Complete subtalar release for older children with neglected CTEV - البروفيسور فريح ابوحسان – استشاري جراحة العظام في الاردن

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Foot and Ankle Surgery 16 (2010) 38–44
Complete subtalar release for older children who had recurrent clubfoot
deformity
Freih Odeh Abu Hassan FRCS*, Samir Jabaiti FRCS, Tarek El tamimi MD
Department of Orthopedics Surgery, Department of Plastic & Reconstructive Surgery, Jordan University Hospital, Amman, Jordan
1. Introduction
Patients presenting for treatment of previously failed clubfoot
or severe neglected club deformities are still common in many
parts of the world. These feet are often rigid and severely
deformed, complete release of these clubfoot is the prevailing
option to obtain a plantigrade foot, but leaves a quite wide residual
defect with exposed tendons, joints, bones and neuro-vascular
bundles. 13–50% of surgically treated clubfeet had relapse, this will
lead to persistent and residual deformities which necessitate
surgical correction [1].We assume that these results are due in part
to the treating orthopaedic surgeons being familiar with this
condition. If this is the case we anticipate even higher incidence of
relapse in cases treated by an orthopaedic surgeon who treat these
cases less frequently. The main aim of surgical treatment of
clubfoot is to achieve a pain free, functional, and plantigrade foot.
The long-term aim is to enable the patient to wear normal shoes.
However the best method to achieve these objectives remains a
controversial issue among all orthopaedic surgeons. Revision
surgery entails repeated or further soft-tissue releases usually
combined with one or more osteotomies in older children to
correct residual deformity. The presence of scarred tissue from
repeated operations highlights the challenges facing the treating
A R T I C L E I N F O
Article history:
Received 11 January 2009
Received in revised form 24 April 2009
Accepted 7 May 2009
Keywords:
Clubfoot
Flap
Deformity
Complete subtalar release
A B S T R A C T
Background: Neglected idiopathic clubfoot deformities, and severe recurrent deformity after previous
surgery presents technical difficulties for correction and challenges for surgeons to achieve primary skin
closure.
Methods: Between 2000 and 2006, 18 children (30 feet), had complete subtalar release (CSTR) for failed
previous surgery in 28 feet and severe neglected congenital talipes equinovarus (CTEV) in 2 feet followed
by cross leg fasciocutaneous flaps for reconstruction of residual defect at the ankle and foot after full
correction of the deformity.
Mean patients followed up were 4.5 years (average 2–8 years). 23 feet were classified as Dimeglio III
and 7 feet as Dimeglio IV.
Results: All cases achieved a plantigrade foot, better walking ability (p < 0.03), and parental satisfaction
with the result (p < 0.001).
Ankle joint doriflexion increased from mean (21.338) preoperatively to (12.58) postoperatively. All
cases showed postoperative improvement in their radiographic findings. The mean preoperative
talocalcaneal angle increased from (15.78 to 30.038). The talo-first metararsal angle improved from a
preoperative mean of 168 mean of 5.538 postoperatively. At the final follow-up cosmetically acceptable
plantigrade foot was achieved in all feet. Four legs (14.28%) developed hypertrophic scars at the donar
flap site. One patient developed 1.5 cmmarginal necrosis of the flap, which did heal after debridement by
secondary intention. None of the feet had recurrence at the final follow up. Despite the enormous
improvement clinically and radiologically, their was no statistical significant difference between
preoperative and postoperative radiological angles (p 0.069).
The number of previous surgical interventions had no influence on the outcome. All the previously
treated feet had inadequate release of important tethered soft tissue.
Conclusion: This is indicative of the enormous value of complete subtalar release combined with cross
leg fasciocutaneous flap without the need for bony intervention in previously operated failed feet or
neglected deformities.
2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author at: P.O. Box 73/Jubaiha 11941, Amman, Jordan.
Tel.: +962 6 5240 346.
E-mail address: freih@ju.edu.jo (F.O.A. Hassan).
