Conditions
1. Dynamic supination - weak peronei
2. Metatarsus adductus with curved lateral border of foot
3. Tight T achilles
4. Residual or recurrent equinovarus
5. Overcorrection / valgus
Options
Soft tissue procedures
Bony procedures
Dynamic Supination
Anatomy
Tibialis anterior inserts into base first MT and medial cuneiform
Options
Split tibialis anterior tendon transfer / SPLATT
Full tibialis anterior tendon transfer / TATT
Both usually in combination with T achilles tenotomy
SPLATT
Indication
- < 3
- for dynamic supination / early recurrence
- correct with ponsetti cast 3/52 first
- transfer will only hold correction
Method
- supine, tourniquet
- 2 cm incision over base first metatarsal
- harvest lateral half of T anterior
- divide with knife distally and take off bone
- 2 cm proximal incision above extensor retinaculum
- insert tendon forcep under extensor retinaculum
- grasp lateral half of tendon
- pull proximally out of wound
- tendon will tear nicely along midsubstance
- 2 cm lateral wound over P brevis insertion into base 5th metarsal
- make tunnel under fat between lateral and proximal wound
- pass tendon forceps, transfer T anterior subcutaneously
- Pulvetaft weave to P brevis
- make split in P brevis, pass T anterior through
- tension tendon with foot held reduced / pronated
- suture onto itself multiple times
- Ponseti cast for 6/52
TATT
Indication
- > 3
- for dynamic supination / early recurrence
- need to have bony ossification lateral cuneiform
- indicated in 7 - 15% of cases
Method
- harvest full T anterior as above
- 3.5 mm drill hole through lateral cuneiform
- tie over button
Metarsus Adductus
Algorithm
- depends on age
- depends if deformity in metatarsals or tarsus
Options
1. ST release
- abductor hallucis brevis + plantar fascia
- young < 5
2. MT osteotomies
- deformity distal to navicular
3. Lateral column shortening and medial ST release
- medial soft tissue release and medial column lengthening
- shortening of the lateral column - decancellation of cuboid / closing wedge osteotomy
4. TDRO / Tibial derotation osteotomy
Hindfoot EquinoVarus
Issues
Later age > 5
- soft tissue procedures insufficient
- bony procedures required
Options
1. Lateral sliding calcaneal osteotomy / lateral closing wedge osteotomy
- varus
2. Wedge tarsectomy
- correction of equinus
3. Talectomy
- rarely indicated
- arthrogryposis or severe neuralgic clubfoot
- resect cuboid also to maintain balance of columns
4. Ilizarov
- excellent salvage
- correction of equinovarus
Hindfoot valgus
Aetiology
Overcorrection
Options
Lambrinudi - for fixed equinus in patients 10 years or older
Triple arthrodesis
- good correction of all elements of club foot
- used in the late presenting child or late recurrence
- should not be used before foot has stopped growing because it shortens the foot / stops growth