactive tibialis anterior muscle
Pitfalls of Ponseti’s technique
• Goriainov et al. reported a Pirani severity score as a predictor of incidence of
relapse with the Ponseti treatment
• 80 patients included
• Average age at presentation as 23.2 days
• They found statistically significant higher relapse rate in more severe/rigid deformities
with higher Pirani score with 21% relapses in 80 feet
• Bhaskar and Rasal highlighted the pitfalls of the Ponseti technique in 40 treated
children
• They got excellent results in 28 children
• The problems of the Ponseti technique
• Undercorrection due to faulty casting on account of poor learning of the rigid technique
• Gradual learning curve
• Noncompliance of bracing
• Improper brace
• Poor follow-up
Pitfalls of Ponseti’s technique
• McElroy et al. commented that the Ponseti method of casting is good
and cost-effective, but that there are numerous obstacles in its
implementation in Uganda, classifying these into six areas:
1. Inadequate resources
2. Distance to treatment centers
3. Poverty
4. Lack of family support
5. Attitude of caregivers
6. Implementing the treatment process effectively (correct casting,prolonged
bracing, etc)
Ponseti method
• Ponseti recommended bracing for four years, with proper positioning
and long daily wear, to prevent relapse, which is difficult to achieve
• Following the strict regimen is difficult but possible and requires
committed surgeon and supporting staff and commitment from the
patient’s parents, along with financial and other various forms of
committed logistical support.
“French method”
• This technique was used for years, until H. Bensahel became Head of the Department of Orthopaedics at
BUCH
• Bensahel believed that
• Plaster cast immobilization after reduction of this deformity was detrimental
• Forced stretching of muscles in a child (even under anesthesia) would lead to a defense reaction with resulting contraction of
the stretched muscles
• He created a new philosophy of treatment based on his novel pathophysiologic concept of clubfoot “the
functional method of conservative treatment”
• A revolutionary philosophy based on
• Relaxation replaced the stretching
• The newly conceived pathophysiology focused on the origins of the deformity at the level of the Chopart-midtarsal joint
• The functional method was developed and implemented during the early 1970s
• Refined through the years and eventually published in English medical literature in 1995
• Curiously, at the turning-point of the current century, “the functional method” was termed the ‘‘French
Method’’,
French method
• It achieved three goals
• Established objective reproducible parameters that are easy to measure even
for those who have limited experience with clubfeet
• Defined a reproducible 20-point value and severity scale
• Made clinical assessment simple by providing a complete and strict checklist
illustrated with drawings to avoid approximate examinations
• The family’s cooperation in regularly attending the daily sessions must
be emphasized and clearly understood
• Open communication between the orthopaedist and physical
therapist is essential for success of this program
The French method
• Aims
• Relax the tibialis posterior and medial fibrous zone
• Progressive passive manipulations
• Active muscle work
• Taping
• Splinting
The French method
• The infant must be relaxed
• Resistance makes this technique difficult
• The daily treatments were continued for approximately 2 months and were
then progressively reduced to three sessions per week for an additional 6
months.
• Sessions last approximately 30 minutes per foot
• It is detailed and very precise in all its steps including
• Finger placement
• Hand position
• Sensing of the infant’s response
• The first few weeks of life are the best for treatment
The French method
• The goal of this treatment
• Reduce the talonavicular joint
• Stretch out the medial tissues
• Sequentially correct
• Forefoot adduction
• Hindfoot varus
• Equinus of the calcaneus
The French method
• First step
• The navicular bone is progressively released from the medial malleolus and from its medial
position on the head of the talus
• The second step
• Correct forefoot adduction by stabilization of the global adduction of the calcaneus forefoot block
• This maneuver stretches all the joints of the medial ray of the foot progressively:
• Naviculocuneiform
• Cuneiform metatarsal
• MTP
• After all joints of the foot have been loosened, forefoot adduction is further decreased by
continuing to stretch the medial skin crease
• To maintain the new passive range of motion
• The toe extensors and peroneals must be strengthened
• To do this, the therapist elicits cutaneous reflexes by tickling the fifth ray and along the lateral border of the foot
The French method
• The third step
• Progressive reduction of hindfoot varus
• This begins after the talonavicular joint has been reduced
• It can be performed in conjunction with correction of the forefoot adduction
• The ankle is externally rotated at the same time that the calcaneus is being mobilized into
valgus
• The knee is kept flexed to 90 degrees during these maneuvers
• The final step
• Corrects the equinus of the calcaneus
• Often difficult because contracture of the posterior soft tissues may not be easily elongated
by manipulations
• The lateral arch is carefully supported in an effort to protect the midfoot from being
stretched (midfoot break)
The French method
• Once the manipulations are concluded, taping is applied to maintain
the passive range of motion achieved during the session
• M-wrap is a very thin layer of foam underwrap that protects the leg from the
adhesive
• Elastoplast tape holds the foot in position but, because it stretches, permits
exercise of the taped foot
• Hypafix tape keeps the proximal edges of the M-wrap and Elastoplast from
sliding distally
French method
• Most of the clubfoot improvement achieved with the functional method
occurs during the first 3 months
• After this period, only modest amounts of further improvement should be
expected
• If successful, this program continues until the child is walking and is then
discontinued (at 2 to 3 years old)
• Follow-up continues until the end of adolescence
• Percutaneous heel cord tenotomy may be performed in the first several
months
• Physiotherapy is started again after the plaster cast is removed
Results
• Bensahel and associates in 1990
• Good results (without continuous passive motion [CPM]) were attained in nearly 50%
of patients
• When complementary surgery was performed in the remaining patients, the overall
good outcomes increased to 86%
• In more recent reports, good results from exclusively nonoperative treatment
were achieved in 63% (mean follow-up of 10 years) and 77% of patients.
