Surgical treatment of clubfoot: the significance of talocalcaneonavicular malposition correction

In a retrospective study on the surgical management of clubfoot based on clinical and radiographic assessments, 171 feet in 137 patients were reviewed. The surgical procedure was selected according to the degree of the deformity. The more severe cases (group A, 75 feet) were surgically treated according to Turco's one-stage posteromedial release, whereas the milder degrees of deformity (group B, 96 feet) were corrected by elongation of the Achilles tendon with posterior capsulotomy. The mean age of the patients at surgery was 12.5 months in group A and 5.2 months in group B. The mean follow-up time for both groups was 12.2 years. At follow-up, 24 feet (41%) in group A and 52 feet (68%) in group B required repeat surgery. In group A the results were good in 51 feet (68%), fair in 15 (20%), and poor in 9 (12%). In group B, good results were obtained in 44 feet (45%), barely satisfactory results in 25 (27%), and poor results in 27 (28%). It is suggested that the accurate correction of talocalcaneonavicular and calcaneocuboid malposition is a prerequisite for successful surgical treatment of clubfoot. There was a tendency for a better result in group A when the patients were surgically treated between 6 and 12 months of age.     

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.     

Opening wedge osteotomy of the medial cuneiform before age 4 years in the treatment of forefoot adduction

Thirty-seven feet in 25 children (12 girls, 13 boys) treated surgically with medial cuneiform opening wedge osteotomy to correct forefoot adduction were assessed. Thirteen patients had unilateral deformity. Primary diagnoses were congenital clubfoot (33 feet), congenital forefoot adduction (3 feet), and skewfoot (1 foot). All children underwent operation before age 4 years. The age at operation ranged from 21 to 47 months (mean 35). In 18 feet, allografts were used. In 5 feet, autograft was used. In 14 feet, ceramic material was inserted as opening wedge. Follow-up ranged from 3 to 8 years (mean 4). In four feet, the ossification center of the medial cuneiform was invisible. The correction of the deformity was assessed clinically and radiographically. The first ray angle and talo-first metatarsal angle were evaluated on anteroposterior radiographs, the latter was evaluated on lateral radiographs, also. In 26 feet, normal position of the forefoot was achieved. In five feet, overgrowth of the medial cuneiform in comparison with the normal side was observed. Forefoot adduction persisted in six feet. The ossification center was often divided into two parts by bone graft, and subsequent independent growth of both parts was observed. This technique is safe and useful for correction of forefoot adduction in young children. It can be performed even in cartilaginous bone. The osteotomy causes overgrowth of the medial cuneiform and the medial ray.     

Correction of severe recurrent clubfoot using a simplified setting of the Ilizarov device

BACKGROUND: Severe recurrent clubfoot deformities are challenging to treat. The Ilizarov method offers a safer alternative; however, the management of the device is complex. METHODS: A simplified standard setting of the Ilizarov device was used to treat 29 patients (35 feet) with a mean age of 14 years with severely stiff recurrent clubfoot deformities and large scars caused by one or more previous surgeries. This simplification involved a correction in two stages: first a gradual correction of the equinus, varus, cavus, and adduction deformities and later an acute correction of the supination deformity. All feet underwent percutaneous Achilles tenotomy and plantar fasciotomy; 11 feet required an additional midfoot osteotomy. The final outcome was scored as good (complete correction and no pain); fair (partial correction with plantigrade foot and occasional pain); or poor (nonplantigrade foot and continuous pain during walking). RESULTS: After a mean followup of 56 months, the results were good in 27 feet (77%), fair in five feet (14%), and poor in three feet (9%). Early complications were complete dislocation of the first metatarsophalangeal joint in two feet and partial dislocation of the distal tibial epiphysis in two feet. Late complications were recurrence of the deformity (11 feet), spontaneous ankylosis (16 feet), and symptomatic foot and ankle arthritis (7 feet). Arthrodesis was performed in 13 feet at an average of 21 months after the index surgery to treat symptomatic arthritis or correct disabling residual deformities. CONCLUSIONS: The Ilizarov device allowed correction of all the complex deformities of severe recurrent clubfoot with minimal operative intervention. Complications were numerous but manageable and for the most part did not compromise overall patient satisfaction in this very difficult to treat clinical condition.     

