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.     

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.     

Foot deformities in diastrophic dysplasia. An analysis of 102 patients.

The exceptionally high prevalence of diastrophic dysplasia in Finland has enabled us to analyse the foot deformities of 102 patients at their first orthopaedic evaluation and classify 204 feet into five categories. The most common finding (43%) was a foot with tarsal valgus deformity and metatarsus adductus; 37% showed either equinovarus adductus (29%) or equinus (8%) deformities. At the first examination 13% showed metatarsus adductus deformity alone, and 7% were clinically normal. The expression 'club foot', generally used for the foot deformity in diastrophic dysplasia is a misnomer. There is a wide spectrum of deformities, some of them specific for the condition.     

Treatment of Severe and Neglected Clubfoot With a Double Zigzag Incision: Outcome of 21 Feet in 15 Patients Followed Up Between 1 and 5 Years

Patients presenting late for treatment of clubfoot deformity are still common in many parts of the world. These feet are often rigid and severely deformed. Surgical correction is the prevailing option to attain a plantigrade foot, and the extent of correction required predisposes to wound-healing problems. We present the results of treatment of 15 patients (21 feet) with severe, untreated congenital talipes equino varus, who underwent operations using a double zigzag incision as a single-stage procedure. These patients ranged in age from 6 months to 4 years and presented late, having received no treatment or inadequate treatment since birth. The desired end point of the study was a fully corrected foot with a wound that would heal primarily without complications. The etiology was isolated congenital talipes equino varus in 11 patients and arthrogryposis multiplex congenita in 4 patients. Eleven patients were boys and 4 were girls; 6 patients underwent bilateral procedures. The patients were graded preoperatively and postoperatively using the Dimeglio classification, with 10 feet classified preoperatively as grade 3 and 11 graded as grade 4. Desired correction was achieved in all feet, and all wounds healed uneventfully with no complications. This single-stage technique is very safe and cost-effective and is an easy alternative to standard techniques for dealing with late-presenting untreated severe clubfoot deformities.     

Resistant clubfoot deformities managed by Ilizarov distraction histogenesis

Background:

Resistant clubfoot deformities of the foot and ankle remain a difficult problem even for the most experienced surgeon. We report a series of neglected resistant clubfoot deformities treated by limited surgery and Ilizarov distraction histogenesis.

Materials and Methods:

Twenty one patients with 27 feet having resistant clubfoot deformities were managed by Ilizarov distraction histogenesis from April 2005 to May 2008. The mean age was 12 years (range 8–20 years). A limited soft tissue dissection like percutaneous Achilles sheath tenotomy and plantar fasciotomy were done. Progressive correction of the deformities was achieved through the standard and simple Ilizarov frame construct setting. After removal of Ilizarov frame, a short leg walking cast was used for an additional 6 weeks, followed by an ankle foot orthrosis for 3 months.

Results:

The mean followup period was 18.7 months (range 20-36 months). The mean duration of fixator application was 3.6 months (range 3–5 months). At the time of removal of the fixator, a plantigrade foot was achieved in 25 feet and gait was improved in all patients. There was residual varus hind foot deformity in two patients. Out of 27 feet, 3 (11.11%) were rated as excellent, 17 (62.96%) as good, 5 (18.51%) as fair, and 2 (7.40%) as poor according to Reinkerand Carpenter scale. Excellent and good results (74.07%) were considered satisfactory, while fair and poor results (25.92%) were considered unsatisfactory.

Conclusion:

The short term clinical and functional results of resistant clubfoot deformities with Ilizarov''s external fixator is promising and apparently a good option.     

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.     

Assessment of percutaneous V osteotomy of the calcaneus with Ilizarov application for correction of complex foot deformities

Complex foot deformity can be described as a foot with multiplanar abnormalities with or without shortening of the foot. Conventional surgical treatment may not be able to correct these deformities. In this study we evaluate the results of percutaneous V osteotomy of the calcaneus with an Ilizarov external fixator for treatment of complex foot deformity. Twenty feet with a complex deformity were treated by the Ilizarov method in 15 patients. The aetiologic factors were neglected or relapsed clubfoot (13 patients) and poliomyelitis (2 patients). All patients underwent percutaneous V osteotomy of the calcaneus and gradual correction of the deformity using Ilizarov's method. The mean duration of fixator application was 9.5 months (range, 6-13 months). The mean follow-up period was 1.8 years (range, 1 to 3 years). At the time of fixator removal, a plantigrade foot was achieved in 18 cases; gait was improved in all patients. There was residual varus deformity in two patients. A pin-tract infection was observed in all patients. No recurrence of the deformity occurred. The V osteotomy offers the most options for correction of complex foot deformities. Percutaneous technique is particularly useful for the complex foot deformity that has poor skin coverage, with poor blood supply. Gradual correction with the Ilizarov method yields good results for complex foot deformities.     

