Clubfoot: Posteromedial Release - Greenville Method
assistance provided by: B.L. Allen M.D.
R. Feurgeson M.D.
J.R. Davids M.D.
- Medial Release
- Posterior Release
- one-stage soft-tissue posteromedial release;
- as a prerequisite, the forefoot adductus deformity should be passively correctable to neutral, in order to avoid wound healing problems
following the release;
- posterior, medial, and subtalar soft-tissue contractures are released to permit the realignment of the abnormal anatomy of the bones, and corrected alignment
is secured with a single Kirschner wire, which transfixes the talonavicular joint;
- aim of the procedure is to excise or release all of the pathologically contracted soft tissues that prevent correction of deformity;
- best age for this procedure is one to two years, and the upper age limit should be approximately six years;
- Sequential Strategy for Release:
- supine position;
- posteromedial skin incision;
- initial identification, mobilization, and protection of the neurovascular bundle;
- release of plantar fascia inorder to adress forefoot equinus (first ray is now aligned with the talus);
- the abductor hallucis is released inorder to optimize exposure of the medial structures;
- distal tendon excision preferred;
- superficial deltoid ligament is released but deep deltoid ligament is preserved;
- identification and mobilization of the tibialis posterior, FDL, and FHL tendons w/ determination of excursions of each;
- Z lengthening of contracted tendons w/ some excursion;
- resection of tendons w/ no excursion
- excision of tendon sheaths from above the medial malleolus thru the Knot of Henry;
- excision of tissue filling the interval between the medial malleolus, tuberosity of the navicular, and sustentaculum tali;
- medial and dorsal release of the talonavicular joint capsule;
- the navicular is moved away from the medial malleolus and then realigned with the talus
- tendon-achilles z-lengthening and posterior ankle joint capsular release to fibula and posterior deltoid ligament release;
- Check Correction of Alignment at this Point:
- if judged normal, verify with x-rays;
- if normal alignment is unobtainable, release the plantar talonavicular capsule including spring ligament if centering of the navicular on the
talar head is the problem;
- release lateral talonavicular capsule if centering on first ray is a problem;
- persistent forefoot adduction may require release of the navicular-cuneiform-metatarsal articulation;
- release calcaneocuboid joint capsule completely if midfoot is adducted on the hindfoot (positive cuboid sign);
- subtalar joint is released in selected cases;
- if restoration of talo-calcaneal relationship is not possible, first release the capsule of the posterior articular facet and test correctability;
- if uncorrectable, release capsule of the anterior and medial facets and test correctability;
- if uncorrectable, release talo-calcaneal interosseous ligament as a last resort;
- residual heel varus will require additional subtalar release;
- lateral release:
- calcaneal-cuboid release allows alignment of cuboid with long axis of the calcaneus;
- recurrent deformity or partial recurrence;
- excessive heel valgus (which may follow complete subtalar release)
Resistant Congenital Club Foot. One-Stage Posteromedial Release with Internal Fixation. A Follow-up Report of a Fifteen-Year Experience.
Residual adduction of the forefoot. A review of the Turco procedure for congenital club foot.
Posteromedial release for idiopathic talipes equinovarus. A long-term follow-up study.
Complete subtalar release in club feet, Part II: Comparison with less extensive procedures.
Original Text by Clifford R. Wheeless, III, MD.
Last updated by Data Trace Staff on Tuesday, May 15, 2012 1:06 pm