Congenital Clubfoot (Talipes Equinovarus)
1. Definition—Deformity
a. Congenital cavus, adductus, varus, and equinus deformities that are not passively correctable (Figure 5-9)
b. Most are idiopathic, though some are associated with myelomeningocele, arthrogryposis, and other syndromes and disorders.
Figure 5-9. A. An infant with congenital clubfeet with the obvious deformities of cavus, adductus, varus/inversion, and equinus. (From Mosca VS. The Foot. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1153, Figure 29-1.) B. AP radiograph shows the severe inversion and adductus. C. Lateral radiograph shows the severe equinus, cavus, and adductus. The hindfoot is pointing to the left and the forefoot is pointing to the right.
2. Elucidation of the segmental deformities
a. Forefoot—pronated
b. Midfoot—adducted
c. Hindfoot—varus/inverted
d. Ankle—plantar flexed (equinus)
3. Imaging
a. Not necessary for diagnosis
b. Maximum dorsiflexion/abduction/eversion AP and lateral of foot (see Figure 5-9)—indicated to:
i. confirm residual deformities preoperatively after failing nonoperative treatment
ii. confirm apparent or obvious recurrent deformities after nonoperative or operative treatment, particularly when contemplating further nonoperative or operative treatment
iii. confirm deformity correction following operative treatment
c. Hip screening imaging for idiopathic clubfoot is not indicated—no documented association of the two deformities
4. Natural history
a. Persistence of deformity with pain, functional disability, and inability to wear normal shoes
5. Nonoperative treatment
a. Ponseti method of serial manipulation and long-leg casting, along with percutaneous Achilles tenotomy in most cases (well described in Clubfoot: Ponseti Management, LT Staheli, editor. www.Global-HELP.org monograph)
i. It should be successful in at least 85% of idiopathic cases.
ii. It should be successful in a smaller percentage of nonidiopathic (arthrogryposis, myelomeningocele) cases, but definitely worth the effort.
6. Operative indications
a. Failure to achieve full deformity correction with nonoperative treatment
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Percutaneous tendo-Achilles tenotomy (see Chapter 7)—perform this when there is less than 10° of ankle dorsiflexion after the cavus, adductus, and varus have been fully corrected with serial casting in an infant or very young child
i. This is a complete tenotomy, not a lengthening.
ii. It should be performed when there is little (or no) expectation that a posterior ankle capsulotomy will be required, which is the assumption in most babies up to at least 2 years of age.
• If a percutaneous tendo-Achilles tenotomy is concurrently converted to an open ankle capsulotomy, the gap in the tendon may not heal and remodel as well, and with as good preservation of excursion, as with percutaneous Achilles tenotomy alone.
iii. If the need for a posterior capsulotomy is anticipated, an open tendo-Achilles lengthening should be performed. If a capsulotomy is then deemed unnecessary, there is no measureable disability from having performed a formal tendo-Achilles lengthening.
b. Posterior release (see Chapter 7)—perform this in an older child in whom there is less than 10° of dorsiflexion after the cavus, adductus, and varus have been fully corrected with serial casting and in whom there is less than 10° of dorsiflexion after TAL
c. À la carte partial-to-complete circumferential release (see Chapter 7)—perform this if there are residual cavus, adductus, and/or varus deformities in addition to an equinus deformity
i. The McKay procedure is the surgical analog of the Ponseti method, in that it embraces the pathoanatomy ascribed to by Ponseti.
ii. In non- idiopathic clubfoot (myelomeningocele, arthrogryposis), the tendons are released rather than lengthened, because of the very high recurrence rate in these feet.
Figure 5-10. Untreated clubfeet in a 2-year-old boy who was adopted from a developing country by parents in the United States.
