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Management Of Non-Idiopathic Clubfeet

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 27-32|Ishani P Shah1, Alvin H Crawford2, Junichi Tamai3, Shital N Parikh4* Authors :Ishani P Shah [1], Alvin H Crawford [2], Junichi Tamai[3], Shital N Parikh[4*] 1 Ashirwad Nursing Home.Jambli Galli, Borivali West, Mumbai India. 2 Department of Orthopaedics, University of Cincinnati. 3 Division of Pediatric […]

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 […]

Management Of Non-Idiopathic Clubfeet

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

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Management Of Non-Idiopathic Clubfeet

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 27-32|Ishani P Shah1, Alvin H Crawford2, Junichi Tamai3, Shital N Parikh4*

Authors :Ishani P Shah [1], Alvin H Crawford [2], Junichi Tamai[3], Shital N Parikh[4*]

1 Ashirwad Nursing Home.Jambli Galli, Borivali West, Mumbai India.
2 Department of Orthopaedics, University of Cincinnati.
3 Division of Pediatric Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center

Address of Correspondence
Shital N Parikh, MD
Division of Pediatric Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Av, Cincinnati, OH 45229
Email: shital.parikh@cchmc.org

Abstract

Background: The management of idiopathic clubfeet with Ponseti method of casting has been well outlined in literature. However management of non-idiopathic clubfeet, like the ones associated with arthrogryposis or myelomeningocele, has been challenging. Various treatment modalities including casting, soft tissue releases, bony procedures and talectomy have been attempted, either in isolation or in combination, with variable results. The aim of the current study was to perform a comprehensive review of the literature related to the classification and management of non-idiopathic clubfeet. Recent literature has shown benefits of a trial of Ponseti method of casting for all non-idiopathic clubfeet. Most of these clubfeet, however, would require surgical treatment due to either insufficient correction or recurrence. We attempt to provide, based on the review of literature and our experience, a treatment algorithm to help with the management of complex, non-idiopathic clubfeet.
Keywords:Non-idiopathic clubfoot, CTEV, Ponseti, arthrogryposis, myelomeningocele.

Introduction
With the success of Ponseti casting technique, the management of most congenital talipes equinovarus deformity or idiopathic clubfeet, has been standardised. The management of non-idiopathic clubfeet, however, continues to be challenging. These non-idiopathic clubfeet are associated with many neuromuscular and congenital syndromes, the most common of which are arthrogryposis and myelomeningocele (Table 1). The diagnosis of the underlying condition associated with clubfeet is important as it can affect management and help predict prognosis. These feet have been considered more rigid with a higher rate of recurrence compared to idiopathic clubfeet. In the past, they have been considered to be resistant to non-operative treatment and have been treated with multiple surgical procedures including extensive soft-tissue releases and radical bony surgeries .
The purpose of this study is to perform a comprehensive review of the existing literature, review our experience and provide guidelines for management of non-idiopathic clubfeet. The article would first describe the distinct features of common conditions associated with non-idiopathic clubfeet and would discuss the need for special considerations, if any, in their orthopaedic management. This would be followed by general principles and treatment algorithm for management of non-idiopathic clubfeet.

ARTHROGRYPOSIS
Arthrogryposis is derived from the Greek words, joint (arthron) and hooked (grupon). It is a condition of non-progressive contractures of two or more joints often resulting from fetal akinesia . Arthrogryposis is not a specific diagnosis but a clinical finding characteristic of more than 300 disorders .
Clubfeet in arthrogryposis are usually stiffer and the deformities are more severe than idiopathic clubfeet. The skin is thin and smooth, muscles are pale and thin and often replaced by fat and fibrous tissue, ligaments and capsular tissues are thickened and tight, and articular surfaces are abnormally shaped with absent skin creases around the joint. Deformities are usually bilateral but rarely symmetrical. Deformities are not progressive but untreated deformities become more rigid with growth . There is a resistance to correction and also a tendency to recur. Of the various types of arthrogryposis, clubfeet in amyoplasia have severe deformities, are stiffer, more rigid and more resistant to treatment than in distal arthrogryposis. .
Concomitant contractures of the knee and/or hip pose a unique problem to clubfeet management in arthrogryposis . The knee could have a fixed deformity in extension (subluxated) or in flexion. During casting for clubfeet, a knee with an extension deformity can cause slippage of the cast and hence loss of correction. Simultaneous gradual correction of the knee and the foot in cast could be attempted. Failure of closed treatment of knee extension contracture may require surgical intervention. Simultaneous surgery of the knee (e.g. quadricepsplasty) and cast treatment of the clubfoot pose a challenge as well, as the knee would require early postoperative mobilization and this may compromise the correction of the foot. When knee has flexion contracture, soft tissue stretching/release or corrective extension osteotomy could be done after correction of clubfoot.
Hip joints in arthrogryposis are often subluxated or dislocated. These dislocations are often teratogenic and can rarely be treated by closed reduction. When both hips are affected, they are best left untreated and when unilateral, closed or open reduction should be attempted in the first few months.
Children with arthrogryposis often require multiple corrective surgeries and hence repeated anaesthesia. Airway access could be challenging and fibre optic intubation should be considered in such circumstances. Intravenous access may be difficult due to presence of tense skin and less subcutaneous tissue. Intra-operative positioning may be difficult due to multiple contractures. Perioperative respiratory issues and malignant hyperthermia should be considered in these children .

