0198-0211/92/1303-0116$03.00/0 FOOT & ANKLE Copyright © 1992 by the American Orthopaedic Foot Society, Inc.
Surgical Treatment of Clubfoot: A Comparison of Two Techniques Prasit Nimityongskul, M.D., Lewis D. Anderson, M.D., and Donald E. Herbert, Ph.D. Mobile, Alabama
in residual metatarsus adductus and an intoeing gait.15 McKay11-13 presented "new concepts of and approach to clubfoot treatment" in which he stressed the importance of abnormal horizontal calcaneal rotation. The calcaneal rotation concept has been supported by Ghali et al.8 In 1985, Simons15 presented Complete Subtalar Release in Clubfoot. In principle, his concepts and procedure agree with that of McKay.11-13 The complete subtalar release (CSR) procedure of McKay and Simons appears to be the most extensive single-stage release for clubfoot at the present time. In this report, we reviewed and compared the results of PMRs (16 feet) and CSRs (12 feet) performed at the University of South Alabama between 1977 and 1989.
ABSTRACT Between 1977 and 1989, 28 clubfeet were operated on, with follow-up ranging from 2 to 131/2 years and averaging 79 months. Group I (16 feet; average follow-up 104 months) underwent a modified Turco's posteromedial release. The functional result in this group was satisfactory in general, but approximately one third of this group required a secondary procedure for persistent intoeing or residual metatarsus adductus. Group II (12 feet; average follow-up 45 months) underwent a modified, complete subtalar release of McKay and Simons utilizing the Cincinnati incision. No patient in this second group required a secondary procedure. In our experience, the more complete subtalar release procedure of McKay and Simons resulted in beUer correction than the Turco posteromedial release. Although follow-up in group II was much shorter than that in group I, we felt that 2 years of minimum follow-up in group II was meaningful, since most of the recurrence or residual deformities were noticed within 18 months after surgery. The Cincinnati incision allowed beUer exposure and a more complete release. Skin flap necrosis was not a problem in this series.
MATERIALS AND METHODS
Between 1977 and 1989 at the University of South Alabama Medical Center, 19 patients (28 feet) underwent clubfoot release because of failure to obtain a satisfactory correction by serial casting. Two groups of patients were identified. Group I (1977-1984) included 16 feet in 11 patients who underwent one-stage Turco or modified Turco posteromedial release. The operation was performed according to the description given by Turco. The approach used in this group was the medial longitudinal incision with vertical extension along the Achilles tendon. Group II (1984-1989) included 12 feet in eight patients who had the more extensive one-stage release as described by McK ay11-13 and Simons." the so-called complete subtalar release or a modified complete subtalar release. The approach used in this group was the Cincinnati incision, described by Crawford et al.5 All operative reports were reviewed to determine which structures were released or lengthened. Results were evaluated clinically and radiographically. Six parameters were used to evaluate the clinical results: 1. Range of motion of the ankle and hindfoot (primarily the subtalar joint). This was measured according
INTRODUCTION
In the treatment of clubfoot, nonsurgical treatment should be attempted initially, and this can be successfuI.4,10,17 However, when adequate nonsurgical treatment fails to correct the deformities, surgery is usually indicated. The one-stage posteromedial release (PMR) for resistant clubfoot has gained wide popularity since its introduction by Turc019 in 1971. The procedure has been used and supported by several authors,1,9,14,18,2o Thompson et ai." reported no single case of overcorrection following the one-stage PMR in 93 feet. A more common problem with posteromedial release is incomplete correction or undercorrection, which results From the Department of Orthopaedic Surgery, University of South Alabama Medical Center, Mobile, Alabama. Address reprint requests to Dr. Nimityongskul at Department of Orthopaedic Surgery, University of South Alabama Medical Center, 2451 Fillingim St., Mastin 508, Mobile, Alabama 36617. 116
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Foot Axis
OF 20°
Normal
85°-90°
""\ Bimalleolar 3..-.....,t-'J'Axis ~ EV 20° Fig. 1. Normal range of motion of ankle and hindfoot.
to the methods described in the AMA Guide to Evaluation of Permanent Impairmenf (Fig. 1). 2. Bimalleolar/foot axis as described by McKay.11-13 This is the angle formed by the bimalleolar plane and the axis of the foot (Fig. 2). 3. Metatarsus adductus angle. This angle was measured on the foot tracing using the heel bisector line described by Bleck 2 and the axis of the second toe ray (Fig. 3). 4. Residual heel varus or valgus on weightbearing. This is estimated using the method described by Bleck" (Fig. 4). 5. Gross evaluation of plantarflexor strength. This is estimated by asking the patient to stand and walk on tiptoes (Fig. 5). 6. Difference in foot sizes. Length and width were measured on foot tracing. The results were compared with the normal foot (only in unilaterally involved patients where this was applicable) (Fig. 6). Six parameters on radiographs were used to determine the radiographic results. 1. Anteroposterior talocalcaneal angle (APTC). The pre- and postoperative angles were compared (Fig. 7). 2. Lateral talocalcaneal angle (LATG). The pre- and postoperative angles were compared (Fig. 8). 3. Talocalcaneal overlap on AP x-rays of the foot (Fig. 9). The talus and calcaneus overlapped about 25% on the AP x-ray of the foot according to Simons." More than 25% of overlap is considered abnormal and indicates undercorrection or that the hindfoot is in varus. However, our measurements revealed that up to 35% of talocalcaneal overlap is quite common in the normal
Fig. 2. Bimalleolar/foot angle between bimalleolar axis and foot axis (according to McKay). 2nd toe
2nd toe
,,
,,
, ,,, ,,
\
\
,, , ,,
\ \ \ \
I
9"
, ,, ,
\
\
\ 12
I
\
Heel BIsector
Fig. 3. Metatarsus adductus angle between the heel bisector line and the axis of the second toe.
foot. Therefore, we modified this criteria and used more than one-third overlap between the talus and calcaneus instead of one-fourth overlap as a criterion for unsatisfactory result. 4. Anteroposterior navicular position." Using Simons' criteria, this is considered unsatisfactory if the navicular deviates medially more than one fourth the diameter of the talar head (this indicates forefoot adduction) or deviates laterally more than one half the
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Fig. 4. Estimation of residual heel varus on valgus on weightbearing (according to Bleck).
diameter of the talar head (this indicates forefoot abduction) (Fig. 10). In case the ossific nucleus of navicular had not yet appeared, the first metatarsal axis was used. Deviation of the talar axis more than one full diameter of the first metatarsal base is considered an unsatisfactory result. 5. Lateral navicular posltlon." This is considered an unsatisfactory height from the talar axis. In the case of an absence of ossific nucleus of the navicular, the first metatarsal axis was used. A deviation of the first metatarsal axis of more than one third of the talar head height is considered an unsatisfactory lateral navicular position (Fig. 11). 6. The presence or absence of flat top talus is also compared for the two groups of patients (Fig. 12).