Management of idiopathic clubfoot in toddlers by Ponseti's method

The Ponseti method has been reported to have successful results in clubfoot patients less than 6 months of age but the literature on its efficacy in older clubfoot patients still remains sparse. In our study, we prospectively evaluated 55 clubfeet (37 patients) to determine clinically whether the Ponseti method is effective in the management of clubfoot in older children between the age of 12 and 36 months (mean: 24.8 months). All the patients belonged to moderate or severe grades of deformity as per the Pirani scoring. Painless, supple, plantigrade and cosmetically acceptable feet were achieved in 49 clubfeet. Seven patients (seven feet) developed recurrence of adduction, varus and equinus deformity whereas three patients (five feet) developed isolated recurrence of equinus deformity. These seven patients responded to repeat treatment and obtained satisfactory outcome. Four of these seven patients underwent tibialis anterior transfer to third cuneiform for dynamic supination. Three patients, those developed isolated recurrence of equinus deformity, underwent repeat tenotomy. One foot achieved satisfactory amount of dorsiflexion, three feet underwent tendoachilles lengthening whereas another foot underwent posterior release to obtain satisfactory dorsiflexion. Six to 12 numbers of casts (mean: 10) were required to obtain correction of clubfoot deformities. Mean period of immobilization in a cast was 13.9 weeks (10-15 weeks). We found that the Ponseti method is effective in children between the age of 12 and 36 months.     

Talectomy in the treatment of resistant talipes equinovarus deformity in myelomeningocele and arthrogryposis

Eighteen patients (28 feet) with spina bifida and arthrogryposis had talectomy for correction of severe equinovarus deformity. In 26 feet, posteromedial release had been performed previously. The average age at surgery was 4 1/2 years, with a range of 1-9 years of age. The length of follow-up averaged 4 years and ranged from 12 months to 8 years. Twenty-three feet were rated good, and five were poor. Six feet, because of forefoot adduction, required further surgery (metatarsal osteotomy). Talectomy is an effective procedure for correction of hindfoot deformity. Forefoot problems must be treated as a separate entity.     

两种术式治疗先天性马蹄内翻足的效果比较

目的应用Diméglio足评分方法,评价肌力平衡术和Mckay术治疗先天性马蹄内翻足（congenital clubfoot,CCF）的远期效果,以指导根据Diméglio分型合理地选择术式。方法1980年1月～2000年1月,收治CCF患儿37例54足,男27例38足,女10例16足;术时年龄5个月～3.5岁,平均1.2岁。左侧7例,右侧13例,双侧17例。按Diméglio足评分法分型,Ⅱ型（6～10分）3足,Ⅲ型（11～15分）26足,Ⅳ型（16～20分）25足。术前将所有足按畸形程度分为2组,A组（Ⅱ、Ⅲ型,29足）,B组（Ⅳ型足,25足）。按手术方式分组,肌力平衡术组31足,Mckay术组23足。术前Diméglio评分：A组12.55±1.84分,B组17.20±1.08分;肌力平衡术组14.16±2.83分,Mckay术组15.43±2.63分。结果所有患者获随访5年～10年6个月,平均8.2年。按Diméglio分型,Ⅰ型32足,Ⅱ型22足。2例行Mckay术后切口坏死感染,经多次换药愈合。术后Diméglio评分：A组4.07±1.25分,B组6.52±1.74分;肌力平衡术组5.29±1.97分,Mckay术组5.09±1.91分;与术前比较差异均有统计学意义（P〈0.05）。两种术式对A组足的畸形矫正程度比较差异无统计学意义（P〉0.05）;B组足的畸形矫正程度则有统计学意义（P〈0.05）。从对不同平面畸形的矫正程度看,对踝关节马蹄的矫正两术式比较差异无统计学意义（P〉0.05）,而对足内翻、前足内旋及内收畸形的矫正能力Mckay术明显强于肌力平衡术（P〈0.05）,其中Mckay术对前足内收畸形的矫正能力最强。结论DiméglioⅢ型以下的CCF,一期行肌力平衡术可取得良好效果,而对于Ⅳ型足则应采用Mckay术;但无论行何种术式,提倡同时切除外展肌,以防止前足内收矫正不良或复发。     

