Multiplanar supramalleolar osteotomy in the management of complex rigid foot deformities in children

Complex rigid foot deformity correction with hexapod external fixator system

PURPOSE

Complex rigid foot deformities include three-plane deformities and usually presents with poor soft tissue coverage. In the last decades, gradual correction with computer-assisted fixator became an appropriate option for the treatment rigid foot deformities. This study aims to report our experience about treatment of complex foot deformities using Smart Correction fixator system®.

METHODS

We retrospectively analyzed 13 complex rigid foot deformities of ten consecutive patients treated with Smart Correction fixator system® from 2016 to 2020. Primary outcomes were classified as good, fair, and poor according to previously determined criteria. The outcomes were also assessed with The Manchester-Oxford Foot Questionnaire (MOXFQ). Non-parametric analysis (Wilcoxon test) for continuous variables and the Fisher's exact test for categorical variables were used.

RESULTS

Plantigrade foot was achieved in all patients after correction program. Supramalleolar osteotomy was applied in nine feet, midfoot osteotomy was applied in two feet, hindfoot osteotomy was required in one foot, and only soft tissue distraction performed in two feet. Two patients had recurrent deformity managed by further acute corrections. The mean MOXFQ scores improved from 72.7 preoperatively to 24.8 at last follow-up.

CONCLUSIONS

Present study shows that SCF the reliable option for the treatment of complex foot deformities, which also facilitates three-plane correction and concomitant lengthening with gradual soft tissue balance.

Effectiveness of Ponseti technique in management of arthrogrypotic clubfeet - a prospective study

BACKGROUND

Clubfoot constitutes roughly 70 percent of all foot deformities in arthrogryposis syndrome and 98% of those in classic arthrogryposis. Treatment of arthrogrypotic clubfoot is difficult and challenging due to a combination of factors like stiffness of ankle-foot complex, severe deformities and resistance to conventional treatment, frequent relapses and the challenge is further compounded by presence of associated hip and knee contractures.

METHOD

A prospective clinical study was conducted using a sample of nineteen clubfeet in twelve arthrogrypotic children. During weekly visits Pirani and Dimeglio scores were assigned to each foot followed by manipulation and serial cast application according to the classical Ponseti technique. Mean initial Pirani score and Dimeglio score were 5.23 ± 0.5 and 15.79 ± 2.4 respectively. Mean Pirani and Dimeglio score at last follow up were 2.37 ± 1.9 and 8.26 ± 4.93 respectively. An average of 11.3 casts was required to achieve correction. Tendoachilles tenotomy was required in all 19 AMC clubfeet.

RESULT

The primary outcome measure was to evaluate the role of Ponseti technique in management of arthrogrypotic clubfeet. The secondary outcome measure was to study the possible causes of relapses and complications with additional procedures required to manage clubfeet in AMC an initial correction was achieved in 13 out of 19 arthrogrypotic clubfeet (68.4%). Relapse occurred in 8 out of 19 clubfeet. Five of those relapsed feet were corrected by re-casting ± tenotomy. 52.6% of arthrogrypotic clubfeet were successfully treated by the Ponseti technique in our study. Three patients failed to respond to Ponseti technique required some form of soft tissue surgery.

CONCLUSION

Based on our results, we recommend the Ponseti technique as the first line initial treatment for arthrogrypotic clubfeet. Although such feet require a higher number of plaster casts with a higher rate of tendo-achilles tenotomy but the eventual outcome is satisfactory. Although, relapses are higher than classical idiopathic clubfeet, most of them respond to re-manipulation and serial casting ± re-tenotomy.

Failed Cavovarus Reconstruction: Reconstructive Possibilities and a Proposed Treatment Algorithm

This article provides an overview of the techniques and strategies to address a failed cavovarus deformity correction. These problems pose significant challenges to the treating surgeons and should be accurately planned before embarking on surgery.

Updates in the Surgical Management of Recurrent Clubfoot Deformity: a Scoping Review

PURPOSE OF REVIEW

This article focuses on the current advances in surgical management for clubfoot deformity, supported by up-to-date longitudinal studies on each approach.