Diastrophic Dysplasia
Diastrophic dysplasia is an autosomal recessive disorder characterised by short stature, multiple joint contractures, cervical spine scoliosis, hitch hiker’s thumb, cauliflower ears and severe clubfoot deformity. Similar to arthrogryposis, clubfeet are usually rigid, difficult to treat and may be co-existent with hip and knee contractures. Surgical correction pose difficulty in these feet due to distorted anatomy. Recurrences after initial treatment are common and may require extensive releases and/or talectomy .

Freeman Sheldon Syndrome
This is a type of distal arthrogryposis characterised by ‘whistling mouth facies’, short stature, hand deformities in form of ulnar deviation and thumb in palm and rigid clubfeet.

Neurogenic Clubfoot
Clubfeet occur in 30-50% of spina bifida patients. It is most commonly seen in lumbar lesions at the level of L3-L4 and above. . The level of lesion should be identified as it would affect the functional motor level and hence the ambulatory capacity. In a potential walker, the aim is to have a plantigrade foot that can weight bear; in a non-walker, the aim is to have a braceable foot to rest on the footpads of a wheelchair. Presence or absence of foot sensation should be assessed. The deformity in neurogenic feet can be attributed to varied causes including intrauterine malposition, muscle imbalance, spasticity and/or fibrotic contractures. These feet are rigid, difficult to treat and have a high risk of recurrence. There is an increased risk of pressure sores and skin breakdown due to altered or absent sensations. Physeal injury is not uncommon with manipulations. There is a high risk of fractures in these children undergoing manipulation which might not be diagnosed early due to absence of pain. There may be delayed healing of wound after surgery.
Casting in these children with myelomeningocele should be used only to maintain the correction and not to correct the deformity. Insensate feet make it difficult to identify pressure sores. Casting and manipulation should be stopped if swelling, sores or ulcers develop.

Mobius Syndrome
Mobius syndrome is a rare non progressive congenital neuromuscular disorder. It is characterised by palsy of the sixth/seventh cranial nerve and malformation of orofacial structures and limbs. Typically they have absent abduction of both eyes. Clubfoot is the most common deformity of the foot. Diagnosis should be suspected when multiple cranial nerve dysfunction exist with clubfeet.

Streeter’s Dysplasia
This is a disorder of fetal development in which the amnion separates from the chorion and forms bands which encircle limbs . Part of the limb distal to the band may be amputated, anomalous or normal. Incidence of clubfeet with constriction bands is 12-56% . These children may or may not have a neurological deficit on the involved side. Neurologic deficit has been found more commonly with zone 2 bands (band between knee and ankle) and grade 3 severity i.e. (reaching up to the level of fascia compromising distal circulation) . Clubfeet with constriction bands are rigid, respond poorly to conservative treatment and often require soft tissue release . Feet with neurological deficit have been more resistant to treatment by earlier authors and require more number of surgeries than ones without a deficit .
In case the constriction band causes circulatory compromise, emergent release should be done. All other bands may be released in a staged manner after correction of clubfoot. Paralytic feet may require tendon transfer depending on the involvement.
Down’s Syndrome
Down’s syndrome is the most frequent trisomy (chromosome 21). It is characterised by hypotonia and hyperlaxity, mental retardation, congenital heart disease, atlanto-axial instability, habitual dislocation of patella and hip and genu valgum. Though typical foot deformity due to hyperlaxity has been pes planus with metatarsus adductus, occasionally soft tissue contracture around the ankle, subtalar and mid-tarsal joints present as clubfoot . In spite of generalised ligament laxity, these feet are resistant to non-operative treatment and often require surgical treatment . These feet, however have a tendency for overcorrection and calcaneovalgus deformity following treatment due to generalised hyperlaxity.
Pre-operative evaluation should include cardiac evaluation and cervical spine x-rays to screen for cervical spine instability.

