History of Clubfoot Management

Over the years approaches to the management of clubfoot have changed and evolved. Numerous surgical, conservative and mixed treatment techniques have been utilised with varying levels of success. In the past decade the Ponseti method has become widely recognised as the gold standard for clubfoot treatment. Recently, two very informative reviews have been published detailing the history of management of clubfoot: Bridgens and Kiely (2010) and Dobbs and Gurnett (2009). Full references for these can be found here. The main historical developments as documented in the literature on clubfoot management are summarised below.

Early non-operative management

As early as 400 BC, Hippocrates described clubfoot and recommended non-operative treatment using manipulations and bandages – remarkably similar to the treatment techniques commonly in use today:

‘manipulate the foot as if holding a wax model, not by force, but gently’ (12)

Clubfoot treatment brace used in 1806- Source: Wellcome images

Later, forceful manipulations were used to correct the deformity. One of the most infamous of these was a wrench devised by Thomas (1834-1891) which was used to forcibly change the position of the foot. Not surprisingly, these techniques resulted in injuries to many patients and poor outcomes (7).

Thomas Wrench

Thomas Wrench – Source: RCPSG archives (41)

Surgical management

Surgical management of clubfoot became popular in the 1970’s, 80’s and 90’s. There are many different types of surgical technique described for treating clubfoot. Two of the most widely used are the postero-medial release (PMR), an extensive release of the tight and contracted soft tissues of the clubfoot and the ‘a la carte’ approach which aims to correct various components of the deformity depending on the presentation of the individual (13).

Surgical management of clubfoot can correct the deformity and give the patient a foot which looks more normal and functions well at first. However, several long-term follow up studies have demonstrated that the outcomes of surgical management are not as good as initially thought. Over time surgically treated feet become painful, stiff and show weakness and early arthritic changes (13). These symptoms all cause limitation of activity which one study that followed up patients treated with soft tissue release at 30 years found to be comparable to the disability caused by Parkinson’s disease and chronic heart failure (14). Surgical treatment can also be expensive and result in higher numbers of complications, such as infection compared to other techniques.

Illustration showing early surgical management of clubfoot in the 1800’s – Source: Wellcome images

Conservative management

Conservative techniques primarily achieve correction of clubfoot by slowly stretching tight structures, allowing time for soft tissue remodelling and for the position of the bones in the foot to be corrected (32).

The Kite method is a conservative technique for treating clubfoot developed by Dr Kite in the USA in the 1930s (7). Kite sought to find a non-invasive treatment strategy for clubfoot after he became dissatisfied with the poor results of surgical treatment (33). 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 (33). These outcomes were not reproducible in further studies, however (34, 35) and up to 90% of children treated using the Kite method needed additional surgical, soft tissue releases (34). 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 (35). The Kite method also requires high numbers of castings and it may be up to two years before the deformity is corrected (7).

The ‘French’ or ‘functional’ method of clubfoot treatment is another conservative technique used in different parts of the world. This method uses daily manipulation and stretching of the foot, stimulation of underactive muscles and strapping of the foot to hold it in position, all carried out by a physiotherapist. In high income settings this method has been found to significantly reduce the need for clubfoot surgery and, in one study, to have comparable outcomes to the Ponseti method (36). However, possibly due to the higher level of input required by the French method parents in the USA were twice more likely to select the Ponseti method of treatment than the French method for their children.

The Ponseti technique

The Ponseti technique combines conservative techniques of manipulation and casting and a small surgery in the form of an Achilles tenotomy. The Ponseti technique was developed in the 1960s by Dr Ignacio Ponseti at the University of Iowa in the USA. He devised the technique after observing poor outcomes of clubfoot surgery and extensive study of the anatomy of the foot and ankle (37).

The Ponseti technique was slow to catch on at first and has only been accepted widely within the last decade. However, in recent years studies have shown that when applied correctly, the Ponseti technique can achieve correction of the clubfoot deformity in up to 98% of cases (38). A long term follow up study 30 years after treatment found very favourable 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 (39). These outcomes have led to the current situation in most high-income countries and many LMIC where the Ponseti method is the treatment of choice for clubfoot by most orthopaedic surgeons (5).

For more information on the Ponseti technique click here.

The information provided by GCI is based on publications in scientific journals (references indicated by numbers within the text). To see the full reference list click here.