Surgery for Clubfoot in Children

The vast majority of babies born with clubfoot, a condition that causes the bones and soft tissues of the foot to twist inward, are successfully treated by doctors at Hassenfeld Children’s Hospital at NYU Langone using the Ponseti method. However, a small percentage of children may still have structural abnormalities in their feet, even after doctors and parents have followed the Ponseti method to completion.

In these rare instances, an orthopedic surgeon may recommend that your child have a surgical procedure to correct the bone structure of the foot. These procedures are most frequently recommended for children two to five years old.

Achilles Tendon Lengthening

If a child’s clubfoot is resistant to treatment because the Achilles tendon doesn’t stretch and grow as much as doctors expected after a percutaneous Achilles tenotomy was performed, doctors may recommend a procedure called Achilles tendon lengthening. This procedure allows your child’s foot to stretch and grow into the right position.

An Achilles tendon lengthening takes place in the hospital and requires general anesthesia. An orthopedic surgeon makes small incisions at the back of your child’s foot to access the Achilles tendon. The doctor then gently stretches and cuts the tendon, lengthening it and moving it into the correct position. The incisions are closed using one or two stitches, which dissolve on their own. The procedure takes about an hour, and you can take your child home that day. Most children experience little if any discomfort after this surgery, and doctors recommend acetaminophen if your child seems uncomfortable.

Immediately after the surgery, a cast is applied to cover your child’s foot and leg from toe to thigh. It’s worn for a minimum of four weeks, or until your child’s doctor determines the Achilles tendon has healed. After this cast is removed, doctors apply a walking cast that your child wears for two weeks. In some instances, the doctor may recommend that your child wear a leg brace for several weeks after the walking cast is removed.

Tendon Transfer Surgery

Some children who are treated with the Ponseti method as babies may experience a slight clubfoot relapse when they are three to five years old. You may notice that your child’s foot starts to turn inward just slightly, or that the foot has too much arch and doesn’t lie flat against the ground.

This “intoeing” is frequently caused by an overactive tendon—not the Achilles tendon—that hasn’t stretched enough to allow for a complete repositioning of the foot. For these children, our orthopedic surgeons may recommend surgery to transfer a tendon from one side of the foot to the other to allow the foot to have more flexibility and a full range of motion.

This procedure takes place in the hospital, and requires general anesthesia. An orthopedic surgeon makes an incision to access and cut the anterior tibialis tendon, located along the inner arch of the foot. This tendon is then moved to the other side of the foot beneath the skin, where it is reattached to the bones there using a small surgical button. This new tendon positioning keeps your child’s foot from turning inward. Dissolvable stitches are used to close the incision. This procedure takes about 90 minutes, and you can expect to bring your child home on the same day as surgery.

After the procedure, the doctor places your child’s leg in a toe-to-thigh cast for six weeks while the tendon heals in its new position. After six weeks, the doctor removes the long cast and performs a quick surgical procedure, either in the doctor’s office or in the hospital, to remove the button holding the tendon in place. Often, anesthesia is not required, but doctors may recommend an injection of a local anesthetic to ensure your child remains comfortable. The doctor creates a mold of your child’s leg that is used to make a custom-fit brace. Usually it takes about two weeks for the brace to arrive. In the interim, doctors apply a short cast to your child’s foot.

After the brace is ready, your child wears it 24 hours a day for 6 to 12 months. In order for the tendon transfer surgery to be successful, the brace must be worn for the entire time your doctor prescribes. This brace allows your child to have full mobility while keeping the foot in its corrected position.

Doctors at Hassenfeld Children's Hospital schedule follow-up appointments every two to three months, adjusting the fit of the brace to accommodate your child’s growing bones and muscles. After your child’s foot has completely healed, doctors remove the brace, and your child can wear regular shoes.

Surgical Procedures for Older Children

If a child has been treated using the Ponseti method but still has structural abnormalities in the foot, or if a medical condition such as spina bifida or arthrogryposis contributes to musculoskeletal problems after infancy, doctors may recommend a reconstructive surgical procedure to correct the position of the feet and provide the child with improved balance and stability.

Our orthopedic surgeons recommend reconstructive surgery based on evaluations of a child’s anatomy and medical history, and they consult with parents regarding the surgical options available to their child. Reconstructive procedures that may be suggested include osteotomy, in which surgeons reshape or reposition a bone in the leg or foot to improve alignment. Surgeons may also recommend external fixation, a procedure in which external braces are surgically applied to the feet using pins and wires. These braces are adjusted daily to slowly reposition the foot.

Reconstructive surgery is performed using general anesthesia, and most children remain in the hospital for one or more nights so doctors can monitor their recovery. Each child receives a customized postoperative recovery plan that may include physical therapy and is based on the age and overall health of the child and the procedure performed.