Vol. 68, No. 1
31
Surgical Management of Idiopathic Clubfoot Deformity MILTON E. ASHBY, M.D., Chief, Orthopedic Surgery, Martin Luther King, Jr. General Hospital and Associate Professor, Charles R. Drew Postgraduate Medical School, Los Angeles, California
TALIPES equinovarus is the most common variety of clubfoot. It is a congenital deformity characterized by plantarflexion, adduction and inversion of the foot. The most convenient classification of this deformity is etiologic as suggested by Hersch.1 The idiopathic is the most common type occurring in approximately one of every 1000 births. Irani and Sherman concluded that, in idiopathic clubfoot deformity, the etiology is actually a primary germ plasm defect causing a defective cartilaginous anlagen of the anterior part of the talus. Their conclusion was based upon multiple pathologic dissections of stillborns or neonatal deaths, in which they found no primary abnormality of vessels, nerves, muscles or tendon insertions. The only constant abnormality of the bones when disarticulated was the anterior part of the talus. All other changes in clubfoot deformity are considered adaptive.2
Fig. 1. Postoperative lateral (left & middle) and anteroposterior (right) roentgenograms following posteromedial release demonstrating normal range talocalcaneal indices.
Early advocates of surgical correction (example Brockman, 1930) were quieted by their high percentage of crippling results worse than the original deformity and the encouragement of J. Hiram Kite in regard to gentle and progressive manipulation with plaster casts.3 For nearly 30 years, orthoped-
ists attempted to reproduce the 90% good results reported by Kite with plaster casts, surgery being futilely reserved for residual deformities. The inabilities of many to duplicate the results of Kite and the reported successes of Bost, et al. and Turco have prompted a new wave of enthusiasm for surgery in clubfoot deformity.4'5 SELECTION AND TIMING OF SURGERY
Hersch divides idiopathic clubfeet into two varieties 1) An intrinsic type associated with marked fibrosis and abnormal bony relationships, which is usually not responsive to non-operative treatment. 2) An extrinsic type which is not associated with significant fibrosis, and responds readily to gentle manipulation with plaster casts.
Most clubfoot clinics readily admit to failure by non-operative methods in 50% of idiopathic clubfoot deformities. In infants treated from birth, it is generally apparent by age six months whether conservative treatment will, indeed, be successful. Some proponents of early surgical intervention would advise a posteromedial release at this time. In the author's opinion, complete posteromedial release as advocated by Bost and Schottstaedt and Turco is the surgical procedure of choice, but not before the age of 12 months. It has been clearly demonstrated that a high percentage of good results can be obtained by this operation between the ages of one and two years. Increasing difficulties are associated with the required meticulous dissection under the age of 12 months to preserve the articular cartilage and also the posterior tibial vessels in such a relatively small foot. It has been demonstrated by arteriography that in clubfoot deformity the dorsalis pedis artery
32
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
may be practically non-existent, indicating the necessity for careful preservation of the posterior tibial artery,6 which may be the sole blood supply to the foot. Therefore, the urgency of such surgery under 12 months of age seems not only unclear, but even contraindicated. FAILED POSTEROMEDIAL RELEASE
Concern is justified in regard to the present enthusiasm for early posteromedial release in idiopathic clubfoot deformity. As in conservative treatment, roentgenographic assessment is required to ascertain the completeness of correction. By this method many relapsed clubfeet have been found to, in fact, be resistant clubfeet never completely corrected. Roentgenograms should be obtained following posteromedial release and the measured talo-calcaneal index should be within normal range for any child having surgery under the age of two years.7'8
JANUARY, 1976
.;:_i~ . i
bines the standard posteromedial release with a wedge resection and fusion of the calcaneocuboid joint. The minimum age for this procedure is four years, ideal six years and the upper limit being eight years. Under the age of four years, disabling valgus deformities may result. Lichtblau indicates preference for wedge resection of the calcaneus at the calcaneo-cuboid joint rather than creating a surgical tarsal coalition.11 Though I have no experience with his alternative, the obvious disadvantage is the necessity for a brace for at least one year postoperative, whereas, with
Fig. 2. Lateral roentgenograms of the same patient following the Evans procedure.
