Search

The patient was identified and the surgical site was marked prior to the transfer to the operating room. General anesthesia was induced by the anesthesia team. The patient was positioned supine on the operating table. A tourniquet was applied.

In an earlier paper (in Chapter 7), I described the important anatomical landmarks and my basic surgical technique of soft tissue release for the previously unoperated clubfoot. This paper will deal with extension of that operation for a specific complication following previous surgery, i.e., dorsal talonavicular subluxation.

The orthopedic surgeon is frequently challenged with the problem of obtaining adequate exposure of the posteromedial and posterolateral aspects of the foot and ankle while avoiding complications that are secondary to the incision itself.

Congenital talipes equinovarus (CTEV) is characterized by osseous deformities in the midfoot and hindfoot, which remain only partly understood. Anatomic dissections disrupt the relationships they seek to demonstrate, and routine radiographs yield truncated information in that the infant foot bones are only partly ossified. A recent advance has been seen in the computerized three-dimensional reconstruction of histologic sections from the clubfoot of a stillborn child. This technique generated in situ bony relationships.1 Magnetic resonance imaging (MRI) offers a further advance through its potential for studying in vivo anatomic relationships in the clubfoot. The present study was undertaken to explore this modality’s value in imaging cartilaginous, osseous, and soft tissue structures in both the normal and abnormal infant hindfoot.

This paper concerns the observations made while managing 537 neglected clubfeet in the age group of 17 months to 50 years, and followed for an average of 37 months. Untreated clubfeet presenting after 9 months of age are “neglected clubfeet.” By 1 year of age, most (70%) require surgical corrections—soft tissue release (with tendon transfers) and bony procedures (beyond 3 years of age).

In the course of the past 30 years, I have developed a philosophy for the treatment of clubfeet that is now the surgical method used at the Twin Cities (Minneapolis-St. Paul) Unit of the Shriner’s Hospitals.

At the Lexington unit of the Shriner’s Hospitals for Crippled Children, analysis of results of posterior releases done prior to 1971 reveals generally a 50% failure rate. That is, half of the children operated upon required further operative procedures. After the introduction of the posteromedial release, popularized by Turco6 in the early 1970s, the failure rate dropped to 20%. It has remained constant over the last 20 years, based on long-term follow-up reports. The failures appear to be due to both undercorrection and now increasingly recognized overcorrection. Both have occurred early and late after surgery in some cases and their genesis remains obscure. Inexplicably in otherwise normal children, two separate clubfeet of similar appearance on clinical and x-ray examination have responded differently to a similar operation by the same surgeon.