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Talar and Calcaneal Y-Osteotomy with Distraction Osteogenesis for the Correction of Rigid Equinus

Posted on April 1, 2011 | Comments Off on Talar and Calcaneal Y-Osteotomy with Distraction Osteogenesis for the Correction of Rigid Equinus

by Sutpal Singh, DPM, FACFAS 1 , Albert Kim, DPM 2, Timothy Dailey, DPM 3, Long Truong, DPM 4, Maria Mejia, DPM 5

The Foot and Ankle Online Journal 4 (4): 3

Types of equinus, surgical management for equinus involving the Y- talocalcaneal osteotomy supplementing an external fixation device is presented. A case report is introduced involving surgical correction of a 53 year old male who had a severe equinus flat top talus with mild varus secondary to clubfoot surgery. Treatment included surgical correction utilizing Steindler stripping, Achilles tendon lengthening, and a rather rare Y- osteotomy of the calcaneus and talus with the use of a multiplaner external fixator in an unconstrained system to correct the equinus and varus deformity. Slow distraction was performed in order to decrease the risks of having neurovascular injury, soft tissue injury, and shortening of the foot. After months of follow-up, there was good healing of the osteotomy sites and the patient had a plantigrade foot.

Key words: Clubfoot, Rigid Equinus, Flat top talus, Y-Osteotomy, External fixation, Distraction Osteogenesis, Ilizarov method.

Accepted: March, 2011
Published: April, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0404.0003

Ankle joint equinus can be divided into a three types; soft tissue, osseous and a combination of the two. [1] Soft tissue equinus alone can be easily repaired, but when multiple deformities occur such as clubfoot, it can complicate the treatment.

The etiology of ankle equinus can include trauma, diabetes mellitus, poliomyelitis, osteomyelitis, contracture from burns, neglected or relapsed clubfeet, prolonged immobilization in plantarflexion, as well as neuromuscular disease. [1,3,7]

Traditionally, correction has been managed through arthrodesis and extensive soft tissue release. Treatments for soft tissue ankle equinus include procedures such as splinting, tendo-Achilles lengthening, gastrocnemius recession, and rare deformities such as accessory soleus release. [10,13]  Neurovascular, soft tissue problems and shortening of the foot may occur with traditional techniques. Also, prior surgeries may make the surgical management of the foot deformities more difficult later in life.

An Ilizarov external fixator can be used to correct equinus and it can be applied in two ways; constrained and unconstrained. The constrained technique places the axis of rotation at a planned anatomical axis of the joint. [9]  The constrained technique can correct deformities within the joint unlike the unconstrained that keeps the natural axis of rotation. The unconstrained technique places the axis of rotation around the natural axes of the joint. [9] The unconstrained technique requires distraction of the ankle joint before an attempted correction.

The Ilizarov external fixator can be used to correct equinus without an osteotomy, only when the equinus is soft tissue in nature. Only correcting the soft tissue deformity with an Ilizarov frame has a high recurrence rate. [3]  When dealing with an osseous equinus an osteotomy must be performed and Ilizarov used the process called distraction osteogenesis to correct the deformity. [18] “Gradual distraction of the soft tissues and bones enables reshaping of the foot.” [8]  The Ilizarov technique can fix these deformities with minimal incisions. The downside to this is the patient has an external fixator for several months. During this time the patient may bear weight on the area which has an advantage over internal fixation. Another advantage is during osseous correction it can also correct for soft tissue deformities at the same time.

There are three main types of Ilizarov rearfoot osteotomies including the U, V and Y osteotomies. [9]  The Y- osteotomy is the least published of the three. The Y is an osteotomy through the neck of the talus and an osteotomy of the posterior calcaneus below and parallel to the subtalar joint making an apex in the anterior calcaneus and then an osteotomy plantarly thus creating the shape of a “Y”. [9]  The Y- osteotomy has the same implications as the V- osteotomy except it doesn’t elongate the foot as much. [9] The Y- osteotomy with external fixation allows small changes each day to allow the new bone to form and correct the deformity. This osteotomy allows correction of complicated equinus cases. Which osteotomy is chosen depends greatly on the surgeons’ experience.

Case Report

A 53 year old male was seen in the office due to severe pain around the sub right 4th and 5th metatarsals. The patient had an equinus deformity of the right lower extremity with varus deformity. (Figs.1A and 1B) His past surgical history was significant for club foot surgery when he was 4 years old, which still left him ambulating on the ball of his right foot. The rest of the history was unremarkable.

 

Figure 1A and 1B  Preoperative photo (A) and  radiograph (B) showing ankle equinus deformity.

Physical exam showed that he had scar tissue around the medial, lateral, and posterior heel on the right foot. The positioning of his right lower extremity included a tight contracted Achilles tendon that correlated with a rigid equinus deformity, varus of the foot with subtalar joint stiffness with no range of motion at the mid foot, rear foot and ankle. Also, there were contractures of all the digits. There was no leg length discrepancy noted and the length of the foot was within normal limits. The patient had difficulty wearing shoes and could only wear sandals. There was increased pain under the right 4th and 5th metatarsophalangeal joints due to the excessive pressure while ambulating secondary to the rigid equinus and inversion of the foot. This, in effect, was placing too much pressure on his 4th and 5th metatarsal heads.

The procedure that was performed included a Steindler stripping, an Achilles tendon lengthening, talar and calcaneal Y-osteotomies, plantar tenotomy of all five digits, and the application of an Ilizarov external fixator.

The patient was prepped and draped in the usual standard manner. No tourniquet was applied. A # 15 blade was used to perform a percutaneous tendon lengthening of the Achilles Tendon. The foot was only able to dorsiflex several degrees due to the severity of the deformity from negative 45 to negative 40 degrees. Along the plantar medial calcaneus a Steindler stripping was then performed. This helped release all the fascial and muscular contractions on the plantar foot from the calcaneus. A prophylactic tarsal tunnel release was also performed by transecting the laciniate ligament. Two tibial rings were then applied to the lower leg. One half-ring was applied to the calcaneus and one half-ring was applied to the distal foot. All wires were then tensioned appropriately. The calcaneal half-ring was attached to the posterior tibial ring. The distal foot half-ring was then connected to the anterior tibial ring.

The calcaneal ring was then connected to the distal foot half ring. All connections had distraction capability to correct the foot in three dimensions. Prior to any distraction, using flouroscan a small incision was made at the medial aspect of the talar neck. The incision was deepened to the subcutaneous tissue and then to the periosteum of the talus. A small osteotome was then used to perform a complete osteotomy of the talar neck. Along the lateral aspect of the calcaneus a small incision was made parallel and inferior to the subtalar joint. The incision was deepened to the subcutaneous level and then to the periosteum of the calcaneus. A small osteotome was used to perform a complete osteotomy of the calcaneus 1 cm posterior and inferior to the subtalar joint. Along the anterior aspect of the calcaneus a small incision was made 1 cm proximal to the calcaneal cuboid joint. The incision was deepened to the subcutaneous level and then down to the periosteum of the calcaneus. A small osteotome was inserted down to bone and rotated being careful not to transect the peroneal tendons or sural nerve. A complete osteotomy was then performed at the distal calcaneus. (Fig. 2)

Figure 2  Intra-operative  radiograph of the  Y- osteotomy.   The left side of the Y is the Talar neck osteotomy, the right side of the Y is the calcaneal osteotomy below the subtalar joint and the stem of the Y osteotomy is located at the distal calcaneus.

Note that a void was created while removing the osteotome at the stem of the osteotomy. This eventually healed well due to the vascular nature of the calcaneus. All surgical sites were irrigated with normal saline and bacitracin and sutured with 3-0 Prolene. Attention was then directed to all the plantar toes and plantar flexor tenotomies were then performed and smooth wires were then inserted and attached to the distal half ring. The surgical site was then dressed with Adaptic, gauze and Kerlex . (Figures 3,4,5A, 5B, and 6)

Figure 3  Initial frame placement at the time of the surgery.

Figure 4  Note the rod rotating the distal ring out of varus and dorsiflexing it.

 

Figure 5A and 5B  Note that the forefoot and rearfoot can be manipulated independent of each other.  Note the wires from the toes being attached to the forefoot half ring. (A)  The plantar view showing the percutaneous plantar tenotomies of all the toes with wires going into the metatarsals and attached to the foot half ring. (B)

Figure 6  The post-operative radiograph.

