the oxford club-foot programme

THE

OXFORD

S. B. TIBREWAL,

CLUB-FOOT M. K. D. BENSON,

From

the Nuffield

PROGRAMME C. HOWARD,

tD.

Centre,

Oxford

Orthopaedic

J. FULLER

We treated 63 club feet in 44 patients by a defined programme of strapping from birth followed by one of two operations performed at six weeks, either a simple calcaneal tendon lengthening or a subtalar realignment, and reviewed them prospectively. The decision as to which operation to perform was taken at four weeks after radiographic measurement of the talocalcaneal angle. All but eight patients (ten feet) were followed for a mean of 8.7 years. The overall results after calcaneal tendon lengthening were satisfactory. The re-operation rate after subtalar realignment was high (39%) due to over or undercorrection of the deformity.

One problem equinovarus for classifying

a senior physiotherapist management of the

in the treatment of congenital talipes (CTEV) is the lack of a quantifiable system the deformity. The assessment of alterna-

the

tive treatments has been presented in such varying ways by different authors that it is almost impossible to compare them. The late D. J. Fuller believed that there was a clear need for a prospective study in which all children with this condition from birth by one surgeon protocol.

We

present

should be seen and managed following a rigidly defined the

results

of

his

Programme. consultant clinical of the

Each

foot

orthopaedic

was

examined

surgeon

(DJF).

mother.

The feet of strapping

The

were and

strapping

the first two weeks weeks. Every foot

was

at birth

by one

Photographs

and

of the three elements hindfoot varus and treated gentle

changed

and then once a week was strapped by DJF

held

in

M. K. Nuffield

D. Benson, Orthopaedic

Consultant London,

FRCS, Consultant Centre, Oxford

C.

Howard, FRCS, Orthopaedic I Sigalon Street, POB 540, Omer,

tD.

J. Fuller,

Correspondence

©

1992 British 0301-620X/92/4375

JBonefoint

528

deceased, should

MS,

Orthopaedic SEIO 9HE,

(a talocalcaneal hindfoot varus

centres

Orthopaedic OX3 7LD,

overlapped

for

was

Surgeon Israel.

be sent

to Mr

and

Joint

was

Surgery

taken

with

the

with on

the of and

was

angle of excluded

1 b),

it was

sole

the

1955). If the ossific centres appeared to be separate

(Fig. 2): fully corrected,

2) if there was persisting evidence of hindfoot varus,

more (Fig.

than la).

concluded

25#{176})

If the

that

the

no

further

treatment

equinus without radiological lengthening of the calcaneal

indicated ; and was radiographic

without clinical dure (STR) and

evidence, lengthening

performed. Strapping

was

for surgery

Calcaneal tendon neal tendon was

S. B. Tibrewal.

Editorial Society ofBone $2.00 Surg[Br] 1992; 74-B :528-33.

(Fig.

and

were

needed;

admitted

FRCS

assessed.

lay in varus beneath the talus (Simons 1977). Surgical treatment. Further treatment was planned for each child at the age of one month. Three possibilities

twice

Surgeon England.

were

of

calcaneum

were considered 1) if the foot

Surgeon England.

20#{176} of equinus

diverging significant

tendon was 3) if there S. B. Tibrewal, FRCS, FICS, Greenwich District Hospital,

the day-to-day the five years

the feet

radiographs

(Davis and Hatt and the calcaneum

by by

for the next two personally or by

ofstrapping,

cassette the talus

immediately manipulation weekly

month

supervised throughout

Further photographs were taken and the improvement achieved was recorded. Hindfoot equinus and mobility were measured clinically but the degree of heel varus was determined by the following radiographic technique.

foot

treatment

METHODS

notes recorded the severity deformity, ankle equinus,

forefoot hooking. the application the

club

AND

one

Anteroposterior

programme.

PATIENTS

study. After

who patients

varus,

even

a subtalar realignment ofthe calcaneal tendon

evidence

procewere

continued

until

at six weeks

lengthening. performed

of

the

children

were

of age.

Z-lengthening of the calcathrough a posterior longitu-

dinal incision. The cut tendon ends were laid side by side but not sutured in about half the patients ; in the other half the ends were sutured. The foot was immobilised in THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

THE

OXFORD

CLUB-FOOT

529

PROGRAMME

an

above-knee

six weeks

plaster

after

Subtalar through

cast

in the

realignment. a posteromedial

This operation incision (Fig.

cular bundle was freed and hallucis longus and extensor Calcaneum

tibialis as was

Fig. Diagrammatic calcaneum

Fig.

representation in a normal foot

and

of the ossified nuclei one with hindfoot

lb

of the varus.

talus

was performed 3). The neurovas-

isolated digitorum

and

the longus

extensor and the

ligament

was

divided.

