Surgical treatment of clubfoot

PRESENTER: DR. VISHWAS DABAS

MODERATORS: DR. UMESH MODI
DR. PANKAJ KUMAR AGGARWAL
Operative techniques

Indications
Resistant clubfoot
Persistent clubfoot
Relapsed club foot that does not
respond to non operative treatment.
METHODS

i) Soft tissue releases

ii) Bony procedures
iii) Tendon transfers
Principles of surgery

Multiple operations are to be

avoided because it increases
stiffness,deepens scars,hardens the
soft tissue.
Thus, the surgeon who performs
first operation has best chances of
correction and thus responsibility of
first surgeon is increased.
Surgery is tailored to the age of the
child and deformity to be corrected.
Timing of surgery
For an infant who has failed non operative treatment, surgery should
be performed before the age of 12 months.
Pous and Dimeglio performed soft tissue release between age of 1 to 6
weeks old but they had to abandon the procedure because of
exvcessive scarring and recurrent fibrosis due to hypermetabolic
reaction of connective tissue in such a young infant.
Consensus indicates that although surgery can be performed as early as
5 months old but there is no advantage of doing that at such a young
age.
MANAGEMENT OF
RECURRENCES

DYNAMIC SUPINATION
Normal function of Tibialis
anterior is to dorsiflex the foot. But
instead of dorsiflexion, tibialis
anterior starts supination of medial
side of foot.
DYNAMIC SUPINATION
It is a disorder of swing phase of walking that produces weight on lateral aspect of
foot.
Treatment : ANTERIOR TIBIAL TENDON TRANSFER
Anterior Tibial Tendon Transfer
Indications : Dynamic supination or inversion of midfoot, specially in the swing
phase that produces weight bearing on the lateral aspect of foot.
If the foot is otherwise mobile and can be placed plantigrade for stance, this is the
only procedure that is necessary.
Pre-requisite: Rigid equinus must be corrected before consideration of anterior tibial
tendon transfer.
Transfer of tibialis anterior can be split transfer or entire tendon transfer.
Anterior Tibial Tendon Transfer

LATERAL ARM OF TENDON IS REROUTED SUBCUTANEOUSLY FROM

ANKLE RETINACULUM AT DISTAL END OF TIBIA AND REINSERTED INTO
LATERAL CUNEIFORM.

IF ENTIRE TENDON IS TRANSFERRED, THEN INCISION IS MOVED TO THE

MIDLINE TO ACHIEVE DORSIFLEXION WITHOUT EXCESSIVE ABDUCTION.
RESIDUAL HINDFOOT EQUINUS IN CHILDREN 6 TO 12
MONTHS OLD
Residual hindfoot equinus in childtren 6 to 12 months old
who have obtained adequate correction of hindfoot varus
and forefoot adduction can be corrected by Achillies
Tendon lengthening and Posterior capsulotomy of ankle
and subtalar joints without an extensive posteromedial
release
Pre requisite: Heel varus and internal rotation must be
fully corrected prior to procedure.
Achillies Tendon lengthening

Make straight incision medial to

achilles tendon.
Dissect the Achillies tendon
circumferentially to expose it for
length of 3-4 cm.
Perform Z-plasty to lengthen the
Achilles tendon by releasing the
medial half distally and lateral half
proximally for a distance of 2.5-4
cm.
Achillies Tendon lengthening

Debride pericapsular fat at level of

subtalar joint.
Identify posterior aspect of ankle
joint by gentle plantar and
dorsiflexion of foot.
Perform transverse capsulotomy at
most medial aspect .
Place foot in 10 degrees of
dorsiflexion and approximate the
tendon to assess tension.
Place the foot in plantar flexion and
repair the tendon.apply long leg cast
with foot in 5 degree dorsiflexion.
Osteotomy of the Calcaneum for Persistent deformity of heel
DWYER AND MODIFIED DWYER PROCEDURE