At one week, the following manipulations to the bones in the external fixator were initiated: 1) distraction of the calcaneus towards eversion and inferior displacement, 2) rotation of the distal foot towards eversion and dorsiflexion, 3) distraction of the forefoot from the rearfoot.

The patient was instructed to increase the movements by a total of 1 mm per day achieved by a ¼ turn of the distraction mechanism 4 times per day. The patient was taken back to the OR at week 3 (Fig. 7) and at week 8 (Fig. 8) for the addition of extra rods and bars for greater manipulation and a better line of pull. At week 12, there was good alignment of the foot in a plantigrade position and at week 20, the external fixator was removed (Fig. 9) At 6 months, the patient was ambulating in a custom made AFO. (Fig. 10)

Figure 7   More rods were applied for more distraction at 3 weeks after surgery.

Figure  8   At 8 weeks , the patient had more bars and rods added with frame manipulation.

Figure 9  At 5 months the frame was removed and the patient was placed in a below the knee cast.

Figure 10   At 6 months, the patient had his foot plantigrade and was full weight bearing in a custom made AFO.

Overall, the patient was able to ambulate with the heel on the ground with minimal pain; however, did not have much range of motion at the ankle or foot. All the pain under the lateral forefoot resolved. The patient was satisfied with his plantigrade foot and able to ambulate with a custom AFO.

Discussion

There are multiple surgical procedures available for correction of acquired ankle equinus, soft tissue as well as bone procedures. [1,2,4] When this deformity becomes fixed it poses a challenge to many foot and ankle surgeons due to soft tissue contraction and bony adaption and requires a combination of soft tissue and bone procedures. [1,2,4] Flexible deformities can be treated with manipulation methods thus preventing surgery.

When manipulation methods don’t work then surgery is required. Surgical correction consisting of extensive soft tissue releases with and without arthrodesis for equinus deformity has been well described. [15] Different osteotomies with and without an external fixator have been described in literature for correction of complex foot deformities. [9,11,14,16,17,20]

Correcting deformities such as clubfoot become a challenge especially after failed surgeries due to stiffness of the soft tissues and residual deformities such as equinus. [16,17] There are several osteotomies and a few of the commonly discussed ones are the U (Scythe-shaped), V, and less commonly discussed Y- osteotomy. [16,17]

The scythe-shaped (U) osteotomy is a curved osteotomy that divides the foot into two sections. It starts posterior to the lateral malleolus and runs from 1-1.5 cm below the posterior subtalar joint, then penetrates the floor of the sinus tarsi and emerges at the talar neck. [9,11] This type of osteotomy allows for correction of equinus with a rigid tibio-talar joint. [9]

The V – osteotomy is a combination of oblique cuts that are angled at 60-70 degrees. [9] The osteotomy is performed along the posterior calcaneus and the anterior calcaneal-talar. This type of procedure is indicated for treatment of complex deformity of the hindfoot and the midfoot. [9,11,19,20] The V- osteotomy offers versatility when combined with an external fixator because it has the ability to preserve foot length and perform simultaneous tibial corrections. [20]

The Y – osteotomy is similar to the V – osteotomy in a sense that it allows one to apply differentiated correction between the hindfoot and the forefoot. The osteotomy results in a three ray star that is all 120 degrees apart. The osteotomy is first performed at the oblique posterior aspect of the calcaneus, then a vertical osteotomy of the calcaneus, and finally the calcaneal-talar ostetomy. [9] This type of procedure allows for the same correction as the V – osteotomy but with fewer complications. [9]

The hinges are positioned on the medial and lateral threaded rods of the calcaneal half ring. The equinus is corrected by lowering the calcaneus and raising the forefoot in relationship to the talar body. [9] Correction is achieved through the movement of the fragments of the osteotomy with the majority of correction of the calcaneal and talar equinus. [9,14] The Y – osteotomy does not cause any skeletal lengthening as with the scythe-shaped osteotomy, therefore it offers three advantages. [9] The advantages include faster consolidation because of less bone regeneration, skin alteration is easily contained, and prevention of calcaneocuboid diastasis is unnecessary. [9]

The Ilizarov method with external fixation was chosen for the correction after performing the osteotomy because it enables correction in all three orthogonal planes. [4,9,11,14,17] Using an external fixator is not only minimally invasive, but it also allows the surgeon to stage the treatment appropriately to manipulate the rate and direction of the correction. It can be used as either a constrained or unconstrained hinge system. In the constrained foot frame, forces applied to the foot are directed around the axis. [14] This technique is usually reserved for large joints. In the unconstrained system, joints of the ankle and the foot are used as the fulcrum points for correction and it is usually used with smaller joints or deformities with multiple joint axes. [14]

The Steindler stripping procedure is recommended for patient with significant contractures of the plantar aponeurosis and plantar musculature.[1] The abductor hallucis, flexor digitorum brevis, and abductor digiti quinti are released from the periosteum of the calcaneus. However, this procedure is limited in that it does not correct fixed deformities and only corrects in the sagittal plane. [1]

The complications associated with the use of an external fixator and any type of osteotomy includes tarsal tunnel syndrome, neurovascular symptoms, pin tract infection, flexor contractures, valgus drift, incomplete osteotomy, residual deformity, and recurrence of problem. [4,9,11,14,16,17,19,20]

Due to such complications, it has been recommended that a prophylactic tarsal tunnel release be performed to decrease the likelihood of nerve entrapment secondary to the correction and to minimize the risk of vascular injury. [16] There is a high incidence of nerve injury as a result of acute angular deformity correction. [20] If compressive symptoms of the tibial nerve are experienced during the correction, it can be addressed either by performing a secondary surgical decompression or by decreasing the rate of correction. [11,14] Pin tract infection and flexor contractures are usually secondary to prolonged fixator utilization. [19,20] Pin tract problem are related to skin motion and controlled with local pin site care. Pin tract infections are minor complications that occurs with any type of external fixator but respond very well to oral antibiotics and rarely lead to osteomyelitis requiring pin removal. [17,20] Premature consolidation of the osteotomy before full correction is reached is also not an uncommon complication. To avoid this problem, it is recommended to start distraction routinely on the third postoperative day. [16]

Despite such complications, the Ilizarov technique remains an effective and safe tool for complex lower limb reconstruction surgery. It allows corrections in all planes at a rate that can be tailored to the deformity without the constraints of traditional methods.

When looking back at the literature regarding the Y- osteotomy there is not much to be found. Our case presentation is unique that to our knowledge there are no other journal articles on which a y calcaneal osteotomy is used in conjunction with an Ilizarov distractor. Furthermore there is close to no literature regarding the Y- osteotomy. In the literature the main focus has been on correcting the structural equinus foot by using the V. [16,17] Also there has not been another study in which the y osteotomy is used in conjunction with the Ilizarov distractor. In our case study we found that the Y- osteotomy allows for correction of a severe deformity while minimizing neurovascular and soft tissue complications as well as avoiding excessive shortening of the foot as is many times encountered with traditional techniques.

Traditional methods although successful with certain patients they involve much more cut in the bone which can lead to excessive shortening and soft tissue complications. Our case report helps to illustrate a successful way in which a rigid equinus can be corrected by the use of an under researched osteotomy with gradual distraction of the structures in the foot. In our case the patient was satisfied with his plantigrade foot even though he did not have much range of motion at the ankle or foot. This view is supported by other studies in which patient satisfaction is achieved with improvement in appearance of the foot. [6,16,21]

Conclusion

In this case study, we presented a rigid equinus foot that was corrected with the use of a Y – osteotomy along with the use of Ilizarov methodology. There is not much literature about the usage of the Y – osteotomy even though it has three main advantages which are: faster consolidation, skin alterations are easier to contain, and there is less chance of calcaneal-cuboid diastasis. [1] Furthermore, the Y – osteotomy avoids excessive lengthening of the foot. Correction of severe foot deformities with the Ilizarov method is technically difficult but when used with the Y – osteotomy, differentiated correction between the hindfoot and forefoot can be applied. In the case study it was successfully shown that the Y – osteotomy allows for correction of a severe deformity while minimizing neurovascular and soft tissue complications as well as avoiding excessive shortening of the foot as is many times encountered with traditional techniques. The final result was a plantigrade foot. Thus, the Y – osteotomy through the talus and calcaneus with distraction osteogenesis using the Ilizarov methodolgy is an effective surgical procedure in correcting rigid equino-varus foot deformities.

