Residual & Recurrent Deformity

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