Posteromedial Release Research Articles

Ponseti Method for Untreated Idiopathic Clubfeet in Nepalese Patients From 1 to 6 Years of Age

Although the Ponseti method has been effective in patients up to 2 years old, limited information is available on the use of this method in older patients. We retrospectively reviewed the records of 171 patients (260 feet) to determine whether initial correction of the deformity (a plantigrade foot) could be achieved using the Ponseti method in untreated idiopathic clubfeet in patients presenting between the ages of 1 and 6 years. A mean of seven casts was required, and there were no differences in the number of casts between the different age groups. Two hundred fifty (95%) of the 260 feet were treated surgically for residual equinus after a plateau in casting, and procedures included percutaneous tendo-Achilles release (n = 205 [79%]), open tendo-Achilles lengthening (n = 8 [3%]), posterior release (n = 21 [8%]), and extensive soft tissue release (posteromedial release, n = 16 [6%]). The mean dorsiflexion after removal of the last cast was 12.5 degrees for the entire group and was greater in 1 year olds compared with 3 year olds. Although all patients achieved a plantigrade foot, the importance of the mild loss of passive dorsiflexion remains to be determined. An extensive soft tissue release was avoided in 94% of patients using the Ponseti method. We intend a followup study to ascertain whether the correction is maintained. Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Use of Ponseti's technique in recurrent clubfeet following Kite's method of correction

We report the results of 18 recurrent clubfeet in 13 children after Kite's method of casting treated successfully by Ponseti's technique. The average age was 8.3 months. The average preoperative Pirani's midfoot contracture score was 1.8, hindfoot contracture score was 2.4, and total score was 4.2. All patients had full correction of deformities with plantigrade feet and the scores were reduced to zero at the end of treatment. Three recurrences were found at 6 months follow-up, amounting to 17% failure rate. Two of them necessitated percutaneous tenotomy of the tendoachilles, and one underwent posteromedial soft tissue release with good result at the end of 1 year. Ponseti's method is an effective treatment option in the management of recurrent clubfeet after Kite's method. Although short-term results are promising, larger series with long-term follow-up is warranted.

Quantification of Effect of Sequential Posteromedial Release on Flexion and Extension Gaps: A Computer-Assisted Study in Cadaveric Knees

A novel sequence of posteromedial release consistent with surgical technique of total knee arthroplasty was performed in 15 cadaveric knees. Medial and lateral flexion and extension gaps were measured after each step of the release using a computed tomography–free computer navigation system. A spring-loaded distractor and a manual distractor were used to distract the joint. Posterior cruciate ligament release increased flexion more than extension gap; deep medial collateral ligament release had a negligible effect; semimembranosus release increased the flexion gap medially; reduction osteotomy increased medial flexion and extension gaps; superficial medial collateral ligament release increased medial joint gap more in flexion and caused severe instability. This sequence of release led to incremental and differential effects on flexion-extension gaps and has implications in correcting varus deformity.

Interposition of the Flexor Hallucis Longus Tendon Through the Subtalar Joint as a Late Complication of Pediatric Clubfoot Repair: A Case Report

Interposition of the flexor hallucis longus tendon through the subtalar joint was identified intraoperatively during a triple arthrodesis for a symptomatic adult clubfoot in a patient who had a posteromedial release as a child. The mechanism for this occurrence is unknown, although it is likely that the flexor hallucis longus tendon deviated into the subtalar joint during the early postoperative period. Interposition of the flexor hallucis longus tendon has not been previously reported as a late complication of pediatric clubfoot repair.