Calcaneal derotation osteotomy for clubfoot revision surgery

To describe a derotation calcaneal osteotomy technique and assess its efficacy in the correction of relapsed clubfoot. Twenty-one osteotomies were performed in 20 children with recurrent clubfoot. Nineteen children had been previously treated operatively. The derotation osteotomy was the first procedure performed in one case. The procedure combined medial and plantar releases, followed by a curvilinear osteotomy of the calcaneus. Patients were evaluated clinically and with standing dorsoplantar and lateral radiographs preoperatively, postoperatively and at follow-up. The talocalcaneal angle was considered as the most important criteria to evaluate the deformity correction. The clubfoot was idiopathic in 16 cases and neurological in five cases. Mean age at surgery was 7 years old (range 3.4-12 years). Total number of procedures per foot averaged 2.4 (range 4-1). The mean postoperative follow-up period was 2.8 years (range 2-6 years). The talocalcaneal angle increased significantly after the procedure (P<0.001), and no significant loss of correction was seen at latest follow-up (P=0.17). Two scarring complications occurred. Only one foot underwent further surgery after the calcaneal osteotomy for residual forefoot adduction, associated to a cavus and severe fibrosis. The calcaneal curvilinear osteotomy, in which the calcaneoforefoot unit derotation is performed around the talus but within the calcaneus, is a safe and efficient technique that can be proposed for clubfoot revision surgery.     

Posteromedial release combined with peritalar release in the treatment of congenital clubfoot]

Basing on the authors' own experiences an attempt to assess the value of posteromedial release in treatment of congenital clubfoot was made. The procedure was performed in 70 feet in 52 children, age ranging from 6 months to 12 years, 90% of the procedures were performed before 4 years of age. Feet were classified as follows: a. non-coerrective--type III according to Marciniak, b. Partially corrective, c. in older children (> 4 years of age) in whom posteromedial release was combined with a lateral resection of the cuboid bone. Late results after 5-20 years (13 years on average) were assessed according to Magone's classification. Deformity free, fully functional feet were achieved in 60% cases. The authors stress the fact that posteromedial release is the method of choice in uncorrective cases of clubfeet, and in cases were conservative treatment was implemented after 10 months of age. In the procedure should be performed at the age of 2-3 months.     

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.     

Eight year’s experience with soft tissue release and Alkhooly external fixator in the treatment of resistant clubfoot

From Aug 1992 to Feb 2001, thirty-two operations on the foot and ankle were performed in the Department of Orthopedics and Traumatology of El-Minia University Hospital in 24 children, 16 boys and 8 girls suffering from severe clubfoot deformity. There were eight cases with bilateral and 16 with unilateral affection. Their ages ranged from three to three and a half years. One of the unilateral deformed patients was aged 13 years and had severe equinovarus deformity due to burn contracture. One case aged 14 years had bilateral deformity that was treated when she was 2 years old and upon recurrence, it was neglected until that age. They were treated by soft tissue release and skin flaps with either rotation or multiple Z-plasty supplemented with the Alkhooly external fixator. The follow-up period ranged between 4 and 8 years. The results according to Mittal (1987) were excellent in 23 feet (71.9%), good in 8 feet (25%) and poor in one foot (3.1%).     

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.     

Anterior tibial tendon transfer in residual dynamic clubfoot deformity

Residual forefoot adduction and supination deformities with functional problems and difficulty with shoe wear may occur during the course of management of the congenital clubfoot. Between 1975 and 1988, 55 patients with 71 feet who had residual dynamic clubfoot deformity underwent anterior tibial tendon transfer. There were 42 full anterior tibial tendon transfers (FTs) and 29 split anterior tibial tendon transfers (STs). The average age of the patient at the time of the procedure was 6 years. The age at surgery for FT was 5.3 years compared with 7.1 years in ST. The clinical appearance of the feet improved in both groups, according to Garceau's criteria. The range-of-motion improvement was noted in dorsiflexion and eversion. There was an increase of eversion strength of both groups by 1.5 grades. The radiographic improvement was noted in both forefoot adduction and supination. Although the FT group had a little better statistical data than did the ST group, the ST group had better preservation of inversion function.     

