Correction of Neglected Clubfoot With Midfoot Closed Wedge Osteotomy and Circular External Frame

Some feet are born twisted, a condition known as clubfoot, where the foot turns inward and downward. For many children, gentle stretching and casting in early infancy can straighten the limb, allowing for a normal life. But for a small group of patients, the condition was never treated, or the treatment failed, leaving them with a severe, rigid deformity that persists into adulthood. These neglected cases are not just a matter of appearance; the bones are locked in a strange shape, the joints are stiff, and the foot cannot touch the ground flat. Walking becomes a struggle, pain is constant, and fitting into a standard shoe is often impossible. The challenge for surgeons has long been how to fix a foot that is both severely deformed and incredibly stiff without causing new problems like permanent stiffness or the need for a complete fusion of the joints.

In a study spanning nearly three decades, a team of surgeons investigated a specific method to tackle this difficult problem. They focused on a technique that combines a precise cut in the middle of the foot with a circular metal frame worn on the outside of the leg. This approach, used on twenty-one patients with twenty-six affected feet, aimed to reshape the bone structure while keeping the foot mobile. The researchers found that for the majority of these patients, the method successfully restored a flat, functional foot, allowing them to walk without pain and wear regular shoes again. While the process required patience and carried some risks, the results suggest that this combination of bone cutting and external bracing offers a powerful alternative to more drastic surgeries for those with severe, neglected clubfoot.

The condition the team addressed is what they call neglected clubfoot. This term covers feet that were never treated as infants, or cases where previous treatments failed, leaving the deformity resistant to standard care. In these feet, the bones have grown into a twisted position, and the soft tissues have tightened around them. Traditional surgery for such severe cases often involves removing parts of the bone or fusing joints together to force the foot into a straight line. While this can stop the deformity, it often leaves the foot stiff and unable to move naturally, which can be just as disabling as the original twist. The surgeons in this study wanted to see if they could correct the shape without sacrificing the foot's ability to move.

The method they tested involves two main steps. First, the surgeon makes a cut in the middle of the foot, specifically removing a wedge-shaped piece of bone from the area that includes the cuboid and sometimes the navicular bones. This is not a simple cut; it is a subtraction, meaning a piece of bone is taken out to allow the foot to be straightened. Imagine a bent piece of wood; if you cut out a wedge from the inside of the bend, the two ends can be brought together to straighten the wood. In the human foot, removing this wedge allows the twisted structure to collapse into a flat, plantigrade position, where the sole of the foot rests evenly on the ground.

Once the bone is cut and the foot is positioned correctly, the surgeon does not rely on internal plates or screws to hold it there. Instead, they attach a circular external fixator, a device made of metal rings that encircle the leg and foot, connected by rods and wires that pass through the skin and into the bone. This frame acts as an adjustable scaffold. It holds the foot in its new, corrected position while the bone heals. The frame can be adjusted over time, allowing the surgeons to make small, gradual changes if needed. This external support gives the bone the stability it needs to fuse in the right shape without the rigidity of a full joint fusion.

The study looked back at twenty-one patients treated between 1993 and 2021. These individuals ranged from children over ten years old to adults up to fifty-eight years old. Their conditions varied; some were born with the deformity, while others had it due to nerve damage, polio, or past injuries. Despite these different causes, the surgeons applied the same core technique: removing the wedge of bone in the middle of the foot and securing it with the circular frame. In some cases, they also performed additional procedures, such as lengthening the Achilles tendon or cutting other bones, depending on how severe the deformity was.

The results were encouraging. After following the patients for at least one year, the researchers found that nearly two-thirds of the feet, specifically fourteen out of twenty-one cases, achieved a "good" result. These patients reported no pain, could walk with a flat foot, and could wear conventional shoes. Another four patients had "fair" results; their feet were flat and functional, but they still had some minor issues like reduced movement or slight residual twisting. Only three patients had "poor" results, meaning the deformity returned or significant problems remained. This suggests that for most people with this difficult condition, the technique successfully restored a functional foot.

The process was not without its challenges. The time the patients wore the external frame varied, lasting anywhere from two to ten months, with most wearing it for three to five months. During this time, the most common complication was pain related to the pins that held the frame to the bone, often caused by minor infections at the skin entry points. Other issues included delays in the bone healing or, in rare cases, the joints becoming stiff and fused on their own. One patient required a second surgery to transfer a tendon. Despite these hurdles, the majority of patients did not need further operations, and the overall rate of complications was considered acceptable given the severity of the initial deformity.

The authors emphasize that their approach differs from other methods because it focuses specifically on the midfoot bone subtraction combined with the external frame, rather than relying solely on soft tissue releases or fusing the entire foot. They argue that this technique preserves more of the foot's natural movement compared to traditional fusion surgeries. While the study was retrospective, meaning it looked back at past records rather than planning the treatment in advance, and the number of patients was relatively small, the consistency of the positive outcomes across different ages and causes of deformity is notable. The study concludes that this method is a valuable option for selected patients with neglected clubfoot, offering a way to correct severe deformities while maintaining the foot's ability to function.