Updates in the Surgical Management of Recurrent Clubfoot Deformity: a Scoping Review

Abstract

Purpose of Review

This article focuses on the current advances in surgical management for clubfoot deformity, supported by up-to-date longitudinal studies on each approach.

Recent Findings

Long-term analysis following primary and repeated soft tissue releases has demonstrated good results in young patients with low relapse rates. Tibialis anterior transfer following the Ponseti method shows no difference in long-term pedographic analysis in comparison to the Ponseti method alone. Furthermore, tibialis anterior transfer following surgical relapses provides good long-term results with improved correction in talus-first metatarsal angle. Bony osteotomies may also play a role in addressing surgical relapses in older children. However, talar neck osteotomy may result in avascular necrosis of the talar dome. Hexapod external fixation may be considered by experienced surgeons to correct rigid clubfoot deformities in older patients with good long-term results and drastic improvements in pain perception. Long-term analysis of anterior distal tibial epiphysiodesis (ADTE) for recurrent equinus deformity following surgical correction has demonstrated statistical improvements in the anterior distal tibial angle (ADTA) and ankle dorsiflexion. Talectomy and naviculectomy are rarely used in today’s practice as long-term studies have demonstrated high relapse rates and residual pain impeding patient mobility.

Summary

Surgical correction following failure of the conservative approaches can be implemented to achieve full correction in clubfoot deformity. It is difficult to achieve a plantigrade feet with pain-free gait with repeated surgical interventions. Therefore, proper choice of the initial surgical technique is essential for achieving satisfactory long-term outcomes.

Introduction

Idiopathic congenital talipes equinovarus, or clubfoot deformity, is one of the most common congenital musculoskeletal deformities with an incidence of one to seven per 1000 live births [1••]. Currently, the Ponseti technique consisting of serial casting and percutaneous tenotomy is the gold standard in management of clubfoot deformity which has led to a decrease in the rate of surgical interventions [1••]. According to Ponseti, 11–48% of patients end up with residual deformities and have a tendency to relapse following correction with Ponseti technique [2,3,4]. Recurrence, relapse, and residual deformities consist of complete or partial equinocavovarus deformity and can be flexible, bony, and with muscle imbalance [36]. Residual clubfoot deformities need additional rehabilitation [5,6]. To this date, there is no literature supporting the optimal age of treatment for recurrent clubfoot deformity [36]. There are some experts that suggest initiating treatment as early as 2 and a half years of age while others reserve surgery for patients at 4 or 5 years of age [36]. Due to a high relapse rate following correction with the Ponseti technique, surgical intervention is still an important option to consider, especially in neglected and syndromic cases [7••]. Current trials of Ponseti recasting are highly suggested with or without surgery [36]. The choice of a proper surgical technique is crucial while managing patients with clubfoot deformity to maintain a plantigrade, pain-free, and pliable foot [7••,8,9].

This article focuses on the current advances in surgical management for clubfoot deformity, supported by up-to-date longitudinal studies on each approach.

Soft Tissue Release

Since the last 20 years, non-operative techniques have become a preliminary tool for correction for both idiopathic and non-idiopathic clubfeet, leading to an estimated decrease in surgical corrections by 2 to 20% [10••, 11•]. However, some studies have demonstrated failure to achieve correction despite consecutive attempts using conservative techniques with a high number of relapses [12, 13, 14]. It is crucial for surgeons to observe these issues as early as possible in order to provide adequate timely correction. Therefore, soft tissue releases can be performed on patients with stiffer and more severe relapses [15]. There are two common surgical techniques adopted to achieve correction: the “a la carte” approach and the one-size-fits-all procedure [16]. Most surgeons prefer the “a la carte” approach as long-term studies regarding functionality following comprehensive surgical correction have demonstrated fewer consecutive operations, improved muscle strength, less hindfoot varus, less subtalar stiffness, and better radiological results [10••, 11•, 15, 16, 17••].