Fig 3 Anteroposterior roentenograms of the following the Evans procedure
The most critical portions of the posteromedial release are the soft tissue releases of the talo-navicular joint and the sub-talar joints. Even with critical attention to all details of surgery and postoperative management, a small percentage of cases will develop recurrent deformities evidenced by heel equinus and varus. In my opinion, such recurrences are related to atrophic muscles, particularly poor return of peroneal function and existing adapative bony changes. The primary pathology still remains at the talonavicular joint and as would be anticipated, the addition of contracting surgical scar creates a problem unlikely to respond to corrective plaster casts. Abrams has reported success with the Evans procedure.9'10 This procedure com-
the Evans operation, an Oxford shoe is wonM six months postoperative with increase in correction possible with growth of the foot. I am unaware of any reported symptomatic congenital calcaneo-cuboid tarsal coalitions which, according to Harris, occurs in approximately one of every 100 tarsal coalitions. Motion at the calcaneo-cuboid joint is minimal and gliding when compared to more significant gliding, angular and rot'atory motion involving the subtalar and talo-navicular joints. Even Grice procedures and Gallie fusions have not always resulted in symptoms requiring completion of triple arthrodeses. For a child with recurrent clubfoot deformity following posteromedial release, I would prefer the Evans procedure at age four years. Triple arthrodesis is always available
same
patient
33
Idiopathic Clubfoot
Vol. 68, No. I
at 10-12 years if tarsal symptoms are disabling. Tendon transfers will never correct existing bony deformity. CASE REPORT L.B. was treated from birth with plaster cast for a bilateral idiopathic clubfoot deformity. At age 12 months, bilateral posteromedial releases were performed one week apart (Fig. 1). Plaster casts were discontinued after seven months postoperative. At age three years, the child re-presented to the clinic, having kept no appointments for more than six months, with an equinovarus deformity. Corrective casting and cabletwisting long-leg braces were all tried and found to be totally ineffective. At age five years, bilateral Evans operations were performed (Figs. 2 & 3). Two a a half years post-surgery, the feet remained corrected with dorsiflexion 20 degrees bilaterally and 30 degrees of plantarflexion possible in both feet. Invertion of each heel was possible to 10 degrees and eversion of five degrees bilaterally. Both heels were in slight valgus. There was no pain, and the mother indicated that the child physically competed in running activities with other children.
SUMMARY
Approximately one-half of patients seen with a diagnosis of idiopathic clubfoot will require surgical intervention to correct their deformities. This surgery should consist of a complete posteromedial release not to be performed under one year of age. No better results should be anticipated under the age of one year, and in my opinion is contraindicated. Beyond the age of two years, most certainly three years, there should be decreasing optimism towards adequate correction with soft tissue release alone. The Evans operation is the procedure of choice for recurrent deformity or residual deformity from ages four to eight years. Without resection of the lateral column of the foot at the calcaneal cuboid-joint, posteromedial release at these ages, will be ineffectual in correcting hind foot varus and the medial displacement of the navicular upon the talar head and neck. There is insufficient evidence to suggest that a surgical caleaneo-cuboid coalition will necessarily require eventual triple arthrodesis for
disabling symptoms. Roentgenographic assessment of postoperative posteromedial release operation is mandatory. The surgeon must know whether postoperative deformities are truly recurrent or the result of an inadequate surgical release. Without this type of proper assessment, it seems conceivable that with the wave of enthusiasm towards early surgical correction of clubfoot deformity, the return of notoriety and crippling results is an eminent possibility. LITERATURE CITED