• Some centres produced success treating idiopathic clubfeet with the French
physiotherapy method has been similar to that found using the Ponseti
method.
• The initial correction rate was 95%, and relapses occurred in 29%
Ponseti Vs French methods
• Gait analysis at 2 years old comparing the French method and Ponseti
• Normal kinematic ankle motion was present more often in the Ponseti group
• Residual intoeing was seen in one third of children treated by both methods
• A French study comparing the two methods at 5-year follow-up
• Similar rates of surgery were required by both groups (16% to 21%)
• The Ponseti treated patients required less extensive surgery compared with those
treated by the French method.
• Surgery “a la carte” by combining the advantages of both methods, optimal
outcomes may be maximized.
• Dimeglio has referred to this as the “Hybrid method” or the “third way.”
• It may come to be considered the best approach in the future
Surgical Treatment - principles
• The surgical release must address all pathoanatomic structures in a
resistant clubfoot
• One of the more complicated procedures performed in all orthopaedics
• The decisions that must be made preoperatively and intraoperatively
• Timing of surgery
• Its extent
• How to plan a salvage procedure
• Surgical correction is the last resort
Surgical Treatment - principles
• Multiple operations are to be avoided
• Increasing stiffness
• Deepening of scars
• Hardening of tissue from repeated surgery
• Atrophy introduced by immobilization
• The surgeon who performs the first operation has the best chance of achieving
permanent correction
• The so-called limited release is often a euphemism for an incomplete or inadequate
operation
• Posterior release consisting of Achilles tendon lengthening and posterior
capsulotomies of the tibiotalar and subtalar joints will be sufficient to correct the
equinus and, if present, minimal hindfoot varus
• In approximately 15% of idiopathic clubfeet, a complete posteromedial release will
be needed
Timing of the Procedure
• Surgery should be performed before the age of 12 months (once the child has
achieved walking status)
• Pous and Dimeglio performed surgical releases between 1 and 6 weeks old under
the reasoning that the earlier the fibrous medial and posterior contractures were
released, the better.
• They subsequently abandoned such a program because of excessive scarring and
recurrent fibrosis, which was attributed to the hypermetabolic reaction of the
connective tissue in such a young infant.
• Turco recommended surgery at the age of 1 year or older
• The structures are larger
• The anatomy more easily evaluated and corrected
• The tendon lengthening repairs more secure.
Various Techniques
• Turco is credited with describing the first complete one-stage
posteromedial release.
• Modification of turco
• Carroll
• Goldner
• Mckay
• Simons
Turco procedure - principles
• In planning the surgical correction of the club foot
• Equinus, varus and adduction occur simultaneously rather than as separate isolated movements of the foot and
ankle
• Three groups of contractures are found
• Posterior contracture
• Posterior capsule of the ankle and subtalar joints
• Achilles tendon
• Posterior talofibular and the calcaneofibular ligaments
• Medial
• Deltoid and spring ligaments
• Talonavicular joint capsule
• Tibialis posterior, flexor digitorum longus and flexor hallucis longus tendons
• Frequent result - navicular, sustentaculum tali and medial malleolus are pulled together
• At surgery these structures are usually fused together into a dense mass of scar tissue
• Subtalar
• Anterior subtalar interosseous ligament
• Bifurcate ligament
Turco procedure - principles
• In older children, marked cavus deformity due to
• contractures of the planter fascia and of the abductor hallucis, intrinsic toe
flexor and the abductor digiti quinti muscles
• Adequate surgical exposure is necessary
• To carry out a meticulous sharp dissection under direct vision without
traumatizing the articular surfaces
• To excise or release all the pathologically contracted soft parts preventing
complete correction of the deformity
• To reduce and stabilize the navicular and calcaneus on the talus by transfixing
the talonavicular joint with a Kirschner wire.