Long-term results of extensive surgical dissection in the treatment of congenital clubfoot

We evaluated the long-term functional and radiographic results of patients who underwent extensive soft tissue dissection for the treatment of congenital clubfoot. We retrospectively evaluated 47 feet of 30 patients (6 girls, 24 boys; mean age 9.8 months) who underwent extensive surgical dissection for congenital clubfoot. Involvement was bilateral in 17 patients. Surgical dissection included complete subtalar release (CSTR) in 35 feet, and posteromedial release (PMR) in 12 feet. The mean age was 9.6 months (range 6 to 23 months) in CSTR-, and 10.6 months (range 5 to 23 months) in PMR-treated patients. The patients were assessed with the Laaveg-Ponseti functional score, foot bimalleolar angle, and other radiographic measurements. The mean follow-up was 117.3 months (106.6 months in the CSTR, and 150.6 months in the PMR group). Functional results were excellent in 24 feet, good in 12 feet, fair in six feet, and poor in five feet. All the poor results were seen in the CSTR group. Of these five feet, two developed recurrences, two had both pes cavus and metatarsus adductus deformities, and one had pes cavus deformity. Considering the foot bimalleolar angle, 83.4% of PMR-treated feet, and 85.7% of CSTR-treated feet were rated as type 1 or 2. Functional scores were significantly correlated with the foot bimalleolar angle, talus-first metatarsus angle on anteroposterior and lateral radiographs, and with the talocalcaneal angle on anteroposterior radiographs (p<0.05). There were no significant differences between the two surgical procedures with respect to functional scores and radiographic measurements (p>0.05). Extensive surgical dissection enables simultaneous correction of all components of deformity and provides satisfactory results not only in the short-term but also in the long-term follow-up.

Use of the Ponseti method for recurrent clubfoot following posteromedial release.

Background:A child with recurrent or incompletely corrected clubfoot after previous extensive soft tissue release is treated frequently with revision surgery. This leads to further scarring, pain and limitations in range of motion. We have utilized the Ponseti method of manipulation and casting and when indicated, tibialis anterior tendon transfer, instead of revision surgery for these cases.Materials and Methods:A retrospective review of all children treated since 2002 (n = 11) at our institution for recurrent or incompletely corrected clubfoot after previous extensive soft tissue release was done. Clinical and operative records were reviewed to determine procedure performed. Ponseti manipulation and casting were done until the clubfoot deformity was passively corrected. Based on the residual equinus and dynamic deformity, heel cord lengthening or tenotomy and tibialis anterior transfer were then done. Clinical outcomes regarding pain, function and activity were reviewed.Results:Eleven children (17 feet) with ages ranging from 1.1 to 8.4 years were treated with this protocol. All were correctable with the Ponseti method with one to eight casts. Casts were applied until the only deformities remaining were either or both hindfoot equinus and dynamic supination. Nine feet required a heel cord procedure for equinus and 15 required tibialis anterior transfer for dynamic supination. Seven children have follow-up greater than one year (average 27.1 months) and have had excellent results. Two patients had persistent hindfoot valgus which required hemiepiphyseodesis of the distal medial tibia.Conclusion:The Ponseti method, followed by tibialis anterior transfer and/or heel cord procedure when indicated, can be successfully used to correct recurrent clubfoot deformity in children treated with previous extensive soft tissue release. Early follow-up has shown correction without revision surgery. This treatment protocol prevents complications of stiffness, pain and difficulty in ambulating associated with multiple soft tissue releases for clubfeet.

Comparative results of the conservative treatment in clubfoot by two different protocols

The current study aims at presenting the results of the two methods of conservative treatment in clubfoot: the Romanian traditional method and the Ponseti method. The study population included 103 children (148 clubfeet) treated in our department between 1998 and 2005. Between 1998 and 2003, the conservative treatment protocol was based upon the Romanian method. The Ponseti method has been used since 2004. The main criterion for the assessment of the efficiency of the two conservative methods in clubfoot is the number of feet requiring surgical treatment - posteromedial release at 18 months. This criterion is clearly in favor of the Ponseti method: four feet (5%) needed posteromedial release in Ponseti group patients versus 13 feet (18%) in Romanian group patients (P=0.0193). The Ponseti method is safe, efficient in the conservative treatment of clubfoot and decreases the number of surgical interventions needed for the correction of the deformation compared with our traditional method.