Bocahut et al. [10••] recently presented a study on a less extensive posteromedial soft tissue release on 199 feet (80% idiopathic clubfeet and 20% non-idiopathic clubfeet) that previously underwent correction with French Functional Method (FFM) with the aim to de-rotate the forefoot prior to the reduction of hindfoot equinus. The mean age at the time of the procedure was 1.4 years (4.3 months to 4.7 years), and the mean follow-up time was 10.8 years (4.1 years to 18.5 years). At the latest follow-up, 70% of feet had very good scores, 27.7% had good scores, and 2.3% of feet had fair scores, with no feet yielding poor results. Erdman et al. [17••] presented a prospective study comparing pedobarograph data on patients that underwent an isolated posterior release (PR) or posteromedial release (PMR) following recurrence and residual deformity with patients that were managed non-operatively (NO). The mean age at the time of the test was 5.2 years (5.0 years to 6.1 years). Patients that underwent NO correction demonstrated reduced contact area percentage (CA%) in comparison to surgical release, indicating some degree of residual equinus. Patients that underwent PR and PMR demonstrated greater contact time percentage (CT%) in the medial foot in comparison to NO cohort. Despite similarities in midfoot outcomes, clubfeet treated with PMR demonstrated an increase in lateral hindfoot CT% in comparison to PR and NO. The authors concluded that clubfeet treated with limited correction (PR) provided comparable pressure variables to those treated with NO techniques.

It is important to consider that recurrence following surgical correction has been reported in 13 to 50% of feet, which inevitably require further surgical correction [11•, 15, 18•]. Bocahut et al. [10••] reported a relapse rate of 12% in their cohort of patients. The authors attributed the relapses to high Dimeglio scores at birth, and the fact that fair results were extracted exclusively from non-idiopathic clubfeet, specifically arthrogryposis. Similarly, Kuo et al. [11•] presented a retrospective analysis of 134 feet that underwent comprehensive surgical release of clubfoot through a Cincinnati incision. A total of 21 feet (15.7%) underwent supplementary corrective surgeries following residual deformities, with forefoot adduction and supination being the most prevalent reason. The authors discussed that failure was common in patients operated prior to 6 months of age and attributed it to their deformities being more severe and the complexity of an infant’s anatomy at an early age. Since the strength of the Achilles tendon plays a pivotal role in the long-term dynamic function in clubfoot treatment, performing surgical correction at an early stage may also lead to over lengthening of the Achilles tendon and weakness in plantar flexion.

Mehrafshan et al. [18•] presented long-term results following repeat soft tissue release following relapses in clubfeet that underwent a primary soft tissue release in 79 feet with an average follow-up time of 12 years (4 to 32 years). The mean age at the time of the procedure was 5.8 years (15 months to 14.5 years). The feet were assessed using the Ghanem and Seringe scoring system, and 26% of the feet yielded excellent, 51% good, 18% fair, and 5% poor outcomes. No pain was reported in 72% of feet, and they were able to ambulate normal footwear. Occasional foot pain was reported in 25% of feet, and 2.5% reported severe and consistent pain. The authors concluded that repeat soft tissue surgery with or without a bony operation, such as the Lichtblau procedure, can yield acceptable long-term results which may help avoid triple arthrodesis in patients who fail to respond to initial surgical correction.

Tibialis Anterior Tendon Transfer

Transfer of tibialis anterior tendon was introduced by Garceau in 1940 for treatment of clubfoot relapse [19•]. This procedure has been recognized as a popular treatment protocol for clubfoot relapse, especially in conjunction with the Ponseti method [19•]. Transfer of tibialis anterior tendon allows correction of supination deformity resulting from the muscle imbalance between foot invertors and evertors [19•]. Different techniques have been described in the literature for this procedure, including using two-incision technique, three-incision technique, and a split tendon transfer. Knutsen et al. [7••] studied the effect of different tibialis anterior tendon transfer techniques on cadaveric foot models to test the biomechanical effects of different techniques on forefoot and hindfoot motion. The study concluded that although all techniques increased forefoot pronation and hindfoot valgus when compared with intact specimens, the greatest increase in supination and valgus was attributed to the three-incision technique followed by split tendon transfer and the two-incision technique.