Contents lists available at ScienceDirect
Foot and Ankle Surgery
journal homepage: www.elsevier.com/locate/fas
1268-7731/$ – see front matter 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.fas.2009.05.002

F.O.A. Hassan et al. / Foot and Ankle Surgery 16 (2010) 38–44 39
Fig. 1. Case number 18: This is an 8.5 years old male patient who had multiple previous surgeries for his bilateral CTEV. (A) Preoperative photograph of the patient from front
while standing showing the significant deformity in both feet. (B) Preoperative photograph of the patient from behind while standing showing the prominent equinus
deformity and varus heels. (C) Intraoperative photograph showing the extensive soft-tissue defect medially and posteriorly after full correction of the deformity. (D)
Postoperative photograph of the patient from front while standing showing the plantigrade alignment and full correction of the deformity in both feet. (E) Postoperative
photograph of the patient from behind while standing showing the neutral alignment of both heels with visible flap covering the posterior aspect of the feet. (F) Postoperative
photograph of the patient from front while standing with abduction of the feet showing normal medial arches with visible flap covering the medial aspect of the feet.
surgeon of such difficult cases. Various surgical procedures were
described to re-align the foot to alleviate pain and allow
plantigrade weight bearing with adequate joint motion despite
the subnormal radiographic presentation [1,3,6–10].
Ilizarov technique has been used as a distraction method in
different directions for realignment of the foot to be plantigrade
with various success rates [11–14].
All the previous methods have some degree of success in
managing the deformity but have certain problems. The objective
of this retrospective review is to evaluate the results of acute
surgical correction of residual and recurrent congenital clubfoot
using complete subtalar release (CSTR) without bony surgery
followed by cross leg fasciocutaneous flaps for reconstruction of
soft-tissue defect.
2. Patients and methods
Eighteen children (30 feet), 12 were bilateral and 6 were
unilateral, treated for severe rigid clubfoot deformity. All children
were treated between 2000 and 2006 by complete subtalar
surgical release for recurrent or neglected foot deformities. The
procedure was performed in 11 boys (17 feet) and 7 girls (11 feet).
Patients ranged in age from 3–11 years Mean 5.6 year. Thirteen
patients (23 feet) had failed surgery of idiopathic congenital talipus
equinovarus (CTEV), 3 patients (5 feet) had failed surgery for
neuromuscular clubfoot and 2 patients (2 feet) had two untreated
idiopathic CTEV. All primary surgical release was performed by
general orthopaedic surgeon at different hospitals using poster-omedial
release similar to the technique described by Turco. They
had an average of 2.8 (range 1–5) operations for CTEV. Medical
records of these patients were reviewed for age, sex, number of
previous surgical procedures, sidedness of deformity, degree of
deformity and complications. The preoperative assessment was
based on clinical evaluation and imaging study. The clinical
evaluation consisted of identification of main complaint, patients’
or parents’ expectations, gait pattern assessment, range of
movement of the ankle and subtalar joint, categorising the type
of clubfoot (primary, revision or neuromuscular), condition of skin
and soft tissues, demographic data of the patient and assessment of
the various components of the residual deformity. In all patients
we obtained digital photographs of the foot and ankle in the
standing position from the front, back and sides, this served as a
preoperative reference (Figs. 1 and 2). We have recognized three
main objectives of deformity correction: a plantigrade foot that fits
in a normal shoe, a stable foot that allows better gait and
cosmetically better looking foot. In all feet the severity of the
deformity was graded preoperatively and postoperatively accord-ing
to the Dimeglio’s method [15]. Twenty-three feet were graded
as severe (grade III), and seven, were very severe (grade IV)
(Table 1). Imaging study included plain X-ray, computed tomo-graphy,
and 3D CT reconstruction when possible Fig. 2a and b).
Four views were performed to allow appropriate preoperative
planning and postoperative evaluation. These were standing AP of
the ankle, standing lateral projection radiographs of the ankle and
foot, mortice ankle view, 458 Oblique and standing AP of the foot.
