- Operative Considerations:
- surgical indications:
- when deformity has not been treated successfully w/ proper manipulation & serial application of casts, supported by limited
operative intervention;
- operative timing:
- surgical goals:
- goal for surgical procedures is concentric reduction of the talonavicular and calcaneocuboid joints;
- deformities of the bones and joints are rarely, if ever, corrected completely;
- some persistent medial displacement of navicular bone & talocalcaneal index that is outside of the normal range are compatible
with a fully functional, normal-looking, pain-free, plantigrade foot;
- soft tissue releases:
- achilles tendon: z lengthening
- calcaneal fibular ligament: release
- post talofibular ligament: release
- tibialis posterior tendon: z-lengthening
- ankle and subtalar capsule:
- posterior capsulotomy of ankle & subtalar joint is avoided in some cases, because the small gain in correction may be later
offset by the retraction of the scar tissue;
- superficial deltoid: release
- talonavicular and tibionavicular: release
- plantar fascia release
- failure to release the plantar fascia may lead to persistant cavus deformity;
- Treatment Options:
- circumferential release: "cincinati incision"
- Goldner four quadrant approach:
- medial release
- posterior release
- posteromedial release
- tendon transfers
- posteroplantar release:
- 133 resistant congenital clubfeet in 93 patients between 3 and 10 months of age were operated on using a standardized
posteroplantar release;
- mean followup of 7 years 4 months (range, 3-12 years);
- 79.7% of the surgically treated clubfeet were classified as having a good or excellent result;
- 3 patients had relapse of their clubfoot that required additional surgery;
- 17 feet in 15 patients had residual forefoot adduction at the time of followup;
- radiographs showed that the early posteroplantar release led to sufficient hindfoot correction in all but the three patients who had
relapse of the clubfoot;
- in patients with persistent talonavicular subluxation after conservative treatment, an additional talonavicular release combined with
the posteroplantar release is recommended.
- Posteroplantar Release for Congenital Clubfoot in Children Younger Than 1 Year
- salvage procedures:
- procedures that involve bone are usually done in older children (may be regarded as salvage procedure);
- combined soft-tissue and bone procedures;
- arthrodesis / osteotomy: (triple arthrodesis)
- in older pts (3-10 yo), medial opening or lateral column shortening osteotomies or cubital decancelization is recommended;
- for children who present w/ refactory clubfoot late (8-10 yo), triple arthrodesis is only procedure possible to eliminate
associated pain;
- note that triple arthrodesis is contraindicated in patients with insensate feet (such as the myelomeningocele club foot) because it
causes a rigid foot that may lead to ulceration;
- talectomy may be a better procedure in these patients;
- Post Op Care:
- long plaster cast is used for the first six weeks and a short cast, for the second six weeks;
- transfixion pins are removed 6 weeks after first surgical procedure;
- following surgery: the foot and ankle are immobilized in a well padded cast above the knee cast;
- casts are changed 1 week and 2 weeks after surgery to allow inspection of the wound and verification of the correction;
- in especially stiff club foot deformities, AFO may be considered after the casts come off (after post op week 12)
- all pts must be followed throughout their growth period to assess and ensure that the correction is maintained
Correction of equinus in clubfoot: the contribution of arthrography.
Dynamic Foot-Pressure Measurement in the Assessment of Operatively Treated Clubfeet