Correcting Varus Deformity

We report our technique and the results of treating severe intra- and extra-articular varus deformity using posterior stabilized fixed-bearing implants. We used a technique of selective posteromedial release and reduction osteotomy of posteromedial tibial flare in 173 knees in 117 patients. Proximal tibial osteotomy was used to correct severe extra-articular deformity. Mean tibiofemoral varus of 22° preoperatively was corrected to 5.3° valgus postoperatively. A total of 86% knees were in 4° to 10° valgus postoperatively. Mean Knee Society score improved from 22.8 to 91.1, and function score from 22.8 to 72.1 at 2 to 9 years. Of 30 bone grafts for tibial defects, 28 were successfully incorporated. No patient reported significant instability. Three knees showed tibial component loosening. Our technique restored alignment and stability without the need for constrained implants.

Long-term follow-up of the surgically corrected clubfoot

We describe a 17-year follow-up of 44 surgically corrected clubfeet. They were classified preoperatively as mild, moderate or severe and grouped into those operated on before or after 3 months of age. Moderate and severe deformities underwent a posteromedial release after a trial of conservative management. The mean Ponseti score for both groups was 83.9 (good). Severely deformed feet achieved a more favourable result when operated upon before 3 months than those operated later. We conclude that early application of surgery yields better results with severely deformed feet and produces a good functional outcome in the majority of feet.

Wound Complications From Idiopathic Clubfoot Surgery

Treatment protocols using the Turco and the Cincinnati incisions are widely used for the surgical correction of clubfoot deformity. However, it is unclear which surgical approach leads to fewer wound problems. We therefore sought to determine which treatment method led to a lower incidence of wound complications. A retrospective chart review of 217 consecutive patients (308 feet) who underwent a primary posteromedial release for the treatment of idiopathic clubfoot under the age of 24 months via either the modified Turco or Cincinnati treatment methods was used to document the incidence of postoperative wound complications. The modified Turco protocol involved immediate postoperative casting in neutral, whereas the Cincinnati method involved staged casting with the foot initially in equinus, then to neutral with a cast change 7 days later. A significantly lower incidence of wound complications was seen in the Cincinnati treatment group when compared with the modified Turco treatment method (6.9% vs 19.6%, respectively, P < 0.003). When patients were stratified based on immediate versus staged postoperative casting methods, there was a significantly lower incidence of wound complications (P < 0.05) in feet in the Cincinnati treatment group versus the modified Turco treatment method; however, the statistical populations were markedly unequal. Among all feet treated with the Cincinnati method, patients who underwent a staged cast change had significantly fewer wound problems when compared with those who underwent immediate casting with the foot in neutral (5.1% vs 16.7%, respectively, P < 0.04). In the surgical correction of idiopathic clubfoot, the incidence of wound complications is significantly decreased with the use of the Cincinnati treatment method rather than the modified Turco treatment protocol. Whether this effect is a result of the incision or the postoperative casting protocol is unclear.

Accessory soleus muscle in clubfoot deformity: a report in four feet

The commonest presentation of accessory soleus muscle is a swelling at the posteromedial aspect of the ankle in adolescents or young adults. Accessory soleus is rarely encountered in children undergoing surgical release for congenital clubfoot, and only a few isolated reports are available in the literature. The purpose of this study is to heighten awareness about the role of accessory soleus muscle in clubfoot deformity. Four cases of accessory soleus muscle in patients undergoing surgical release for clubfoot deformity are reported here in which, a distinct anomalous muscle deep to the tendoachilles was identified. Hindfoot varus and equinus persisted in each of these cases despite an adequate posteromedial soft tissue release, which could be corrected only on tenotomizing the tendon of the accessory soleus muscle at its insertion. An awareness about the accessory soleus muscle is important, particularly when non-operative methods of clubfoot management with tendoachilles tenotomy or limited surgery are employed. Failure to recognize this muscle if present in patients with congenital clubfoot may lead to persistent hindfoot deformity. A high index of suspicion should be maintained in cases in which hindfoot deformity persists despite an otherwise adequate soft tissue correction.