Dwyer did osteotomy of calcaneum for relapsed clubfoot using an opening wedge
medial osteotomy to increase height and length of calcaneum.
Osteotomy is held by a wedge of bone taken from tibia.
Modification of this technique is laterally based closing wedge osteotomy of
calcaneus.
Steps:
Expose the calcaneum through a lateral incision over calcaneum.
MODIFIED DWYER PROCEDURE
Expose the lateral surface of bone. Do not injure the peroneal tendons.
Resect a wedge of bone, place the heel into corrected position.
Fix the osteotomy with k wire if necessary.
Apply short leg cast with foot in corrected procedure.
Lateral couloumn shortening techniques
In recurrence of clubfoot, the deformity may consist of length disparity between
medial and lateral borders of foot.
Any attempt of abduction, is resisted by medial contracture and excessive length of
lateral coloumn.
Treatment: EVANS APPROACH: PROCEDURE OF CHOICE BETWEEN 4-8
YEARS OF AGE.( before 4 years of age calcaneo-cuboid fusion is more difficult to
achieve because of large amount of cartilage in both bones)
Wedge resection of calcaneocuboid joint to shorten the lateral coloumn as part of
treatment.
Evans procedure:
resection and fusion
of calcaneocuboid
joint.
Lichtblau procedure:
3/8 wedge resection
of anterior end of
calcaneum including
calcaneal articular
cartilage
The procedure is
indicated in children
younger than 6 yrs
who need lateral
coloumn shortening.
LICHTBLAU
PROCEDURE
Selective joint sparing osteotomies for residual cavo varus
deformity
MUBARK AND VAN VALIN PROCEDURE

Stepwise correction of each aspect of deformity with a closing wedge osteotomy of

first meta tarsal, opening plantar wedge osteotomy of medial cunneiform, closing
wedge osteotomy of cuboid, osteotomy of second and third metatarsals
MUBARK AND VAN VALIN
PROCEDURE
A. DORSAL CLOSING WEDGE
OSTEOTOMY OF FIRST
METATARSAL
B. OPEN WEDGE OSTEOTOMY
OF MEDIAL CUNNEIFORM
C. LATERALY BASED CLOSING
WEDGE OSTEOTOMUY OF
CUBOID.
Transverse
circumferential
(Cincinnati) Incison
This incision provides excellent
exposure of subtalar joint and is
useful in patients with severe
rotational deformities of calcaneum.
Technique : starting the incision at
naviculocuneiform joint, carrying
the incision posteriorly beneath the
medial malleolus and ascending
slightly to pass transversely over
Achilles tendon, continuing the
incision giving gentle curve over
medial malleolus.
Transverse circumferential (Cincinnati) Incison
Incision can be extended distally, medially or laterally depending on the requirement.
Problems with incision: Tension on the suture line when attempting to place the foot
in dorsiflexion to apply postoperative cast.
Foot is placed in plantarflexion in immediate postoperative cast and is dorsiflexed in
subsequent casts when the wound has healed at 2 weeks.
If primary skin closure is difficult, then fasciocutaneous skin closure can be used.
SOFT TISSUE CONTRACTURTES IN CLUBFOOT

3 types of contractures are found in the clubfoot :

1) Posterior : posterior capsule, tendoachilles , posterior

talofibular and calcaneofibular ligaments

2) Medial : deltoid and spring ligaments , talonavicular

capsule, posterior tibialis tendon and to a lesser

degree flexor digitorum longus and flexor hallucis
longus.
3) Subtalar : anterior interosseous ligament , bifurcated