References

1. Banks AS, Downey MS, Martin DE, Miller SE. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia, Lippincott Williams & Wilkins, 2001.
2. Coughlin, Michael J, Roger A. Mann, Charles L. Saltzman. Surgery of the Foot and Ankle. Philadelphia, Mosby 2007.
3. Digiovanni CW, Holt S, Czerniecki JM, Ledoux WR, Sangeorzan BJ. Recurrence after correction of acquired ankle equinus deformity in children using Ilizarov Technique. Strategies Trauma Limb Reconstruction 3: 105-108, 2008.
4. Emara Khaled M, Allam Mohamed Farouk, ElSayed Mohamed Nabil MA, Ghafar Khaled Abd EL. Recurrence after correction of acquired ankle equinus deformity in children using Ilizarov technique. Strat Traum Limb Recon 3:105-108, 2008.
5. Easley, Mark E., Wiesel Sam. Operative Techniques In Foot and Ankle Surgery. Philadelphia, Lippincott Williams & Wilkins 2011.
6. Freedman JA, Watts H, Otsuka NY. The Ilizarov method for the treatment of resistant clubfoot: is it an effective solution? J Pediatr Orthop 26:432–437, 2006.
7. Guyton G, Saltzman C. The Diabetic foot. JBJS 83A: 1083-1096, 2001.
8. Ilizarov GA. Transosseous osteosynthesis. Berlin/Heidelberg: Springer-Verlag, 1992.
9. Kirienko Alexander, Villa Angelo, Calhoun Jason H. Ilizarov Technique for Complex Foot and Ankle Deformities. Marcel Dekker, Inc, 2004.
10. Kishta WE, Mansour EH, Ibrahim MM. The accessory soleus muscle as a cause of persistent equinus in clubfeet treated by the Ponseti method : A report of 16 cases. Acta Orthopaedica Belgica 76: 658-662, 2010.
11. Kocaoğlu M, Eralp L, Atalar AC, Bilen FE. Correction of complex foot deformities using the Ilizarov external fixator. J Foot Ankle Surg 41: 30-39, 2002.
12. Laughlin RT, Calhoun MD. Ring fixators for reconstruction of traumatic disorders of the foot and ankle. Orthop Clin North Am 287-294, 1995.
13. Lopez A, Kalish S, Mathew J, Willis FB. Reduction of ankle equinus contracture secondary to diabetes mellitus with dynamic splinting. Foot Ankle Online Journal. 3 (3):2, 2010.
14. Mendicino RW, Murphy L J, Maskill MP, Catanzariti AR, Harry P. Application of a constrained external fixator frame for treatment of a fixed equinus contracture. J Foot Ankle Surg 47: 468-475 , 2008.
15. Galli M , Cimolin V, Crivellini M, Albertini G. Gait analysis before and after gastrocnemius fascia lengthening in children with cerebral palsy. J Appl Biomaterials Biomechanics 3: 98-105, 2005.
16. Segev E, Ezra E, Yaniv M, Wientroub S, Hemo Y. V Osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet. J Orthopaedic Surg 16: 215-219, 2008.
17. Shalaby H, Hefny H. Correction of complex foot deformities using the V-osteotomy and the Ilizarov technique. Strat Traum Limb Recon 1: 21-30, 2007.
18. Spielberg Parratt Dheerendra Khan Jennings Marsh. Ilizarov principles of deformity correction. Annals of The Royal College of Surgeons of England 92: 101–105, 2010.
19. Gerhardt S, Vinay S, Bernhard ZE, Uitz C, Wolfgang L. Complex foot deformities associated with soft-tissue scarring in children. Journal Foot Ankle Surg 40: 42-49, 2001.
20. Theis JC, Simpson H, Kenwright J. Correction of complex lower limb deformities by the Ilizarov technique: An audit of complications. J Orthopaedic Surgery 8: 1448-1552, 2000.
21. Utukuri MM, Ramachandran M, Hartley J, Hill RA. Patient-based outcomes after Ilizarov surgery in resistant clubfeet. J Pediatr Orthop B 15:278–84, 2006.

Address correspondence to: Sutpal Singh, DPM, FACFAS, Chief Ilizarov Surgical Instructor at Doctors Hospital West Covina, Fellow of the American College of Foot and Ankle Surgeons, Private practice in Southern California.

1 Chief Ilizarov Surgical Instructor at Doctors Hospital West Covina, CA.  Fellow American College of Foot and Ankle Surgeons. Private practice in Southern California
2 PM&S 36, R3 (Foot and Ankle Medicine and Surgery) Doctors Hospital of West Covina.
3 PM&S, R2 (Foot and Ankle Medicine and Surgery) Doctors Hospital of West Covina.
4 PM&S, R1 (Foot and Ankle Medicine and Surgery) Doctors Hospital of West Covina.
5 PM&S, R1 (Foot and Ankle Medicine and Surgery) Doctors Hospital of West Covina.

© The Foot and Ankle Online Journal, 2011

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A Literature Review of Non-Surgical Intervention for the Treatment of Idiopathic Talipes Equinovarus: A Podiatric Perspective

Posted on October 1, 2010 | Comments Off on A Literature Review of Non-Surgical Intervention for the Treatment of Idiopathic Talipes Equinovarus: A Podiatric Perspective

by Janet McGroggan, BSc(Hons)1 , Gloria Dunlop2

The Foot and Ankle Online Journal 3 (10): 2

This article aims to discuss the current surgical and non-surgical interventions in the treatment of idiopathic talipes equinovarus. It examines the literature from 1964 to the present day and includes a detailed anatomical description of the condition. The treatment of this condition has evolved from complicated surgical procedures with low long term success rates to less traumatic closed treatments with good outcomes. The latter, specifically the Ponseti Method of treatment, has been practiced by orthopaedic surgeons in the United Kingdom for seven years now and this article examines the podiatrist’s potential role in the management of this lower limb complaint.

Key Words: Clubfoot, Idiopathic talipes equinovarus

Accepted: September, 2010
Published: October, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0310.0002

Idiopathic talipes equinovarus (ITEV) is characterised by the ankle in a plantarflexed and inverted position with the heel, midfoot and forefoot adducted and inverted producing a cavus deformity. [1] The Achilles tendon acts as an invertor [2] and the calf muscles are shortened. [3] ITEV, more commonly known as clubfoot, is a disorder affecting one or both lower limbs with fifty percent of cases being bilateral. Worldwide statistics show an incidence ratio of 1.2 babies affected in every 1,000 live births [4] with a 2:1 male:female ratio. [5] Bakalis, et al., reported in their retrospective study that of 103,228 routine ultrasound foetal scans taken between January 1991 and October 2000 in three separate London teaching hospitals, 0.1% (n=107) showed talipes equinovarus.

The scans were observed at 18-23 weeks of foetal gestation with occurrence being bilateral in 64 cases and unilateral in 43. The researchers reported 51.4% of these cases were idiopathic and 48.6% were associated with other pathologies.6 Idiopathic talipes equinovarus has a familial link and displays clear racial prevalence [7] however, the reason for the abnormal development is still unkown. [4] In third world countries ITEV is frequently left untreated and affected people will suffer diminished mobility, ulcerations from abnormal weight bearing and be socially ostracised. In the United Kingdom (UK) ITEV has historically been treated primarily through orthopaedic surgery until around 2003 when non surgical methods became more widely available.

ITEV is a congenital dysplasia which affects all tissue below the knee. [4] In a two part anatomical study [8,9] Windisch, et al., dissected seven foetal feet affected with ITEV aborted in weeks 27-36 of gestation and compared the pathoanatomy with two anatomically normal feet in weeks 27 and 36 of gestation. When describing the bone and joint relationships the authors reported a talar neck-troclea angle of 37° to 41° in ITEV compared to 27° to 33° in normal feet. Deviation of the talar neck relative to the body was 28° to 43° in ITEV compared to 22° to 24° in normal feet. The posterior surface of the talus was flat and triangular with the subtalar joint unattainable. The talar head turned along a longitudinal axis opposite to that in the normal foot.

The researchers found the anterior surface of the calcaneus to be flat, medially twisted and orientated upwards, although there was no significant difference in its angle of torsion to that of a normal foot. They concluded that an ossification disturbance of the calcaneus was the primary fault which then influences the varus position of the foot. The soft tissues merely conform to the misshapen bones. The medial ligaments are shortened and thickened, and depending on the severity of the club foot, the tendons of tibialis posterior, flexor hallucis longus and flexor digitorum longus can be wrapped up in a fibrotic mass.