Holt et al. [1••] presented long-term results of tibialis anterior transfer following the Ponseti method in 35 patients to evaluate the effect of the transfer on the functional and clinical outcomes in comparison to patients who underwent the Ponseti technique alone. A total of 14 patients underwent tibialis anterior transfer (11 bilateral and 3 unilateral) and 21 patients underwent the Ponseti method without transfer. Patients were assessed using the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle questionnaire and the Laaveg-Ponseti questionnaire. The outcome of the questionnaires was quite similar in both groups. The study demonstrated that patients that underwent tendon transfer had greater talar flattening, smaller AP talocalcaneal angle, and more moderate-to-severe osteophytes at the naviculocuneiform joints which was different from earlier reports showing normal AP talocalcaneal angels. No differences between the two groups were observed using the pedographic analysis which uses pressure sensors to analyze pressure points during free walk. Surface electromyography from tibialis anterior, lateral gastrocnemius, and proneus longus showed no significant decrease in muscle firing amplitudes in patients with prior tendon transfer.

Lampasi et al. [20••] studied the long-term results of tibialis anterior transfer in the treatment of relapse after surgical intervention in 27 feet. The mean age of the patient was 4.8 years (2.6 to 10.1 years), and the mean follow-up time was 23.5 years (10.8 to 35.6 years). Patients were categorized according to severity of reducibility of varus, equinus, and supination deformity. Grade I reducibility was less than 20° (10 feet), grade II reducibility was 20 to 45° (22 feet), and grade III reducibility up to 45° (6 feet). Tibialis anterior tendon transfer was performed using the Garceau technique to move the tendon laterally and re-insertion into the third metatarsal, third cuneiform, and base of fourth metatarsal in 10, 5, and 23 cases, respectively. The tendon was transferred under the retinaculum in 24 cases and above the retinaculum in 14 cases. Patients were assessed clinically using the Laaveg-Ponsetti scoring system. Radiological assessment included talocalcaneal angle and talus-first metatarsal angle which were measured in the AP weight bearing radiographs, and talocalcaneal and first-fifth metatarsal overlap ratio were measured in the lateral radiographs. The clinical outcome was excellent in 4 feet, good in 16 feet, fair in 5 feet, and poor in 2 feet. Pain with excessive exercise, scarring, loss of calf mass, and stiffness were the most common complaints. In terms of radiological evaluation, the talus-first metatarsal angle showed a higher degree of correction in more flexible feet which was statistically significant. Other angles did not show statistically significant variation.

Tibialis anterior tendon transfer does not provide much improvement in rigid and partially correctable feet [20••]. The ideal site for the transfer is along the axis of the third metatarsal, and a more lateral site should be spared for severe deformities to avoid overcorrection [20••]. Tibialis anterior tendon transfer can be used as a tool to treat relapse following the Ponseti technique or surgical release [20••]. Consequently, with a higher number of surgical interventions, the rate of poor results may increase. Analysis for causes and severity of the deformity should be taken into consideration prior to the decision of undergoing correction with tendon transfer. Appropriate technique for the transfer should be determined to achieve full correction with minimal complications [20••].

Bony Osteotomies

Midfoot Osteotomies

Midfoot osteotomies are typically used for clubfoot patients with residual adduction deformity [21]. Patients that undergo bony osteotomies are either too old for soft tissue release or too young for arthrodesis, with the age range between 4 and 9 years [19•].

Loza et al. [22••] presented a study using double column osteotomies for 15 patients (20 feet) with bean-shaped feet with forefoot adduction deformity plus midfoot supination deformity. The double column osteotomy technique is a cuboid closing wedge and a medial cuneiform opening wedge followed by fixation using wires or stables [22••]. All patients were diagnosed with idiopathic clubfoot deformity and were previously treated with surgical correction. The procedure was carried out in conjunction with soft tissue release (plantar fasciotomy and abductor hallucis release). Patients were followed for a mean period of 2 years and 4 months (2.0 to 2.5 years). During the latest follow-up, 18 feet presented with pain-free gait and two feet had pain associated with sutures and wires. The radiological assessment demonstrated full improvement in forefoot adduction in 16 feet and partial improvement in 4 feet with less than 5° adduction deformity. The study concluded that double column osteotomy is a safe operation which offers correction for the residual fixed forefoot adduction deformity in revision clubfoot surgery.

