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Short Term Outcomes of Cuboid Closing Wedge Osteotomy with Percutaneous Soft Tissue Release in Resistant and Relapsed Cases of Clubfoot – A Prospective Study of Forty-four Feet

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 23-26| Sukalyan Dey1, Taral Nagda1, Jaideep Dhamele1, Chasnal Rathod1 Authors : Sukalyan Dey[1], Taral Nagda[1], Jaideep Dhamele[1], Chasnal Rathod[1] Consultant Institute of Pediatric Orthopedic Disorders Mumbai India. Fellow Institute of Pediatric Orthopedic Disorders Mumbai India Address of Correspondence Dr . Taral Nagda Consultant Institute of Pediatric Orthopedic […]

Dorso-Lateral Wedge correction osteotomy: Is this the way forward?

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 19-22|Viraj U Shingade1 Authors :Viraj U Shingade[1] Children Orthopaedic Care Institute and Pravira Hospital Daya chambers, Wardha road , Nagpur, Maharashtra. Address of Correspondence Dr Viraj U Shingade Children Orthopaedic Care Institute and Pravira Hospital Daya chambers, Beside Haldiram Building, Ajani square, Wardha road. Nagpur, […]

Short Term Outcomes of Cuboid Closing Wedge Osteotomy with Percutaneous Soft Tissue Release in Resistant and Relapsed Cases of Clubfoot – A Prospective Study of Forty-four Feet

Dorso-Lateral Wedge correction osteotomy: Is this the way forward?

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Short Term Outcomes of Cuboid Closing Wedge Osteotomy with Percutaneous Soft Tissue Release in Resistant and Relapsed Cases of Clubfoot – A Prospective Study of Forty-four Feet

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 23-26| Sukalyan Dey1, Taral Nagda1, Jaideep Dhamele1, Chasnal Rathod1

Authors : Sukalyan Dey[1], Taral Nagda[1], Jaideep Dhamele[1], Chasnal Rathod[1]

Consultant Institute of Pediatric Orthopedic Disorders Mumbai India.
Fellow Institute of Pediatric Orthopedic Disorders Mumbai India

Address of Correspondence
Dr . Taral Nagda
Consultant Institute of Pediatric Orthopedic Disorders Mumbai India.
Email address: taralnagda@gmail.com

Abstract

Background: Recurrences and relapses are formidable aspects of clubfoot management. Most cases present with stiff, nonreducible feet which donot respond to conservative treatment. To treat these difficult cases, a procedure that addresses both soft tissue and bony restraints, provides sustained correction with minimal complications would be ideal. This prospective study was carried to evaluate the outcome of cuboid osteotomy with percutaneous soft tissue release as an effective procedure in difficult clubfeet in children younger than five years.
Material and Methods: The study cohort consisted of 44 feet in 29 children in whom the forefoot adduction and midfoot cavus relapsed or persisted after Ponseti method of casting or previous surgeries. In addition to clinical evaluation by modified Pirani scoring, comprehensive radiological evaluation was performed before after the surgery. Patients underwent a percutaneous five-point release of the posteromedial soft tissues followed by a mini-open lateral closing wedge cuboid osteotomy and fixation with K-wires. Patients were followed up for mean of 29 months (23-58 months).
Results: Mean age at the time of surgery was 42 months (8-59 months). In all cases Pirani score improved by minimum of two points, reaching full correction in 88% (n=37). Straightening of the lateral border of the foot was achieved in 91% feet (n=40). Marked improvements were also seen in radiological parameters viz. talus-1st MT angle in AP (by 20.5°, p<0.001), calcaneum-5th MT angle in AP (by 18.6°, p<0.001), talus-1st MT angle in lateral views (by 14.5°, p<0.001) and calcaneum-1st MT angle in lateral views (by 12.2°, p<0.001). There was no recurrence of the deformity. Only one case had superficial wound dehiscence which healed in one week with regular care.
Discussion and Conclusion: Percutaneous release of postero-medial soft tissues coupled with lateral column shortening has consistently provided instant, sustained correction in our study. Relative ease, safety and low rates of complications or recurrences make the procedure an attractive option for managing difficult clubfeet especially in those younger than five years.
Keywords: Clubfoot, Cuboid Osteotomy, Percutaneous Release.