In contrast, Bensahel, et al., found that the midtarsal joint played a major role in ITEV. [10] They noted that the tibialis posterior turns the talo-navicular joint towards supination with the mid and forefoot following the deviation. This allows the talus to become unstable and the calcaneus to be deviated towards an equinus and varus position. Again the surrounding soft tissues contracts and increases the deformity. Calf muscle atrophy is usual in a limb affected by ITEV [4,5] with the triceps surae and the tibialis posterior affected the most. [7] Measurements ranging from 1.25 cm to 10cm difference in the circumference of the calf muscle have been reported between the affected limb and the unaffected limb in unilateral cases. [2]

In her research Whynne-Davis [2] reported an average limb length discrepancy of 2.5cm in 47 unilateral cases of ITEV as a result of shortened bones. This shortening may occur in any one site: femur, tibia, fibula and any of the bones of the foot. Less than half the males studied were affected but all the females were affected in this study which likely is due to the earlier closing of the female epiphyses. Further studies have reported associated musculoskeletal abnormalities occurring in patients with ITEV such as internal tibial torsion and internal femoral torsion. [11]

Eighty nine to ninety percent of ITEV cases present with an absent or reduced anterior tibial artery. [12,13] In such cases the artery is always hypoplasic and stops at the level of the distal tibial epiphysis.

This phenomena is only seen in up to 3.5% of normal feet although difficulties have been reported in interpreting the arteriograms due to the rotation of the feet. [14] Preservation of four persistent primitive arteries have also been reported ‘the embryonic interosseus, tibial posterior superficialis, peronea posterior superficialis and ramus communicans inferior arteries.’ [13] There may also be absence or reduction of the posterior tibial artery and in these cases the peroneal artery becomes dominant. [11] Research shows not only are the distal vessels affected by hypoplasia, [15] but the proximal deep femoral and popliteal arteries also display circulatory disturbances. It is possible that an arterial aberration in the sixth and eighth week of gestation is related to the positioning of the calcaneus in equinus. [16] All foetal feet resemble ITEV at this point of development and although some previous studies have reported no vascular anomalies in still born infants with ITEV, [12] other research studies have identified an interruption in foot development during the ninth week of gestation. [17,18] which may provide defective positional information preventing the foot from de-rotating into a normal position. Researchers have claimed that limbs affected show fewer fibroblasts, smaller cells and less cytoplasmic volume suggesting cellular hypoplasia. [19] It has also been suggested that ITEV may result from growth of the anterolateral foot growing round the stunted posteromedial foot. [17] This theory suggests a neural abnormality may be present, since muscle fibre type is neurally determined.

Surgical interventions for ITEV

Surgical intervention is normally carried out before the child is twelve weeks old. [20] A complete subtalar release [21] is an extensive soft tissue surgical procedure that is only advised when the foot is at least eight centimetres long. During surgery the talus and calcaneus are repositioned and post operatively the limb is cast with the knee flexed at 90° and the foot externally rotated at a 10 degree angle to the knee. The limb is then elevated for 10 days. Further casts are applied as an outpatient until six weeks after the procedure. Foot orthoses are then worn at night and straight last shoes during the day.

The parents will perform physiotherapy on the affected limb for two years post operatively. Advantages of the subtalar release are to produce a high degree of correction as well as alignment between the foot and leg. Disadvantages include post operative scarring which may be so extensive that subsequent soft tissue procedures are difficult. There is also a tendency to over correct with the subtalar release and rarely (less than 1/1,000) ischemic necrosis post operatively may develop due to the poor vascular perfusion of the affected limb. [22]

The posteriomedial release is an alternative soft tissue surgical procedure in which the tendo calcaneus is lengthened leaving its lateral attachment intact. Posterior excision of the ankle capsule and the talocalcaneal capsule, including cutting the calcaneofibular ligament, and the tibialis posterior tendon is divided. If necessary the flexor hallucis longus tendon is lengthened and the plantar fascia released including any small muscles arising from the calcaneum. The posterior component of the medial ligament of the ankle is brought forward. Post operatively the limb is cast with the knee in flexion and the foot in dorsiflexion for five days. The limb is then strapped for seven to ten days until 20°of dorsiflexion is attained. At this point splints are applied and worn continuously until the child is walking. Splints are then reduced to sleep times. [20] This procedure aims to prevent the pes cavus and metatarsus adductus deformities which occur as a result of over correction after a complete subtalar release. [23] The reported success rates of the posteriomedial release vary from 50% – 84%. [23,24,25] This can be compared to a reported poor result in 15% of cases treated with a complete subtalar release. [23] A 30 year follow up of 73 feet treated with extensive soft tissue release concluded that repeated surgery can result in a stiff, painful and arthritic foot causing significant impaired quality of life. [26]

Non Surgical Interventions for ITEV

The French Functional method is a non surgical method of correction commonly used today. [27] This method was developed in the 1970’s [28] and consists of daily gentle mobilization and stretching of contracted tissues in order to stimulate and strengthen weakened muscles. Taping and splinting are used to maintain the correction’. [29] The treatment aims to obtain full correction in five months. The parents are taught the technique to continue at home until the child is walking. A splint is then used until the child is two or three years old to prevent relapse.

The Ponseti method of correction is currently the most popular closed technique. [27,30] Gentle sequential manipulation of the foot is performed to achieve a plantigrade, functional foot. [29] (See images: Images and description courtesy of www.Global_HELP.org.) Photographs and images describe the foot before, during and after treatment. Before treatment, the navicular is displaced to the medial side of the head of the talus. Note how this relationship normalizes during cast treatment. Similarly, the cuboid becomes aligned with the calcaneus during the same cast treatment (Images and description courtesy of www.Global_HELP.org.) (Fig. 1) The deformities are dealt with in the following order, cavus, adductus, varus, equinus, and serial casting, with casts used to immobilise the knee at right angles while the leg is rotated to correct tibial torsion. [31] This process is repeated weekly for five or six weeks until the anterior calcaneus can be abducted from underneath the talus allowing the foot to be safely dorsiflexed without crushing the talus. At this point a Achilles tenotomy may be required to completely correct the equinus deformity producing an average improvement in the lateral tibiocalcaneal angle of 16.9°. [32] The foot is then cast again for three weeks by which time the defect in the tendon should be healed. [33] The child must then wear ‘boots and bar’ splints (Denis-Browne splints) day and night for 10 weeks and then during sleep until the child is four years old to prevent relapse. [33] The result is a foot which may appear overcorrected however as the child grows and walks this overcorrection relaxes into a normal foot.

Figure 1   The foot before, during and after treatment. Before treatment, the navicular is displaced to the medial side of the head of the talus. Note how this relationship normalizes during cast treatment. Similarly, the cuboid becomes aligned with the calcaneus during the same cast treatment. Images and description courtesy of www.Global_HELP.org .

Complications may result with the Ponseti method if the practitioner does not manipulate sequentially. [34] Such an error can usually be corrected with further serial casting if detected early enough. However, if the talus gets crushed or a rocker bottom deformity develops, [35] surgery will be required. Lack of compliance precedes the majority of relapses as the child may have trouble sleeping wearing the Denis-Brown splints therefore parental education is vital. [34] Other closed methods such as the ‘extra space cast correction technique’ have been documented [36] however the Ponseti method is emerging as the most popular manageable treatment routine which has an average 70% success rate [27,29] and produces positive long term results in foot function and aesthetics. [27,37,38] Abnormalities such as knee hyper-extension, equinus gait and foot drop are not reported with the Ponseti method but have been reported with other manipulation techniques.

Currently clinics providing the Ponseti treatment generally comprise of an orthopaedic surgeon, physiotherapists, nurses and an orthotist at the stage of splinting. However the Ponseti method has been extended to other healthcare professionals which has already been trialled successfully in the UK within two separate secondary care settings. [39,40] Kampa, et al., [40] used a multidisciplinary team comprising of junior doctors, physiotherapists, nurses and plaster technicians or orthotists. They concluded that the combined approach of a multidisciplinary team and a surgeon when necessary was a success. Docker, et al., [39] used a team of trained physiotherapists who referred only to the orthopaedic surgeons in the case of complications or the need for a tenotomy. Tenotomies in this study were carried out under general anaesthetic although a local anaesthetic is recommended. [41] A significant difference in the number of tenotomies required between the two groups was reported in favour of the physiotherapy department. The authors hypothesised that this may be due to the treatment initiating at an earlier stage.

