Recurrent Clubfoot

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

Top Contributors - Naomi O'Reilly, Rachael Lowe, Tarina van der Stockt and Meaghan Rieke  

Introduction

Recurrence means the reappearance of any or all of the components of the original clubfoot deformity after successful treatment. It is common in the first and second years after treatment especially if bracing has not been continued, but can happen at any time until skeletal maturity is reached. [1]

Clinical Features

There is a spectrum of recurrence, ranging from a dynamic or flexible deformity, to stiffness or fixed deformity. Dynamic imbalance occurs when the foot is still flexible but there is a tendency for muscles to pull the foot into a deformed position. Fixed deformity occurs when ligaments tighten up and the foot is no longer flexible.

Dynamic Imbalance

  • Early recurrence
  • Foot is supple on physical exam
  • Results in dynamic supination
  • Easy to miss
  • Worsens over time, can lead to fixed deformity. Example of dynamic imbalance. As the child starts to walk the big toe and first metatarsal are lifted first and supination of the foot can be seen as the foot is lifted. This is called “dynamic supination” and is usually because of an overactive tibialis anterior muscle.[1]

Fixed Deformity

  • Equinus: The heel cannot get to the ground
  • Loss of abduction
  • Walk on the outside of their foot.
  • This child has recurrent equinus and varus, and walks on the outside of the foot [1]

Prevention

  • Make sure initial treatment is adequate, especially tenotomy
  • Make sure braces are worn properly
Remember: “Talk to Parents from the start, especially about Braces!” [1]

Treatment

If there is any fixed deformity then it is always worth repeating the Ponseti manipulations and casting, with intervals of 1-2 weeks to try to regain a corrected foot position. If this is achieved then tenotomy may need repeating, and bracing can follow, encouraging parents to be regular.

If the foot is flexible but dynamic imbalance continues then a small operation can be done to treat this. This is a Tibialis Anterior Tendon Transfer (TATT)[2]. The tibialis anterior tendon normally inserts on the medial side of the foot. It is divided just where it inserts then moved laterally and reattached by inserting it into a bone on the lateral side of the foot, usually the lateral cuneiform. Sometimes this is combined with a release of the achilles tendon if this is tight. Post-operatively, following a TATT the patient has a cast for 6 weeks to allow the tendon to reattach in its new position, then depending on the surgeon’s preference, the patient may have either night bracing in a FAB or an Ankle Foot Orthosis (AFO) that prevents plantar flexion.[1]

Physiotherapy Input Pre TATT

  • TATT is most effective when there is full, or near full, range of movement prior to surgery
  • Any fixed element of deformity should have manipulation and casting according to the principles of the Ponseti method prior to TATT to correct it as far as possible
  • In children of walking age the knee may be bent to 30-50 degrees to allow for walking
  • Education of the family and child about post-op mobility needs

Physiotherapy Input Post TATT

  • Provision of walking aids
  • Change of plaster as directed by surgeon
  • Gradual return to weight bearing as directed by surgeon
  • Provision of orthotics as directed by surgeon (some specify AFO for a period following TATT)
  • Strengthening exercises/gait re-education if needed
  • It can take a long time, often 1 year or more, for the full benefit of TATT to be realised

References

  1. 1.0 1.1 1.2 1.3 1.4 Africa Clubfoot Training Project. Chapter 13 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.
  2. Gray K, Burns J, Little D, Bellemore M, Gibbons P. Is tibialis anterior tendon transfer effective for recurrent clubfoot?. Clinical Orthopaedics and Related Research®. 2014 Feb 1;472(2):750-8.