Talo-Calcaneal Osteotomy and Soft-Tissue Procedures in the Treatment of Clubfeet: II. Results in 36 Surgically Treated Feet

Thirty-six refractory or recurrent clubfeet were treated by correction osteotomy through the talar neck and calcaneus in combination with various soft tissue procedures. the aim of the osteotomies was to correct the pronounced deformities observed at simultaneous arthrography of the talocrural and talonavicular joints. the soft tissue procedures were carried out to facilitate the correction and to prevent recurrence by creating muscle balance.

Twenty-four clubfeet were idiopathic and 12 were secondary to neurological or other diseases. the observation period since the osteotomies were performed was, at the time of writing, 1.5 to 5.5 years (median 3 years). A brief report of the indications and methods of operation is given.

Good or fair results were achieved in 21 of the 24 idiopathic clubfeet, while the results were somewhat poorer in the secondary clubfeet. A correlation between the degree of arthrographically demonstrated talar deformity and the results of surgical treatment was found.

The main reason for a poor result was incomplete correction of the most extreme talar deformity in combination with marked preoperative joint rigidity.     

When does the flat-top talus lesion occur in idiopathic clubfoot: evaluation with magnetic resonance imaging at three months of age.

Flat-top talus has been described as a pathologic change secondary to idiopathic clubfoot condition and/or as a direct result of nonoperative manipulation involving forced dorsiflexion and molding of the cartilaginous talus. No definitive study, however, on the etiology and the timing of the flat-top talus deformity has been performed to date. The authors evaluated the magnetic resonance images of eleven patients with idiopathic clubfoot deformities treated with 2 to 3 months of casting to assess if flattening of the talar dome occurred at this age with this amount of casting. All children were 3 months of age, were casted for a maximum of 2 to 3 months, and sedated before MRI examination. The images were evaluated for maximum talar head height, maximum talar body height, and deviation of the talar body from a perfect circle. Maximum talar head height ranged from 4 to 9 mm, maximum talar body height ranged from 6 to 10 mm. Eight of the eleven had maximum talar body measurements 3 to 5mm greater than maximum talar head height. Three of the eleven patients had head and body size of equal proportion. Two of the eleven had a talar body that was within 1 mm of a perfect circle. The remaining nine patients had perfectly round talar bodies. In the senior author's (RSD) experience with treating clubfeet, a substantial increase has been seen at operation in flat-top tali among children that were casted for more than 1 year before surgical correction, compared to children casted for 3 months before surgical correction. The current investigation indicated that although tali of children with clubfeet are abnormally shaped, the talar body remains larger than the talar head and maintains its roundness after two to three months of corrective casting. Maintenance of cast treatment for more than three months may lead to the flat-top talus deformity. The authors recommend surgical intervention following three months of failed manipulation and casting to prevent this deformity.     

Clinical and radiographic features of operatively treated stiff clubfeet after skeletal maturity: etiology of the deformities and how to prevent them

BACKGROUNDS: Residual deformities of operatively treated severe clubfeet evaluated radiographically have been rarely studied in detail in adults. METHODS: Twenty-five operatively treated stiff clubfeet were analyzed at a mean age of 21 years and 6 months. The clinical evaluation used the Laaveg and Ponseti scale for clubfeet. Radiographic assessment was done with weightbearing and dynamic views. RESULTS: Clinical evaluation was globally good except for motion (poor). Radiographic assessment showed residual abnormalities in all feet. The distal tibial epiphysis showed slanting of its posterior part in seven feet (28%) and notching of its anterior lip in 13 (52%). Talar length, calcaneal length, and talar trochlear height were significantly smaller in clubfeet compared to normal feet. Undercorrection of hindfoot varus, was found in 19 feet (76%) but was well tolerated. Navicular wedging was present in seven (28%), and cavus deformity was found in seven (28%). Dorsal bunion, hallux varus, and skewfoot were found in four (16%), two (8%), and three (12%), respectively. The dynamic views demonstrated a significant decrease in the foot and ankle mobility with compensation mechanisms such as anterior talar incongruence or midfoot hypermobility. CONCLUSION: Severe clubfeet never become normal at adult age either clinically or radiographically. Multiple radiographic deformities exist. Their etiology and possible prevention are discussed. Despite the numerous abnormalities, clinical results were good at skeletal maturity.     