• Release of the interosseous talocalcaneal ligament so that the
calcaneus can be everted and rotated by moving the anterior end
laterally and the posterior tuberosity downward was part of Turco’s
original description
• It is generally avoided in other techniques
• Turco immobilized his patients for a total of 4 months and removed
the K-wires at 6 weeks
• Night splints were used for an additional year after the end of cast
immobilization
Turco procedure
• Incision
• A medial incision
• Begun at the base of the first
metatarsal and continued
posteriorly to the tendo achillis
curving slightly under the medial
malleolus
• A vertical extension of the incision
along the tendo achillis is not
necessary and is contraindicated
Turco procedure
• Exposure
• Most difficult
• Following five structures are identified and
exposed in the order given
1.Posterior tibial tendon
2.Flexor digitorum longus
3.Posterior tibial neurovascular bundle
4.Flexor hallucis longus
5.Achilles tendon
• Posterior tibial tendon must be
identified, and its sheath incised from its
insertion to above the ankle
• Flexor hallucis longus is identified under
the sustentaculum tali and freed from its
sheath
• Only the distal two to three centimeters
of the Achilles tendon is exposed
Turco procedure
• The exposure is completed by
freeing the sheaths of the flexor
digitorum longus and flexor
hallucis longus tendons by
dividing the master knot of
Henry
• Excision of the master knot is
necessary to mobilize the
navicular
Turco procedure
• Excision of the pathological
contractures is performed in
three steps
1.The posterior release
2.The medial release
3.The subtalar release
Turco procedure
• Posterior release
• Must be done first to facilitate the
exposure and excision of the
medial and subtalar contractures
• Final step incise the posterior
insertion of the deltoid ligament
Turco procedure
• Medial release
• Begun by cutting the posterior
tibial tendon just above the medial
malleolus
Turco procedure
• Medial release
• completed by returning to the site
of posterior release which ended
at the subtalar joint and everting
the foot
Turco procedure
• Subtalar release
• The talocalcaneal interosseous ligament located above sustentaculum
tali
• Exposed by everting the foot and is transected under direct vision

• Talonavicular joint transfixed with K wire

• The Achilles tendon is repaired
Outcome of turco procedure
• In this preliminary report, he used this procedure in 58 feet in 41 patients up to six years of age
• Out of 31 feet with follow-up for two or more years, results were
• Excellent in 15 feet
• Good in 12
• Fair in 3
• Poor in 1 foot
• Turco reported with 240 operated resistant clubfeet in 176 patients in 1979
• The end results in 149 feet with follow-up for 2–15 years were
• Excellent or good in 83.8%
• Fair in 10.7%
• poor in 5.3%
• The best results obtained were in children operated on between one and two years of age
• He state that a completely normal foot cannot be achieved; there will be some residual deformity
• Previous surgery acted as a spoiler of results
• For older children, he recommended triple arthrodesis at skeletal maturity
Modification of Turco’s basic procedure
• Carroll emphasized plantar fascial release and capsulotomy of the
calcaneocuboid joint
• Because forefoot adduction and supination (actual cavus) were not
addressed by Turco’s procedure
• Through a medial incision the abductor hallucis is identified and released
• The plantar fascia is divided
• The calcaneocuboid joint is opened from the medial side and fully released
• Posterolateral release through a posterior longitudinal incision
• Posterior capsulotomy of the ankle joint is performed
Modification of Turco’s basic procedure
• Goldner
• Complete release of the tibiotalar joint - deep medial deltoid ligaments
• Subtalar capsulotomy is minimized to protect against valgus overcorrection
• The medial and plantar structures (all tendons) are lengthened, as is the Achilles
tendon
• Via a separate lateral incision in the sinus tarsi region, a calcaneocuboid
capsulotomy is performed
• lateral talo navicular capsulorrhaphy to obviate internal fixation is then
performed
• De-emphasizing the subtalar circumferential release and replacing it with the
more complete tibiotalar and midfoot release make Goldner’s approach unique
• The results of clubfoot release without formal subtalar release indicate more
under correction (residual internal foot progression angle), but rarely valgus
overcorrection, a more difficult deformity to reconstruct.
