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.     

Residual clubfoot correction by means of lateral cuboid resection]

The paper presents the late results (after 5-16 years; mean follow-up--9.5 years) of lateral cuboid resection performed in 55 children with pathologic foot adduction. The age of the children ranged from 18 months to 12 years (average age 41 months). This residual deformity resulted from the treatment of clubfoot (both conservative and surgical). The procedure was performed in cases with severe forefoot adduction (type III according to Simondsa). Late results of treatment of 54 feet (75.9%) of the cases were assessed according to the Magone classification yielding good and very good results in 41 (75.9% feet; satisfactory in 10 (18.6%) feet. In 95% of case correction of adduction deformity was achieved. The authors stress the fact, that the degree of correction is correlated to the extent of the primary clubfoot defect. This procedure allowed correction of talo-navicular relation. The described procedure may be performed with no regard to age, although the optimal age is 3 to 8 years.     

Comparison of posteromedial and subtalar release in surgical treatment of resistant clubfoot

This preliminary study evalluated two surgical techniques for the treatment of resistant clubfoot: the posteromedial and the subtalar release. Two groups of matched patients with idiopathic clubfoot who underwent surgery between 1983 and 1995 were compared. In group 1 (12 patients, 18 feet), posteromedial release was performed. In this group, the results were satisfactory with a tendency to hypocorrection: 4 (22%) feet needed a secondary procedure (average follow-up: 97.8 months). Group 2 (12 patients, 17 feet) underwent complete subtalar release. The results were clinically better for group 2 (average follow-up: 38.8 months). Only 1 (5.9%) patient needed a secondary procedure. These results suggest complete subtalar release yields better postoperative correction than posteromedial release.     

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.     

Conservative and surgical treatment of clubfoot

One hundred twenty-four patients (174 feet) were treated for clubfoot deformity, with an average follow-up of 7 years. All patients were initially treated by manipulation and serial casting. Early soft tissue surgeries were performed for resistant cases (73 feet). In 33 feet with residual hindfoot deformity only, posterior release was performed with 85% good results. In the remainder, where there was forefoot as well as hindfoot deformity, full posteromedial release was necessary, giving good results in 90% of cases. All clubfeet should initially be treated conservatively. However, resistant cases should have early surgery, with the extent of surgery performed being determined by the type of residual deformity present.     

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.     

Results of surgical treatment of talipes equinovarus congenita

A series of 153 feet in 103 patients were surgically treated for idiopathic clubfeet (mean follow-up period of 10.3 years). Thirty-four percent had prior surgery before referral to the authors' institution. Functional results were excellent in 28.7%, good in 37.9%, fair in 13.1%, and unsatisfactory in 20.3%. The complication rate was 7.4%. Serious complications included translocation of os calcis, avascular necrosis of the talus, and injuries to neurovascular structures. Pain after strenuous activities was noted in 11.3% of the feet. In 9.8% of feet, limitation of activities was noted by the patients. Translocation of the hindfoot was associated with extensive subtalar release and often resulted in poor function. At operation, extensive subtalar release should only be performed with caution after failure of correction from release of other medial and posterior structures.     

Extra-articular subtalar arthrodesis. A long-term follow-up in patients with cerebral palsy

Of 23 children (35 feet) with cerebral palsy who had undergone a Grice extra-articular subtalar arthrodesis for a valgus hindfoot between 1976 and 1981, we reviewed 17 (26 feet), at a mean of 20 years (17 years 3 months to 22 years 4 months) after operation. Seven were quadriplegic, eight spastic diplegic, and two hemiplegic. They were all able to walk at the time of operation. Thirteen patients (20 feet) were pleased with the Grice procedure, 13 had no pain and 15 (23 feet) were still able to walk. The clinical results were satisfactory for most feet. Radiography showed that the results had been maintained over time but 14 feet developed a mean ankle valgus of 11 degrees (6 to 18) with a compensatory hindfoot varus in 12 feet. No deformity of the talus or arthritis of adjacent joints was noted. The Grice procedure gives good long-term results in children with cerebral palsy.     