Neglected Clubfoot
1. Definition—Deformity
a. Untreated congenital equino-cavo-adducto-varus in an older child or adolescent (Figures 5-10 and 5-11)
2. Elucidation of the segmental deformities
a. Forefoot—pronated
b. Midfoot—adducted
c. Hindfoot—varus/inverted
d. Ankle—plantar flexed (equinus)
3. Imaging
a. Standing AP and lateral of foot
b. Standing AP and lateral of ankle
4. Natural history
a. Persistence of deformity with pain, functional disability, and inability to wear normal shoes
5. Nonoperative treatment
a. Ponseti method of serial manipulation and long-leg casting, along with percutaneous Achilles tenotomy in most cases (well described in Clubfoot: Ponseti Management, LT Staheli, editor. www.Global-HELP.org monograph), starting in children up to at least 5 to 6 years of age (and possibly older)
i. Should be successful less often than when initiated in infants, with the rate of success inversely proportional to age at initiation
6. Operative indications
a. Failure or age-inappropriateness of serial casting to correct one or more of the clubfoot segmental deformities
b. Pain, shoe-fitting difficulties, dysfunction
Figure 5-11. Neglected clubfeet in an 18-year-old immigrant to the United States. The natural history of clubfoot is clear: persistence of deformities, inability to wear shoes, ostracism, poverty, and eventual pain.
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Percutaneous tendo-Achilles tenotomy (see Chapter 7)—perform this when there is less than 10° of ankle dorsiflexion after the cavus, adductus, and varus have been fully corrected with serial casting in a young child
i. This is a complete tenotomy, not a lengthening.
ii. It should be performed when there is little (or no) expectation that a posterior ankle capsulotomy will be required.
• If a percutaneous tendo-Achilles tenotomy is concurrently converted to an open ankle capsulotomy, the gap in the tendon may not heal and remodel as well, and with as good preservation of excursion, as with percutaneous Achilles tenotomy alone.
iii. If the need for a posterior capsulotomy is anticipated, an open tendo-Achilles lengthening should be performed. If a capsulotomy is then deemed unnecessary, there is no measureable disability from having performed a formal tendo-Achilles lengthening.
b. Posterior release (see Chapter 7)—perform this if there is less than 10° of dorsiflexion after the cavus, adductus, and varus have been fully corrected with serial casting and the tendo-Achilles has been lengthened
c. À la carte partial-to-complete circumferential release (see Chapter 7)—perform this if there are residual cavus, adductus, and/or varus deformities in addition to an equinus deformity
i. The McKay procedure is the surgical analog of the Ponseti method, in that it embraces the pathoanatomy ascribed to by Ponseti.
ii. In non- idiopathic clubfoot, the tendons are released rather than lengthened, because of the high recurrence rate in these feet.
d. À la carte partial-to-complete circumferential release (see Chapter 7) along with one or more of the following procedures—perform one or more of these additional procedures if there are residual cavus, adductus, and/or varus deformities in addition to an equinus deformity, and structural metatarsus adductus (MA), fixed hindfoot varus with a long lateral column of the foot, and/or muscle imbalance
i. Medial column lengthening for structural MA
• Medial cuneiform opening wedge osteotomy (see Chapter 8)
ii. Lateral column shortening for structural MA (see Management Principle #18, Chapter 4)
• Closing wedge osteotomy of the cuboid (see Chapter 8)
iii. Lateral column shortening for resistant hindfoot varus/inversion with a long lateral column of the foot (see Management Principle #18, Chapter 4)
• Calcaneocuboid resection/fusion (see Chapter 8)
• Lichtblau resection of the anterior calcaneus (see Chapter 8)
• Closing wedge osteotomy of the anterior calcaneus (see Chapter 8)
iv. Posterior calcaneus lateral displacement osteotomy (see Chapter 8)
v. Anterior tibialis tendon transfer to lateral (3rd) cuneiform (see Chapter 7)
e. Triple arthrodesis (see Chapter 8)—perform this if there are no other options for correcting the deformities because of severity and/or rigidity, or because of existing degenerative arthritis of the subtalar joint (see Management Principle #13, Chapter 4)
f. Gradual deformity correction with external fixation (not elucidated in this book)
Severe, Rigid, Resistant Arthrogrypotic Clubfoot in an Infant or Young Child
1. Definition—Deformity
a. Severe, rigid, resistant congenital clubfoot in an infant with arthrogryposis (Figure 5-12)
b. More flexible congenital clubfoot deformities in infants with arthrogryposis should be treated exactly like idiopathic congenital clubfoot (see this chapter).
