Evaluation of the child with ligamentous laxity

Many opportunities for participation in the care of children with ligamentous laxity have been described in this article. The podiatric physician must determine his or her contribution based on knowledge, experience, and interest. Each podiatric physician is not necessarily expected to be familiar with all of the diseases and treatments described here. Novice podiatrists should be mandated to recognize only the presence of ligamentous laxity and be familiar with an appropriate referral pattern. In addition to the previously listed podiatric concerns, Hobson has described some specific concerns in even the most basic podiatric treatment. He recommends the use of skin adherents to avoid wrinkling and tearing the skin of individuals with Ehlers-Danlos syndrome. He also reiterates research that has determined a resistance to local anesthetics in these individuals. He further provides some detail for the manufacture of appropriate orthoses. Continuing education may be obtained through a variety of sources. These may include not only traditional podiatric courses and conferences, but also similar venues offered by clinicians in other specialties. Also, courses and conferences held by organizations with a special interest in these unusual disorders can be educational and rewarding. The author has found interactions with this patient population rewarding. The patients and their families are often exceptionally knowledgeable regarding their illness because most have experienced many years with unsatisfactory medical help and delayed or incorrect diagnoses. Most of these families are also extraordinarily grateful for the concern and interest expressed by the clinician. They are particularly impressed when the health care professional has at least a cursory knowledge of their unusual disorder. As a member of the Ehlers-Danlos National Foundation Medical Advisors Panel, the author has contact with world-renowned geneticists, rheumatologists, and other specialists. The leader of the organization has pointed out that patients have found that podiatric clinics provided during the national meetings are often one of the most appreciated aspects of those meetings. He stated that although podiatrists may not cure the disease, small improvements in the everyday lives of these patients add up to a significant contribution. The author hopes that this article will stimulate further interests in the care and understanding of individuals with ligamentous laxity. It is further hoped that experience with these individuals will translate to the broader population who experience milder disorders of hypermobility.

Congenital talipes equinovarus in spina bifida: treatment and results

The results of the surgical treatment of clubfoot deformity in spina bifida by radical posteromedial-lateral release (PMLR) are presented. In all cases, the Cincinnati incision was used and the tendons excised, including the anterior tibial tendon. In 21 feet, a special K-wire was used to derotate the talus in the ankle mortise. The minimum follow-up was 2 years. The average age at surgery was 14 months. The overall results showed 63% good, 14% fair, and 23% poor results. In the 21 feet in which the talus K-wire was used, 76% had a good result, 14% fair, and 10% poor. The results were also analyzed based on the motor level. In the thoracic/high lumbar level, 50% had a poor result. In the low lumbar and sacral level groups together, of 45 feet, five had a poor result. This study shows that a radical PMLR can produce an overall good and fair result in 77% of the cases. The use of the K-wire to derotate the talus led to an improvement in the result. The tendon excision leading to a flail foot corrects any residual muscle imbalance. The poor results seen in the thoracic/high lumbar patients are likely to be related to the lack of weight bearing in view of their motor paralysis.

Statistical evidence for shared transient causes of anatomically distinct birth defects

Certain pairs of anatomically distinct birth defects co-occur in the same baby more often than predicted under independence. Such an excess might reflects either the fact that some subpopulations of parents have inherently increased risk for both, or that certain pregnancies are at increased risk for both, even within the same couple, perhaps, due to transient exposures specific to the pregnancy. We focus on the latter possibility in the context of a large birth registry and two relatively common types of defects, by testing the null hypothesis that within sibships the two defects occur independently. Focusing on sibships where both defects occurred, we propose a test based on the total number of 'co-incidences', sibships where both occurred in the same baby. Such a test can be carried out either with or without allowance for possible dependence of risk on birth order. Applying this to club foot and sex organ defects among sibships from the Medical Birth Registry of Norway, we find strong evidence for excess within-family co-incidence, suggesting that there are shared, time-varying (hence perhaps modifiable) causal components in their aetiology.

