Atypical Clubfoot- A Systematic Review

Background: The management of congenital talipes equinovarus (clubfoot) has been transformed by the Ponseti technique. However, 5-7% of clubfeet present as atypical or complex variants that are resistant to standard treatment protocols. These challenging cases require early recognition and modified management strategies. Purpose: To systematically review the literature on atypical/complex clubfoot, defining its clinical characteristics, pathogenesis, and evidence-based treatment modifications. Methods: A systematic literature search was conducted across PubMed, Embase, Scopus, and Ovid databases through April 2025. Studies reporting on atypical or complex clubfoot characteristics, pathogenesis, management techniques, and outcomes were included. Quality assessment and data extraction followed PRISMA guidelines. A total of 32 studies met the inclusion criteria and were analyzed. Results: Atypical clubfoot is characterized by a deep transverse plantar crease, hyperextension of the big toe, and a stubby foot appearance. Complex variants demonstrate excessive oedema and stiffness during casting. The challenges encountered during treatment are due to intrinsic anatomical factors and iatrogenic factors such as frequent cast slippage. Key management modifications include: prevention of cast slippage through metatarsophalangeal joint termination, application of the Ponseti 2 manoeuver for forefoot equinus correction, delayed tenotomy timing, and increased vigilance for recurrence. Recurrence rates range from 15-45%, higher than idiopathic clubfoot. Long-term outcomes demonstrate satisfactory correction with modified protocols, though complex clubfoot requires more casts and closer follow-up. Conclusions: Early recognition of atypical/complex clubfoot enables timely implementation of treatment modifications. Prevention of iatrogenic cast slippage, appropriate application of the Ponseti 2 manoeuver, and extended follow-up are essential for optimal outcomes. Further research is needed to standardize terminology and establish evidence-based algorithms. Keywords: Clubfoot, Atypical, Complex, Review