Talo-Calcaneal Osteotomy and Soft Tissue Procedures in the Treatment of Clubfeet: I Indications,Principles and Technique

By simultaneous arthrography of the talocrural and talonavicular joints it is possible to demonstrate and measure the most important skeletal deformities in clubfoot. in this way it has been possible to establish the indications for alternative forms of treatment with a greater degree of precision.

Most of our refractory or recurrent clubfeet have been treated successfully by various soft tissue procedures. in cases with severe talar deformity, however, these procedures have been complemented by correction osteotomy through the talar neck and calcaneus.

The aim is to create muscle balance by soft tissue procedures and to correct pronounced skeletal deformities by osteotomy. This treatment plan has been used in about 50 of our clubfoot cases. the principles, objectives and indications of the surgical therapy are discussed in this article.

The operative technique, as it has been developed with increasing experience, is described, and if careful attention is paid to all details the risk of complications is small and the correction is generally satisfactory.

It must be emphasized that correction osteotomy is only a part of an overall treatment plan and that this operation is only indicated in a minority of clubfoot cases.     

Patient-based outcomes after Ilizarov surgery in resistant clubfeet

We present the results of clinical evaluation and patient-based outcomes after Ilizarov surgery in resistant clubfeet (grade D clubfeet, Dimeglio-Bensahel system). This is a retrospective study of 26 resistant clubfeet in 23 children who were managed by the Ilizarov technique. The average age of the patients at the time of the operation was 9 years and the average follow-up period was 47 months. A calcaneal or mid-foot osteotomy followed by bony distraction was undertaken in nine feet and a soft-tissue distraction, with or without soft-tissue release, was undertaken in 17 feet. Clinical evaluation of the degree of correction of the deformity and functional evaluation, using patient-based questionnaires, were used in assessing the outcome in these patients. Patient-based outcomes give useful information about the functional status following surgery, complementing the objective assessment by the surgeon. Clinical evaluation revealed stiff, plantigrade feet in nine patients and a recurrent deformity after initial correction in the remaining 14 patients. The patient-based outcomes were good to excellent in 52% for satisfaction, 57% for cosmesis, 48% for walking and 73% for teasing (made fun of because of the shape of foot), showing that the functional results were better in these patients in spite of a poor surgical outcome.     

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.     

Avascular necrosis after osteotomy of the talar neck to correct residual club-foot deformity in children. A long-term review

In order to determine the incidence of avascular necrosis after osteotomy of the talar neck, we re-evaluated 11 patients (16 feet) with idiopathic club foot who had undergone this procedure at a mean age of eight years (5 to 13) to correct a residual adduction deformity. All had been initially treated conservatively and operatively. The mean follow-up was 39 years (36 to 41). Surgery consisted of a closing-wedge osteotomy of the talar neck combined, in 14 feet, with lengthening of the first cuneiform and a Steindler procedure. At follow-up eight feet were free from pain, three had occasional mild pain and five were regularly painful after routine activities. Two patients were unlimited in their activity, six occasionally limited after strenuous and three regularly limited after strenuous activity. Using the Ponseti score, the feet were rated as good in four, fair in three and poor in nine. In seven feet avascular necrosis with collapse and flattening of the talar dome had occurred. In all of these feet the children were younger than ten years of age at the time of surgery. In three feet, avascular necrosis of the talar head was also observed. We conclude that osteotomy of the talar neck in children under the age of ten years can cause avascular necrosis and should be abandoned.     

