Comparison of the soft-tissue release methods in idiopathic clubfoot

The aim of this study was to compare the clinical and radiologic results of three different surgical procedures (posterior release with lengthening of the tendo calcaneus and posterior capsulotomy, Turco's technique of posteromedial release, and Simons' technique of complete subtalar release) in idiopathic clubfoot in 77 patients who were operated on at 10 months of age or younger. The clinical examination alone is not sufficient to determine the type of the surgical intervention needed in idiopathic clubfoot; the decision must be supported by the radiologic parameters (anteroposterior and lateral talocalcaneal, first metatarsal-talar, and lateral tibiotalar angles) and all the components of the multiplanar deformity must be corrected at the same time. Simons' technique of complete subtalar release was found to be the most efficient method of surgery both functionally and radiologically in cases of idiopathic clubfoot in infants. The overcorrection of the deformity as a consequence of the concern that the tarsal alignment did not improve adequately is a mistake we make not infrequently and in our opinion this may be avoided by taking perioperative radiographs.     

Tarsal decancellation in the residual resistant arthrogrypotic clubfoot

INTRODUCTION

Conservatism is well recognised after Ponseti''s method in the treatment of congenital clubfoot; however, this is not applicable to the complex and resistant arthrogrypotic type which challenges the orthopaedic surgeon. In such a type, soft tissue releases as fasciotomies, tenotomies, and capsulotomies, as well as osteotomies are insufficient, and joint fusions are not suitable in early childhood before skeletal maturity.

PATIENTS AND METHODS

Twelve children (15 feet) with residual resistant arthrogrypotic clubfeet between 2-4 years of age were analysed clinically and radiographically. All of the cases received previous conservative Ponseti''s method of treatment in their first year of life followed by soft tissue releases (plantar fasciotomy, posteromedial tenotomies, capsulotomies, and abductor hallucis release) before treatment by decancellation of the cuboid, the calcaneus, and the talus to correct the complex adduction, supination, varus, and equinus deformities. Pre-operative measurements of certain foot angles were compared with their corresponding postoperative values.

RESULTS

A grading scheme for evaluation of the results using a point scoring system was suggested to evaluate accurately both clinical and radiographic results after a follow-up period of an average of 3.3 years. Six feet (40%) had excellent, six (40%) good, three (20%) fair, and no poor (0%) outcome. There was no major complication. There was significant improvement in the result (P > 0.035).

CONCLUSIONS

Tarsal decancellation is particularly applicable to residual resistant clubfoot such as the arthrogrypotic type at an early age. It shortens the period of disability, improves the range of foot motion, and does not interfere with the foot bone growth.     

Radical one-stage posteromedial release for the resistant clubfoot

A large proportion of congenital talipes equinovarus is resistant to correction by nonoperative means. The authors reviewed 54 feet which required surgical intervention, and the operative management utilized was a radical one-stage posteromedial release. Application of plastic surgical techniques has obviated problems of skin healing. Comparable to results reported by others, a good-to-excellent functional and cosmetic result can be expected in 90% of the cases. Careful attention to a well-designed postoperative regimen will frequently obviate the need for additional surgery.     

Evaluation of the hemi-Cincinnati incision for posteromedial soft-tissue release in clubfoot

Posteromedial soft-tissue release operations were performed on 42 idiopathic clubfeet in children younger than 2 years of age through the medial half of the Cincinnati incision (the hemi-Cincinnati incision). This incision gave adequate exposure to all structures to be released. Wound closure was possible in all 42 feet without having to hold the foot in plantarflexion or inversion. Wound healing was satisfactory in the majority of instances and 81% of the scars, assessed 9 months after the operation, were graded as excellent or good. The scar is located in an area of the foot that can be concealed easily and should a more radical soft-tissue operation be needed later, the same incision can be extended easily. The authors recommend this incision as the incision of choice for performing posteromedial soft-tissue release operations on clubfeet in children younger than 2 years of age.     