McKay手术矫治僵硬型先天性马蹄内翻足畸形

为了总结ＭｃＫａｙ手术矫治僵硬型先天性马蹄内翻足畸形的手术效果，对术后７１例１０３只足进行了２年～９年随访。根据足部功能恢复、外观形态及Ｘ线片检查评定结果，优５５例７８只足，良１１例１６只足，可５例９只足，无一例复发。术后７例１２只足出现跟、舟骨形态改变，９例踝关节活动受限，５例７只足出现平足。认为，手术年龄以６个月～１８个月为佳。详细讨论了影响足部功能恢复的因素，手术年龄与疗效的关系等     

Anatomy of the varus foot and ankle

In summary, varus deformity of the foot and ankle encompasses a spectrum of deformities from mild to severe. The cause of this deformity may be bone, muscle imbalance, or a combination of both. Surgical intervention should be planned only after the patient's anatomy is understood. Uncorrected symptomatic varus deformities may have significant consequences on gait kinematics and foot biomechanics.     

Accelerated Ponseti method: First experiences in a more convenient technique for patients with severe idiopathic club feet

BackgroundCongenital Idiopathic Talipes Equinovarus (CTEV), or clubfoot, is a complex deformity that involves pathological anatomy in the foot with ankle equinus, hindfoot varus, midfoot cavus and forefoot adductus [1]. Universal agreement is established about Ponseti technique as the initial management for this deformity. This preliminary study aims to investigate the possibility of having a braceable foot through a proposed accelerated Ponseti method by which, manipulations, 5 castings and Achilles tendon tenotomy are implemented in a week.MethodsThis study included 11 patients with 16severe congenital idiopathic clubfeet treated by an accelerated Ponseti method. The method involves manipulation of the deformed foot, and 1st casting in one day, with the 2nd, 3rd, 4th, 5th castings in the 4th, 5th, 6th, 7th day post-manipulation. After the 4th cast removal, Achilles tenotomy was performed with subsequent three-week casting for all patients. Nonparametric tests were used for comparing the Pirani scores before starting the treatment and after removal of final cast.ResultsFive patients had bilateral club foot deformity. Average age at treatment was 54.8 days (range 8–150 days). All patients, who had severe congenital idiopathic club feet with a Pirani score of 6, underwent the accelerated Ponseti technique. After removal of the three-week cast, the scores median was 0.59, (range 0–1.5), indicating a correction of the deformity and having braceable feet in all patients without experiencing any short-term complication.ConclusionsThe first step accelerated Pnoseti technique was found to be safe and effective for initial correction of severe idiopathic clubfoot deformity in children below three months of age , though it is an initial study that needs more studies with more follow up data.     

Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity

BACKGROUND: Flatfoot presents as a wide spectrum of foot deformities that include varying degrees of hindfoot valgus, forefoot abduction, and forefoot varus. Medial displacement calcaneal osteotomy, lateral column lengthening, and subtalar fusion can correct heel valgus, but may not adequately correct the fixed forefoot varus component. The purpose of this study was to determine the effectiveness of plantarflexion opening wedge medial cuneiform (Cotton) osteotomy in the correction of forefoot varus. METHODS: Sixteen feet (15 patients) had plantarflexion opening wedge medial cuneiform osteotomies to correct forefoot varus associated with flatfoot deformities from several etiologies, including congenital flatfoot (six feet, average age 37 years), tarsal coalition (five feet, average age 15 years), overcorrected clubfoot deformity (two feet, ages 17 years and 18 years), skewfoot (one foot, age 15 years), chronic posterior tibial tendon insufficiency (one foot, 41 years), and rheumatoid arthritis (one foot, age 56 years). RESULTS: Standing radiographs showed an average improvement in the anterior-posterior talo-first metatarsal angle of 7 degrees (9 degrees preoperative, 2 degrees postoperative). The talonavicular coverage angle improved an average of 15 degrees (20 degrees preoperative, 5 degrees postoperative). The lateral talo-first metatarsal angle improved an average of 14 degrees (-13 degrees preoperative, 1 degree postoperative). Correcting for radiographic magnification, the distance from the mid-medial cuneiform to the floor on the lateral radiograph averaged 40 mm preoperatively and 47 mm postoperatively (average improvement 7 mm). All patients at followup described mild to no pain with ambulation. There were no nonunions or malunions. CONCLUSIONS: Opening wedge medial cuneiform osteotomy is an important adjunctive procedure to correct the forefoot varus component of a flatfoot deformity. Advantages of this technique in comparison to first tarsometatarsal arthrodesis include predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Because of the variety of hindfoot procedures done in these patients, the degree of hindfoot correction contributed by the cuneiform osteotomy alone could not be determined. We have had excellent results without major complications using this technique.     