Larsen’s Syndrome
Larsen’s syndrome is a rare congenital connective tissue disorder caused by mutation in gene encoding filamin B (FLNB). It has genetic heterogeneity with both autosomal dominant and autosomal recessive patterns. It is characterised by flat facies, cardiac defects and varied musculoskeletal Issues that include joint hypermobility, vertebral anomalies, recalcitrant dislocations of multiple major joints and clubfeet. Early detection of the syndrome is important for management decisions and prognostic counselling. Management of cervical spine instability should be a priority in these children. When hips, knees and feet are involved, treatment of the knee should be a priority. Clubfeet in these children should be treated by conservative method soon after birth and surgical treatment should be postponed until knee dislocation is corrected . Due to hyperlaxity, care should be taken to prevent overcorrection of these feet as they can often develop calcaneovalgus deformity. Hip dislocation, if bilateral, should be managed by careful neglect due to poor results of surgical treatment.
Preoperative assessment should include thorough respiratory, cardiac and neurologic evaluation. Lateral cervical spine x-rays in flexion and extension should be mandatory prior to anaesthesia to evaluate cervical spine instability which is common in this syndrome.

Principles of Treatment
Conventional non-operative treatment has been considered ineffective in cases of non-idiopathic clubfeet . Serial manipulations and casting of these feet often resulted in incomplete correction and frequent recurrences. Previous literature thus focused on the operative treatment of these feet, with most feet requiring multiple procedures. Soft tissue releases, however, also resulted in recurrences and required brace wear till skeletal maturity . Due to high incidence of failure of soft tissue releases, talectomy has been considered to be the procedure of choice as a primary surgery as well as in cases of recurrence .
Ponseti popularised the method of serial casting to correct idiopathic clubfeet with excellent results. In non-idiopathic feet Ponseti method decreases the severity of deformity and hence decreases the need for extensive surgery. Trial of Ponseti method should be the first line of treatment for all clubfeet, irrespective of their etiology. In recent literature, short term results of Ponseti method for correction of non-idiopathic clubfeet have been encouraging (Table 2). Most of these feet were Dimeglio grade IV or Pirani grade 4 or above . More number of casts were required than idiopathic feet, however good initial correction was achieved in most non-idiopathic feet . Arthrogrypotic feet being more rigid than idiopathic, complete correction as in idiopathic foot might not be achieved. Usually, 40-45 degree of abduction and 5 degree dorsiflexion could be achieved . The recurrence rate has been higher, but the deformity tends to improve with re-casting in most cases . Moroney el al reported that after Ponseti casting, the Pirani score in feet which required surgery reduced from 5.1 to 3.7. Thus casting, even if not successful, reduced the morbidity of future surgery.
Severity in non-idiopathic clubfeet has not been classified in literature probably because of low incidence. Most often these feet are either not graded or are graded as per Dimeglio score or Pirani scores which have been described for idiopathic clubfeet. Since most non-idiopathic clubfeet are rigid and a trial of Ponseti method has been justified for most patients, we have classified non-idiopathic feet on basis of response to Ponseti casting to standardize management protocols (Table 3).
A treatment algorithm for non-idiopathic clubfeet has been outlined (Fig 1). After initial correction with Ponseti method, the main factor leading to relapse has been non-compliance of brace . The thick rigid capsule is incapable of stretching with growth and results in recurrence despite adequate bracing. . Ill-fitting brace could contribute to non-compliance. In non-idiopathic clubfeet, it is important to maintain the correction obtained which might be less than that obtained in idiopathic feet. The brace may have to be modified to the degree of correction achieved i.e. 40 – 45 degrees of abduction and 5 degrees of dorsiflexion instead of 70 degrees and 20 degrees, respectively, as in idiopathic feet. The brace modification can improve compliance . As and when flexibility improves, more bend can be added to the brace as required. Often due to concomitant hip and knee contractures, Ankle Foot Orthosis (AFO) should be considered instead of Foot Abduction Brace (FAB) for better fit and compliance. Brace might have to be modified in case of a congenital constriction band with an amputation of the other leg – by using an AFO instead of an abduction bar. A brace in the form of an AFO should be generally worn till skeletal maturity.
If there has been partial correction with Ponseti method, surgery may be required. When no visible change is seen between two consecutive casts, casting should be stopped and surgery should be considered. The procedure of choice in such cases has been controversial. It would depend on the severity of the residual deformity, the age of child and ambulatory potential. Not all cases require extensive surgery. When only residual equinus and/or forefoot varus persists, a heel cord lengthening and anterior tibialis transfer can give good results (Fig 2). With more severe residual deformities, some authors prefer extensive soft tissue releases, reserving talectomy as a salvage procedure for the most severe of all deformities. Some favour talectomy primarily stating the higher failure of soft tissue releases . Extensive soft releases i.e. posteromedial and lateral have shown good results when performed by 1-2 years of age to preserve articular congruity. If the child presents after 2 years of age or does not have ambulatory potential then a primary talectomy should be preferred to avoid recurrence and repeat surgery. Often only a talectomy is not enough to correct the deformity and should be accompanied by soft tissue release (Fig 3, 4). Cincinnati incision adequately provides the required extensive visualization for dissection medially, posteriorly and laterally .
In very severe rigid clubfeet, correction might not be achieved with Ponseti casting. Primary talectomy with extensive soft tissue releases should be considered in these children for best results.
Soft tissue releases have shown good results when done at 7-8 months of age. When soft tissue releases are done, care should be taken to do as complete of a release as possible with excision of 1-2 cm of tendon to prevent recurrence. Soft tissue releases often correct the forefoot varus, though in cases of severe rigid equinus, the equinus is often not corrected even after release of tendo Achilles and posterior capsular releases. Complete excision of the talus provides enough laxity for correction of the equinus and varus deformity. Talectomy however might not correct the forefoot deformity and additional procedure in the form of an osteotomy might be required for such severe deformities. Failure of soft tissue releases could be either due to inadequate initial correction because of tight skin and soft tissues on the medial side or due to a relapse after cast removal due to the wide medial gap created secondary to the severe deformity . However, soft tissue release is preferred in younger patients as later salvage in the form of talectomy can be done in cases of failure. When presenting at a later age, the adaptive changes in joints preferably warrant a primary bony surgery to prevent failure and recurrence.
Talectomy has shown satisfactory outcomes after short term as well as long term follow up . In younger children, however, less radical surgery may be preferred before talectomy. If a child presents late, talectomy could be performed primarily with the best results achieved when done at 1-5 years of age. Failure of talectomy may be due to poor technique, due to either partial excision or incorrect placement of the talus under the calcaneus allowing for a later posterior drift and recurrence of equinus . A failure after poorly performed talectomy, could be difficult to treat and may require a corrective osteotomy.
Triple arthrodesis is recommended if child presents after 10- 12 years of age as earlier surgery may limit the growth of that foot.
Non-idiopathic feet have a higher rate of recurrence and hence could require secondary and tertiary procedures. Recurrence within six months of previous surgery suggest incomplete correction and hence complete correction at the initial surgery should be attempted. In case of recurrence after extensive soft tissue releases, talectomy should be considered instead of revision of soft tissue releases due to scar tissue. Ilizarov external fixator can also be used primarily or in case of secondary or tertiary recurrence.
Similar to idiopathic clubfeet, the primary aim of management of non-idiopathic clubfeet should be to achieve a painless, platigrade foot with minimal number of procedures as possible. When possible, this should be achieved before walking age to prevent adaptive changes in bone. The evaluation of result should be based on the final outcome as well as the number of procedures required to achieve it.