Alignment axes were measured preoperatively and postopera-tively,
talus-first metatarsal angle, talocalcaneal index and shape of
talar dome recorded. Revision surgery was performed through a
Cincinnati approach [16,17] with complete posteromedial–lateral
release and lengthening all structures causing the deformity
(Fig. 1). All patients had the same surgical soft-tissue release by the
first author and cross leg flap by the second author at the same
surgical setting.
2.1. Operative technique
With the patient lying supine, above knee tourniquet applied,
cleaning and draping both feet and legs to the level of midthigh.
After partial exsanguination the tourniquet was elevated to 200/
mmHg. Every foot in this study group underwent a comprehensive
posteromedial–lateral release using a Cincinnati incision. A
transverse incision that extends from the anteromedial (region
of navicular-cuneiform joint) to the anterolateral (just distal and
medial to the sinus tarsi) aspect of the foot and over the back of the
ankle at the level of the tibiotalar joint was observed. The skin
incision was deepened down to the level of deep fascia without
dissection in the subcutaneous tissue. The neurovascular bundle
was identified and mobilized and held by vascular tape. All four
quadrants of the foot were approached to enable the release of all
contracted tissues (Table 2). In each foot the surgery consisted of
elongation of the Achilles tendon in the frontal plane, a posterior
capsulotomy of the posterior aspect of the ankle and subtalar joint
was performed. Medially, the following structures were included
in the release: Z-lengthening of the tibial posterior, flexor hallucis
and flexor digitorum muscles was performed at the musculoten-doneous
junction above the level of the ankle. There was a release
of the superficial deltoid ligament and spring ligament complex,
and capsulotomy of the talonavicular and medial and anterior
aspect of the subtalar joint. Plantar fascia, abductor hallucis, flexor
digitorum brevis and the long and short plantar ligaments were

40 F.O.A. Hassan et al. / Foot and Ankle Surgery 16 (2010) 38–44
Fig. 2. (a) Case number 13: 8 years old male presented with neglected CTEV. (A and B) Preoperative photograph of the patient from front and behind while standing showing
the significant deformity of the left foot. (C) Anterior–posterior and lateral preoperative plain radiograph of the left foot showing the gross malalignment of the foot. (D)
Preoperative 3D computerized axial tomography scan of the left foot showing the abnormalities in ankle and foot. (b) Same case number 13. (A) Standing postoperative
photograph of the patient from front, showing the plantigrade alignment and full correction of the deformity in left foot. (B) Standing postoperative photograph of the patient
from behind, showing the slight valgus alignment of left heel with visible flap covering the posterior aspect of the foot. The posterior aspect of the right leg showing
hypertrophic scar at the donar site. (C) Postoperative photograph of the patient while lying, showing good active dorsiflexion of both feet. (D) Standing postoperative lateral
plain radiograph of the left foot showing, well aligned talocalcaneal angle and correction of the deformity. (E) Postoperative 3D computerized axial tomography scan of the left
foot and ankle showing the restoration of anatomy in ankle and foot.
released. The deep deltoid and interosseous talocalcaneal liga-ments
were preserved.
The posterolateral corner behind the lateral ankle was easily
approached and release of peroneal sheath, calcaneofibular and
posterior talofibular ligament was carried out. There was a
capsulotomy of the lateral portions of the talonavicular and the
subtalar joints. Release of the calcaneocuboid joint and calcaneo-navicular
ligament were performed. The reduction of the
talonavicular was stabilized with one temporary horizontal
Kirschner wire in all feet, and the talocalcaneal joint with one
vertical Kirschner wire in 6 feet. The foot was put in fully corrected
position and the tendons were sutured, including the restoration of
the tendon sheaths, followed by haemostasis. In all cases the
lateral wound could be closed primarily, the medial and post
aspects of the wound were large enough to be closed (Fig. 1). The
next step is the covering the wound defect in all feet with
a proximally based fasciocutaneous flaps by the second author.