Early results of a new method of treatment for idiopathic congenital vertical talus

BACKGROUND: The treatment of idiopathic congenital vertical talus has traditionally consisted of manipulation and application of casts followed by extensive soft-tissue releases. However, this treatment is often followed by severe stiffness of the foot and other complications. The purpose of this study was to evaluate a new method of manipulation and cast immobilization, based on principles used by Ponseti for the treatment of clubfoot deformity, followed by pinning of the talonavicular joint and percutaneous tenotomy of the Achilles tendon in patients with idiopathic congenital vertical talus. METHODS: The cases of eleven consecutive patients who had a total of nineteen feet with an idiopathic congenital vertical talus deformity were retrospectively reviewed at a minimum of two years following treatment with serial manipulations and casts followed by limited surgery consisting of percutaneous Achilles tenotomy (all nineteen feet), fractional lengthening of the anterior tibial tendon (two) or the peroneal brevis tendon (one), and percutaneous pin fixation of the talonavicular joint (twelve). The principles of manipulation and application of the plaster casts were similar to those used by Ponseti to correct a clubfoot deformity, but the forces were applied in the opposite direction. Patients were evaluated clinically and radiographically at the time of presentation, immediately postoperatively, and at the time of the latest follow-up. Radiographic measurements obtained at these times were compared. In addition, the radiographic data at the final evaluation were compared with normal values for an individual of the same age as the patient. RESULTS: Initial correction was obtained both clinically and radiographically in all nineteen feet. A mean of five casts was required for correction. No patient underwent extensive surgical releases. At the final evaluation, the mean ankle dorsiflexion was 25 degrees and the mean plantar flexion was 33 degrees . Dorsal subluxation of the navicular recurred in three patients, none of whom had had pin fixation of the talonavicular joint. At the time of the latest follow-up, there was a significant improvement (p < 0.0001) in all of the measured radiographic parameters compared with the pretreatment values, and all of the measured angles were within normal values for the patient's age. CONCLUSIONS: Serial manipulation and cast immobilization followed by talonavicular pin fixation and percutaneous tenotomy of the Achilles tendon provides excellent results, in terms of the clinical appearance of the foot, foot function, and deformity correction as measured radiographically at a minimum two years, in patients with idiopathic congenital vertical talus.     

组合性手术治疗脊柱裂后遗踝足畸形

目的:探讨脊柱裂后遗踝足畸形的外科治疗策略以及不同踝足的畸形手术组合方法及其疗效。方法:回顾性分析1990年1月至2009年7月收治的107例脊柱裂后遗踝足部畸形患者的病例资料。其中男44例,女63例;年龄1.3～52岁,平均17.7岁;双踝足畸形58例,单侧49例(左侧22例,右侧27例)。马蹄足畸形类99足,行跟腱延长及肌腱移位术;跟行足畸形类25足,行踝前肌腱松解及肌腱移位术;内外翻足畸形类17足,行肌腱移位及跟骨截骨术;连枷足畸形15足,行跟距关节融合及跟腱短缩术;爪形趾畸形9足,行趾间关节融合或Ilizarov技术牵拉矫正。采用AOFAS综合评分系统从主观疼痛感觉、客观功能检查等方面评定疗效。结果:107例中79例127足获得随访,时间48～180个月,平均64个月。根据AOFAS综合评分系统,结果优89足,良26足,中9足,差3足。结论:脊柱裂踝足畸形外科治疗策略包括矫正畸形、平衡肌力、稳定关节和保留足的弹性4个基本原则。针对不同类型足畸形,采用相应的组合性手术方案进行治疗,不但可以有效的矫正畸形,而且能改善患者的行走功能,获得满意的疗效。     