Management of the resistant myelodysplastic or arthrogrypotic clubfoot with the Verebelyi-Ogston procedure

The Verebelyi-Ogston (V-O) procedure, consisting of subchrondral excision of the talus and cuboid, was used for the treatment of 13 resistant clubfeet secondary to myelomeningocele or arthrogryposis. Nine feet were initially satisfactory, but the condition recurred in both feet of one patient after bracing was discontinued 3 years postoperatively. Three feet were graded as satisfactory after a second V-O procedure, and one after a third. The procedure must be monitored by intraoperative fluoroscopy or radiography, and followed by orthotic support. Despite the theoretical long-term disadvantage of incongruent joint surfaces, we consider the V-O procedure to be a good method for the treatment of this subset of rigid neuropathic clubfeet.     

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.     

Ponseti method compared with soft-tissue release for the management of clubfoot: A meta-analysis study

AIM: To compare the functional outcomes of patients who underwent open surgery vs Ponseti method for the management of idiopathic clubfoot and to determine whether correlations exist between functional outcome and radiographic measurements.METHODS: A meta-analysis of the literature was conducted for studies concerning primary treatment of patients with idiopathic clubfoot. We searched PubMed Medline, EMBASE, and the Cochrane Library databases from January 1950 to October 2011. Meta-analyses were performed on outcomes from 12 studies. Pooled means, SDs, and sample sizes were either identified in the results or calculated based on the results of each study.RESULTS: Overall, 835 treated idiopathic clubfeet in 516 patients were reviewed. The average follow-up was 15.7 years. Patients managed with Ponseti method did have a higher rate of excellent or good outcome than patients treated with open surgery (0.76 and 0.62, respectively), but not quite to the point of statistical significance (Q = 3.73, P = 0.053). Age at surgery was not correlated with the functional outcome for the surgically treated patients (r = -0.32, P = 0.68). A larger anteroposterior talocalcaneal angle was correlated with a higher rate of excellent or good outcomes (r = 0.80, P = 0.006). There were no other significant correlations between the functional and radiographic outcomes.CONCLUSION: The Ponseti method should be considered the initial treatment of idiopathic clubfeet, and open surgery should be reserved for clubfeet that cannot be completely corrected.     

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.     

One-stage posteromedial release of congenital clubfoot

Turco's one-stage posteromedial release with internal fixation has been performed in 51 children with a total of 73 congenital clubfeet since 1973. Thirty-one children (44 feet) followed for 4-12 years were evaluated using the McKay rating system. The occurrence of good and excellent results was 70%. The relationship between these results and angles measured from roentgenograms was analyzed using multiple regression. The results showed a closer relationship to the anteroposterior talocalcaneal angle, the tibiocalcaneal angle, and the MTR angle.     

Results of posteromedial release for the resistant clubfoot

Sixty-nine children with 99 resistant clubfeet were operated on between 1973 and 1979 at the James Whitcomb Riley Hospital for Children (Indianapolis, IN). Three groups of children according to age at the time of surgery were identified: Group I, less than 12 months of age; Group II, between 12 and 36 months of age; and Group III, greater than 36 months of age. Minimum follow-up was 30 months, with an average follow-up for the entire series of 58 months. The radiographic results based on the talocalcaneal index revealed 95 of the 99 feet to have good or acceptable results. The clinical assessment of pain and function mirrored these good results, although, on occasion, the appearance was somewhat less than optimal.     

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.     

Peritalar release in the treatment of congenital talipes equinovarus clubfoot

It is the purpose of this retrospective study to evaluate the results of the surgical treatment of congenital talipes equinovarus clubfoot. Seven patients affected with congenital talipes equinovarus clubfoot, 2 of which bilateral, treated surgically using peritalar release according to Simons were re-examined. The long-term follow-up results obtained after an average of 4 years were evaluated from clinical, morphofunctional, and radiographic points of view, and with the help of a photopodogram and computed baropodometry. The subjective satisfaction of the patients was also evaluated. Results were considered to be good in all of the cases. In conclusion, surgery involving peritalar release allows for correction of abduction of the forefoot, and restores physiological calcaneal valgus, re-balancing standing on the plantar surface; the persistence of an area of hypostanding in the forefoot operated on and of mild, residual cavus of the plantar arch do not, thus, seem to influence the good results obtained.     

