Clubfoot: Definition, Treatment, and Specialists

What is Clubfoot?

Congenital clubfoot in newborns is a foot (and leg) malformation presenting in an incorrect position from birth. When referring to this condition, it is almost always understood to be clubfoot, as this presentation is the most frequent.

The term equinovarus clubfoot means the following:

• The foot is turned inward and the toe points downward (equinus);
• Being bent inward, the plantar arch is curved (cavus);
• The heel is turned inward when the foot is viewed from the back (varus);
• The sole of the foot is turned inward and upward (adduction and supination);

Clubfoot is defined as such when, when manipulated to assume a "normal" position, it tends to recur and fails to maintain the correct position. Obviously, even from a simple visual observation, it does not appear straight but downright "twisted".

Causes: How Does Clubfoot Develop?

The nature of this pathology can be:

• Post-traumatic;
• Congenital;
• Neurological;
• Spina bifida;
• Muscular dystrophy;
• Hip dysplasia;
• Cerebral palsy in children;
• Stroke; cerebral hemorrhage; cerebral ischemia;

This is a congenital skeletal deformation, particularly affecting the sole of the foot, especially the outer part. This part tends to turn towards the median part of the body, thus creating a kind of inward twisting of the foot itself.

As already mentioned, one of the main causes of this pathology is undoubtedly the genetic factor, and this is why there are no particular symptoms since it presents from birth. The main characteristic of this foot is that it is shorter and slightly wider than a standard foot.

Clubfoot Therapy with Splint or Surgery?

The main method for correcting clubfoot has been, for many years, the Ponseti method, named after the Spanish doctor Ignacio Ponseti, who was the first to effectively treat this deformity.

This method can be used from the first weeks after birth, based on a series of manipulation and casting maneuvers that allow for progressive and gradual correction of the foot; surgery is only used if necessary, at the end of the casting phase, and reduced to percutaneous tenotomy of the Achilles tendon (a few millimeter incision to dissect the tendon). Casts are usually changed weekly.

To maintain the correct correction obtained, it will then be essential, as a second step, to use splints that keep the foot in abduction (turned outwards); for the first months, it will be a fixed splint, subsequently the wearing hours decrease, but it will still need to be used until the age of 4.

In severe cases of clubfoot, or in those where more conservative treatment has failed, more extensive surgery may be necessary, consisting of stretching the joints, tendons, and muscles. Even after this type of intervention, it will be necessary to wear a fixed cast for a few months, as well as an orthopedic device for an additional year.

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Clubfoot Splint

The clubfoot splint involves a series of casts in knee braces (long casts from the root of the thigh to the foot).

The foot is progressively and gently brought from a position with the toes pointing inward to a position with the toes pointing outward.

Specific manipulations are performed at each session and the foot is cast in the correction position that can be achieved at that precise moment, without forcing it. The cast is then kept in place for about 7 days: during this period, the different anatomical structures (joints, ligaments, etc.) relax and adapt to the new position, preparing to be stretched again during the next session. Once the cast is removed, an immediate improvement in the foot deformity is observed, which will be ready to be immobilized in a more corrected position. This prevents worsening the consequences of clubfoot.

Clubfoot Surgery

All possible surgical techniques to correct clubfoot mainly aim to lengthen the triceps surae muscle. Shortening or retraction of the triceps surae determines clubfoot and may constitute an indication for surgery to lengthen this structure. Once the necessary assessments have been made, the surgeon can plan the type of clubfoot surgery. The techniques are subdivided into surgical levels, i.e. according to the anatomical area of the triceps surae to which they are addressed.

The following surgical procedures are distinguished:

• Baumann technique: it consists of lengthening the aponeurosis covering the gemellus muscles in the proximal part of the leg; the muscle fibers of the gastrocnemius and soleus are left intact;
• The Strayer technique consists of lengthening (or simple tenotomy) of the distal tendon of the gastrocnemius, upstream of its junction point with the soleus aponeurosis; lengthening of the soleus aponeurosis at the same level (deeper) can be associated;
• Vulpius and Baker techniques consist of lengthening the articular gastrocnemius-soleus tendon, keeping the soleus muscle fibers intact at a deeper level;
• Achilles tendon lengthening techniques: particularly indicated when the extent of the equinus deformity is marked and the shortening affects both the gastrocnemius and the soleus. This procedure can be performed open or by a percutaneous technique;

In the postoperative period, the surgeon generally performs a cast from below the knee to the toes, which will be maintained for 3 to 6 weeks, depending on the technique used and the associated procedures. Any variation or the possible need for postoperative bracing will be discussed with the parents during surgical planning.

Which Doctors and Clinics Specialize in Clubfoot Treatment?

Clubfoot requires management by a multidisciplinary team generally composed of a pediatrician, an orthopedic surgeon specializing in clubfoot, a physiotherapist, but above all, treatments must be provided in specialized structures. Clubfoot is a malformation that, if treated in time, allows for remarkable results. Ask your doctor for before and after clubfoot photos to get an overview of the results.

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