Posteroplantar release for congenital clubfoot in children younger than 1 year

A silent massive ossification of Achilles tendon as a suspected rare late effect of surgery for club foot

We report the case of a 66-year-old male patient with massive ossification of the distal portion of the Achilles tendon, as a late consequence of a surgical release for club foot conducted in his childhood. The singularity of the case report derives from its clinical features: the bone mass was of abnormal dimensions, almost substituting the entire tendon; the condition had always been asymptomatic, without deficits in range of motion, in absence of either pain or biomechanical defects with age. In fact, the condition was diagnosed just recently as a consequence of a tear. Despite an ultrasound diagnosis after the injury, only during the surgical treatment, a proper evaluation of the entity of the pathology was possible. Although the ossification of Achilles tendon is a rare clinical condition with a complex multifactorial etiology, in our case report, some of the elements in the patient's medical history could be useful for the pathogenesis and early diagnosis of the disease. The aim of this case report is to emphasize the importance both of a correct evaluation of clinical history and of an accurate diagnosis, in order to conduct a proper management of this pathology.

Surgical versus Ponseti approach for the management of CTEV: a comparative study

BACKGROUND

Results from a comparative study of Ponseti versus surgical management for congenital talipes equino varus (CTEV), using historically managed patients, are presented. No bias existed in terms of management choice or participants recruited.

METHODS

Twenty-three surgically treated children (31 club feet; mean age 9.1 y) and 29 treated by the Ponseti technique (42 club feet; mean age 6.5 y) agreed to participate in the study. Twenty-six typically developing children (mean age 7.9 y) were also recruited as a control group. A physical examination and 3-dimensional gait analyses were carried out on all participants, and each child and his/her parent also, independently, completed the Oxford Ankle Foot Questionnaire (OxAFQ).

RESULTS

The Ponseti group underwent fewer joint-invasive procedures than the surgical group. Passive range of dorsiflexion and plantarflexion were significantly less in the CTEV groups when compared with the control group (P<0.001), and plantarflexion was also significantly less in the surgical than in the Ponseti group (P<0.05). The bimalleolar axis was found to be significantly less in the CTEV groups than in the control group (P<0.001) and also significantly less in the surgical than in the Ponseti group (P<0.05). The gait deviation index, a gait score based on kinematics, showed a more normal gait pattern in the Ponseti group compared with the surgical group (P<0.001). The CTEV groups did not differ significantly from each other in terms of ankle sagittal and transverse plane kinematics or kinetics, but foot progression angle for the Ponseti group was external, whereas that for the surgical group was internal. The Ponseti group also scored higher than the surgical group in terms of patient satisfaction, with significantly better parent-rated OxAFQ scores in the "emotional" and "school and play" domains.

CONCLUSIONS

The adoption of the Ponseti technique has resulted in fewer and less-invasive operations for our CTEV population, with accompanying improvement in the overall gait pattern (gait deviation index) and parent satisfaction (OxAFQ).

LEVEL OF EVIDENCE

Level III.

Is it hazardous or mandatory to release the talocalcaneal interosseous ligament in clubfoot surgery?: a preliminary report

Extreme overcorrection and avascular necrosis are recognized complications in clubfoot surgery and are thought to be the result of division of the talocalcaneal interosseous ligament (TCIL). This is a preliminary report of a prospective study of the cases of 46 patients with 66 idiopathic clubfeet treated by means of soft tissue release using a posteromedial approach at a mean age of 9 months. The deformity was very severe in 51 feet and severe in 15. The feet were divided into 2 equal groups (33 feet each). In group A feet, the TCIL was released, whereas in group B, the ligament was left intact. At a mean follow-up period of 28 months, the result was satisfactory (excellent and good) in 96.9% of feet in group A and in 87.9% of feet in group B. When the mean overall clinical and radiological score was investigated, group A graded excellent whereas group B graded good. In feet with satisfactory outcome, group A showed statistically significant improvement of the anteroposterior and lateral talocalcaneal angles, talocalcaneal index, and lateral calcaneus-first metatarsal angles when compared with group B. This was reflected clinically on better hind foot correction with the release of the TCIL, with no evidence of significant overcorrection. Magnetic resonance imaging of the ankle and foot confirmed no evidence of talar avascular necrosis or extreme overcorrection in 40 feet (60.1%), 20 in each group. We conclude that it is advisable to release the TCIL in severe and very severe clubfeet.

Ponseti management of clubfoot in older infants

Treatment of clubfoot with the Ponseti method is successful when performed immediately after birth. We treated 23 infants (36 feet) who presented to us after casting, applied at other institutions, failed or after 3 months of age. Twenty-two infants had serial casting started during the first 2 months, and one infant who was 6 months old at presentation had not received previous treatment. The original orthopaedists of 18 patients advised posteromedial release. The parameter studied was the need for posteromedial release (ie, failure of Ponseti casting and percutaneous Achilles tenotomy to obtain satisfactory clinical appearance). Only one (2.8%) of 36 feet required open surgical release (posterior only). Thirty-five feet required percutaneous Achilles tenotomy. A mean of six Ponseti casts were applied before tenotomy. Two feet (two infants) required anterior tibialis transfer for mild relapse; three other feet (two infants) required repeat casting for mild relapse. Most pediatric orthopaedists think that successful clubfoot casting depends on treatment started immediately after birth. Our data suggest that older infants with clubfoot can be treated successfully without extensive surgery. Our results in older infants are similar to the results of a previous study we conducted with younger infants. In that study, one (2.9%) of 34 feet required posteromedial release surgery.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (Case series). See the Guidelines for Authors for a complete description of levels of evidence.

Modified Turco procedure for treatment of idiopathic clubfoot

Since 1980 we have used a modified Turco procedure for treating congenital clubfoot. The modifications include: (1) lateral position with the unaffected side on top; (2) Cincinnati-type transverse heel crease incision from the base of the first metatarsal around the ankle up to the lateral border of the tendoachilles; (3) complete excision of the abductor hallucis muscle; (4) complete tibialis posterior tendon tenotomy in the sheath; (5) no lengthening of long toe flexors; (6) no K wires for maintaining the correction; and (7) special splints instead of Denis Browne splints. Thirty-three feet in 18 patients were followed up prospectively at a mean of 13.8 years (range, 10-16 years). There were no wound complications. The mean Laaveg and Ponseti score was 87.2 (range, 49-98). Twenty-seven (82%) of 33 feet had good to excellent results. There were seven feet (21%) with recurrent deformities, which included two feet (6%) with recurrence of all deformities, two feet (6%) with forefoot adduction, one foot each (3%) with equinus and heel varus, and one (3%) with cavus. Ninety-four percent of patients were very satisfied or satisfied with the results. We think this modified approach has helped us to reduce the recurrence of forefoot adduction deformity and wound complications.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series-no, or historical control group). See Guidelines for Authors for a complete description of levels of evidence.