Introduction
Clubfoot is the commonest congenital musculoskeletal disorder. With 1,50,000 children born with it each year, the global burden of the disease is tremendous because of its consequent disability with financial loss and social stigma if left untreated[1]. Fortunately, with the advent of the Ponseti Technique, the management of clubfoot has become effective, affordable and easy to accomplish [2]. However, the very cause of the disease being multifactorial, ranging from collagen abnormalities to neuromuscular disorders, all clubfeet do not respond uniformly to Ponseti protocol of serial casting, tenotomy and bracing. Some feet may initially show response, yet relapse as soon as the treatment is completed. A relapsed clubfoot is defined as any foot requiring further intervention following successful correction with the Ponseti technique. [3]. A foot is considered resistant when the deformity shows no evidence of further improvement after three months of adequate conservative treatment [4].
Ponseti himself said that regardless of the mode of treatment, the clubfoot has a strong tendency to relapse especially some feet which Ponseti labelled as “ severe and stiff with small calf size”[5]. Relapse rate in Ponseti method has been variously stated to range from 5 to 41% [6]. These relapsed clubfeet pose unique difficulties. Soft tissues adapt to the increasing body mass of the growing child and effect of weight bearing. Gradually bony changes take place including overgrowth of the lateral column of the foot. In such a stiff deformed foot, only casting is not likely to be entirely effective.
Various surgical procedures have been described for correction of deformities. Each technique has its own advantages and drawbacks.
Soft tissue releases have been described for clubfeet. They can bring the clubfoot to acceptable alignment so long as bony architecture maintains some degree of conformity. When columnar disparity occurs due to lateral overgrowth, which becomes clinically evident as forefoot adduction, midtarsal ostotomies are required. Combined procedure of lengthening of the medial column and shortening the lateral column would seem to be the optimum treatment. However, operating on both sides of the foot and forcing correction by stretching of the medial side puts contracted medial soft tissues at risk of dehiscence.
Hence we proposed that a percutaneous posteromedial soft tissue release would avoid wound related complications frequently associated with an open dissection and when combined with a trans-cuboid lateral column shortening osteotomy will bring about the full correction of all the deformities. So, with the primary objective of evaluation of outcome of the procedure we carried out the prospective study.

Material and Method
Twenty nine consecutive children younger than five years with resistant or relapsed clubfoot were enrolled for the study. A total of forty four feet in these 29 subjects were thus included in the study. Inclusion criteria consisted of: presence of forefoot adduction or mid foot cavus deformities have recurred due to any reason after full correction, or b) deformities were not corrected by any conservative treatment by Ponseti technique or operative techniques. Such previous intervention on the study cohort consisted of Ponseti casting & tenotomy (n=19), operative techniques, which consisted of soft tissue release (n=12), JESS fixation (n=2), bony procedures (n=2) and tibialis anterior transfer (n=2). We also included 7 feet of neglected cases which were not treated previously by any of the methods. These feet were clinically evaluated using the Pirani Scoring. A comprehensive radiological evaluation was performed before and after the surgery. This consisted of talus-first metatarsal angle (TFMA-AP) and calcameum-fifth metatarsal angle (CFMA-AP) in standing AP views and talus-first metatarsal angle (TFMA-L) and calcaneum-first metatarsal angle (CFMA-L) in weight-bearing lateral radiographs.
The patients were operated under general anaesthesia with a caudal block for postoperative pain control. We used tourniquet for a blood less field during dissection. The first stage consisted of percutaneuos “Five Point Release” of the tight postermedial structures. These structures which impede correction are namely the Tendo Achilles, tibiallis posterior, plantar fascia, abductor hallucis , and the long toe flexors. This was followed by a transverse incision along the dorsolateral aspect of the foot, centring over the cuboid. The extensor digitorum brevis was separated from its origin on the lateral side of the calcaneus and retracted towards the top of the foot, thus giving exposure of the cuboid, anterior portion of the calcaneus, and the neck of the talus. Two K wires were passed through the cuboid to assess the amount of wedge to be resected. The proximal K wire was perpendicular to the axis of the hindfoot and the distal one perpendicular to that of the forefoot. A dorsolaterally based wedge from the cuboid was resected using the K wires as the guide. When the gap was closed, the k wires essentially became parallel and the normal axis of the foot was achieved. The closure of the lateral cuboid wedge was also accompanied by the rotation of the forefoot, which corrected adduction and supination. The osteotomy site was secured with two k wires passing through the osteotomy site. Wound was closed and the limb was kept in an above knee plaster slab for initial two weeks. At two weeks sutures were removed and below knee plaster was applied and kept for subsequent four weeks. At six weeks, K wires were removed as the osteotomy site had healed by then. Gait training and progressive full weight bearing with ankle foot orthoses were encouraged. Orthoses were gradually weaned off and patients continued with regular footwear. For radiological evaluation, serial radiographs starting from six weeks postoperative and every three months thereafter were taken to assess the same parameters as that of the preoperative evaluation. Patients were followed up for a mean period of 29 months (23-58 months)
Along with Pirani Score, pain or difficulty in walking if any, were noted. Ease of wearing normal foot wear was assessed. Parents’ satisfaction with the appearance and function of the foot was also evaluated.
For statistical analysis was performed using Chi Square test, paired t test & Student t tests. Statistical significance was set at 99% confidence interval (p=0.01).