Surgical correction of talipes equinovarus following foot and leg compartment syndrome

Between 1984 and 1994, 40 patients with a posttraumatic compartment syndrome of the lower leg and foot were treated for talipes equinovarus adductus foot deformity, which subsequently developed. Twenty patients had a wedge osteotomy followed by arthrodesis of the midtarsal joint (Chopart joint). Another 17 patients had an arthrodesis of the midtarasal and subtalar joints. In the remaining three patients, in addition to arthrodesis, lengthening of the tendons of the long flexors and the Achilles tendon was performed. Complications included wound infections (six cases), drill hole infections (three cases), chronic osteomyelitis (one case), and an ankle joint infection (one case). The clinical result was assessed as good in 37.5%, fair in 52.5%, and poor in 10% of the patients. Before the operation, 37 patients required modified footwear. After the operation, only eight patients needed them. Wedge osteotomy of the midtarsal and subtalar joints followed by an arthrodesis is an advantageous treatment modality for the correction of severe postischemic equinovarus adductus foot deformities. In our study, patient satisfaction was high. While complications frequently occur, it is not extraordinary considering the salvage nature of the procedure.

Clubfeet in congenital annular constricting bands

Thirty-five children who had congenital annular constricting bands (Streeter's dysplasia) with associated clubfeet seen by the author from September 1989 to March 1992 were reviewed with respect to quality of the clubfeet,the relationship of the bands with the clubfeet, possible prenatal factors, and treatment results. It was noted that all the clubfeet were rigid even if there were no constricting bands in the leg with the clubfoot. The clubfeet responded poorly to casting (6% success) and 77% required surgical correction. Z-plasties of deep bands were done before clubfoot correction. There was a high incidence of abnormal pregnancies with attempts at abortion in 66% of the cases, suggesting intrauterine insult early in the pregnancy as a factor causing both the clubfeet and the Streeter's dysplasia.

Correction of foot deformity by the Ilizarov method in a patient with Segawa disease

Hereditary progressive dystonia, or Segawa disease, is rare. Diagnosis depends on typical clinical features with normal laboratory findings. It responds well to levodopa treatment. This article contains a case report of a patient with Segawa disease with a fixed equinovarus foot. A 21-year-old woman was diagnosed with Segawa disease since she was 8 years old; she became wheelchair dependent at the age of 15. The dystonia responded well to levodopa, except for the fixed-foot deformity. The deformity was corrected successfully by the Ilizarov method. The patient returned to independent ambulation after surgery. Because similar types of foot deformities appeared in several progressive degenerative neurologic diseases, the treatable Segawa disease should be added to the list of differential diagnoses of progressive degenerative neurological diseases with talipes equinovarus.

Management of the adult, spastic, equinovarus foot deformity

Management of the persistent, acquired, neurogenic equinovarus foot may be a confounding rehabilitative dilemma. Victims of cerebrovascular accidents and traumatic brain injury commonly develop this neurogenic deformity. The plantarflexed and inverted foot position results from an imbalance of forces about the hindfoot due to exaggerated muscle tone and hyperactive stretch reflexes. Significant functional impairment may ensue if a plantigrade foot position cannot be achieved and maintained. Surgical correction may be necessary if conservative measures fail. Determination of the dynamic and static components contributing to the equinovarus deformity is difficult. Gait analysis and dynamic electromyographic studies are valuable adjuncts for operative planning. The wide-ranging goals of surgery vary from improving transfer and ambulation skills, to assisting wheelchair positioning, to facilitating use of braces and/or shoe wear.

Anterior transfer of the toe flexors for equinovarus deformity due to hemiplegia

We report the results of transfer of the long toe flexors and lengthening of the calcaneal tendon in 33 patients with equinovarus deformity requiring orthoses after a stroke. Review of 29 patients more than two years after surgery showed that 21 were able to walk without an orthosis. Equinovarus deformity had recurred in six patients and hammer toe in 11, but walking ability without bracing was still better in seven of these. Results are improved by the release of the short toe flexors.

Soft-tissue expander failure in severe equinovarus foot deformity

Soft-tissue expanders have recently been reported to be useful in clubfoot surgery. We report our experience with this procedure in five patients with seven severe equinovarus foot deformities. The primary diagnoses of these patients included distal arthrogryposis, cerebro-oculo-facial syndrome, ischemic contracture and spina bifida. Our patients' major complications included ischemia, infection, and sepsis, which resulted in premature removal of the soft-tissue expanders in five of seven clubfeet. Minor complications, such as partial wound dehiscence, occurred in the two successful expansions. Predisposing factors may include soft-tissue expanders with self-contained ports, poor compliance, and extremely tight tissues that limit the subcutaneous space available for expansion, with resultant diminution of the vascular supply to the overlying skin.