2. Elucidation of the segmental deformities
a. Forefoot—pronated
b. Midfoot—adducted
c. Hindfoot—varus/inverted
d. Ankle—plantar flexed (equinus)
3. Imaging
a. Maximum dorsiflexion/abduction/eversion AP and lateral of foot—indicated to:
i. confirm residual deformities preoperatively after failing nonoperative treatment
4. Natural history
a. Persistence of deformity with pain, functional disability, and inability to wear normal shoes
5. Nonoperative treatment
a. Ponseti method of serial manipulation and long-leg casting
6. Operative indications
a. Little (or no) improvement in the severe, rigid clubfoot deformities in an infant with arthrogryposis after a long series of casts, with the presumption that it would be challenging to stretch the posterior ankle skin and align the foot in the ankle mortis even if a talectomy were performed (Figure 5-12).
i. The expectation is that, following surgery, the deformities will be improved (Figure 5-13) and serial casting will be reinitiated. The deformities might then be corrected with further serial casting or improved enough with further serial casting that conventional á la carte partial-to-complete circumferential release will be successful.
Figure 5-12. Severe, rigid, resistant arthrogrypotic clubfoot. A–D after 14 casts: A. Top photo. B. AP x-ray. C. Medial photo with maximum dorsiflexion. D. Lateral x-ray with maximum dorsiflexion.
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Limited, minimally invasive soft tissue releases for clubfoot (see Chapter 7), as an incidental event to enable more effective ongoing serial casting (Figure 5-13)
i. Percutaneous tendo-Achilles tenotomy
ii. Limited open plantar fasciotomy
iii. Limited open posterior tibialis tenotomy
iv. Percutaneous tenotomies of FHL and FDL to toes 2-to 5
b. Talectomy—perform this for failure of “a” (see Chapter 8)
Figure 5-13. A. One week after percutaneous tenotomies of tendo-Achilles and long toe flexors, as well as mini-open plantar fasciotomy and posterior tibialis tenotomy in the foot in Figure 5-12. B to E after four more casts: B. Simulated standing top photo. C. Simulated standing AP x-ray. D. Medial photo with maximum dorsiflexion. E. Lateral x-ray with maximum dorsiflexion. F to H one year later, following two serial casts for minor recurrence: F. Standing top photo. G. Medial photo with maximum dorsiflexion. H. Lateral x-ray with maximum dorsiflexion.
Corrected Congenital Clubfoot (Talipes Equinovarus) with Anterior Tibialis Overpull
1. Definition—Deformity
a. Structurally corrected clubfoot with stronger anterior tibialis than peroneus tertius and relatively weak peroneus longus resulting in a dynamic supination deformity of the foot (Figure 5-14)
2. Elucidation of the segmental deformities
a. None
3. Imaging
a. Standing AP and lateral of foot
i. to confirm full correction of deformities
ii. to ensure adequate size of the ossification center of the lateral (3rd) cuneiform to accept the anterior tibialis tendon
4. Natural history
a. Instability of gait with frequent inversion injuries
b. Pain and exaggerated callus formation along the plantar–lateral border of the foot
5. Nonoperative treatment
a. Peroneus tertius strengthening exercises. Efficacy is not documented.
b. Serial casting to correct any residual or recurrent deformities prior to tendon transfer surgery.