Fig. 5. Ability to stand and walk on tiptoe (plantarflexor strength evaluation). 0, Cannot rise on tiptoe; 1, can, but weak; 2, can stand and walk normally.
RESULTS (See Tables 1-7) Flat Top Talus
1
1
7.8 em
- - -1- - - - - - - - - 1
This condition was noted in 10 of 16, or 62.5% of group I patients and one of 12, or 8.3%, of group II patients. The incidence of flat top talus for the whole series was 11 of 28 feet, or 39.3%.
1
I I
I
I I I
/18.4 em 1
I
Secondary Procedures
1
I 1
Six of 16 feet, or 37.5%, in group I required secondary procedures that included: the Heyman-Herndon procedure, plantar fascia release in one foot, repeat tendo achillis lengthening and posterior capsulotomy and supramalleolar osteotomy in one foot, abductor hallucis release and plantar fascia release in two feet,
I I I I
I I
I
,,I I
Fig. 6.
Measurement of foot length and width on foot tracing.
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AP-NAVICULAR POSITION 1/4 TALUS MED. 1/2 TALUS LAT.
AP-TC ANGLE 20° 40°
~\
~.
tJ
~
~."
tJ
1 DIAMETER OF 1ST MT. BASE
Fig. 10. AP navicular position according to Simons. LAT. NAVICULAR POSITION 1/3 NAVICULAR HEIGHT
~~~ 1/3 TALAR HEAD Fig. 11. Lateral navicular position according to Simons.
Fig. 7. AP talocalcaneal angle. LAT-TC ANGLE 35° 50"
Fig. 8. Lateral talocalcaneal angle.
Fig. 12. An example of patient with flat top talus.
Talo-Calcaneal Overlap 1/3 Abnormal
>
Fig. 9. AP talocalcanealoverlap (modified from Simons).
and metatarsal osteotomies and plantar fascia release in two feet. Another three of 16 feet, or 19%, were considered for secondary procedures. Overall, approximately 55% of patients in group I had or will have secondary procedures.
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NIMITYONGSKUL ET AL. TABLE 1
Data on the Two Groups of Patients Group I
Group 1\
Groups I & II
(1977-1984) (1985-1989) (1977-1989) Patients (N) Feet (N) Patients with unilateral clubfoot (N) Patients with bilateral clubfoot (N) Blacks (N) Whites (N) Age at surgery (months) Range Average Age at follow-up (months) Range Average
11 16 6
8 12 4
19 29 10
5
4
9
5 6
5 3
10 9
5-45 10.6
6-24 13.7
5-45 11.9
89-161 104.9
24-69 45.25
24-161 79.4
None of the patients in group II required a secondary procedure at the time of this report. However, three of 12, or 25%, were noted to have residual metatarsus adductus on follow-up. Two of 12, or 16.7%, may need secondary procedure. DISCUSSION
Surgical correction of clubfoot rarely, if ever, resulted in a normal foot.1.9.11-13.15.2o In our experience, between 1977 and 1989, it appeared that the result of a more extensive one-stage complete subtalar release was better than that of the one-stage posteromedial release, as shown by the significant difference in the clinical and radiographic parameters used to measure the results. Most of our patients continue to walk and function with mild discomfort, can wear normal shoes, have occasional mild pain with strenuous activities, and remain generally active. The Thoroughness of Complete Subtalar Release
We would expect that the complete subtalar release group would have a higher percentage of structures released and lengthened. However, as documented in the operative reports that we reviewed, the PMR group had a higher percentage of releases of the superficial deltoid ligament, anterior subtalar capsulotomies, and lateral talonavicular capsulotomies. We believe this may reflect the failure to mention all the structures that were released in the operative report by the (dictating) surgeons. Skin Problem after Cincinnati Incision
None of the patients in groups I or II had problems with wound healing or skin necrosis. We believe, in our limited experience, that the Cincinnati incision provides
an easier approach to the posterior and lateral structures and allows more complete release of the posterior and lateral subtalar capsules. The prone position does not interfere with access to the medial aspect of the foot. Our experience agrees with that of Crawford, et al." McKay,11-13 and Simons." Ankle Range of Motion (Table 3)
Group I lost 60% of ankle dorsiflexion and 40% of plantarflexion. Group II lost 25% each of dorsiflexion and plantarflexion; the difference was statistically significant (P < .0001). Loss of inversion of the hindfoot was 60% for group I and 40% for group II. Loss of eversion was 60% in group I and 25% in group II. The difference was significant (P = .0001). The total range of motion loss was 50% in group I and 30% in group II. The whole group showed a 40% loss of total ankle and hindfoot range of motion. A normal ankle has 60° of motion in the sagittal plane, which consists of 20° of dorsiflexion and 40° of plantarflexion." The stance phase of gait in normal walking requires a minimum of 10° of ankle dorsiflexion and 15° of plantarflexlon." a combination of 25°, or 42%, of normal ankle range of motion. The result of ankle range of motion measurement in our patients showed a 55% retention in group I and a 76% retention in group II. This may explain why our patients, despite rather severe loss of ankle dorsiflexion and plantarflexion, continue to walk with little or no problem. The inversion and eversion of the hindfoot (primarily the subtalar joint) also showed approximately 50% loss of motion in this plane in the whole group. Group I retained about 45% range of motion in this plane and group II retained about 65%. The difference was statistically significant. Bimalleolar/Foot Axis, Residual Metatarsus Adductus, Heel Varus and Valgus, and Plantarflexor Strength (Table 4)
The blrnaueolar/toot axis averaged 72° in group I and 80° in group II. The difference was significant (P = .0003). Residual metatarsus adductus averaged 7.8° in group I and 3.3° in group II. This was also statistically significant (P = .0002). The method we used to determine hindfoot varus or valgus is another weakness in our study and is quite subjective and will change with different observers. The radiographic method is more reproducible and less subjective to interobserver difference. However, we felt that this is one of the most common methods used in interpreting hindfoot varus or valgus in clinical practice. Residual heel varus or valgus was not significant in the two groups since both fall within the normal range of 0-5° valgus. The gross estimation of plantarflexor
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TABLE 2 Percentageof Structures Released or Lengthened"
1. 2. 3. 4. 5. 6. 7.
