Cincinnati Incision Research Articles

Wound healing following partial closure of the Cincinnati incision: results in surgery for congenital talipes equinovarus

The Cincinnati incision is widely utilized in club-foot surgery and allows access to the medial, lateral and posterior structures that may need to be addressed during surgical correction. Closure of the skin at the end of the procedure without undue tension may be difficult. Wound necrosis and excessive scarring may occur, and may lead to inadequate correction. We reviewed 14 feet in 10 children who had undergone partial closure of the Cincinnati incision following peritalar release. All wounds were cosmetically acceptable both to the surgeon and the parents. The widest scar was 3 mm and the average time to healing was 4 weeks. No infections had occurred although two wounds were treated for overgranulation. Partial wound closure leaves cosmetically acceptable scarring with minimal complications. As the foot may be placed in a fully corrected position at the time of initial surgery, a subsequent change of position under anaesthetic is avoided. Parents should be warned about the initial appearance of the wound but reassured regarding the final outcome.

Functional results of surgical treatment in congenital talipes equinovarus (clubfoot): a comparison of outcome measurements.

A total of 151 children with 234 grade 2 or grade 3 congenital talipes equinovarus were treated by lateral-posteromedial peritalar release utilizing the Cincinnati incision. The feet were reviewed independently after a mean follow-up period of 10 years (5-19 years), using a modified rating scale, and the results compared to the severity of the initial deformity. An excellent or good result was achieved in 196 feet (84%) and a modest correlation (r = 0.48) noted between the preoperative grading of the foot and the functional result at later review. Both gender and bilaterality were also influential since a boy with bilateral deformity has a 1 in 4 chance of only a fair result, compared to a girl with a unilateral clubfoot where the chance is 1 in 10. The total range of ankle movement and the talocalcaneal index correlated strongly with the eventual surgical outcome [r = 0.69 and 0.65 (P = 0.001 and 0.01) respectively].

Evaluation of the Hemi-Cincinnati Incision for Posteromedial Soft-Tissue Release in Clubfoot

Posteromedial soft-tissue release operations were performed on 42 idiopathic clubfeet in children younger than 2 years of age through the medial half of the Cincinnati incision (the hemi-Cincinnati incision). This incision gave adequate exposure to all structures to be released. Wound closure was possible in all 42 feet without having to hold the foot in plantarflexion or inversion. Wound healing was satisfactory in the majority of instances and 81% of the scars, assessed 9 months after the operation, were graded as excellent or good. The scar is located in an area of the foot that can be concealed easily and should a more radical soft-tissue operation be needed later, the same incision can be extended easily. The authors recommend this incision as the incision of choice for performing posteromedial soft-tissue release operations on clubfeet in children younger than 2 years of age.

Muscular strength after extensive operative treatment of congenital talipes equinovarus.

Maximum isometric voluntary contraction (MIVC) strength of muscles (extensors, plantar flexors, pronators and supinators of the foot) in children with congenital talipes equinovarus who underwent extensive operative treatment was evaluated. The first group consisted of 28 children (50 clubfeet) operated on with posteromedial-lateral release aged 7 months to 76 months (mean, 22 months), with mean follow-up period of 85 months. The second group consisted of 32 children (39 clubfeet) operated on with complete subtalar release from Cincinnati incision aged from 3 months to 50 months (mean, 11 months), with mean follow-up period of 51 months. In both groups, the muscles moving the foot in the sagittal and coronal plane showed a decreased MIVC. The greatest deficit was observed in the supinators and extensors, less in the pronators and plantar flexors. Better results were accompanied by greater MIVC, but significant relations existed in the first group between the strength of the extensors and the quality of results (better results correlated with better MIVC of the extensors). No significant differences between both patient groups were noted. For the plantar flexors, the difference of the MIVC strength between the normal and affected feet is stable; instead, for the extensors, supinators and pronators, it increases in the analyzed age interval.

Single-stage surgical correction of congenital vertical talus.

Forty-one patients (55 feet) with congenital vertical talus (CVT) were reviewed. Thirty of the feet were associated with neural tube defects, 10 with neuromuscular disorders, five with congenital malformation syndromes, and none with chromosomal aberrations. Ten of the feet were idiopathic. All were treated with a single-stage surgical correction as described, by using the Cincinnati incision, and performed by the same surgeon. Thirty-two patients (42 feet) were available for clinical and radiographic follow-up averaging 7 years (range, 2-12) from the time of surgery. There were no wound complications or avascular necrosis of the talus. In 10 feet, subsequent reoperation was necessary. At final follow-up, results were based on the clinical and radiographic outcomes and included 31 good and 11 fair. All patients and families were satisfied with the results and appearance of the feet. There were no bony prominences or skin problems. The presence of mild pain was noted in only three feet. Radiographically, there was a significant improvement in the anteroposterior (AP) and lateral talocalcaneal and talo-first metatarsal angles, and at follow-up, the group averages for each of these angles were within the normal range. In treating CVT, good clinical and radiographic results can be obtained with a low incidence of complications using this single-stage surgical correction of the hindfoot and midfoot deformities.