Y ligament.
SOFT TISSUE RELEASE
Amount of release required varies according to the
amount and rigidity of deformity in each patient
i) Simple posterior release
ii) Posteromedial release
iii) Extensile posteromedial release
iv) Posteromedial and posterolateral release and
subtalar release ( Modified Mckay procedure )
Posterior release
- Basically required to correct equinus deformity(which is
resistant to tenotomy and Z lenghtening of tendoachilles).
- Sufficient strength of calf muscles is a prerequisite.
- Structural alteration of the talus preventing its engagement
in the ankle mortise is a contraindication.
Medial release
- Presence of equinus and varus deformity simultaneously
requires medial release in addition to the posterior release.
Release of abductor hallucis at musculotendinous junction
Exposure of tendoachilles by excising the sheaths of tibialis posterior ,
flexor digitorum longus and flexor hallucis longus
The master knot of henry is then tackled and cut in order to mobilize the
navicular.
Z lenthening of tendoachilles along with capsulotomy of posterior
tibiotalar ,posterior tibiofibular, posterior and medial subtalar , posterior
talofibular, calcaneofibular, talonavicular and medial calacneocuboid joint
capsule
Release of Spring ligament and Y ligament along with lenthening of
tibialis posterior, flexor digitorum longus and flexor hallucis longus
tendons.
Last structure to be released is superficial deltoid ligament.
Preservation of its deep part is essential to avoid development of a
flatfoot with tilted talus.
Lateral release
Structures released are :
Lateral subtalar joint capsule
Lateral talocalcaneal ligament
Calcaneofibular ligament
Peroneal tendon sheath
Cubonavicular ligament
Origin of extensor digitorum brevis
Inferior extensor retinaculum
Structures always to be preserved :
Deep deltoid ligament
Interosseous ligament
NV bundle
Extensile Posteromedial and Posterolateral Release
MODIFIED MCKAY TECHNIQUE

Cincinnati incision is used.

The majority of peritalar structures, including all hindfoot and midfoot joint are
released.
Medial and lateral circumferential talocalcaneal release is performed.
Complete release of talonavicular and calcaneocuboid joint is performed.
Calcaneum derotated by pushing the anterior end laterally and and posterior tuberosity
medially.
K wires used to internally fix the joints.
Extensile Posteromedial and Posterolateral Release
McKay also used the concept of cable cast in which hinge is centred around the ankle
joint. It was intended to increase the ankle motion. Although use of cable cast is
dimnished due to wound complications due to early motion.
Long leg cast is applied with the foot in plantar flexion. The cast is changed at two
weeks and foot is placed in corrected position.
Cast and pins are removed at 6 weeks and correction is maintained in foot orthosis.
A. Posteriolaterally
peroneal tendons are
retracted to allow
complete calcaneofibular
and lateral subtalar
release.
B. Deep calcaneofibular
release.
C. Z lengthening of
achillis tendon.
D. Posteriomedial release
of tibiotalar and and
subtalar joint after
retraction of flexor
hallucis longus.
Clinical appearance
after correction
using modified
Mckay procedure
Post operative Complications
Loss of correction: most commonly it is due to inadequate postoperative position as a
result of cast becoming too loose once post operative swelling has subsided.
After first 4 weeks, cast changes would be ineffective in regaining any dorsiflexion
that is lost. Thus if a cast change is required to regain position, it must be done early.
Maintaining the corrected foot position despite wound complications and pin tract
infections is the main dilemma as premature pin removal can also lead to loss of
correction.
Post operative Complications
Dorsal bunion: it can be considered a complication of surgery because underlying
muscle imbalance requiredto produce deformity is caused by some of surgical
maneuvers gone wrong.
Dorsal bunion a/k/a hallux flexus is caused when depressing strength of peroneus
longus is lost, either through disease ( polio) or iatrogenically( scarring), in the
presence of first metatarsal elevation by tibialis anterior.
Treatment includes first metatarsal osteotomy and tendon transfer for Dorsal bunion
known as Smith and Kuo procedure
DORSAL BUNION
First Metatarsal Osteotomy and
Tendon Transfer for Dorsal bunion
(Smith and Kuo procedure)