Tendo achillis lengthening Posterior tibialis lengthening Flexor hallucis longus lengthening Flexor digitorum longus lengthening Anterior tibialis transfer Adductor hallucis & plantar fascia release Subtalar capsulotomy Posterior Medial Anterior Lateral 8. Ankle caps ulotomy Posterior Medial Anterior Lateral 9. Interosseous talocalcaneal ligament release 10. Deltoid ligament release Superficial Deep 11. Talonavicular capsulotomy Medial Dorsal Plantar Lateral 12. Calcaneofibular ligament release 13. Posterior taloflbular ligament release 14. Calcaneocuboid capsulotomy 15. Master Knot of Henry release 16. Spring ligament 17. Bifurcate ligament release 18. No. of pins used
0 1 2 3
Group I
Group II
Groups I & II
(1977-1984) 100% 100 69 69 12 12
(1985-1989) 100% 100 83 83 0 50
(1977-1989) 100% 100 75 75 7 29
100 62 50 0
100 83 17 42
100 71 36 18
100 0 0 12 31
100 0 0 25 25
100 0 0 18 29
87 0
58 0
75 0
81 75 25 12 56 37 6 44 44 44
75 67 75 0 75 50 0 50 42 17
78 71 46 7 64 43 4 46 43 32
0 6 87 6
17 67 17 0
7 32 57 4
" Data on the percentage of structures released or lengthened according to the operative reports. The Achilles tendon and posterior tibial tendon were lengthened in 100% of the feet. The posterior ankle and subtalar capsulotomies were performed in all of the feet. The calcaneofibular ligament was released in 64% of the feet. The interosseous talocalcaneal ligament was released in 29% of the feet.
TABLE 3 Follow-Up Range of Motion of Ankle and Hindfoot Expressed as Percentageof Normal
Group I Range Average Group II Range Average Groups I and II Range Average
Dorsiflexion
Plantarflexion
Dorsiflexion & plantarflexion"
Inversion
Eversion
Inversion & eversion"
Total ankle & hindfoot ROM
0-75 39
25-87 62
25-83 55
17-67 42.6
0-75 43.7
10-70 43
18-77 50
50-100 77
50-87 76
50-92 76
33-67 60
50-100 75
40-90 64
45-82 71
0-100 55
25-87 68
25-92 64
17-67 50
0-100 54
10-90 53
18-82 59
"P < .0001. b P = .0001.
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TABLE 4 Data on Result of Bimalleolar/Foot Axis, Residual Metatarsus Adductus, Heel Varus/Valgus, and Ability to Stand on Tiptoe Ability to Residual Residual stand or Bimalleolar/ metatarsus heel varus (-) walk on foot axis" adductus" or valgus (+}C (0) tiptoed (0) (0) (0) Group I Range Average Group II Range Average Groups I & II Range Average
60-80 72
0-18 7.8
-5-+5 +0.2 (Valgus)
0-2 1.18
70-85 80
0-13 3.3
-3-+10 +3.1 (Valgus)
0-2 1.6
60-80 75
0-18 5.9
-5-+10 +1.4 (Valgus)
0-2 1.35
• Normal, 85-90; P = .0003, significant. b Measured on foot tracing. Heel bisector against second toe axis; P = .02, significant. C Normal heel, 0 to +5 (valgus); insignificant; both fall within normal range. dO, Cannot rise on tiptoe; 1, can but weak; 2, normal; P = .05.
TABLE 5 Loss or Gain in Foot Length and Width at Follow-Up' Loss in length b
Group I (N = 6) Group II (N = 4) Groups I and II (N = 10)
Loss (-}/gain (+) of width"
Range
Average
Range
Average
(%)
(%)
(%)
(%)
11-14 3-22 3-22
12 12 12
0-+23 -1--10 -10-+23
+4.5 -3.5 +1.4
• Table 5 shows the loss or gain in length and width of the foot at follow-up in each group. Only the unilaterally involved cases are used to calculate this. Data were too few to be statistically meaningful. On average, foot was 12% shorter and slightly (1.4%) wider. b Percentage of normal foot length. C Percentage of normal width.
strength (the ability to stand or walk on tiptoes) also showed that the CSR group was better than the PMR group. Foot Size (Table 5)
The loss of foot length was the same in both the PMR and CSR groups. However, group I resulted in a slightly wider foot (4.5% wider) when compared with the normal, opposite foot, and group II had a slightly narrower foot (3.5% narrower). In bilateral clubfoot, our foot tracing measurements indicated that the foot that looked and felt better to the patient and parents was usually the longer and wider foot. Radiographic Results: Talocalcaneal Angle (Table 6)
The APTC angle improved from 10° preoperatively to 23° postoperatively in group I and from 9° preoper-
TABLE 6 Improvement in APTC and LATC Angles Group I Preoperative APTC angle (O) Range Average Postoperative APTC angle (O) Range Average Preoperative LATC angle Range Average Postoperative LATC angle Range Average
Group II
Groups I & II
0-15 (N = 8)· 5-21 (N = 7}b 0-21 (N = 15) 10.1 9.0 9.6
13-43 23.1
16-44 26.1
13-44 24.4
0-22 (N = 7) 5-25 (N = 8) 0-25 (N = 15) 12.6 15.9 14.3
16-44 30.9
32-54 38.8
16-54 34.3
• Due to a flood in the city in early 1980, some x-rays were permanently damaged and discarded. This results in incomplete data on the preoperative AP and lateral talocalcaneal angle of some patients. b Only seven cases have complete x-rays for this measurement.
TABLE 7 Percentage of Unsatisfactory Radiographic Results in Talocalcaneal Overlap, Navicular Position on AP, and Lateral X-Rays of the Foot Talocalcaneal
overlap" (%) Group I (N = 16) Group II (N = 12) Groups I and II (N = 28)
69 8 46
AP navicular position"
Lateral navicular posltlon"
(%)
(%)
25 0 14
19 33 25
• P = .0009, significant. b Not significant. C Not significant.
atively to 26° postoperatively in group II. The difference was not significant. The LATC angle improved from 12.6° to 30.9° in group I and from 15.9° to 38.8° in group II. This difference was statistically significant (P = .0009). Overall, in this whole series, the APTC angle improved approximately 15° on average and the LATC angle improved approximately 20° on average. Talocalcaneal Overlap and Navicular Position (Table 7)
Measurements of APTC overlap showed that the PMR group had 69% unsatisfactory result and the CSR group had 8% unsatisfactory result. The difference was significant. The AP navicular position was unsatisfactory in 25% of feet in group I and all feet were satisfactory in group II. The lateral navicular position was unsatisfactory in 33% of group " and in 19% of group I. There was no
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Foot & AnkJefVoJ. 13, No. 3jMarchjApriJ 1992
statistical difference of unsatisfactory results between the PMR and CSR groups based on the navicular position both on AP and lateral x-rays. The follow-up in group II was shorter than in group I, and in most cases in group II, the navicular had just begun to ossify or had not yet ossified. We believe this makes the measurements of group II patients less reliable than those of group I patients, in whom the navicular were much better developed and easier to measure on x-ray. Although the percentage of unsatisfactory radiographic results in this category was high, our review showed no definite correlation between this radiographic measurement and pain, function, and limitation of activities. Flat Top Talus
A true flat top talus following clubfoot treatment is the result of a forced dorsiflexion of the ankle against a tight posterior structure, the so-called nutcracker effect.4 The high incidence of flat top talus in group I most likely represents an undercorrected or incompletely corrected foot that was forced into dorsiflexion by subsequent casting or ambulation. The CSR group had a much lower incidence (8.3%) of flat top talus compared with the PMR group (62.5%). Overall, the series showed a 39% incidence of flat top talus. Dunn and samuelson" reported on the long-term result of flat top talus and found that it was a common problem following closed treatment of clubfoot, but that the presence of flat top talus did not correlate with pain or function. Our results agree with this finding. Secondary Procedures
The CSR, so far, has resulted in a foot that does not require a secondary procedure. However, three of 12 feet, or 25%, were noted to have mild residual metatarsus adductus. Two of 12, or 16.7%, may need secondary procedure. Six of 16 feet, or 37%, of the PMR group required secondary procedures and another three of 16 feet, or 19%, were considered for a secondary procedure. Although the follow-up in group II was shorter (average 45.25 months versus 104.9 months in group I), most of the residual deformities in group I were noticed and recorded within 18 months after surgery. On this basis, we believe there will not be a substantial change of result in group II with longer follow-up. However, this remains to be seen and we intend to follow all the patients to at least skeletal maturity.