6. Operative indications
a. Exaggerated dynamic supination of a well-corrected and flexible clubfoot during the swing phase of the gait cycle
i. that creates instability of gait and/or excessive weight-bearing on the plantar–lateral aspect of the foot
ii. after failure of strengthening exercises to balance the strength of the anterior tibialis and peroneus tertius muscles
iii. in which there is a large ossification center of the lateral (3rd) cuneiform
Figure 5-14. Assess muscle balance in a clubfoot by asking the child to dorsiflex the foot, or by stimulating the plantar aspect of the foot. A. Normal muscle balance between the anterior tibialis and the peroneus tertius. The plane of the MT heads is perpendicular to the tibial shaft. B. Relative overpull of normal anterior tibialis vs. weak peroneus tertius and longus in a child with a clubfoot that has excellent deformity correction and flexibility. The plane of the MT heads is supinated in relation to the tibial shaft.
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Anterior tibialis tendon transfer to lateral (3rd) cuneiform (see Chapter 7)
Recurrent/Persistent Clubfoot Deformity
1. Definition—Deformity
a. Recurrence or persistence of one or more of the clubfoot segmental deformities following nonoperative or operative initial treatment (Figure 5-15).
2. Elucidation of the segmental deformities
a. Forefoot—pronated
b. Midfoot—adducted
c. Hindfoot—varus/inverted
d. Ankle—plantar flexed (equinus)
3. Imaging
a. Maximum dorsiflexion/abduction/eversion AP and lateral of foot—for younger children
b. Standing AP and lateral of foot—for older children
c. AP, lateral, mortis of ankle
4. Natural history
a. Persistence of deformity with pain, functional disability, and inability to wear normal shoes
5. Nonoperative treatment
a. Ponseti method of serial manipulation and long-leg casting, along with percutaneous Achilles tenotomy in most cases (well described in Clubfoot: Ponseti Management, LT Staheli, editor. www.Global-HELP.org monograph), starting in children up to at least 5 to 6 years of age (and possibly older)
i. Should be successful less often than when initiated in infants, with the rate of success inversely proportional to age at initiation
6. Operative indications
a. Failure or age-inappropriateness of serial casting to correct one or more of the clubfoot segmental deformities
b. Pain, shoe-fitting difficulties, dysfunction
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Percutaneous tendo-Achilles tenotomy (see Chapter 7)—perform this when there is less than 10° of ankle dorsiflexion after the cavus, adductus, and varus have been fully corrected with serial casting in an infant or very young child
i. This is a complete tenotomy, not a lengthening.
ii. It should be performed when there is little (or no) expectation that a posterior ankle capsulotomy will be required, which is the assumption in most babies up to at least 2 years of age.
• If a percutaneous tendo-Achilles tenotomy is concurrently converted to an open ankle capsulotomy, the gap in the tendon will not heal and remodel as well, and with as good preservation of excursion, as occurs with percutaneous Achilles tenotomy alone.
iii. If the need for a posterior capsulotomy is anticipated, an open tendo-Achilles lengthening should be performed. If a capsulotomy is then deemed unnecessary, there is no measureable disability from having performed a formal tendo-Achilles lengthening.
Figure 5-15. Left clubfoot in a 10-month-old boy who was treated from birth with serial casting. He apparently achieved full correction of all segmental deformities, but was lost to follow-up and returned with recurrence of all segmental deformities. A. Foot at rest. B. Maximum passive dosiflexion and eversion.
