The Classic: Observations on Pathogenesis and Treatment of Congenital Clubfoot

This Classic article is a reprint of the original work by Ignacio V. Ponseti and Jeronimo Campos, Observations on Pathogenesis and Treatment of Congenital Clubfoot. An accompanying biographical sketch on Ignacio V. Ponseti, MD, is available at DOI 10.1007/s11999009-0719-8 and a second Classic article is available at 10.1007/s11999-009-0720-2. This article is 1972 by Lippincott Williams and Wilkins and is reprinted with permission from Ponseti IV, Campos J. Observations on Pathogenesis and Treatment of Congenital Clubfoot. Clin Orthop Relat Res. 1972;84:50–60. The Association of Bone and Joint Surgeons 2009 Richard A. Brand MD & Clinical Orthopaedics and Related Research, 1600 Spruce Street, Philadelphia, PA 19103, USA e-mail: [email protected] In the treatment of clubfoot, as in many other orthopedic disorders, the orthopedic surgeon is handicapped because of his ignorance of the primary causes of the deformity. Many scholarly studies blame congenital clubfoot on: abnormal leg muscle development [3], connective tissue genetic defect [22], defective cartilaginous anlage of the anterior part of the talus [16], intra-uterine compression [6], dislocation of the talonavicular joint [5], defect in peroneal muscle innervation [7], defective anterior horn cells [8], abnormal tendon insertions [14, 21], arrest of development [4], tight deltoid ligament [13], etc. The clubfoot deformity has not been described in embryos, but it has been observed as early as the twelfth gestational week [1]. We studied 6 congenital clubfeet, 2 in a 90-mm-long (crown to rump) male fetus, 2 in a 7-month premature fetus and 2 in a 3-day-old infant. The clubfeet were the only apparent abnormalities in our specimens. The 90-mm male fetus was thought to be in the seventeenth gestational week and had a bilateral clubfoot deformity, severe on the left and mild on the right (Fig. 1A). Hips and knees were normal. Following removal of the dermis, the leg muscles appeared to be normally developed. The talus was in normal position in the ankle mortise; the other tarsal elements were displaced medially. Serial histologic sections of both legs and feet revealed periosteal and enchondral ossification in the tibia, fibula, metatarsals, and in some phalanges. The other skeletal elements of the foot were formed by cartilage, and their shapes resembled those of normal feet in newborns. Cartilage canals were observed in these elements [10]. Normal foot joint cavities with synovial folds at their margins were apparent. The navicular articulated only with the medial aspect of the head of the talus. The calcaneocuboid joint was directed medially. The joint surfaces were congruent and no gapping was observed. No abnormalities were detected in the joint capsules and ligaments. The deltoid ligament was not unusually thick or fibrotic, and it was slightly folded and not under tension. Tendon insertions were normal. The tibialis posticus branched in the plantar aspect of the foot, sending strong insertions into the navicular, the first cuneiform and the bases of the third and fourth metatarsals. The peroneus longus tendon was also well developed and had a wide 123 Clin Orthop Relat Res (2009) 467:1124–1132 DOI 10.1007/s11999-009-0721-1