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McKay and Simons resulted in a better correction than the Turco posteromedial release. We felt that the Cincinnati incision allowed a better exposure and more complete posterior and lateral release than the longitudinal-vertical incision used by Turco. We did the Cincinnati approach with the patier:t in both supine and prone position and we feel that the prone position allows better access to the subtalar joint. So far, we have not had skin necrosis following the Cincinnati incision since we began this ir11985 (12 feet). It appears from our data that the posteromedial release resulted in a slightly undercorrected foot and the complete subtalar release resulted in a better corrected or sometimes slightly overcorrected foot. This is demonstrated in the significant improvement of blmalleolar/foot axis, less residual metatarsus adductus, and slightly higher degrees of residual heel valgus in the CSR group. The discrepancy in length of follow-up between the two groups is an obvious shortcoming in our study. The reason is that this is a retrospective study and we have been doing complete subtalar releases since 1985. However, we feel that a minimum of 2 years of follow-up in the second group is meaningful, since most of the residual deformities are noted within 18 months following surgery. There are many variables involved in the treatment and evaluation of results in clubfoot. Some of these include difference in degree and severity of pathology in each clubfoot, the thoroughness of each step of surgical release, and the differences in postoperative immobilization. The measurement of range of motion of hindfoot and subtalar joint, at best, is only an approximation of the true motion. All these variables make it difficult to draw a definite conclusion in a study like this. Also, we realize that our better result in the complete subtalar release group may partly reflect the "learning curve" in the operative treatment of clubfoot at our institution. Despite our better result with the complete subtalar release group, both the posteromedial release and the complete subtalar release resulted in a functional foot without major physical handicaps. All of these children are active in general and able to wear regular shoes with minor adjustments. Our experience indicates that the more extensive one-stage complete subtalar release appears to give a better result than the one-stage posteromedial release.
SUMMARY AND CONCLUSION
ACKNOWLEDGMENTS
In our limited experience with 29 clubfeet, the more complete subtalar release procedure advocated by
The authors wish to thank Sarah O'Donnell for her help in the preparation of the manuscript.
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REFERENCES 1. Bethem, D., and Weiner, D.: Radical one-stage posteromedial release for the resistant clubfoot. Clin. Orthop., 131:214-223, 1978. 2. Bleck, E.E.: Metatarsus adductus: classification and relationship to outcomes of treatment. J. Pediatr. Orthop. 3:2-9,1983. 3. Bleck, E.E.: Orthopaedic Management in Cerebral Palsy. Philadelphia, J.B. Lippincott, 1987. 4. Coleman, S.S.: Complex Foot Deformities in Children. Philadelphia, Lea & Febiger, 1983, pp. 23-110. 5. Crawford, A.H., Marxen, J.L., and Osterfeld, D.L.: The cincinnati incision: a comprehensive approach for surgical procedures of the foot and ankle in childhood. J. Bone Joint Surg., 64A:1355-1358, 1982. 6. Dunn, H.K., and Samuelson, K.M.: Flat-top talus. A long-term report of twenty club feet. J. Bone Joint Surg., 56A:57-62, 1974. 7. Engelberg, A.L. (Ed.): AMA Guides to the Evaluation of Permanent Impairment, 3rd Ed. 1988, pp. 56-60. 8. Ghali, N.N., Smith, R.B., Clayden, A.D., and Silk, F.F.: The results of pantalar reduction in the management of congenital talipes equinovarus. J. Bone Joint Surg., 65B:1-7, 1983. 9. Johanson, J.E., Horak, R.D., and Winter, R.B.: Gillette children's hospital experience with the turco procedure for clubfeet (talipes equinovarus). Minn. Med., 745-749, 1981. 10. Lovell, W.W., and Winter, R.B.: Pediatric Orthopaedics, Vol. 2. Philadelphia,J.B. Lippincott, 1978, pp. 917-930. 11. McKay, D.W.: New concept of and approach to clubfoot treatment: section I-principles and morbid anatomy. J. Pediatr. Orthop., 2:347-356, 1982.
12. McKay, D.W.: New concept of and approach to clubfoot treatment: section II-correction of the clubfoot. J. Pediatr. Orthop., 3:10-21,1983. 13. McKay, D.W.: New concept of and approach to clubfoot treatment: section III-evaluation and results. J. Pediatr. Orthop., 3:148, 1983. 14. Porat, S., Milgrom, C., and Bentley, G.: The history of treatment of congenital clubfoot at the royal liverpool children's hospital: improvement of results by early extensive posteromedial release. J. Pediatr. Ortnop., 4:331-338, 1984. 15. Simons, G.W.: Complete subtalar release in club feet. Part I-a preliminary report and Part II-comparison with less extensive procedures. J. Bone Joint Surg., 67A:1044-1065, 1985. 16. Stauffer, R.N., Chao, E.Y.S., and Brewster, R.C.: Force and motion analysis of the normal, diseased, and prosthetic ankle joint. Clin. Orthop., 127:189-196,1977. 17. Tachdjian, M.O.: Pediatric Orthopaedics, Vol. 1. Philadelphia, W.B. Saunders, 1972, pp. 1274-1322. 18. Thompson, G.H., Richardson, A.B., and Westin, G.W.: Surgical management of resistant congenital talipes equinovarus deformities. J. Bone Joint Surg., 64A:652-665, 1982. 19. Turco, V.J.: Surgical correction of the resistant club foot. Onestage posteromedial release with internal fixation: a preliminary report. J. Bone Joint Surg., 53A:477 -497, 1971. 20. Turco, V.J.: Resistant congenital club foot-one stage posteromedial release with internal fixation. A follow-up report of a fifteen-year experience. J. Bone Joint Surg., 61A:805-814, 1979.