Observation and Results
Amongst the study cohort, there were twenty one boys eight girls. Mean age at the time of surgery was 42 months (range 8-59 months). Fifteen cases were bilateral and the rest unilateral.
Pirani score in all cases improved by minimum of two points , the mean improvement being 2.4±1.2 points which was statistically significant (p<0.001)(Table 1). Full correction was achieved in 88% cases. Straightening of the lateral border of the foot was achieved in 91% feet (n=40). Marked improvements were also seen in radiological parameters viz. talus-1st MT angle in AP (by a mean of 20.5°±13.5, p<0.001), calcaneum-5th MT angle in AP (by 18.6°±13.4, p<0.001), talus-1st MT angle in lateral views (by 14.5°±11.4, p<0.001) and calcaneum-1st MT angle in lateral views (by 12.2°±10.1, p<0.001). There was no recurrence of the deformity. Al patients were able to bear weight on a painless plantigrade feet and could use regular shoes.

Complications
None of the patients suffered from any major complications like infection, loss of fixation, displacement of the osteotomy or non-union at the osteotomy site. Only one case had superficial wound dehiscence which healed in one week with regular care. One case had residual equinus deformity of 10° which was found to be due to flat topped talus, unrelated to the surgery.

Discussion
The ultimate goal of treatment of a clubfoot is to achieve a functional , pain-free plantigrade foot with good mobility. However in recurrent or resistant cases, achieving this goal becomes progressively challenging. The effectiveness of Ponseti method diminishes with increasing age of the child. [7]. Penny has described how the effect of weight bearing exaggerates the existing equinus , varus and cavus deformities eventually rendering it non-reducible.[8]. This happens because the lateral column of the foot (calcaneus plus cuboid) elongates more than the medial one(talus, navicular, and cuneiform) and in that process the bones lose their natural reciprocal conformity. [9,10] After finding the obvious limitations of conservative methods to treat relapsed and resistant clubfeet, many surgeons devised soft-tissue release procedures[11,12]. But it was found that although STR can be used to correct some cases of resisitant clubfoot [12-14], in patients with bony deformity and columnar disparity, it can at most, provide only partial correction. Extensive STRs may have short-term complications, and as much as 47% of patients may undergo additional surgery[15,16].
Bony procedures have the ability to restore the normal foot alignment through equalisation of the columnar length and thus provide a definitive solution to resistant deformities. This involves shortening the lateral column and/or lengthening of the medial column. Combination of these midfoot osteotomies and soft tissue releases can correct the hindfoot deformities also. This is possible by elongation of medial flexors, invertors and by direct reduction of the navicular bone over the head of the talus.[17]
The complex deformities of the foot can be corrected by number of ways. Shortening the lateral column by resecting wedge of bone from the midtarsal region is effective in aligning the foot. Bone can be removed by resecting distal part of calcaneum (Lichtblau procedure), cuboid enucleation or by a formal dorsolaterally based wedge subtraction osteotomy of cuboid. Conversely, the medial column can be lengthened by opening wedge osteotomy of the medial cuneiform bone. These two procedures can be combined together whereby the wedge removed from the cuboid is grafted into the distracted osteotomy gap of the medial cuneiform.
Whatever procedure in performed, the resultant foot should be plantigrade, articular surfaces should be preserved to prevent further stiffness and the growth potential of the bone should be left undisturbed. In addition the procedure should provide one-time correction so that no further surgeries are required later in life. Medial cuneiform opening osteotomies are more appropriate for children older than four years as the ossific nucleus does not appear till then and the bone remains soft, leading to higher incidence of graft extrusion and reoperation rates[18]. According to Gordon et al. [19], this procedure should be reserved for patients aged 5 years or older because the medial osteotomy is technically difficult in a small, partially ossified cuneiform . Lourenco et al. [20] treated 39 feet with a closing who achieved good results with this dual column osteotomy. He stressed the importance of a well formed medial cuneiform ossification centre for which appears when the child is at least four years old.
