SLR - May 2013 - Matthew Wagoner
Reference: Hsu, L, L Dias, and V Swaroop. "Long-Term Retrospective Study of Patients with Idiopathic Clubfoot Treated with Posterior Medial-Lateral Release." Journal of Bone and Joint Surgery. 2013;95:e27
Scientific Literature Reviews
Reviewed by: Matthew Wagoner, DPM
Residency Program: Temple University Hospital, Philadelphia, PA
Podiatric Relevance: Idiopathic clubfoot is a congenital deformity that affects approximately 0.1 percent to 0.2 percent of newborns. There has been a trend in nonsurgical treatment of the deformity due to the success of the Ponseti casting technique. In a small percentage of patients, surgical intervention is necessary with refractory clubfoot. McKay and Carroll reported with idiopathic clubfoot, the talus undergoes abnormal external rotation relative to the mortise. According to Simons and Sarrafian, Smith, and Ghali, the subtalar joint must be fully released in order to adequately mobilize the hindfoot. A posterior medial release alone is insufficient to allow full correction. The talus must be derotated out of external rotation and the talonavicular joint realigned prior to fixation. The authors demonstrate that a full posterior medial-lateral release in addition to derotation of the talus with fixation utilizing K-wires produces acceptable results in cases of refractory clubfoot.
Methods: A retrospective review of patients with idiopathic clubfoot who underwent posterior medial-lateral release was reviewed. Exclusion criteria included patients with less than 10 years of follow-up, previous surgical intervention other than an Achilles tendon lengthening, and patients with an underlying neuromuscular etiology. A total of 172 patients met the inclusion criteria. Ninety-one patients were reached by telephone, and of those, 50 patients (75 club feet) had an in-person examination. An additional 30 patients (45 club feet) returned surveys. The follow-up rate was 47 percent.
All clubfeet were initially treated with short leg casts using the Kite method. Surgical correction was recommended if casting failed to achieve adequate correction which included a full posterior medial-lateral release with manual derotation of the talus. K-wires were used to hold the corrected position. In those patients with residual tibial torsion, a Denis Browne bar was used for an average of seven months, and with residual forefoot adduction, tarsal pronator shoes were used for an average of 20 months. Patients underwent a detailed physical examination and completed four quality of life surveys at an average of 21 years postoperatively.
Results: Fifty patients underwent physical examination and completed the questionnaire, while 30 patients returned the questionnaire through mail. At the time of follow-up, 27 percent of patients required at least one additional surgical procedure, at an average of 6.7 years postoperatively. The most commonly performed procedure in the forefoot was a cuboid closing-wedge osteotomy for treatment of adduction, and in the hindfoot a medial calcaneal sliding osteotomy for treatment of calcaneovalgus. One foot required complete revision of the posterior medial-lateral release for recurrence. No patient required a subtalar or triple arthrodesis. In patients with unilateral clubfoot, there was a decrease in range of motion, foot length, and calf circumference on the affected side. On all the quality-of-life surveys, there was a significantly worse score in patients who required additional surgical procedures.
Conclusions: The Ponseti method of casting for idiopathic clubfoot has a success rate of over 95 percent however in a small percentage of cases, surgical correction is necessary. In cases with residual clubfoot, the authors have demonstrated that a posterior medial-lateral release with derotation of the talus utilizing k-wire fixation is a viable option. Only one patient required a revision of the posterior medial-lateral release while only 27 percent required additional procedures.