The Ponseti method would be equally relevant and applicable to podiatry practice as Podiatrists already treat patients with surgically corrected ITEV as part of routine clinical practice, already work in multidisciplinary teams, have extensive specialist knowledge in anatomy and biomechanics of the lower limb and foot, and care on a regular basis for patients with a broad range of physically disabling conditions. The adaptation and the inclusion of current podiatry skills in biomechanical diagnosis, foot casting and orthoses manufacture into the multidisciplinary approach to the Ponseti method, is highly likely to augment delivery of the treatment technique and improve the availability of Ponseti clinics. Having multidisciplinary clinics available at a local level has the potential to reduce the weekly journey time for parents and children making the experience less stressful. As parent education is key to the treatment’s success, having podiatrists available close to home for mid week visits to respond to problems when they arise is likely to reduce the long waiting times in out patients departments which is already a problem cited by both Docker, et al., [39] and Kampa, et al., [40] Docker, et al., also suggested that the earlier intervention of the multidisciplinary team reduced the number of tenotomies required, again cutting the overall healthcare costs.

Halananski, et al., [42] compared the resource utilization between the Ponseti method and the standard surgical routes and found a significant difference in the use of resources between the two methods. He did however highlight difficulties in the study as non monetary resources were difficult to quantify. A similar in depth study would be proposed to compare the costs of a surgically led Ponseti clinic with a multidisciplinary Ponseti clinic which ideally should also included a podiatrists as a member of the team.

Conclusion

It is proposed that the inclusion of podiatry skills to the Ponseti method for the treatment of ITEV, would enhance the continuity of care for the patients in the long term in the assessment and monitoring of post operative care and in identifying further intervention if and when necessary.

Using podiatrists to practice the Ponseti method in a multidisciplinary setting has the potential to develop a more foot focused, cost effective, and patient centred practice and it is proposed that future research into the efficacy and the cost efficiency of the Ponseti method will include the professional and clinical skills of the podiatrist.

The authors invite other clinicians to write in expressing their views on podiatry and the Ponseti method and discuss research results pertaining to this literature review.

References

1. Pryor GA, Villar RN, Ronen A, Scott PM. Seasonal variation in the incidence of congenital talipes equinovarus. JBJS 1991 73B (4): 632-634.
2. Wynne-Davies R. 1964. Talipes equinovarus: a review of eighty-four cases after completion of treatment. JBJS 1964 46B (3): 464-476.
3. Ippolito E, De Maio F, Mancini F, Bellini D, Orefice A. Leg muscle atrophy in idiopathic congenital clubfoot: is it primitive or acquired? J Childrens Orthopaedics 2009 3: 171-178.
4. Falks S, Luther B. Changing paradigm for the treatment of clubfoot. Orthopaedic Nursing 2005 24(1): 25-30.
5. Vitale M. Clubfoot. EP Magazine 2007 March: 48-50.
6. Bakalis S, Sairam S, Homfray T, Harrington K, Nicholaides K, Thilaganthan B. Outcome of antenatally diagnosed talipes equinovarus in an unselected obstetric population. Ultrasound Obstetric Gynaecology 2002 20: 226-229.
7. Wang J., Palmer R.M., Chung C.S. 1988. The role of major gene in clubfoot. Am J Human Genetics 1988 42 772-776.
8. Windisch G. Anderhuber F, Haldi-Brändle V, Exner GU. Anatomical study for an updated comprehension of clubfoot. Part I: Bones and joints. J Childrens Orthopaedics 2007 1: 69-77.
9. Windisch G. Anderhuber F, Haldi-Brändle V, Exner GU. Anatomical study for an updated comprehension of clubfoot. Part II: Ligaments, tendons and muscles. J Childrens Orthopaedics 2007 1: 79-85.
10. Bensahel H, Jehanno P, Benaroya A. Adduction in clubfoot. In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, 2008; August 27-28, Hong Kong. J Childrens Orthopaedics 2009 3: 67-83.
11. Howlett JO, Vincent SM, Bjornson K. The association between idiopathic clubfoot and increased internal hip rotation. Clin Orthopaedic Rel Res 2009 467: 1231-1237.
12. Dobbs MB, Gordon JE, Schoenocker PL. Absent posterior tibial artery associated with idiopathic clubfoot. JBJS 2004 86A: 599-602.
13. Hootnick DR, Dobbs MB, Crider RJ. Are talipes equinovarus and congenital fibular dysplasia different manifestations of aberrant vasculogenesis? In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, August 27-28, 2008, Hong Kong. J Childrens Orthopaedics 2009 3:67-83.
14. Greider T D, Siff SJ, Gerson P, Donovan MM. Arteriography in club foot. JBJS 1982; 64: 837-840.
15. Klychkova IJ. Clinical and physiological examination of congenital clubfoot (principles and results). In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, August 27-28, 2008, Hong Kong. J Childrens Orthopaedics 2009 3:67-83.
16. Crider RJ, Hootnick DR, Dobbs MM, Seimon L. Do talipes equinovarus (TEV) and congenital vertical talus (CVT) have a common aetiology? In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, August 27-28, 2008, Hong Kong. J Childrens Orthopaedics 2009 3:67-83.
17. Rebbeck TR, Dietz FR, Murray JC. A single-gene explaination for the probability of having idiopathic talipes equinovarus. Am J Human Genetics 1993 52:1051-1063.
18. Stabile RJ, Giorgini RJ. A review of talipes equino varus. Podiatry Management 2009 Feb: 167-174.
19. Kruse LM, Bobs MB, Gurnett CA. Polygenic threshold model with sex dimorphism in clubfoot inheritance: the Carter effect. JBJS 2008; 90A: 2688-2694.
20. Green ADL, and Lloyd-Roberts GC. The results of early posterior release in resistant club feet. JBJS 1985 6B: 588-593.
21. Simons GW. Complete subtalar release in club feet. Part 1 – A preliminary report. JBJS 1985 67A: 1004-1055.
22. Hootnick DR, Dobbs MB, Crider RJ. Review of ischemic necrosis following clubfoot surgery with case of retained primitive arterial rete. In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, August 27-28, 2008, Hong Kong. J Childrens Orthopaedics 2009 3: 67-83.
23. Deniz G, Bombaci H, Tuygun H, Görgeç M, Köse O, Yanik HS. Long-term results of extensive surgical dissection in the treatment of congenital clubfoot. Acta Orthopaedica Traumatologica Turcica 2008 42(1):44-52.
24. Prichasuk S, Mulpruok P. Problems in surgical treatment of congenital clubfoot. J Medical Association Thailand 1992 75(1):106-111.
25. Macnicol MF, Nadeem RD, Forness M. Functional results of surgical treatment in congenital talipes equinovarus (clubfoot): a comparison of outcome measurements. J Paediatric Orthopaedics 2000 9(4): 285-292.
26. Dobbs MB, Nunley R, Shoenecker PL. Long-term follow up of patients with clubfeet treated with extensive soft-tissue release. JBJS 2006 88A:986-996.
27. Richards BS, Faulks S, Rathjen KE, Karol LA, Johnston CE, Jones SA. A Comparison of two nonoperative methods of idiopathic clubfoot correction: The Ponseti method and the French Functional (physiotherapy) method. JBJS 2008 90A: 2313-2321.
28. Bensahel H, Bienayme B, Jehanno P. History of the functional method for conservative treatment of clubfoot. J Childrens Orthopaedics 2007 1: 175-176.
29. Faulkes S, Richards S. Clubfoot treatment: Ponseti and French functional methods are equally effective. Clin Orthopaedic Rel Res 2009 467: 1278-1282.
30. Changulani M, Garg NK, Rajagopal TS, Bass A, Nayagam SN, Sampath J, Bruce CE. Treatment of idiopathic clubfoot using the Ponseti method. JBJS 2006; 88B: 1385-1387.
31. Ponseti IV, Smoley EN. Congenital club foot: the results of treatment. JBJS 1964 45: 261-344.
32. Radler C, Manner HM, Suda R, Burgardt R, Herzenberg JE, Ganger R, Grill F. Radiographic evaluation of idiopathic clubfeet undergoing Ponseti treatment. JBJS 2007 89A: 1177-1183.
33. Ponseti I, Morcuende J, Mosca V, Pirani S, Dietz F, Herzenberg J, Weinstein S, Penny N, Steenbeek M. In: Staheli. L. ed. Clubfoot: Ponseti Management. 2nd ed. [electronic book] Global-HELP publications. Available from: http://www.globalHELP.org [Accessed September 26 2008].
34. Goksan SB. Treatment of congenital clubfoot with the Ponseti method. Acta Orthopaedica Traumatologica Turcica, 2002 36: 281-287.
35. Wicart P, Koureas, G Seringe R. Rocker bottom deformity: a complication of idiopathic congenital clubfoot conservative treatment. In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, August 27-28, 2008, Hong Kong. J Childrens Orthopaedics 2009 3: 67-83.
36. Baindurashvili AG, Rumyantsev NJ, Omarov GG. Extra space casting technique in clubfoot: 20 years of experience. In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, August 27-28, 2008, Hong Kong. J Childrens Orthopaedics 2009 3: 67-83.
37. Ippolito E, Farsetti P, Caterini R, Tudisco C. Long-term comparative results in patients with congenital clubfoot treated with two different protocols. JBJS 2003 85A: 1286-1294.
38. El-Hawary R, Karol LA, Jeans KA, Richards BS. Gait analysis of children treated for clubfoot with physical therapy or the Ponseti cast technique. JBJS 2008 90A: 1508-1516.
39. Docker CEJ, Lewthwaite S, Kiely NT. Ponseti treatment in the management of clubfoot deformity – a continuing role for paediatric orthopaedic services in secondary care centres. Annals of the Royal College of Surgeons of England 2007 89(5): 510-512.
40. Kampa R, Binks K, Dunkley M, Coates C. Multidisciplinary management of clubfeet using the Ponseti method in a district general hospital setting. J Childrens Orthopaedics 2008 2: 463-467.
41. Bor N, Katz Y, Vofsi O, Herzenberg JE, Zuckerberg AL. Sedation protocols for Ponseti clubfoot Achilles tenotomy. J Childrens Orthopaedics 2007 1: 333-335.
42. Halanski MA, Huang J, Walsh SJ, Crawford HA. Resource utilization in clubfoot management. Clin Orthopaedic Rel Res 2009 467: 1171-1179.