Extraarticular subtalar arthrodesis with internal fixation

Forty extraarticular subtalar arthrodeses with internal fixation were performed in 26 patients with cerebral palsy who had a mobile, paralytic planovalgus deformity. We assessed the correction achieved and maintained by evaluating the clinical status, improvement in gait, correction of deformity, and foot stability. Union was achieved in a mean interval of 10 weeks with no instance of mechanical failure of the fixation screw. At a mean follow-up of 30 months, 38 feet (95%) were rated excellent or good and two were rated fair. The advantages of this technique of extraarticular subtalar arthrodesis warrant continued use of this procedure.     

循原骨折线截骨矫正跟骨骨折畸形愈合

目的 探讨循原骨折线截骨矫正跟骨骨折畸形愈合方法的可行性.方法 2004年8月至2007年5月,跟骨骨折畸形愈合患者25例28足,男23例26足,女2例2足;年龄22～56岁,平均31岁;受伤至手术时间1.5～12个月,平均4.6个月.采用循原骨折线截骨术进行治疗.按照Zwipp和Rammelt跟骨骨折畸形愈合的分类方法进行分类,其中Ⅲ型11例12足,Ⅳ型14例16足.术前均摄双足跟骨侧位、轴位X线片及行CT检查,12例患者(14足)行三维CT重建.根据Sander及Essex-Lopresti分类,参考原始X线片对不同骨折类型制定截骨线,重现原始骨折.根据CT轴位载距突及外侧骨块所带关节面的宽度和轴位骨折线的斜度从前外上到后内下斜行截骨,恢复跟骨的高度,将后关节骨折块向后上撬起,使塌陷的后关节面骨块复位.骨缺损处,用劈下的跟骨外侧壁填塞植骨,或取自体髂骨植骨,最后用钢板螺钉固定.结果 24例26足获得随访,随访时间10～16个月,平均12个月.骨折愈合时间10～14周,平均12周.2例发生伤口感染,经抗生素治疗后10周取出钢板伤口愈合.无一例发生钢板螺钉断裂和骨折再移位.按照Maryland足部评分标准,优10足,良12足,可4足,优良率84%.结论 循原骨折线截骨重现原始骨折,可恢复跟骨的骨性结构,能更好地矫正跟骨各方位畸形,同时保留距下关节,减少了手术对足踝功能的影响,近期疗效满意.     

Dynamic foot-pressure measurement in the assessment of operatively treated clubfeet

BACKGROUND: Decreased motion of the subtalar joint is common after operative treatment of idiopathic clubfeet. The purposes of this study were to validate parameters of dynamic foot-pressure measurement that enable detection of physiological pronation of the subtalar joint and to analyze the consequences of absent or decreased pronation following clubfoot surgery on long-term functional results. METHODS: To validate parameters of dynamic foot-pressure measurement, we initially analyzed two control groups: one of forty asymptomatic normal feet and the other of five feet with a previous subtalar joint arthrodesis. The resulting parameters were then applied to a group of nineteen patients with twenty-four idiopathic clubfeet for whom initial conservative treatment had failed and in whom a posterior surgical release (lengthening of the Achilles tendon and release of the posterior ankle capsule) had been performed at a mean age of twenty months. The mean duration of follow-up was forty-one years. All feet were evaluated radiographically, and the clinical results were assessed with the American Orthopaedic Foot and Ankle Society score. RESULTS: An interruption in the rise of the pressure-time curve and a short medial deviation of the center of pressure path immediately after heel strike are reliable and objective characteristics of pronation movement of the subtalar joint. Nineteen clubfeet had a demonstrable pronation movement, and five clubfeet did not. The nineteen feet with pronation movement were either asymptomatic (twelve feet) or mildly painful on occasion (seven feet). The mean American Orthopaedic Foot and Ankle Society score for the nineteen feet was 87 points. The five feet without pronation movement were moderately painful during strenuous activities only (four feet) or were nearly always painful (one foot). The mean score for those feet was 57 points. There was a significant difference between these two groups with regard to the pain scores and the total scores (p < 0.001), but there was no appreciable difference regarding function and hindfoot motion. It was not possible to distinguish between these two groups on the basis of the findings of the physical or radiographic examinations. CONCLUSIONS: Idiopathic clubfeet with preserved hindfoot pronation have a better long-term prognosis. Preservation of functional mobility of the subtalar joint is a key factor in the treatment of clubfoot deformity.     

