Sr. no.	Category	Points
1.	ANKLE DORSIFLEXION > 90o 90o < 90o	15 5 0
2.	SUBTALAR JOINT MOTION > 15o < 15o Stiff	10 5 0
3.	POSITION OF HEEL WHEN STANDING 0o – 5o valgus 5o valgus varus	10 5 0
4.	FOREFOOT APPEARANCE Neutral <5o Abd/ Add. >5o Abd/Add.	10 5 0
5.	GAIT Normal heel/ toe gait Can not heel walk Can not toe walk Flat foot gait	10 -2 -2 -4
6.	RADIOGRAPHIC MEASUREMENT * T.C. INDEX > 40o < 40o TALUS- FIRST METATARSAL ANGLE < 10o > 10o	5 0   5 0
7.	SHOES Regular(No complaints ) Regular (With complaints) Orthopaedic shoe/inserts/braces	5 2 0
8.	FUNCTION No limitations Occasional limitations Usually limited	15 8 0
9.	PAIN Never Occasionally Usually	10 5 0
10.	FLEXOR TENDONS Full function Partial function No function	5 3 0

At the time of follow-up, radiographic examination in detail and following angles were measured- AP Talocalcaneal angle, Lateral talocalcaneal angle, Talo First Metatarsal angle Tibio-calcaneal angle

Operative Technique

Radical Posteromedial Release: Total 30 patients (50 feets) were treated by radical posteromedial release⁵.       Patients planned for surgery were admitted two days before the day of operation. All necessary investigations Hb, CBC, urine examination were done. Surgical fitness from the paediatrician is taken. Preoperative anaesthetic check up was done and as suggested by the anaesthesiologists, Inj.Atropine 0.3mg( i.m.) administered 30 minutes before surgery. All procedure is done under general anaesthesia. A pnumatic tourniquet is applied to the midthigh region. Foot and leg is first cleaned with 2% savlon, starting from the tip of the toes to the knee and then iodine was painted all over the foot and leg. The part was covered with sterile drapes. Tourniquet inflated. Tourniquet time was noted by anaesthesiologists.

Position: Supine position given with sandbag kept under opposite hip. So that posteromedial part of leg and foot will come into operative field.

Incision: Modified Caroll’s incision⁶ is taken.

Posterior Incision: While assistant holds the foot in dorsiflexion the post. incision taken slightly lateral to the tendoachilles from it’s insertion to 5-6 cm.above. Sural nerve is identified and protected. Incision deepened till the glistening sheath of tendoachilles is seen. The sheath of T.A. is released. The ‘z’ plasty of the tendoachilles is done. Plantaris tendon is identified and cut. The neurovascular bundle is located medially and was identified by the bluish discolouration of the posterior tibial vein. It was retracted with a wet tape gauze passed around it. The superior peroneal retinaculum is cut and ankle joint is identified by passive upward and downwards movements of the ankle joint. First a small incision is made and then the capsulotomy is completed. Posterior talofibular ligament is cut by extending the capsular incision laterally to the fibular side. The posterior talocalcaneal and calcaneofibular ligament which is the main tether on lateral side are released. Then sheath of the peroneal tendon was cut alongwith the tibiofibular syndesmosis.

Medial Incision: A gently curved incision is taken from the base of the first metatarsal curving below the medial malleolus towards the tendo Achilles, two fingerbreadths anterior to it. The subcutaneous tissue dissected and the neurovascular bundle (med. and lat. plantar nerves and associated vascular components) was protected. The tibialis posterior (T.P.) tendon is identified. The sheath of tibialis posterior entered just post. to and above the medial malleolus. The tendon traced downward up to talonavicular joint and then ‘z’ plasty of T.P. is done. The talonavicular joint is opened by pulling on the remaining tibialis posterior tendon and then the capsule of talonavicular joint released all the way around med., inf., sup. and lat.aspect. The superficial deltoid, dorsal talonavicular ligament, plantar calcaneonavicular ligament (spring ligament) cut close to navicular. The Master knot of Henry is identified and released. The tendons of flexor digitorum longus (F.D.L.), and flexor hallucis longus (F.H.L.) are freed, and traced proximally until talocalcaneal joint is entered. “Z” plasty of FHL and FDL is done. The medial capsule of the talocalcaneal joint is released along with superficial deltoid ligament. The interosseous talocalcaneal ligament is kept intact. Both ends of bifurcated Y ligament are cut. Then the naviculo-cuniform joint is released. The abnormal origin of abductor hallucis is also released. The cut ends of T.P., FDL, FHL are sutured to each other with 3-0 ethilon suture. Through normal saline and betadine wash is given. Steindlers procedure- Stab incision is taken below and posterior to medial malleolus through which plantar fascia is cut and the origin of quadratus plantae is stripped in cases of severe cavus deformity.

