COMPARISON OF TWO SURGICAL APPROACHES IN CLUBFOOT : SINGLE POSTEROMEDIAL RELEASE VERSUS COMBINED POSTEROMEDIAL AND LATERAL RELEASES

This comparative prospective study was conducted to assess surgical outcome and postoperative complications in 70 children with 115 idiopathic clubfeet treated at Basrah General Hospital. Children up to age of 5 years were included. There were 49 males and 21 females. Male to female ratio was 2.3:1. The deformity was bilateral in 61.4% and unilateral in 38.6% of cases. The indications for surgery were failure of early conservative treatment and late patient presentation beyond 6 months of age. Patients were placed into two groups; group A in whom a standard posteromedial soft tissue release through single incision including 58 feet (19 moderate, 28 severe, and 11 very severe), whereas in group B, combined posteromedial and lateral releases through two separate incisions in 57 feet (19 moderate, 28 severe, and 10 very severe). Analysis of data reveals that combined release is superior to single release in the rates of operative wound breakdown and more important in term of correction of initial preoperative clubfoot deformity for which the surgery was performed. Postoperative skin necrosis occurred in 8.8% of combined release feet compared to 17.2% in single posteromedial release feet. With combined release 87.7% of feet obtained satisfactory deformity correction outcome in contrast to only 63.8% in single release feet. The most common single residual deformity reported in this study following surgical correction whether by single posteromedial release (13.8%) or by combined release (12.3%) was forefoot adduction. The risk of wound infection was approximately the same for both procedures 8.6% in single release, and 8.8% in combined release. The study showed that the proportion of satisfactory deformity correction results decreases as the patient age at operation increases, particularly if single posteromedial release alone was performed. With single release a 100% satisfactory deformity correction outcome will be obtained only if surgery was performed during the first 6 months of life, beyond which this rate had dropped to 63.6% when operation was delayed to the age of 7-12 months, and to 25% at 1-3 years of age. After 3 years of age single posteromedial release alone did not yield any satisfactory results. On the other hand a100% satisfactory results were obtained in all feet treated with combined release during the whole period of the first 3 years of life, after which the rate of satisfactory results decreased to 50%. The study highly recommends the use of combined posteromedial and lateral release through two separate incisions when operating on clubfeet above the age of 6 months. This is a very valuable procedure with high success rate both in correcting the initial deformity and minimizing the rates of surgical wound breakdown. Introduction ongenital idiopathic clubfoot (talipes equinovarus) is one of the most common congenital orthopedic anomalies which still continues to challenge the skills of the orthopedic C surgeon as it has a notorious tendency to relapse irrespective of whether the treatment was conservative or by operative means. Confusion and divergent opinions regarding etiology, Bas J Surg, 16, September, 2010 38 Two surgical approaches in clubfoot Alaa abdulemmam Barrak & Ouday Falih Al-Ali pathogenesis, treatment and prognosis still exist. To appreciate the condition one must consider the foot as a whole. The deformity is an equinus and varus of the hindfoot and adduction and supination of forefoot with cavus. As the child grows adaptive changes develop in the bone and soft tissue as the result of the abnormal position. There are many controversies in assessing the severity of deformity, the role of operative versus non-operative treatment, optimum age at surgery, type of incision and postoperative regimen of immobilization. Ponseti method of conservative treatment is very useful, if started very early in life, done by experienced orthopedic surgeon, and proper type of splint till four years of age when recurrence rate would disappear. Surgical treatment of clubfoot is indicated after failure of conservative treatment and supported by limited operative intervention .The list of operative procedures is endless as no single procedure gives a longlasting correction. The surgery must be tailored to correct the specific elements of the deformity taking in consideration the age of patient at time of surgery. Surgical goal is concentric reduction of talo-navicular and calcaneo-cuboid joints. Deformity of bones and joint are rarely completely corrected. Operating time of clubfoot is debatable, most surgeons delay surgical intervention until the infant is 4-6 months age. In small foot and earlier age there is abundant amount of fatty tissues with small bone and cartilage structure. Patients and methods Between October 2005 and October 2007, a group of 70 children with 115 idiopathic congenital Talipes equino varus club feet was evaluated and treated surgically in a prospective comparative study at the orthopedic unit of Basrah general hospital. Children up to age of 5 years were included. Other varieties of club foot such as neuropathic, postural, and arthrogryposis as well as recurrent club feet after previous surgical correction were excluded from the study. Forty nine patients (87 feet) were males representing 70% of patients and the remaining 21 (28 feet) were females representing 30%. Male to female ratio was 2.3/1. The deformity was bilateral in 43 patients (61.4%) and unilateral in 27 patients (38.6%). Involvement of the left foot was recorded in 70 % of the unilateral deformity. Positive family history of clubfoot was found in 14% of patients (10 out of 70). Age at operation was 3-6 months in 54 feet (termed early cases in the study), and more than 6 and up to 60 months in the remaining 61 feet (termed late cases in the study). Dimeglio classification was utilized to assess the severity of clubfoot deformity into moderate, severe and very severe grades. The indications for surgery were: failure of conservative treatment (serial manipulative correction and casting) and late presentation more than 6 months of age. Operative details In essence the operation is an extensive release of all the structures contributing to the deformity. Tourniquet was used in every case. The patients were divided into two groups: Group A: Single incision (Turco's posteromedial release): this was performed in 58 feet (19 moderate, 28 severe, and 11 very severe). Group B: Two separate incisions (Combination of posteromedial release and lateral release): performed in 57 feet (19 moderate, 28 severe, and 10 very severe).The lateral release was soft tissue or combination of soft tissue and bony surgery which included: 1Release of all capsular structure of calcaneo-cuboid joint (other Bas J Surg, 16, September, 2010 39 Two surgical approaches in clubfoot Alaa abdulemmam Barrak & Ouday Falih Al-Ali than the lateral capsule) which is retained as locating hinge against which reduction is held. 2Mobilization of the tendons of the peroneus longus and brevis. 3Release of the calcaneo-cuboid ligament. 4Division of the calcaneofibular ligament. 5Wedge resection of the calcaneo-cuboid joint (if the age is 3-5 years). Postoperative care: The limb is held in a well padded above knee complete plaster of Paris. No attempt is made to maintain full correction until the skin is healed at two weeks. Stitches are removed after two weeks at which time full correction is maintained in a long leg plaster cast for one month. Thereafter splint is worn day and night until the child begun to walk. Follow-up visits were arranged , the first visit at two weeks, the second at one month, the third at three months, the fourth at six months and the last at one year. In each visit the following six parameters were assessed; presence or absence of wound infection, skin necrosis, forefoot adduction, equinus deformity, heel varus deformity, and recurrence of all elements of clubfoot. Results Surgery was performed at age 3-6 months in the majority of cases (54 feet representing 47% of all feet), in 22 feet (19.2%) at age 6-12months, and in 23 feet (20%) at 13-36 months as shown in table I. Table II shows that the most frequent grade of club foot severity encountered in the study was the severe grade in 56 feet (48.6%), followed by moderate in 38 (33%), and lastly very severe in 21 feet (18.4%) as table II shows. Table I: Distribution of patients according to age at operation. Table II: Distribution of patients according to severity of clubfoot deformity Severity grade Group A Group B Total Feet Per cent Feet Per cent Feet Per cent Moderate 19 16.5 19 16.5 38 33 Severe 28 24.3 28 24.3 56 48.6 Very severe 11 9.7 10 8.7 21 18.4 Total 58 50.5 57 59.5 115 100 To assess the results of operative treatment regarding correction of the deformity, the method of Main et al of clinical evaluation was used. The results were graded excellent, good or poor on strict criteria. Excellent refers to obtaining normal function and appearance of the foot. Bas J Surg, 16, September, 2010 Total Group B Group A Age (months) Per cent Feet Per cent Feet Per cent Feet 47 54 23.5 27 23.5 27 3-6 Ea rly 19.2 22 9. 6 11 9.6 11 7-12 La te 20 23 9. 6 11 10.4 12 13-36 13.8 16 6.9 8 6.9 8 36-60 100% 115 49.6% 57 50.4% 58 Total