A. META TARSO PHALANGEAL

JOINT IS RELEASED TO
REDUCE PHALANX ON FIRST
METATARSAL HEAD.
FIRST RAY IS CLOSED WITH
PLANTAR CLOSING WEDGE
OSTEOTOMY.
POST
OPERATIVE
APPEARANC
E OF FOOT
Post operative Complications
Valgus over correction : overcorrected foot with excessive hindfoot valgus and
forefoot abduction and pronation is significant complication of surgical release.
This leads to further surgery due to pain from excessive medial arch weight bearing,
lateral ankle impingement.
An overcorrected foot generally results from horizontal breech in foot, primarily
through subtalar joint, where talus is still in internal rotation due to incomplete
talofibular and deltoid release. And subtalar joint is completely released and unstable.
The calcaneum is then translated laterally during improper cast maneuvers resulting in
deformity.
Valgus
overcorrection
VALGUS
OVER
CORRECTION
Treatment of Valgus over-correction
Varus osteotomy of calcaneum/ talus for restoration of heel height.
Forefoot realignment requires medial coloumn shortening and lateral coloumn
lengthening through subluxed joints.
The entire procedure can be best accomplished by a procedure named Triple
Arthrodesis.
Triple
arthrodesis
1. Opening
wedge bone
graft for lateral
coloum
lengthening
2. Medial
coloumn
shortening
3. Varus
osteotomy of
calcaneum/talus
.
UNTREATED CLUBFOOT

The term Neglected clubfoot is not

used now.
Talectomy is the salvage procedure
for untreated clubfoot in adoloscents
and older children.
Functionality of foot is improved
despite postoperative joint stiffness.
Talectomy
This procedure is reserved for
severe, untreated clubfoot that is
uncorrectable by other surgical
procedures or for children with
neuromuscular deformities and
syndromes.
Correction depends on complete
removal of talus and proper
positioning of talus.
Triple arththrodesis
-Triple arthrodesis corrects the severely deformed foot by a lateral closing wedge osteotomy
through the subtalar and midtarsal joints.
Technique
Make an incision along the medial side of the foot parallel to the inferior border of the
calcaneus.
Free the attachments of the plantar fascia and of the short flexors of the toes from the
plantar aspect of calcaneus.
By manipulation, correct the cavus deformity as much as possible.
Through an oblique anterolateral approach, expose the
midtarsal and subtalar joints.
Resect a laterally based wedge of bone that includes the midtarsal joints. Resect enough
bone to correct the varus and adduction deformities of the forefoot.
Through the same incision, resect a wedge of bone, again
laterally based, which includes the subtalar joint. Resect
enough bone to correct the varus deformity of the calcaneum
Triple arthrodesis
If necessary, include in the wedge the navicular and most of the cuboid and
lateral cuneiform and the anterior part of the talus and calcaneus, and in the
second wedge include much of the superior part of the calcaneus and the
inferior part of the talus.
Lengthen the Achilles tendon by Z-plasty and perform a posterior capsulotomy
of the ankle joint. By manipulating the ankle, correct the equinus deformity.
Hold the correct position with a Kirschner wire inserted through the
calcaneocuboid and talonavicular joints or with staple fixation.
POSTOPERATIVE CARE: With the foot in the corrected position and the
knee flexed 30 degrees, a long leg cast
is applied from the base of the toes to the groin. The
Kirschner wire and cast are removed at 6 weeks. A short leg walking cast is
worn for 4 more weeks.
Triple Arthrodesis with partial
talectomy for untreated
clubfoot. Area between blue
lines represent amount of bone
to be removed.
Correction using ilizarov technique
Multiple planed corrections through the use of hinged distraction between a tibial
frame and a foot framewith the hindfoot and forefoot usually treated separately.
As there are fewer other options for treatment of late recurring or neglected deformity,
this technique remains extremely useful to correct such deformities without further
shortening the foot by more bone resection.
There are physical and psychological disturbances and time taken for correction is
very lengthy.
ILIZAROV
CORRECTIO
N
Treatment of resistant clubfoot
Deformity Age Surgical procedure
i) Metarsus adductus > 5 years Metarsal osteotomy
ii) Hindfoot varus < 2-3 years Modified Mckay procedure
3-10 years - Dwyer osteotomy
- Dilwyn – Evans procedure
- Lichtblau procedure
10-12 years Triple arthrodesis
iii) Equinus - Lengthening of Achilles tendon along with capsulotomy of
subtalar joint,ankle joint ( mild – moderate deformity )

iv ) All 3 deformities Triple Arthrodesis