Another difficulty with acute lengthening of the medial column is that the procedure is likely to stretch the skin and soft tissues which have so long remained contracted, to an extent beyond their elastic limit. Results from the arteriography study by Greider et al. [21] in children with clubfoot showed there is only one major vessel supplying the foot: the posterior tibial artery. While performing surgery on the medial side the vessel may get injured unless protected. Also , undue stretching of the medial side at attempt to correct a severely deformed foot may result in segemental thrombosis of the artery. This can seriously affect the outcome of the surgery. Following the correction of severe deformities, problems with skin closure can also occur [18].
Much of these potential difficulties can be avoided if posteromedial releases are performed using percutaneous technique to make the foot more mobile and then performing a formal lateral closing wedge osteotomy to accomplish columnar alignment. No patient in our study suffered from any medial soft tissue related problems. The present study reflects that correction of deformities can be achieved by percutaneous releases even without opening the critical medial aspect of the foot.
At the end of the study period, all our patients walked with a painless plantigrade and supple foot. There was no recurrence or persistence of deformity and hence none of the cases had to undergo surgery. Ninety-one percent feet achieved a straight lateral border. In the rest nine percent cases, the calcaneus-5th metatarsal angle was less than 10 degrees and hence were acceptable in appearance and function.
In the series published by Loza where double column osteotomy was performed, the mean post-operative radiographic angles were : talus first metatarsal angle in AP view (TFMA-AP)-7º (–10º to 25º), Calcaneo Fifth Metatarsal angle in AP view (CFMA-AP) was 9º (10–20º), lateral talo-first metatarsal angle (TFMA-L) was 11º (0–29º) [22]. The corresponding values of the parameters in our study were : TFMA-AP was 4.7º ( –5º-17º), CFMA-AP was 3.1º (-8-18º), TFMA-L was 8.5º (-2º-28º), which are comparable to that of Loza et al. It means that even with a single column osteotomy with a selective medial release, a correction comparable to double column osteotomy can be achieved.
Arjandas et al performed a retrospective analysis of 14 feet in children younger than five years having a persistent “bean shape” deformity despite treatment by Ponseti method [23]. Each was operated with using a combination of a closing wedge cuboidal osteotomy and trans-midfoot osteotomy without a medial opening wedge osteotomy. At the end of the last follow up (mean 2.6 years) the mean TFMA-AP was 12, CFMA-AP was 10, TFMA-L was 8 and CFMA-L was 13. These figures are comparable to those of our study. Marginally more correction (especially talus-first metatarsal angle in AP view, which reflects extent of adduction deformity), achieved in our study may be the result of Percutaneous medial release performed by us.
Similar results were also shown by Cesare et al (2012) in their study with 53 neglected rigid non-reducible clubfeet in children 6-9 years in whom, selective medial soft tissue release with lateral closing wedge cuboid osteotomy was performed [17].
The study however had some limitations. It was a study from a single institute. Another shortcoming of the study was short duration of follow up. The long term outcome of the study remains to be assessed. Pohl and Nicol reported one case of recurrence at 2 years [24], Schaefer and Hefti observed a tendency to adduction deformity with longer followup. Hence, following these patients for a longer duration would be more desirable [25].

Conclusion
Thus the procedure of lateral closed wedge osteotomy of the cuboid with medial percuateneus soft tissue release has shown consistently good overall results in terms of deformity correction, painfree weight bearing and preserving range of movement. Ease of the procedure, short period of convalescence, exceedingly low recurrence rates and complications are the attractive attributes of the procedure which make it ideal for children younger than five years with resistant or recurrent clubfoot.

Clinical Message
The findings of the present study reveal that surgical procedure of percutaneous soft tissue release with lateral closing wedge osteotomy of the cuboid is effective in managing recurrent and relapsed cases of clubfoot, while minimising the complications and rates of recurrence or reoperation. This could be the optimal answer to the entity of difficult clubfoot which has so long been a challenge to the orthopaedic surgeons.

