EVALUATION OF THREE DIFFERENT SURGICAL PROCEDURES FOR CONGENITAL TALIPES EQUINOVARUS

ORIGINAL ARTICLE EVALUATION OF THREE DIFFERENT SURGICAL PROCEDURES FOR CONGENITAL TALIPES EQUINOVARUS Ismatullah Department of Casualty, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar ABSTRACT Objective: To assess and compare the results of three different surgical procedures in congenital talipes equinovarus (CTEV) in children. Material and Methods: This study was conducted at Lady Reading Hospital Peshawar, from January 99 to January 99 and from October to February. The deformity was classified into grades of severity according to modified Somppi classification. Depending upon the age and the severity of the deformity, different operations were performed: Posterior release, Posteromedial release and Complete subtalar release. The results were rated according to the modified Turco criteria. The patients were followed up to years after surgery. Results: Study included feet of patients ( males, females) ranging in age from months to years. There were excellent, 7 good, fair and failure results. The outcome of surgery was related with the grade of the deformity and the procedure employed. In grade II clubfeet the posterior release achieved good results. In grade III, posteromedial release and in grade IV complete subtalar release gave good results. Most of the good or excellent results were obtained in the younger age group. Conclusion: There is no single surgical procedure, which suits all the cases of CTEV. The best surgical procedure is tailored according to the age of the patient and the severity of the deformity. Best results regarding cosmetic and functional aspects, are achieved in the younger age group. Key Words: Congenital Talipes Equinovarus, Posterior Release, Posteromedial Release, Complete Subtalar Release. INTRODUCTION There are many types of surgical procedures employed for this deformity. The Congenital talipes equinovarus (CTEV) is choice of surgical procedure depends upon the age a common congenital anomaly of the foot. Its of the patient, and the severity of the deformity. In overall incidence is about to in live the early age up to years the deformity can be births. The male to female ratio is about two to corrected by only soft tissue release operations but one. It is a complex deformity consisting of in the late age group the deformity may require equinus, varus and adductus components. It has bony procedures for its correction. been defined as subluxation of the talo-calcaneonavicular joint. Attenborough advised posterior soft tissue release operation for the correction of CTEV. If the deformity is properly treated, a This procedure is best suited for the correction of painless, functional and plantigrade foot is the residual equinus deformity of the hindfoot obtained. But if it is left untreated, it becomes a when the adductus and varus components of CTEV crippling affliction and creates a great amount of have already been eliminated by conservative functional disability and social stigma for the 7 treatment or previous surgical procedures. This is patient. There is much controversy in the literature a small procedure and involves lengthening of the regarding treatment of clubfoot. Conservative tendo-achilles and capsulotomy of the subtalar and treatment is very effective when done during early ankle joints on their posterior aspects. infancy. However this may correct only mild cases of clubfoot and surgery is usually required for the Turco VJ studied the anomaly of the,9 moderate and severe forms of the deformity. CTEV with great enthusiasm and interest. He

introduced a one- stage posteromedial release operation which produces a plantigrade and pliable foot and reduces the incidence of recurrent deformity. He described two indications for this procedure: Failure to attain correction after a fair trial of non-operative treatment and This study was designed to evaluate three different soft tissue release operations for the correction of CTEV deformity in children from the age of four months up to six years. This is a prospective study of feet of patients having CTEV deformity. This study was conducted in the Orthopedic Unit of Lady Reading Hospital, Peshawar. The study was completed in two periods, from January 99 to January 99 and from October to February. The following inclusion and exclusion criteria were used: Failure to maintain correction with recurrent Inclusion Criteria: deformity. Only congenital cases of talipes equinovarus The upper age limit of the child for this deformity procedure is up to years. However, best results Either Sex are achieved in the age range of - years. Age group: from months up to years. Mckay (9) presented a new concept about the pathological anatomy and treatment of Exclusion Criteria:, CTEV. According to him the complex deformity Paralytic clubfoot as in poliomyelitis, cerebral of CTEV results from abnormal rotation of the palsy or nerve injury calcaneus under the talus in the sagittal, coronal and horizontal planes. He designed four-quadrant Te r a t o l o g i c c l u b f o o t a s s o c i a t e d w i t h release operation (posterior, medial, plantar and a r t h r o g r y p o s i s m u l t i p l e x c o n g e n i t a, lateral release), also known as complete subtalar myelomeningocoele or diastrophic dwarfism release, performed in one stage for the correction Cases below months of age and above of the CTEV. This procedure is recommended only years of age. for severe and resistant cases of clubfoot which can not be corrected by less extensive soft tissue A detailed history, clinical evaluation and release operations. Dobb, Nunley and Schoenecker laboratory investigations of each patient were have found a correlation between the extent of soft recorded on a proforma. An anteroposterior and a tissue r elease and the degree of functional forced dorsiflexion lateral view radiographs were impairment. Because of the availability of obtained for each patient preoperatively. multiple surgical procedures for the correction of The severity of the deformity was CTEV and because of the good results achieved by classified according to the modified Somppi surgery in the early age patients of this deformity, Classification adopted by Shah and Saleem as R.W. Porter has aptly stated that failure rests more follows:- ' in surgeons hand than in the child s foot. MATERIAL AND METHODS Procedure Posterior Release n= Posteromedial Release n= Complete Subtalar Release n= Total Grade I: Grade II: Grade III: Grade IV:. % Table Mild or postural clubfoot Moderate clubfoot which can be manipulated partially to neutral position Severe clubfoot, which cannot be manipulated into neutral position Resistant and recurrent cases of RESULTS AS RELATED TO THE SEVERITY OF THE DEFORMITY Number of Feet Grade of Severity of Deformity Grade II Grade III Grade II Grade III Grade IV Grade III Grade IV Results Excellent Good Fair Failure 7.7%.79%.%