Significance of talar distortion for ankle mobility in idiopathic clubfoot

The abnormal bony feature found most consistently in clubfeet is talar distortion. The significance of the talar distortion for mobility of the tibiotalar joint was investigated. Twenty-seven congenital clubfeet in 19 patients were examined at a minimal followup of 20 years. In all patients Turco's posteromedial release was done because of idiopathic clubfoot. Radiographic assessment of the feet included measurement of the talocalcaneal angle and index, and the tibiocalcaneal angle. The degree of talar flattening was estimated by the ratio of the curvature of the talar dome to the length of the talar bone (radius to length ratio). Three-dimensional gait analysis was done to assess the dynamic range of ankle motion. The static range of motion was measured with a goniometer. The degree of talar flattening correlated significantly with the dynamic range of ankle motion but not with the static mobility. For assessment of idiopathic clubfoot, evaluation of talar flattening should be done because of its significance for dynamic ankle mobility.     

Distal tibial osteotomies for the treatment of foot and ankle disorders.

Distal tibial osteotomy is an effective treatment for a variety of pediatric and adult foot and ankle disorders. Exposure osteotomies provide access to the tibiotalar joint for such problems as talar body fractures and osteochondral lesions of the talus. The channel osteotomy provides improved access to posterior talar dome lesions, especially for the use of osteochondral autograft. Although technically demanding, the supramalleolar osteotomy can benefit many patients, including patients with residual clubfoot deformity, primary and secondary osteoarthritis, malunion, and physeal arrest.     

Osteotomy for malunion of a talar neck fracture: a case report

A malunion of the talar neck after a Hawkins type II fracture/dislocation of the talar neck occurred in a 34-year-old man after nonoperative treatment. Rigid varus deformity of the forefoot was a source of severe pain and disability in this patient. We describe our surgical technique for osteotomy of the talar neck with insertion of a tricortical iliac crest bone graft to correct the deformity. At follow-up (56 months), the patient had consistent relief of pain and was employed at his preinjury job doing heavy labor. The score on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale improved from 11 points, preoperatively, to 85 points, postoperatively. Radiographs showed maintenance in the position of the osteotomy and no evidence of avascular necrosis in the talar body. Evidence of arthrosis of the talonavicular joint was apparent radiographically, but the patient did not complain of symptoms referable to this area.     

Recurrent clubfoot

About 25% of operated clubfeet will develop a recurrency or show a marked residual deformity. As main factor the failure of concentric reduction at the time of initial surgery has to be considered. Residual forefoot adduction and supination are the most common persistent deformities. Based on the experience with 94 recurrent/residual clubfeet (patients < 10 years) the surgical treatment at different age-groups is presented. As a general rule soft tissue release is applicable as a repeated procedure until the age of about eight to ten years. For revision in patients between two and eight years we recommend a closing wedge osteotomy of the cuboid and a tibialis transfer additional to repeated release-procedures. In patients older than eight to ten years mid-tarsal osteotomies, correction according to llizarov with the external fixator or triple arthrodesis are to be considered as single or combined procedures.     

Is it hazardous or mandatory to release the talocalcaneal interosseous ligament in clubfoot surgery?: a preliminary report

Extreme overcorrection and avascular necrosis are recognized complications in clubfoot surgery and are thought to be the result of division of the talocalcaneal interosseous ligament (TCIL).This is a preliminary report of a prospective study of the cases of 46 patients with 66 idiopathic clubfeet treated by means of soft tissue release using a posteromedial approach at a mean age of 9 months. The deformity was very severe in 51 feet and severe in 15. The feet were divided into 2 equal groups (33 feet each). In group A feet, the TCIL was released, whereas in group B, the ligament was left intact. At a mean follow-up period of 28 months, the result was satisfactory (excellent and good) in 96.9% of feet in group A and in 87.9% of feet in group B. When the mean overall clinical and radiological score was investigated, group A graded excellent whereas group B graded good. In feet with satisfactory outcome, group A showed statistically significant improvement of the anteroposterior and lateral talocalcaneal angles, talocalcaneal index, and lateral calcaneus-first metatarsal angles when compared with group B. This was reflected clinically on better hind foot correction with the release of the TCIL, with no evidence of significant overcorrection. Magnetic resonance imaging of the ankle and foot confirmed no evidence of talar avascular necrosis or extreme overcorrection in 40 feet (60.1%), 20 in each group. We conclude that it is advisable to release the TCIL in severe and very severe clubfeet.     

