REASONS FOR RECURRENT ADDUCTUS AFTER OPERATIVE TREATMENT OF CLUBFOOT BY SOFT TISSUE RELEASE: RADIOGRAPHIC ANALYSIS

Abstract

Conservative management of talipes equinovarus has a good effect on adductus deformity of the forefoot, whereas equinus deformity cannot usually be treated well conservatively. However, adductus is the most common recurrent deformity after operations. The aim of the study was to use radiological analysis to explore the reasons that lead to recurrent adductus.

In 86.7% of the cases, either a correction was evaluated as radiologically inadequate but seemed to be good physically, or compensation for an operative over-correction resulted in recurrent adductus some years later. In spite of adequate correction from both a physical and radiological view, recurrent adductus developed in 13.3% of the cases. In our opinion, these recurrences were due to persistent muscle imbalance.

In our department, 458 children were operated on for clubfoot from 1982 to 1997. The patients involved in this study were those managed by medial and posterior soft tissue release after an ineffective six to nine month period of conservative treatment that was started when they were one to two weeks old. Children treated previously in another hospital were excluded from the study. We controlled 228 feet and 42 cases of recurrent adductus were found 2 to 16 years (mean 6.8) after the operations. The radiographs were examined at the end of ineffective conservative treatment, during the early postoperative days, and finally at the follow-up. The anteroposterior talocalcaneal (ATC) angle, the talometatarsal (TM) angle and the naviculometatarsal (NM) angle were measured in all of the radiographs. Based on the measured angles, three main groups of patients were formed.

Recurrent adductus in 24 feet (Group A) was caused by inadequate operative corrections, including inappropriate correction of either the hind foot (reduced ATC angle) or the forefoot (reduced NM angle), or both. Although the talocalcaneal and talometatarsal positions were normal in early postoperative radiographs, adductus developed again two to five years later in seven cases (Group B). In these cases, we think that persistent muscle imbalance was responsible for the recurrent deformity.

In 11 feet the ATC angles were in normal range or increased (Group C). These adductus deformities were caused by either an overcorrected talocalcaneal position resulting in compensatory metatarsal varus or medial subluxation of the talonavicular joint, which had been only partially compensated by the lateral deviation of the 1st ray.