1. HERSH, A. J. The Role of Surgery in the Treatment of Clubfeet. J. Bone & Joint Surg., 55a: 1377, 1973. 2. IRANI, R. N. and M. D. SHERMAN. The Pathological Anatomy of Clubfoot. J. Bone & Joint Surg., 45a:45-52, 1963. 3. KITE, T. H. Nonoperative Treatment of Congenital Clubfeet: A Review of One Hundred Cases. South. Med. J., 23:334-345, 1930. 4. BOST, F. C. and E. R. SCHOTTSTEADT, and L. J. LARSEN. Plantar Dissection. An Operation to Release the Soft Tissues in Recurrent or Recalcitrant Talipes Equinovarus. J. Bone & Joint
Surg., 42a:151-164, 1960. 5. TURCO, F. J. Surgical Correction of the Resistant Clubfoot. One-stage Posteromedial Release with Internal Fixation: A Preliminary Report. J. Bone & Joint Surg., 53a:477, 1971. 6. BEN-MENACHEN, Y. and J. E. BUTLER. Arteriography of the Foot in Congenital Deformities. J. Bone & Joint Surg., 56a:1625, 1974. 7. BEATSON, T. R. and J. R. PEARSON. A Method of Assessing Correction in Clubfeet. J. Bone & Joint Surg., 48b:40-50, 1966. 8. ASHBY, M. E. Roentgenographic Assessment of Soft Tissue Medial Release Operations in Clubfoot Deformity. Clin. Orthop., 90: 146-149, 1973. 9. ABRAMS, R. C. Relapsed Clubfoot: A Study of the Dillwyn Evans Operation. J. Bone & Joint Surg., 51a:270, 1969. 10. EVANS, D. Relapsed Clubfoot. J. Bone & Joint Surg., 43b:722-733. 11. LICHTBLAU, S. A Medial and Lateral Release Operation for Clubfoot. A Preliminary Report. J. Bone & Joint Surg., 55a: 1377, 1973. 12. HARRIS, R. I. Retrospect: Peroneal Spastic Flatfoot (Rigid Valgus Foot). J. Bone & Joint Surg., 47a: 1657, 1965.
(Williams and Grigsby, from page 4 1) Improving Existing Methods of Control of TuberReport of Five New Cases. Am. Rev. Resp. Dis. culosis: A Prime Challenge to the Experimentalist. 108:1320, 1973. Am. Rev. Resp. Dis., 105:183, 1972. 5. SCHMIDT L. H. The John Barnwell Lecture.
31
Surgical Management of Idiopathic Clubfoot Deformity MILTON E. ASHBY, M.D., Chief, Orthopedic Surgery, Martin Luther King, Jr. General Hospital and Associate Professor, Charles R. Drew Postgraduate Medical School, Los Angeles, California
TALIPES equinovarus is the most common variety of clubfoot. It is a congenital deformity characterized by plantarflexion, adduction and inversion of the foot. The most convenient classification of this deformity is etiologic as suggested by Hersch.1 The idiopathic is the most common type occurring in approximately one of every 1000 births. Irani and Sherman concluded that, in idiopathic clubfoot deformity, the etiology is actually a primary germ plasm defect causing a defective cartilaginous anlagen of the anterior part of the talus. Their conclusion was based upon multiple pathologic dissections of stillborns or neonatal deaths, in which they found no primary abnormality of vessels, nerves, muscles or tendon insertions. The only constant abnormality of the bones when disarticulated was the anterior part of the talus. All other changes in clubfoot deformity are considered adaptive.2
Fig. 1. Postoperative lateral (left & middle) and anteroposterior (right) roentgenograms following posteromedial release demonstrating normal range talocalcaneal indices.
Early advocates of surgical correction (example Brockman, 1930) were quieted by their high percentage of crippling results worse than the original deformity and the encouragement of J. Hiram Kite in regard to gentle and progressive manipulation with plaster casts.3 For nearly 30 years, orthoped-
ists attempted to reproduce the 90% good results reported by Kite with plaster casts, surgery being futilely reserved for residual deformities. The inabilities of many to duplicate the results of Kite and the reported successes of Bost, et al. and Turco have prompted a new wave of enthusiasm for surgery in clubfoot deformity.4'5 SELECTION AND TIMING OF SURGERY
Hersch divides idiopathic clubfeet into two varieties 1) An intrinsic type associated with marked fibrosis and abnormal bony relationships, which is usually not responsive to non-operative treatment. 2) An extrinsic type which is not associated with significant fibrosis, and responds readily to gentle manipulation with plaster casts.