Results of step-cut medial malleolar osteotomy

BACKGROUND: Treatment of certain complex ankle pathology, such as a talar body fracture or osteochondral lesion requiring grafting, can necessitate medial malleolar osteotomy for adequate operative exposure. This paper evaluates the step-cut medial malleolar osteotomy for exposure of the ankle joint. METHOD: Fourteen patients with intra-articular pathology, including talar body fractures or osteochondral lesions necessitating extensive intra-articular exposure had step-cut malleolar osteotomy. The average age of the patients was 37 (range 20-90) years, and the average followup was 8 months. RESULTS: All 14 patients had an uncomplicated intraoperative course, with excellent exposure of the ankle joint. All patients had prompt healing of the osteotomy by 6 weeks after surgery without loss of reduction. None of the patients had pain at the osteotomy site. CONCLUSIONS: Step-cut medial malleolar osteotomy is an excellent, reproducible method for extensive exposure of the talar dome.     

Talar neck osteotomy for the treatment of severe structural flatfoot deformities

A new surgical procedure for the treatment of severe structural flatfoot with forefoot varus is presented. The talar osteotomy for flatfoot deformity and the pathology in the talus with medial column forefoot varus is described. The flatfoot considerations, adjunctive deformities, and the surgical reduction are presented. The talar osteotomy has been performed on 47 feet with a follow-up that is intermediate in length from 1 to 7 years. The results indicate that the procedure is specific and allows for good reduction when indicated in the majority of the cases.     

A quantitative comparison of surgical approaches for posterolateral osteochondral lesions of the talus

BACKGROUND: Exposure of the posterolateral talar dome for osteochondral autograft transfer can be challenging. The purpose of this study is to compare surgical exposures for perpendicular access to the posterolateral talar dome using osteochondral transfer instrumentation. MATERIALS AND METHODS: Five surgical approaches were performed on each of eight cadaveric ankles. The sequence was: (1) Anterolateral arthrotomy with ATFL release, (2) Anterolateral tibial osteotomy, (3) Fibular osteotomy with ATFL intact, (4) Fibular osteotomy with ATFL release, and (5) Fibular osteotomy with ATFL/CFL release. (ATFL repaired between 1 and 2). While maintaining the orientation of the harvester perpendicular to the talar dome articular surface, osteochondral plugs were harvested as far posteriorly as possible using a 6-mm harvester. Distances from the anterior talar articular surface to the posterior aspect of the recipient site were measured. Statistical analysis used ANOVA and Fisher post hoc tests. RESULTS: Average AP exposure (mm) and percentage of AP talar dome dimensions exposed: (1) Anterolateral arthrotomy with ATFL release: 21.2 mm (43.3%), (2) Anterolateral tibial osteotomy: 33.7 mm (68.5%), (3) Fibular osteotomy(ATFL intact): 43.2 mm (87.8%), (4) Fibular osteotomy with ATFL release: 44.9 mm (91.2%), and (5) Fibular osteotomy with ATFL/CFL release: 46.6 mm (94.6%). All osteotomies provided greater exposure than anterolateral arthrotomy with ATFL release (p < 0.0001). A significant difference was obtained between each of the fibular osteotomies and tibial osteotomy (p < 0.0001). Differences between the fibular osteotomy approaches (3 to 5) were not significant. CONCLUSION: Fibular osteotomy provides the greatest perpendicular exposure to the posterolateral talar dome. Anterolateral tibial osteotomy provides greater exposure than arthrotomy alone. CLINICAL RELEVANCE: This study provides a guide for surgical exposures to the posterolateral talar dome for osteochondral autograft transfer.     