Address correspondence to: Janet McGroggen janetmcgroggan@hotmail.co.uk

1  Private Practice, Instep Podiatry Ltd, 26 Greenwood Street, Altrincham, Cheshire, WA14 1RZ.
2  Lecturer, School of Health Sciences, Subject area of Podiatry, Queen Margaret University, Edinburgh.

© The Foot and Ankle Online Journal, 2010

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Aberrant Tendo-Achilles Tendon in Club Foot: A case report

Posted on February 1, 2009 | Comments Off on Aberrant Tendo-Achilles Tendon in Club Foot: A case report

by J. Terrence Jose Jerome, MBBS, DNB (Ortho), MNAMS (Ortho)1, Mathew Varghese, M.S. (Ortho)2, Balu Sankaran, FRCS, FAMS3, Rajendra Kumar Gupta4, Simon Thomas, MBBS, DNB (Ortho), MNAMS (Ortho)5, Amit Mittal6

The Foot & Ankle Journal 2 (2): 2

This case report discusses the presentation and treatment of a baby boy with club foot deformity. He was initially treated by Ponseti’s method of weekly plaster of paris casting. The club foot did not reduce after 6 weeks of serial casting. The boy then underwent percutaneous Achilles tendon lengthening and placed in a Steinbek Splint. After 12 weeks, the equinus persisted and we decided to perform an open Achilles lengthening. An aberrant tendo-achilles tendon was discovered during open tenotomy and this was released. Once the aberrant tendon was released, the club foot reduced and at 9 months, the baby could walk with good heel strike and the foot was supple with no residual deformity.

Key words: Aberrant tendo-Achilles tendon, club foot, talipes equinus, Ponseti’s casting method

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: January, 2009
Published: February, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0202.0002

Congenital club foot is a complex deformity that is difficult to correct. It has a tendency to recur until the age of six or seven years. While there may be a so-called recurrence in an adolescent, this is usually associated with incomplete initial correction rather than being secondary to growth alone. We present a case report of a 15 day-old boy with aberrant tendo-Achilles tendon of the right side which caused an incomplete correction of club foot.

Case Report

A 15 day- old baby was referred by a pediatrician for the management of right clubfoot. The baby was a full-term, normal delivery in a governmental hospital. On examination the baby was found to have a 3-dimensional deformity (CAVE) with four components in the right foot (Figs. 1)

 

Figures  1   A 15 day- old baby presents with right club foot deformity.  The deformity is 3-dimensional with 4 components including cavus, forefoot adduction, heel varus and equinus (CAVE).

• C-Cavus-increased longitudinal arch of foot.
• A-Adduction-tarsal bones are directed towards the median plane
• V-Varus-inversion and adduction of calcaneum
• E-Equinus-increased plantar flexion of foot

The spine and pelvis were clinically normal. The baby was treated by Ponseti’s method of weekly POP (plaster of paris) cast. Simultaneous correction of the three components of deformity (Cavus, Forefoot, Adduction and heel varus) was achieved in 6 weeks. (Fig. 2)

Figure 2   The baby is treated with serial casting  by Ponseti’s method of weekly plaster of paris cast.

The baby had persistent equinus (Fig. 3A) after 6 weeks of serial POP casting. The foot could be abducted and externally rotated to 60 degrees.A percutaneous tenotomy of the tendo-Achilles was done under local anesthesia. Postoperatively, toe to groin cast with knee in 90 degrees of flexion to maintain the corrected position and to allow tendon healing was applied for 3 weeks. Then the foot was maintained in 60-70 degrees of abduction, external rotation and 15-20 degrees of dorsiflexion by Steinbek Splint (open toe high top straight shoes attached to bar of length equal to shoulder width). This splint is usually worn 23 hours/day for the first 3 months and 14-16 hours/day up to 3-4 years of age.

Twelve weeks later, the parents were complaining that their baby touches the floor only with tip of the right toe. On examination, the heel cord was found tight. (Fig. 3B)

 

Figures 3A and 3B  The boy presents with persistent equines following 6 weeks of serial casting. (3A)  After 12 weeks, the heel cord was still found to be tight and open Achilles tendon lengthening was planned. (3B)

Equinus was found to be persistent. We decided to do an open tendo-Achilles lengthening. Intra-operatively, we found an aberrant tendo-Achilles tendon (Fig. 4) attaching just posterior to the tendo-Achilles tendon and the calcaneal tuberosity. This was released from the calcaneum and the foot could be dorsiflexed to 20 degrees on the operating table. The baby was given an above- knee POP cast for 3 weeks and followed with Steinbek Splint in 70 degrees of abduction, external rotation on affected side and 45 degrees on normal side with 15 degrees of dorsiflexion.

Figure 4  An aberrent tendo-Achilles tendon was discovered during open tenotomy.  The aberrent tendon was located just posterior to the Achilles tendon and calcaneal tuberosity.

At 9 months, the baby could walk with a good heel strike and the foot was supple with no residual deformity. (Fig. 5) At 18 months follow up the baby was found to have a pain-free, plantigrade foot, with good mobility. (Fig. 6) The parents were advised to continuously use the brace for the baby, 14 to 16 hours a day until 3 to 4 years of age.

Figure 5  At 9 months, the boy could walk with good heel strike and the foot was supple with no deformity.

Figure 6  At 18 months follow-up, the baby was found to have a pain-free, plantigrade foot, with good mobility.

Discussion

Club foot deformity has four components [3-5,6,14,15]: equinus, varus, adductus, and cavus. The goal of treatment is to reduce or eliminate these four deformities so that the patient has a functional, pain-free, plantigrade foot, with good mobility and without calluses, and does not need to wear modified shoes. The most severe deformities in a club foot occur in the hind part of the foot. The talus and calcaneus are generally deformed and in severe equinus, the calcaneus is in varus angulation and medially rotated, and the navicular is severely displaced medially. [2,11,12,17,18,20,21] These components of the deformity are inextricably inter-related. The ligaments of the posterior aspect of the ankle and of the medial and plantar aspects of the foot are shortened and thickened. The muscles and tendons of the gastrocnemius tibialis posterior, and toe flexors are shortened. [4,14,15,20]

Most orthopedists have agreed that the initial treatment of a club foot should be non-operative. [4,5,8,11,12,14,15] The preferred method is manipulation and application of a plaster cast at weekly intervals. Less favored methods of initial treatment are use of a Denis Browne splint, stretching and adhesive strapping, and physiotherapy. Manipulation and serial application of casts, supported by limited operative intervention, yielded satisfactory functional results in 89 percent of the feet. [8,14,15] However, at other institutions, manipulative treatment has resulted in increased cavus deformity, rocker-bottom deformity, a longitudinal breach, flattening of the proximal surface of the talus, lateral rotation of the ankle, and increased stiffness of the ligaments and joints. [1,2,3,4] To avoid these distressing outcomes, early and even primary operative treatment of club foot is practiced in some centers [5,7,9,10,12,15,19,23], often with equally disturbing failures and complications, such as wound infection, necrosis of the skin, severe scarring, stiff joints, overcorrection and under correction, dislocation of the navicular, flattening and beaking of the talar head, talar necrosis, and weakness of the plantar flexors of the ankle with major disturbances of gait.