The

subtalar

joint

and

the

neum

to be pulled

more

normally.

away This

from

movement

the

talus of the

and

‘I, FOUR-WEEK ASSESSMENT

1’ I VARUS=STR]

I

EQUINUS=ETA

FOUR

STR

=

NO SURGERY

/ COMPLETE

Fig. programme.

=

MONTHS

PROGRAMME

treatment

I CORRECTED

]

‘I,

The

Subtalar

2

realignment.

ETA

=

lengthening

of calcaneal

tendon.

Tibialis posterior tendon

Fig. The

VOL.

74-B,

No. 4, JULY

1992

was

repositioned

calcaneum

BIRTH]

I

I

for

opened posteriorly (where it is easiest to find) and then medially and distally as far as the talonavicular joint. The talocalcaneal interosseous ligaments were divided and the lateral subtalar capsule and the lateral calcaneofibular ligaments released, thereby allowing the calca-

Clubfoot

Ia

position

posterior tendons were elongated in a ‘Z’ fashion, the calcaneal tendon. The superficial part of the

deltoid

Normal

corrected

surgery.

surgical

approach

3

for subtalar

realignment.

took

S. B. TIBREwAL,

530

the

remainder

of

talonavicular plantar release

the

joint was

foot

with

it

M. K. D. BENSON,

and

the

subluxed

was automatically realigned. performed and the ankle capsule

divided. Although the talus was of abnormal disposition, it remained the reference point

No was

C. HOWARD,

D. J. FULLER

initially

without

in the

assessment

any

surgery.

rection

was

not

the

purpose

A well-

padded long-leg plaster cast was worn until the were removed three weeks later. A further plaster was then in whom granulation

applied and worn for three weeks. the surgical wound could not be tissue and a new epithelium

quickly and all wounds were removed. No removed.

further The

consisted

plaster

Assessment. Ten

feet

53 feet of

the

these were

six

even

was at three-monthly and at six-monthly

the

one

operation

for

the

and the

lost to follow-up, leaving nine female). Elongation

tendon

had

been

subtalar realignment up for an average

12) in a special clinic radiographic assessments

Grading

performed

and

25 of

on 28. The patients of 8.7 years (range 7 to

where clinical, were made.

of equinus

on

varus

photographic

deformities,

and

and

of hindfoot

mobility Grade

Equinus

Varus

0

1

2

3

Nil

Tightness

Heel strike reduced or absent

Heel fixed

Nil

Mobility

of

Full

high

Less than 10’ on weightbearing with plantigrade foot

More than 10#{176} Fixed varus with with weightplantigrade bearing on weight-bearing outer foot foot

Reduced

Minimal

Totally

and

hindfoot included

clinical

evaluation

measured

equinus,

mobility (Table I). Functional the occurrence of pain, limitation

shoe wear and ability to walk on tiptoe. The angle and talocalcaneal index (Beatson 1966) were determined radiographically. feet

varus

In the treatment with true CTEV

programme appeared

be

common

until

these

children

available

report our observations years. is no overlap between

postural

equinovarus

been included in this series. feet and with the passage stigmata of that condition diagnosis

in all cases.

The

which to early

tendon

At primary

who

were true club characteristic confirming there

deformities

which

unsatisfactory

were

the

on

25 feet

were

treated

by

lengthening, six required further surgery or undercorrection of the deformity. In

one patient with Down’s syndrome a subtalar was necessary at the age of 4.5 years. Three forefoot hooking

and medial release for and cavus, and two tibialis

improve

dorsiflexion.

None

by calcaneal tendon Subtalar realignment. required

result

re-operated

Of

lengthening.

calcanealtendon for recurrence

an

true has not

presentation

those

had

and

at a

which

All our cases of time the have developed,

predicted strapping.

patients

a further

realignment feet required

persistent anterior

of the

lengthening Eleven

feet

forefoot transfer to

treated

initially

was overcorrected. of the 28 feet in this

group

for undercorrection,

recur-

operation

rence

or overcorrection of the deformity. Two feet underwent repeat subtalar realignment and two had calcaneal osteotomy for recurrence of varus deformity at five years. One patient had bilateral external rotation tibial osteotomies to correct intoeing five years after the initial surgery. Several further operations were required for infected nonunion on one side of this patient but the function

result and

anterior

transfers

was eventually satisfactory in alignment. Three feet required at six years

deformity. Examination weight predominantly

stiff

and

assessment of activity, talocalcaneal and Pearson

as defined, to have been

included

and

are now

terms of tibialis

asymptomatic.