RECENT FINDINGS

Long-term analysis following primary and repeated soft tissue releases has demonstrated good results in young patients with low relapse rates. Tibialis anterior transfer following the Ponseti method shows no difference in long-term pedographic analysis in comparison to the Ponseti method alone. Furthermore, tibialis anterior transfer following surgical relapses provides good long-term results with improved correction in talus-first metatarsal angle. Bony osteotomies may also play a role in addressing surgical relapses in older children. However, talar neck osteotomy may result in avascular necrosis of the talar dome. Hexapod external fixation may be considered by experienced surgeons to correct rigid clubfoot deformities in older patients with good long-term results and drastic improvements in pain perception. Long-term analysis of anterior distal tibial epiphysiodesis (ADTE) for recurrent equinus deformity following surgical correction has demonstrated statistical improvements in the anterior distal tibial angle (ADTA) and ankle dorsiflexion. Talectomy and naviculectomy are rarely used in today's practice as long-term studies have demonstrated high relapse rates and residual pain impeding patient mobility. Surgical correction following failure of the conservative approaches can be implemented to achieve full correction in clubfoot deformity. It is difficult to achieve a plantigrade feet with pain-free gait with repeated surgical interventions. Therefore, proper choice of the initial surgical technique is essential for achieving satisfactory long-term outcomes.

Results of talectomy for inveterate or recurrent clubfoot

INTRODUCTION

The aim of the present study was to define indications for talectomy in congenital paralytic, dystrophic or idiopathic, inveterate or recurrent, clubfoot.

HYPOTHESIS

Talectomy is a valid option for paralytic, dystrophic or idiopathic, inveterate or recurrent, clubfoot.

PATIENTS AND METHODS

A single-center retrospective series comprised 52 clubfeet in 31 patients. Etiology was paralytic in 34 feet (65%) (17 arthrogryposes, 10 myelomeningoceles, 4 encephalopathies, 3 peripheral neuropathies), dystrophic in 6 (12%) and idiopathic in 12 (23%). In 27 feet, there was history of surgery (52%). Mean age at talectomy was 4.7 years. In 45 feet (87%), there were associated procedures (soft-tissue release, tendon surgery, calcaneal or lateral arch osteotomy, tibiocalcaneal fusion) and talectomy was isolated in 7 feet (13%). Mean follow-up was 9 years. Final assessment was based on the modified Ghanem and Seringe classification (G&S) and the Ankle-Hindfoot Scale (AHS).

RESULTS

All feet required at least one complementary procedure, either in the same step or as revision. Revision surgery was performed in 17 cases (33%), including all 7 feet with isolated talectomy (7 calcaneal tendon lengthenings, 10 mid- or hind-foot osteotomies, 6 tibiocalcaneal fusions, one calcaneocuboid fusion, and 2 progressive corrections by external fixator). Finally, 33 feet (63%) had good G&S results, 44 (85%) were pain-free, and 40 (77%) were plantigrade.

DISCUSSION

Talectomy for paralytic or dystrophic inveterate or recurrent clubfoot provided satisfactory medium-term results. Associated to other procedures, it achieves a pain-free plantigrade foot in most cases. Tibiocalcaneal fusion has an analgesic effect. Talectomy may, however, not be indicated in idiopathic clubfoot, given the patients' high functional demand and the existence of alternative treatments.

LEVEL OF EVIDENCE

IV, retrospective series.

Arthrogryposis: an update on clinical aspects, etiology, and treatment strategies

Arthrogryposes - multiple joint contractures - are a clinically and etiologically heterogeneous class of diseases, where accurate diagnosis, recognition of the underlying pathology and classification are of key importance for the prognosis as well as for selection of appropriate management. This treatment remains challenging and optimally in arthrogrypotic patients should be carried out by a team of specialists familiar with all aspects of arthrogryposis pathology and treatment modalities: rehabilitation, orthotics and surgery. In this comprehensive review article, based on literature and clinical experience, the authors present an update on current knowledge on etiology, classifications and treatment options for skeletal deformations possible in arthrogryposis.

Treatment of Severe Recurrent Clubfoot

Understanding the pathoanatomy of severe recurrent clubfoot and its implication on treatment options is important for the successful treatment. A comprehensive clinical evaluation of the different components helps in selecting procedures. Individual needs and social and psychological factors influencing treatment and the impact of treatment on the child have to be considered. With increasing dissemination and improved understanding of the Ponseti method, a further decrease in the frequency of severe recurrent clubfoot can be hoped for and expected.

Supramalleolar Osteotomies: An Algorithm for the Deformed Ankle

Supramalleolar osteotomies are powerful osteotomies that realign the tibiotalar and optimize hindfoot position in the presence of varus, valgus, procurvatum, recurvatum, as well as internal and external rotation of the tibia. Although used in the pediatric and hemophilic population earlier, supramalleolar osteotomy is a relatively new reconstructive surgical technique that was introduced in 1995. Conducted primarily in cancellous bone, supramalleolar osteotomies offer rapid, reliable bony consolidation compared with dome osteotomies and complex arthrodesis.