The reported results of operations in newborns have been either short term and not encouraging. Early operative treatment often results in reduced motion of the ankle and foot, whereas manipulation and the application of plaster casts with proper technique lead to greater mobility and less disability. [7,9,10,13,15]

Most orthopedists have agreed that an operation [3,4,5,11,12,15,21] should be considered only after manipulation and serial application of casts have failed to obtain correction in a specified period of time, preferably not more than three months. The poor results of manipulative treatment of most club feet in many clinics suggest that the attempts at correction have been inadequate or that the technique has been faulty. [8,14,15] Books and papers on pediatric orthopedics have devoted scant space to manipulative technique in the treatment of this deformity, and often the descriptions have been incorrect. The correction of the cavus component of the deformity is usually not addressed. [14,15] The equinus is corrected by dorsiflexion of the foot with the heel in valgus after the adduction of the foot and the varus deformity of the heel has been corrected. The correction entails stretching of the tight posterior capsules and ligaments of the ankle and subtalar joints and the tendo-Achilles. [4,5,8,12,14,15] Two or three plaster casts that carefully mold the heel, applied after manipulation, are usually needed to correct the equinus deformity. Care should be taken not to cause a rocker-bottom deformity, which can occur when dorsiflexion of the foot is attempted with pressure under the metatarsals rather than under the mid-part of the foot, particularly when the varus deformity of the heel has not been corrected. [1,8]

A simple subcutaneous tenotomy of the tendo-Achilles, performed with the patient under local anesthesia, facilitates correction of the equines. [8,14,15] This tenotomy is done in about 70 percent of patients, when 15 degrees of dorsiflexion has not been obtained with the use of the casts. Dorsiflexion of the ankle to more than 10 to 15 degrees is rarely possible because of the talar and calcaneal malformations and tight ligaments. A posterior capsulotomy of the ankle and subtalar joint is rarely done, because the few additional degrees of correction that are obtained may be completely lost later due to retraction of the scar tissue. [4,5,13,14,15]

Regardless of treatment, a club-foot deformity tends to relapse until the child is about seven years old. [3,4,5,8,12,14,15] To prevent relapse, some orthopedists hold the foot in maximum correction with a series of plaster casts or with splints. Denis Browne splints and high-top shoes with well-molded heels that hold the feet in lateral rotation are the most effective means for maintenance of the correction. The splints are worn full time for two to three months and thereafter at night for two to four years. The splint should maintain the foot in 60 to 70 degrees of external rotation, to prevent recurrence of varus deformity of the heel, adduction of the foot, and in-toeing. [8,14,15] With careful supervision and with cooperative and responsible parents who follow instructions faithfully; relapse can be prevented in about 50 percent of patients. In the other 50 percent, a relapse will occur between the ages of ten months and seven years (average age, two and one-half years). A relapse is detected when slight equinus and varus deformity of the heel is observed, usually without increased cavus and adduction deformity of the fore foot. [16,18,22,23]

The original correction may be recovered in four to eight weeks with manipulations followed by application of a toe-to-groin plaster cast, with the foot held in marked lateral rotation, every ten to fourteen days. This treatment is often followed by lengthening of the tendo-Achilles, if the tendon prevents dorsiflexion of the ankle to at least 15 degrees, and by use of the Denis Browne splint at night. [3,4,5,8,12,14,15] A large proportion of club feet that are treated with this procedure found the correction of the equinus, varus deformity of the heel, was obtained with manipulation and application of casts. If this can be maintained, the anteroposterior talocalcaneal angle will become normal. Cavus component of the club-foot deformity rarely recurs. [8,14,15] When this deformity is resistant to manipulation, it should be treated with plantar fasciotomy and recession of the extensor hallucis longus tendon to the neck of the first metatarsal. The adductus component of the club-foot deformity does not recur in patients who have received good treatment and follow-up care. When proper treatment with manipulation and casting has been started shortly after birth, operative release of the tarsal joints is seldom needed. [19]

An early operation (not later than the second month of life) is indicated only in the small percentage of patients who have short, rigid feet, with very severe equino varus deformity, that do not respond to proper manipulations. Many orthopedists also favor release of the tarsal joints in less rigid feet when manipulations have failed to completely correct the displacement of the navicular and the talocalcaneal alignment to a normal talocalcaneal index. Extensive posteromedial release, with or without internal fixation of the tarsal bones, is the preferred procedure, but there has been much disagreement about the timing of the operation. Recently, more radical [19,22,23] techniques have been tried in younger patients. The objective of all of these operations is release of the tight capsules and ligaments of the ankle and tarsal joints, and lengthening of the shortened tendons of the foot to facilitate placement of the tarsal bones in normal alignment.

The baby in this case report had a persistent eqinus deformity even after percutaneous tenotomy. Intra-operatively an aberrant tendo-Achilles was noted and was released from its calcaneal attachment. This could be the reason for the resistant equinus deformity. The literature rarely describes the aberrant tendo-Achilles tendon and the management.

Conclusion

The initial treatment of club foot should be non-operative. Corrective manipulation and serial application of casts, followed by calcaneal tenotomy and release of an aberrant tendo-Achilles tendon if found, should be successful in at least 85 percent of patients who are initially treated a few days after birth. High index of suspicion for an aberrant tendon should be there, if there is a resistant equinus deformity alone, especially after manipulation, POP cast correction and percutaneous tendo-Achilles tenotomy.

The orthopedist and podiatrist must have a thorough understanding of the deformity and be highly skilled with regard to manipulation and the application of plaster casts. Most relapses can be treated successfully with additional manipulations and applications of casts for four to eight weeks. Operative correction of a club foot is indicated when the deformity has not been treated successfully with proper manipulation and serial application of casts, supported by limited operative intervention. Most of these resistant club feet can be corrected with the use of an extensive posteromedial release and release of aberrant tendo-Achilles tendon with satisfactory functional results.

References

1. Altar D, Lehman WB, Grant AD.: Complications in clubfoot surgery. Orthop Rev 20: 233 – 239, 1991.
2. Beatson TR, Pearson JR. A method of assessing correction in club feet. J Bone Joint Surg 44B( 1): 40 – 50, 1966.
3. Brockman EP. Congenital Club-Foot (Talipes Equinovarus). Bristol, John Wright. 1930.
4. Carroll NC. Congenital clubfoot: patho anatomy and treatment. In Instructional Course Lectures, in American Academy of Orthopedic Surgeons. Vol. 36. pp. 117 – 121. Park Ridge, Illinois. The American Academy of Orthopaedic Surgeons, 1987.
5. Cummings RJ, Lovell WW. Current concepts review. Operative treatment of congenital idiopathic club foot. J Bone Joint Surg 70A: 1108 – I112, 1988.
6. Evans D. Relapsed club foot. J Bone Joint Surg 43B(4): 722 – 733, 1961.
7. Green ADL, Lloyd-Roberts C. The results of early posterior release in resistant club feet. A long-term review. J Bone Joint Surg 67B (4): 588 – 593, 1985.
8. Laaveg SJ, Ponseti IV.: Long-term results of treatment of congenital club foot. J Bone Joint Surg 62A: 23-31, 1980.
9. Lau JHK, Meyer LC, Lau HC. Results of surgical treatment of talipes equinovarus congenita. Clin Orthop. 248:219 – 226. 1989.
10. Levin MN, Kuo KN, Harris CF, Matesi DV. Posteromedial release for idiopathic talipes equinovarus. A long-term follow-up study. Int Orthop 242: 265 – 268, 1989.
11. Lovell WW. Bailey T, Price CT, Purvis JM. The non-operative management of the congenital clubfoot. Orthop. Rev 8: 1l3 – 115, 1979.
12. McKay DW. New concept of and approach to clubfoot treatment: section I principles and morbid anatomy. J. Pediat Orthop. 2: 347 – 356, 1982.
13. Main BJ, Cnder RJ. An analysis of residual deformity in club feet submitted to early operation. J Bone Joint Surg 60B (4): 536 – 543, 1978.
14. Ponseti IV, Campos J. Observations on pathogenesis and treatment of congenital clubfoot. Clin Orthop. 84: 50 -60, 1972.
15. Ponseti IV, Smoley EN. Congenital club foot: the results of treatment. J Bone Joint Surg 45A (344): 261 – 275, 1963.
16. Porter RW. Congenital talipes equinovarus: Resolving and resistant deformities. J Bone Joint Surg 69B (S): 822- 825, 1987.
17. Porter RW, Roy A, Rippstein J. Assessment in congenital talipes equinovarus. Foot and Ankle Int 1: 16 – 21, 1990.
18. Scott WA, Hosking SW, Catterall A. Club foot. Observations on the surgical anatomy of dorsiflexion. J Bone Joint Surg 66B (1): 71-76. 1984.
19. Simons CW. Complete subtalar release in clubfeet. Part I- a preliminary report. J Bone Joint Surg 67A: 1144 – 1055, 1985.
20. Swann M, Lloyd-Roberts G, Catterall A. The anatomy of uncorrected club feet. A study of rotation deformity. J Bone Joint Surg 51B (2): 263 – 269, 1969.
21. Tachdjian MO. The Child’s Foot. Philadelphia, W. B. Saunders, 1985.
22. Thompson GH., Richardson AB, Westin GW. Surgical management of resistant congenital talipes equinovarus deformities. J Bone Joint Surg 64A 652 – 665, 1982.
23. Turco VJ. Resistant congenital club foot – one-stage postero medial release with internal fixation. A follow-up report of a fifteen-year experience. J Bone Joint Surg 61A: 805 – 814, 1979.