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Surgical Treatment of Clubfoot: A Comparison of Two Techniques Prasit Nimityongskul, M.D., Lewis D. Anderson, M.D., and Donald E. Herbert, Ph.D. Mobile, Alabama
in residual metatarsus adductus and an intoeing gait.15 McKay11-13 presented "new concepts of and approach to clubfoot treatment" in which he stressed the importance of abnormal horizontal calcaneal rotation. The calcaneal rotation concept has been supported by Ghali et al.8 In 1985, Simons15 presented Complete Subtalar Release in Clubfoot. In principle, his concepts and procedure agree with that of McKay.11-13 The complete subtalar release (CSR) procedure of McKay and Simons appears to be the most extensive single-stage release for clubfoot at the present time. In this report, we reviewed and compared the results of PMRs (16 feet) and CSRs (12 feet) performed at the University of South Alabama between 1977 and 1989.
ABSTRACT Between 1977 and 1989, 28 clubfeet were operated on, with follow-up ranging from 2 to 131/2 years and averaging 79 months. Group I (16 feet; average follow-up 104 months) underwent a modified Turco's posteromedial release. The functional result in this group was satisfactory in general, but approximately one third of this group required a secondary procedure for persistent intoeing or residual metatarsus adductus. Group II (12 feet; average follow-up 45 months) underwent a modified, complete subtalar release of McKay and Simons utilizing the Cincinnati incision. No patient in this second group required a secondary procedure. In our experience, the more complete subtalar release procedure of McKay and Simons resulted in beUer correction than the Turco posteromedial release. Although follow-up in group II was much shorter than that in group I, we felt that 2 years of minimum follow-up in group II was meaningful, since most of the recurrence or residual deformities were noticed within 18 months after surgery. The Cincinnati incision allowed beUer exposure and a more complete release. Skin flap necrosis was not a problem in this series.
MATERIALS AND METHODS
Between 1977 and 1989 at the University of South Alabama Medical Center, 19 patients (28 feet) underwent clubfoot release because of failure to obtain a satisfactory correction by serial casting. Two groups of patients were identified. Group I (1977-1984) included 16 feet in 11 patients who underwent one-stage Turco or modified Turco posteromedial release. The operation was performed according to the description given by Turco. The approach used in this group was the medial longitudinal incision with vertical extension along the Achilles tendon. Group II (1984-1989) included 12 feet in eight patients who had the more extensive one-stage release as described by McK ay11-13 and Simons." the so-called complete subtalar release or a modified complete subtalar release. The approach used in this group was the Cincinnati incision, described by Crawford et al.5 All operative reports were reviewed to determine which structures were released or lengthened. Results were evaluated clinically and radiographically. Six parameters were used to evaluate the clinical results: 1. Range of motion of the ankle and hindfoot (primarily the subtalar joint). This was measured according
INTRODUCTION
In the treatment of clubfoot, nonsurgical treatment should be attempted initially, and this can be successfuI.4,10,17 However, when adequate nonsurgical treatment fails to correct the deformities, surgery is usually indicated. The one-stage posteromedial release (PMR) for resistant clubfoot has gained wide popularity since its introduction by Turc019 in 1971. The procedure has been used and supported by several authors,1,9,14,18,2o Thompson et ai." reported no single case of overcorrection following the one-stage PMR in 93 feet. A more common problem with posteromedial release is incomplete correction or undercorrection, which results From the Department of Orthopaedic Surgery, University of South Alabama Medical Center, Mobile, Alabama. Address reprint requests to Dr. Nimityongskul at Department of Orthopaedic Surgery, University of South Alabama Medical Center, 2451 Fillingim St., Mastin 508, Mobile, Alabama 36617. 116
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Foot Axis
OF 20°
Normal
85°-90°
""\ Bimalleolar 3..-.....,t-'J'Axis ~ EV 20° Fig. 1. Normal range of motion of ankle and hindfoot.
to the methods described in the AMA Guide to Evaluation of Permanent Impairmenf (Fig. 1). 2. Bimalleolar/foot axis as described by McKay.11-13 This is the angle formed by the bimalleolar plane and the axis of the foot (Fig. 2). 3. Metatarsus adductus angle. This angle was measured on the foot tracing using the heel bisector line described by Bleck 2 and the axis of the second toe ray (Fig. 3). 4. Residual heel varus or valgus on weightbearing. This is estimated using the method described by Bleck" (Fig. 4). 5. Gross evaluation of plantarflexor strength. This is estimated by asking the patient to stand and walk on tiptoes (Fig. 5). 6. Difference in foot sizes. Length and width were measured on foot tracing. The results were compared with the normal foot (only in unilaterally involved patients where this was applicable) (Fig. 6). Six parameters on radiographs were used to determine the radiographic results. 1. Anteroposterior talocalcaneal angle (APTC). The pre- and postoperative angles were compared (Fig. 7). 2. Lateral talocalcaneal angle (LATG). The pre- and postoperative angles were compared (Fig. 8). 3. Talocalcaneal overlap on AP x-rays of the foot (Fig. 9). The talus and calcaneus overlapped about 25% on the AP x-ray of the foot according to Simons." More than 25% of overlap is considered abnormal and indicates undercorrection or that the hindfoot is in varus. However, our measurements revealed that up to 35% of talocalcaneal overlap is quite common in the normal
Fig. 2. Bimalleolar/foot angle between bimalleolar axis and foot axis (according to McKay). 2nd toe
2nd toe
,,
,,
, ,,, ,,
\
\
,, , ,,
\ \ \ \
I
9"
, ,, ,
\
\
\ 12
I
\
Heel BIsector
Fig. 3. Metatarsus adductus angle between the heel bisector line and the axis of the second toe.
foot. Therefore, we modified this criteria and used more than one-third overlap between the talus and calcaneus instead of one-fourth overlap as a criterion for unsatisfactory result. 4. Anteroposterior navicular position." Using Simons' criteria, this is considered unsatisfactory if the navicular deviates medially more than one fourth the diameter of the talar head (this indicates forefoot adduction) or deviates laterally more than one half the
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Fig. 4. Estimation of residual heel varus on valgus on weightbearing (according to Bleck).
diameter of the talar head (this indicates forefoot abduction) (Fig. 10). In case the ossific nucleus of navicular had not yet appeared, the first metatarsal axis was used. Deviation of the talar axis more than one full diameter of the first metatarsal base is considered an unsatisfactory result. 5. Lateral navicular posltlon." This is considered an unsatisfactory height from the talar axis. In the case of an absence of ossific nucleus of the navicular, the first metatarsal axis was used. A deviation of the first metatarsal axis of more than one third of the talar head height is considered an unsatisfactory lateral navicular position (Fig. 11). 6. The presence or absence of flat top talus is also compared for the two groups of patients (Fig. 12).
