Management of Clubfoot

Original Editor - in conjunction with Africa Clubfoot Training Team as part of ICRC and GCI Clubfoot Content Development Project

Top Contributors - Evan Thomas, Naomi O'Reilly, Rachael Lowe and Meaghan Rieke

Introduction

The treatment of clubfoot has evolved over time and can generally be divided into two main approaches: Conservative and Surgical Approaches.  The goal of treating clubfoot remains the same whatever the approach: to provide long-term correction of the deformity resulting in a foot that is fully functional and pain-free.[1] Other authors add the additional goals of achieving a foot that is in a plantigrade position and ability to wear normal shoes. Conservative techniques primarily achieve correction of clubfoot by slowly stretching tight structures, allowing time for soft tissue and cartilaginous remodelling[2].  Surgical management of clubfoot achieves these aims through division or lengthening of bony or soft tissue structures which are tight or misshapen and are causing deformity.[3] Over time there have been many different treatment techniques used for clubfoot and it is not possible to provide details of all of them. Those which appear most frequently in the literature namely the Ponseti Method, Kite Method, French Method and Surgical Approaches are summarised below.

In recent years, a number of articles published have acknowledged lack of services for clubfoot as a serious public health issue resulting in high levels of impairment which may be preventable.[4][5][6] 

Conservative Methods

Numerous treatment techniques are available, but the most prominent appear to be Ponseti's, Kite's, and the French methods.

Ponseti's Method

The Ponseti Method, developed by Dr Ponseti, an Orthopaedic Surgeon based at the University of Iowa in 1963 following extensive anatomical study of the foot,[7] has been shown to be safer and more efficient than surgery for the treatment of clubfoot.[8][9] The first study of the long-term outcomes of the Ponseti Technique, which led to the widespread popularisation of the technique was published in 1995.[10] This technique uses a very specific series of manipulations and castings to correct the foot deformity and complete tenotomy of the Achilles’ tendon in most cases to eliminate equinus deformity followed by a further three weeks in a cast. The patient must then wear a foot abduction orthosis, a set of boots set in abduction and dorsiflexion on an immovable bar, fulltime for three months and then at night at least until the age of four.[11] Used correctly, results of the Ponseti Method can achieve full correction of the clubfoot deformity in up to 98% of cases.[12]  Long-term follow-up at approximately 30 years showed excellent treatment results, with ‘excellent or good’ foot function demonstrated in 78% of individuals with clubfoot compared with 85% of matched individuals without congenital foot deformities[10]  These outcomes have led to the current situation in most high-income countries where the Ponseti Method is the treatment of choice for clubfoot almost by most orthopaedic surgeons.[3]

Kite's Method

This technique is a conservative method of treating clubfoot, which is now no longer widely used or accepted in the orthopaedic community[10] The Kite method was developed by Dr Kite in the USA in the 1930’s.[1] Kite sought to find a non-invasive treatment strategy for clubfoot after he became dissatisfied with the poor results of surgical treatment and the often traumatic outcomes following forcible manipulations of clubfoot deformity using the Thomas Wrench, popular at the time.[13]  Kite’s Method of treatment consists of a series of manipulations and castings followed by night splinting with the feet held in dorsiflexion and slight abduction.

Kite reported good outcomes with non-invasive treatment in 800 cases of clubfoot.[13] These outcomes were not reproducible in further studies;[14][15] however, up to 90% of children treated using the Kite method needed additional surgical, soft tissue releases.[15]  These unsatisfactory outcomes were attributed to two main factors: anatomically inaccurate method of manipulation of the foot which prevents the deformity from resolving and the use of short leg (below knee) casts which are inadequate to hold the corrected position of the foot.[14]  The Kite method also requires high numbers of castings and it may be up to two years before the deformity is corrected.[1]

The French Method

Readers may also wish to be aware of the French Functional (Physical Therapy) Method, a less commonly used technique for which there is a much smaller body of supporting research evidence.

The French Method consists of daily manipulations of the infant's clubfoot, stimulation of the muscles acting on the foot to maintain the reduction achieved through manipulation, and foot immobilization using nonelastic adhesive strapping. Treatment usually lasts over a course of approximately two months and is then gradually reduced. Improvement typically occurs within the first three months and is achieved at a slower rate when compared to the Ponseti Method.[16]

Richards et al (2008) compared the Ponseti and French Methods, and found after 51.4 months average follow-up that feet managed with the Ponseti Method demonstrated a trend towards a better clinical outcome versus those managed with the French Method (p = 0.31); however, the results were very close. For the Ponseti Method, outcomes were considered 'Good' for 72%, 'Fair' for 12%, and 'Poor' for 16% of the participants, compared to 67%, 17%, and 16%, respectively, for the French Method. The authors report that this may have been attributed to the amount of substantial effort required to train the parents and have them implement the technique reliably (i.e. perform the stretching, taping, and splinting on a daily basis) for up to two years.[16]

Surgical Intervention

Early surgical management of clubfoot in the late 1800’s mainly consisted of different types of soft tissue release but had satisfactory outcomes in as low as 45% of patients treated[1].  Surgical techniques regained popularity in the 1970’s and were the treatment of choice throughout the 1980’s and 1990’s; many of these were variations on the posteromedial release (PMR) involving extensive release of the soft tissues of the foot.[1]  Turco, whose work was particularly influential in the rise of surgical techniques reported his method of PMR as having excellent or good results in 83% of cases at follow up ranging from 2-15 years after initial treatment.[17]  However, other long-term follow-up studies, notably that by Aronson & Puskarich (1990) found high levels of foot and ankle stiffness and weakness amongst patients ten years after treatment with surgical release.[18] This and other evidence led to the current stance adopted by most orthopaedic clinicians: that clubfoot should ideally initially be managed non-invasively.[1][3][19]