Scarf osteotomy for hallux valgus repair: the dark side

HYPOTHESIS/PURPOSE: The Scarf osteotomy has gained popularity as treatment of choice in parts of Europe and is based on sound structural principles. The excellent results reported by others could not, however, be reproduced by the author and the results are presented. METHODS: From January 1997 to June 1997 the Scarf osteotomy was selected in 20 consecutive patients (12 female and eight male patients, ages 18 to 60, mean: 41 years) with moderate metatarsus primus varus (IMA 13 to 20 degrees) and hallux valgus deformities (less than 40 degrees). The AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale, visual analog scale and patient satisfaction were monitored prior to surgery, six and 12 months post-op. The patients were treated in a short leg cast, non-WB for two weeks followed by four weeks partial WB in a cast shoe. Routine post-bunion rehabilitation followed once the radiological and clinical diagnosis of healing was made. RESULTS: Multiple complications were encountered. The most common was "troughing" of the metatarsal with loss of height. This occurred in seven patients (35%). Other complications include delayed union (5%), rotational malunion (30%), proximal fracture (10%), infection (5%) and early recurrence of deformity in 25%. All 20 patients were available for follow-up at six months, and 19 of 20 at 12 months. The AOFAS score pre-op was a mean of 53. At six months a mean of 54 (19 to 69) and at 12 months 62 (24-100). Forty-five percent (9/20) were unsatisfied at one year and would not recommend the surgery to a friend. CONCLUSIONS/SIGNIFICANCE: The Scarf osteotomy has multiple potential pitfalls and should probably be reserved for moderate bunions in young people with good bone quality. There are multiple potential problems and the salvage of a failed Scarf osteotomy is difficult.     

A new dynamic foot abduction orthosis for clubfoot treatment

Recurrent clubfoot deformity after successful initial correction with the use of the Ponseti method continues to be a common problem and is often caused by noncompliance with wear of the traditional foot abduction brace. The purpose of this study was to assess the results of a newly designed dynamic foot abduction orthosis in terms of (1) parental compliance and (2) effectiveness in preventing recurrent clubfoot deformities. Twenty-eight patients (49 clubfeet) who were treated with a dynamic foot abduction orthosis in accordance with the Ponseti method were included in this study. Of the 28 patients, 18 had idiopathic clubfeet (31 clubfeet), 2 had complex idiopathic clubfeet (4 clubfeet), 5 had myelodysplasia (8 clubfeet), and 3 were syndromic (6 clubfeet). The mean duration of follow-up was 29 months (range, 24-36 months). Noncompliance was reported in only 2 (7.1%) of the 28 patients in the new orthosis compared with the authors' previously reported 41% (21/51) noncompliance rate in patients treated with the use of the traditional foot abduction brace. The two patients in this study, in which parents were noncompliant with orthosis wear, developed recurrent deformities. There were 2 patients (7%) who experienced skin blistering in the new orthosis compared with 12 (23.5%) of 51 patients who experienced blistering with the use of traditional abduction brace in the authors' previously reported study. Logistic regression modeling compliance and recurrence revealed that noncompliance with the foot abduction orthosis was most predictive of recurrence of deformity (odds ratio, 27; 95% confidence interval, 2.2-326; P = 0.01). The articulating foot abduction orthosis is well tolerated by patients and parents and results in a higher compliance rate and a lower complication rate than what were observed with the traditional foot abduction orthosis.     

