Approach to Clubfeet – Late or Recurrent Deformity
– most commonly secondary to incomplete release, especially of the plantar fascia and short/long plantar ligaments
– make sure it is not neurologic in origin – tethered cord?
– was post-op casting and orthotic use sufficient
– Is there motor imbalance around the foot?
– Where is the anatomic pathology? Hindfoot equinus? Hindfoot varus? Forefoot/Midfoot adduction/supination?
Management – stiff deformity
– if young (less than 4) you can probably get away with repeating the posteromedial release (or whatever parts of it that you think are necessary to address the anatomic pathology)
– if older you need to think about osteotomies to help with the alignment. If curved lateral border, think about trying to shorten the lateral column with a Dwyer lateral closing wedge osteotomy with a release of the scar tissue that holds the cuboid medially. Or, a cuboid decancellation. Alternatively, if the hindfoot is still in a fair amount of fixed varus, you can do a medial opening wedge osteotomy of the calcaneus (if you donï¿½t want to shorten the foot any more with a Dwyer)
Management – dynamic deformity
– if there is a dynamic adductus and supination that is reducible passively try tendon transfer. This is often due to incoordination of tib ant and posterior tib. Can do a split anterior tib transfer to base of fifth MT, or do a whole anterior tib transfer; or alternatively, bring tib post through interosseous membrane to third cuneiform.
Remember: the key is the age (and therefore the correctability) and the identification of what the pathology is (either dynamic or fixed). Above 4 years, really think about doing osteotomies.