References

1. Dobbs MB, Gurnett CA. Update on clubfoot: etiology and treatment. ClinOrthopRelat Res. 2009;467:1146–1153.
2. Cesare Faldini MD, Francesco Traina MD, Alberto Di Martino MD, PhD, MatteoNanni MD, Francesco Acri MD , Can Selective Soft Tissue Release and Cuboid Osteotomy Correct Neglected Clubfoot? ClinOrthopRelat Res. 2013; 471:2658–2665.
3. Abdelgawad AA, Lehman WB, van Bosse HJ, Scher DM, Sala DA. Treatment of idiopathic clubfoot using the Ponseti method: Minimum 2-year follow-up. J PediatrOrthop B. 2007;16:98–105.
4. Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg Am. 2004;86-A:22–7.
5.Parsa A, Moghadam MH, Mohammad HJ. Relapsing and residual clubfoot deformities after the application of the Ponseti method: a contemporary review. Arch Bone Jt Surg 2014; 2:7–10.
6. Ponseti IV. Relapsing clubfoot: Causes, prevention and treatment. Iowa Orthop J. 2000;22:55–7.
7. Bhaskar A, Patni P. Classification of relapse pattern in clubfoot treated with Ponseti technique. Indian J Orthop. 2013;47:370–6.
8. Yagmurlu MF, Ermis MN, Akdeniz HE, Kesin E, Karakas ES. Ponseti management of clubfoot after walking age . Pediatr Int. 2011;53(1):85–9.
9. Penny JN. The neglected clubfoot. Tech Orthop. 2005;20:153–166.
10. Lavy CB, Mannion SJ, Mkandawire NC, Tindall A, Steinlechner C, Chimangeni S, Chipofya E. Club foot treatment in Malawi: a public health approach. Disabil Rehabil. 2007;29:857–862.
11. Pirani S, Naddumba E, Mathias R, Konde-Lule J, Penny JN, Beyeza T, Mbonye B, Amone J, Franceschi F. Towards effective Ponseti clubfoot care: the Uganda Sustainable Clubfoot Care Project. Clin Orthop Relat Res. 2009;467:1154–1163.
12. Codivilla A. The classic: Tendon transplant in orthopedic practice by A Codvilla. Clin Orthop Relat Res. 1976;118:2–6.
13.Turco VJ. Surgical correction of the resistant club foot: one-stage posteromedial release with internal fixation: a preliminary report. J Bone Joint Surg Am. 1971;53:477–497.
14. Zadek I, Barnett EL. The importance of the ligaments of the ankle in correction of congenital clubfoot. JAMA. 1917;69:1057.
15. Huang YT, Lei W, Zhao L, Wang J. The treatment of congenital club foot by operation to correct deformity and achieve dynamic muscle balance. J Bone Joint Surg Br. 1999;81: 858–862.
16. Kruse L, Gurnett CA, Hootnick D, Dobbs MB. Magnetic resonance angiography in clubfoot and vertical talus: a feasibility study. Clin Orthop Relat Res. 2009;467:1250–1255.
17. Dobbs MB, Nunley R, Schoenecker PL. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am. 2006;88:986–996.
18. Faldini C, Traina F, Di Martino A, Nanni M, Acri F. Can Selective Soft Tissue Release and Cuboid Osteotomy Correct Neglected Clubfoot? ClinOrthopRelat Res 2013; 471:2658–2665.
19. Ettl V, Kirschner S, Krauspe R, Raab P. Midterm results following revision surgery in clubfeet. IntOrthop 2009;33:515–520.
20. Gordon JE, Luhmann SJ, Dobbs MB, Szymanski DA, Rich M, Anderson DJ, Schoenecker PL. Combined midfoot osteotomy for severe forefoot adductus. J Pediatr Orthop. 2003; 23(1):74–78
21. Lourenco AF, Dias LS, Zoellick DM, Sodre H. Treatment of residual adduction deformity in clubfoot: the double osteotomy. J Pediatr Orthop. 2001; 21(6):713–718
22. Greider TD, Siff SJ, Gerson P, Donovan MM. Arteriography in club foot. J Bone Joint Surg Am. 1982;64:837–840.
23. Loza ME, Bishay SN, El-Barbary HM, Hanna AA, Tarraf YN, Lotfy AA. Double column osteotomy for correction of residual adduction deformity in idiopathic clubfoot. Ann R CollSurgEngl 2010; 92: 673–679).
24. ArjandasMahadev MD, Ismail Munajat MD, AzuraMansor MD, James H. P. Hui MD Combined Lateral and Transcuneiform without MedialOsteotomy for Residual Clubfoot for Children, ClinOrthopRelat Res. 2009; 467:1319–1325.
25. Pohl M, Nicol RO. Transcuneiform and opening wedge medial cuneiform osteotomy with closing wedge cuboid osteotomy in relapsed clubfoot. J Pediatr Orthop. 2003;23:70–73.
26. Schaefer D, Hefti F. Combined cuboid/cuneiform osteotomy for correction of residual adductus deformity in idiopathic and secondary club feet. J Bone Joint Surg Br. 2000;82:881–884.

