The role of bilateral talectomy in the management of bilateral rigid clubfeet

Severe clubfoot is a common sequela of arthrogryposis multiplex congenita and myelomeningocele. Talectomy is a practical surgical procedure to assist in the correction of severe, rigid equinovarus foot deformity. However, the results of talectomy may be less predictable in rigid bilateral equinovarus foot deformity than in the treatment of unilateral clubfoot. To determine the outcome of talectomy in the treatment of bilateral rigid clubfoot, we reviewed the cases of all patients at our center who underwent bilateral talectomy. Seven children were treated for bilateral talipes equinovarus with talectomy. The patient group consisted of 3 children with arthrogryposis, 3 with myelomeningocele, and 1 with Duchenne muscular dystrophy. The age at surgery averaged 6 years and ranged from 1 year and 10 months to 15 years and 7 months. The length of follow-up averaged 5 years and 6 months and ranged from 3 years to 12 years and 6 months. Three feet had a good and 7 feet a satisfactory correction of the deformity. Four feet had poor results. Bilateral talectomy was found overall to be a successful and predictable procedure, with low morbidity for the attainment of functional feet.     

Talectomy in patients with recurrent deformity in club foot. A long-term follow-up study

We reviewed 24 feet in 15 patients who had undergone talectomy for recurrent equinovarus deformity; 21 were associated with arthrogryposis multiplex congenita, two with myelomeningocele and one with idiopathic congenital talipes equinovarus. The mean follow-up was 20 years. Good results were achieved in eight feet (33%) in which further surgery was not needed and walking was painless; a fair result was obtained in ten feet (42%) in which further surgery for recurrence of a hindfoot deformity had been necessary but walking was painless; the remaining six feet (25%) were poor, with pain on walking. All patients wore normal shoes and could walk independently, except one who was wheelchair-bound because of other joint problems. Recurrent deformity, the development of tibiocalcaneal arthritis and spontaneous fusion of the tibia to the calcaneum were all seen in these patients.     

Congenital talipes equinovarus: I. Resolving and resistant deformities

Comparisons were made between 54 children with resolving congenital talipes equinovarus deformity and 81 children whose feet required surgical correction. There was a significant difference in the incidence of bilateral deformity, sex ratio and family history of congenital talipes in the two groups. The children with resolving deformity had feet which were indistinguishable from the normal side of unilaterally affected children in their calf muscle measurements at six weeks of age, and in the range of movement and radiographs at four years of age. Those requiring surgery had varying degrees of muscle reduction, and although often well corrected, had a reduced range of movement and altered joint anatomy at four years of age. This suggests that they are two distinct populations.     

Clinical outcome of congenital talipes equinovarus diagnosed antenatally by ultrasound

Congenital talipes equinovarus is a common anomaly which can now be diagnosed prenatally on a routine ultrasound scan at 20 weeks of gestation. Prenatal counselling is increasingly offered to parents with affected fetuses, but it is difficult to counsel parents if there is a chance that the fetus may not have talipes. Our study correlates the prenatal ultrasound findings of 14 infants diagnosed as having unilateral or bilateral talipes during their routine 20-week ultrasound scan with their clinical findings at birth and the treatment received. No feet diagnosed as talipes on the ultrasound scan were completely normal at birth and therefore there were no true false-positive results. One foot graded as normal at 20 weeks was found to have a mild grade-1 talipes at birth, but did not require treatment other than simple stretches. A total of 32% of feet required no treatment and so could be considered functional false-positive results on the scan. Serial casting was required by 13% of feet and surgical treatment by 55%. The severity of the talipes is difficult to establish before birth. A number of patients are likely to need surgical treatment, but a proportion will have talipes so mildly that no treatment will be required. In counselling parents at 20 weeks, orthopaedic surgeons need to know whether or not there is a small chance that the ultrasound diagnosis could be wrong and also that the talipes may be so mild that the foot will not require treatment.     