Evidence

A recent meta-analysis of nine eligible studies concluded that Ponseti’s Method decreases the number of surgical interventions required as compared to other “non-Ponseti” methods. Analysis of the pooled odds ratios demonstrated a significantly higher rate of poor-to-fair results, relapses, and requirement for major surgery when using Kite’s method as opposed to Ponseti’s, but no significant difference was detected comparing Ponseti’s to the French method.[8]

This present meta-analysis showed that Ponseti’s method avoided major surgery among various institutions in an average of 84.9% patients, succeeded in an average of 75.6% patients, and achieved a good-to-excellent functional prognosis in an average of 91.1% patients.[8]

Guidelines

Recently, the Dutch Clubfoot Guideline on Primary Treatment of Clubfoot was developed aimed at providing evidence-based advice to both clinicians and parents in order to minimise variation in treatment and improve therapeutic compliance. This guideline covers the primary diagnosis and treatment of idiopathic clubfoot in children presenting with the deformity in the first 6 months after birth, but does not cover the treatment of clubfeet after delay or in children with residual deformities.[9]

The Dutch Clubfoot Guidelines address the following four clinical questions:

  1. What is the optimal treatment for clubfoot?
  2. What is the importance of brace compliance and other patient-related factors in the successful treatment of clubfoot?
  3. What is the optimal method to be used for the diagnosis and classification of a clubfoot?
  4. With respect to organization of care, what are the preconditions for optimal treatment of patients with clubfoot?

Resources

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Dobbs MB, Gurnett CA. Update on Clubfoot: Etiology and Treatment. Clin Orthop Relat Res, 2009; 467(5): 1146-1153.
  2. Pirani S, Zeznik L, Hodges D. Magnetic resonance imaging study of the congenital clubfoot treated with the Ponseti method. Journal of Pediatric Orthopaedics. 2001 Nov 1;21(6):719-26.
  3. 3.0 3.1 3.2 Bridgens J, Kiely N. Current Management of Clubfoot (Congenital Talipes Equinovarus). BMJ, 2010; 340: 308-312.
  4. Saltzman HM. Foot Focus: International Initiative to Eradicate Clubfeet Using the Ponseti Method. Foot Ankle Int, 2009; 30(5): 468-71.
  5. Lavy CB, Mannion SJ, Mkandawire NC, Tindall A, Steinlechner C, Chimangeni S, Chipofya E. Clubfoot Treatment in Malawi - A Public Health Approach. Disabil Rehabil, 2007; 29(11-12): 857-62.
  6. Penny JN. The Neglected Clubfoot. Techniques in Orthopaedics, 2005; 20(2): 153-166.
  7. Morcuende JA. Congenital Idiopathic Clubfoot: Prevention of Late Deformity and Disability by Conservative Treatment with the Ponseti Technique. Pediatr Ann, 2006; 35(2): 128-30,132-6.
  8. 8.0 8.1 8.2 He JP, Shao JF, Hao Y. Comparison of different conservative treatments for idiopathic clubfoot: Ponseti's versus non-Ponseti's methods. J Int Med Res, 2017; 45(3): 1190-1199.
  9. 9.0 9.1 Besselaar AT, Sakkers RJB, Schuppers HA, Witbreuk MMEH, Zeegers EVCM, Visser JD, Boekestijn RA, Margés SD, Van der Steen MCM, Burger KNJ. Guideline on the diagnosis and treatment of primary idiopathic clubfoot. Acta Orthop, 2017; 88(3): 305-309.
  10. 10.0 10.1 10.2 Cooper DM, Dietz FR. Treatment of Idiopathic Clubfoot. A Thirty-year Follow-up Note. JBJS. 1995 Oct 1;77(10):1477-89.
  11. Ponseti IV, Zhivkov M, Davis N, Sinclair M, Dobbs MB, Morcuende JA. Treatment of the Complex Idiopathic Clubfoot. Clin Orthop Relat Res, 2006; 451: 171-176.
  12. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical Reduction in the Rate of Extensive Corrective Surgery for Clubfoot using the Ponseti Method. Pediatrics, 2004; 113(2): 376-80.
  13. 13.0 13.1 Kite JH. Some Suggestions on the Treatment of Clubfoot by casts. J Bone Joint Surg Am, 1963; 45-A: 406-12.
  14. 14.0 14.1 Herzenberg JE, Radler C, Bor N. Ponseti Versus Traditional Methods of Casting for Idiopathic Clubfoot. J Pediatr Orthop, 2002; 22(4): 517-21.
  15. 15.0 15.1 Zimbler S. Nonoperative Management of the Equinovarus Foot: Long-term results. In: Simons GW, ed. The Clubfoot. New York: Springer-Verlag, 1994: 191-193.
  16. 16.0 16.1 Richards BS, Faulks S, Rathjen KE, Karol LA, Johnston CE, Jones SA. A Comparison of Two Nonoperative Methods of Idiopathic Clubfoot Correction: The Ponseti Method and the French Functional (Physiotherapy) Method. J Bone Joint Surg Am, 2008; 90: 2313-2321.
  17. Turco VJ. Resistant Congenital Clubfoot - One-stage Posteromedial Release with Internal Fixation. A Follow-up Report of a Fifteen-Year Experience. J Bone Joint Surg Am, 1979; 61(6A): 805-14.
  18. Aronson J, Puskarich CL. Deformity and Disability from Treated Clubfoot. J Pediatr Orthop, 1990; 10(1): 109-119.
  19. Siapkara A, Duncan R. Congenital Talipes Equinovarus: A Review of Current Management. J Bone Joint Surg Br, 2007; 89-B(8): 995-1000.