Our 23-month old son is having surgery on his little clubfeet because casting and splinting didn’t work. The surgeon is thinking that only one surgery will be needed but of course, no one knows for sure. What are the reasons why a child with this problem might need a second surgery? I’m not really sure how this works.

Clubfoot (also known by the medical term: equinovarus) describes a condition in which the foot is turned under and towards the other foot. Equinus means that the toes are pointed down and the ankle flexed forward (sort of like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.

This twisted position of the foot causes other problems. The ligaments between the bones are contracted, or shortened. The joints between the tarsal bones do not move as they should. The bones themselves are deformed. This results in a very tight stiff foot that cannot be placed flat on the ground for walking. To walk, the child must walk on the outside edge of the foot rather than on the sole of the foot.

To avoid these problems, infants born with this condition are treated with a nonsurgical treatment approach called the Ponseti method. The Ponseti method is a series of casts put on the lower leg and foot to gradually straighten the bones out and restore normal motion and alignment of the foot and ankle. The technique works well for about 90 to 95 per cent of children with a clubfoot deformity.

But if correction is not successful with this nonoperative care, then surgery is needed. Some of the soft tissues (tendons, ligaments, joint capsule) in the foot and ankle are cut. The surgeon may realign the bones and hold them in place with wires. Splinting and casts are used to maintain the correct position until healing takes place.

A second surgery could be needed if, for example, the deformity isn’t corrected or the toes start to drift inward (a condition called metatarsal adduction). Studies show that about two-thirds of the children who need the first surgery do fine and need no further treatment. But the remaining one-third still need some surgical follow-up to achieve the best results. Sometimes, this is something as simple as a tendon release. In other cases, the surgeon has to cut the joint capsule to allow for better joint motion.

Recent research has shown that early, aggressive surgical treatment gives better correction, thus reducing the need for further surgeries. It sounds like your surgeon has a plan in mind that he or she thinks will be the only procedure needed and one that will be successful!