The possibilities of operative treatment of residual and recurrent congenital clubfoot]

The paper presents 14 different surgical procedures recommended in literature for the correction of singular deformed elements of congenital clubfeet. Basing on clinical material collected from patients treated during the last five years, the authors introduce the application of the presented procedures for the correction of residual and recurrent deformities occurring in congenital clubfeet. Basing on their own experience, knowledge and available publications the authors attempt to assess the indications for each particular procedure and their mutual connections, which depend on: the kind and extend of the deformity, its location and the age of the child.     

Pathogenesis of congenital clubfoot]

Experiments, carried out by the author, have shown that the pathogenesis of congenital talipes is based on congenital muscular disbalance between flexors-supinators and extensors-pronators at the expense of strengthening of the former and insufficiency of the latter. An object of treatment of the considered developmental defect is restoration of myogenic balance. The existing methods of conservative treatment result in preservation of insufficiency of the anterolateral group of the crus muscles. Only the method of Vilensky V. Ya. allows to completely solve the posed problem. Operations on the posteromedial section of foot result in reduction of the myogenic disbalance as there is preserved insufficiency of extensors-pronators. Only operations, accompanied by shortening of anterolateral groups of the crus muscles allow to restore the myogenic balance straight on the operating table. The cause of recurrencies in case of congenital talipes is preservation of myogenic disbalance between flexors-spinators and their antagonist more frequent at the expense of insufficiency of the latter.     

先天性马蹄内翻足的实验及临床初步观察

目的在动物模型和临床电生理检测基础上,探索先天性马蹄内翻足的病理与临床病变间的可能联系。方法83只大白鼠从怀孕第10天起,将维甲酸石蜡油混悬液经胃管单次注入,以建立马蹄内翻足动物模型;应用躯体感觉诱发电位等电生理检测方法,对48例(63足)先天性马蹄内翻足患儿的神经功能进行检测。结果动物模型的马蹄内翻足发病率为53．7％。距骨持续停滞在胚胎阶段,距骨、跟骨间重叠不良和跟骨内翻,脊髓前角细胞有凋亡现象;68．3％的患儿电生理检测异常,明确病变位点位于腰骶脊髓占48．8％。结论先天性马蹄内翻足在胚胎发育期即有足的马蹄内翻,且畸形程度随生长发育而逐步加重。脊髓前角细胞凋亡可能同时诱发脊柱裂、肛门直肠畸形、先天性马蹄内翻足等疾患。     

Our experiences with the early operative treatment of congenital clubfoot

In operative clubfoot therapy, early operation plays an important role. Between 1975 and 1982, we operated on 55 children with 72 clubfeet: 56 posteroplantar releases in patients with an average age of 5.8 months, and 16 posteromedial releases in patients with an average age of 8.1 months. The average follow-up was 3.5 years. The results, based on an investigation scheme according to Henkel, were good and very good in 94%. Operative treatment is indicated after 3 to 4 months of intensive plaster treatment if there has been no further correction.     

Long-term results of posteromedial release for the treatment of congenital clubfoot]

The aim of this paper was to evaluate long-term results of posteromedial release in the treatment of congenital clubfoot in 46 patients (61 clubfeet) treated at the author's institution between 1979 and 1990. The average follow-up period was 15.7 years (from 20.4 to 10.1 years). The average age at the time of surgery was 12.3 months (from 5 to 48 months). The final evaluation based on Magone et al. criteria gave the following results: excellent in 17 feet (28%), good in 17 feet (28%), fair in 11 feet (18%) and poor in 16 feet (26%).     

Early surgery of the soft tissues in congenital clubfoot]

The role and position of early complete operative procedures on the soft tissues in the treatment of the congenital club foot is discussed in the article. The authors report on the operative indications in principles and in their own practice. Closed and operative treatment are not contradictory but complementary terms. The aim of the operative treatment is to bring all residual contractures following conservative treatment to an end. It must be done by relatively minimal intervention on the soft tissues and as early as possible. Thus the proper development of the foot and the prevention of bone deformation can be attained.     

Surgical treatment of congenital clubfoot with constriction band syndrome]

Twelve feet in 11 patients with constriction band syndrome age ranging from 3 to 18 months (mean age 11 months) were evaluated in this study. The constriction band was located at the in the calf, at distal, media and proximal third levels. All these patients were treated surgically by a wide peritalar release using the Cincinnati incision, followed by a two-stage Z-skin plasty. Both clinical and radiological results were evaluated. In our material an excellent result was achieved in 1 case, good results in 3 cases, satisfactory in 4 cases and poor in the remaining four cases. Very good and good results were achieved in feet with shallow bands type II and III, while poor results were found in feet with deep constriction band type I. Early surgical treatment followed by serial casting leads to better functional results.     

