Original Research


https://doi.org/10.5005/jp-journals-10066-0094
Indian Journal of Physical Medicine and Rehabilitation
Volume 31 | Issue 4 | Year 2020

Comparative Study of Different Incision Methods for Posteromedial Soft Tissue Release of Idiopathic Club Foot in Children: An Institutional Study


Jagannatha Sahoo

Department of PMR, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Corresponding Author: Jagannatha Sahoo, Department of PMR, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India, Phone: +91 9437081814, e-mail: pmr_jagannath@aiimsbhubaneswar.edu.in

How to cite this article Sahoo J. Comparative Study of Different Incision Methods for Posteromedial Soft Tissue Release of Idiopathic Club Foot in Children: An Institutional Study. Indian J Phys Med Rehab 2020;31(4):80–85.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Introduction: Various surgical procedures and techniques have been described for club foot to achieve the goal of complete anatomic restoration. As in any procedure involving multiple anatomic steps, exposure is key to a successful comprehensive release. In this study, we were doing posteromedial soft tissue release (PMSTR) in club foot through different incisions. The better approaches for the PMSTR were found out by clinical, footprint radiological evaluation.

Materials and methods: This prospective study of 35 patients (57 feet) with idiopathic club foot presenting to the Balaji Institute of Surgery Research and Rehabilitation for the disabled from October 2007 to May 2009 were treated with PMSTR by three exposures. Three groups were formed as per exposure. Clinical evaluation for deformity and radiological evaluation was done in each group.

Results: In the case of single, double, and hemi-Cincinnati procedures, average incision lengths were 8.3, 10.7, and 6.1 cm, respectively. Among all the post-operated feet, 25, 20, and 35.2% had %3C;10° of dorsiflexion as well as 20, 15, and 5.9% of feet had <15° plantar flexion in case of double, single, and hemi-Cincinnati incision, respectively. In comparison with other incisions, the hemi-Cincinnati incision had less postoperative pain, better function, and less complication rate.

Conclusion: Wound healing was satisfactory in the hemi-Cincinnati incision. The scar was well concealed under the strap of the sandal. In the future, the hemi-Cincinnati incision will be time-demanding in the case of a club foot.

Keywords: Club foot, CTEV, Hemi-Cincinnati incision, Posteromedial soft tissue release.

INTRODUCTION

Talipes equinovarus was first introduced into the medical literature by Hippocrates in 400 BC. 1 The deformity known as club foot is probably most common (1–2 in 1,000 live births) congenital dysplasia of all musculoskeletal tissues distal to the knee. The initial treatment of club foot is nonoperative. Although some success with nonsurgical management has been reported in the literature, results have often been less than optimal. This has led to a trend towards surgical intervention. Various surgical procedures and techniques have been described to achieve the goal of complete anatomic restoration. As in any procedure involving multiple anatomic steps, exposure is key to a successful comprehensive release. There is no better place to begin emphasis of exposure.

In this study, we were doing posteromedial soft tissue release (PMSTR) in the club foot through different incisions mentioned below. The better approaches for the PMSTR can be found out by clinical evaluation, footprint, and radiological evaluation. Analysis of data was carried out to answer the following questions:

Additional data from this study may stimulate the surgeon for emphasizing over skin incisions to get an uncomplicated plantigrade foot.

MATERIALS AND METHODS

This prospective study of 35 patients (57 feet) with idiopathic club foot presenting to the Balaji Institute of Surgery Research and Rehabilitation for the disabled (BIRRD) from October 2007 to May 2009 were treated with PMSTR by different exposures. All patients with idiopathic club foot requiring PMSTR were divided into three groups as per incisions.

Group-I consisted of 20 feet: PMSTR was done through the double incision by using a medial incision on the medial side of the foot and one curvilinear incision around the tendon Achilles on the medial side (Fig. 1).

Group-II consisted of 20 feet: PMSTR was done through a single incision described by Turco (Fig. 2).

Fig. 1: Double incision

Fig. 2: Hemi-Cinccinati incision

Fig. 3: Turco’s single incision

Group-III consisted of 17 feet: PMSTR was done through a hemi-Cincinnati incision (Fig. 3).

Inclusion Criteria

All the patients aged between 1 year and 3 years with idiopathic clubfoot for PMSTR surgery during the specified period were included in this study.

