Children with clubfoot often present after the walking age, especially in low- and middle-income countries where approximately 80% of children with clubfoot are born. With advancing age, there is increased stiffness of the soft tissue structures and decreased remodeling potential of the bones of the foot. Not all clubfeet in older children are rigid—some are flexible and amenable to stretching and conservative treatment. Hence, the initial evaluation of the deformity must include an assessment of correctability. The treatment of clubfoot in the older child is challenging and was traditionally performed using complex soft tissue and bony surgeries, often with poor outcomes in the long term. Recent literature has focused on the role of conservative treatment utilizing Ponseti principles of serial manipulation and casting, combined with limited surgery. The purpose of this review is to report the changing trends in the management of clubfoot in the walking child, to review the current literature regarding various treatment modalities, and to recommend a practical approach to treatment based upon age, inherent flexibility of the foot, available resources, and contextual factors.
Pirani S, Zeznik L, Hodges D. Magnetic resonance imaging study of the congenital clubfoot treated with the Ponseti method. J Pediatr Orthop 2001;21(6):719–726. DOI: 10.1097/01241398-200111000-00004.
Nogueira MP, Amaral DT. How much remodeling is possible in a clubfoot treatment? magnetic resonance imaging study in a seven-year-old child. J Limb Lengthen Reconstr 2018;4(1):49–54. DOI: 10.4103/jllr.jllr_18_17.
Penny JN. The neglected clubfoot. Techniq Orthopaed 2005;20(2):153–166. DOI: 10.1097/01.bto.0000162987.08300.5e.
Nunn TR, Etsub M, Tilahun T, et al. Development and validation of a delayed presenting clubfoot score to predict the response to Ponseti casting for children aged 2-10. Strategies Trauma Limb Reconstr 2018;13(3):171–177. DOI: 10.1007/s11751-018-0324-z.
Böhm S, Sinclair MF. The PBS score-a clinical assessment tool for the ambulatory and recurrent clubfoot. J Child Orthop 2019;13(3):282–292. DOI: 10.1302/1863-2548.13.190077.
Lourenco AF, Morcuende JA. Correction of neglected idiopathic clubfoot by the Ponseti method. J Bone Joint Surg Br 2007;89(3):378–381. DOI: 10.1302/0301-620X.89B3.18313.
Nogueira MP, Clubfoot treatment: The Ponseti method in Brazil. Presented at the 2nd. International Conference on Birth Defects and Disabilities in the Developing World. Beijing, China. September 11, 2005.
Spiegel DA, Shrestha OP, Sitoula P, et al. Ponseti method for untreated idiopathic clubfeet in Nepalese patients from one to six years of age. Clin Orthop Rel Res 2009;467(5):1164–1170. DOI: 10.1007/s11999-008-0600-1.
Banskota B, Yadav P, Rajbhandari T, et al. Outcomes of the Ponseti method for untreated clubfeet in Nepalese patients seen between the ages of one and five years and followed for at least 10 years. J Bone Joint Surg Am 2018;100(23):2004–2014. DOI: 10.2106/JBJS.18.00445.
Shah A, Mehta R, Aroojis A. The Ponseti method of Clubfoot treatment in walking aged children: is it effective? A study of 56 children from 1 to 10 years of age. J Pediatr Orthop B 2019;28(2):159–166. DOI: 10.1097/BPB.0000000000000562.
Khan SA, Kumar A. Ponseti's manipulation in neglected clubfoot in children more than seven years of age: a prospective evaluation of 25 feet with long-term follow-up. J Paediatr Orthop B 2010;19(5):385–389. DOI: 10.1097/BPB.0b013e3283387cc8.
Banskota B, Banskota AK, Regmi AK, et al. The Ponseti method in the treatment of children with idiopathic clubfoot presenting between five and ten years of age. Bone Joint J 2013;95-B(12):1721–1725. DOI: 10.1302/0301-620X.95B12.32173.
