This document discusses soft tissue procedures for treating talipes equinovarus (clubfoot deformity). It describes the typical components and presentation of clubfoot as well as conservative and surgical treatment options. Initial treatment involves serial casting while older, more rigid cases may require soft tissue releases and bony corrections like talectomy. The document provides details on specific soft tissue and bone procedures and references studies on outcomes of talectomy and fixation methods for tibiocalcaneal fusion.

1. Soft Tissue Procedures
for Talipes
Equinovarus
Owen Morris

2. Talipes Equinovarus
 Most accepted theory
 Germ plasma defect-malposition of head and neck in talus
 1/1000 live births
 M>F 2:1
 50% B/l
 R>L
 3 Components of Clubfoot (Triplanar deformity)
 Forefoot adductus, Rearfoot varus, Ankle equinus
 Simon’s rule of 15
 Talo-Calcaneal angle is <15, talo-1st met angle is >15
 Conservative Treatment (Ponsetti Method)
 Children <2 y/o Serial Casting
 Correct Adduction, then Varus, then Equinus

3. Initial visit
 CC: 5 year old male presents to clinic with
right ankle joint pain
 HPI: Patient’s mother states her son has been
wearing a right ankle brace since he was 2
years old. Patient’s mother admits that her
son trips and falls a lot. Patient’s mother
believes that her son’s foot has gotten worse
overtime.

4. Orthopedic Exam Right Left
External Hip ROM 30 degrees 25 degrees
Internal Hip ROM 45 degrees 45 degrees
Malleolar torsion 12-13 degrees 10 degrees
Bleck’s test 3rd interspace Medial 3rd toe
Ankle DF -15 degrees KE, -10
degrees KF
10 degrees with KE, 15
degrees KF
Patellar reflex 2/5 2/5
Achilles Tendon reflex 0/5 1/5
Additional: N/A Bulging talus prominent
on lateral side

5. Pre-op: DP View

6. Walking

7. Surgical Plan
 Assessment:
 Severe Equinus of right foot secondary to Neonatal CVA,
hemiplegia, Complete right toe walking
 Diagnosis:
 Right Spastic Equinus Deformity
 Operation:
 R Tendo Achilles Lengthening, Posterior Ankle Joint Capsular Release,
Steindler Stripping, Posterior Tibialis Tendon Transfer, Flexor Hallucis
Longus Tendon Deformity

8. Procedures
1. R TAL
 Z-plasty TAL was made with
notable reduction of the
equinus deformity
 Mild contracture was still
noted
 Resection of the Plantaris
Tendon and Posterior Ankle
Capsule Release
2. Steindler Stripping
 Help reduce the cavovarus
deformity of the foot
 Continued contracture to
the hallux at the level of
the interphalangeus was
noted
3. FHL tendon lengthening
 Z-type lengthening
procedure was made at the
level of the flexor tendon
4. Posterior Tibialis Tendon Transfer

9. Post op- DP view
• Posterior splint, Webril,
ACE bandage, and
stockinette

10.  14 weeks post-op
Ortho Exam Right Left
Ankle DF 90 degrees 90 degrees
1st Ray ROM PF normal, limited DF WNL
Hallux ROM WNL WNL
Midtarsal ROM WNL WNL
Subtalar ROM WNL WNL
Structural Limb Length 53.25 cm 54 cm

11. 26 weeks post-op

12. 51 y/o Female with Neglected Clubfoot

13. Development of Hyperkeratosis

14. Walking on her Talus

15. Surgical Plan
 Fix the Rigid Plantarflexed and Varus Hindfoot
 Soft Tissue Procedures First
 Achilles Tenotomy
 Posterior Tibial Tenotomy
 Posterior Ankle Capsulotomy
 Posterior Tibial Nerve Release

16. Surgical Plan
 Fix the Hindfoot
 Talectomy
 Fix the Forefoot Varus
 Midfoot Osteotomy
 Midterm Follow-Up of Talectomy for Severe Rigid Equinovarus Feet
 Evaluated the effectiveness of talectomy in the treatment of Dimeglio grade IV
rigid equinovarus feet.
 Nineteen feet in 13 patients were treated by talectomy from September 2001
through January 2012
 An anterolateral incision was made over the ankle and extended distally to the
level of the navicular, and the head and neck of the talus were exposed starting
from the anterior aspect of the ankle
 Complete removal of the talus was performed, and the foot was easily corrected to the neutral,
plantigrade position.
 Posterior displacement of the foot was undertaken until the middle facet of the calcaneus was
situated directly under the tibial plafond
 Postoperatively, all the feet improved to Dimeglio grade II and were painless

17. Dimeglio Classification System
 Four aspects of the deformity (the equinus,
varus, rotation of the foot, and forefoot
medial deviation) are scored on a scale of 1
(good) to 4 (bad)
 Four other categories (depth of posterior
crease, medial crease, cavus, and muscle
power) being assigned a present/absent
score of 0 or 1 to give a total maximum
score of 20

18. Surgical Plan
 Correct the Deformity
 Ilizarov or Hexapod frame
 Mechanical rigidity of the Ortho-SUV frame compared to the Ilizarov frame in
the correction of femoral deformity
 Determined the rigidity of the OSF in its initial configuration and after
dynamisation. The results were then compared with those obtained for the
rigidity of fixation using the Ilizarov frame
 Results:
 The OSF, as tested in this study, is equal or better than the Ilizarov fixator in all
zones in the femur and in all planes
 This is due to the fact that the four-threaded Ilizarov rods are located substantially
in the sagittal plane. With the OSF, the struts lie in or near the frontal plane, which
would explain the advantage of the OSF in frontal plane stiffness.

19. Surgical Plan
 Once deformity is corrected
 Tibiocalcaneal Fusion
 Associated Limb Length Discrepancy
 Biomechanical comparison of blade plate and intramedullary nail fixation for
tibiocalcaneal arthrodesis
 Methods:
 Nine matched pairs of fresh frozen cadaveric legs underwent talectomy followed by fixation with a blade
plate and 6.5-mm fully threaded cancellous screw or an ankle arthrodesis intramedullary nail
 Results:
 Intramedullary nail fixation demonstrated greater mean stiffness throughout the fatigue endurance
testing, from cycles 10 through 250,000 (blade plate versus intramedullary nail
 Conclusion:
 Intramedullary nail fixation was biomechanically superior to blade plate and screw fixation in a
tibiocalcaneal arthrodesis construct.

20. References
 El-Sherbini, Mostafa H., and Ahmed A. Omran. "Midterm Follow-Up of
Talectomy for Severe Rigid Equinovarus Feet." The Journal of Foot and Ankle
Surgery 54.6 (2015): 1093-098. Web. 20 Aug. 2016.
 Lee, Arthur T., Eric B. Sundberg, Derek P. Lindsey, Alex Hs Harris, and Loretta
B. Chou. "Biomechanical Comparison of Blade Plate and Intramedullary Nail
Fixation for Tibiocalcaneal Arthrodesis." Foot Ankle Int Foot & Ankle
International 31.02 (2010): 164-71. Web. 20 Aug. 2016.
 Skomoroshko, Petr V., Victor A. Vilensky, Ahmed I. Hammouda, Matt D. A.
Fletcher, and Leonid N. Solomin. "Mechanical Rigidity of the Ortho-SUV Frame
Compared to the Ilizarov Frame in the Correction of Femoral
Deformity." Strategies in Trauma and Limb Reconstruction Strat Traum Limb
Recon 10.1 (2015): 5-11. Web. 20 Aug. 2016.