Most clubfoot clinics readily admit to failure by non-operative methods in 50% of idiopathic clubfoot deformities. In infants treated from birth, it is generally apparent by age six months whether conservative treatment will, indeed, be successful. Some proponents of early surgical intervention would advise a posteromedial release at this time. In the author's opinion, complete posteromedial release as advocated by Bost and Schottstaedt and Turco is the surgical procedure of choice, but not before the age of 12 months. It has been clearly demonstrated that a high percentage of good results can be obtained by this operation between the ages of one and two years. Increasing difficulties are associated with the required meticulous dissection under the age of 12 months to preserve the articular cartilage and also the posterior tibial vessels in such a relatively small foot. It has been demonstrated by arteriography that in clubfoot deformity the dorsalis pedis artery
32
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
may be practically non-existent, indicating the necessity for careful preservation of the posterior tibial artery,6 which may be the sole blood supply to the foot. Therefore, the urgency of such surgery under 12 months of age seems not only unclear, but even contraindicated. FAILED POSTEROMEDIAL RELEASE
Concern is justified in regard to the present enthusiasm for early posteromedial release in idiopathic clubfoot deformity. As in conservative treatment, roentgenographic assessment is required to ascertain the completeness of correction. By this method many relapsed clubfeet have been found to, in fact, be resistant clubfeet never completely corrected. Roentgenograms should be obtained following posteromedial release and the measured talo-calcaneal index should be within normal range for any child having surgery under the age of two years.7'8
JANUARY, 1976
.;:_i~ . i
bines the standard posteromedial release with a wedge resection and fusion of the calcaneocuboid joint. The minimum age for this procedure is four years, ideal six years and the upper limit being eight years. Under the age of four years, disabling valgus deformities may result. Lichtblau indicates preference for wedge resection of the calcaneus at the calcaneo-cuboid joint rather than creating a surgical tarsal coalition.11 Though I have no experience with his alternative, the obvious disadvantage is the necessity for a brace for at least one year postoperative, whereas, with
Fig. 2. Lateral roentgenograms of the same patient following the Evans procedure.
Fig 3 Anteroposterior roentenograms of the following the Evans procedure
The most critical portions of the posteromedial release are the soft tissue releases of the talo-navicular joint and the sub-talar joints. Even with critical attention to all details of surgery and postoperative management, a small percentage of cases will develop recurrent deformities evidenced by heel equinus and varus. In my opinion, such recurrences are related to atrophic muscles, particularly poor return of peroneal function and existing adapative bony changes. The primary pathology still remains at the talonavicular joint and as would be anticipated, the addition of contracting surgical scar creates a problem unlikely to respond to corrective plaster casts. Abrams has reported success with the Evans procedure.9'10 This procedure com-
the Evans operation, an Oxford shoe is wonM six months postoperative with increase in correction possible with growth of the foot. I am unaware of any reported symptomatic congenital calcaneo-cuboid tarsal coalitions which, according to Harris, occurs in approximately one of every 100 tarsal coalitions. Motion at the calcaneo-cuboid joint is minimal and gliding when compared to more significant gliding, angular and rot'atory motion involving the subtalar and talo-navicular joints. Even Grice procedures and Gallie fusions have not always resulted in symptoms requiring completion of triple arthrodeses. For a child with recurrent clubfoot deformity following posteromedial release, I would prefer the Evans procedure at age four years. Triple arthrodesis is always available
same
patient
33
Idiopathic Clubfoot
Vol. 68, No. I
at 10-12 years if tarsal symptoms are disabling. Tendon transfers will never correct existing bony deformity. CASE REPORT L.B. was treated from birth with plaster cast for a bilateral idiopathic clubfoot deformity. At age 12 months, bilateral posteromedial releases were performed one week apart (Fig. 1). Plaster casts were discontinued after seven months postoperative. At age three years, the child re-presented to the clinic, having kept no appointments for more than six months, with an equinovarus deformity. Corrective casting and cabletwisting long-leg braces were all tried and found to be totally ineffective. At age five years, bilateral Evans operations were performed (Figs. 2 & 3). Two a a half years post-surgery, the feet remained corrected with dorsiflexion 20 degrees bilaterally and 30 degrees of plantarflexion possible in both feet. Invertion of each heel was possible to 10 degrees and eversion of five degrees bilaterally. Both heels were in slight valgus. There was no pain, and the mother indicated that the child physically competed in running activities with other children.