Compliance with continuous passive movement is low after surgical treatment of idiopathic club foot in infants

Treatment by continuous passive movement at home is an alternative to immobilisation in a cast after surgery for club foot. Compliance with the recommended treatment, of at least four hours daily, is unknown. The duration of treatment was measured in 24 of 27 consecutive children with a mean age of 24 months (5 to 75) following posteromedial release for idiopathic club foot. Only 21% (5) of the children used the continuous passive movement machine as recommended. The mean duration of treatment at home each day was 126 minutes (11 to 496). The mean range of movement for plantar flexion improved from 15.2 degrees (10.0 degrees to 20.6 degrees ) to 18.7 degrees (10.0 degrees to 33.0 degrees ) and for dorsiflexion from 12.3 degrees (7.4 degrees to 19.4 degrees ) to 18.9 degrees (10.0 degrees to 24.1 degrees ) (both, p = 0.0001) when the first third of therapy was compared with the last third. A low level of patient compliance must be considered when the outcome after treatment at home is interpreted.

Association française de chirurgie du pied: Le pied bot varus équin : traitement chez l’enfant et devenir à l’âge adulte

Purpose of the symposium Treatment of idiopathic talipes varus, or congenital clubfoot, is designed to realign the foot to alleviate pain and allow plantigrade weight bearing with adequate joint motion despite the subnormal radiographic presentation. This symposium was held to review current management practices for congenital clubfoot in children and to analyze outcome in adults in order to propose the most appropriate therapeutic solutions. Management of congenital clubfoot in children Idiopathic talipes varus can be suspected from the fetal ultrasound. Parents should be given precise information concerning proposed treatment after birth. Deviations must be assessed in the newborn then revised regularly using objective scales during and after the end of treatment. This enables a better apprehension of the evolution in comparison with the severity of the initial deformation. Conservative treatment is proposed by many teams: a functional approach (rehabilitation and minimal use of orthetic material) or the Ponseti method (progressive correction using casts associated with percutaneous tenotomy of the calcaneal tendon) are currently preferred. If such methods are insufficient or unsuccessful, surgery may be performed as needed at about 8 to 11 months to achieve posteromedial release. Good results are obtained in 80% of patients who generally present minimal residual deformations (adduction of the forefoot, minimal calcaneal varus, residual medial rotation, limitation of dorsal flexion), which must be followed regularly through growth. The difficulty is to distinguish acceptable from non-acceptable deformation. At the end of the growth phase, severe articular sequelae are rare (stiff joint, recurrence of initial deformation, overcorrection) but difficult to correct surgically: osteotomy, tendon transfer, double arthrodesis, Ilizarov fixator. Gait analysis is essential to quantify function and obtain an objective assessment of the impact on higher joints, providing valuable guidance for surgical correction. Outcome in adulthood There have been very few studies evaluating the long-term functional outcome after treatment during childhood. According to two studies presented at this symposium (Brussels, Lausanne), results have been generally good but with subnormal radiographs irrespective of the type of treatment or how early treatment started in childhood. Hypoplasia of the talar dome is a constant finding and is correlated with limitation of dorsal flexion of the ankle joint. A small degree undercorrection is often observed but well tolerated while overcorrection is generally less well tolerated. Functional outcome depends highly on preservation of subtalar joint motion. There have been no reports on the results of treatment of sequelae in adults. Most problems (pain, stiffness, osteoarthritis) are observed in the mid or rear foot. Indications for conservative surgery (osteotomy) of the mid or rear foot are rare compared with indications for combined arthrodesis. Talocrural decompensation is a turning point observed in the adult. Management at this point is difficult: fusion of the ankle worsens the situation by increasing the stress on the forefoot and aggravating the disability; implantation of an ankle prosthesis is technically difficult and remains to be fully developed. Treatment of the dorsal bunion of the great toe may require tendon transfer and/or fusion. Conclusion A child born with clubfoot will never have a normal foot in adulthood. Sequelae present at the end of growth will intensify during adult life; undercorrection is easier to treat in adulthood than overcorrection. The most difficult problems in adulthood are: neglected clubfoot, over correction, and degradation of the talocrural joint.

