Approach to Clubfeet – Surgical Management
– no consensus on when it should be done
– probably initiate between 4-12 months of age (some time before the kid is walking)
– indicated for failure of casting/manipulations – do not continue with forceful manipulations if you are getting nowhere!
– as there is disagreement on the pathoanatomy, there is disagreement on what the surgery should accomplish.
– in general: patients younger than 4 get soft tissue procedures
patients between 4 and 12 get both soft tissue and bony procedures
patients in their adolescent/teen years get bony procedures
Approach to Complete Postero-medial Release
– prone, antibiotics, tourniquet; have K-wires ready
– Cincinnatti incision, half finger-breadth beneath malleoli.
– Start posteriorly: identify sural nerve and vein – protect; then go after tendoachilles. Z-lengthen. Then identify posterolateral structures – calcaneofibular ligament, posterior talofibular ligament – and cut them. Then go medially and identify the neurovascular bundle behind the medial malleolus and protect it. Now safe to go open the posteromedial and posterolateral capsule to the subtalar joint and ankle joint so that you release these – you cannot correct the equinus by just cutting the tendoachiles, because these contracted capsular structures. Releasing the interosseous ligament is controversial.
– Then go medially: find abductor hallucis brevis and release is origin, dissecting both plantarly and dorsally around the muscle. Beneath the NV bundle is the lancinate ligament under which the medial plantar nerve dives; cut the ligament, and then find the lateral plantar nerve diving beneath the calcaneus. Find tib post, FDL, FHL, and z-lengthen them all.
– find peroneus longus, protect it, and cut the long and short plantar ligaments to reduce the cavus.
– open the talonavicular joint and calcaneocuboid joint from the medial side – release the capsule and structures on the plantar surface to be able to reduce them. In a child > 8 months, the calcaneocuboid may have to be opened laterally.
– small smooth K-wire through the posterolateral corner of the talus, through the head and into the navicular with the navicular reduced.
– Cast for 6weeks
– AFO for a year