Another technique for midfoot osteotomy was presented by Elgeidi et al. [23] for treating bean-shaped deformity in 35 patients. The authors incorporated a double tarsal osteotomy to correct the forefoot adduction deformity with a transcuneiform osteotomy to correct the rotation in the supination deformity. A soft tissue release (plantar fasciotomy and abductor hallucis) was done when needed. The study reported clinical and radiological improvement among all patients with improved shoe fitting and cosmetic appearance [22••, 23]. Madhev et al. [21] incorporated a single lateral column osteotomy with transcuneiform osteotomy to treat 12 patients (14 feet) with bean-shaped feet. The mean age of the patients was 4.7 years (4 to 5 years). The study reported radiological and clinical improvement, with reduced foot pain, lateral callus disappearance, and better shoe fitting. The authors recommended medial osteotomy after the age of 5 years as the cuneiform ossific center will be well developed. In conclusion, midfoot double column osteotomies are efficient and safe protocols for recurrent adduction and bean-shaped deformity following surgical correction of clubfoot deformity [19•, 21, 22••, 23].

Hindfoot Osteotomies

Historically, Dwyer calcaneal osteotomy was the most common technique used for treatment of a varus heel and is no longer considered common practice due to the high complication rates associated with the procedure [19•]. Lateralization slide osteotomy may be used to treat varus heel deformity in adolescents and young adults [19•]. Talar neck dorsolateral osteotomy was used to correct forefoot adduction deformity [24]. The main complication of this procedure was avascular necrosis of the talar head as the vascularity of the talus is more vulnerable in children than adults with talar neck fractures [24]. A long-term study carried by Huber et al. [24] assessed the incidence of avascular necrosis of the talus after talar dorsolateral osteotomy. The study included 11 patients (16 feet) with idiopathic clubfoot deformity who had undergone dorsolateral talar osteotomy at a mean age of 8 years (5 to 13 years). At the latest follow-up, 7 feet developed avascular necrosis with collapse and flattening of the talar dome and 3 feet presented with avascular necrosis of the head. The authors concluded that the dorsolateral talar neck osteotomy under the age of 10 years can result in avascular necrosis of the talar dome and should, therefore, be avoided.

Supramalleolar Osteotomy

Supramalleolar osteotomy is used for rigid midfoot and hindfoot deformities when soft tissue procedures are no longer feasible [9]. Nelman et al. [9] used multiplanar supramalleolar osteotomy for correction of residual and recurrent rigid clubfoot deformities in 7 patients (9 feet). All patients were treated using multiplanar supramalleolar osteotomy through an anterior approach of the distal tibia. They recommended that rotation must be corrected first followed by correction of the angular deformity. Fixation for the osteotomy can then be carried out using pins or wires without violating the distal tibial physis. At the latest follow-up, all feet were plantigrade with a failure rate of 44% in 4 patients (9 feet).

Distraction Osteogenesis

Over the last decades, many researchers have advocated for the use of distraction osteogenesis to treat rigid clubfoot deformity in older patients that fail to respond to both conservative and surgical correction [25]. The gradual correction allows for lengthening of the foot, as opposed to shortening and helps develop an individualized treatment plan for patients [26••]. New advancements in the field have provided data on the benefits of using the latest hexapod external fixator systems over Ilizarov’s external fixator to treat complex foot deformities [26••]. Hexapod external fixators allow a three-dimensional correction with the same frame during the course of the treatment, making it an ideal tool for both researchers and patients [26••].

A study published by Floerkemeier et al. [27] demonstrated good outcomes in 8 out of 9 patients with multiplanar foot deformities using the Taylor Spatial Frame (TSF). Comparably, Eidelman and Katzman [28] reported successful outcomes in 11 out of 13 patients with multiaxial deformity using the TSF. Riganthi et al. [26••] recently presented a retrospective analysis on a cohort of 10 patients who underwent correction with the TrueLok Hexapod (TL-HEX) external fixator. The mean age at the time of the procedure was 14 years (13 to 16.5 years) and the mean follow-up period following removal of the external fixator was 13.5 months (7 to 27 months). At the final follow-up, fully plantigrade feet were demonstrated in 8 patients (80%) with drastic improvements in pain perception in 6 patients (60%) reported with the Visual Analogue Scale (VAS) score.