Clubfoot in children

Clubfoot, or talipes equinovarus, is a deformity consisting of equinus, varus, and adductus foot deformity. The true etiology of congenital clubfoot is unknown; several theories have been proposed. The pathology of the individual bones contributes to the clubfoot deformity and soft tissue contractures around the ankle and talocalcaneonavicular joint maintains the deformity and involve muscles, tendons, tendon sheaths, ligaments and joint capsules. Various treatment regimens have been proposed, including the use of corrective splinting, taping, and casting. Surgery in clubfoot is indicated for deformities that do not respond to conservative treatment by serial manipulation and casting. Surgery in the treatment of clubfoot must be tailored to the age of the child and to the deformity to be corrected. The main goals of treatment is the painless, functional and anatomical normal foot without need for custom made footwear, and those can be achieved after detailed, indivudial approach with great experience in pediatric orthopedics.     

Neglected neurogenic clubfoot treated with Achilles tendon lengthening using Z-plasty,total talectomy,and tibiocalcaneal arthrodesis

IntroductionThe most common foot and ankle deformity from injury to the nervous system is equinocavovarus. This deformity comprises of equinus, cavus, varus, and adduction of the forefoot which leads to pain and poor stability in stance phase of gait. Treatment for this condition is difficult regarding literature limitation of the neurogenic clubfoot management. We reported a 18-year-old female with neglected right neurogenic clubfoot treated with 2 stage deformity correction.Case reportA 18-year-old female presented with crooked right foot since birth. It caused pain, especially during walking and standing for a long time and resulted in occasional skin infection on the bottom of the foot. However, currently she could walk in limping gait without walking aid. The patient was born aterm 39 weeks through caesarean delivery due to severe preeclampsia. There was delayed development of walking at 2 years and 9 months. Previously, she had history of spina bifida and undergone surgery in 2001. Afterward, she underwent VP shunt surgery. Physical examination demonstrated cavus varus, tenderness of the right foot, and limited ankle motion. The patient was diagnosed with neglected right neurogenic clubfoot and underwent two stage deformity correction consisting of Achilles tendon lengthening using Z-plasty, total talectomy, and tibiocalcaneal arthrodesis followed by posteromedial release, tendon lengthening (Tibialis posterior, FDL, FDB) and plantar fascia release.ConclusionsTwo stage deformity correction can be successful in patients with neglected neurogenic clubfoot. Further studies are required to investigate the safety and efficacy of such procedure in neurogenic clubfoot.     

The adult clubfoot (congenital pes cavus)

Clubfoot occurs in approximately 1 of every 1000 live births, with multiple theories proposed regarding the cause. The pathologic anatomy of the adult clubfoot consists of four components (cavus, adductus, varus, and equinus) and the specific soft tissue and bony procedures indicated for correction depend completely on the constellation of residual deformity that may exist. If the patient was successfully treated at a younger age and has only limited deformity, all that may be required is symptomatic treatment or bracing. Flexible deformities may be treated with a combination of soft tissue procedures and osteotomies or limited fusions, which will not compromise the essential joints of the ankle, subtalar, and talonavicular joints. More rigid deformities require fusions with their associated functional loss, in an attempt to obtain a plantigrade foot.     

Functional outcome of salvage of residual and recurrent deformities of clubfoot with Ilizarov technique

Relapse may occur in severe clubfeet deformities whether treated surgically or nonsurgically. In this study, we evaluate the results of correction of residual and recurrent congenital clubfoot using soft tissue distraction or osteotomy using the Ilizarov external fixation system. This study included 35 feet in 28 patients who were treated between 1999 and 2007. Of these 16 feet in 13 patients with an average age of 13.7 years (range from 11 to 29 years) were treated by percutaneous calcaneal V-osteotomy and gradual correction by the Ilizarov method. Nineteen feet in 15 patients with an average age 10.5 years (range from 4 to 22 years) were treated by soft tissue distraction by the Ilizarov technique. The mean average follow up period was 5.6 years (range from 1 to 8 years). At the time of fixator removal, a plantigrade foot was achieved in 30 feet. Mild residual varus and equinus deformities were present in five feet.At the final follow foot pressure measurement showed recurrent or residual deformity in 10 feet (7 treated by osteotomy and 3 treated by soft tissue distraction). Recurrence may occur with both techniques, depending on many factors such as bone morphology, the number of the pervious operations and the degree of stiffness of the foot prior to the operation.     