Exclusion Criteria

  • Patients who had only equines angulations of the hindfoot.
  • Patients ages <1 and %3E;3 years were excluded.
  • Patients having any other associated deformities.
  • CTEV due to other neurological causes.

The surgical release had addressed all of the pathoanatomic structures including a complex release of the hindfoot and midfoot. Such as the Achilles tendon was lengthened by Z-plasty and the tibialis posterior tendon and flexor digitorum longus (FDL) were lengthened by Z-plasty. Following the FDL, flexor hallucis longus (FHL) was identified and tenotomized. The abductor hallucis muscle was sectioned. The posterior capsules of the ankle and subtalar joint, entire medial capsule of subtalar joint, superficial deltoid ligament, and talonavicular capsule were divided. In all the groups, primary wound repair was undertaken with a two-layer closure. Above knee, the cast was applied in 90° of knee flexion with the foot held in near plantigrade for 2 weeks. The sutures were removed under anesthesia on the 14th postoperative day and the foot was manipulated into maximum dorsiflexion-eversion and maintained with a fresh groin to toe cast for 2 months. Clinical evaluation for deformity and radiological evaluation was done in the groups. Statistical analysis was expressed in mean, percentage, and ratios. Results were expressed in an appropriate bar, pie, and tables.

Table 1: Length of the incision
Type of surgery Anterior third Middle third Posterior third Total length
Double incision 3.6 cm 4.7 cm   8.3 ± 3 cm
Single incision (Turco) 3.6 cm 3.5 cm 3.6 cm 10.7 ± 2 cm
Hemi-Cincinnati incision 2.4 cm 1.3 cm 2.4 cm   6.1 ± 2 cm

OBSERVATIONS AND RESULTS

In the evaluation of the clinical, functional, cosmetic, and radiological outcomes, the following criteria were taken into account.

Length of the Incision

In the case of single, double, and hemi-Cincinnati procedures, average incision lengths were 8.3, 10.7, and 6.1 cm, respectively (Table 1).

Number of Manipulations Required after Surgery

Post-PMSTR surgery, 1–2 times after manipulation required in all types of the incision.

Foot Print

Though footprints are not so reliable, out of 57 feet 52 feet got uniform and 5 feet had nonuniform footprints due to persisting deformity (Fig. 4 and Table 2).

Fig. 4: Footprint

Table 2: Footprint
Preoperative Postoperative
Double Turco Hemi-Cincinnati
Uniform 02 18 17 17
Nonuniform 55   2   3   0
Table 3: Appearance of foot
Appearance of hind part of foot Double incision Single-incision Hemi-Cincinnati
Hindfoot equines Normal/mild 14 15 10
Moderate   6   5   7
Severe   0   0   0
Hindfoot varus Normal/mild 10 11 13
Moderate   8   7   4
Severe   2   2   0
F adduction Normal/mild 16 15 14
Moderate   4   5   3
Severe   0   0   0
Inversion Normal/mild 12 14 15
Moderate   7   6   2
Severe   1   0   0
Equines Normal/mild 14 15 16
Moderate   6   5   1
Severe   0   0   0
Foot knee alignment Double incision Single incision Hemi-Cincinnati
Neutral 20 20 17
Not aligned   0   0   0

Appearance of Feet

Equines persisting in seven (41%) cases of the hemi-Cincinnati incision whereas six (30%) and five (25%) feet had equines in case of double incision and single incision, respectively. Four (23%) children had hindfoot varus in the case of the hemi-Cincinnati incision whereas eight (40%) and seven (35%) children had hindfoot Varus in case of double incision and single incision, respectively. Four, five, and three children had forefoot adduction in case of double, single, and hemi-Cincinnati incision, respectively. Eight, six, and two children had forefoot inversion in case of double, single, and hemi-Cincinnati incision, respectively. Six, five, and one children had forefoot equines in case of double, single, and hemi-Cincinnati incision, respectively (Table 3).

Fig. 5: Postoperative pain

Fig. 6: Postoperative dorsiflexion achieved

Functional Result

Eight feet (8) in case of double incision, eight feet (8) in case of single incision, and three feet (3) in case of hemi-Cincinnati incision had postoperative pain (Fig. 5).

Dorsiflexion of Foot

Among all the postoperated feet, 25% in case of double incision, 20% in case of single incision, and 35.2% in case of hemi-Cincinnati incision had %3C;10° of dorsiflexion. But later all the cases had come to near normal plantigrade position (Fig. 6).