Operative treatment
• More extensive procedures are performed by
• McKay
• Simons
• The majority of peritalar structures, including all hindfoot and midfoot joints,
are released
• A medial and lateral circumferential talocalcaneal release
• Complete release of the talonavicular and calcaneocuboid is included, and
both these structures are pinned
• Once the calcaneus has been adequately derotated by pushing the anterior
end laterally and the posterior tuberosity medially and downward, the
interosseous ligament is internally fixed
• McKay also introduced the concept of an articulated “cable cast”
• The hinge is centered at the ankle joint for immediate postoperative
movement
• the connection between the foot and leg portions of the cast being a
large gauge telephone wire
• This was intended to increase hindfoot (ankle) motion, with 30 to 60
degrees of total motion being reported, although dorsiflexion is usually
limited to 10 to 15 degrees
• Wound complications from early motion of the cable cast have
decreased acceptance of this method of postoperative management
Postoperative Complications
• Loss of Correction
• Dorsal Subluxation of the Navicular
• Valgus Overcorrection
• Dorsal Bunion
• Revision and Secondary Procedures
Loss of Correction
• Most commonly, loss of correction involves inadequate postoperative position as a
result of the cast’s becoming too loose once the postoperative swelling has
resolved
• change the cast during the first 3 to 4 postoperative weeks under anesthesia if necessary
• After the first 4 weeks, cast changes will probably be ineffective
• Maintaining the corrected foot position despite wound complications follows the
principle of obtaining maximum correction by the first cast change
• Pin tract infection can be a dilemma because premature pin removal can lead to
loss of correction
• If a pin tract becomes infected within the first 4 weeks of postoperative
management vigorous pin care should be ensured and antibiotics administered to
maintain the fixation until the normal time for removal.
Dorsal Subluxation of the Navicular
• It produces a shortened cavovarus foot
• It has been reported frequently after Turco procedures
• Tachdjian stated, failure to release the tibionavicular ligament and dorsolateral
talonavicular capsule for the complication
• Kuo and Jansen, however, found this complication to occur just as frequently after a
Carroll-type subtalar and calcaneocuboid release as after Turco procedures
• Reasons
• Failure to release the important tethering structures of the navicular
• Failure to accurately reduce the navicular head of the talus
• Loss of talonavicular reduction as a result of premature pin removal
• Anatomic analysis of the deformity has shown it to be a rotatory subluxation
• The medial edge of the navicular rotated superiorly while the lateral edge is tethered
Dorsal Subluxation of the Navicular
• Indication for revision surgery
• Cavovarus foot deformity
• In children younger than 6 years old
• Release on the lateral side
• Combined with repeat plantar release
• Tibialis anterior lengthening
• Talonaviculocuneiform alignment should be maintained by internal fixation
• In an older child
• Reduction and concomitant medial column lengthening may not be possible
• May need more extensive surgery, including bone resection laterally for
shortening
Valgus Overcorrection
• Excessive hindfoot valgus and usually forefoot
abduction and pronation, is a significant complication
• Generally, results from a horizontal breach in the foot
• The typical background for this involves two scenarios
• The surgeon is unable to obtain or is dissatisfied with the
intraoperative correction and cuts the interosseous
ligaments in the presence of severe internal talar rotational
persistence
• The postoperative position is deemed unsatisfactory
because of forefoot adduction or heel inversion, and
aggressive casting to evert the hindfoot and abduct the
forefoot is carried out to redress the unsatisfactory position
• Plantar release in the absence of fixed cavus will
likewise contribute to this finding
Valgus Overcorrection
• The result is
• Valgus hyperabducted foot
• Weak plantar flexion caused by possible heel cord
incompetence or weakening
• Surgical intervention is generally required
• Restoration of heel height and triceps function
• Varus osteotomy of the calcaneus
• Opening wedge lateral subtalar fusion
• Forefoot realignment
• requires medial column shortening and lateral column
lengthening through the subluxed joints
Valgus Overcorrection
• The entire procedure may best be accomplished by a triple
arthrodesis
• Indication for Triple arthrodesis
• Failed nonoperative methods
• The midfoot is stiff and simple hindfoot correction or lateral column
elongation will not correct the excessive forefoot abduction and
pronation
• Although pseudarthrosis is not common for valgus triple
arthrodesis, there is a definite tendency to undercorrect a
valgus triple arthrodesis.
• Conscious avoidance of overcorrection into varus and “settling” of
opening wedge grafts as they incorporate
• Any foot subjected to triple arthrodesis will exhibit
radiographic degenerative changes in adjacent joints,
particularly the ankle after 10 or more years of follow-up.
Valgus Overcorrection
• Extraarticular correction of valgus deformity has been recommended by
Rathjen and Mubarak
• Medial column shortening
• Lateral column lengthening
• Medial translation of the calcaneus are combined to avoid fusion of any joints.
• Although radiographic correction was noted, functional follow-up was
insufficient to determine whether joint-sparing surgery was beneficial
as hypothesized
Valgus Overcorrection
• Ankle valgus may be present and is an often-overlooked problem that evolves with growth.