Transverse medial slide osteotomy for bunionette deformity: long-term results

BACKGROUND: Bunionette deformity of the fifth metatarsal infrequently requires operative treatment. This study presents the long-term results of a simple operative technique. METHODS: Forty-four distal metatarsal medial slide osteotomies with pin fixation were performed for symptomatic bunionette deformity in 30 patients. After an average of 7 years and 8 months (range 69 to 110 months), 30 feet in 21 patients were available for clinical and radiographic evaluation. RESULTS: The patients' subjective assessment was excellent and good in 81% and fair and poor in 19% of feet. The mean pain score on a visual analogue scale was 1.8 (range 0 to 7) and the mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 88.2 (range 47 to 100). Postoperative complications included pin track infection in three feet and delayed union in one. One patient developed transfer metatarsalgia and another patient had repeat surgery for recurrent symptoms on both feet after 5 years. CONCLUSIONS: This procedure combines technical simplicity with satisfactory and predictable long-term results in the operative treatment of bunionette deformity in the lateral forefoot.     

距下关节融合与跟骨丘部矫形术治疗严重跟骨骨折畸形愈合

目的观察距下关节融合与跟骨丘部矫形术联合治疗严重跟骨骨折畸形愈合的临床疗效,探讨其手术适应证及优、缺点。方法1994年12月~2006年1月,对84例(96足)跟骨骨折畸形愈合的患者行距下关节融合与跟骨丘部矫形术,采取跟骨外侧手术入路,取自体松质骨植骨距下关节融合及内固定。其中男51例62足,女33例34足;年龄21~58岁,平均38.5岁。单侧72例,双侧12例。损伤原因:高处坠落伤57例,交通事故伤22例,其他5例。损伤至手术时间6~31个月,平均9.5个月。结果术后患者均获随访1~132个月。根据美国足踝外科协会足与踝关节评分标准,优31足,良53足,差12足,优良率87.5%。术后X线片示Bo。hler角、Gissane角、跟骨丘部高度及跟骨宽度与术前比较,差异均有统计学意义(P<0.01)。结论自体松质骨植骨距下关节融合与跟骨丘部矫形术是治疗跟骨骨折畸形愈合的一种有效方法,能恢复后足外形及功能,明显降低跟骨骨折步行疼痛后遗症的发生率。     

Posterolateral release for idiopathic clubfoot: review of 18 patients.

The authors treated and reviewed 18 patients with 26 idiopathic clubfeet by posterolateral release and elongation of the tendo Achillis at a mean age of 14.6 months (range 7-32 months). The mean follow-up of these patients was 43 months (range 6- 100 months). Function, appearance, and pain were studied. The mean ankle dorsiflexion was 20 degrees at the time of review. In all but one case, the hindfoot equinus had been well corrected. Subtalar movement was 75% of normal in six feet, and 50% of normal in 16 feet. Revision of the posterolateral release combined with anteromedial release was carried out for six patients with residual hindfoot varus and forefoot adduction at an average of 13.5 months following the initial procedure. In one patient, the deformity was overcorrected, but the results of the rest of the revision operations were otherwise good. No skin or wound problems were observed in this series. In conclusion, of 26 feet undergoing posterolateral release for severe clubfoot, 70% had a satisfactory result. Six feet required further surgery (reoperation rate of 23.1%).     

跟骨丘部及后距下关节重建治疗跟骨骨折畸形

目的探讨保留距下关节跟骨丘部及后距下关节重建治疗严重陈旧性跟骨骨折畸形愈合的方法及适应证。方法跟骨丘部及后距下关节重建治疗严重陈旧性跟骨骨折畸形愈合8例，均为男性，年龄在21～34岁，平均31．5岁。单侧7例，双侧1例。损伤时间1～7个月，平均4．6个月。行重建丘部及后距下关节保留距下关节自体植骨的方法进行治疗，切除跟骨外膨的外侧壁，取跟骨外侧壁植骨7例，取髂骨植骨1例。结果8例9足获得随访，随访时间8～24个月，平均11个月。按美国足踝外科协会Maryland足部评分系统评价术后功能：优4足，良4足，可1足，差0足，优良率为88．9％。所有患者术后足外形恢复良好。术后切口感染裂开1例、螺钉断裂1例，无跟骨内翻等并发症。骨折愈合时间10．5～16．2周，平均12．6周。术后X线片显示跟骨丘部高度、宽度、BoNer角，以及Gissane角基本恢复正常。结论重建跟骨丘部及距下关节自体植骨术具有矫正跟骨畸形，恢复后足外形及功能明显的优点，是治疗严重陈旧性跟骨骨折畸形愈合的有效方法。     