Fig. 5. Ability to stand and walk on tiptoe (plantarflexor strength evaluation). 0, Cannot rise on tiptoe; 1, can, but weak; 2, can stand and walk normally.
RESULTS (See Tables 1-7) Flat Top Talus
1
1
7.8 em
- - -1- - - - - - - - - 1
This condition was noted in 10 of 16, or 62.5% of group I patients and one of 12, or 8.3%, of group II patients. The incidence of flat top talus for the whole series was 11 of 28 feet, or 39.3%.
1
I I
I
I I I
/18.4 em 1
I
Secondary Procedures
1
I 1
Six of 16 feet, or 37.5%, in group I required secondary procedures that included: the Heyman-Herndon procedure, plantar fascia release in one foot, repeat tendo achillis lengthening and posterior capsulotomy and supramalleolar osteotomy in one foot, abductor hallucis release and plantar fascia release in two feet,
I I I I
I I
I
,,I I
Fig. 6.
Measurement of foot length and width on foot tracing.
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AP-NAVICULAR POSITION 1/4 TALUS MED. 1/2 TALUS LAT.
AP-TC ANGLE 20° 40°
~\
~.
tJ
~
~."
tJ
1 DIAMETER OF 1ST MT. BASE
Fig. 10. AP navicular position according to Simons. LAT. NAVICULAR POSITION 1/3 NAVICULAR HEIGHT
~~~ 1/3 TALAR HEAD Fig. 11. Lateral navicular position according to Simons.
Fig. 7. AP talocalcaneal angle. LAT-TC ANGLE 35° 50"
Fig. 8. Lateral talocalcaneal angle.
Fig. 12. An example of patient with flat top talus.
Talo-Calcaneal Overlap 1/3 Abnormal
>
Fig. 9. AP talocalcanealoverlap (modified from Simons).
and metatarsal osteotomies and plantar fascia release in two feet. Another three of 16 feet, or 19%, were considered for secondary procedures. Overall, approximately 55% of patients in group I had or will have secondary procedures.
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NIMITYONGSKUL ET AL. TABLE 1
Data on the Two Groups of Patients Group I
Group 1\
Groups I & II
(1977-1984) (1985-1989) (1977-1989) Patients (N) Feet (N) Patients with unilateral clubfoot (N) Patients with bilateral clubfoot (N) Blacks (N) Whites (N) Age at surgery (months) Range Average Age at follow-up (months) Range Average
11 16 6
8 12 4
19 29 10
5
4
9
5 6
5 3
10 9
5-45 10.6
6-24 13.7
5-45 11.9
89-161 104.9
24-69 45.25
24-161 79.4
None of the patients in group II required a secondary procedure at the time of this report. However, three of 12, or 25%, were noted to have residual metatarsus adductus on follow-up. Two of 12, or 16.7%, may need secondary procedure. DISCUSSION
Surgical correction of clubfoot rarely, if ever, resulted in a normal foot.1.9.11-13.15.2o In our experience, between 1977 and 1989, it appeared that the result of a more extensive one-stage complete subtalar release was better than that of the one-stage posteromedial release, as shown by the significant difference in the clinical and radiographic parameters used to measure the results. Most of our patients continue to walk and function with mild discomfort, can wear normal shoes, have occasional mild pain with strenuous activities, and remain generally active. The Thoroughness of Complete Subtalar Release
We would expect that the complete subtalar release group would have a higher percentage of structures released and lengthened. However, as documented in the operative reports that we reviewed, the PMR group had a higher percentage of releases of the superficial deltoid ligament, anterior subtalar capsulotomies, and lateral talonavicular capsulotomies. We believe this may reflect the failure to mention all the structures that were released in the operative report by the (dictating) surgeons. Skin Problem after Cincinnati Incision
None of the patients in groups I or II had problems with wound healing or skin necrosis. We believe, in our limited experience, that the Cincinnati incision provides
an easier approach to the posterior and lateral structures and allows more complete release of the posterior and lateral subtalar capsules. The prone position does not interfere with access to the medial aspect of the foot. Our experience agrees with that of Crawford, et al." McKay,11-13 and Simons." Ankle Range of Motion (Table 3)
Group I lost 60% of ankle dorsiflexion and 40% of plantarflexion. Group II lost 25% each of dorsiflexion and plantarflexion; the difference was statistically significant (P < .0001). Loss of inversion of the hindfoot was 60% for group I and 40% for group II. Loss of eversion was 60% in group I and 25% in group II. The difference was significant (P = .0001). The total range of motion loss was 50% in group I and 30% in group II. The whole group showed a 40% loss of total ankle and hindfoot range of motion. A normal ankle has 60° of motion in the sagittal plane, which consists of 20° of dorsiflexion and 40° of plantarflexion." The stance phase of gait in normal walking requires a minimum of 10° of ankle dorsiflexion and 15° of plantarflexlon." a combination of 25°, or 42%, of normal ankle range of motion. The result of ankle range of motion measurement in our patients showed a 55% retention in group I and a 76% retention in group II. This may explain why our patients, despite rather severe loss of ankle dorsiflexion and plantarflexion, continue to walk with little or no problem. The inversion and eversion of the hindfoot (primarily the subtalar joint) also showed approximately 50% loss of motion in this plane in the whole group. Group I retained about 45% range of motion in this plane and group II retained about 65%. The difference was statistically significant. Bimalleolar/Foot Axis, Residual Metatarsus Adductus, Heel Varus and Valgus, and Plantarflexor Strength (Table 4)
The blrnaueolar/toot axis averaged 72° in group I and 80° in group II. The difference was significant (P = .0003). Residual metatarsus adductus averaged 7.8° in group I and 3.3° in group II. This was also statistically significant (P = .0002). The method we used to determine hindfoot varus or valgus is another weakness in our study and is quite subjective and will change with different observers. The radiographic method is more reproducible and less subjective to interobserver difference. However, we felt that this is one of the most common methods used in interpreting hindfoot varus or valgus in clinical practice. Residual heel varus or valgus was not significant in the two groups since both fall within the normal range of 0-5° valgus. The gross estimation of plantarflexor
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TABLE 2 Percentageof Structures Released or Lengthened"
1. 2. 3. 4. 5. 6. 7.