b. Posterior release (see Chapter 7)—perform this if there are less than 10° of dorsiflexion after the cavus, adductus, and varus have been fully corrected with serial casting in an older child, particularly if there is suspicion that the posterior ankle joint capsule is contracted in addition to the tendo-Achilles
c. À la carte partial-to-complete circumferential release (see Chapter 7)—perform this if there are residual cavus, adductus, and/or varus deformities in addition to an equinus deformity
i. The McKay procedure is the surgical analog of the Ponseti method in that it embraces the pathoanatomy ascribed to by Ponseti
ii. In non-idiopathic clubfoot, the tendons are released rather than lengthened, because of the high recurrence rate in these feet
d. À la carte partial-to-complete circumferential release (see Chapter 7) along with one or more of the following procedures—perform one or more of these additional procedures if there are residual cavus, adductus, and/or varus deformities in addition to an equinus deformity, and structural MA, resistant hindfoot varus with a long lateral column of the foot, and/or muscle imbalance
i. Medial column lengthening for structural MA
• Medial cuneiform opening wedge osteotomy (see Chapter 8)
ii. Lateral column shortening for structural MA (see Management Principle #18, Chapter 4)
• Closing wedge osteotomy of the cuboid (see Chapter 8)
iii. Lateral column shortening for resistant hindfoot varus/inversion with a long lateral column of the foot (see Management Principle #18, Chapter 4)
• Calcaneocuboid resection/fusion (see Chapter 8)
• Lichtblau resection of the anterior calcaneus (see Chapter 8)
• Closing wedge osteotomy of the anterior calcaneus (see Chapter 8)
iv. Posterior calcaneus lateral displacement osteotomy (see Chapter 8)
v. Anterior tibialis tendon transfer to lateral (3rd) cuneiform (see Chapter 7)
e. Triple arthrodesis (see Chapter 8)—perform this if there are no other options for correcting the deformities because of severity and/or rigidity, or because of existing degenerative arthritis of the subtalar joint (see Management Principle #13, Chapter 4)
f. Gradual deformity correction with external fixation (not elucidated in this book)
Rotational Valgus Overcorrection of the Subtalar Joint
1. Definition—Deformity
a. Iatrogenically acquired flatfoot in an operatively treated clubfoot with excessive external rotation of the subtalar joint (Figure 5-16)
i. due to excessive release of the subtalar joint, but without release of the talocalcaneal interosseous ligament
ii. with all components of eversion of the subtalar joint. Essentially, an acquired “physiologic” flatfoot
Figure 5-16. Previously operated clubfoot with rotational valgus overcorrection of the subtalar joint. A. Posterior view of severe valgus deformity of the hindfoot, similar to that seen in translational valgus overcorrection of the subtalar joint (see Figure 5-17A). B. Standing top image showing external rotation of the foot. Pain is typically experienced under the medial midfoot (similar to a flexible flatfoot with a tight tendo-Achilles), and there is often impingement-type pain in the sinus tarsi area or between the calcaneus and the lateral malleolus. C.Eversion of the subtalar joint is evident, with the navicular laterally positioned on the head of the talus. The abducted foot-CORA (see Assessment Principle #18, Figure 3-19, Chapter 3) is in the talar head-neck, as in an idiopathic flexible flatfoot. D. Example of an outward (positive) thigh–foot angle, as seen in this deformity.