Internal fixation: After reduction of navicular on talus, the talonavicular joint is fixed with ‘K’ wire. Anather ‘K’ wire is passed from plantar aspect of calcaneus into the talar body after reducing calcaneus under talus. Tourniquet is released and vascularity is checked. Then subcutaneous sutures are taken with 3-0 vikryl. The skin is closed with 3-0 ethilon. Wound is dressed with betadine gauze. Above knee C.T.E.V. cast is given in corrected position and splitted longitudinally.

Postoperative Management: The operated extremity is kept elevated over the pillow. Injectable antibiotics-Inj. Cefotaxime and inj. Gentamycin are given intravenously according to the body weight for three days and afterwards switched over oral antibiotics in syrup form for next four days. If the deformity is bilateral other side is operated after two to three days. On fifth postoperative day if the swelling is reduced, distal neurovascular status is checked, the cast is reinforced and patient is discharged. On the first follow-up, after one month the cast is removed, the sutures and “K’’ wires are removed radiographs are taken and the correction is assessed. Again above knee C.T.E.V. cast is given for three weeks. On the second follow-up below knee C.T.E.V. cast is given after taking shoe measure. After three weeks cast is removed and C.T.E.V. shoes are given. The shoes are continued till five years. Radiographic assessment done on each follow up after three months in first year and at six months afterwards.

OBSERVATIONS

In the present series, there were 25 males and 5 females making the ratio of 5:1.

 

Table 2: Distribution of cases as regards the gender and incidence of involvement of extremities

From above data, it is obvious that bilateral cases are 83.33% and unilateral are 16.66%. Graph showing distribution of cases as regards the gender and incidence of involvement of extremities

Figure 1:

 

Table 3: Type of deformity and number of feet

47 feet (30 patients) were operated by this method and results were studied as per the score chart (Dan Atar et. al.) It is clear that satisfactory results (excellent and good) were noted in 35 feet and unsatisfactory results (fair and poor) in 12 feet (25.54%)

 

Table 4: Results of RPMR operation

 

Figure 2:

Table 4: Type of deformity and clinical results

Nine feet belonging to moderate deformity obtained unsatisfactory results. Most of the moderate type (21 feet) obtained satisfactory results. While 3 feet in severe grade had a failure.

 

Table 5: Preoperative and postoperative angles

 

Figure 3:

Table 6: Clinical results and ranges of parameters

Comparison of clinical results as (Excellent, Good, Fair, Poor) with respect to talocalcaneal angles in anteroposterior, lateral films and with T.C.index (sum of talocalcaneal angles in AP and Lat. view) was done.

 

Table 7: Postoperative complications

Undercorrection is observed in majority of cases (17.02%) as evidenced by residual forefoot adduction, equinus at ankle, heel varus while other complications are small in number. Neurovasular injury or deep wound infection is not noted in any case.

 

Figure 4:

Table 8: Residual deformities

 It is obvious that forefoot adduction is the most common residual deformity.

 

Figure 5:

DISSCUSSION

Clubfoot is still a major problem to all of us. Various theories regarding its etiology fall short on some vital point, its pathology is not clear. With Ponsetty’s cast treatment the requirement of major surgical procedures is reduced. But due to lack of awareness in rural areas cases of neglected ctev are still there. The aim of present study was to study the results of Radical Posteromedial Release (R.P.M.R.) operation in details^3,4. To find residual deformities and their correlation with radiological findings, to study various deciduas such as calf atrophy which are accompaniments of clubfoot surgery in each case and finally to analyse the surgical results⁷. In the present series, 30 clubfoot patients were studied, 25 males and 5 female showing M : F = 5 : 1 with 83.33 % male and 16.67 % females. Turco¹³ in his series of 468 patients found 334 (71.36 % ) males and 134 (28.63 % ) female having a ratio of 2.5 male to 1 female. Debrunner gives 58.6 % boys and 41.4 % girls. Max bohm gave the sex ratio 4: 1. Ponsetti found six male to one female. Kite in his series of 1509 patients found 70.58 % males and 29.42 % female. Thus the literature varies as to the percentage of boys to girls in clubfeet. Thus, the finding of 5 : 1 affection more in boys than girls coincides with the series in literature. In the present series 20 patients were bilateral (66.67%) and 10 patients were unilateral 33.33 %.Turco¹³ in his series found 56.76% bilateral cases. Chung reported bilaterality in 55.75 % cases. Kite found in his series 49.37 % bilateral cases. Ponsetti¹¹ found 40% bilateral cases. Preponderance of bilateral cases coincides well with other series in the literature. In the unilateral cases, more involvement is on the right side.

