Introduction

Problem 
Clubfoot is predominantly a hindfoot deformity caused by malalignment of the calcaneotalar-navicular complex.  The deformity includes plantarflexion of the 1st ray, adduction of the forefoot/midfoot on the hindfoot, and the hindfoot is in varus and equinus.  The mnemonic CAVE (cavus, adductus, varus, equinus) is useful in remembering the components of this deformity.

Epidemiology 
Congenital clubfoot is seen in approximately 1/1,000 births. The risk is approximately 1 in 4 when both a parent and one sibling have clubfeet. It occurs more commonly in males (2 : 1) and is bilateral in 50% of cases.

Etiology 
Although numerous theories have been proposed, the etiology is multifactorial and likely involves the effects of environmental factors in a genetically susceptible host.

Pathoanatomy 
The pathoanatomy involves both abnormal tarsal morphology where there is plantar and medial deviation of the head and neck of the talus.  Additionally there is abnormal relationships between the tarsal bones in all three planes, as well as associated contracture of the soft tissues on the plantar and medial aspects of the foot.

Clinical Presentation 
Infant clubfoot demonstrates forefoot cavus and adductus and hindfoot varus and equines.  There is a range in the degree of flexibility though all patients will exhibit calf atrophy.  Additionally, in some cases, children will have both internal tibial torsion and leg-length discrepancy where there is shortening of the ipsilateral extremity.

Workup

In the office, a complete physical examination should be performed to rule out coexisting musculoskeletal and neuromuscular problems. The spine should be inspected for signs of occult dysraphism.  

While many clinicians reserve radiographs for older children with persistant or recurrent deformities, anteroposterior and lateral radiographs are most commonly used to obtain radiographic measurements to describe the malalignment between the tarsal bones.  Most clinicians will hold the foot in the maximally corrected position. A common radiographic finding is "parallelism" between lines drawn through the axis of the talus and the calcaneus on the lateral radiograph, indicating hindfoot varus.

Treatment

Immediate nonoperative treatment is recommended for all infants following birth. These include techniques such as manipulation and casting (Ponseti method) and functional treatment (French method). 

The Ponseti method of clubfoot treatment involves a specific technique for manipulation and serial casting and may be best described as minimally invasive rather than nonoperative. The order of correction follows the mnemonic CAVE (described above). Weekly cast changes are performed; five to 10 casts are typically required. The most difficult deformity to correct is the hindfoot equinus, and approximately 90% of patients will require a percutaneous tenotomy of the heel cord as an outpatient. Following the tenotomy, a long leg cast with the foot in maximal abduction (70 degrees) and dorsiflexion is worn for 3 weeks; the patient then begins a bracing program in which the patient wears the brace full time for 3 months and then at nighttime for 3-5 years. A subset of patients will require transfer of the tibialis anterior tendon to the middle cuneiform for recurrence. The results of the Ponseti method are excellent at up to 40 year of follow-up. Compliance with the splinting program is essential as recurrence is common if the brace is not worn as recommended. 

Functional treatment, or the "French method," involves daily manipulations (supervised by a physical therapist) and splinting with elastic tape, as well as continuous passive motion (machine required) while the baby sleeps. While the early results are promising, the method is labor intensive, and it remains unclear whether the technique will achieve greater popularity in the United States. 

Surgical realignment has a definite role in the management of clubfeet, especially in the minority of congenital clubfeet that have failed nonoperative or minimally invasive methods, and for the neuromuscular and syndromic clubfeet that are characteristically rigid. In such cases, nonoperative methods such as the Ponseti technique may potentially be of value in decreasing the magnitude of surgery required. Common surgical approaches include a release of the involved joints (realign the tarsal bones), a lengthening of the shortened posteromedial musculotendinous units, and usually pinning of the foot in the corrected position. The specific procedure is tailored to the unique characteristics of each deformity. For older children with untreated clubfeet or those in whom a recurrence or residual deformity is observed, bony procedures (osteotomies) may be required in addition to soft-tissue surgery. Triple arthrodesis is reserved as salvage for painful, deformed feet in adolescents and adults.

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