• If it is mistaken for hindfoot valgus (“overcorrected clubfoot”), inappropriate hindfoot
surgery may ensue
• Ankle valgus may result in
• Prominence of the medial malleolus
• Lateral shift of the ground reactive forces
• Compression of the lateral portion of the distal tibial epiphysis
• Fibular impingement
• Excessive shoe wear
• Options
• Medial malleolar epiphysiodesis
• Supramalleolar osteotomy
Dorsal Bunion (hallux flexus)
• Can be considered a complication of clubfoot surgery
• Traditionally, a dorsal bunion (hallux flexus) is thought to occur when the depressing
strength of the peroneus longus on the first metatarsal is lost, either through disease
(e.g., poliomyelitis) or iatrogenically (scarring or division), in the presence of
unopposed first metatarsal elevation by the tibialis anterior
• In clubfoot, a dorsal bunion probably occurs as a result of overpull of the long and,
especially, the short great toe flexors in the foot with weak plantar flexion (calcaneus
gait)
• McKay has emphasized the flexor hallucis brevis and abductor hallucis as being
responsible for the hallux flexus.
• A dorsal bunion is often manifested in an overcorrected valgus foot as a poor triceps
and a horizontal breach deformity
Treatment of a dorsal bunion
• Realignment of the first ray - both proximally and
distally
• The flexed MTP joint is released by volar, medial,
and lateral capsulotomy
• Lengthening of the flexor hallucis longus tendon
• Release or dorsal transfer of the flexor hallucis
brevis (to become an MTP extensor)
• The elevated metatarsal shaft is depressed by a
proximal plantar closing wedge osteotomy
• The tibialis anterior is either lengthened or
transferred laterally to the second metatarsal
Revision and Secondary Procedures
• The prevalence of repeat surgery is estimated to be in the range of 10%
• The surgeon must candidly assess the original procedure
• Most “recurrences” are merely a persistence of deformity that was
never completely corrected in the first place
• If it is true recurrence
• Nonidiopathic causes must be considered
• Diagnostic workup should be undertaken
• Electrophysiologic testing
• MRI of the spinal cord
Revision and Secondary Procedures
• Consider the inevitable additional stiffness and muscle weakness that
result from repeat surgery and immobilization
• The primary goal of additional procedures
• Achieve the eventual realistic foot position
• The least possible number of procedures
• If possible, delay one definitive final surgery until 10 years old, when a
bony correction can be accomplished without significant further soft tissue
dissection and immobilization
Types of revision surgeries
• Soft tissue surgery
• Anterior tibial tendon transfer
• Transfer for insufficient triceps surae
• Bony surgery
• Lateral column Shortening
• Calcaneal Osteotomy
• Supramalleolar Osteotomy
• Triple Arthrodesis
Anterior Tibialis Tendon Transfer
• Indication
• Transfer is indicated if the child is more than 30 months of age and
has a second relapse.
• Indications include persistent heel varus and forefoot supination
during walking; the sole shows thickening of the lateral plantar skin.
• Correct deformity
• Make certain that any fixed deformity is corrected by two or three
casts before performing the transfer.
• Usually cavus, adductus, and varus correct.
• Equinus may be resistant.
• If the foot easily dorsiflexes to 10 degrees, only the transfer is needed.
• Otherwise, a tenotomy of the heelcord is needed.
• Anesthesia, positioning and incisions
• Put the patient under a general anesthetic,
positioned supine.
• Use a high-thigh tourniquet.
• Make a dorsilateral incision centered on the
lateral cuneiform.
• Its surface marking is a proximal projection of
third metatarsal in front of the head of the
talus
• The dorsomedial incision is made over the
insertion of the anterior tibialis tendon.
• Expose anterior tibialis tendon
• Expose the tendon and detach at its insertion.
• Avoid extending the dissection too far distally to avoid injury to the
growth plate of the first metatarsal.
• Place anchoring sutures
• Place a #0 dissolving anchoring suture. Make multiple passes through
the tendon to obtain secure fixation.
• Transfer the tendon
• Transfer the tendon subcutaneously to the
dorsolateral incision.
• The tendon remains under the retinaculum
and the extensor tendons.
• Free the subcutaneous tissue to allow the
tendon a direct course laterally.
• Localize lateral cuneiform
• If available, use X-ray. [inset arrow].
• Otherwise identify by delineating the joint
between it and the third metatarsal.
• Identify site for transfer
• Make a drill hole (3.8–4.2) in the middle of the
lateral cuneiform large enough to
accommodate the tendon.
• Thread sutures
• Thread a straight needle on each of the
securing sutures. Pass one needle into the hole.
• Leave the first needle in the hole while passing
the second needle to avoid piercing the first
suture.