Introduction
ongenital idiopathic clubfoot (talipes equinovarus) is one of the most common congenital orthopedic anomalies which still continues to challenge the skills of the orthopedic C surgeon as it has a notorious tendency to relapse irrespective of whether the treatment was conservative or by operative means.Confusion and divergent opinions regarding etiology, pathogenesis, treatment and prognosis still exist 1 .To appreciate the condition one must consider the foot as a whole.The deformity is an equinus and varus of the hindfoot and adduction and supination of forefoot with cavus.As the child grows adaptive changes develop in the bone and soft tissue as the result of the abnormal position.There are many controversies in assessing the severity of deformity, the role of operative versus non-operative treatment, optimum age at surgery, type of incision and postoperative regimen of immobilization.Ponseti method of conservative treatment is very useful, if started very early in life, done by experienced orthopedic surgeon, and proper type of splint till four years of age when recurrence rate would disappear 2 .Surgical treatment of clubfoot is indicated after failure of conservative treatment and supported by limited operative intervention .The list of operative procedures is endless as no single procedure gives a longlasting correction.The surgery must be tailored to correct the specific elements of the deformity taking in consideration the age of patient at time of surgery 3,4 .Surgical goal is concentric reduction of talo-navicular and calcaneo-cuboid joints 1 .Deformity of bones and joint are rarely completely corrected.Operating time of clubfoot is debatable [5][6][7][8] , most surgeons delay surgical intervention until the infant is 4-6 months age.In small foot and earlier age there is abundant amount of fatty tissues with small bone and cartilage structure.