Address correspondence to: Dr. J. Terrence Jose Jerome, MBBS.,DNB (Ortho), MNAMS (Ortho)
Registrar in Orthopedics, Dept. of Orthopedics
St. Stephen’s Hospital, Tiz Hazari, Delhi 54, India

1  Registrar in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.
2  Head Professor, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.
3  Professor Emeritus, Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India. E-mail: pasle@bol.net.in
4  Consultant in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India. Phone: 991-23966021-27.
5-6  Registrar in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India. Phone: 991-23966021-27.

© The Foot & Ankle Journal, 2009

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Transected Talus Inflicted during a Soft Tissue Release for Congenital Talipes Equino Varus: A 17 year follow up

Posted on October 1, 2008 | Comments Off on Transected Talus Inflicted during a Soft Tissue Release for Congenital Talipes Equino Varus: A 17 year follow up

by Manzoor Ahmed Halwai, MS1, Shabir Ahmed Dhar, MS2 , Murtaza Fazal Ali, MS3, Mohammed Farooq Butt, MS4, Mohammed Ramzan Mir, MS5, Altaf Ahmed Kawoosa, MS6

The Foot & Ankle Journal 1 (10): 3

A case of transected talus that occurred during surgical Talipes Equino Varus (club foot) correction in childhood is presented. Seventeen years later, the patient is asymptomatic and free of pain. One of the complications that can occur during clubfoot soft tissue release is sectioning of the talar head. This case demonstrates that favorable long term results are possible with this type of complication.

Key words: Congenital Talipes Equino Varus deformity, CTEV, club foot, transected talus

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: September, 2008
Published: October, 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0110.0003

The posteriomedial release for correction of congenital talipes equinovarus (CTEV) or club foot defromity was proposed in 1906 by Codvilla and reiterated in the more recent literature by Turco. [1,2] The foundation of successful surgery focuses on a complete reduction with extensive release of the posterior, medial, subtalar and plantar soft tissue contractures and K wire fixation.

Several complications have been reported in the surgical management of club foot. These include wound healing and scarring, residual equinus, cavus, calcaneal gait, persistent forefoot adduction and hind foot valgus. [3]

This case report presents a 17 year follow-up where during the posteromedial release, the talus was transected.

Case Report

A 17 year old male reported to the outpatient department of our hospital for the management of a callosity of the right foot. The patient’s medical history revealed that he had been operated for CTEV of the left foot at an age of 4 months.

Clinical examination of the operated foot revealed a plantigrade foot with mild heel varus. (Fig. 1) The arch of the foot was well maintained. (Fig. 2) The patient was pain free and reported no abnormal shoe wear.

Figure 1  After 17 years, the foot remains in a slight heel varus with excellent correction.

Figure 2  After 17 years, the foot maintains a well constructed arch with only minimal scarring of the foot following CTEV release. 

The patient was not able to produce the operative records from the hospital where he had the surgery, but his father was able to recall that a pin had been placed in the foot. He also stated that he had been informed that his child would require a slightly different post operative regimen due to an operative complication.

The range of motion at the ankle was 10 degrees of dorsiflexion and 25 degrees of plantarflexion. There was no scarring and the talocalcaneal index was more than 20 degrees. The patient was classified into the good category as per the criteria of Brougham, et al. [4]

The patient consented to the radiographic examination of the left foot, which showed that the talus had a clear area of radiolucency along the transected part. (Fig. 3) The overall contour of the bone was maintained. The radiograph in the anterior posterior plane showed a wedge shaped navicular. (Fig. 4)

Figure 3  There is a wedge-shaped navicular without loss of significant range of motion to the joint.

Figure 4  Lateral radiograph shows unusual contour to the talus and navicular bones.  However, the overall contour of the joint is maintained. 

Discussion

Among the most characteristic osseous disturbances seen after the treatment of the CTEV are those involving the tarsal navicular. According to Napontiek, decreased size of the ossification centre, flattening, fragmentation, cyst like changes and wedging of this bone are seen. [5]

The talus is particularly vulnerable in terms of avascular necrosis with an incidence of 14.3%. In a series of 104 clubfeet, Laaveg. et al., reported that wedge-shaped navicular bones caused abnormal loading. [7] Talonavicular subluxation and avascular necrosis of the calcaneus have been reported by Magone, et al. [6]

Other complications include the transection of the sustentaculam tali, sectioning of the head of the talus , aseptic necrosis of the talus and navicular. [9] Occasionally the biomechanics of cast treatment lead the surgeon to suspect that the head of the talus has been amputated, as flattening is seen on radiograph. This is often caused by aggressive soft tissue release of the talonavicular joint and not recognizing that the talar head often lies deep within the joint. If the surgeon is overly aggressive with the soft tissue release the talar head can be sectioned or injured.

Even though this surgical error is considered as severe, which often require k –wires to stabilize the talar head, this case report demonstrates that a good functional result is still possible. This patient had no functional limitation or pain seventeen years after surgery.

References

1. Turco VJ. Surgical correction of the resistant club foot. One stage posteromedial release with internal fixation: A preliminary report. JBJS [Am] 53: 477- 497, 1971.
2. Turco VJ. Resistant congenital clubfoot-one stage posteriomedial release with internal fixation. A follow-up report of a fifteen year experience. JBJS 61A (6):805-14, 1979.
3. Rumyantsev NJ, Ezrohi VE. Complete subtalar release in resistant club foot. A critical analysis of results in 146 cases . J Pediatric Orthop 17 (4): 490-495. 1997.
4. Brougham DI, Nicol RO. Use of the Cincinnati incision in congenital talipes equinovarus. J of Pediatric Orthop 8 (6): 696-698, 1988.
5. Naoiontck M . Clinical and radiographic appearance of congential talipes equino varus after successful nonoperative treatment. J Pediatric Orthop 16 (1): 67-72. 1996.
6. Cummings RJ. Bashore CJ, Bookout CB et al: Avascular necrosis of the talus after McKay clubfoot release for idiopathic congenital clubfoot. J Pediatric Orthop 21 (2): 221 – 224, 2001.
7. Laaveg SJ, Ponseti IV.Long term results of treatment of congenital club foot. JBJS. 62A (1): 23-31, 1980.
8. Magone JB ,Torch MA , Clark RN et al. Comparative review of surgical treatment of the idiopathic clubfoot by three different procedures at the Columbus Children’s hospital. J Pediatric Orthop 9 (1): 49-58. 1989.
9. Tachdjian MO. In Pediatric Orthopaedics. Second Edition . p 2539-2540. WB Saunders Company, Philadelphia, 1990.

Address correspondence to: Shabir Ahmed Dhar, MS
Government Hospital for Bone and Joint surgery ,Bagat Barzulla, Srinagar Kashmir, 190005.
Email: shabirdhar@yahoo.co.in

1-6All these authors can be reached at the Government Hospital for Bone and Joint surgery ,Bagat Barzulla, Srinagar Kashmir, 190005.

© The Foot & Ankle Journal, 2008

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