Single-Stage Surgical Correction of Congenital Vertical Talus

Forty-one patients (55 feet) with congenital vertical talus (CVT) were reviewed. Thirty of the feet were associated with neural tube defects, 10 with neuromuscular disorders, five with congenital malformation syndromes, and none with chromosomal aberrations. Ten of the feet were idiopathic. All were treated with a single-stage surgical correction as described, by using the Cincinnati incision, and performed by the same surgeon. Thirty-two patients (42 feet) were available for clinical and radiographic follow-up averaging 7 years (range, 2-12) from the time of surgery. There were no wound complications or avascular necrosis of the talus. In 10 feet, subsequent reoperation was necessary. At final follow-up, results were based on the clinical and radiographic outcomes and included 31 good and 11 fair. All patients and families were satisfied with the results and appearance of the feet. There were no bony prominences or skin problems. The presence of mild pain was noted in only three feet. Radiographically, there was a significant improvement in the anteroposterior (AP) and lateral talocalcaneal and talo-first metatarsal angles, and at follow-up, the group averages for each of these angles were within the normal range. In treating CVT, good clinical and radiographic results can be obtained with a low incidence of complications using this single-stage surgical correction of the hindfoot and midfoot deformities.

Rotatory Dorsal Subluxation of the Navicular: A Complication of Clubfoot Surgery

One hundred fifty-seven patients with 208 idiopathic clubfeet were operated on by a single surgeon (K.K.) from 1976 through 1987. Retrospective analysis was performed with a mean follow-up of 7.3 years on 126 patients with 168 operated-on feet. Twelve (7.1%) of 168 feet developed dorsal subluxation of the tarsal navicular. Six (6.3%) of 95 patients developed subluxation with the posterior medial incision. Six (8.2%) of 78 patients developed subluxation with the Cincinnati incision. Seven (58%) of these 12 feet required additional surgery. An anatomic model was constructed to demonstrate how rotation of the navicular alone mimics the radiographic appearance of dorsal subluxation of the navicular. The navicular dorsal subluxation is a common complication and is associated with a high rate of additional corrective surgery. We suggest that dorsal subluxation of the navicular should be redefined as a rotatory deformity with the medial border of the navicular rotating superiorly in the coronal plane. Attention to the position and rotation of navicular at the time of internal fixation may prevent this complication.

Subtalar realignment in congenital clubfoot using the Cincinnati approach

Surgical correction of clubfoot through an extensive and meticulous posterior, lateral, medial, subtalar, and plantar release. Failed conservative treatment of clubfoot at 6 months of age. Previous failed surgery with a different incision. Radiographs of both foot and ankle in the anterior-posterior and lateral projections. Supine. Tourniquet. General anaesthesia. Free draping above the knee. Through a Cincinnati incision the Achilles tendon is exposed and lengthened and the posterior capsule excised. The talofibular and the calcaneofibular ligaments are incised and released. The plantar aponeurosis is divided and the small plantar muscles are detached. Finally a medial release is achieved having excised the abductor hallucis muscles. Release of the dorsal talonavicular joint capsule. In severe cases the calcaneoucuboid joint must also be released. The corrected position is maintained with Kirschner wires. Long leg cast with the knee bent at 90 degrees . Cast changed after 10 to 14 days. Eight weeks postoperatively removal of cast and Kirschner wires and prescription of a Dennis-Brown boot to be worn for 12 to 18 months. Injury to neurovascular structures. Pin tract infection. Tightness, loosening or slipping of cast. Inadequate correction and damage to articular surfaces. From 1985 to 1992 60 infants (70 feet) were operated. Average follow-up was 5 years (1 to 7). Assessment of clinical and functional results was based on the Magone rating system: 60% excellent, 18.6% good, 11% fair results were obtained; 2 infants had a minor skin breakdown, 7 were undercorrected and 2 were overcorrected.