2. Elucidation of the segmental deformities
a. Forefoot—supinated
b. Midfoot—neutral, abducted, or adducted
c. Hindfoot—valgus/everted
i. Positive thigh–foot angle
d. Ankle—plantar flexed (equinus)
e. Looks like an idiopathic flatfoot, clinically and radiographically
3. Imaging
a. Standing AP, lateral, Harris view of foot
b. AP, lateral, and mortis of ankle
4. Natural history
a. Persistence of deformity with pain under the medial midfoot and/or in the sinus tarsi area and/or in the lateral hindfoot—in some cases
5. Nonoperative treatment
a. Over-the-counter soft arch support or gel cushion insert
b. Accommodative shoe
6. Operative indications
a. Activity-related pain under the medial midfoot and/or in the sinus tarsi area and/or in the lateral hindfoot that is not relieved with prolonged attempts at nonoperative treatment
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Calcaneal lengthening osteotomy (see Chapter 8)
i. with possible tendo-Achilles lengthening (see Chapter 7) or gastrocnemius recession (see Chapter 7)
ii. with possible medial cuneiform plantar-based closing wedge (or dorsal opening wedge) osteotomy (see Chapter 8)
b. If there is coexisting ankle valgus (often present), correct the ankle valgus first (see Management Principle #23-6, Chapter 4), either by guided growth (see Medial Distal Tibia Guided Growth with Retrograde Medial Malleolus Screw, Chapter 8) or by distal tibia and fibula osteotomies (see Chapter 8)
Translational Valgus Overcorrection of the Subtalar Joint
1. Definition—Deformity
a. Iatrogenically acquired flatfoot in an operatively treated clubfoot with excessive lateral translation of the calcaneus under the talus (Figure 5-17)
Figure 5-17. Previously operated clubfoot with translational valgus overcorrection of the subtalar joint. A. Posterior view of severe valgus deformity of the hindfoot, similar to that seen in rotational valgus overcorrection of the subtalar joint (see Figure 5-16A). Impingement-type pain is typically experienced between the calcaneus and the lateral malleolus. B. Standing top image of the foot showing lateral translation of the heel (black arrow). C. The talonavicular joint is well-aligned (black oval). The talus and 1st MT are parallel, but can have a foot-CORA (see Assessment Principle #18, Figure 3-18, Chapter 3) in the talar head that is usually abducted less than 12°. D. Example of a neutral thigh-foot angle, as seen in this deformity.
i. due to excessive release of the subtalar joint with release of the talocalcaneal interosseous ligament
ii. often, with acceptable alignment at the talonavicular joint
2. Elucidation of the segmental deformities
a. Forefoot—neutral or supinated
b. Midfoot—neutral, abducted, or adducted
c. Hindfoot—valgus without eversion, i.e., with well-aligned talonavicular joint
i. Neutral thigh–foot angle
d. Ankle—neutral or plantar flexed (equinus)
e. Looks somewhat like an idiopathic flatfoot clinically, but not radiographically
3. Imaging
a. Standing AP, lateral, Harris view of foot
b. AP, lateral, and mortis of ankle
4. Natural history
a. Persistence of deformity with pain in the lateral hindfoot and/or in the sinus tarsi and occasionally under the medial midfoot—in some cases
5. Nonoperative treatment
a. Over-the-counter soft arch support or gel cushion insert
b. Accommodative shoe
6. Operative indications
a. Activity-related pain in the lateral hindfoot and/or in the sinus tarsi and occasionally under the medial midfoot that is not relieved with prolonged attempts at nonoperative treatment
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Posterior calcaneus medial displacement ± medial closing wedge osteotomy (see Chapter 8)
i. with possible tendo-Achilles lengthening (see Chapter 7) or gastrocnemius recession (see Chapter 7)
ii. with possible medial cuneiform plantar-based closing wedge (or dorsal opening wedge) osteotomy (see Chapter 8)
b. If there is coexisting ankle valgus (often present), correct the ankle valgus first (see Management Principle #23-6, Chapter 4), either by guided growth (see Medial Distal Tibia Guided Growth with Retrograde Medial Malleolus Screw, Chapter 8) or by distal tibia and fibula osteotomies (see Chapter 8)
Dorsal Subluxation/Dislocation of the Talonavicular Joint
1. Definition—Deformity
a. Iatrogenically acquired dorsal subluxation or dislocation of the navicular on the head of the talus in an operatively treated clubfoot (Figure 5-18)
i. due to overly extensive release of the talonavicular joint, usually with failure to release a contracted plantar fascia
2. Elucidation of the segmental deformities
a. Forefoot—pronated, neutral, or supinated
b. Midfoot—dorsal, and often lateral, subluxation or dislocation of the navicular on the head of the talus with appearance of cavus
c. Hindfoot—neutral, varus, or valgus
d. Ankle—neutral, plantar flexed (equinus), or dorsiflexed (calcaneus)
Figure 5-18. Previously operated clubfoot with dorsal subluxation of the talonavicular joint. A. Clinical image shows a tall instep (cavus) and short toe-to-heel length. B. Lateral radiograph shows dorsal subluxation of the navicular on the head of the talus and exaggerated plantar flexion of the first ray, including the MT, cuneiform, and navicular.