 

RESULTS

In the present study we found 74.46% satisfactory results, unsatisfactory results were noted in 25.54% feet, comparison of the results of clubfoot surgery from different centers is difficult because the preoperative severity of the feet in different studies may be different and no standard means exists for evaluating the residual deformity present after clubfoot surgery. One advantage in using the functional rating scale of Dan Atar et.al.¹ is that it allows direct comparison with their results.

 

Table 9:

 

Results of our series coincides with the results of comparative study of Dan Atar et. al.¹ Our series had good percentages of satisfactory results. This can be explained on the fact that making awareness of parents for the physiotherapy instructions and used orthosis, once they go home.

Postoperative Complications

1. Superficial skin infection noted in one feet. (2.12%)
2. Sloughing of skin in one patient (2.12%)
3. No deep wound infection is noted in any case.
4. Wound gaping was noted in 1 feet (2.12%)
5. Hypertrophic scar noted in 2 feet (4.26%)
6. Overcorrection is seen in 2 feet (4.26%)                               

The most common residual deformity noted was forefoot adduction (19.14%), next was varus 4 feet (8.52%), equinus in 2 feet (4.26%),and cavus in 3feet (6.38%). Varus ranging from 3-10 degrees. In residual equinus, pitch of ankle was ranging from 0.5 to 1cm.

 

REFERENCES

1. Atar D, Lehman W, A. D. Grant, A. M. Strong water- Functional rating system for evaluating the results of clubfoot surgery. Quoted in book“The clubfoot”Simons Pg. 114 - 116, 1994.
2. Attenborough G.G.: Early posterior soft tissue release in severe congenital talipes equinovarus. J. B. J. S. (British ): 48B,Pg. 31-39, 1966..
3. Barnett R.M. ‘Surgical release and reduction of congenital Talipes Equinovarus’, In book -“The clubfoot”  Simons, Pg. 216-222,1994.
4. Bagatur E. T. Centel; Comparison of soft tissues release methods in idiopathic clubfoot. J. of pediatric orth., Vol.-20, No.5, Spt./Oct, 2000.
5. Campbell’s operative orthopaedics, edited by S. Terry Canale 13 ^th edition vol.1 Page: 937-952.
6. Carrol N. C. – Operative technique, “The clubfoot”-Simons, Page: 480, 1994.
7. Deniz G, Bombaci H, Tuygun H, Gorgec M. Long-term results of extensive surgical dissection in the treatment of congenital clubfoot. Acta Orthop et Acta Orthop Traumatol Turc 2008;42(1):44-52
8. Grant’s atlas- Colour drawings of med. and lat. aspect of bones of foot. Page: 312.
9. Hennigan S.P., Ken.N.Kuo. Resistant Talipes Equinovarus associated with congenital constriction band syndrome. J.of paed. Orth. Vol-20, no.2, March/April 2000.
10. Karakurt L, Belhan O, Varol T, Yilmaz E, Serin E. Comparison of the mid-term results of complete subtalar release by the Cincinnati and the posteromedial incisions in clubfoot. Eklem Hastalik Cerrahisi 2009;20(1):32-40
11. Ponsetti I.V. : Quoted in the book “The clubfoot” by J.H. Hite, pg. 44.
12. Simons GW. The complete subtalar release in clubfoot.”The Clubfoot”.
13. Turco : Quoted by V.J. Turco in “The clubfoot” 1981.
14. Uglow and Clarke – The functional outcome of staged surgery for the correction of talipes equinovarus. Ped.J. of ortho. Vol-20, no.4, July/August 2000.
15. Van Gelder JH, van Ruiten AG, Visser JD, Maathuis PG. Longterm results of the posteromedial release in the treatment of idiopathic clubfoot. J Pediatr Orthop 2010; 30(7):700- 704.
16. Weimann-Stahlschmidt K, Krauspe R, Westhoff B. Congenital clubfoot. Orthopade 2010;39(11):1071-1084