Tendo achillis lengthening Posterior tibialis lengthening Flexor hallucis longus lengthening Flexor digitorum longus lengthening Anterior tibialis transfer Adductor hallucis & plantar fascia release Subtalar capsulotomy Posterior Medial Anterior Lateral 8. Ankle caps ulotomy Posterior Medial Anterior Lateral 9. Interosseous talocalcaneal ligament release 10. Deltoid ligament release Superficial Deep 11. Talonavicular capsulotomy Medial Dorsal Plantar Lateral 12. Calcaneofibular ligament release 13. Posterior taloflbular ligament release 14. Calcaneocuboid capsulotomy 15. Master Knot of Henry release 16. Spring ligament 17. Bifurcate ligament release 18. No. of pins used
0 1 2 3
Group I
Group II
Groups I & II
(1977-1984) 100% 100 69 69 12 12
(1985-1989) 100% 100 83 83 0 50
(1977-1989) 100% 100 75 75 7 29
100 62 50 0
100 83 17 42
100 71 36 18
100 0 0 12 31
100 0 0 25 25
100 0 0 18 29
87 0
58 0
75 0
81 75 25 12 56 37 6 44 44 44
75 67 75 0 75 50 0 50 42 17
78 71 46 7 64 43 4 46 43 32
0 6 87 6
17 67 17 0
7 32 57 4
" Data on the percentage of structures released or lengthened according to the operative reports. The Achilles tendon and posterior tibial tendon were lengthened in 100% of the feet. The posterior ankle and subtalar capsulotomies were performed in all of the feet. The calcaneofibular ligament was released in 64% of the feet. The interosseous talocalcaneal ligament was released in 29% of the feet.
TABLE 3 Follow-Up Range of Motion of Ankle and Hindfoot Expressed as Percentageof Normal
Group I Range Average Group II Range Average Groups I and II Range Average
Dorsiflexion
Plantarflexion
Dorsiflexion & plantarflexion"
Inversion
Eversion
Inversion & eversion"
Total ankle & hindfoot ROM
0-75 39
25-87 62
25-83 55
17-67 42.6
0-75 43.7
10-70 43
18-77 50
50-100 77
50-87 76
50-92 76
33-67 60
50-100 75
40-90 64
45-82 71
0-100 55
25-87 68
25-92 64
17-67 50
0-100 54
10-90 53
18-82 59
"P < .0001. b P = .0001.
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TABLE 4 Data on Result of Bimalleolar/Foot Axis, Residual Metatarsus Adductus, Heel Varus/Valgus, and Ability to Stand on Tiptoe Ability to Residual Residual stand or Bimalleolar/ metatarsus heel varus (-) walk on foot axis" adductus" or valgus (+}C (0) tiptoed (0) (0) (0) Group I Range Average Group II Range Average Groups I & II Range Average
60-80 72
0-18 7.8
-5-+5 +0.2 (Valgus)
0-2 1.18
70-85 80
0-13 3.3
-3-+10 +3.1 (Valgus)
0-2 1.6
60-80 75
0-18 5.9
-5-+10 +1.4 (Valgus)
0-2 1.35
• Normal, 85-90; P = .0003, significant. b Measured on foot tracing. Heel bisector against second toe axis; P = .02, significant. C Normal heel, 0 to +5 (valgus); insignificant; both fall within normal range. dO, Cannot rise on tiptoe; 1, can but weak; 2, normal; P = .05.
TABLE 5 Loss or Gain in Foot Length and Width at Follow-Up' Loss in length b
Group I (N = 6) Group II (N = 4) Groups I and II (N = 10)
Loss (-}/gain (+) of width"
Range
Average
Range
Average
(%)
(%)
(%)
(%)
11-14 3-22 3-22
12 12 12
0-+23 -1--10 -10-+23
+4.5 -3.5 +1.4
• Table 5 shows the loss or gain in length and width of the foot at follow-up in each group. Only the unilaterally involved cases are used to calculate this. Data were too few to be statistically meaningful. On average, foot was 12% shorter and slightly (1.4%) wider. b Percentage of normal foot length. C Percentage of normal width.
strength (the ability to stand or walk on tiptoes) also showed that the CSR group was better than the PMR group. Foot Size (Table 5)
The loss of foot length was the same in both the PMR and CSR groups. However, group I resulted in a slightly wider foot (4.5% wider) when compared with the normal, opposite foot, and group II had a slightly narrower foot (3.5% narrower). In bilateral clubfoot, our foot tracing measurements indicated that the foot that looked and felt better to the patient and parents was usually the longer and wider foot. Radiographic Results: Talocalcaneal Angle (Table 6)
The APTC angle improved from 10° preoperatively to 23° postoperatively in group I and from 9° preoper-
TABLE 6 Improvement in APTC and LATC Angles Group I Preoperative APTC angle (O) Range Average Postoperative APTC angle (O) Range Average Preoperative LATC angle Range Average Postoperative LATC angle Range Average
Group II
Groups I & II
0-15 (N = 8)· 5-21 (N = 7}b 0-21 (N = 15) 10.1 9.0 9.6
13-43 23.1
16-44 26.1
13-44 24.4
0-22 (N = 7) 5-25 (N = 8) 0-25 (N = 15) 12.6 15.9 14.3
16-44 30.9
32-54 38.8
16-54 34.3
• Due to a flood in the city in early 1980, some x-rays were permanently damaged and discarded. This results in incomplete data on the preoperative AP and lateral talocalcaneal angle of some patients. b Only seven cases have complete x-rays for this measurement.
TABLE 7 Percentage of Unsatisfactory Radiographic Results in Talocalcaneal Overlap, Navicular Position on AP, and Lateral X-Rays of the Foot Talocalcaneal
overlap" (%) Group I (N = 16) Group II (N = 12) Groups I and II (N = 28)
69 8 46
AP navicular position"
Lateral navicular posltlon"
(%)
(%)
25 0 14
19 33 25
• P = .0009, significant. b Not significant. C Not significant.
atively to 26° postoperatively in group II. The difference was not significant. The LATC angle improved from 12.6° to 30.9° in group I and from 15.9° to 38.8° in group II. This difference was statistically significant (P = .0009). Overall, in this whole series, the APTC angle improved approximately 15° on average and the LATC angle improved approximately 20° on average. Talocalcaneal Overlap and Navicular Position (Table 7)
Measurements of APTC overlap showed that the PMR group had 69% unsatisfactory result and the CSR group had 8% unsatisfactory result. The difference was significant. The AP navicular position was unsatisfactory in 25% of feet in group I and all feet were satisfactory in group II. The lateral navicular position was unsatisfactory in 33% of group " and in 19% of group I. There was no
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Foot & AnkJefVoJ. 13, No. 3jMarchjApriJ 1992
statistical difference of unsatisfactory results between the PMR and CSR groups based on the navicular position both on AP and lateral x-rays. The follow-up in group II was shorter than in group I, and in most cases in group II, the navicular had just begun to ossify or had not yet ossified. We believe this makes the measurements of group II patients less reliable than those of group I patients, in whom the navicular were much better developed and easier to measure on x-ray. Although the percentage of unsatisfactory radiographic results in this category was high, our review showed no definite correlation between this radiographic measurement and pain, function, and limitation of activities. Flat Top Talus
A true flat top talus following clubfoot treatment is the result of a forced dorsiflexion of the ankle against a tight posterior structure, the so-called nutcracker effect.4 The high incidence of flat top talus in group I most likely represents an undercorrected or incompletely corrected foot that was forced into dorsiflexion by subsequent casting or ambulation. The CSR group had a much lower incidence (8.3%) of flat top talus compared with the PMR group (62.5%). Overall, the series showed a 39% incidence of flat top talus. Dunn and samuelson" reported on the long-term result of flat top talus and found that it was a common problem following closed treatment of clubfoot, but that the presence of flat top talus did not correlate with pain or function. Our results agree with this finding. Secondary Procedures
The CSR, so far, has resulted in a foot that does not require a secondary procedure. However, three of 12 feet, or 25%, were noted to have mild residual metatarsus adductus. Two of 12, or 16.7%, may need secondary procedure. Six of 16 feet, or 37%, of the PMR group required secondary procedures and another three of 16 feet, or 19%, were considered for a secondary procedure. Although the follow-up in group II was shorter (average 45.25 months versus 104.9 months in group I), most of the residual deformities in group I were noticed and recorded within 18 months after surgery. On this basis, we believe there will not be a substantial change of result in group II with longer follow-up. However, this remains to be seen and we intend to follow all the patients to at least skeletal maturity.