How to Cite this Article:Dey S, Nagda T, Dhamele J, Rathod C. Short Term Outcomes of Cuboid Closing Wedge Osteotomy with Percutaneous Soft Tissue Release in Resistant and Relapsed Cases of Clubfoot- A Prospective Study of Forty-four Feet. International Journal of Paediatric Orthopaedics Jan-Apr 2016;2(1):23-26.

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Dorso-Lateral Wedge correction osteotomy: Is this the way forward?

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 19-22|Viraj U Shingade1

Authors :Viraj U Shingade[1]

Children Orthopaedic Care Institute and Pravira Hospital Daya chambers, Wardha road , Nagpur, Maharashtra.

Address of Correspondence
Dr Viraj U Shingade
Children Orthopaedic Care Institute and Pravira Hospital Daya chambers, Beside Haldiram Building, Ajani square, Wardha road. Nagpur, Maharashtra-440015.
Email: virajshingade@rediffmail.com

Abstract

In the present era of more and more advancements, when we are talking about mini invasive procedures, developing countries are still facing the major burden of neglected clubfoot deformities; where children present to orthopaedic surgeon at 5-18 years of age, not treated in the past. The orthopaedic surgeon to whom they present is in great dilemma about how to treat these cases. Majority of children cannot afford surgical procedures like Ilizarov which need expensive implants, and frequent visits to the specialised centres. Patients usually ask for one-time procedure which will give them the best chance of cure since they are brought for the treatment by charitable agencies or social workers. Dilemma in choosing correct method of treatment for these neglected or relapsed feet led to the evolution of a new single-staged, simpler and effective technique of dorso-lateral wedge corrective osteotomy. The procedure has been extensively studied in neglected as well as relapsed cases of club feet with long term follow up of more than 10 years. This review briefly describes the technical details of the procedure.
Keywords: Clubfoot, Club feet, Neglected, Relapsed, Osteotomy, Ponseti.

Introduction
The Need for new surgical technique: In the present era of more and more advancements, when we are talking about mini invasive procedures, developing countries are still facing the major burden of neglected clubfoot deformities; where children present to orthopaedic surgeon at 5-18 years of age, not treated in the past. These children walk on dorsum or dorso-lateral aspect of foot (Figure 1). They cannot use normal shoe-wear and are prone for injuries while playing games and walking long distances. They get repeated wounds at callosities, formed over dorsum of foot. They also have difficulty in squatting, which is the commonest position, used for day-to-day activities including toileting. Social stigma of having reversed feet is an important factor as such children are avoided by friends and girls experience problems in getting married.
The orthopaedic surgeon to whom they present is in great dilemma about how to treat these cases. Majority of children cannot afford surgical procedures like Ilizarov[1] which need expensive implants, and frequent visits to the specialised centres. Patients usually ask for one-time procedure which will give them the best chance of cure since they are brought for the treatment by charitable agencies or social workers.
Extensive soft tissue releases in these cases, pose problems of skin approximation, wound healing and scarring[1, 2, 3]. Conventional bony procedures cannot fully correct these severe deformities and combination of multiple procedures is required[1,2,3,4,5,6]. Triple arthrodesis[5] is associated with stiffness and ankle arthritis. Ponseti’s method for managing neglected cases have problems of compliance, frequent visits for plastering, expenses involved and subsequent need of osteotomies[7,8,9] to get complete correction.
Dilemma in choosing correct method of treatment for these neglected or relapsed feet due to above reasons led to the evolution of a new single-staged, simpler and effective technique of dorso-lateral wedge corrective osteotomy. The aim was not to obtain a normal anatomical foot; but to obtain a foot which is more or less plantigrade and able to fit shoes. A longitudinal follow up study was conducted by our institute to measure the outcome of this procedure in neglected as well as relapsed clubfoot deformities. The study was published [10] in the year 2012 with good follow up of cases and in fact now we have follow up more than 10 years of majority of our cases. Subsequently we found that the procedure was equally useful for neglected and relapsed cases of clubfoot associated with myelomeningocele and it was published[11] in the year 2014.