Marking the flap on the posterior aspect of the opposite leg,
based on the axial blood supply of the posterior descending
subfascial cutaneous branch of the popliteal artery. Dissection was
started from the distal end of the flap towards the base, incision
was made perpendicular to the skin plane, including the skin,
subcutaneous tissue and deep fascia, when the pedicle reached a
trial was made to fit the flap to the defect, so the flap was raised
with minimal dissection that is only sufficient to cover the defect
without tension and kinking of the pedicle. After meticulous
haemostasis the donor site was closed primarily. After skin closure
correction was maintained by plaster casts applied below the knee.
A window was subsequently made in the cast to check on possible
kinking or tension of the skin flap pedicle. When the cast hardened
a window was made opposite to the pedicle for later flap
inspection. Patients received one dose of second-generation
cephalosporin (Zinacef) preoperatively and an additional dose
postoperatively. Three weeks later, division of the flap and closure
of the defect with suturing the divided edge of the flap to the foot
was performed.
Kirschner wires were removed and a complete plaster of Paris
below the knee was applied for another 4 weeks in the corrected
foot position. After removal of the plaster cast, physiotherapy was
advised and an ankle foot orthosis (AFO) was used for 2 months.
2.2. Statistical analysis
The Wilcoxon signed-rank test (SPSS 16.00 for Windows) was
used to compare pre- and postoperative variables. p values of 0.05
or less were considered significant.

Table 1
Demographic patients data and Dimeglio’s preoperative and postoperative scoring values.
Demographic patients data Preoperative score Postoperative score
ID Age/year Sex Side Type of CTEV Equinus Varus Derotation Adduction Total Equinus Varus Derotation Adduction Total
1 11 M Rt Primary/idiopathic 4 4 4 3 15 1 1 1 1 4
2 9 F Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
9 F Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
3 3 F Rt Revision/N.M. 4 4 4 3 15 1 1 1 1 4
3 F Lt Revision/N.M. 3 4 4 2 13 1 1 1 2 5
4 6 M Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
6 M Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
6 5 F Rt Revision/N.M. 4 4 4 3 15 1 1 1 2 5
10 5 M Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
13 8 M Lt Primary/idiopathic 4 4 4 4 16 1 1 1 1 4
15 3 F Lt Revision/idiopathic 4 4 4 3 15 1 1 1 1 4
3 F Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
3 M Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
17 3 F Lt Revision/N.M. 4 4 4 3 15 1 1 1 2 5
3 F Rt Revision/N.M. 4 4 4 3 15 1 1 1 2 5
8 M Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
3. Results
The mean average follow-up period was 4.5 years (range 2–8
years). From clinical point, in all cases parents were satisfied at the
time of the final follow up with their child’s results in terms of
distinct subjective improvement in the shape of the foot with
regard to cosmetic appearance and subjective complaints such as
pain and difficulty in walking (p 0.001).
There were no plantigrade feet preoperatively, whereas all
cases had a plantigrade foot that fits in a normal shoe post-operatively,
both in stance and during ambulation (p 0.03).
At the last follow up the range of the ankle joint movement was
increased in all feet from mean preoperative doriflexion (21.338)
range (10/408), to mean postoperative doriflexion (12.58) range
(10–258) (Table 3). While mean preoperative plantarflexion was
(36.168) range (30–508) and mean postoperative plantarflexion
(33.168) range (30–408). All cases showed postoperative improve-ment
in their radiographic findings. The mean preoperative
talocalcaneal angle in standing lateral profile was (15.78) (range,
11–228), and the mean postoperative range talocalcaneal angle
was 30.038 (range, 24–418). Finally, the talo-first metatarsal angle
improved from a preoperative mean of 168 (range, 35 to 108)
to a mean of 5.538 (range, 0–108) at follow up, indicative of
sufficient correction of forefoot adduction. Both angles showed a
statistical trend towards improvement, but failed to reach
statistical significance (p = 0.069). None of the patients required
a further correction using the same technique. Statistically, the
number of previous operations had no influence on the outcome
(p 0.05). When we started this study the Outcome Evaluation in
Clubfoot generated by the International Clubfoot Study Group
(ICSG) and now advocated as one of the instruments to be used for
outcome measures were not available [18].We found the system of
Dimeglio as the most reliable evaluation method [15].