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123
McKay and Simons resulted in a better correction than the Turco posteromedial release. We felt that the Cincinnati incision allowed a better exposure and more complete posterior and lateral release than the longitudinal-vertical incision used by Turco. We did the Cincinnati approach with the patier:t in both supine and prone position and we feel that the prone position allows better access to the subtalar joint. So far, we have not had skin necrosis following the Cincinnati incision since we began this ir11985 (12 feet). It appears from our data that the posteromedial release resulted in a slightly undercorrected foot and the complete subtalar release resulted in a better corrected or sometimes slightly overcorrected foot. This is demonstrated in the significant improvement of blmalleolar/foot axis, less residual metatarsus adductus, and slightly higher degrees of residual heel valgus in the CSR group. The discrepancy in length of follow-up between the two groups is an obvious shortcoming in our study. The reason is that this is a retrospective study and we have been doing complete subtalar releases since 1985. However, we feel that a minimum of 2 years of follow-up in the second group is meaningful, since most of the residual deformities are noted within 18 months following surgery. There are many variables involved in the treatment and evaluation of results in clubfoot. Some of these include difference in degree and severity of pathology in each clubfoot, the thoroughness of each step of surgical release, and the differences in postoperative immobilization. The measurement of range of motion of hindfoot and subtalar joint, at best, is only an approximation of the true motion. All these variables make it difficult to draw a definite conclusion in a study like this. Also, we realize that our better result in the complete subtalar release group may partly reflect the "learning curve" in the operative treatment of clubfoot at our institution. Despite our better result with the complete subtalar release group, both the posteromedial release and the complete subtalar release resulted in a functional foot without major physical handicaps. All of these children are active in general and able to wear regular shoes with minor adjustments. Our experience indicates that the more extensive one-stage complete subtalar release appears to give a better result than the one-stage posteromedial release.
SUMMARY AND CONCLUSION
ACKNOWLEDGMENTS
In our limited experience with 29 clubfeet, the more complete subtalar release procedure advocated by
The authors wish to thank Sarah O'Donnell for her help in the preparation of the manuscript.
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REFERENCES 1. Bethem, D., and Weiner, D.: Radical one-stage posteromedial release for the resistant clubfoot. Clin. Orthop., 131:214-223, 1978. 2. Bleck, E.E.: Metatarsus adductus: classification and relationship to outcomes of treatment. J. Pediatr. Orthop. 3:2-9,1983. 3. Bleck, E.E.: Orthopaedic Management in Cerebral Palsy. Philadelphia, J.B. Lippincott, 1987. 4. Coleman, S.S.: Complex Foot Deformities in Children. Philadelphia, Lea & Febiger, 1983, pp. 23-110. 5. Crawford, A.H., Marxen, J.L., and Osterfeld, D.L.: The cincinnati incision: a comprehensive approach for surgical procedures of the foot and ankle in childhood. J. Bone Joint Surg., 64A:1355-1358, 1982. 6. Dunn, H.K., and Samuelson, K.M.: Flat-top talus. A long-term report of twenty club feet. J. Bone Joint Surg., 56A:57-62, 1974. 7. Engelberg, A.L. (Ed.): AMA Guides to the Evaluation of Permanent Impairment, 3rd Ed. 1988, pp. 56-60. 8. Ghali, N.N., Smith, R.B., Clayden, A.D., and Silk, F.F.: The results of pantalar reduction in the management of congenital talipes equinovarus. J. Bone Joint Surg., 65B:1-7, 1983. 9. Johanson, J.E., Horak, R.D., and Winter, R.B.: Gillette children's hospital experience with the turco procedure for clubfeet (talipes equinovarus). Minn. Med., 745-749, 1981. 10. Lovell, W.W., and Winter, R.B.: Pediatric Orthopaedics, Vol. 2. Philadelphia,J.B. Lippincott, 1978, pp. 917-930. 11. McKay, D.W.: New concept of and approach to clubfoot treatment: section I-principles and morbid anatomy. J. Pediatr. Orthop., 2:347-356, 1982.
12. McKay, D.W.: New concept of and approach to clubfoot treatment: section II-correction of the clubfoot. J. Pediatr. Orthop., 3:10-21,1983. 13. McKay, D.W.: New concept of and approach to clubfoot treatment: section III-evaluation and results. J. Pediatr. Orthop., 3:148, 1983. 14. Porat, S., Milgrom, C., and Bentley, G.: The history of treatment of congenital clubfoot at the royal liverpool children's hospital: improvement of results by early extensive posteromedial release. J. Pediatr. Ortnop., 4:331-338, 1984. 15. Simons, G.W.: Complete subtalar release in club feet. Part I-a preliminary report and Part II-comparison with less extensive procedures. J. Bone Joint Surg., 67A:1044-1065, 1985. 16. Stauffer, R.N., Chao, E.Y.S., and Brewster, R.C.: Force and motion analysis of the normal, diseased, and prosthetic ankle joint. Clin. Orthop., 127:189-196,1977. 17. Tachdjian, M.O.: Pediatric Orthopaedics, Vol. 1. Philadelphia, W.B. Saunders, 1972, pp. 1274-1322. 18. Thompson, G.H., Richardson, A.B., and Westin, G.W.: Surgical management of resistant congenital talipes equinovarus deformities. J. Bone Joint Surg., 64A:652-665, 1982. 19. Turco, V.J.: Surgical correction of the resistant club foot. Onestage posteromedial release with internal fixation: a preliminary report. J. Bone Joint Surg., 53A:477 -497, 1971. 20. Turco, V.J.: Resistant congenital club foot-one stage posteromedial release with internal fixation. A follow-up report of a fifteen-year experience. J. Bone Joint Surg., 61A:805-814, 1979.
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