Ponseti method in the treatment of post-operative relapsed idiopathic clubfoot after posteromedial release. A short term functional study

BackgroundRelapsed clubfeet deformity after surgical treatment by posteromedial release are frequently encountered in pediatric orthopedic practice and further revision surgery may be needed. As surgery adds more fibrosis and scaring, complication may be devastating and treatment is challenging. Ponseti method, the gold standard technique for treatment of clubfoot may be of a value in the management of postoperative relapses.Aim of the studyDetermine the effectiveness of Ponseti casting Method in treatment of relapsed idiopathic clubfoot in children after being treated with surgical posteromedial release.Materials and methodsProspective interventional study of 17 patients (25 feet) presented with a relapsed idiopathic clubfoot deformity after previous surgical posteromedial release. The patients were reviewed using Pirani and Dimeglio score. Ponseti method was done to obtain supple, flexible foot rather than a fully corrected foot, the residual deformity were treated by, heel cord lengthening or tenotomy, tibialis anterior transfer, follow up was for a minimum of 12 months.Result17 Patients (25 feet) their age ranging from 1 to 10 years were evaluated and treated. Casts were applied until the only deformities remaining were either hindfoot equinus and/or dynamic supination.22 feet required a heel cord procedure for equinus and 13 required tibialis anterior transfer for dynamic supination. The follow up (average 56.1 months) was for a minimum of one year. 4 feet had persistent heel varus deformity which required Calcaneal osteotomy later. Three feet didn’t need more casting and 2 feet were resistant cases that required further Ilizarov procedure, 4 needed lateral arch shortening and other 4 needed posterior capsulotomy. Improvement in the Pirani and Dimeglio scores was highly statistically significant.ConclusionPonseti method for treatment of relapsed clubfeet after a previous posteromedial soft tissue surgical release is an effective, non invasive, with excellent results.     

Talo-navicular arthrodesis for residual midfoot deformities of a previously corrected clubfoot

Triangular navicular, dorsal-lateral subluxation of the talo-navicular (TN) joint with a secondary forefoot cavovarus deformity, and degenerative changes of the TN joint are frequent causes of residual clubfoot deformity and pain in the midfoot after surgical correction. This study investigates the usefulness of TN arthrodesis to correct these deformities and to resolve symptoms resulting from these deformities. During the period from 1991-1996, the senior author performed 19 TN fusions (16 patients) for the above residual clubfoot deformities involving a painful TN joint. Eight of the procedures (seven patients) also required a lateral column shortening with a calcaneal wedge osteotomy to allow for a complete correction of the TN joint. The procedure was only performed in cases involving a hindfoot that was adequately aligned during a previous clubfoot correction. The average age of the patients at the time of surgery was 11 years (range: 4-20). One patient (bilateral procedures) was lost to follow-up. Fifteen patients (17 procedures) were followed-up for an average of four years (range: 2-6). All patients reported symptomatic improvement after the TN arthrodesis. Fourteen of the patients (15 procedures) were completely satisfied. The remaining patient (bilateral procedures) was only partially satisfied due to the subsequent development of navicular-cuneiform osteoarthritis in both feet. Two cases (2 patients) developed complications requiring a second procedure for satisfactory results. In addition, the procedure resulted in an improvement of the talus-first metatarsal angle on both antero-posterior and lateral radiographs. TN arthrodesis produced a correction of the residual clubfoot deformities of the midfoot and resulted in satisfactory clinical improvement in all the patients.     

Salvage of severe ankle varus deformity with soft tissue and bone rebalancing

The etiology of ankle varus is multifactorial. Treatment recommendations after failed conservative care include hindfoot and ankle fusions or total ankle arthroplasty (TAA) with ligament rebalancing. The purpose of this study was to evaluate chronic varus ankle deformities through corrective calcaneal osteotomies and lateral soft tissue reconstruction. All skeletally mature patients with at least 5 degrees of ankle varus were included in the study. Pre and postoperative radiographs were retrospectively reviewed measuring talar tilt. All patients had a lateral closing wedge (Dwyer) calcaneal osteotomy, joint debridement, and lateral ankle ligament reconstruction. Eight feet were included in the study. The average follow-up time was 20.6 months. Six patients (six feet) were asymptomatic and did not have any additional surgery at their most recent follow-up. Two patients failed treatment, requiring surgical intervention for persistent pain and/or deformity. The average postoperative ankle varus correction overall was 4.9 degrees. We found ankle varus on average of less than 10 degrees can be reliably corrected with a combination of lateral ligament reconstruction and calcaneal osteotomy. Approximately 50% of the deformity was corrected when comparing pre and postoperative talar tilt values. In patients with varus deformity greater than 10 degrees preoperatively, persistent varus may occur.