SLR - August 2016 - Lara Whitford
Medial to Posterior Release Procedure After Failure of Functional Treatment in Clubfoot: A Prospective Study
Reference: Bocahut N, Simon A-L, Mazda K, Ilharreborde B, Souchet P. Medial to Posterior Release Procedure After Failure of Functional Treatment in Clubfoot: A Prospective Study. Journal of Children’s Orthopaedics. 2016;10 (2):109–117.
Scientific Literature Review
Reviewed By: Lara Whitford, DPM
Residency Program: SUNY Downstate
Podiatric Relevance: To assess the results of a surgical technique in patients with clubfeet followed prospectively from birth.
Methods: A prospective study of all clubfeet patients undergoing surgery between October 1995 and February 2009. Severity of clubfoot was assessed by the Dimeglio’s Classification. All patients were initially treated conservatively by the French functional method (FFM). The aim of FFM is to derotate the forefoot in order to reduce medial talonavicular joint dislocation before correction of equinus. After initial treatment, patients were seen by the same experienced senior surgeon at the age of 6 weeks, and at 3, 9, 12,18 and 24 months and then once per year. X-rays were taken at each visit.
Surgical intervention was indicated if patients had four of the following criteria: a nonplantigrade foot posture on visual observation of gait, dorsiflexion less than 10 degrees, a lack of talocalcaneal angle on the dorsoplanar view x-ray and misalignment of the talo-first metatarsal angle or of the calcaneo-fifth metatarsal angle on dorsoplanar x-rays. The FFM was continued up until the surgery, and no patient received any additional conservative treatments. Idiopathic clubfeet (ICF) and nonidiopathic clubfeet (NIFC) were analyzed in this study.
The surgical procedure included the posterior-medial soft-tissue release technique. This technique is performed through a medial approach and follows steps according to the pathophysiology of the deformity. The procedure starts with an anteromedial release to reduce the talonavicular joint dislocation and medial rotation of calcaneoforefoot unit. The deformity is reduced once the navicular bone is in front of the talus. After this release, a posterolateral release, if necessary, corrects equinus. If a residual equinus persists after the Achilles tendon Z-lengthening, a posterior ankle arthrotomy is performed. Next, dissection of the posterior-lateral node is performed and this obtains 10 degrees of ankle dorsiflexion. The talocalcaneal ligament is visualized to avoid overcorrection. The Achilles tendon and tibialis posterior tendon are sutured in a neutral position. To maintain correction, one k-wire is introduced from first metatarsal bone to talus across talonavicular joint. Patients are immobilized for 6 weeks in a nonweightbearing cast with knee flexed at 90 degrees maintaining ankle and foot dorsiflexion. The pin is removed after 6 weeks.
Postoperatively, the same surgeon saw patients at 6 weeks and at 3 and 12 months until skeletal maturity. X-rays and gait analysis were done at each visit. The International Clubfoot Study Group (ICFSG) score with a minimum postoperative follow-up of 5 years was utilized to evaluate the final outcomes. The procedure is performed after the age of 6 years due to skeletal and gait maturity is not fully developed before that age.
Results: Three hundred fifty-nine patients and 513 feet were treated by the FFM between 1995 and 2009. One hundred thirty-seven patients and 199 feet underwent surgery (80 percent ICF vs 20 percent NICF). These patients had a significantly higher Dimeglio’s score at birth and a higher ICFSG score compared to successfully treated patients by the FFM. Mean Dimeglio score was 12.0 +/- 0.2. The mean age at surgery was 1.4 years.
The mean follow-up was 10 years with mean age at 12.3 years. Twenty-one patients (34 feet) were lost to follow-up. The mean ICFSG score was 4.3 with the scores being good to fair between the ICF vs NICF patients. There were no poor results. Mean passive tibotalar ROM was 30.
Subtalar joint and forefoot pronosupination were stiff in 45 percent of ICF and 29.7 percent of NICF patients. All patients had normal assessment on visual observation of gait and no limping. 97.5 percent of patients had a painless walk and 5 patients had pain. Fifty-nine feet had no deformities, and 157 feet had dynamic deformities.
Radiographic measurements were considered normal in 57 percent (94 feet), and 26 percent (43 feet) had one radiological anomaly. The most common anomaly was a misalignment of the talo-first metatarsal angle on lateral views.
Outcomes of the NICF group had worst results. The prevalence of severe deformities at initial assessment was significantly higher for NICF. Fair results were found in 4 feet of the NICF patients and were secondary to arthorgryposis and required revisional surgeries. Passive ROM was significantly lower in the NICF patients with mean ankle ROM 15.4 degrees vs. 33.4 degrees in the ICF patients.
Twenty-four feet (12 percent) required revision surgery for relapsing. A second revisional surgery was performed on 3 patients (1 NICF, 2 ICF), and 1 patient required a third procedure. Eight feet had a fixed deformity of forefoot supination (5 ICF, 2 NICF) and cavus (1 NICF). Seventeen feet had an overcorrection (2 NICF and 15 ICF). Eleven feet were undercorrected with 4 feet relapsed (2 NICF and 2 ICF), and 7 feet had a dynamic cavus and forefoot adduction.
Conclusions: Severe deformities of clubfoot are more resistant to conservative treatments. These deformities require further treatment, including surgery. The medial-posterior soft-tissue release is an effective surgical procedure with stable results.
One limitation of this study is that it had shorter follow-up times, and it would be beneficial to perform longer follow-up to detect relapsing. Another limitation of this study is risk of bias. The same surgeon evaluated the initial and final assessments, and this study would have less of a risk of bias if an independent examiner reviewed final assessment.