Radical soft-tissue release of the arthrogrypotic clubfoot

The purpose of this study was to evaluate the results of primary radical soft-tissue release of arthrogrypotic clubfeet in children less than 1 year of age. We performed a retrospective review of six patients (12 feet) who underwent radical release of clubfoot deformity. Primary surgery was performed at an average of 7.4 months and the average follow-up was 4.3 years. We graded our results using a modified functional clubfoot rating system. We had two excellent, four good, three fair and three poor results. Revision surgery was performed on one foot for residual equinus. All patients ambulated independently with orthoses. Our short-term results with primary radical release of clubfoot deformity in arthrogryposis in infants under 1 year of age have been very encouraging. Correction of hindfoot equinus is excellent, and the recurrence rate remains low. Salvage talectomy has not been necessary in this population of children.     

Relapsed clubfoot correction with soft-tissue release and selective application of Ilizarov technique

The Ilizarov technique is an alternative for the treatment of complex foot deformities in children. The authors retrospectively reviewed children with relapsed clubfoot deformity, treated with soft tissue procedures and additional correction with an Ilizarov frame. Twelve consecutive patients (13 feet) with relapsed clubfoot deformity after previous surgical correction were reviewed. Treatment included open releases. An Ilizarov frame was applied as an adjunct in seven patients (mean age of 7.8 years) with severe deformity where complete intraoperative correction was not achieved. Clinical and radiographic assessment was undertaken. The mean Laaveg–Ponseti score, for the 7 feet treated with the Ilizarov frame, was 85.1 after minimum 4 years follow-up. One recurrence of forefoot deformity required metatarsal osteotomies. Postoperative radiographic measurements revealed values that can be considered as normal. Complications included pin tract infections (12% of inserted wires). Flat-topped talus was observed in 3 feet. Deformity correction was possible when soft tissue procedures were combined with the use of Ilizarov technique, in order to support and gradually improve surgical correction.     

有限矫形手术与Ilizarov技术治疗青少年先天性马蹄内翻足

目的观察应用有限矫形手术与Ilizarov技术治疗青少年先天性马蹄内翻足(congenital clubfoot,CCF)的临床疗效,探讨CCF外科矫正与功能重建新技术、新理念。方法 2003年9月-2010年7月,收治25例40足青少年CCF。男14例20足,女11例20足;年龄12～25岁,平均15.7岁。左足4例,右足6例,双足15例。根据秦氏马蹄内翻足畸形分度:Ⅰ度9足,Ⅱ度17足,Ⅲ度14足。合并小腿内旋畸形9足,右侧髋关节半脱位1例。采用有限软组织松解与骨性截骨手术后,9足Ⅰ度畸形者安装组合式外固定器,31足残留畸形安装Ilizarov外固定牵伸器。术后5～7 d开始矫正,以0.5～1.0 mm/d为宜;待踝关节矫正至过伸5～10°,足呈轻度外翻后停止牵伸,矫正位携带外固定架并负重行走4～6周。双足畸形患者分两期进行手术,手术间隔3～6个月,平均4个月。结果 9足术后佩戴组合式外固定器6～12周,平均8周;31足佩戴Ilizarov外固定牵伸器6～17周,平均13周。患者均获随访,随访时间8个月～6年,平均37个月。牵拉矫形期间6例6足发生针道轻度感染,均经对症处理后感染消失。术后2年1例1足畸形部分复发,经再次安装Ilizarov外固定牵伸器负重行走4周,矫正满意;其余畸形足在随访期内均获得满意矫正和全足底持重。末次随访时根据国际马蹄足畸形研究会(ICFSG)的评分系统,获优28足,良10足,可2足,优良率95%。结论有限矫形手术结合Ilizarov技术矫治青少年CCF,符合生物学原理和微创外科原则,安全、微创、疗效确切。该马蹄内翻足手术矫形策略遵循骨科自然重建理念,尤其适用于传统矫形骨科手术难以治疗的Ⅲ度CCF。     