• Note that the needle penetrates the sole of the
foot [arrow].
• Consider performing a heel-cord
tenotomy
• If required, perform a percutaneous
tenotomy with a #11 or #15 blade.
• Pass two needles
• Place the needles through a felt pad and
then through different holes in the button
to secure the tendon.
• Secure tendon
• With the foot held in dorsiflexion, pull the
tendon into the drill hole [arrow] by
traction on the fixation sutures and tie the
fixation suture with multiple knots.
• Supplemental fixation
• Supplement the button fixation by
suturing the tendon to the periosteum at
the site where the tendon enters the
cuneiform, using a heavy absorbable
suture.
• Local anesthetic
• Inject a long-acting local anesthetic into
the wound to reduce immediate
postoperative pain.
• Neutral position without support
• Without support, the foot should rest in
neutral plantar flexion and neutral valgus-
varus.
• Skin closure
• Close the incisions with absorbable
subcutaneous sutures.
• Tape strips reinforce the closure.
• Cast immobilization
• Place a sterile dressing and apply a long-leg cast.
• Keep the foot abducted and dorsiflexed.
• Postoperative care
• Remove the cast and button at 6 weeks.
• The child may mobilize weight-bearing as
tolerated.
• Bracing and follow-up
• No bracing is necessary after the procedure.
• See the child again in 6 months to assess the effect
of the transfer.
• In some cases, physical therapy is required to
regain strength and normalize gait.
Transfer for insufficient triceps surae
• Overlengthening of the Achilles tendon or triceps insufficiency
secondary to inadequate excursion from scarring is notoriously difficult
to reconstruct
• Long term functional evaluations have shown plantar flexion weakness
is universal after even the most meticulous technique in an otherwise
“good” result.
• The plantar flexion insufficiency may not be apparent for years, until
the child has grown sufficiently
• The strength of the muscles available for tendon transfer may be inadequate to
replace the missing triceps
• Diagnose plantar flexion weakness as early as possible if muscle transfer is to
have any chance of being effective
Transfer for insufficient triceps surae
• Muscles available for transfer
• Peroneals
• Tibialis posterior
• Long toe flexors
• Incision
• one longitudinal incision centered over the Achilles
• Separate posterolateral and posteromedial incisions
• The tibialis posterior is often scarred and nonfunctional as
a result of the index procedure
• If the tibialis posterior is unavailable, the flexor hallucis
longus is rerouted
• Because of the inter tendinous connections between the flexor
hallucis and flexor digitorum longus distally at their decussation,
flexion power of the great toe does not appear to suffer greatly
 Lateral column Shortening
• “Essential” deformity may consist of a length disparity
between the medial and lateral borders of the foot
• Any attempt to abduct and externally rotate the forefoot is
resisted by the medial contracture and excessive length of
the lateral column
• The cuboid may be displaced medially on the anterior
end of the calcaneus
• Evans suggested that this obstruction to forefoot positioning
by the length and adaptive obliquity of the calcaneocuboid
joint was the essential lesion of clubfoot and described the
use of a wedge resection of the calcaneocuboid joint to
shorten the lateral column as part of treatment of the
relapsed deformity.
• Evans’ procedure relies on concepts of
midfoot (talonavicular and calcaneocuboid)
dislocation and by allowing reduction of the
navicular on the talar head by lateral column
shortening.
• Heel varus was also corrected adequately in
Evans’ original series, although most
investigators find that heel varus must often
be formally corrected by either repeat
subtalar release or a calcaneal osteotomy
Evan’s surgery
• “Collateral operation” the name preferred by Evan
• This operative technique consists of four stages
• The first three stages being extensive soft tissue release realigning the
hindfoot
• Stage one - plantar fasciotomy
• Stage two - medial release
• Stage three - posterior release by Z plasty of tendoachilles and
opening of the talocalcaneal joint
• The fourth stage, the calcaneo-cuboid wedge is excised, shortening the
lateral border
• Plaster cast is kept for four months
• The patient can bear no weight for the first six weeks
• Complications
• Shortening
• Circulatory disturbance
• Stiffness
• Pseudarthrosis
• Total failure led to triple arthrodesis
• The observation of Evans that this operation is likely to succeed below the
age of four years.
Calcaneal Osteotomy
• Indication
• Foot with fixed heel varus
• Types
• Opening wedge osteotomy
• Closing wedge osteotomy
• Lateral displacement osteotomy
• The advantage - subtalar motion is
preserved
• Proposed by Dwyer
• It does not hinder the performance
of a future triple arthrodesis
 Calcaneal Osteotomy
• The opening wedge
• Theoretically increases the height of the heel
• May require Achilles tendon or other posterior release to avoid producing
equinus
• Wound closure on the medial aspect of the ankle can be compromised.