Supramalleolar osteotomy for realignment of the ankle joint

Ankle replacement systems have not been as reliable as hip replacements in providing long-term relief of pain, increased motion, and return to full activity. Supramalleolar Osteotomy is an extraarticular procedure that realigns the mechanical axis, thereby restoring ankle function. The literature discussing knee arthritis has shown that realignment osteotomies of the tibia improve function and prolong total knee replacement surgery. The success of the procedure is predicated on understanding the patient's clinical and radiographic presentation and proper preoperative assessment and planning.

The management of the neglected congenital foot deformity in the older child with the Taylor spatial frame

BACKGROUND

Neglected or inadequately treated rigid congenitally deformed feet in older children are a nightmarish challenge for the child, the parents, and the orthopaedic surgeon. Because of the multiplicity of spatial deformities exhibited by these feet and legs, it was hypothesized that correction using the Taylor spatial frame (TSF) would decrease morbidity, facilitate correction, and minimize treatment time in children from remote regions with extremely rigid deformed feet.

METHODS

Recent experience with the management of 11 such feet (Dimeglio type IV) in 9 children with an average age of 9.2 years using the TSF has been gratifying. Six children had associated leg length discrepancy, which was corrected by concomitant tibial lengthening. All feet underwent soft tissue releases, whereas forefoot and/or hindfoot osteotomies were performed in 7 feet.

RESULTS

All children attained plantigrade, functional feet, and were fully ambulatory and capable of wearing normal footwear. Complications were minor consisting of pin tract infections, residual metatarsus varus in 3, and wound dehiscence in 1. There were no neurovascular events. This was attributed to the slower 3 plane correction using the TSF technique as well as the elimination of the need for plaster immobilization thus allowing direct monitoring of the foot and limb.

CONCLUSIONS

The rigid foot deformity in the older child can be safely and effectively corrected with the aid of the TSF, which facilitates a 3 plane correction and concomitant limb lengthening.

Anterior distal tibial epiphysiodesis for the treatment of recurrent equinus deformity after surgical treatment of clubfeet

The treatment of clubfeet has changed constantly. Before the acceptance of the Ponseti serial casting, extensive surgical release was widely used. The treatment of relapse in these surgically treated clubfeet can be very challenging. Many methods have been used ranging from osteotomies to new posteromedial release, or correction using the Ilizarov fixator. Supramalleolar osteotomy was practiced for the treatment of residual equinus. The aim of this study is to evaluate the effect of anterior epiphysiodesis of the distal tibia on recurrent equinus deformity in patients with clubfeet treated surgically.

METHODS

We evaluated 25 children (31 feet) with recurrent equinus deformity after surgical treatment of clubfoot treated in our institution from 2003 through 2009. There were 16 boys and 9 girls, of whom 11 had recurrent equinus deformity on the left side, 8 on the right side, and 6 on the bilateral side. Three patients were treated with Richard staples and 22 were treated with 8-plates. Patients were examined clinically and radiologically, preoperatively. The mean dorsiflexion of the ankle was 2.5 degrees (-5 to 10 degrees) and the anterior distal tibial angle (ADTA) was 85 degrees. The patients were followed postoperatively and evaluated clinically and radiographically. The plates or staples were removed if the desired effect of around 15 degrees of dorsiflexion was achieved, or the ADTA shifted >15 degrees.

RESULTS

Mean follow-up was 22 months. Mean improval of dorsiflexion was 2 degrees, with a mean of dorsiflexion of 4.5 degrees, and mean radiological changes of ADTA were 13 degrees. We found no correlation between the radiographic changes and the clinically measured dorsiflexion.

CONCLUSIONS

The use of anterior distal tibial epiphysiodesis does not seem to give a clinically significant improvement in dorsiflexion of the ankle despite a marked shift in the ADTA.

Deformity correction using supramalleolar gigli saw osteotomy and Taylor spatial frame: how to perform this osteotomy safely?

Supramalleolar osteotomy (SMO) is useful for the correction of various deformities around the ankle joint,especially deformities of the distal tibia secondary to partial growth arrest, foot equinus, and hind foot deformities. By definition, this osteotomy cuts through the tibia and fibula approximately 2–3 cm above the ankle joint.It can be performed by various techniques, each of them have advantages and disadvantages. Gigli saw SMO can be performed percutaneously with minimal soft tissue dissection, leaving a very smooth bone surface, which is especially useful for the correction of rotational deformities. Over a period of 6 years we performed eight gigli saw SMO in seven male patients and one female patient with a mean age of 13.6 years. All patients had multiplanar deformities with some shortening (range 15–40 mm) and underwent correction and lengthening by Taylor spatial frame. Treatment goal was achieved in all patients with minimal complications. On the basis of our experience, we believe that gigli saw SMO can be performed safely. This osteotomy, in conjunction with the Taylor spatial frame, became our treatment of choice for the correction of ankle and hindfoot deformities.The evidence is level 4, case series.