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Clubfoot: Posteromedial Release – Greenville Method

                                                           assistance provided by:  B.L. Allen M.D.
                                                                         R. Feurgeson M.D.
                                                                          J.R. Davids M.D.
- See:  
      - Medial Release
      - Posterior Release

- Discussion:
    - 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;

- Complications:
    - 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.