Use of the Ponseti method for recurrent clubfoot following posteromedial release

Background:

A child with recurrent or incompletely corrected clubfoot after previous extensive soft tissue release is treated frequently with revision surgery. This leads to further scarring, pain and limitations in range of motion. We have utilized the Ponseti method of manipulation and casting and when indicated, tibialis anterior tendon transfer, instead of revision surgery for these cases.

Materials and Methods:

A retrospective review of all children treated since 2002 (n = 11) at our institution for recurrent or incompletely corrected clubfoot after previous extensive soft tissue release was done. Clinical and operative records were reviewed to determine procedure performed. Ponseti manipulation and casting were done until the clubfoot deformity was passively corrected. Based on the residual equinus and dynamic deformity, heel cord lengthening or tenotomy and tibialis anterior transfer were then done. Clinical outcomes regarding pain, function and activity were reviewed.

Results:

Eleven children (17 feet) with ages ranging from 1.1 to 8.4 years were treated with this protocol. All were correctable with the Ponseti method with one to eight casts. Casts were applied until the only deformities remaining were either or both hindfoot equinus and dynamic supination. Nine feet required a heel cord procedure for equinus and 15 required tibialis anterior transfer for dynamic supination. Seven children have follow-up greater than one year (average 27.1 months) and have had excellent results. Two patients had persistent hindfoot valgus which required hemiepiphyseodesis of the distal medial tibia.

Conclusion:

The Ponseti method, followed by tibialis anterior transfer and/or heel cord procedure when indicated, can be successfully used to correct recurrent clubfoot deformity in children treated with previous extensive soft tissue release. Early follow-up has shown correction without revision surgery. This treatment protocol prevents complications of stiffness, pain and difficulty in ambulating associated with multiple soft tissue releases for clubfeet.     

Correction of clubfoot through a peritalar release using the cincinnati approach

Surgical Principles The Cincinnati approach described by Crawford et al. [1] allows a complete medial, posterior and lateral exposure of hind- and midfoot as well as a correction of any deformity of the subtalar, talonavicular, and calcaneocuboid joints (subtalar joint complex): Correction of the rotational malposition between talus and os calcis with simultaneous reduction of the talonavicular and calcaneocuboid joints. After wound closure the corrected position is maintained by a long leg cast. In severe clubfeet an additional fixation with Kirschner wires of the talonavicular and the subtalar joints may be indicated.     

Results of complete soft tissue clubfoot release combined with calcaneocuboid fusion in the 4-year to 8-year age group following failed clubfoot release.

A subset of postoperative recurrent clubfeet was isolated in a group of patients 4 to 8 years old. Twenty-seven consecutive patients who underwent redo surgery consisting of complete soft tissue clubfoot release combined with a calcaneocuboid fusion were reviewed for this study. Twenty-six feet of 27 feet in 20 patients had a long-term good result, suggesting that this procedure is the one of choice for this age group.     

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%).     

Carpal wedge osteotomy for the arthrogrypotic wrist

The upper limbs of the child with the amyoplasia form of arthrogryposis are typically internally rotated at the shoulders, extended at the elbows, and flexed and deviated ulnarly at the wrists. This position results in an obligatory crossed-limb pattern of bimanual use, as neither hand is sufficiently strong or agile to function independently. A change in the position of deformity to one that allows the palms to come together without crossing the arms, and also allows access to desktops and keyboards, is a reasonable goal for children with this condition. A severe internal rotation deformity at the shoulder can be corrected with external rotation osteotomy, and elbow extension contractures can be released with soft-tissue procedures to increase the passive range of motion. However, most attempts to improve wrist position have been disappointing because they have resulted in the loss of any limited motion that might be present. This paper describes a technique of resection of a portion of the carpus that improves position and retains motion because it spares the radiocarpal joint.