SPLATT combined with tendo achilles lengthening for spastic equinovarus in adults: results and predictors of surgical outcome

During a 4-year period, split anterior tibial tendon transfer (SPLATT) was performed on 42 adults with cerebrospastic equinovarus deformity. Twenty-one patients (24 feet) had a minimum 1-year follow-up, which included detailed documentation of foot appearance position and function as well as ambulatory status. Thirteen patients were male and 8 were female. Average age of the patients was 41 years. Seventeen patients were independent ambulators with orthoses, one was a maximally assisted ambulator. Three patients with spastic quadriparesis were nonambulatory. All patients had uniform surgical technique and postoperative management. This paper presents the results of SPLATT and identifies risk factors for poor surgical outcomes. After an average follow-up of 39 months, 83% of the feet were rated as having good or excellent results. All ambulatory patients had improved gait and 35% of them were able to discontinue their orthoses. Poor surgical outcomes were associated with nonambulatory status in brain injured patients (P = .018). Salvage of failed SPLATT is discussed.

Split tibialis posterior transfer for equinovarus deformity in cerebral palsy. Long-term results of a new surgical procedure

We report the results of a new surgical procedure for spastic equinovarus deformity due to cerebral palsy. This is the transfer of the anterior half of the split tibialis posterior to the dorsum of the foot through the interosseous membrane. We performed the operation on 23 feet in 18 children. All patients were assessed before operation and at follow-up at a mean of 8.4 years postoperatively. Using the criteria of Kling et al (1985), excellent results were obtained in 14 feet, good results in eight, and a poor result in only one.

One-stage release of congenital circumferential constriction bands

A one-stage release of circumferential congenital constriction bands was performed in four extremities (three patients). No wound problems occurred, even when there had been marked swelling of the extremity distal to the band. The one-stage release facilitated postoperative care, and there was no need for additional periods of anesthesia or for additional operations, which are necessary when this problem is treated with a release performed in two or three stages.

Preoperative and postoperative assessment of surgical intervention for equinus gait in children with cerebral palsy

We compared the effects of different methods of surgical correction of equinus gait in children with spastic cerebral palsy (CP) using pre- and postoperative measurements of gait, electromyography (EMG), range of motion (ROM), and dynamic ankle motion. Operative results significantly improved all variables that produced more normal ankle motion in subjects, although no differences were observed between surgical methods. We conclude that preoperative gait analysis can assist in surgical planning regardless of surgical method for Achilles lengthening and can provide an objective measure of results after surgical correction of equinus deformity.

Paralytic drop foot and gluteal fibrosis after intramuscular injections

Eight children with paralytic drop foot after intramuscular injections later developed gluteal fibrosis. Sciatic palsy, presenting as equinovarus or equinus deformity, was diagnosed on average 3.8 months after the intragluteal injections, but gluteal fibrosis was not diagnosed until 5.1 years after the injections. In three patients the equinovarus recurred after surgical correction due to persistent muscle imbalance and the effect of the external rotation contracture of the hip.

Split tibialis posterior tendon transfer and tendo-Achillis lengthening for spastic equinovarus feet

Twenty-one patients with a minimum follow-up of 2 years who underwent combined split tibialis posterior tendon transfer and tendo-Achilles lengthening for equinovarus foot deformities were evaluated. The results in 15 of 18 ambulatory patients were graded as excellent or good; patients had marked improvement of their equinovarus foot deformity in both stance and swing phases of gait and became brace-free postoperatively. All non-ambulatory patients had a plantigrade foot. The complication rate was low, and patient satisfaction with the procedure was very high. In three patients, however, the procedure failed because of technical errors. We address the causes of failure and methods to avoid these errors. Preoperative computerized gait analysis does not appear to be essential in achieving a good result.

Relationship between acquired spastic talipes equinovarus and dystonia musculorum deformans

Acquired spastic talipes equinovarus associated with dystonia musculorum deformans (DMD) presents orthopaedic surgeons with a difficult treatment problem. We reviewed the natural history, diagnostic evaluation, and treatment of this deformity in 12 patients. Two patients initially had the generalized form of dystonia, and 10 patients had the focal form (in which acquired spastic talipes equinovarus was the only manifestation). With time, five of these 10 developed the generalized form. A positive family history and age < 14 years at onset were prognostic of this progression.

