In this study we evaluated the results of midtarsal release and open reduction for the treatment of children with convex congenital foot (CCF) (vertical talus) and compared them with the published results of peritalar release. Between 1977 and 2009, a total of 22 children (31 feet) underwent this procedure. In 15 children (48%) the CCF was isolated and in the remainder it was not (seven with arthrogryposis, two with spinal dysraphism, one with a polymalformative syndrome and six with an undefined neurological disorder).

Pre-operatively, the mean tibiotalar angle was 150.2° (106° to 175°) and the mean calcaneal pitch angle was -19.3° (-72° to 4°). The procedure included talonavicular and calcaneocuboid joint capsulotomies, lengthening of tendons of tibialis anterior and the extensors of the toes, allowing reduction of the midtarsal joints. Lengthening of the Achilles tendon was necessary in 23 feet (74%).

The mean follow-up was 11 years (2 to 21). The results, as assessed by the Adelaar score, were good in 24 feet (77.4%), fair in six (19.3%) and poor in one foot (3.3%), with no difference between those with isolated CCF and those without. The mean American Orthopaedic Foot and Ankle Society midfoot score was 89.9 (54 to 100) and 77.8 (36 to 93) for those with isolated CCF and those without, respectively. At the final follow-up, the mean tibiotalar (120°; 90 to 152) and calcaneal pitch angles (4°; -13 to 22) had improved significantly (p < 0.0001). Dislocation of the talonavicular and calcaneocuboid joints was completely reduced in 22 (70.9%) and 29 (93.6%) of feet, respectively. Three children (five feet) underwent further surgery at a mean of 8.5 years post-operatively, three with pes planovalgus and two in whom the deformity had been undercorrected. No child developed avascular necrosis of the talus.

Midtarsal joint release and open reduction is a satisfactory procedure, which may provide better results than peritalar release. Complications include the development of pes planovalgus and persistent dorsal subluxation of the talonavicular joint.

Cite this article: Bone Joint J 2014;96-B:837–44.

Purpose of the study: The purpose of this work was to study outcome at the end of grow after surgical treatment for idiopathic congenital equinovarus club foot.

Material and methods: From 1983 to 1991, 63 children (85 club feet) given functional treatment underwent surgery because of insufficient results. At birth, the Dimeglio classification was II:11.7%; III:40%; IV:25.8%. Surgery was performed before the age of 2 years for 52 fee (61%) and after 2 years for 33. The indication for surgery was a triple deformity: equin (8.1±15.2, varus (8.2±13.1, adductus (32.5±13.8). Surgery was associated as needed with posterolateral release (94.1%), anteromedial release (92.9%), plantar release (61.1%) and Lichtblau shortening of the lateral column (42%). The tendon of the tibialis anterior was lengthened for 86% of the feet. Functional, clinical, and radiographic outcomes were noted at last follow-up.

Results: Mean follow-up was 15 years (8–22). Fifteen feet (17.6%) had a second operation: 13 for recurrence (repeat release), one for over correction (lengthening of the calcaneum) and one for metatarsus adductus (metatarsal osteotomies). One foot had a third operation for recurrence (repeat release). Three feet (3.5%) did not have surgery; a double arthrodesis followed progressive aggravation during growth. In the first group (surgery before 2 years), outcome was very good, good or fair for 76.9, 17.3 and 5.8% of the feet. The “fair” outcomes concerned three children who had more than one operation. In the second group (surgery after 2 years), the outcomes were 78.8%, 18.2% and 3% (n=1) respectively. The “fair” result concerned the double arthrodesis. There was no significant difference for the final outcome as a regards age at surgery (p=0.07). Among the four feet with a “fair” outcome, two were initially Dimeglio III and two Dimeglio IV.

Discussion: Soft tissue release enables correct results at the end of growth for the majority of these club feet. While the Dimeglio score is an element predictive of an indication for surgery, it is not a prognostic element for the final outcome. Age at surgery does not have a significant impact on the final outcome.

Purpose of the study: The anatomic, clinical and radiographic expression of congenital genu recurvatum corresponds to femorotibial subluxation. The clinical presentation can vary, ranging from an easily reducible subluxation to irreducible dislocation.

Material and methods: Fifty five patients (82 knees) were treated, mean age 2 days. Genu recurvatum was isolated (n=15 children), associated with hip dislocation or foot deformity (n=40 children), arthrogyrposis (n=10 children, or Larsen syndrome (n=3 patients). Were studied: anterior skin folds, anteroposterior femorotibial instability, joint range of motion at first exam and last follow-up. The Seringe classification was noted at birth: I – reducible (n=59 knees), II – difficult to reduce (n=12 knees), III – irreducible (n=11 knees). Mean follow-up was 4 years, 13 years, and 9 years for class I, II and III knees respectively. Orthopaedic treatment was performed in all cases with manipulations, braces, traction and plaster cast for at least 40 days. In the event of failure, a V/Y lengthening of the quadriceps was performed, associated with joint release.