Ponseti Management of Clubfoot in Older Infants

Treatment of clubfoot with the Ponseti method is successful when performed immediately after birth. We treated 23 infants (36 feet) who presented to us after casting, applied at other institutions, failed or after 3 months of age. Twenty-two infants had serial casting started during the first 2 months, and one infant who was 6 months old at presentation had not received previous treatment. The original orthopaedists of 18 patients advised posteromedial release. The parameter studied was the need for posteromedial release (ie, failure of Ponseti casting and percutaneous Achilles tenotomy to obtain satisfactory clinical appearance). Only one (2.8%) of 36 feet required open surgical release (posterior only). Thirty-five feet required percutaneous Achilles tenotomy. A mean of six Ponseti casts were applied before tenotomy. Two feet (two infants) required anterior tibialis transfer for mild relapse; three other feet (two infants) required repeat casting for mild relapse. Most pediatric orthopaedists think that successful clubfoot casting depends on treatment started immediately after birth. Our data suggest that older infants with clubfoot can be treated successfully without extensive surgery. Our results in older infants are similar to the results of a previous study we conducted with younger infants. In that study, one (2.9%) of 34 feet required posteromedial release surgery. Therapeutic study, Level IV (Case series). See the Guidelines for Authors for a complete description of levels of evidence.

Postero-medial release in clubfoot -A retrospective study of causes of failures

Introduction : Postero-medial release is the most common surgical procedure used to correct the deformity of clubfoot. It has been seen that despite a good correction immediately following the surgery, the long-term results are not satisfactory. Material and methods : A retrospective study was carried out in a total number 52 clubfeet in 36 patients treated by posteromedial release to assess the causes of failures. The mean duration after surgery was 5.1±1.2 years, mean age at operation was 1.1±0.5 years and mean age of patient at final follow up was 6.9±2.1 years. The results were plotted and compared with different variables. Results : The results were successful in 36 and failure in 16 patients. A significantly high failure rate of 80% was found when postero-medial release was done after 3 years of age as a sole procedure as compared to 25.5% only if age was less than 3 years (p<0.05). The patient compliance to follow bracing protocol showed significantly high failure rate of 52.4% in non-compliant patients versus 16.1% in compliant patients (p<0.05). A significantly high failure rate was also seen when bracing was not continued beyond 3 years after surgery (p<0.05). Neurological clubfoot had a significantly high failure rate (80%) compared to idiopathic clubfoot (25.5%) (p<0.05). A significantly high failure rate was also noted when infection and skin necrosis lead to skin grafting or flap coverage as compared to those healed with dressings alone (p<0.05). Conclusion : Postero-medial release achieves best results in patients of less than 3 years of age and patients with compliance for bracing for at least up to 3-4 years following surgery and idiopathic clubfoot. Infection in clubfoot does not increase the failure rate unless it is severe enough to require plastic coverage. Any deviations from the above significantly increase the chances of failure of the procedure and hence can be labeled as the causes of failures of postero-medial release.

Congenital talipes equinovarus: comparison of outcome between a prenatal diagnosis and a diagnosis after delivery

To establish the impact on outcome of prenatally versus postnatally detected talipes equinovarus (TEV). The prenatal group was represented by pregnancies with sonographically detected TEV of which 18 were isolated and 39 were complex. The postnatal group contained 64 infants with an isolated and 10 infants with a complex TEV detected at birth. Treatment consisted of redressement followed by surgical postero-lateral or postero-medial release at the University Paediatric Orthopaedic Centre. The postnatal isolated TEV group underwent redressement treatment at the University Centre (subset A, n = 39) or at a regional general hospital (subset B, n = 25). For isolated TEV, statistically significant difference existed for the surgical procedure (p < 0.001), age at surgery (p < 0.01) and admission time (p < 0.001) between the prenatal and postnatal subset B and between the postnatal subsets A and B. For the complex TEV, no significant difference was found for these variables between the six surviving infants of the prenatal group and the postnatal group. Prenatal detection of isolated TEV results in earlier and less complicated postnatal surgery and a shorter admission time, provided treatment is arranged at a paediatric orthopaedic centre. After prenatal detection of a complex TEV, survival is low and determined by associated anomalies.