Patients and methods
Between October 2005 and October 2007, a group of 70 children with 115 idiopathic congenital Talipes equino varus club feet was evaluated and treated surgically in a prospective comparative study at the orthopedic unit of Basrah general hospital.
Children up to age of 5 years were included.Other varieties of club foot such as neuropathic, postural, and arthrogryposis as well as recurrent club feet after previous surgical correction were excluded from the study.Forty nine patients (87 feet) were males representing 70% of patients and the remaining 21 (28 feet) were females representing 30%.Male to female ratio was 2.3/1.The deformity was bilateral in 43 patients (61.4%) and unilateral in 27 patients (38.6%).Involvement of the left foot was recorded in 70 % of the unilateral deformity.Positive family history of clubfoot was found in 14% of patients (10 out of 70).Age at operation was 3-6 months in 54 feet (termed early cases in the study), and more than 6 and up to 60 months in the remaining 61 feet (termed late cases in the study).Dimeglio 9 classification was utilized to assess the severity of clubfoot deformity into moderate, severe and very severe grades.The indications for surgery were: failure of conservative treatment (serial manipulative correction and casting) and late presentation more than 6 months of age.

Operative details
In essence the operation is an extensive release of all the structures contributing to the deformity.Tourniquet was used in every case.The patients were divided into two groups: Group A: Single incision (Turco's posteromedial release): this was performed in 58 feet (

Postoperative care:
The limb is held in a well padded above knee complete plaster of Paris.No attempt is made to maintain full correction until the skin is healed at two weeks.Stitches are removed after two weeks at which time full correction is maintained in a long leg plaster cast for one month.Thereafter splint is worn day and night until the child begun to walk.Follow-up visits were arranged , the first visit at two weeks, the second at one month, the third at three months, the fourth at six months and the last at one year.In each visit the following six parameters were assessed; presence or absence of wound infection, skin necrosis, forefoot adduction, equinus deformity, heel varus deformity, and recurrence of all elements of clubfoot.