Before operation there were 23 feet (76.66%) grade III (severe)
and 7 feet 23.33%). Grade IV (very severe) deformities. At the last
follow up 26 feet (86.66%) was graded as grade I (benign) and 4 feet
(13.33) as grade II. Mean total preoperative score was 12.76 (range,
12–16) while the mean postoperative score was 4.13 (range, 4–5).
86.66% of the feet (26 feet) were painless during daily activities,
13% (4 feet) had occasional mild pain after strenuous activity, but
Table 2
Surgical procedures performed during revision surgery.
Surgical procedures Number of feet
Lengthening of tendoachilis 28
Peritalar release 28
Medial release 28
Lengthening of flexor hallucis 28
Lengthening of flexor digitorum 28
Lengthening of tibialis posterior 28
Lateral release 24
Peroneal sheath release 28
Plantar fascia release 18
K-wiring of talonavicular joint 28
K-wiring of talocacaneal joint 11

Table 3
Radiographic measurements of the alignment of the foot and ankle preoperatively and postoperatively.
Demographic data Radiographic value TC–TM (8) Ankle (DF/PF) (8)
ID Age/sex Side Type of CTEV Preoperative Postoperative Preoperative Postoperative
1 11/M Rt Primary/idiopathic 17/10 29/8 40/30 10/30
2 9/F Rt Revision/idiopathic 20/10 31/6 20/30 10/30
9/F Lt Revision/idiopathic 15/20 30/5 10/40 10/30
3 3/F Rt Revision/N.M. 13/18 25/0 15/30 20/30
3/F Lt Revision/N.M. 16/10 28/5 10/35 15/30
4 6/M Rt Revision/idiopathic 20/14 35/7 40/50 10/40
6/M Lt Revision/idiopathic 10/25 30/6 30/30 20/30
6 5/F Rt Revision/N.M. 19/18 30/6 20/35 10/30
10 5/M Lt Revision/idiopathic 11/18 39/5 30/30 20/30
13 8/M Lt Primary/idiopathic 11/18 28/6 40/50 10/35
15 3/F Lt Revision/idiopathic 18/15 33/8 10/40 20/30
3/F Rt Revision/idiopathic 16/12 28/6 15/30 20/30
3/M Rt Revision/idiopathic 11/18 24/5 20/45 15/40
17 3/F Lt Revision/N.M. 15/18 25/10 30/30 20/35
3/F Rt Revision/N.M. 19/15 40/4 20/30 15/35
8/M Rt Revision/idiopathic 20/12 28/7 20/35 15/30
TC: talocalcaneal angle on standing lateral view. TM: talo-first metatarsal angle on standing AP view of the foot. DF: dorsiflexion. PF: plantarflexion.
none complained about frequent pain. The most common
procedure in the original surgery was lengthening of the Achilles
tendon followed by posterior capsular release and the least dealt
with pathology was peroneal sheath and lateral release (Table 4).
Four legs (14.28%) developed hypertrophic scars at the donar flap
site. One patient developed 1.5 cm marginal necrosis of the flap,
which did heal after debridement by secondary intention.
4. Discussion
Recurrent deformity with scarring of the foot from previous
surgery makes it more difficult to correct with remanipulation and
recasting, although there is a place for this in some feet.
The most common persistent deformities in the residual
clubfoot are forefoot adduction and midfoot deformities [2–4,19].
All patients had deformity of the forefoot, midfoot and hindfoot,
equinovarus being the most common. Neglected idiopathic
clubfoot deformities and severe recurrent deformity after
previous surgery not only presents technical difficulties for
correction, but also challenges surgeons to achieve primary skin
closure and prevent skin necrosis. These problems can be
minimized by placing the foot in under-correction at the end of
surgery followed by gradual correction of the deformity byweekly
manipulations and casting. This will need prolonged post-operative
casting, loss of initial correction, and inability to
under-correct if the subtalar and talonavicular joints have been
transfixed in the corrected position [20]. All our patients are of
older childrenwith recurrent clubfeet with marked scarring at the
site of surgery which is difficult to apply these options. Others
suggested the use of soft-tissue expander to provide sufficient
skin, but it is liable to infection, skin necrosis, and premature
exposure of the expander [21,22]. Despite the great variety of
flaps, the choice of the most suitable reconstruction remains
debated. Different types of local, rotational or regional faciocu-taneous
flaps were used for covering defects of clubfeet for
children less than 3 years, but the use of complicated skin
incisions gave rise to the risk of ischaemic change in the flap,
which could be prone to ischaemic changes [23–26]. Other well-defined
lower extremity fasciocutaneous flaps based on a named
Table 4
Surgical procedures performed in the original surgery for correction of
clubfoot.