Operative Technique
The details of the operative technique are described in the published article in Journal Current Orthopaedic Practice [10] in the year 2012. The technique in brief is as follows: Under epidural anesthesia, the patient is placed supine; after painting and draping, the tourniquet is inflated. For correction of the cavus deformity, a percutaneous plantar fasciotomy is done (Figure 2A) from the medial aspect of the sole. The foot is then stretched manually to confirm complete release of plantar fascia. To correct the equinus, percutaneous Achilles complete transverse tenotomy (Figure 2B) is done and foot is stretched (dorsiflexed) manually. The Achilles tenotomy unlocks the heel, correcting equinus as well as heel varus. In rare cases of relapsed deformity if equinus is not corrected completely, the posterior ankle capsular release can be done through same incision. Attention is then directed to the dorsal closing wedge osteotomy. An elliptical skin incision is made on the dorso-lateral aspect at the apex of the deformed foot (Figure 2C).The incision extends from the lateral border of the foot to just short of the medial border. The elliptical skin and preformed bursa are excised. All dorsal musculature is separated and preserved with a periosteal elevator and chisel and then retracted. The dorsal neurovascular bundles are protected. The osteotomy is marked with an osteotome at the apex of the deformed foot. The wedge should be wider dorsally (1-2 cm) and taper towards the sole (Figure 2D). The amount of bony wedge required depends on the severity of the deformity. A rough clinical guide that can be used is that children who walk on the lateral border of the foot usually do not require more than 1-1.5cm of wedge; those who walk on the dorsum of foot may need more than 1.5cm of wedge. One can always remove additional bone if the correction is found to be inadequate. This also prevents the over-correction. The bones included in wedge are cuboid and all three cuneiforms. Occasionally, the navicular or distal calcaneus or base of the metatarsals may require osteotomy, depending on the severity of the deformity. Occasionally impingement of the navicular against the head of the talus occurs, not allowing full correction of the deformity, even with cuboid and cuneiform osteotomy. In those patients, naviculectomy should be done, and sometimes an additional terminal portion of the talar head may need to be excised, taking care not to disturb the subtalar joint. After wedge removal, care is taken to remove cartilage from the osteotomy bed and approximating edges to prevent nonunion and pseudarthrosis. No attempt is made to touch the subtalar joint. The deformity is then corrected by closing the space manually by everting and dorsiflexing the foot and by approximating the bony surfaces, as if closing an open book (Figures 2E and F). The forefoot is stabilized to the hindfoot with three Kirschner-wires passed from the metatarsals to the calcaneus(Figure 2G). Cancellous bone from the resected wedge is grafted at the osteotomy site. No attempt is made to look for radiographic correction because judgement is clinical. The wound is closed after placing a drain (Figure 2G) and the tourniquet is deflated. An above-knee cast was applied. A window was made in the cast (Figure 2I), and the limb was kept elevated on pillows.
Three days of intravenous antibiotics are given along with an epidural for pain relief. On the third postoperative day, the wound is inspected through the window in the cast
(Figure 2I). Hematoma, if present, should be removed along with the drain. Patients are discharged on the fourth postoperative day and non-weight bearing is advised for 6 weeks. After 6 weeks, the Kirschner-wires and cast are removed, and a plastic molded ankle-foot orthosis is applied to be worn for 6 months. Squatting is encouraged at home.
The foot deformities were graded according to classification system described by Dimeglio [12] and the results of the surgical procedure were studied extensively using evaluation system described by International Clubfoot Study group and Bensahel [13].

