Clubfoot

History

Treatment of idiopathic clubfoot is surgical or manipulative. Despite long-term experience in many centers, there still are outcome controversies surrounding both alternatives. Controversies persist because of lack of a) standards for evaluating functional outcomes, rendering comparisons between treatment groups problematic, and b) long-term follow-up studies of surgically treated clubfeet. The longest published follow-up is the 30-year follow-up of 45 patients (with 71 clubfeet; average age 34 years) treated with the Ponseti method of manipulation and casting at the University of Iowa Hospitals and Clinics between 1950 and 1967.

Clubfoot is a complex congenital deformity consisting of equinus, varus, adductus, and cavus The foot is displaced and adducted beneath the talus. The talus and calcaneus are generally deformed and in a severe equinus. The calcaneus is in varus and adducted. The cuboid and the cuneiforms are displaced. The forefoot is somewhat pronated with respect to the hindfoot, and the first metatarsal is plantar-flexed to a greater degree than the fifth metatarsal (cavus). Clubfoot has greater chances of being fully corrected if treatment is initiated in the first days after birth. This treatment should be non-operative, benefiting from the favorable fibroelastic properties of the ligaments, capsules, and tendons. Early operation induces fibrosis and stiffness, thus, must be delayed until the child is at least three months old. The 50-year personal experience of Ignacio V. Ponseti, MD, indicates that most clubfeet, when treated shortly after birth, can be easily corrected by manipulation and application of five or six plaster casts. A small number of infants with short, fat feet and stiff ligaments, which don’t yield to stretching, need surgical correction.

New Facts

The 30-year follow-up focused on comparing the patients’ subjective assessment of treatment results with the objective radiographic and physical evaluation. Patients were evaluated using a questionnaire for pain and functional performance throughout their lives, physical examination, and radiography. Self-evaluation of satisfactory function of the foot was interpreted in the context of patients’ occupations, the latter being divided into low-foot-demand and high-foot-demand category. Objective evaluation did not correlate with pain and function of the foot. The radiographs demonstrated a number of differences between the treated clubfeet and the normal contralateral feet. Electrogoniometric analysis revealed markedly decreased passive and active dorsiflexion, plantar flexion, and inversion of the treated clubfeet compared with those of the normal feet. Pedobarographic data revealed no differences in pressure between the clubfeet and the normal feet when the entire foot was assessed, but showed substantial regional differences. Regardless of the differences in almost all objective measurements, very few could be predictive for excellent, good, or poor functional outcome.

Subjective assessments provided a better measure of long-term functional outcome than radiographic and physical findings. Moreover, with the use of pain and functional limitation as the outcome criteria, the group of 45 patients with clubfeet was doing nearly as well as a matched control group of individuals who did not have congenital deformity of the foot (78% vs. 85% excellent and good results). In the absence of any radiographically detectable progression of degenerative osteoarthrosis in the foot or ankle, one may well affirm that the excellent and good subjective results will persist for many years.

Low-foot-demand occupations had a significant correlation with excellent and good results compared with high-foot-demand occupations (p=0.03). This shows that early counseling of the patient to obtain sedentary job and avoid excess weight gain is appropriate.

Practice

At the UI Hospitals and Clinics, the uniform type of treatment by manipulation and casting has been performed on more than 1,000 patients since 1948. The Ponseti method requires that all components of the clubfoot be corrected simultaneously, except for equinus, which should be corrected last. The cavus is corrected together with the adduction by supinating and abducting the forefoot in proper alignment with the hindfoot. Then, with the arch well molded and the foot in slight supination, the entire foot can be gently and gradually abducted under the talus, which is secured against rotation in the ankle mortise by applying counterpressure with the thumb against the lateral part of the talus head. Heel varus is corrected when the entire foot is fully abducted. Finally, equinus is corrected by dorsiflexing the foot. This is generally facilitated by a simple percutaneous tenotomy of the tendo achillis. Well-molded, long-leg plaster casts are applied after completion of each manipulation. The purpose of the casting is to immobilize the contracted ligaments at the maximum stretch obtained after each manipulation.

To prevent recurrences, the corrected feet must be maintained in outward rotation in open shoes attached to a bar at nighttime for several years. The results, although anatomically not always perfect, are almost perfect functionally, at least into the fifth decade of patients’ lives.

Highlights

  1. Most clubfeet, when treated shortly after birth, can be easily corrected by manipulation and application of five or six plaster casts (the Ponseti method).
  2. Radiographic and physical evaluation of clubfoot treated patients is not predictive of excellent, good, or poor functional results.
  3. The timely and well treated clubfoot is compatible with a normal active life.
  4. Clubfoot patients should be counseled to obtain sedentary jobs and avoid weight gain.