[Dystrophia myotonica and pregnancy]

We describe the maternal and neonatal complications of pregnancy in two patients with myotonic dystrophy. The disease leads to an increased spontaneous abortion rate, hydramnios, prolonged first and second stages of labour, retained placenta, postpartum haemorrhages and anaesthetic sensitivity in the mother. The neonatal problems are caused by the congenital form of the disease. The major clinical features of congenital myotonic dystrophy are bilateral facial weakness, hypotonia, neonatal distress, feeding difficulties, talipes, tent-shaped mouth, mental retardation and delayed motor development. Relatives of a known myotonic dystrophy patient should be advised to let themselves be examined for this disease. If the disease is diagnosed, information should be given regarding possibilities for prenatal diagnosis. Pregnancy in myotonic dystrophy patients should be monitored by a gynaecologist. Labour has to take place in a hospital with intensive care facilities for mother and child.

[Pathogenesis of congenital clubfoot]

Experiments, carried out by the author, have shown that the pathogenesis of congenital talipes is based on congenital muscular disbalance between flexors-supinators and extensors-pronators at the expense of strengthening of the former and insufficiency of the latter. An object of treatment of the considered developmental defect is restoration of myogenic balance. The existing methods of conservative treatment result in preservation of insufficiency of the anterolateral group of the crus muscles. Only the method of Vilensky V. Ya. allows to completely solve the posed problem. Operations on the posteromedial section of foot result in reduction of the myogenic disbalance as there is preserved insufficiency of extensors-pronators. Only operations, accompanied by shortening of anterolateral groups of the crus muscles allow to restore the myogenic balance straight on the operating table. The cause of recurrencies in case of congenital talipes is preservation of myogenic disbalance between flexors-spinators and their antagonist more frequent at the expense of insufficiency of the latter.

Seasonal variation in the incidence of congenital talipes equinovarus

A review of 77 neonates who presented with congenital talipes equinovarus over a seven-year period revealed an increase in the condition amongst babies born in the winter quarter. This finding was particularly apparent among the less severe cases of club-foot. Possible reasons for this seasonal variation are discussed.

Talipes equinocavovarus deformities corrected with the aid of a hinged-distraction apparatus

In 56 patients (70 feet) with talipes equinocavovarus, various components of deformity were surgically corrected in multiple stages with the aid of a hinged-distraction apparatus and concurrent training and rehabilitation of motion in the ankle joint. Good results were obtained in 53 feet, satisfactory results in 13 feet, and unsatisfactory results in four feet. The complications brought on by apparatus-assisted therapy of talipes equinocavovarus deformities require additional treatment but do not depreciate the method.

[Coexistent paralytic drop foot and gluteal fibrosis after intramuscular infections--therapeutic implications]

Six children with paralytic drop foot, which developed after intramuscular injections and who had co-existing gluteal fibrosis are presented in this study. Paralytic drop foot was diagnosed on an average of 5.5 months after intra-gluteal injections. This was the major therapeutic problem. The diagnosis of gluteal fibrosis was made on an average only 3 years and 7 months later. In 3 cases the external rotation and abduction contracture of the extremity in the hip joint, caused by gluteal fibrosis, with active plantar flexors and supinators of the foot could contribute to the recurrence of the equinovarus deformity of the surgically corrected foot.

[Transposition of the posterior tibial tendon in neuropathic talipes equinovarus]

Equinovarus foot deformity as seen in neurologic disease is often caused by imbalance in muscle tone. One of the possible operative procedures to correct this deformity is transposition of the posterior tibial tendon. The effect of this intervention is disputed in the orthopaedic literature. The results of this procedure are presented in a retrospective study of 9 children (11 feet). The mean follow-up period was 19 months (8-40). In all cases but one the results were satisfactory. The indications and complications of this operation are discussed.

Complete subtalar release in clubfeet

Complete subtalar release was performed in 18 children with 22 clubfeet between 1987 and 1989. The ages of the patients ranged from 3.5 months to 8.5 years. The patients were evaluated at 9 to 30 months (average 19 months). Twenty procedures were performed through the Cincinnati incision, and the remaining two through two separate posteromedial and posterolateral incisions. At 6 weeks, the pins were removed and cast immobilization was discontinued at 3 to 3.5 months. Complications were superficial necrosis in three feet, and extensive posteromedial skin necrosis in one foot. No recurrences were encountered. Overall results were very good in 18, and good in four feet.