Plantar Flexion

20, 15, and 5.9% of feet had <15° plantar flexion, in case of double, single, and hemi-Cincinnati incision, respectively (Fig. 7).

Fig. 7: Postoperative plantar flexion achieved

Fig. 8: Increased width of scar of different incisions

Fig. 9: Hypertrophy of scar of different incisions

Fig. 10: Adherence of scar of different incisions

Table 4: Complications
Incision Skin necrosis Abscess/infection Gaping of suture Revision surgery/additional surgery
Double 6 2 2 3
Single 7 4 5 4
Hemi-Cincinnati 2 1 2 3

Complications

Skin Necrosis

Out of 57 feet, six feet, seven feet, and two feet had skin necrosis in case of double, single, and hemi-Cincinnati incision type, respectively (Table 4).

Increased Width of Scar

Increased width scar noted in the posterior part of incisions irrespective of incision type. 20, 25, and 11% foot had an increased width of the scar in case of double, single, and hemi-Cincinnati incision type, respectively. No scar hypertrophy was found in the hemi-Cincinnati incision, whereas 25% each in case of double, single incision type. 20, 15, and 6% scar adhesion were seen in the anterior aspect of the incision in double, single, and hemi-Cincinnati incisions. Whereas, in double and single incision types, 30% of cases shown posterior scar adhesion (Figs 8 to 10).

Radiological Findings

There was a wide range of variation seen in the radiographic evaluation of the angles. But postoperative angles of all the three groups came to a normal range without any statistical significance (Table 5).

DISCUSSION

Grade of the Foot

In our study, we had come across 66% of severe grade 2 club foot in the age group of one to three. 3 Nordin et al. had documented 61% of cases were stiff/severe grade foot among the club foot population. In 1995, 2 Dimeglio et al. had reported 35% severe grade and 30% moderate grade of club foot.

Length of Incision

In our study, our average applied incision length was 8.3, 10.7, and 6.1 cm, in the case of single, double, and hemi-Cincinnati type of incision, respectively. 4 Mountney et al. had reported the median scar length of Cincinnati incision was 6.5–11.5 cm and width was 1–4 cm. In our study, the scar length remains within the proposed length.

Table 5: Radiological findings
Radiological angle Views Preoperative Postoperative
Double Single Hemi-Cincinnati
Talocalcaneal AP 16.14 27.11 28.45 26.5
Lateral 14.66 23.15 24.66 25.65
Tibiocalcaneal Lateral 49.48 86.77 85.23 82.33
Talo-1st metatarsal AP 50.88   6.7   8.98 12.96

Persisting Hind Foot Deformity

Equines persisting in seven (41%) cases of hemi-Cincinnati incision whereas six (30%) and five (25%) feet had equines in case of double incision and single incision, respectively. Four (23%) children had hindfoot Varus in case of hemi-Cincinnati incision, whereas eight (40%) and seven (35%) children had hindfoot Varus in case of double incision and single incision, respectively. 5 Hussain et al. in the case of modified Turco method reported that the heel was in Varus in 7 (10%) patients while neutral in the remaining 45 (64.29%) patients.

Persisting Forefoot Deformity

In our study, four, five, and three children had forefoot adduction in case of double, single, and hemi-Cincinnati incision, respectively. Eight, six, and two children had forefoot inversion in case of double, single, and hemi-Cincinnati incision, respectively. Six, five, and one children had forefoot equines in case of double, single, and hemi-Cincinnati incision, respectively. 5 Hussain et al. in case modified Turco procedure described the forefoot was in neutral position in 40 (57.14%) patients, with 5° adduction in 6 (8.57%) patients and was in %3E;5° adduction in the remaining 7 (10%) patients.

Postoperative Functional Result

Eight (40%) feet in case of double incision, eight (40%) feet in case of single incision, and three (17.6%) feet in case of hemi-Cincinnati incision had postoperative pain. 6 Simons and Milwaukee published 50% of cases had a satisfactory result in case of double incision and 72% of cases had satisfactory result in case of complete sub-talar release by single incision.