Surgical procedures Number of feet
Lengthend tendoachilis 28
Posterior release of ankle 24
Medial release 20
Lengthening of flexor hallucis 16
Lengthening of flexor digitorum 19
Lengthening of tibialis posterior 19
Tendon transfer 3
Lateral release 2
Peroneal sheath release 2

perforator or branch were used in adult traumatic injuries but
requires a much more meticulous dissection to determine the
source of the perforator, which frequently may be anomalous
[27,28]. The sacrifice of a major limb vessel would not be
acceptable in clubfeet if other options were available.
Cross leg fasciocutaneous flaps are dependent on multiple
suprafascial vessels entering their base from predictable sources
[29]. Although relapse is a common problem in clubfoot surgery,
there are very few reports concerningmid- and long-termresults
of this challenging problem [30,31]. Closingwedge osteotomy of
the cuboid, a cuneiform osteotomy, and an anterior tibial tendon
transfer is suggested in addition to repeated release procedures
[32]. Numerous osteotomies were described in the literature for
older children with clubfoot and can be broadly classified in
terms of which deformity they aim to correct. Mid-tarsal
osteotomies, calcaneocuboid fusion, and excision of the distal
calcaneus, cuboid decancellation or triple arthrodeses are used to
correct the deformity in a single or combined procedure [32]. No
doubt such surgery leads to a shortening of the foot and,
inevitably, to an irreparable growth disturbance of the foot
skeleton. Until skeletal maturity, additional shortening of these
already small feet is a regular occurrence. The cosmetic result
will therefore be poor with the risk of skin or soft-tissue necrosis
and infections that may result from bone surgery on the foot.
None of our patients required bony surgery or tendon transfer
procedures.
The most common cause of relapse is often the consequence
of inadequate primary surgery [5]. This is highly concurrent with
all revision cases. From our experience of limited number of
patients, peritalar release will result in good cosmetic correction
with no shortening, a plantigrade foot and no complications.
Since damage to the foot skeleton during childhood is avoided,
the proportions of the foot are preserved until the end of growth
[33].
Gradual correction using the Ilizarov system and the Taylor
Spatial Frame have been used alone or with soft tissue or bone
surgery or combination for correction of recurrent clubfoot, with
a reliable correction of individual components of the deformity.
It is usually combined with either a midfoot or calcaneal
osteotomy, although purely soft-tissue Ilizarov correction has
been performed in older children with good early results [34].
But as any other procedure it has its problems, pin site problems,
intraoperative vascular injuries, and tendon impingement,
pseudo-aneurysm, wire breakage, and wire cut-through [35–37].
Results of Ilizarov correction are variable with frequent late
complications, spontaneous ankylosis, recurrence of deformity
and requirement for surgical arthrodesis [38,39]. At the final follow
up, cosmetically acceptable plantigrade foot was achieved in
all patients without shortened feet.
5. Conclusion
Complete subtalar release for revision clubfoot surgery through
a circumferential Cincinnati incision gave good postoperative
results, which was achieved in all our patients. We observed a
statistical trend towards improvement in radiological forefoot and
hind foot correction and all of our patients were able to wear
normal footwear.
This indicates the enormous value of revision surgery without
the need for bony intervention in previously operated feet.
Conflict of interest
No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the
subject of this article.
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Complete subtalar release for older children with neglected CTEV - البروفيسور فريح ابوحسان – استشاري جراحة العظام في الاردن