外固定器治疗脊髓栓系综合征僵硬性足部畸形

[目的]观察外固定器治疗脊髓栓系综合征僵硬性足部畸形的临床效果,探讨脊髓神经源性足部畸形外科矫正和功能重建的新技术.[方法] 1988年10月～2006年6月,回顾性分析脊髓栓系综合征僵硬性足部畸形61例97足;年龄6～42岁,根据足部畸形的特征,设计不同构型的外固定器.上运动神经元损伤型足部畸形主要实施选择性胫神经缩窄手术和距下关节外融合手术或距下关节融合术,同时安装外固定器.下运动神经元损伤型足部畸形主要实施软组织松解、肌腱转位术或截骨手术,同时安装外固定器.[结果]得到至少3年随访的54例、86足进行分析,马蹄内翻足39足,马蹄足21足,马蹄外翻足16足,跟行足6足,高弓足4足.其中上运动神经元损伤型足部畸形19足,下运动神经元损伤型67足.佩戴外固定器时间8～12周,平均11周.采用Laaveg - Ponseti足功能评分系统:优38足,良29足,可13足,差6足.优良率77.9％.第1次术后复发3足,复发率3.5％.钉道感染18足,清理炎性分泌物或更换钉道位置后治愈.足底溃疡3足,清创和短期避免负重后治愈.[结论]外固定器治疗脊髓栓系综合征僵硬性足部畸形符合生物学重建理论,可提高疗效,减少复发.     

组织牵伸与有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形

目的探讨组织牵伸结合有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形的临床问题。方法 2004年6月至2009年2月共治疗17例成人足外伤后严重的马蹄内翻足畸形。Dimeglio分型：Ⅲ型,严重畸形13足;Ⅳ型,畸形非常严重4足。牵伸矫形器由胫骨外固定器和特殊形状的足部外固定器构成,在畸形状态能适应牵伸器顺利安装情况下,仅选择距下关节融合。如果畸形超出牵伸支架的可调空间,选择有限截骨三关节融合术,部分矫正足的内翻、内收畸形,至能顺利安装牵伸支架,残留的畸形通过牵伸逐渐矫正。结果治疗结束时所有病例的马蹄内翻足畸形均得到完全矫正。14例随访半年至3年,平均11个月;5足轻度复发,马蹄畸形均未大于20°,仍能跖行;踝关节活动度部分有一定改善。根据国际马蹄足畸形研究学组（ICFSG）的评分系统：优3足,良9足,可2足,差0足。结论组织牵伸结合有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形,便于外固定器的安装,更好地预防畸形复发、减少牵伸的时间,发挥Ilizarov技术的优势。     

距跟周围松解旋转术治疗儿童先天性马蹄内翻足

目的：探讨距跟周围松解旋转术治疗儿童先天性马蹄内翻足（CCF）的临床应用及近期疗效。方法：2004年至2006年采用距跟周围松解旋转术治疗儿童先天性马蹄内翻足24例（共36足）,术中行广泛的软组织松解、距跟去旋转矫正,保留跟距骨间韧带,去旋转绞链,避免跟骨失稳,行胫前肌腱延长。术后管型石膏固定6-8周。去除内固定后穿矫形支具〉1年。结果：均痊愈,平均随访2．3年（1～3年）,根据术后足的外观形态、足印、踝部功能、有无疼痛及x线检查评价疗效,疗效优16例25足;良6例8足;可2例3足,优良率为93．33％。结论：距跟周围松解旋转术是矫正儿童先天性马蹄内翻足的有效手术方法,其优点是手术松解充分、畸形纠正彻底,矫形效果良好。     

Treatment of spastic club foot]

In 38 patients with spastic cerebral palsy, treatment was carried out for talipes equinovarus. There were 12 children with spastic hemiplegia, while 24 had diplegia or tetraplegia. Surgery was done with the goal of achieving plantigrade and muscle-balanced feet. In 24 feet of 19 children tibialis anterior transfer was performed, while tibialis posterior transfer was done in 20 feet of 19 patients. Without exception, additional surgery was performed on the triceps surae (30 x ATLs and 16 Vulpius operations); medial arthrolysis was also necessary in 6 cases. The clinical results were assessed by the senior author in the weekly neuro-orthopedic clinic an average of 3.2 years after surgery. An additional questionnaire was sent to all patients' families asking for their subjective assessment of the surgery performed. Figures were collected for 30 patients with 38 treated feet. The results were evaluated according to Kling's criteria. We saw good and very good results in 75% of the patients (4 feet very good, 23 feet good), while 25% of the patients (9 feet in 7 patients) showed poor results with over-corrections and calcaneo-valgus foot as the main problem. The best results were seen in spastic hemiplegia and the poorest in patients with severe tetraplegia and total body involvement.     

