Clubfoot: Causes, Treatments, and Surgery

What is Clubfoot?

Clubfoot is a malformation of the foot (and leg) present from birth in an incorrect position. It's defined as such because, even when manipulated into a "normal" position, it tends to revert and fail to maintain correction. Visually, the foot appears twisted. Consequences can include early-onset osteoarthritis of the foot and ankle, significant limitations in motor activity and sports participation, and severe limping.

Ankle torsion can prevent walking on the sole of the foot. Children may compensate by walking awkwardly on the outside or, in severe cases, the top of the foot, leading to calluses or wounds. Orthopedic surgeons lead the treatment team, collaborating with physicians, pediatric surgeons, anesthesiologists, nurses, and others.

Another type of clubfoot results from extrinsic factors (reduced amniotic fluid, abnormal uterine position, uterine malformations) forcing a position during the final months of pregnancy. Unlike other forms, this type is often transient and resolves spontaneously or with corrective manipulations.

Causes

Clubfoot is a skeletal deformity affecting multiple planes; equinus is just one. The most frequent cause is congenital clubfoot, manifesting in various deformities.

It is a common pathology in African and Mediterranean countries.

In developing countries, it poses a greater problem, potentially causing mortality due to walking disabilities.

Treatments

The Ponseti method (1970s) uses corrective casts worn until the child can walk, correcting the foot as it grows. However, it may not fully correct the problem and can potentially crush developing bones and joints, resulting in internal deformities despite a normal external appearance.

Post-traumatic (adults) and congenital deformities differ significantly. Congenital deformities adapt proprioceptive capacities and skeletal structure during growth. However, if deformity causes pain and disability, correction is advised, primarily aiming to enable full weight-bearing.

Simple tendon lengthening is rarely sufficient; skeletal corrections and tendon surgery (planned using weight-bearing radiographs) are often necessary. Irreversible ankle involvement may require an ankle prosthesis, combined with time for comfortable plantigrade support. Results can be well-tolerated for years.

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Clubfoot Surgery

Traditional surgical treatment (Codivilla method) is recommended in specific cases, usually around 3-4 months of age (6 kg minimum weight for anesthesia). This is for cases unresponsive to plaster treatment, requiring surgical release. It's also an option when logistical or family reasons prevent frequent check-ups needed for the Ponseti method.

Surgery involves double incisions (back and inside of the foot), releasing/lengthening tendons, muscles, and joints restricting the foot. It lasts 45-60 minutes per foot, depending on severity. A thigh-length cast is applied post-surgery to maintain correction.

• Preoperative study: blood tests, anesthetic evaluation, electromyography (muscle function), spine and pelvis X-rays (associated malformations).
• Postoperative monitoring: general condition, local issues (toe swelling, pain, wound issues). This is longer than for Achilles tenotomy due to invasiveness. Clubfoot splints and shoes are worn post-surgery for healing.

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