Results: At the first exam, the skin folds were present in all cases in group I, 2/3 in group II, and absent in group III. Mean maximal flexion was 66, 43 and 17 respectively in groups I, II and III. The even operated knees were in group III. At last follow-up, the mean maximal flexion was 146, 124 and 77 respectively in groups I, II and III. Six knees presented anteroposterior instability in groups I, 3 in group II and 3 in group III. In group I, the final clinical outcome was good or very good in 55 knees (93%), fair in 4. In group II, good or very good outcome was noted in 8 knees (67%), fair in 3 (25%), and poor in 1 knee. In group III, outcome was faire in 4 (36%) and poor in 7 (64%). In this group, poor outcome corresponded to 86% of the operated knees.

Discussion: At the first exam, factors having the most unfavourable impact were: absence of an anterior skin fold, knee flexion < 50, irreducible femorotibial dislocation, and syndrome context. We emphasise the importance of adapted conservative treatment which, in our experience, provides the better clinical outcomes.

Purpose of the study: Among the causes of secondary congenital equinovarus club foot, neurological disorders predominate. The entity we examine here corresponds to irreversible pure motor paralysis with no sensorial disorder affecting the lateral compartment predominantly and sometimes associated with involvement of the anterior compartment. There is no literature on this entity. Beyond the question of the aetiology, the demonstration of this pathological condition can modify therapeutic strategy in order to prevent recurrence.

Material and methods: We examined 42 congenital equinovarus club feet with persistent pure motor paralysis involving the lateral compartment and sometimes the anterior compartment with a mean 10 years follow-up. The Dimeglio classification was used and an analytical muscle score was noted for each patient. Complementary tests included an electromyogramme when possible. Conservative treatment was the rule either using a functional method or the Ponseti method; surgery was then proposed when necessary for posteromedial release with or without palliative muscle transfer. The following procedures were performed: posteromedial release (n=33) and muscle transfer (n=26): tibialis posterior (n=22), tibialis anterior (n=3); hemisoleus (,n=1); tibialis posterior associated with flexor digitorum longus (n=3).

Results: Conservative treatment was used for all feet but all presented recurrence and required secondary surgery (33 posteromedial releases and 26 muscle transfers).

Discussion: This study opens the discussion on the similarity between idiopathic and arthrogryoposis club foot since the electromyography sometimes reveals an anomaly of the anterior horn. Thus club foot with pure motor and persistent paralysis involving the lateral and/or anterior compartment will not respond sufficiently to nocturnal contention if an adapted muscle transfer is not associated.

Conclusion: Muscle transfer to reactivate dorsal flexion of the foot enables a better functional outcome. First intention conservative treatment can be instituted while waiting for potential recovery. If the paralysis persists beyond one year, muscle transfer is indicated before the deformity recurs and requires an associated posteromedial release.

Thanks to neonatal screening, idiopathic congenital dislocation of the hip (CDH) is generally diagnosed and treated at an early age. Despite this measure, late diagnosis of CDH still occurs. The goal of this article is to analyse the results of Petit-Morel’s closed reduction (CR) technique in the treatment of CDH diagnosed between 1 and 5 years old. We reviewed 72 hips in 60 patients. The treatment method was the same for all patients, beginning by bilateral longitudinal traction to achieve ‘presentation’ of the hip. It was followed by ‘penetration’ in a hip spica cast made under general anesthesia. The third step was an almost systematic surgical treatment of the remaining acetabular dysplasia. Results were evaluated using the radiological Severin score. Average follow-up was 11.9 years. The failure of CR occurs only twice. In this two cases, open reduction showed intraarticular obstacles to reduction. The only case of avascular necrosis (AVN) occured in one of this two failures of CR. At last follow-up, 95.8% of hips were rated as normal, or midly deformed. Young age at treatment significantly influenced the prognosis in our series. Neither the gender nor the height of the dislocation did appear to have any influence on the result. The patients which did not undergo a periacetabular osteotomy were significantly younger than the other one in the series. Pelvic osteotomy is an integral part of the method, as after 18 months many hips have lost their capacity to correct the remaining dysplasia. However, we only perform this osteotomy if the hip shows no sufficient correction during the semesters following the reduction od the dislocation. Considering Severin score, it is impossible to privilege closed or open reduction, as the results of both methods are close. However, in case of failure of reduction, which occurs in both methods, a second open reduction is much more difficult to achieve than and open reduction in a hip first treated by closed reduction. The results of this second surgery on the hip are poorer, with higher rates of AVN. Moreover, long-term functional and radiological deterioration of the hip is higher after open reduction than closed reduction. Lowest rates of AVN are reported after traction followed by closed reduction compared with exteporaneous reduction or open reduction, thanks to progressive reduction of the hip. Finally, mention should be made of the cost of the treatment. Petit-Morel’s protocole is expensive, both because of the duration of stay in the hospital, and by indirect costs as parent adaptation of its work during the treatment. The cost of open reduction is lower. However, considering the prooved better results of the closed method, requiring lower rates of further surgical procedure, we think that this method is the one to be promoted for treatment of CDH in children between 1 and 5 years old.