Operative Procedure Posterior Release Posteromedial Release Complete Subtalar Release Total RESULTS AS RELATED TO THE AGE OF THE PATIENTS Age to operation months to months months to months years to years months to months months to months years to years months to months months to months years to years clubfoot deformity and the residual deformity after incomplete surgical correction Posterior release alone was performed for cases which had only residual equinus deformity of grade II or grade III severity. Posteromedial release of Turco was performed in those cases who had clubfoot deformity of grade II or grade III and in some cases having grade IV deformity as well. Complete subtalar release of Mckay was performed mostly in patients having grade IV deformity and in some patients of grade III deformity as well. residual deformity or functional impairment of the foot. Depending upon the age of the patient RESULTS and the grade of the deformity, the This is a short series of patients ( following procedures were performed:- feet) treated surgically for correction of clubfoot. Posterior release. deformity. Out of patients, were male and were female. The male to female ratio was :. In. Posteromedial release and cases the deformity was unilateral whereas in. Complete subtalar release. Number of Feet 7 Table Results Excellent Good Fair Failure. % 7.7%.79%.% cases the deformity was bilateral and both the feet were operated. Thus, in patients, the total number of operated feet was. The age range of the patients was from months up to years. Out of total feet, were primary deformities of CTEV which had no prior surgical procedure and were relapsed deformities in which prior surgical procedures had failed. Of the feet, (.%) were grade II, (.%) were grade III and (.%) were grade IV deformities. None of the feet having grade I deformity was included in the study because it is treated conservatively. Procedure performed were Posterior Release (n=), Posteromedial Release (n=) and Complete Subtalar Release (n=). A uniform follow up was adopted for all cases in this series. In the first months after surgery, the patients were followed up at intervals of weeks, weeks and weeks. Later on the patients were followed up at intervals of months up to total period of ½ to years. The total period of immobilization in the plaster cast was In this series, according to modified Turco upto months. At the end of this period, the criteria, there were excellent, 7 good, fair functional and cosmetic aspects of the results were results and failures (table ). Some minimal noted. The criteria used by Turco for assessment of residua which were cosmetically as well as the results of clubfoot surgery were applied to all functionally acceptable were present in most of, 9 cases such as calf atrophy, pes planus, pliable these cases. We used these criteria in a modified metatarsus adductus and decreased size of the foot. manner, giving more importance to clinical evaluation as compared to radiological evaluation. Of the failures, one was having grade III The child was referred to orthopedic workshop for deformity preoperatively and had grade IV preparing a clubfoot splint. For a walking child a deformity. There was no failure in grade II pronator shoe was also prepared. At each follow- clubfeet. This showed an increased risk of failure up, the patient was assessed for any recurrence, with increase in the severity of the deformity. 7

POSTOPERATIVE COMPLICATIONS S.No Complication No. of Feet Percentage...... 7.. 9. Injuiry to neurovascular bundle Tourniquet skin blisters Skin flap necrosis and wound dehiscence Wound infection i. Superficial ii. Deep Pin tract infection Postoperative pyrexia Residual deformity i. Forefoot adduction ii. Equinus iii. Varus heel iv Valgus heel Functional impairment due to pain & stiffness Failures Table Functional impairment of the foot due to pain and deformity. Most orthopedic surgeons agree that a stiffness was found in feet. Of these were of fair trial of non-operative treatment should be grade III and were of grade IV deformity. given in every case of CTEV before embarking on Moreover, amongst these clubfeet, were surgical treatment. This will differentiate the primary clubfeet and were relapsed clubfeet. pliable cases, responding favourably to non- This indicated that the complication of functional operative measures, from the resistant cases which impairment increased with repeated surgery and require surgery. with the grade of the deformity. Many authors have used clinical as well as Posterior release(n= feet) had excellent radiological criteria for the assessment of the,9, results in (%) cases, good results in (%) results after clubfoot surgery. In this study more cases, fair results in (.%) case and failure in importance was given to clinical evaluation, (.%) case. Posteromedial release (n= feet) because difficulty was found in radiological had excellent results in (7.%) cases, good evaluation of some of the small feet of the results in (.%) cases, fair results in (.7%) younger patients. Moreover, Ippolito et al have cases and failure in (.%) cases. Complete questioned the validity of talocalcaneal angle Subtalar Release (n= feet) had excellent results (Kite's angle) in the anteroposterior radiograph of in (%) cases, good results in (.7%), fair the foot which is a parameter for assessment of the hind foot correction after surgery. There are many results in (.7%) cases and failure in (.7%) divergent opinions regarding the best age of the cases. Overall feet had excellent results in child for surgery and the choice of the surgical (.%) cases, good results in 7 (.7%), fair procedure. Great difficulty arises in comparing the results in (.79%) cases and failure in results of surgical procedures performed at (.%) cases. The results related to the severity different centers because there are pre-operative of deformity (table-) and age of the patients at variables like the severity of the deformity, the age the time of surgery (table-) and the complications at surgery and the previous non-operative found after surgery (table-) are presented as treatment or operative treatment received by the follows: child. Unfortunately the current classification systems for the analysis of the CTEV are not DISCUSSION entirely satisfactory and it may be difficult to predict appropriate management or to compare the CTEV is an interest-provoking problem for 7 results after management. an orthopedic surgeon, because most of these children usually have no other mental or physical Lau et al reviewed clubfeet treated abnormality except the stigma of this crippling surgically. Out of these feet underwent 7.9 7.9.....7......