Congenital Talipes Equinovarus in Spina Bifida: Treatment and Results

The results of the surgical treatment of clubfoot deformity in spina bifida by radical posteromedial-lateral release (PMLR) are presented. In all cases, the Cincinnati incision was used and the tendons excised, including the anterior tibial tendon. In 21 feet, a special K-wire was used to derotate the talus in the ankle mortise. The minimum follow-up was 2 years. The average age at surgery was 14 months. The overall results showed 63% good, 14% fair, and 23% poor results. In the 21 feet in which the talus K-wire was used, 76% had a good result, 14% fair, and 10% poor. The results were also analyzed based on the motor level. In the thoracic/high lumbar level, 50% had a poor result. In the low lumbar and sacral level groups together, of 45 feet, five had a poor result. This study shows that a radical PMLR can produce an overall good and fair result in 77% of the cases. The use of the K-wire to derotate the talus led to an improvement in the result. The tendon excision leading to a flail foot corrects any residual muscle imbalance. The poor results seen in the thoracic/high lumbar patients are likely to be related to the lack of weight bearing in view of their motor paralysis.

Congenital Talipes Equinovarus in Spina Bifida: Treatment and Results

Summary The results of the surgical treatment of clubfoot deformity in spina bifida by radical posteromedial-lateral release (PMLR) are presented. In all cases, the Cincinnati incision was used and the tendons excised, including the anterior tibial tendon. In 21 feet, a special K-wire was used to derotate the talus in the ankle mortise. The minimum follow-up was 2 years. The average age at surgery was 14 months. The overall results showed 63% good, 14% fair, and 23% poor results. In the 21 feet in which the talus K-wire was used, 76% had a good result, 14% fair, and 10% poor. The results were also analyzed based on the motor level. In the thoracic/high lumbar level, 50% had a poor result. In the low lumbar and sacral level groups together, of 45 feet, five had a poor result. This study shows that a radical PMLR can produce an overall good and fair result in 77% of the cases. The use of the K-wire to derotate the talus led to an improvement in the result. The tendon excision leading to a flail foot corrects any residual muscle imbalance. The poor results seen in the thoracic/high lumbar patients are likely to be related to the lack of weight bearing in view of their motor paralysis.

Transposed skin graft for wound closure after Cincinnati incision. Experience in 7 patients with severe foot deformities.

I report a technique of wound closure by a transposed skin graft after operative treatment of foot deformities, using a Cincinnati incision. Three-dimensional correction of severe foot deformities (congenital talipes equinovarus, congenital vertical talus, etc.) results in skin excess on one side of the foot and lack of this on the opposite side. The skin excess can be cut out and used as a full-thickness skin graft for wound closure on the opposite side of the foot.

The Cincinnati Incision for the Split Posterior Tibial Tendon Transfer

The split posterior tendon transfer has been effective in correcting equinovarus deformity in children with cerebral palsy. The original report of this procedure described a four incision approach. We have modified the technique by substituting the single transverse, Cincinnati incision, which permits better visual and physical access to the operative field and has no major disadvantages.

Use of the Cincinnati incision in congenital talipes equinovarus.

A series of 16 patients (24 feet) with idiopathic congenital talipes equinovarus (CTEV) corrected by a Cincinnati incision is presented. Minimum follow-up was 2 years. This series demonstrated that the incision does not adversely affect the outcome, since 75% of these feet had a good or excellent correction. No significant wound problems were encountered. The advantages of the Cincinnati incision, together with the fact that no adverse sequelae resulted from its use, mean that it can be recommended for future use and should be taught to other physicians.

The Complete Subtalar Release in Clubfeet

CSTR is a release of the subtalar joint and the talonavicular joint that corrects calcaneal rotation, a major deformity of the clubfoot, as well as the other major deformities of the midfoot and hindfoot. Indications for the CSTR are presented. These include failure of conservative treatment or unsatisfactory surgical results with residual varus deformity, and a foot longer than 8 cm. Contraindications to CSTR include radiographic evidence of a flat-top talus and uncorrected anterior ankle contractures. The Cincinnati incision, which permits excellent visualization of all the relevant structures and good cosmesis, is described and compared with other approaches. The technique of the CSTR is described in detail. Key steps include marking the knee for later alignment with the foot (a major advantage of this procedure), superficial medial dissection, posterior dissection, lateral dissection, and deep medial dissection. Technical details and criteria for evaluation are provided. Four supplemental procedures and their indications are described. These include metatarsal osteotomy, calcaneocuboid capsulotomy, calcaneal wedge osteotomy, and plantar release. Procedures for pinning and casting are described, with special attention to accuracy of realigning the foot and measures for avoiding avascular necrosis and other complications. The importance of intraoperative radiographs is presented, together with methods for obtaining and assessing these films to assure that surgical correction is complete. It is imperative that these films be taken before tendon repair or wound closure so that pinning procedures can be repeated, if necessary.

The Cincinnati incision. A new surgical approach for clubfoot and ankle surgery.

The Cincinnati incision. A new surgical approach for clubfoot and ankle surgery.