Surgical Release for Clubfoot: Principles, Indications, and Evaluation

Comprehensive surgical release served as the standard for many cases of clubfoot from 1970 to 1990. During that period, surgical procedures were refined, and many studies were published. However, with improved understanding and practice of the Ponseti techniques since the 1990s, the comprehensive release became less popular. While the Ponseti Method has proven to be quite effective in treating both the idiopathic and the syndromic clubfoot, recurrences, incomplete correction, and progressive deformity can present. It is important to recognize the importance and power in serial casting of the recurrent deformity to minimize grandiose surgical exposures. Still, there are a small percentage of clubfeet that fail the Ponseti method and require surgical procedures. It is incumbent upon the pediatric orthopedic surgeon to be familiar with the detailed anatomy of the child’s foot and to understand the art of releasing just the right amount to correct the deformity. One should avoid any iatrogenic complication, such as neurovascular injury and articular cartilage damage. The Cincinnati incision is the approach of choice for clubfoot release as it is versatile in visualizing the whole structure of the clubfoot deformity. Gentle handling of the soft tissue is essential. The ideal progression of the release should be from posterior to lateral, then plantar and medial. It is necessary to protect the neurovascular structures at the posterior medial corner. External rotation of the calcaneus under the talus is essential when the release is done. Care is taken to not overlengthen the Achilles tendon. The corrected position can be stabilized and maintained with Kirschner wire fixation to pin the talonavicular joint in a reduced position. Observe the tension of the posterior part of skin to prevent skin sloughing. After any kind of clubfoot treatment, it is important to evaluate the functional outcome to track the progress and provide adequate follow-up care if required. This includes physical examination, measurement of plantar flexor strength, plain radiographs, and gait analysis. Outcomes can be tracked with instruments such as the International Clubfoot Study Group (ICFSG) Scoring System and other Quality of Life Outcomes Self-Assessment. In essence, extended follow-up is key to evaluate for improved functional outcomes and maintenance of a plantigrade foot.