posterior release operation in which tendo-achilles lengthening was combined with posterior capsulotomy of talocalcaneal and tibiotalar joints. The authors have claimed good results from this procedure. We performed this procedure in selected group of patients who had only residual equinus deformity. The results were excellent in patients, good in patients, fair in one and poor in one,9 operation theatre environment may not be up to the mark, in contrast to the developed countries. Moreover our experience with the extensive release operations was limited and extensive dissection might have devascularized the tissues in some cases leading to infection. CONCLUSION patient. Similarly Ippolito et al have reported Surgical treatment of CTEV results in a that limited posterior release operation along with lasting correction and a plantigrade and functional manipulation and casting techniques, affords good foot. No single surgical procedure is suitable for results. They had performed three dimensional C.T. all cases of CTEV. The extent of surgical release reconstruction of the whole foot and found that must be tailored to the type and severity of the cavus, supination and adduction deformities were persisting deformity of the foot and the age of the corrected much better in selected patients. patient at the time of operation. From this study it is clear that posterior release, postero-medial Turco reviewed resistant club-feet release and complete subtalar release, all afford treated by one-stage posteromedial release with,9 good results in selected group of patients. internal fixation. The ages of the patients ranged Moreover this study indicates that all the from months to years. He reported.% procedures are more effective when performed at a excellent or good results. The best results with younger age. We consider months of age as the least incidence of complications were in children best age for surgery after the non-operative who were operated between one and two years of measures have failed to correct the deformity. age. A similar finding was noted in our series of patients who underwent Turco's posteromedial REFERENCES release. Among feet there were excellent or good results. Most excellent or good results were. Nordin S, Aidura M, Razak S, Faisham WI. achieved in the early age group. The number of C o n t r o v e r s i e s i n c o n g e n i t a l c l u b f o o t : poor results and fair results increased with the Literature review. Malaysian J Med Sci increase in the age of the patients. ;9: -. Mckay in 9 and Simons in 9 advocated complete subtalar release for the,, correction of C.T.E.V. Since then many authors have preferred this procedure to the less extensive release operations. Centel et al compared the results of posterior release, posteromedial release and Simons technique of complete subtalar release in 77 patients. According to them Simons technique was found to be the most efficient method of surgery both functionally and radiologically in cases of C.T.E.V. Tschopp et al also achieved better results with complete subtalar release as compared to posteromedial release. In our series patients underwent this procedure and patients had good or excellent results. This extensive release operation may result in a more complete correction of the deformity but the risks of over-correction and limitation of the movements of the foot are increased. We selected this procedure for the most severe and resistant cases of clubfoot. The post-operative infection rate was quite high in our series. There were five cases of wound infection and two cases of pin tract infection, among feet operated. Uglow and Clarke have reported infection rate of.% in their series. This difference in rate of infection may be because our sterilization standards and cleanliness of the. Wynne-Davies R. Family studies and cause of congenital clubfoot. J Bone Joint Surg 9; -B:-7.. Ponseti IV. Current Concepts Review: Treatment of congenital clubfoot. J Bone Joint Surg 99;7-A:-.. Tindall AJ, Steinlechner CWB, Lavy CBD. Results of manipulation of idiopathic clubfoot deformity in Malawi by orthopedic clinical officers using the Ponseti method. A realistic alternative for the developing world? J Pediatr Orthop ; : 7-9.. Papavasiliou VA, Papavasiliou AV. A Novel surgical option for the operative treatment of clubfoot. Acta Orthop Belg ;7: -.. Attenborough CG. Early posterior soft tissue release in severe congenital talipes equinoarus. Clin Orthop 97; :7-. 7. Pecak F, Paulovcic V, Srakar F. Treatment of resistant idiopathic pes equinovarus: Ten years experience. J Pediatr Orthop 99; 9:-.. Turco VJ. Surgical correction of resistant clubfoot: one- stage posteromedial release with internal fixation. A preliminary report. J Bone Joint Surg 97;- A: 77-97. 9. Turco VJ. Resistant congenital clubfoot: one- 9

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