Range of Movement of Ankle

In our study, 25, 20, and 35.2% of cases had <10° of dorsiflexion in case of double, single, and hemi-Cincinnati incision, respectively. But all the cases had come nearly normal plantigrade. 20, 15, and 5.9% feet had <15° plantar flexion in case of double, single, and hemi-Cincinnati incision, respectively. 7 Christopher et al. in their study observed that gross foot motion of the surgically treated clubfoot was generally less than that of the contralateral normal foot. The mean SD range of dorsiflexion/plantar flexion of the nine surgically treated clubfeet (32.5 ± 9.5°) was 19% less (p = 0.028) than that observed in the nine contralateral normal feet (40.1 ± 5.3°). 5 Hussain et al. in case modified Turco procedure described that the mean angle of maximum dorsiflexion was 15° (range: 10–25°) and of plantar flexion 45° (range: 43–59°) in 43 of the patients, while maximum dorsiflexion was 14° (range: 10–18°) in 8 patients and the maximum plantar flexion was 19° in 1 patient and 16° (range: 14–20°) in 8 patients.

Radiological Evaluation

There was a wide range of variation seen in the radiographic evaluation of the angles. But postoperative angles of all three groups came to a normal range without any statistical significance. 6 George documented that there was no significant shift out of the normal range of angular measurement postoperatively in different methods. 8 Josheph had reported a wide range of variation from 10 to 25 in the radiological angle measurement both preoperatively as well as postoperatively.

Skin Complication

In our study, 5.88, 20, and 10% skin complications were there in the case of hemi-Cincinnati, single, and double incision, respectively. 9 Hsu et al. documented that in the Cincinnati cohort, 6.9% wound complications and Turco cohort 19.2% complications were identified.

Reoperation

Three (15%), four (20%), and three (17.7%) cases had required a second procedure for final correction in case of double, single, and hemi-Cincinnati incision. As per 10 Hogervorst et al. in their study recorded a 23.1% reoperation rate during posterior procedures in club foot.

Incision Complication

In all the incision types, there was increased width of the scar on the posterior incision. Which is 20, 25, and 11% in the case of double, single, and hemi-Cincinnati incision type, respectively. 25% of cases each in case of double and single incision type shown scar hypertrophy, whereas no scar hypertrophy was seen in case of the hemi-Cincinnati incision. 20, 15, and 6% scar adhesion were seen in the anterior aspect of the incision in double, single, and hemi-Cincinnati incisions type. Whereas in 30% of cases both on double and single incisions, posterior adhesion of scar was seen. 8 Joseph et al. had reported 21.4, 50, and 64.3% of cases had an increase in width of scar in anterior 1/3rd, middle 1/3rd, and posterior 1/3rd of the incision, respectively. 19, 33.3, and 38.1% had hypertrophy of scar seen in the anterior 1/3rd, middle 1/3rd, and posterior 1/3rd of the incision, respectively. 11.9, 14.3, and 26.2% had scar adhesion seen in anterior 1/3rd, middle 1/3rd, and posterior 1/3rd of the incisions.

CONCLUSION

Many controversies in the treatment of idiopathic talipes equinovarus exist in the literature, such as the role of operative vs nonoperative treatment, optimum age for surgery, postoperative immobilization regimen, and type of incision.

In our study, all the criteria for evaluating the suitability of the hemi-Cincinnati incision, modified Turco incision and double incision for performing the PMSTR were studied and the hemi-Cincinnati incision was found to be satisfactory. The hemi-Cincinnati incision gave adequate access to release the structures for PMSTR as well as Turco’s incision. However, when a lateral release or complete subtalar release is needed, the incision would have to be extended across to the lateral side in case of the hemi-Cincinnati incision. This was the limitation of the hemi-Cincinnati incision.

Wound healing was satisfactory in the hemi-Cincinnati incision. The scar is well concealed under the strap of the sandal. Our study supports the use of hemi-Cincinnati incision in PMSTR for treating idiopathic club foot. In the future, the hemi-Cincinnati incision will be time-demanding in the case of club foot. But there was some limitation of the study. It was an institutional-based study. It lacked randomization and blinding procedures for case selection. This study had the limitation of a short duration study.

However, this study will stimulate the surgeons for emphasizing over skin incisions to get an uncomplicated plantigrade foot.

CARRY HOME MESSAGE

Acknowledgments

I acknowledge the guidance of my director and helps of my all the staff members of BIRRD(T) Hospital, Tirupati for completing my work.

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