Rheumatoid Forefoot Reconstruction in Nonrheumatic Patients: Lesser Metatarsal Head Resection versus Osteotomy

In the literature, first metatarsophalangeal joint arthrodesis with lesser metatarsal head resection seems to be a reliable procedure in rheumatoid foot deformity. Maybe this procedure could be proposed in nonrheumatoid severe forefoot deformity (hallux valgus angle >40° and lesser metatarsophalangeal dislocation). The aim of this study was to compare radiological and clinical outcomes between lesser metatarsal head resection and lesser metatarsal head osteotomy in nonrheumatoid patients. Thirty-nine patients (56 feet) suffering from well-defined nonrheumatoid severe forefoot deformity were retrospectively enrolled in our institution between 2009 and 2015. Metatarsal head resection and metatarsal head osteotomy represented 13 patients (20 feet) and 26 patients (36 feet), respectively. In this observational study, a rheumatoid population (21 patients) was included as the control. The clinical outcome measures consisted of American Orthopaedic Foot and Ankle Society score, Foot and Ankle Ability Measurement, and Short Form-36. The radiological outcomes were: intermetatarsal angle, hallux valgus angle, and metatarsophalangeal alignment. Mean follow-up was 24 months. Satisfaction rate was, respectively, 92% for resection, 91% for osteotomy procedure, and 80% for surgery in rheumatoid patients. Short Form-36 global score was, respectively, 80.7 (52.5-96.4), 76 (57.7-93), and 68.3 (22.6-86). No functional outcome difference was found between resection and osteotomy procedures, except that the metatarsal head resection group had poorer results in sports activities than the osteotomy group. Complications were similar between osteotomy and resection (p > .05). The radiological outcomes were improved significantly from preoperative to postoperative. First metatarsophalangeal joint arthrodesis with lesser metatarsal head resection in nonrheumatoid severe forefoot deformity might be a good therapeutic option.     

Comparison of Lateral Opening Wedge Calcaneal Osteotomy and Medial Calcaneal Sliding-opening Wedge Cuboid-closing Wedge Cuneiform Osteotomy for Correction of Planovalgus Foot Deformity in Children

The purpose of the present study was to compare the clinical and radiographic results between 2 procedures, lateral opening wedge calcaneal osteotomy (LCL) and medial calcaneal sliding-opening wedge cuboid-closing wedge cuneiform osteotomy (3C) in patients with planovalgus foot deformity. A total of 38 patients who underwent either LCL (18 patients, 28 feet) or 3C (20 patients, 32 feet) were included in the present study. The etiology of the planovalgus foot deformity was idiopathic in 16 feet and cerebral palsy in 44 feet. The 2 procedures used in the present study were indicated in symptomatic (pain or callus) children in whom conservative treatment, such as shoe modifications or orthotics, had been applied for more than 1 year but had failed. The patients were evaluated preoperatively, postoperatively, and at the last follow-up visit, both clinically and radiologically, and the interval to union and postoperative courses were compared between the 2 groups. In the LCL group, 19 of the 28 feet (68%) showed a satisfactory outcome and 9 (32%) an unsatisfactory outcome. In the 3C group, 28 of the 32 feet (88%) showed a satisfactory outcome and 4 (12%) an unsatisfactory outcome. The clinical results were not significantly different between the 2 groups, with mild to moderate pes planovalgus deformity. However, the clinical results were better in the 3C group with severe pes planovalgus deformity than in the LCL group with severe pes planovalgus deformity. All 4 radiographic parameters were improved at the last follow-up visit in both groups. In particular, the talar–first metatarsal angle and the calcaneal pitch angle on the weightbearing lateral radiographs were significantly improved in the 3C group with mild to moderate planovalgus foot deformity. All 4 parameters were significantly improved in the 3C group with severe planovalgus foot deformity. No significant differences were observed between the 2 groups in terms of the interval to union and postoperative care. No case of postoperative deep infection or nonunion was encountered in either group. 3C is a more effective procedure than LCL for the correction of pes planovalgus deformity in children, especially severe pes planovalgus deformities.