Two feet underwent calcaneal osteotomy for excessive valgus due to overcorrection, one at two years and the other at seven years. One of these patients later required anterior ankle release to correct a rigid calcaneus

hindfoot

The

and

Cakaneal

a

(eight patients) were in 36 patients (27 male,

not

from primary surgery classified as failures.

severe

intervals until intervals thereafter.

CTEV

Failures.

cast was therefore

most

will

were no features would respond

casts

63 club feet in 44 patients.

calcaneal

I.

weeks,

the

results

have reached maturity. We minimum follow-up of seven We believe that there

the

In patients fully closed, developed

when

offered after programme

wires cast

The study included

feet and followed

Table

healed

for six weeks,

for

cases. Follow-up age of one year

fully

treatment was entire treatment

of strapping

long-leg

were

Final

was to produce a a normal foot. With underneath the talus, Kirschner wires passed subtalarjoint. Overcoroperation.

are not

RESULTS

shape and around which

aim

of the

feet

of results.

not

the heel was repositioned. The plantigrade foot, not (unrealistically) the calcaneum carefully positioned the bones were transfixed by two upward through the heel and the

These

only two corrected

Outcome. including

confirmed through the

The outcome is the failures detailed

Equinus

recurrence.

calcaneal equinus

tendon and two

realignment had Varus recurrence.

One

varus

heels

and mobility.

described above.

foot

in

for

the

all

group

53

took feet,

treated

lengthening had residual in the group treated by

by

grade subtalar

1

residual grade 1 calcaneus deformities. In those treated by calcaneal tendon

lengthening, one foot had subtalar realignment group Hindfoot

that these feet heel (Fig. 4).

one

with No

THE

feet

a grade 1 varus there were six

minimal were

JOURNAL

valgus completely

OF BONE

AND

heel. In the with grade 1

overcorrection. stiff JOINT

but

most

SURGERY

THE

OXFORD

CLUB-FOOT

wedge-shaped the former. seen. Pain. had

531

PROGRAMME

in 70% of the Some flattening

No patient occasional

complained aching

Limitation

of

limitation

of

activity. their

ofpain

after Thirty activity.

and was

when

strenuous

in none invariably

walking.

of

Two

activities.

patients Four

plained of slight limitation play sport due to discomfort Tiptoe sutured

latter group of the talus

(83%)

patients

had

(1 1%)

no com-

and two (6%) were unable in the operated feet.

standing. No correlation and non-sutured tendons

was and

to

found between the the patients’ ability

to stand on tiptoe ; 65% of patients of the tendonlengthened group and 46% of the subtalar realignment group were able to stand on tiptoe with the knee extended.

Fig. Weight-bearing

pattern

Shoe wear. Twelve smaller size shoe normal size, two

4

in overcorrected

calcaneus

feet ; five were

in 33% of the patients required a were two sizes smaller than the one size smaller and five were a

half size smaller. The other patients were able to wear shoes of the same size although often with toe-block

feet.

insoles. lost some mobility (Table subtalar realignment group only minimal movement additional lengthening

surgery. group

2 or 3 mobility.

II). Only one foot in the had full mobility. Five had ; three of these had had

Six feet in the calcaneal had full mobility and none

The

remaining

feet had grade

had

DISCUSSION

tendon grade

In this series the entire completed in three months. weeks only, one operation

1 mobility.

Forefoot deformities. The incidences of residual deformities of the arch, forefoot adduction and rotation are given in Table III. Radiographic analysis. The talocalcaneal indices (Beatson and Pearson 1966) measured on the follow-up radiographs did

not

differ

between

the

two

treatment

age = 55#{176} for the tendon-lengthening the subtalar realignment group).

Table II. Flexibility groups. Pre-operatively as flexible or stiff graded 0 to 3

of and

groups

group navicular

The

for the most severe cases. Early assessment of the surgical approach have made

Treatment

group

Flexible

(aver-

and 61#{176} for appeared

small and reasonable surgery. In those who final

0

1

2

3

ETA(n=25)

23

2

6

19

0

0

STR(n=28)

11

17

1

22

5

0

*

ETA,

elongation

ofthe

calcaneal

tendon

;

STR,

III.