3. Imaging
a. Standing AP, lateral, oblique of foot
b. Consider CT scan of the foot and ankle in all three planes and with 3D reconstruction in older children and adolescents
4. Natural history
a. Persistence of deformity with pain over the dorsum of the midfoot and/or shoe-fitting problems related to the tall instep and relatively short toe-to-heel length of the foot—in some cases
5. Nonoperative treatment
a. Accommodative shoe
6. Operative indications
a. Pain over the dorsum of the midfoot and/or shoe-fitting problems related to the tall instep and relatively short toe-to-heel length of the foot.
b. Painful anterior ankle impingement between the navicular and the anterior distal tibial epiphysis
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. 3rd street procedure (see Chapter 7)—perform this in children up to around age 6 years
b. Talonavicular joint arthrodesis—perform this in older children and adolescents
c. Resection of impinging portion of dorsally subluxated navicular (see Chapter 8)—perform this for isolated painful anterior ankle impingement in an older child or adolescent
d. Triple arthrodesis (see Chapter 8)—perform this in an older child or adolescent if the subluxation/dislocation is associated with severe deformities and degenerative arthritis of the other joints of the subtalar complex
Figure 5-19. Postsurgical clubfoot in a 15-year-old girl with anterior ankle impingement pain. A. Flattop talus with shallow/absent dorsal talar neck concavity (and small heterotopic ossicle) causing anterior ankle impingement and pain. B. Sagittal CT scan image confirming the pathology.
Anterior Ankle Impingement
1. Definition—Deformity
a. Iatrogenically acquired impingement between the dorsal talar neck (or the navicular) and the anterior distal tibial epiphysis that limits dorsiflexion
i. Causes include:
• iatrogenic flattop talus from casting-induced and/or surgery-related crush injury to the dome of the talus (Figure 5-19)
• iatrogenic flattop talus from surgery-related avascular necrosis (Figure 5-20)
• iatrogenic posterior distal tibial growth arrest with progressive procurvatum deformity and flexion mal-orientation of the ankle joint (Figure 5-21)
• iatrogenic dorsal subluxation of the talonavicular joint (see Dorsal Subluxation/Dislocation of the Talonavicular Joint, above)
Figure 5-20. Avascular necrosis of the talus after clubfoot surgery with anterior impingement-type pain due to flattening of the dome and neck of the talus.
2. Elucidation of the segmental deformities
a. Flattop talar dome with shallow or flat dorsal neck of talus
b. Or, rarely, procurvatum deformity of distal tibia with flexion mal-orientation of the ankle joint
c. Or, dorsal subluxation of the navicular on the head of the talus
3. Imaging
a. Standing AP and lateral of foot
b. Standing AP, lateral, and mortis of ankle
c. CT scan of foot and ankle in all three planes and with 3D reconstruction in older children and adolescents
4. Natural history
a. Persistence or progression of deformity with anterior ankle pain that is exacerbated by dorsiflexion of the ankle—in some cases
5. Nonoperative treatment
a. High heel shoes
b. Heel wedge orthotics
6. Operative indications
a. Failure of nonoperative treatment to relieve the anterior ankle impingement-type pain that is exacerbated by dorsiflexion of the ankle.
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Debridement/reshaping of dorsal talar neck (see Chapter 8)—perform this if there is a dorsally prominent talar neck and a relatively normally shaped talar dome in a skeletally mature adolescent (see Figure 5-19)
b. Anterior distal tibia and fibula closing wedge/posterior translational dorsiflexion osteotomies (see Chapter 8)—perform this in a skeletally mature adolescent with a flat talar dome
c. Anterior distal tibia guided growth with anterior plate–screw construct to orient the joint into recurvatum (see Chapter 8)—perform this in a skeletally immature child with a flat talar dome
d. Posterior distal tibial physeal bar resection with fat grafting and concurrent posterior distal tibial opening wedge osteotomy (see above)
e. Do not lengthen tendo-Achilles! It will only increase the impingement.