Continuous passive motion versus immobilisation in a cast after surgical treatment of idiopathic club foot in infants

Continuous passive motion has been shown to be effective in the conservative treatment of idiopathic club foot. We wished to determine whether its use after operation could improve the results in resistant club feet which required an extensive soft-tissue release. There were 50 feet in the study. Posteromedial lateral release was performed in 39 feet but two were excluded due to early relapse. The mean age at surgery was eight months (5 to 12). Each foot was assigned a Dimeglio club foot score, which was used as a primary outcome measure, before operation and at 6, 12, 18 and 44 months after. Nineteen feet were randomly selected to receive continuous passive motion and 18 had standard immobilisation in a cast. After surgery and subsequent immobilisation in a cast the Dimeglio club foot score improved from 10.3 before to 4.17 by 12 months and to 3.89 at 48 months. After operation followed by continuous passive motion the score improved from 9.68 before to 3.11 after 12 months, but deteriorated to 4.47 at 48 months. Analysis of variance adjusted for baseline values indicated a significantly better score in those having continuous passive motion up to one year after surgery, but after 18 and 48 months the outcomes were the same in both groups.

Local flap coverage following posteromedial release in clubfoot surgery in older children

The article to which this letter refers can be found at http://dx.doi.org/10.1007/s00264-004-0615-5

Total Knee Arthroplasty for Profound Varus Deformity: Technique and Radiological Results in 173 Knees with Varus of More Than 20°

One hundred seventy-three knees in 117 patients with varus deformity exceeding 20° were prospectively evaluated. Using selective posteromedial release, reduction osteotomy of posteromedial tibial flare, and extra-articular tibial osteotomy, with the preservation of medial collateral ligament integrity, mean tibiofemoral angle of 22.7° varus preoperatively (range, 15°-62°) was corrected to 5.3° valgus (range, 2°-9°) postoperatively. Eighty-six percent of the knees were in 4° to 10° valgus postoperatively. Mean Knee Society score improved from 22.8 (range, 0-64) to 91.1 (range, 52-99), and function score from 22.8 (range, 0-64) to 72.1 (range, 5-100) at 2.6 years (range, 2-9 years). Mean femoral component valgus was 95.5° (range, 92°-98°), and mean tibial component valgus was 89.8° (range, 86°-94°). Of 30 grafts for posteromedial tibial defects, 28 were successfully incorporated. No patient reported significant instability. Three knees (1.7%) showed tibial component loosening with recurrence of deformity. Correction of severe varus deformity by the technique reported can successfully restore alignment, pain-free motion, and stability.

Gait characteristics of patients with bilateral club feet following posteromedial release procedure

In this study we intended to evaluate the gait characteristics of children who had bilateral operated clubfeet, and to compare the results with gait parameters of children without clubfeet or lower extremity abnormalities. Fifteen children with bilateral plantigrade and asymptomatic clubfeet, operated bilaterally with posteromedial release method, were included in group P. Means+/-SD of age and follow-up time were 8.5+/-2.6 years (range, 4-14 years) and 7.7+/-2.8 years (range, 3-10 years), respectively. Age, sex, height-and weight-matched 24 children without clubfeet or lower extremity abnormalities were included in the control group (group C). Three-dimensional computerized gait analysis was performed for all subjects, and time-distance, kinematic and kinetic gait characteristics of the groups were compared. Time-distance characteristics of the groups were identical. Ankle plantar flexion angles, plantar flexor moment and generated power were significantly decreased in group P (P<0.05). Knee hyperextension during midstance was observed in 17 of 30 (57%) knees in the P group. Kinetic analysis revealed excessive knee valgus and flexion moments, as well as decreased second peak values of vertical ground reaction forces for group P. This study shows that even successfully operated, plantigrade and clinically asymptomatic children with bilateral clubfeet have significant gait deviations involving all lower limb joints. Future studies are needed to investigate the accountable factors of gait deviations and possible long-term musculoskeletal morbidity of operated children with bilateral clubfeet.