应用Ilizarov技术治疗青少年重度马蹄内翻足

目的 :探索青少年重度马蹄内翻足的治疗方法。方法 :应用足踝部有限软组织松解 ,结合术后外固定器缓慢牵伸松解关节挛缩 ,以及二期关节融合与肌力平衡手术治疗青少年重度马蹄内翻足 10例 (16足 )。结果 :16足均获得满意的畸形矫正及足底持重 ,3例遗有轻度前足内收。结论 :应用Ilizarov技术结合有限的手术治疗 ,可获得青少年重度马蹄内翻足的良好畸形矫正和功能恢复。     

Ilizarov技术矫治复杂僵硬性马蹄内翻足

 目的 探讨Ilizarov技术矫治复杂僵硬性马蹄内翻足的临床疗效。方法 回顾性分析2005年7月至2011年7月28例（41足）僵硬性马蹄内翻足患者的病例,男18例（26足）,女10例（15足）;年龄3~45岁,平均15.3岁;左足8例,右足7例,双足13例。根据Diméglio畸形分级：Ⅲ级31足,Ⅳ级10足。23足采用有限软组织松解、18足配合有限截骨后均安装Ilizarov外固定牵伸器。比较术前及末次随访时踝关节跖屈及背伸角度、踝关节活动度、正侧位X线片上患足距跟角的变化。结果 28例患者均获得随访,随访时间5~38个月,平均25个月。术后外固定支架佩戴2~14个月,平均5.1个月;去除支架后所有患足均获跖行步态,外形接近正常,无足短缩。足背伸角度：术前-45.0°±12.0°,末次随访9.5°±5.5°;跖屈角度：术前67.0°±14.0°,末次随访45.5°±7.8°;正、侧位X线片距跟角：术前分别为6.5°±4.5°和5.5°±11.0°,末次随访分别为22.5°±5.5°和40.6°±8.5°。1足术后发生急性血管痉挛性缺血,予减缓牵伸速度后缓解;5足发生针道感染,予更换针道及换药后感染控制。去支架后3个月,1足出现畸形复发,予二次矫形;3足畸形残留,5足趾屈曲挛缩,均给予二次软组织矫形术,未再复发。结论 Ilizarov技术矫治复杂僵硬性马蹄内翻足疗效确切,能最大程度保留足外形和功能,避免足短缩,不影响足发育。     

A novel surgical option for the operative treatment of clubfoot

Clubfoot (talipes equinovarus) is a condition well known since the time of Hippocrates. Numerous conservative treatments have been introduced for this condition; few are still in favour. Conservative treatment was used in our department up to the third month of age. The indication for surgery was failure to correct or maintain the correction after conservative treatment. We report on 134 children (206 feet) who had operative treatment for clubfoot in our department during the period 1990-1996, using a novel surgical technique based on extensive posteromedial release combined with the lateral spread of the "extensor forces" of the foot. This new technique has produced excellent results.     

Subtalar release in clubfeet: a retrospective study of 10-year outcomes

BACKGROUND: Optimal management of congenital talipes equinovarus continues to be controversial. There is a dramatically renewed emphasis on non-operative management partly because there has been a high recurrence rate among operated feet. Our hypothesis is that early, extensive subtalar ligament release as the cornerstone of aggressive hindfoot realignment prevents recurrence and retains mobility. MATERIALS AND METHODS: Twenty-two congenital clubfeet (14 patients) corrected by one surgeon were evaluated using two validated patient-based outcome instruments, dynamic pedobarographic analysis, hindfoot mobility, and weightbearing radiographs. Pedobarographic analysis consisted of quantifying peak plantar forces and pressures during the gait cycle in 22 corrected feet and 24 control feet using the FSCAN in-shoe device. RESULTS: The mean age at surgery was 8 months and mean followup was 10 years. No patients experienced recurrence of deformity. Reported foot function and satisfaction were very high for all patients and were comparable to reported normal population values. AP and lateral talocalcaneal angles for each foot were within normal limits for age. Hindfoot range of motion, including dorsiflexion, was preserved in all feet. Peak regional forces throughout the gait cycle and plantar pressures at foot flat were mildly, but statistically significantly, higher in the midfoot of corrected feet suggesting slight flattening of the arch. One patient had tendon transfers for bilateral calcaneal deformity and one patient had surgical correction of a bilateral valgus deformity. CONCLUSION: Aggressive hindfoot realignment provides definitive treatment of an equinovarus deformity, but care must be taken to avoid overcorrection.     