Purpose of the study: The aim of this study was to evaluate the results of the repeated soft tissue release for recurrent postoperative idiopathic congenital talipes equinovarus. There is no real consensus on the appropriate therapeutic option.

Materials and Methods: Fifty two patients (74 feet) underwent revision surgery performed by our senior surgeon between 1974 and 2001. One, two or three soft tissue release procedures were performed on 59, 12 and 3 feet respectively. Mean age at the time of the revision surgery was 5.7 years (range 15m-14y). Triple deformity (varus, equinus, adductus) was found in 46 feet, while 28 feet had one dominant deformity. The operation consisted of complete release of the soft tissues in 26 feet and partial release in 48. Subtalar release was indicated in 21 feet. Lichtblau osteotomy was performed in 48 feet. The clinical and radiological outcome was assessed using the Ghanem and Seringe scores recorded before surgery and at last follow-up.

Results: Mean follow-up was 11 years (range 4–30). Complications included overcorrection in valgus (n=6) and recurrence (n=8). The anatomic correction was highly significant. Dorsoplantar X-rays show the improvements in the mean talocalcaneal divergence (18–21°), the mean talus-first metatarsal angle (reduced from 28° to 4°), and the calcaneus-fifth metatarsal angle (reduced from 20° to 2°). The average of tibiocalcaneal angle in lateral view increased from 1° to 10° and the average of calcaneal incidence from 6° to 9°. At last follow-up, outcome was considered as ‘excellent’ in 29% and ‘good’ in 42% of the cases. We had ‘fair’ results in 14 feet (19%) because of poor functional results in one third and anatomical defects in two-thirds of them. The outcome was considered ‘poor’ in seven feet (10%), which was due to significant anatomical defects. Triple arthrodesis was needed in seven feet after skeletal maturity.

Discussion and Conclusion. Repeated soft tissue release provides an effective means for correcting anatomical anomalies caused by recurrent postoperative talipes equinovarus. The mid-term results are however affected by functional limitations characterised by decreased range of motion and joint pain, particularly in ankle joint. Excessive subtalar release raises the risk of valgus overcorrection. A splint worn at night may be helpful for preventing the recurrence.

The results of further soft-tissue release of 79 feet in 60 children with recurrent idiopathic congenital talipes equinovarus were evaluated. The mean age of the children at the time of re-operation was 5.8 years (15 months to 14.5 years). Soft-tissue release was performed in all 79 feet and combined with distal calcaneal excision in 52 feet. The mean follow-up was 12 years (4 to 32). At the latest follow-up the result was excellent or good in 61 feet (77%) according to the Ghanem and Seringe scoring system. The results was considered as fair in 14 feet (18%), all of whom had functional problems and eight had anatomical abnormalities. Four feet (5%) were graded as poor on both functional and anatomical grounds.

The results were independent of the age at which revision was undertaken.

The treatment of developmental dysplasia of the hip diagnosed after the first year of life remains controversial. A series of 36 children (47 hips), aged between one and 4.9 years underwent gradual closed reduction using the Petit-Morel method. A pelvic osteotomy was required in 43 hips (91.5%). The patients whose hips did not require pelvic osteotomy were among the youngest. The mean age at final follow-up was 16.1 years (11.3 to 32). The mean follow-up was 14.3 years (10 to 30).

At the latest follow-up, 44 hips (93.6%) were graded as excellent or good according to the Severin classification. Closed reduction failed in only two hips (4.3%) which then required open reduction. Mild avascular necrosis was observed in one (2.1%).

The accuracy of the reduction and associated low complication rate justify the use of the Petit-Morel technique as the treatment of choice for developmental dysplasia of the hip in patients aged between one and five years.

Rocker bottom deformity may occur during the conservative treatment of idiopathic congenital clubfoot. Between 1975 and 1996, we treated 715 patients (1120 clubfeet) conservatively. A total of 23 patients (36 feet; 3.2%) developed a rocker bottom deformity. It is these patients that we have studied. The pathoanatomy of the rocker bottom deformity is characterised by a plantar convexity appearing between three and six months of age with the hindfoot equinus position remaining constant. The convexity initially involves the medial column, radiologically identified by the talo-first metatarsal angle and secondly by the lateral column, revealed radiologically as the calcaneo-fifth metatarsal angle. The apex of the deformity is usually at the midtrasal with a dorsal calcaneocuboid subluxation. Ideal management of clubfoot deformity should avoid this complication, with adequate manipulation and splinting and early Achilles’ percutaneous tenotomy if plantar convexity occurs.

Adequate soft-tissue release provides satisfactory correction for rocker bottom deformity. However, this deformity requires more extensive and complex procedures than the standard surgical treatment of clubfoot. The need for lateral radiographs to ensure that the rocker bottom deformity is recognised early, is demonstrated.