N umber Arch

74-B.

No.

4, JULY

in the

two

treatment

groups

______________________ Forefoot adduction Neutral

PIanos

Adduction

Neutral

Abduction

ETA

10(40)

15(60)

0

Il (44)

14(56)

0

16(57)

ETA,

1992

elongation

8(29) of the calcaneal

4(14) tendon,

has been a second

retained operation

after the

satisfactory.

although no worse than some other Ponseti 1980; Thompson, Richardson

18(64.5) STR,

8(28.5) subtalar

realignment

with

residual

et al 1983; et al 1985).

forefoot

deformity

___________________ Rotation

Cavus

*

mobility did require

and Westin 1982; Ghali Roberts 1985 ; Hutchins

of feet

shape

an early separate

of the reoperations in this group was for the of hindfoot varus deformity. This confirms differentiation by measurement of the talocal-

been less satisfactory, series (Laaveg and

subtalar

percentage)

was

Treatment group

STR

VOL.

(and

and to

caneal angle can distinguish a group of children who can be successfully treated by posterior surgery alone. The results of radical subtalar realignment have

realignment

Table

result

None correction that early

tive

Stiff

deformity it feasible

simple hindfoot equinus from equinovarus deformities, the radiographs at four weeks allowing identification of hidden hindfoot varus (Fig. 5). The outcome of those treated by simple calcaneal tendon release has been encouraging. The reoperation rate in this group has been

Grade

Pos topera

programme was strapping for six in a plaster cast,

even

feet in the two treatment the feet were classified simply postoperatively stiffness was

Pre-operative

treatment It included and six weeks

2(7)

Neutral

Supinated

Pronated

8(32)

17(68)

0

12(43)

13(46)

3(11)

Green and LloydThey represent the

S. B. TIBREWAL,

532

M. K. D. BENSON,

C. HOWARD,

D. J. FULLER

should be compared been able to compare and equinus figures cavus, adductus operatively. The very subtalar satisfactory.

with postoperative values. We have the pre-operative mobility, varus with the postoperative results but

and posterior

were

position

realignment was The advantages

(Crawford,

Marxen

there

measured

of the

after

less than incision have

Nicol

in the

CTEV and a lack ofagreed criteria to make comparisons between

pre-

scar

1982)

and use.

conformity

heel

to be Cincinnati

Osterfeld

(Brougham for future

is no

not

considered of the

and

recently confirmed can be recommended As

rotation

been

1988)

and

it

management

of

it is almost impossible series. Some studies

consider only children treated from birth (Ryoppy and Sairanen 1983) and others include children of several ages (Green and Lloyd-Roberts 1985) and after different initial treatments (Turco 1979). Some report functional results, others the cosmetic appearance, and some Fig.

categorise

5

Anteroposterior radiographs of both feet of one infant. On the left the overlapping ossific centres of the talus and calcaneum contrast with the normally divergent talocalcaneal angle on the right. There was good correction and function eight years after elongation of the calcaneal tendon on the right and subtalar realignment on the left.

so-called ‘resistant’ rate of approximately that of some other

of club feet; their reoperation 39% compares favourably with series (Main et al 1977; Harrold and

overcorrection

in three

posteromedial and treated by complete rected

lateral subtalar

foot is a serious Our reoperation

of

26 feet

release and realignment.

problem. rate after

treated

five

of The

subtalar

difficulties (1979). method

as

pointed

comparison in every

by

25 feet overcor-

realignment

years after the initial operation at first to have been successful.

operative

radiographs

as suggested may decrease Eight tiptoe

patients with

found between this respect. Stiffness group but operative

the

degree

in the

tendon-lengthening

realignment group the knee extended. the sutured

and

subgroups

was

a problem feet

in the

subtalar

were stiff of deformity

Tayton

and

Thompson

described deformity.

another

between series easier. parameter then we

If the foot can claim

to add between

is a

different different

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out

The authors would like to dedicate this paper to the memory of D. J. Fuller, tragically killed in 1983. They would also like to thank Ms Leigh Bryan for her secretarial assistance. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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group

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is

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15 in the subtalar on

to verify

The

and

successful outcome. It is inappropriate scores as this makes comparison treatment programmes difficult.

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Catterall (1991) has recently of assessment of the club-foot

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into

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