Results
.The list of operative procedures is endless as no single procedure gives a long-lasting correction.The surgery is tailored to the deformity 3,12 .The two important factors to achieve lasting correction are that complete correction of all components must be obtained and this correction must be maintained while the tarsal bones remodel.The rationale behind Turco"s posteromedial release was that the deformity is due to congenital subluxation of the talocalcaneonavicular joint, the correction of the abnormal tarsal relationship is prevented by rigid pathologic soft tissue contractures 1 .McKay et al 13 and Herzenberg et al 14 Have shown that the presence of an internal rotation deformity of the calcaneus cannot be adequately corrected by a posteromedial release alone.Other causes of recurrence may be due to type of surgery, complete release of all the structures that participate in the deformity, postoperative immobilization (proper type of the splint and duration of the splint).Part of the reason that the foot relapses is the surgeon's failure to recognize the underlying pathoanatomy of the disease.When comparing the outcome of surgery for clubfeet in this study, it was evident that combined release through two separate incisions (group B) feet gave much more superior outcome compared to posteromedial release alone through single incision (group A) feet in regard to the rates of wound edge necrosis and the more important the correction of initial pre-operative deformities for which surgery was performed.The risk of wound infection was approximately the same for both procedures 8.6% in single release, and 8.8% in combined release.Necrosis of skin edges occurred in 8.8% of combined release feet (group B) compared to 17.2% rate in single release feet (A).After posteromedial incision Wellington et al 15 found wound breakdown in 19.6% whereas Bethan et al 16 reported only 3.7%.Porats et al 17 found wound slough following two separate incisions to be 3.7%.The outcome of satisfactory deformity correction in this study was 87.7% for group (B) feet compared to only 63.8% for group (A) feet.It is not easy to compare our results precisely to the results of other studies since substantial difficulties in outcome research for clubfoot deformity exist for a number of reasons such as variability in the severity of the deformity as well as the age of initial presentation.Many studies in the clubfoot literature have small size and include patients from infants to adolescent's .In addition different studies utilized different parameters to assess the final outcome following operative treatment in clubfoot such as subjective 18 , objective 19 , and radiographic parameters 20,21 .While Main et al 10 found excellent results in more than half of cases following posteromedial release surgery, Lau et al 4 in his study found 80% satisfactory results after the same procedure, as also Turco 22 who had found excellent and good results in 83.8%.Other studies showed variable results: Magone et al 23 found poor and fair results in 52% following three different procedures.Gunther 24 found excellent and good results following serial casting and additional posterior release in about 59.7%.For separate incisions the results in literatures were also variable.Pandy et al 25 in their study found that unsatisfactory results following two separate incisions were 18%.The most common single residual deformity reported in this study following surgical correction whether by single posteromedial release or by combined release was forefoot adduction.In the literatures, forefoot deformity is also the most common residual one following surgery on clubfoot regardless to the number of incisions or procedure performed 11,26 28 recommend surgery at or around one year of age reporting the disadvantages of early surgery to be difficulty in the identification of the anatomical structures and in the handling of the small cartilaginous bones when operating on a small foot.Furthermore it is hard to hold the small foot in plaster.One major benefit of operating close to the age of walking is that it takes advantage of the normal physiological stimulus of weight bearing for remodeling .While Osterman & Merikato 5 recommend surgery at the earlier age of three to six months to utilize the remodeling potential of the foot.This study agrees with the results of Edmondson et al 7 and Simon 29 who had found that best results would be obtained when operation on club foot is performed early.In this current study inverse relationship was found between the age of the patient at operation and the outcome.Performing surgery after 6 months showed that combined release (B) was superior to single release (A) in correcting the deformity.It is clear that the proportion of satisfactory results decreases as the age at which operation is performed increases.This was so evident in posteromedial release group (A) feet in which the 100% rate of satisfactory deformity correction achieved when operation performed at first 6 months of age had decreased to 63.6% when operation was delayed to the age of 7-12 months, 25% at 13-36 months of age.On the other hand , group B combined release surgery allowed greater flexibility in delaying surgery especially if other co morbidities in the infants like recurrent respiratory tract infections and anemia would otherwise force the surgeon to defer operation.A 100% satisfactory results were obtained in all group B feet operated upon within the whole period of the first 3 years of life.High failure rate was reported by Sanghvi 30 when surgery was performed after the age of three years.This was also reported in this study, with group (A) feet the chance of obtaining satisfactory correction results when operating at 36-60 months of age was almost nil.but with group (B) feet ,there is still a 50% chance to obtain satisfactory results using combined release (mostly bony resection of calcaneocuboid joint on the lateral side) at the same age.

Conclusion
Surgery at an early age as possible in clubfoot that failed to respond to conservative treatment gives better results.Satisfactory results is more when the operation done in the first six months of life.The use of two different surgical approaches in the treatment of idiopathic club foot can lead to different outcome.Combined posteromedial and lateral release through two separate incisions is a very valuable procedure with high success rate regarding both correcting clubfoot deformity and decreasing the rates of skin complications of surgery.

Table I : Distribution of patients according to age at operation. Table II: Distribution of patients according to severity of clubfoot deformity
Bas J Surg, 16, September, 2010