Ferreira GF, Stefani KC, de Podesta Haje D, et al. The Ponseti method in children with clubfoot after walking age - systematic review and meta-analysis of observational studies. PLoS ONE 2018;13(11):e0207153. DOI: 10.1371/journal.pone.0207153.
Shabtai L, Specht SC, Herzenberg JE. Worldwide spread of the Ponseti method for clubfoot. World J Orthop 2014;5(5):585–590. DOI: 10.5312/wjo.v5.i5.585.
Owen RM, Capper B, Lavy C. Clubfoot treatment in 2015: a global perspective. BMJ Glob Health 2018;3(4):e000852. DOI: 10.1136/bmjgh-2018-000852.
McElroy T, Konde-Lule J, Neema S, et al. Understanding the barriers to clubfoot treatment adherence in Uganda: a rapid ethnographic study. Disabil Rehabil 2007;29(11-12):845–855. DOI: 10.1080/09638280701240102.
Penny N, Zulianello R, Steenbeek M. Community based rehabilitation and orthopaedic surgery for children with motor impairments in an african context. Disabil Rehabil 2007;29(11-12):839–843. DOI: 10.1080/09638280701240052.
Owen RM, Penny JN, Mayo A, et al. A collaborative public health approach to clubfoot intervention in 10 low-income and middle-income countries: 2-year outcomes and lessons learnt. J Pediatr Orthop B 2012;21(4):361–365. DOI: 10.1097/BPB.0b013e3283504006.
Islam MS, Masood QM, Bashir A, et al. Results of a standard versus an accelerated Ponseti protocol for clubfoot: a prospective randomized study. Clin Orthop Surg 2020;12(1):100–106. DOI: 10.4055/cios.2020.12.1.100.
Mehtani A, Prakash J, Vijay V, et al. Modified Ponseti technique for management of neglected clubfeet. J Pediatr Orthop B 2018;27(1):61–66. DOI: 10.1097/BPB.0000000000000450.
Clubfoot: Ponseti Management. Third Edition. Accessed online November 22, 2020. https://storage.googleapis.com/global-help-cdn/2020/07/5e0684b9-help_cfponseti.pdf.
Gupta P, Mittal N, Jindal N, et al. A study of normal foot abduction across various age groups in children. Int Orthop 2017;41(11):2365–2369. DOI: 10.1007/s00264-017-3603-2.
Lang PJ, Avoian T, Sangiorgio SN, et al. Quantification of the ossification of the lateral cuneiform in the feet of young children with unilateral congenital talipes equinovarus. Bone Joint J 2017;99-B(8):1109–1114. DOI: 10.1302/0301-620X.99B8.BJJ-2016-0999. R2.
Eidelman M, Kotlarsky P, Herzenberg JE. Treatment of relapsed, residual and neglected clubfoot: adjunctive surgery. J Child Orthop 2019;13(3):293–303. DOI: 10.1302/1863-2548.13.190079.
Graham GP, Dent CM. Dillwyn evans operation for relapsed clubfoot. Long-term results. J Bone Joint Surg Br 1992;74(3):445–448. DOI: 10.1302/0301-620X.74B3.1587899.
Saltzman CL, Fehrle MJ, Cooper RR, et al. Triple arthrodesis: twenty-five and forty-four year average follow-up of the same patients. J Bone Joint Surg Am 1999;81(10):1391–1402. DOI: 10.2106/00004623-199910000-00004.
Suresh S, Ahmed A, Sharma VK. Role of Joshi's external stabilization system fixator in the management of idiopathic clubfoot. J Orthop Surg (Hong Kong) 2003;11(2):194–201. DOI: 10.1177/230949900301100216.
Freedman JA, Watts H, Otsuka NY. The Ilizarov method for the treatment of resistant clubfoot: is it an effective solution? J Pediatr Orthop 2006;26(4):432–437. DOI: 10.1097/01.bpo.0000226276. 70706.0e.