Clubfoot in the twentieth century: where we were and where we may be going in the twenty-first century.

In the twentieth century clubfoot was one of the commonest congenital deformities of the musculoskeletal system with an incidence in some races as low as 0.6 and in others as high as 6.8 per thousand live births (Polynesia). Males have the deformity twice as often as females. In the early 1900s forceful correction of the deformity as espoused by Hugh Owen Thomas was in vogue. In the 1930s Joseph Hiram Kite, like Hippocrates (400 BC), recommended repeated gentle manipulations to achieve a correction. Instead of bandages Kite used serial plaster casts to maintain the correction. During the late 1940s Ignatio Ponseti developed his technique of correction through the normal arc of the subtalar joint. In a clubfoot the soft tissues are more resistant to pressure than the bones. With this concept in mind soft tissue procedures were developed in which the capsules and ligaments were released surgically. With safer pediatric anesthesia the 1960s, 1970s, and 1980s saw surgical approaches that were more and more aggressive even including a complete subtalar release. The improved imaging modalities and computer graphics of the 1980s led to a better understanding of the pathoanatomy. Long-term follow-up studies demonstrating malcorrection, overcorrection, pain, and stiffness dampened the enthusiasm for very aggressive surgery. The main problem with surgery is that clubfoot wounds heal by a patching up process called repair. The losses are made good not with the original tissue but with a material that is biologically simple, cheap, and handy - connective tissue scar! As the century drew to a close there was a major swing of the pendulum to the Ponseti method. Surgeons are now learning the limitations of this method. Finally, the author tries to imagine what may happen in the future prevention, classification, and treatment of clubfoot with all the advances in cell biology, molecular biology, biomechanics, biomaterials, surgery, orthotics, and evidence-based medicine.