Recurrent Clubfoot

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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.

Clinical Features

There are two patterns of recurrence: firstly dynamic or flexible deformity, and secondly 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.

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

Prevention

Make sure initial treatment is adequate, especially tenotomy. Make sure braces are worn properly.

Remember: “Talk to the parents from the start (especially about braces!)”.

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 or TATT. 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 will have either night bracing in a FAB or an Ankle Foot Orthosis (AFO) that prevents plantar flexion.

References

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