Histochemistry of abductor hallucis muscle in children with idiopathic clubfoot and in controls

The histochemical composition of the abductor hallucis (AH) muscle was investigated in 39 children with idiopathic clubfoot (CF), aged 0-11 years, and in 42 controls. In the youngest group of patients (0-2 years) the percentage of type 1 (slow twitch, tonic) fibers was significantly higher than in controls. In older groups, there was no difference between patients and controls. The relative predominance of type 1 fibers could be due to immobilization, passive shortening or stretching, or primary overactivity of this muscle in CF promoted by an unknown neural factor. None of these interpretations could be proven.

Interosseous transfer of tibialis posterior for common peroneal nerve palsy

The interosseous route remains popular for tibialis posterior tendon transfer for drop-foot. It leaves a smaller range of movement than the circumtibial route, but lengthening the calcaneal tendon may improve this. The results of this present series indicate that, in order to predict a good functional result, the ankle must be held in at least 20 degrees of dorsiflexion at the time of tendon transfer.

Congenital clubfoot. Etiology, pathoanatomy, pathogenesis, and the changing spectrum of early management

Congenital clubfoot is a common problem of uncertain etiology with a broad spectrum of clinical severity. Much remains controversial and unsolved about this disorder. It is agreed, however, that early management should be conservative and that operative management should comprehensively address the deformities, to avoid if possible, subsequent operations. No single monograph can comprehensively review all aspects of this complex disorder. Our intent has been to touch upon the basic concepts and philosophies, to give perspective to the overall picture, for some, and to provide a stimulus and basis for further investigation and review for others.

Equinovarus deformity in arthrogryposis and myelomeningocele: evaluation of primary talectomy

As initial surgical management for rigid equinovarus deformities, 16 children with arthrogryposis (30 involved feet) and 16 myelodysplastic children (26 involved feet) underwent primary talectomies or extensive posterior-medial releases (PMR). When compared with primary PMRs in arthrogrypotic children, primary talectomies revealed a greater number of good and fair results, decreased recurrence rates, less procedures per foot, and maintenance of ambulatory status. Recurrent forefoot and cavus deformities were present after primary talectomies. Primary talectomy in arthrogrypotic children was more effective than posterior-medial releases or secondary (salvage) talectomy. Because of the small number of feet involved, the role of primary talectomy in myelomeningocele was not clarified by this study. Radical PMRs in myelodysplastic children resulted in a significant number of hindfoot valgus deformities that required secondary procedures.

[Restorative-reconstructive surgery of the sequelae of osteomyelitis of the lower extremities]

Results of reconstructive-restorative operations on 40 patients with sequellae of acute hematogenic osteomyelitis of lower extremities are described. Most frequent of them are pathologic dislocations, axial extremity, ankylosis and contractures of large vessels in a faulty position. Extrafocal compression-distraction osteosynthesis after Ilizarov was used. Little-traumatic character of the method, stable fixation and early functional loading gave smooth course of the postoperative period and good anatomo-functional results in most of the patients.

Congenital constriction band syndrome

A retrospective study of 55 patients with congenital constriction band syndrome was performed. Multiple extremity involvement was found to be the most common clinical feature associated with the disease, and 34% of the patients studied were premature at birth. Malformations included constriction bands, clubfoot, intrauterine amputation, syndactyly, and acrosyndactyly (fenestrated syndactyly). The extremities were most often affected distally, involving the longer central fingers and medial two toes. More proximal involvement with constriction bands was associated with a higher frequency of neurologic deficit. Significant leg-length discrepancy exceeding 2.5 cm was seen in 9 of 38 patients (24%) with lower extremity involvement, a condition that has not been previously reported.

[Flexion contracture of the upper ankle joint from its phlebologic aspects]

We report on talipes equinus as a consequence of chronical venous insufficiency, stage IV, and the therapeutic approaches. We describe in detail the autogenous mobilization of the proximal ankle joint. Regular measurements of the degree of ankylosis can objectify the findings, control the course of therapy, and motivate the patients.

Anterior transfer of the long toe flexors for the treatment of spastic equinovarus and equinus foot in cerebral palsy

Anterior transfer of the long toe flexors combined with the Baker procedure, or heel cord lengthening was used to correct equinus foot deformity in 21 patients with cerebral palsy. In more than two-thirds of the cases, heel-to-ball gait became possible. There were no significant recurrences that required re-operation. There were no complications caused by loss of original function in the long toe flexors even in younger patients. Excellent and good results were seen in 57.1% of the patients according to the overall results.