There have been some complications associated with the use of external fixators. Superficial pin tract infections are a common occurrence, and can be successfully treated with the use of appropriate antibiotics [25]. Pain, dysthesia, and edema can also follow the process of distraction [25]. Subluxation of the talus and the first metatarsophalangeal joint, lysis of the distal tibial epiphysis, and vascular complications have also been reported [25]. Riganthi et al. [26••] reported 2 metatarsophalangeal joint subluxations in their cohort of patients. Similarly, Eidelman et al. demonstrated 1 metatarsophalangeal joint and 1 talus subluxation with the use of external [29, 30].

Waizy et al. [31] advocates for the use of temporary arthrodesis of the metatarsophalangeal joint to prevent possible subluxation and dislocations during distraction. In patients where subluxations and dislocations are unavoidable, surgical correction can be implemented following removal of the external fixator [26••]. Some studies have demonstrated recurrence of the clubfoot deformity requiring surgical procedures such as triple arthrodesis to address poor outcomes [25, 26••]. Ankle-foot orthosis can be used for support following the use of external fixators and should be worn for a minimum of 1 year after the removal of the frame [25].

Hemiepiphysiodesis

Ebert et al. [32] used anterior distal tibial epiphysiodesis (ADTE) to treat residual and recurrent clubfoot equinus deformity following surgical correction. The inclusion criteria were set as patients with open epiphysis and increased anterior distal tibial angle (ADTA). The study included 18 patients (23 feet) with mean age of 11.3 years (10.2 to 12.9 years). The mean follow-up was 43.9 months (10 to 76 months). The mean preoperative ankle dorsiflexion was − 3.3° (− 2.2 to 0°), and preoperative mean ADTA was 87.5° (83 to 110°). ADTE was carried out through an anterior approach using 8 plates and 2 self-tapping cannulated screws. Solid screws are recommended especially for the small size screws. At the final follow-up, the ankle dorsiflexion improved to 6.1° (− 15 to 10°) and ADTE improved to 75.8° (63 to 106°). The study concluded that ADTE is an effective and safe procedure in the treatment of recurrent equinus deformity in surgically treated clubfoot.

Talectomy

Talectomy can be used as a salvage procedure to treat resistant clubfoot deformities, particularly in patients with syndromic clubfeet such as arthrogryposis and myelomeningocele [33]. Legaspi et al. [33] presented a study to assess the long-term results of talectomy in patients with recurrent clubfoot deformity with a mean follow-up period of 7.5 years (2 to 13 years). The study included 15 (24 feet) with 21 feet being arthrogryposis multiplex congenita, two feet with myelomeningocele, and one with idiopathic congenital talipes equinovarus. Patients’ mean age was 5.3 years (3 to 11 years). The results were good in 8 feet (33%) where the patients needed no further correction and pain-free gait. Fair results were documented in 10 feet (42%) where pain-free gait was achieved with recurrence of hindfoot deformity. A total of 6 feet (25%) demonstrated poor results with painful gait. The authors concluded that talectomy is a useful operation in the management of complex clubfoot deformities, where other resources have been exhausted.

Naviculectomy

Naviculectomy has been described in the correction of rigid cavovarus deformity. Mubarak and Dimeglio [34••] performed a retrospective review from 2 centers of navicular excision and cuboid closing wedge osteotomy for severe cavovarus foot deformities in 11 patients (16 feet). Patients included in the study comprised those with prior clubfoot correction (5 feet), as well as foot deformity associated with arthrogryposis (6 feet) or deformity associated with neurogenic etiology (5 feet). All of the severe clubfoot patients had fusion of the cuneiforms to the talus at a reported mean age of 9.3 years. In this small series, none of the clubfoot patients required additional surgery, and all reported no pain at their most recent follow-up (mean 4.9 years). Although short-term results were positive, the high rate of additional procedures and continued pain in the current series suggests that even as a salvage procedure, therefore, naviculectomy does not provide optimal results in these conditions [35].

Conclusion

Recurrence, relapse, and residual clubfoot deformities consist of complete or partial equinocavovarus deformity and can be flexible, bony, and with muscle imbalance. Surgical correction should be implemented following failure of the conservative approaches to achieve full correction. It is difficult to achieve a plantigrade feet with pain-free gait with repeated surgical interventions. Therefore, proper choice of the initial surgical technique is essential for achieving satisfactory long-term outcomes.

Data availability

Not applicable.

Declarations

Conflict of Interest

Not applicable.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.