Rehabilitative therapy after correction of congenital clubfoot in children]

There have been analysed 49 children with congenital club foot (79 feet). All patients before arrival were treated according to the common methods and 42 children (64 articulations) were subjected to operative or apparatus-made correction of the club foot recurrence. In spite of the treatment obtained all children arrived with the residual signs of club foot. There are described the mechanisms of the club foot recurrence development, proposed a method of stage-by-stage redressment, needle and manual therapy realization.     

The role of posterior release in the treatment program for congenital clubfoot]

The aim of this paper was to assess the utility of this procedure and to define it's role in treatment of congenital clubfeet. The material comprises 123 children, among whom 154 feet were treated by posterior release. The age of the patients ranged from 5 to 36 months (average age: 16 months). The procedure involved the lengthening of the Achilles tendon in the sagittal plane, partial resection or transverse dissection of the articular capsule of the ankle joint. In selected cases lengthening of the tendon of the extensor hallucis muscle was performed and sometimes of the posticus muscle. The described procedure was performed in all cases where all forefoot components of the deformity were found, as well as an equines position of the foot. A group of 87 patients (70.7%), among whom posterior release was performed in 101 feet (65.6%). The follow-up time ranged from 5 to 15 years (average: 12.3 years). Results were assessed according to the classification by Magone et al. Very good results (95-100 points) were achieved in 27 feet (26.8%), good results (80-89 points) were found in 40 feet (39.6%), satisfactory (70-79 points) in 25 feet (24.7%), and bad results (less than 70 points) in 9 feet (8.9%). Basing on their own experience the authors' believe this procedure is very useful in treatment of congenital clubfeet. It's therapeutic usefulness is at it's best when deformities of the forefoot have been conservatively corrected. The extent of posterior release depends on the severity of the deformity.     

Results of treatment of congenital clubfoot with modified Goldner's technique]

The authors present the results of surgical treatment of resistant idiopathic and recurrent clubfoot (type IV according to Dimeglio classification). In the group who underwent a primary procedure, results were noted according to the Magone classification: 35.7% very good results, 11.9% good results, 9.52% satisfactory and 42.5% bad results (recurrent clubfeet accounts for 37.5%). The authors noted that the Goldner technique yields results comparable to the peri-talar release technique.     

Modification of the surgical technique for one stage peri-talar correction of congenital clubfoot]

The surgical technique for one-stage peri-talar correction of congenital clubfoot was modified by the author who introduced an accessory lateral approach to the tarsus. It enables true elimination of the soft tissue contracture maintaining deformity of the foot.     

Evaluation of treatment outcome in congenital clubfoot by subtalar release]

This paper presents an analysis of the results of congenital clubfoot treatment by partial or complete subtalar release performed through the Cincinnati approach. Of 116 patients (142 feet) who underwent surgery in the years 1995-1996, 33 (47 feet) came in for final follow-up. The type of primary deformity was defined in only in 36 feet. There were 25 type II deformity and 1 type III deformity. Total subtalar release was performed in 39 feet. Partial subtalar release was performed in 8 feet. During the release procedure, the calcaneo-cuboid joint was not opened, but stabilized with a K-wire. Clinical results were assessed according to the Magone classification. Radiological results were assessed according to the modified criteria of Scientific Committee of the XXI Meeting of the Polish Orthopedic Society held in 1976. Talo-navicular reposition was assessed according to Napiontek. Follow-up time ranged from 40 to 54 months (mean: 48 months). The clinical assessment revealed that the analyzed group as a whole gave 82.2 points (yielding a good result). Very good results were noted in 12 feet (25%), good results in 21 (45%), satisfactory results in 7 (15%) and poor results in 7 (15%). Analysis of radiological results yielded on average 2.5 points (0-7 points). Good results were noted in 45 feet (96%) and satisfactory in 2 feet. A talo-calcaneal index of less than 55 degrees was noted in 23 feet.     

Avascular necrosis of the talus after McKay clubfoot release for idiopathic congenital clubfoot

Avascular necrosis of the talus is a serious potential complication of clubfoot surgery. In the few cases described in the literature, the necrosis has involved the entire talus and resulted in progressive fragmentation and collapse. Serial postoperative radiographs of 96 idiopathic clubfeet in 70 patients are reviewed here to determine the incidence of avascular necrosis after McKay soft tissue release. Based on criteria in the literature for making the diagnosis, no cases of avascular necrosis were seen. Growth lines were observed in the cuboids and calcanei of all the feet during the follow-up period. Eight feet failed to develop growth lines in the talus during follow-up. Five of these feet showed flattening of the dome of the talus and three hypoplasia of the talar head and neck at the most recent follow-up. Absence of normal growth lines in the talus after operation seems to predict talar abnormalities.