胫神经缩窄术治疗下肢痉挛性瘫痪

目的探讨胫神经缩窄术治疗下肢痉挛性瘫痪、矫正内翻马蹄足的手术适应证、手术方法。方法25例患者,其中脑瘫患者15例,其他患者10例。术前明确诊断病因,详细分析挛缩肌肉及神经支配,在显微镜下行胫神经缩窄术。术中神经电刺激定位运动神经和诱发肌电图监测。结果行胫神经缩窄术37例次,术后功能改善36肢。踝关节增加10°～45°背屈,改善率97%。内翻足26例,22足改善,改善率85%。37足中术后足底位置正常(足底完全着地)9例(24%),尚不正常4例(11%)。25例患者中,术后随意运动功能改善21例(84%),其中显著改善5例(20%)。4例无效均为脑瘫患者。结论胫神经缩窄术是治疗下肢痉挛性瘫痪、矫正内翻马蹄足,改善下肢运动的有效方法。     

Split tibialis posterior tendon transfer on peroneus brevis for equinovarus foot in CP children]

Equinovarus deformity of the foot is a result of the muscles imbalance in which inventors of the foot, mostly posterior and anterior tibialis muscle, overpower evertors. In children with cerebral palsy untreated spastic equinovarus deformity may cause severe fixed foot deformity and painful callosities under metatarsal heads and on the lateral side of the foot. The gait pattern becomes less effective and needs more energy. The study group consisted of 154 children with cerebral palsy treated in our Clinic by the multilevel soft tissue surgery. For foot problems 136 children needed surgical intervention. In 19 ambulatory patients, with hemiplegia or diplegia, split tibialis posterior tendon transfer together with tendo Achilles lengthening and plantar aponeurectomy were performed. The study was based on clinical examination, parents' questionnaire, radiology and gait analysis at least one year after surgery. The mean follow up was 4.6 years. The functional improvement was observed in 17 (89%) children with tendon transfer. At the last follow up those patients were brace free, with plantigrade foot while walking (without DAFO orthesis) and normal shoes were used. All painful callosities disappeared. On a standing AP X-ray adequate correction of the hindfoot-forefoot relation was achieved in 14 (74%) cases. Persistent equinovarus deformity over 10 degrees was observed in 2 cases. Those patients underwent additional bone surgery. With a properly planned approach the split tibialis posterior tendon transfer can bring good clinical and functional results in CP children with equinovarus deformation. We recommend this procedure in early stage of the deformity what can eliminate more harmful triple arthrodesis in severe deformities.     

Surgical versus accommodative treatment for Charcot arthropathy of the midfoot

BACKGROUND: The treatment of Charcot foot arthropathy is one of the most controversial issues facing orthopaedic foot and ankle surgeons. Although current orthopaedic textbooks are in almost universal agreement that treatment should be nonoperative, accommodating the deformity with orthotic methods, most peer-reviewed clinical studies recommend early surgical correction of the deformity. In a university health system orthopaedic foot and ankle clinic with a special interest in diabetic foot disorders, a moderate approach evolved for management of this difficult patient population. METHODS: Patients with Charcot arthropathy and plantigrade feet were treated with accommodative orthotic methods. Those with nonplantigrade feet were treated with surgical correction of the deformity, followed by long-term management with commercial therapeutic footwear. The desired outcome for both groups was long-term management with standard, commercially available, therapeutic depth-inlay shoes and custom-fabricated accommodative foot orthoses. During a 6-year period, 198 patients (201 feet) were treated for diabetes-associated Charcot foot arthropathy. The location of the deformity was in the midfoot in 147 feet, in the ankle in 50, and in the forefoot in four. RESULTS: At a minimum 1-year follow-up, 87 of the 147 feet with midfoot disease (59.2%) achieved the desired endpoint without surgical intervention. Sixty (40.8%) required surgery. Corrective osteotomy with or without arthrodesis was attempted in 42, while debridement or simple exostectomy was attempted in 18 feet. Three patients had initial amputation (one partial foot amputation, one Syme ankle disarticulation, and one transtibial amputation), and five had amputation (two Syme ankle disarticulations and three transtibial amputations) after attempted salvage failed. CONCLUSION: Using a simple treatment protocol with the desired endpoint being long-term management with commercially available, therapeutic footwear and custom foot orthoses, more than half of patients with Charcot arthropathy at the midfoot level can be successfully managed without surgery.     