• Weight bearing must be delayed
• The lateral closing wedge
• Less wound healing morbidity
• Decreases the height of the heel to some degree
• It risks lateral impingement
• For effective displacement, the plantar fascia and muscle origins
must be stripped or divided to fully mobilize the distal osteotomy
fragment
• The osteotomy should be made roughly parallel to the subtalar joint
Supramalleolar Osteotomy
• Persistence of a in toeing gait is common in an otherwise plantigrade
foot, regardless of the surgical technique performed
• Yngve and colleagues documented postoperative intoeing more than
2 standard deviations from normal 48% of patients
• in toeing gait was the indication for further surgery in 8% to 25% of
postoperative patients in other series
• Loren et.al. reported an increased incidence of internal torsional
deformity, in patients with abnormal peroneal muscle histopathology,
presumably caused by the muscle imbalance
• Reasons for in toeing
• True internal tibial torsion
• Medial spin of the hindfoot in the ankle mortise
• Medial deviation of the forefoot, with or without true metatarsus adductus
Supramalleolar Osteotomy
• In a younger child, a residual internal foot progression angle should
be observed for spontaneous correction
• If the in-toeing gait persists for 2 years after clubfoot surgery
• Correction to avoid the long-term secondary deformity at the knee
primarily valgus
• It is unknown, however, whether earlier correction of an internal foot
progression angle will change the degree of knee valgus documented
in follow up studies.
• If in toeing gait be severe and not resolve with 2 years of observation,
correction by supramalleolar osteotomy can be effective.
• Benefits
• Avoids additional foot dissection
• It does not contribute to further stiffness
• Indications
• The deformity should be secondary to persistent internal tibial torsion
• Hindfoot medial spin in a patient who has previously undergone subtalar
release but exhibits persistent medial rotation of the talus and calcaneus
• Supramalleolar osteotomy is not generally effective for multiple-plane
corrections.
• It should be reserved only for rotational correction.
Triple Arthrodesis
• After the age of 10-year- Management of residual
deformity requires bony stabilization
• Triple arthrodesis has been the standard orthopaedic
procedure for producing and maintaining correction since
it was first described in the 1920s.
• Indications
• Varus foot
• Overcorrected valgus foot
• Neglected club foot
• Should not be done before skeletal maturity - 10–12
years
• Incision
• A classic lateral incision over the sinus tarsi and
curved dorsomedially toward the talar head
• Align the foot with the ankle mortise.
• Care must be taken to not align the foot with the knee
Correction using the Ilizarov technique
• Ilizarov himself have
reported application of
the technique to clubfoot
• Multi plane corrections
are achieved using hinged
distraction between a
tibial frame and a foot
frame
• The hindfoot and forefoot
usually treated separately
Correction using the Ilizarov technique
• Indications
• Neglected clubfeet
• Severely scarred or multiply operated tissue
• Hold the foot in the corrected or overcorrected position for 2 to 4 months, either in a
frame or in a cast
• Correction of deformity by soft tissue lengthening may be transient.
• Be prepared to perform soft tissue release, tenotomies, or bony stabilization after
frame correction
• Surgery on a foot made stiff and atrophic by frame immobilization may be
complicated by infection and poor wound healing, a waiting period is recommended
• Functional bracing is used during this waiting period
Correction using the Ilizarov technique
• Rehabilitation is a major problem after frame removal
• All reports universally document ankle and subtalar stiffness (less than 20 degrees of motion with no
dorsiflexion), even when only tissue distraction is used
• Long (5 to 9 months) treatment period
• The underlying ankylosis of the deformity itself
• The stiffness induced by cartilage pressure
• Controversy exists concerning the use of ankle hinges to control the talus, which may subluxate anteriorly
if nonconstrained correction of equinus is attempted
• Some authors report correction without constrained ankle correction
• Others recommend hinges and an anterior motor rod to aid in dorsiflexion between the forefoot and distal tibial ring
• The disadvantages
• Osteopenia
• Soft tissue edema
• Trophic changes
• Psychological impact
Neglected clubfoot
• A neglected clubfoot is one which has been inadequately or never treated and deformity is severe
and rigid
• Common problem in low-income countries
• Very little literature available on their treatment
• The bones become deformed
• Treatment before the walking age by the Ponseti technique can bring back the typical appearance
• As the age advances, in neglected clubfoot, the spectrum of severity varies
• Treatment of neglected clubfoot is largely surgical
• The choice of method depends on
• Age
• Severity
• Rigidity
Neglected clubfoot
• Francis and Addis
• Ponseti’s technique of manipulation and casting is effective in children up to
two years of age
• Lourenco and Morcuende have reported ponseti’s technique use in a
small series of 24 neglected clubfeet of older children. 1.2–9 years of
age with percutaneous tenotomy in all and a second posterior surgical
release required in eight of the feet.
