Neglected clubfoot deformity in a 4 year old Mongolian boy

Soo-Sung Park M.D

Department of Orthop. Surgery

AMC Children’s hospital

Seoul KOREA

IntroductionIntroduction

Late-presenting clubfoot deformity is rarely found, but

still common in developing countries

Non-op tx. usually fails and is no longer an option

Surgery is necessary but can lead to problems of poor

wound healing and infection

Variety of skin incision & rotation flaps

Staged surgery – tissue expanders, partial wound closure with healing

by secondary intention, casting with suboptimal correction after surgery

followed by serial manipulation

Ilizarov technique w/ or w/o preliminary surgery

Case Case (4Y/M)(4Y/M)

C.C: nelected clubfoot deformities P/E: Rigid Talipes equinocavovarus deformity (Lt>Rt)

OperationOperation

Rt : SSTR(achilles tenotomy, TPAL, PF, AHR) + Ilizarov inst.

Lt (Staged Op): SSTR(achilles tenotomy, TPAL, PF, AHR)

Ilizarov instrumentation 1wk later

6 weeks after deformity correction 6 weeks after deformity correction

Removal of EF & CAST Removal of EF & CAST (DC 6w)(DC 6w)

Cast for 3 weeks AFO (day & night)

Post Op 3M before leaving to Mongolia Post Op 3M before leaving to Mongolia

Discussion Discussion (recent papers)(recent papers)

Ponseti Method (JBJS-B 2007)

17 children (24 feet), mean age 3.9 yrs. cast for 3.9 mos.

Painless plantigrade foot in 16 feet ; effective method

But 7/16 recurred, 8 feet failed

Circumferential release & fasciocut. flap (JPO-B 2007)

Case report

Single staged tech. w/ double zigzag incision Age 6M~4Y, very safe and cost-effective method

(J of Foot & Ankle Surg. 2006)

Discussion Discussion

Ilizarov External Fixator Role of soft tissue release before or after correction of the

deformity ?

Ilizarov inst. alone w/o preliminary surgery

• ischemic necrosis after preliminary extensive dissection

(Tachdjian’s Pediatric orthop. 4th Ed.)

Ilizarov External Fixator Ilizarov inst. w/ minimal release

• recurrent arthrogrypotic clubfoot after prev. PMR

Medial TN joint release ± TP tenotomy, PC

(Choi el al. JBJS-B 2001)

• Neglected clubfoot in pts. with mean age of 19 (5~39) yrs.

Limited soft tiss. dissection achilles tenot., plantar fasciotomy

; high recurrence(50%) and ankylosis(74%)

; reduce risk of NV Cx. & avoid excessive shortening of foot

(Foot & Ankle international 2006)

DiscussionDiscussion

ConclusionConclusion STAGED Operation; SSTR followed by Ilizarov inst. is thought to be

a useful method in a 4 yrs old boy

Based on literature review, Ponseti method also seems to be a

effective and low-cost strategy in older children

Thank you for your attention