Summary
In recent literature, Ponseti method of casting has shown promising results in non-idiopathic feet albeit in short term. Although it may not avoid surgery in these patients in long term, it definitely reduces the severity of deformity and hence the magnitude of surgery required. It should be the first line of approach in all clubfeet, irrespective of their etiology. Later, depending on the amount of correction achieved, rigidity of the feet, walking potential and age of the patient, decision related to surgical treatment should be made. Attempt to ensure complete correction should be made in the first surgery itself to avoid recurrence. This often might require extensive soft tissue release with talectomy with or without midfoot osteotomy to correct forefoot varus. Patients should be followed long-term to identify and treat recurrence and family should be strongly counselled about the importance of such follow-up visits.

References

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2. Lloyd-Roberts, G. and A. Lettin, Arthrogryposis multiplex congenita. J Bone Joint Surg Br, 1970. 52: p. 494-508.
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16. Chang, C.H. and S.C. Huang, Clubfoot deformity in congenital constriction band syndrome: manifestations and treatment. J Formos Med Assoc, 1998. 97(5): p. 328-34.
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How to Cite this Article:Shah IP, Crawford AH, Tamai J, Parikh SN. Management of Non-Idiopathic Clubfeet. International Journal of Paediatric Orthopaedics Jan-April 2016;2(1):27-32.

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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

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6. Ponseti IV. Relapsing clubfoot: Causes, prevention and treatment. Iowa Orthop J. 2000;22:55–7.
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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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Management Of Non-Idiopathic Clubfeet

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

Management Of Non-Idiopathic Clubfeet

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

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Management Of Non-Idiopathic Clubfeet

Authors :Ishani P Shah [1], Alvin H Crawford [2], Junichi Tamai[3], Shital N Parikh[4*]

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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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