Arthroscopic release for painful subtalar stiffness after intra-articular fractures of the calcaneum

We describe the surgical technique and results of arthroscopic subtalar release in 17 patients (17 feet) with painful subtalar stiffness following an intra-articular calcaneal fracture of Sanders' type II or III. The mean duration from injury to arthroscopic release was 11.3 months (6.4 to 36) and the mean follow-up after release was 16.8 months (12 to 25). The patient was positioned laterally and three arthroscopic portals were placed anterolaterally, centrally and posterolaterally. The sinus tarsi and lateral gutter were debrided of fibrous tissue and the posterior talocalcaneal facet was released. In all, six patients were very satisfied, eight were satisfied and three were dissatisfied with their results. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from a mean of 49.4 points (35 to 66) pre-operatively to a mean of 79.6 points (51 to 95). All patients reported improvement in movement of the subtalar joint. No complications occurred following operation, but two patients subsequently required subtalar arthrodesis for continuing pain. In the majority of patients a functional improvement in hindfoot function was obtained following arthroscopic release of the subtalar joint for stiffness and pain secondary to Sanders type II and III fractures of the calcaneum.     

Dillwyn Evans operation for relapsed club foot. Long-term results.

We reviewed the long-term results of the Dillwyn Evans procedure for club foot in 60 feet of 45 patients with an average age of 29 years, using four different scoring systems. The results at 12 to 38 years were compared with those of an earlier study of the same group of patients. Function was satisfactory in 68% of feet; 90% of the patients were able to perform all desired activities. Mild residual deformity was compatible with satisfactory function, and poor function was related to ankle and subtalar stiffness. Our results suggest that this procedure has a low rate of deterioration and degenerative change with time.     

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.     

Subtalar arthrodesis in children

We present a clinical and radiological retrospective study of 30 patients (51 feet) with valgus deformity of the feet who had three different types of subtalar extraarticular and intraarticular arthrodesis. Children with cerebral palsy, myelomeningocele, and agenesis of the corpus callosum associated with progressive polyneuropathy were studied. The results were considered excellent and satisfactory in 73% of the feet. The combined Grice-Green-Batchelor procedure gave the best results, with 84% excellent and satisfactory results, with bony union in 96% of the feet. Weight-bearing films of the ankles in the anteroposterior plane are essential to determine the true extent of the deformity before operation.     

Posterior Arthroscopic Subtalar Arthrodesis: Clinical and Radiologic Review of 19 Cases

Arthroscopic subtalar arthrodesis has recently gained popularity in the treatment of primary subtalar or post-traumatic arthritis, coalition, or inflammatory diseases with subtalar arthritis. The present study reports the clinical and radiologic results of 19 patients (19 feet) who underwent posterior arthroscopic subtalar arthrodesis using 2 posterior portals. A total of 19 posterior arthroscopic subtalar arthrodeses (minimum follow-up of 24 months) performed without a bone graft and with 2 parallel screws were prospectively evaluated. The fusion rate was 94% (mean time to fusion 9.8 weeks). Modified American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score (maximum 94 points) improved significantly from 43 to 80 points and the visual analog scale for pain score improved from 7.6 to 1.2. The 12-item short-form physical and mental scores at the last follow-up point were 52.5 and 56.4, respectively. One (5.3%) patient underwent open repeat fusion for nonunion, 2 (10.5%) patients required a second procedure for implant removal, and 1 (5.3%) experienced reversible neuropraxia. In conclusion, posterior arthroscopic subtalar arthrodesis is a safe technique with a good union rate and a small number of complications in patients with no or very little hindfoot deformity.