Plantar opening-wedge osteotomy of cuneiform bones combined with selective plantar release and dwyer osteotomy for pes cavovarus in children

Neurological pes cavovarus is a challenging deformity to treat during childhood. Based on physiopathology, we propose the following original surgical procedure. Plantar-opening wedge osteotomy of the three cuneiform bones, preceded by selective plantar release, corrects forefoot pronation which is the primum movens of the deformity, and corrects the cavus at its apex. A calcaneal valgisation closing wedge osteotomy, is indicated if pre-operative planning revealed subtalar joint stiffness, incompatible with secondary hind foot realignment in valgus. The follow-up had to be at least 5 years or to reach skeletal maturity. Twenty-six children (36 feet) satisfied these criteria. Mean age at surgery was 10.3 years old. All the children had a neurological disease which was progressive for 65% of them (75% of the feet). Mean follow-up was 6.9 years. This treatment was effective, with a mean percentage of cavus correction of 74%, reaching 100% for 31% of the feet. Complete or partial cavus correction was still observed at last follow-up for 75% of the feet. At last follow-up, global result was satisfactory in 63.9% and non satisfactory in 36.1% of feet. Flat-foot was observed, of minor type, in only 2 cases. Apart from triple arthrodesis, iterative surgery relative to residual deformity (foot adduction, plantar sticking of the first metatarsal head) was indicated for 4 feet (11%). A triple arthrodesis was required in 12 cases (33%). In conclusion, this treatment provides mid-term satisfactory correction of the cavus and may allow avoiding triple arthrodesis at skeletal maturity.     

Treatment of residual adduction deformity in clubfoot: the double osteotomy.

Forefoot adduction is the most common residual deformity after clubfoot surgery. Surgical treatment of this deformity is often required for moderate and severe cases. This study reports the results of a closing wedge osteotomy of the cuboid and opening wedge osteotomy of the medial cuneiform in 39 feet. The average follow-up was 4.8 years. Clinical and radiographic improvement was seen in all patients, and no complications were seen. Surgery is advocated in children older than age 4, or when the medial cuneiform ossific nucleus is well developed.     

Correction of neglected clubfoot using the Ilizarov external fixator

BACKGROUND: This study was conducted to evaluate the corrective capability of the Ilizarov external fixator in the treatment of neglected clubfoot. METHODS: Thirty patients (38 feet) with a mean age of 19 (5 to 39) years with severe deformities and stiff feet associated with neglected clubfoot were studied. A limited soft-tissue dissection, Achilles tenotomy, and plantar fasciotomy were done. Progressive correction of the deformities was achieved through a standard setting of the Ilizarov external fixator. The device was used for 16 weeks, on average, and after removal a short-leg walking cast was used for an additional 6 weeks, followed by an ankle-foot orthosis (AFO) for 6 months. RESULTS: The final outcome was scored as good (complete correction and no pain); fair (partial correction with plantigrade foot and occasional pain); or poor (nonplantigrade foot and continuous pain during walking). After a mean followup of 58 (range 12 to 107) months, the results were good in 30 feet (78.9%); fair in three feet (7.9%); and poor in five feet (13.2%). Early complications were a distal tibial fracture in one foot, dislocation of the first metatarsophalangeal joint in one foot, and arterial damage that resulted in amputation of the toes in one foot. Recurrence of the deformity was found in 19 feet (50%): 11 minor, three mild, and five severe. Spontaneous ankylosis developed in 28 feet (73.7%). Nine feet (23.7%) required arthrodesis for symptomatic arthritis of the ankle or midfoot and deformity that could not be treated with orthoses. CONCLUSION: The Ilizarov external fixator allows simultaneous correction of all the severe foot deformities associated with neglected clubfoot with minimal surgery, reducing risks of cutaneous or neurovascular complications and avoiding excessive shortening of the foot. Even in those patients in whom final corrective arthrodesis is necessary, this may be carried out with minimal bone resection, since the severe deformities of the foot and ankle have been corrected.