Results of surgical treatment of congenital clubfeet with the Sotirow method]

Clinical and radiological results of surgical treatment of congenital clubfeet by an antero-lateral approach first introduced by Sotirow in 1976 are presented. The aim of this paper was to assess long-term results of this procedure on children (aged 5-18 months at the time of surgery). A series of 65 feet in 42 cases diagnosed with congenital talipes equinovarus was evaluated. Forty-two cases were treated conservatively with casts--changed on a weekly basis for 2-3 months and then every 2 weeks. Magone's score criteria were used to assess the method. Average follow-up was 7 years. Clinically 72% of the results were rated as excellent or good. We found the biggest problem during the Sotirow procedure was placing the trochlea of the talus bone into his anatomical into its' anatomical position in the talo-crural joint. The method introduced by Sotirow seems to be highly effective and worth applying. It enables a real elimination of soft-tissue contractures, which retains the deformity of the foot through an antero-lateral approach.     

软组织松解结合截骨治疗僵直性先天性马蹄内翻足

目的探讨软组织松解和（或）截骨治疗僵直性先天性马蹄内翻足畸形的手术方法及疗效。方法 2003年1月至2007年12月采用软组织松解和（或）截骨治疗僵直性先天性马蹄内翻足患者7例13足。男3例6足,女4例7足;年龄3～12岁,平均（5.3±3.1）岁;术前畸形程度按Dimeglio评分系统进行评分为13～20分,平均（15.1±2.2）分。按其评分进行分类,Ⅲ度畸形10足,Ⅳ度畸形3足。结果 7例13足的Cummings评分为31～88分,平均（75.5±14.3）分,其中优3足,良9足,差1足。结论充分而有序的软组织松解结合有限的截骨治疗僵直性先天性马蹄内翻足可获得良好疗效。     

Treatment of macrodactyly and foot gigantism]

Between 1996 and 2000 the authors followed-up 6 children with congenital hypertrophy of 7 feet. Surgical treatment was performed in 4 children (4 feet). The average age at the time of surgery was 9 years, and the average follow-up period was 3 years. 2 cases of macrodactyly of the I and II rays of the foot and 1 case of macrodactyly of the II ray of the foot were observed. Amputations of phalanges or toes in all 3 cases were performed with amputations of distal parts of adjacenet metatarsals in 2 cases. Soft tissue debulking was routinely done. Operative treatment of 1 case of the foot gigantism connected a resection of the IV and V metatarsals, a removal of the III metatarsal, an epiphysiodesis of II metatarsal and an amputation of all toes at the MIP joint level. A good cosmetic result was achieved in all children with macrodactyly and all of them were normal shoes. The treatment in the case of foot gigantism yielded good functional result and satisfactory cosmetic result. The patient required orthopaedic foot-wear. In the authors' opinion the resection of the lateral rays of the foot is superior the central ray resection.     

Congenital talipes equinovarus: II. A staged method of surgical management

A staged method of surgical management for congenital talipes equinovarus is described. The hindfoot was corrected and rebalanced early in 125 feet, and in 66 feet a second-stage medial forefoot correction was performed in the second, third or fourth year. The hindfoot relapsed in 19% and the forefoot in 9%; these feet were treated by further soft-tissue surgery. No bony operation was necessary. Assessment before and after operation allows comparison with other series.     

Transposition of the dorsal fascio-cutaneous flap of foot in treatment of talipes equinovarus]

For the purpose of one stage correction of severe congenital Talipes equinovarus, a new technique was designed to fashion a fascio-cutaneous flap from the redundant tissue on dorsolateral area of the foot, and it is then transposed to cover the defect left on the posteromedial part of the same foot following complete releasing and correcting the contractured soft tissue and lengthening the shortened tendons. This newly designed method was applied to 26 feet of severe congenital talipes equino-varus in 16 children aged 3/4-4 years. The foot deformity has been beautifully corrected and the transposed flap soundly healed in every foot without complication of any kind. The surgical procedures are fully described in the paper.