 TREATMENT
FOR CLUB
FOOT

Infant and Children age

Adolescent
young children from 4 - 7
 TREATMENT OF EQUINOVARUS DEFORMITY IN THE INFANT AND YOUNG CHILD

Newborn From around 9months of age until 3 years of age

With neurogenic With idiopathic club Ponseti technique

club foot (e.g. foot and no
multiple congenital underlying No response
contractures / neuromuscular
arthrogryposis disease
Predominant All components of
Serial manipulation equinus deformity the deformity
and casting to reduce Ponseti technique persisting (other persisting
the severity of Serial manipulation components
deformity prior to and casting with or corrected)
surgery without Some components are All components are
percutaneous not very rigid very rigid
Posterior soft tissue
Early (by 6 months) tendo-Achilles
release + splint
posterior and medial tenotomy, and
followed by Denis Posterior and medial Complete subtalar
release
Browne splint soft tissue release + release + Splint
Splint
Cast and protracted
splint use to prevent
recurrence
 TREATMENT OF RESIDUAL DEFORMITIES IN CHILDREN BETWEEN FOUR AND
SEVEN YEARS OF AGE

Residual forefoot deformity Residual forefoot and Forefoot adductus/ supination

(adductus and supination) hindfoot deformity and hindfoot equinovarus
+ +
Not correctable passively Partially correctable passively
+ +
Partially correctable Not correctable Previous surgery No previous surgery
passively passively + +
Age > 6 years Age > 6years (more likely seen
(more likely in relapsed in neurologic conditions of late
Aged 3–4 years CTEV) onset, e.g. Duchenne muscular
Age <4years Age >4 years dystrophy, rather than relapsed
+ + congenital talipes equinovarus)
Medial soft tissue
Ossific nucleus Ossific nucleus
Repeat of cuneiform of cuneiform
release + Posterior soft
tissue release + Split
serial casts not appeared appeared tibialis anterior tendon
+ Medial soft tissue release + Tendo
transfer to the lateral
Achilles lengthening + Tibialis
Transfer border
of the dorsum of the foot posterior tendon transfer through the
of tibialis Tibialis posterior lengthening
Tibialis posterior lengthening +
+ Lateral displacement interosseous membrane to the lateral
Abductor hallucis release +
anterior to + Abductor hallucis release +
Talonavicular capsulotomy + osteotomy of the border of the dorsum of the foot +
Talonavicular capsulotomy +
the lateral Laterally based closed wedge
Laterally based closed wedge calcaneal tuberosity or Bracing after correction
osteotomy of Gradual correction
cuneiform osteotomy of
cuboid/decancellation of
cuboid/decancellation of cuboid through soft tissue
+/- Open wedge osteotomy of
cuboid distraction in an external
the medial cuneiform
fixator
TREATMENT OF RESIDUAL OR RECURRENT EQUINOVARUS DEFORMITY IN THE
ADOLESCENT

Stiff forefoot and hindfoot deformity + History of previous soft tissue releases

Normal dome shape ‘Flat top’ shape to

to body of talus on body of talus on
lateral radiograph lateral radiograph
view view

Gradual correction
through soft tissue Age >10 years Changes of joint degeneration
distraction in (subarticular sclerosis with joint space
external fixation loss)
+
Gradual correction Age >12 years
through V-type
osteotomy across
calcaneum and
midfoot with Triple arthrodesis
distraction in OR
external fixation Gradual correction through V-type osteotomy
across calcaneum and midfoot with distraction
in external fixation
SUMMARY
• Clubfoot, also known as congenital talipes equinovarus, is a
common idiopathic deformity of the foot that presents in
neonates. 
• Diagnosis is made clinically with a resting equinovarus
deformity of the foot.
• Treatment is usually ponseti method casting.
• Supplemental surgical procedures such as tendoachilles
lengthening and tibialis anterior transfer may be required during
treatment to correct residual deformity. 
REFERENCES
• https://www.orthobullets.com/pediatrics/4062/clubfoot-congenital-t
alipes-equinovarus
• Clubfoot:Ponseti Management.Third Edition
• Campbells operative orthopedics. 14th edition
• Ponseti IV, Smoley EN. Congenital clubfoot: the results of treatment. J
Bone Joint Surg Am 45(2):2261¬–2270.
• Pirani S, Zeznik L, Hodges D. Magnetic resonance imaging study of the
congenital clubfoot treated with the Ponseti method. J Pediatr Orthop
21(6):719–726.