Posterior tibial-tendon transfer in patients with cerebral palsy

The results of fifty-seven posterior tibial-tendon transfers through the interosseous membrane to the dorsum of the foot that were performed in fifty-one patients who had cerebral palsy, and who were followed for a mean of 9.3 years (range, five to twenty-six years), were evaluated in terms of pattern of gait, alignment of the foot, formation of callus on the sole of the foot, and requirements for bracing. A good or excellent result was achieved in twenty-seven of thirty feet in the hemiplegic patients, twelve of sixteen feet in the paraplegic patients, and two of eleven feet in the quadriplegic patients. We found that in order for the tendon transfer to be successful the foot had to be passively correctable to at least a neutral position and that the tendon had to be passed superficial to the extensor retinaculum and inserted into the lateral cuneiform bone. The heel cord should be lengthened before the tendon transfer.

Talipes equinovarus: two case reports and literature review

Clubfoot, or talipes equinovarus, was introduced into the medical literature by Hippocrates in 400 B.C. The clubfoot deformity is a pathologic condition consisting of inversion and adduction of the forefoot, equinus of the ankle, and inversion of the heel. The condition has also been described as a congenital subluxation of the talocalcaneonavicular joints. This manuscript will review the literature with respect to history, incidence, etiology, anatomy, classification, radiology, and treatment. Two case reports are also presented.

Hemitransplantation of the tendo calcaneus in children with spinal neurological disorders

In paralytic lesions in which the triceps surae is the only active muscle in the leg, elongation or division of the tendo calcaneus alone may not be enough to prevent recurrence of equinus deformity. In 10 patients (13 limbs) with this pattern of muscle activity, equinus deformity was treated by hemitransplantation of the tendo calcaneus. At follow-up, which was beyond the end of growth in seven limbs, there was no recurrence of deformity in nine. In three of the four failures, a technical fault may have caused loss of activity in the transplanted part of the tendon. The two-stage operation described is recommended in the management of this pattern of paralytic deformity.

Congenital postural deformity of the wrist. A report of two cases

Two girls with congenital postural deformity of the wrist associated with deformity of the feet are reported. Fetal position in utero is discussed as a likely cause, and treatment by simple manipulation is recommended.

An electron microscopic study of the fascia from the medial and lateral sides of clubfoot

Two cell types were observed in fascia from the lateral side of the clubfoot: a cell resembling the fibroblast of hypertrophic scar and a fibroblast-like cell with dilated rough endoplasmic reticulum. Three cell types were observed in fascia from the medial side of the clubfoot: typical fibroblasts, cells resembling myofibroblasts, and mast cells. The contracture of the medial side may be due to the myofibroblast-like cells, and this contracture may be enhanced by histamine released from the mast cells. The stretching of the lateral side is probably due to a compensatory fibrosis that maintains the tissue density.

[Causes of recurrence of congenital clubfoot in children and indications for surgical treatment]

Unsatisfactory results of the conservative treatment of club foot deformity in 220 patients (346 feet) were analyzed. Data of roentgenograms in 86 patients enabled the authors to make a conclusion that an early cause of recurrent club foot is the delayed formation of nuclei of ossification of the navicular and I sphenoid bones, the later cause of the recurrent deformity is early synostosis of the epiphysis of the metatarsal bone. The importance of dispensary observation ad prophylactic measures after the treatment of congenital club foot is emphasized.

On the pathogenesis of clubfoot

Empirical testing has not revealed an indisputable cause of clubfoot. Evidence put forward for intrauterine moulding as a cause of idiopathic clubfoot does not stand up to scrutiny. The hypothesis that a regional growth disturbance is the cause of clubfoot would explain clinical and existing research data.

Management of the resistant myelodysplastic or arthrogrypotic clubfoot with the Verebelyi-Ogston procedure

The Verebelyi-Ogston (V-O) procedure, consisting of subchrondral excision of the talus and cuboid, was used for the treatment of 13 resistant clubfeet secondary to myelomeningocele or arthrogryposis. Nine feet were initially satisfactory, but the condition recurred in both feet of one patient after bracing was discontinued 3 years postoperatively. Three feet were graded as satisfactory after a second V-O procedure, and one after a third. The procedure must be monitored by intraoperative fluoroscopy or radiography, and followed by orthotic support. Despite the theoretical long-term disadvantage of incongruent joint surfaces, we consider the V-O procedure to be a good method for the treatment of this subset of rigid neuropathic clubfeet.