The Hip: Preservation, Replacement and Revision

Myelomeningocele Club Foot

- See: Myelomeningocele:

- Discussion:
    - most common foot deformity in myelomeningocele;
    - teratological club-foot deformity in children w/ myelomeningocele is often more severe and more rigid than seen in 
           congenital club foot deformity;
    - secondary foot deformities may also develop as a result of muscle imbalance and/or spasticity;
    - goals of treatment:
           - these children will usually have insensate feet, and it is therefore important to keep the foot in a plantigrade position;
           - the initial emphasis should be placed on achieving a mobile plantigrade foot, but arthrodesis may be required in order to achieve a 
                   plantigrade surface & foot that can be braced;
           - most children w/ mylelomenigocele club foot will require lower-extremity bracing on a long-term basis;

- Non Operative Treatment:
    - serial plaster casts should be begun as early as possible;
           - slow but persistent correction should be gained over first year of life;
           - special care is be taken to avoid pressure sores under cast in insensitive feet;
    - recurrence of deformity is frequent because of muscle imbalance, & surgical release is often needed for lasting correction;

- Operative Treatment:
    - timing of surgery:
          - because of common neurological & urological problems & high risk of recurrence in these children, an operation is done later 
                  than it would be in a child who has idiopathic congenital club foot;
          - generally, operative intervention should be delayed until the child is 12 to 18 months old.
    - treatment options:
          - tenotomy and/or tendon transfers may be used prevent recurrence;
                  - complex tendon transfers should be avoided because of lack of selective muscle control & tendency to create new deformity.
                  - contracted tendons should be resected rather than lengthened;
                  - to correct an equinus deformity consider heel cord tenotomy rather than lengthening to prevent recurrence;
          - talectomy:
                  - severe equino-varus deformities related to arthrogryposis or myelomeningocele, can be managed w/ talectomy;
                  - in most cases, talectomy is indicated for management of severe equinovarus deformities which have been resistant to 
                         previous attempts at operative correction;
                  - in cases of bilateral rigid clubfoot, primary bilateral talectomy may be an option;
                         - desired outcome is bilateral plantigrade feet, which transmit wt bearing eveningly over the foot;
                         - in the study by Letts and Davidson (1999), 10 out of 14 feet had a good or satisfactory result from bilateral talectomy;
                         - essential technical details include need for complete talar removal and relocation of the talus;
                  - bracing is needed after correction to prevent recurrent equinus;

- Revision Surgery:
    - residual deformities after correction of club foot may require additional surgery;
    - talectomy:
          - in revision cases, but it can effective to return the foot to a neutral position;
          - in younger children, the Verebelyi-Ogston procedure (talar decancellation) may be preferred over talectomy;
          - w/ severe scarring, enucleation of navicular, talus, & cuboid as well as the talectomy may be required;
    - osteotomy:
          - closing-wedge osteotomy (Dwyer procedure): indicated for persistent varus angulation of hind part of foot;
          - sliding osteotomy of the calcaneus: indicated for valgus overcorrection of the hindfoot;
          - residual adduction of fore part of foot may necessitate metatarsal osteotomies or shortening of the lateral border of the foot;
    - arthrodesis:
          - arthrodesis of ankle & triple arthrodesis should be avoided

Talectomy for equinovarus deformity in myelodysplasia.

Equinovarus deformity in arthrogryposis and myelomeningocele: evaluation of primary talectomy.

The role of bilateral talectomy in the management of bilateral rigid clubfeet.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, May 15, 2012 11:17 am