SUMMARY
Approximately one-half of patients seen with a diagnosis of idiopathic clubfoot will require surgical intervention to correct their deformities. This surgery should consist of a complete posteromedial release not to be performed under one year of age. No better results should be anticipated under the age of one year, and in my opinion is contraindicated. Beyond the age of two years, most certainly three years, there should be decreasing optimism towards adequate correction with soft tissue release alone. The Evans operation is the procedure of choice for recurrent deformity or residual deformity from ages four to eight years. Without resection of the lateral column of the foot at the calcaneal cuboid-joint, posteromedial release at these ages, will be ineffectual in correcting hind foot varus and the medial displacement of the navicular upon the talar head and neck. There is insufficient evidence to suggest that a surgical caleaneo-cuboid coalition will necessarily require eventual triple arthrodesis for
disabling symptoms. Roentgenographic assessment of postoperative posteromedial release operation is mandatory. The surgeon must know whether postoperative deformities are truly recurrent or the result of an inadequate surgical release. Without this type of proper assessment, it seems conceivable that with the wave of enthusiasm towards early surgical correction of clubfoot deformity, the return of notoriety and crippling results is an eminent possibility. LITERATURE CITED
1. HERSH, A. J. The Role of Surgery in the Treatment of Clubfeet. J. Bone & Joint Surg., 55a: 1377, 1973. 2. IRANI, R. N. and M. D. SHERMAN. The Pathological Anatomy of Clubfoot. J. Bone & Joint Surg., 45a:45-52, 1963. 3. KITE, T. H. Nonoperative Treatment of Congenital Clubfeet: A Review of One Hundred Cases. South. Med. J., 23:334-345, 1930. 4. BOST, F. C. and E. R. SCHOTTSTEADT, and L. J. LARSEN. Plantar Dissection. An Operation to Release the Soft Tissues in Recurrent or Recalcitrant Talipes Equinovarus. J. Bone & Joint
Surg., 42a:151-164, 1960. 5. TURCO, F. J. Surgical Correction of the Resistant Clubfoot. One-stage Posteromedial Release with Internal Fixation: A Preliminary Report. J. Bone & Joint Surg., 53a:477, 1971. 6. BEN-MENACHEN, Y. and J. E. BUTLER. Arteriography of the Foot in Congenital Deformities. J. Bone & Joint Surg., 56a:1625, 1974. 7. BEATSON, T. R. and J. R. PEARSON. A Method of Assessing Correction in Clubfeet. J. Bone & Joint Surg., 48b:40-50, 1966. 8. ASHBY, M. E. Roentgenographic Assessment of Soft Tissue Medial Release Operations in Clubfoot Deformity. Clin. Orthop., 90: 146-149, 1973. 9. ABRAMS, R. C. Relapsed Clubfoot: A Study of the Dillwyn Evans Operation. J. Bone & Joint Surg., 51a:270, 1969. 10. EVANS, D. Relapsed Clubfoot. J. Bone & Joint Surg., 43b:722-733. 11. LICHTBLAU, S. A Medial and Lateral Release Operation for Clubfoot. A Preliminary Report. J. Bone & Joint Surg., 55a: 1377, 1973. 12. HARRIS, R. I. Retrospect: Peroneal Spastic Flatfoot (Rigid Valgus Foot). J. Bone & Joint Surg., 47a: 1657, 1965.
(Williams and Grigsby, from page 4 1) Improving Existing Methods of Control of TuberReport of Five New Cases. Am. Rev. Resp. Dis. culosis: A Prime Challenge to the Experimentalist. 108:1320, 1973. Am. Rev. Resp. Dis., 105:183, 1972. 5. SCHMIDT L. H. The John Barnwell Lecture.
