We can help you find a Dr. who can help your child's foot/feet.
clubfoot relapse.
Some feet will continue to relapse no matter what you do, even with strict bracing (about 3% - 5%).
Many feet can be re-corrected with casting alone. However there are some persistent and stubborn feet that may need additional treatment and potential ATTT surgery.
This kind of relapse is treated with a much more minor surgery than has been typical in the past 100 years called the Anterior Tibialis Tendon Transfer (ATTT/TATT).
Dr Ponseti described this surgery as a last resort, but also a final corrective measure for feet with persistent reoccurence of the clubfoot deformity. Once this surgery is done, feet should have full functionality and should also not need further treatment. Officially the ATTT surgery is considered part of the Ponseti Method.
Unfortunately, this is not always the case for every foot treated with the ATTT surgery. Many feet experience further issues and pain. This is why it is of paramount importance to make sure that your child has no other options, and that they are old enough to have passed the big growth spurts that tend to try to pull the foot back in. Second, third, or even fourth opinions may be needed for you to feel comfortable consenting to this surgery
As always, the ATTT surgery should only be considered after all casting and bracing options have been exhausted.
These online support groups can be a great place for advice and information:
Swing Phase Supination - one of many photographic examples in this paper
This paper shows photographic and clinical signs of relapse in walking age kids. This can apply to pre-walking age kids, or anyone. The images are clear and easy for anyone to understand even without ever reading the text.
NOTE: This paper shows awesome images of what clubfoot relapse looks like. It is a great reference for parents and providers alike.
This surgery is usually only done after the age of 4-6 years old, and AFTER growth spurts are finished and all casting and bracing options have been exhausted, and also after the foot has been fully corrected again if possible through Ponseti Casting. The function of the tendon transfer is not to provide correction; rather, it is to maintain correction that has been previously obtained. If your doctor wants to do this surgery earlier than the age of 4-6yo, a second opinion might be an option just to be sure of this course of treatment before consenting to surgery.
POSI Webinar 31: Management of relapsed clubfoot by Jose Morcuende with Panellists: Christof Radler
Listen to the leading Ponseti Doctors discuss the management of relapsed clubfoot with other physicians and providers via Zoom in 2000
Deciding to do surgery, or not to do it, or to wait....
Surgery is not a decision to take lightheartedly. Nor should it be consented to without taking some time researching the specific surgery the doctor is recommending, and most importantly, seeking out another trusted Ponseti doctor's opinion prior to consenting to any surgical intervention.
When it comes to clubfoot, any surgical approach has every chance of damage to the foot, create scar tissue and stiffness, and as with any surgery, there are serious risks such as amputation and even death possible. While these risks are very small to non-existent under normal circumstances, they are real and possible. For these reasons, please be certain you are ready to proceed with surgical treatment before you consent to it.
Make sure to talk through any of the options your doctor offers. And if you're seeking out second opinions, this will help you understand better the approach your doctor has, or it could provide you with alternative options. It's perfectly fine to choose another route or option, surgical or not with another provider.
What is the ATTT/TATT or Anterior Tibialis Tendon Transfer Surgery?.
The Annterior Tibialisis Tendon Transfer surgery is a moderately inastive surgery that moves where the anterior tibialis tendon attaches to the in inside of the foot, to the outside of the foot, so that if and when it tries to pull in again, it pulls OUT instead of IN. It's a relatively simple concept, and does not involve large incisions.
There will be 3 incisions total. One on each side of the foot on top, and one on the sole where the anchor for the newly attached tendon is. It is usually a button, similar to any button on clothing. This button anchors the tendon in place while it heals and attaches to the new position.
It's a somewhat simple concept, but should only be used when all other casting and bracing options have been exhausted and also after the big major growth spurts that pull clubfeet back in. This is why it should be delayed as long as possible and other options employed if possible.
The Anterior Tibialis Tendon (the tendon, not the surgery) has one purpose. To provide ability to dorsiflex a foot. For clubfeet, this tendon is pulling to the inside and supinating the foot. When it pulls in after the foot has been fully corrected, clubfoot reoccurs. When it pulls after being re-attached to the outside of the foot instead, it should pull out. Theoretically. That is the point of this surgery.
Anterior Tibialis Tendon with Residual Clubfoot Deformity
ATTT Surgery - moving the anterior tibialis tendon from inside to outside of foot
Growth spurts are a major concern as this is often when the tendon tries to pull back in. Bracing through all the big growth spurts is how to combat this major contributor to relapse. This is why we brace for 4-5y, or even longer if needed.
Despite this surgery being somewhat simple and minimal as compared to the classic bigger and very invasive surgeries done in the past, it is still a surgery that carries with it real risks of increased damage, scar tissue, pain, and in very rare cases even death (as do all surgeries). Holding off until you are certain there are no other options is an option every parent should consider.
These research studies may help you with your search for information about clubfoot relapse and treatment.
Note: This paper uses data from Pirani score, number of casts, and bracing compliance to get their results. Therefore it will be listed in 3 categories on this page.