Discussion
Here we are not discussing about Dimeglio grade I or II deformities. We are discussing the neglected cases who have Dimeglio-grade III/IV deformities and who have came for the treatment at 5 yrs of age or later. Also we are discussing about patients with relapsed clubfeet in developing countries who present late to the hospital and may have been operated on at hospitals where no experts were available. Hence, at the time of presentation, they usually have severe (Dimeglio-grade III/IV) deformities that cannot be corrected with conventional procedures such as those described by Dwyer or Dillwyn Evans alone, and a combination of procedures[14,15,16] is required.
With the described technique, excellent and good results were achieved in 89.6% feet at our centre; indicating that the technique is effective and extremely useful in both relapsed as well as neglected clubfeet (Figure 3 and 4). When we compared the results of neglected feet and relapsed feet we found that the results were better in neglected feet. The lower proportion of excellent and good results in relapsed feet compared with neglected feet could be from scarring of previous surgeries with resultant stiffness at the ankle, subtalar, or mid tarsal joints. This was consistent [16,17,18] with other studies. We also found that the results were better in younger (<10 years) children due to less bony incongruency and better ability to remodel.
Bones in these feet are so deformed that they cannot achieve normal radiographic relationships. Our results were independent of radiographic findings and were consistent with other [18,19] studies. Only one child with poor results (bilateral relapsed feet) had complete correction of the deformity intraoperatively but was lost to follow-up for 59 months. The patient neither performed squatting exercises nor used splints, leading to recurrence. This suggests that squatting has an important role to play. In spite of poor results, he maintained good function.
No feet (including those with poor results) had clinical or radiographic evidence of arthritis at the ankle or any other joint in last 10 years of follow-up. A possible reason could be that our procedure preserves the subtalar joint. This is an advantage over triple5 arthrodesis.
Patients usually have foot discomfort and plantar pain during the initial few months after cast removal. This is due to sensitivity of the sole and disuse osteoporosis of the calcaneus and metatarsals. None of the patients complained pain during follow-up, which might be attributed to good fusion at the osteotomy site with the use of cancellous grafting.
Clubfoot is a three-dimensional deformity, with a contracted tendo-Achilles being the main deforming force. Achilles tenotomy unlocks the heel and corrects equines and heel varus. No separate procedure or calcaneal osteotomy is necessary for varus correction (Figures 2 H).
With the described technique one can achieve good correction of all components intra-operatively (Figures 2 G, H) and can have varus-valgus movements on the table. Meticulous preservation of dorsal structures preserves function and prevents wound complications.
In bilateral cases, we advice surgery on both feet under a single anesthesia; which reduces the rehabilitation time, saves resources, and provides a unique opportunity for correction. This single-stage surgical procedure is easy, safe, and reproducible, and it can be performed with basic orthopaedic instruments.
There are no rigid criteria about specific bones to be osteotomized. If the surgeon performs an osteotomy at the apex of a deformed foot and takes out a wedge dorsally, tapering towards the sole, no error can occur.
There is no risk of neurovascular damage. By removing a dorsal wedge, tension in the system is released. Problems of medial scarring and wound breakdown are avoided because the technique is percutaneous medially. No iliac crest graft or major implants are required. Fewer follow-ups are required than with other techniques. We believe that the technique is cost effective, requiring only 10% of the cost involved in the Ilizarov or other techniques. The only disadvantage is possible shortening of foot length in unilateral cases. We observed an average shortening of 1.18cm which is comparable to other series of bony procedures and even those feet treated[19,20,21] conservatively.
We agree that the best approach in developing countries to reduce the load of neglected cases and to avoid long-term problems associated with extensive soft-tissue releases is early[21] intervention during infancy. This can be achieved by seeking help from paramedical persons like nurses or physiotherapists to use the Ponseti technique[21,22] at outlying hospitals, but until that time this load of neglected cases persists;the described technique provides a good alternative procedure to surgeons of the developing world. It is a good alternative to conventional procedures for management of neglected or relapsed, late presenting clubfoot deformities. We do not claim that this is the only best alternative, but it may suit the needs of developing countries, particularly in settings like ours, where patients mostly of low socioeconomic means come from remote villages and are unable to comply in terms of follow-up

References

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How to Cite this Article:Shingade VU. “Dorso-Lateral Wedge correction osteotomy: Is this the way forward?”. International Journal of Paediatric Orthopaedics Jan-April 2016;2(1):19-22.

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Short Term Outcomes of Cuboid Closing Wedge Osteotomy with Percutaneous Soft Tissue Release in Resistant and Relapsed Cases of Clubfoot – A Prospective Study of Forty-four Feet

Dorso-Lateral Wedge correction osteotomy: Is this the way forward?

Short Term Outcomes of Cuboid Closing Wedge Osteotomy with Percutaneous Soft Tissue Release in Resistant and Relapsed Cases of Clubfoot – A Prospective Study of Forty-four Feet

Dorso-Lateral Wedge correction osteotomy: Is this the way forward?

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Short Term Outcomes of Cuboid Closing Wedge Osteotomy with Percutaneous Soft Tissue Release in Resistant and Relapsed Cases of Clubfoot – A Prospective Study of Forty-four Feet

Authors : Sukalyan Dey[1], Taral Nagda[1], Jaideep Dhamele[1], Chasnal Rathod[1]

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Dorso-Lateral Wedge correction osteotomy: Is this the way forward?

Authors :Viraj U Shingade[1]

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