The complete subtalar release in clubfeet

CSTR is a release of the subtalar joint and the talonavicular joint that corrects calcaneal rotation, a major deformity of the clubfoot, as well as the other major deformities of the midfoot and hindfoot. Indications for the CSTR are presented. These include failure of conservative treatment or unsatisfactory surgical results with residual varus deformity, and a foot longer than 8 cm. Contraindications to CSTR include radiographic evidence of a flat-top talus and uncorrected anterior ankle contractures. The Cincinnati incision, which permits excellent visualization of all the relevant structures and good cosmesis, is described and compared with other approaches. The technique of the CSTR is described in detail. Key steps include marking the knee for later alignment with the foot (a major advantage of this procedure), superficial medial dissection, posterior dissection, lateral dissection, and deep medial dissection. Technical details and criteria for evaluation are provided. Four supplemental procedures and their indications are described. These include metatarsal osteotomy, calcaneocuboid capsulotomy, calcaneal wedge osteotomy, and plantar release. Procedures for pinning and casting are described, with special attention to accuracy of realigning the foot and measures for avoiding avascular necrosis and other complications. The importance of intraoperative radiographs is presented, together with methods for obtaining and assessing these films to assure that surgical correction is complete. It is imperative that these films be taken before tendon repair or wound closure so that pinning procedures can be repeated, if necessary.