What Happens Years Later When Surgery is Needed for Clubfoot

In this study from Northwestern University School of Medicine, one surgeon presents the long-term results of his technique for surgical correction of clubfoot. Infants with equinovarus (medical term for clubfoot) are treated first with a conservative approach called the Ponseti method. This involves a series of casts used to gradually correct the alignment of the ankle and foot.

But if correction is not successful with this nonoperative care, then surgery is needed.
The technique used by this surgeon was described as “extensive soft-tissue releases.” Details of the surgical procedure are provided by the author. Briefly, here’s what was done. The Achilles tendon (attaches the calf muscle to the calcaneus (heel bone)) was cut in a Z-pattern and lengthened. Two other tendons (posterior tibialis tendon and abductor hallucis brevis tendon) were also surgically released.

Then several ligaments in the ankle were divided and the capsule (a tough fibrous structure) around the ankle joints was cut. Once the bones (especially the rotated talus bone were properly aligned, a special wire (called a Kirschner wire) was passed through the talus to hold it in place. The talus is between the calcaneus (heel bone) and the rest of the ankle.

Another wire was passed through both the talus and the calcaneus. The wires were used like a “joystick” to maintain the derotation of the talus in order to straighten the ankle and foot out. The whole leg was put in a splint for two weeks and then a long-leg cast replaced the splint for another four weeks.

After that, the wires were taken out and the child was given a special brace called an ankle foot orthosis or AFO. An AFO holds the foot and ankle in proper position and alignment. The AFO was used for an average of one year. Some of the patients wore a special night splint called a Denis Browne bar. A few others were fitted with special tarsal pronator shoes (to help keep the bones of the foot in the middle and prevent them from drifting inwards).

There were a total of 80 children in the study. Some had bilateral clubfoot (both feet affected), so there was a total of 120 feet surgically corrected. For two-thirds of the group, the authors described the results as “acceptable” and “durable.”

The remaining one-third had to have additional surgery because the deformity was not fully corrected. No one needed to have the ankle fused. For the children who only had one foot involved, there was a significant difference in motion, calf size, leg length, and foot length between the two feet at the final check-up years after the surgery. Muscle strength was normal for half the group.

In summary, using this surgeon’s unique, uniform surgical treatment of clubfoot (extensive soft tissue releases and realignment of the bones) provided good correction of the foot and ankle. Results were best for children who had unilateral (one-sided) clubfoot and only one surgery. Pain, activity level, and disability scores were significantly worse in patients who had to have a second surgery.

Other studies have shown gradual worsening over the years after surgical correction of clubfoot using other techniques. The long-term results obtained using this surgeon’s approach were much more favorable. More patients had fewer problems with residual deformity or need for additional surgery than has been reported in other studies using other surgical methods.

Conservative care with serial casting (the Ponseti method) is still advised as the first-line of treatment for clubfoot. But for those children who need surgical assistance in restoring ankle and foot alignment, this surgeon recommends the type of comprehensive subtalar release and derotation described in this article. With more optimal correction early on, children get better results in their adult years.