Figure 5-21. Postsurgical clubfoot in a 5-year-old boy who had progressive loss of dorsiflexion and accompanying anterior ankle impingement-type pain. A. Lateral radiograph shows large posterior arrest of distal tibial physis, between arrow heads. Black line is Park–Harris growth arrest line. Resultant procurvatum deformity of the distal tibia created secondary anterior ankle impingement, despite normal anatomy of the talus. B. AP radiograph shows the arrest, roughly between the arrow heads. C. Sagittal MRI scan image shows the large, solid posterior physeal bar, between arrow heads. D. Coronal MRI scan image of the pathology. E. Lateral radiograph immediately after resection and fat grafting of the physeal bar (purple oval) and concurrent posterior distal tibia opening wedge osteotomy (purple wedge). F. AP image of the same.G. and H. Lateral and AP images 9 years later showing black Park–Harris line parallel with, and far from, the physis. The normal sagittal 10° extension tilt of the distal tibial articular surface has been restored.
Dorsal Bunion
1. Definition—Deformity
a. Dorsal prominence of the distal end of the 1st MT associated with dorsiflexion of the medial (1st) ray of the forefoot and hyperplantar flexion of the hallux at the 1st metatarsophalangeal (MTP) joint (Figure 5-22)
i. Iatrogenic, usually following surgical treatment of clubfoot deformity
ii. Occasionally seen in a child with severe spastic quadriplegia as the result of primary muscle imbalance or after surgical treatment
2. Elucidation of the segmental deformities
a. Forefoot—supinated
i. Dorsiflexed medial (1st) ray of the forefoot—flexible or rigid
ii. Hyper-plantar flexed hallux at 1st MTP joint—flexible or fixed
b. Midfoot—neutral, abducted, or adducted
c. Hindfoot—neutral or valgus (laterally translated)
i. Stiff or rigid
ii. with good or fairly good alignment at the talonavicular joint
d. Muscle imbalances (opposite those seen in cavovarus foot deformities) (see Cavovarus Foot, Figure 5-6, this chapter)
i. Strong anterior tibialis
ii. Weak peroneus longus
iii. Recruited and, therefore, stronger FHL than EHL
Figure 5-22. Dorsal bunion in a teenager. A. Standing lateral radiograph shows dorsiflexion of the 1st ray/MT and plantar flexion of the hallux at the 1st MTP joint. The hindfoot and midfoot are reasonably well-aligned. B. Matching clinical picture. The 1st MT head does not touch the ground in weight-bearing. There is redness, callus formation, and pain over the dorsal aspect of the 1st MT head and under the distal tip of the hallux. C. Standing AP radiograph shows good hindfoot/midfoot alignment, but malalignment at the 1st MTP joint with apparent plantar flexion. D. Matching clinical picture.
3. Imaging
a. Standing AP and lateral of foot
b. Standing AP, lateral, and mortis of ankle
c. Consider CT scan of foot and ankle in all three planes and with 3D reconstruction in older children and adolescents
4. Natural history
a. Persistence of deformity with pain and skin pressure injuries (inflammation, callus formation, blistering, ulceration) on the dorsum of the 1st MT head and/or at the tip of the hallux—in some cases
5. Nonoperative treatment
a. Accommodative shoe wear
6. Operative indications
a. Failure of nonoperative treatment to relieve the pain and skin pressure irritation on the dorsum of the 1st MT head (where it contacts the shoe) and/or at the tip of the hallux (where it contacts the ground)
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Combination of procedures (Figure 5-23):
i. Medial cuneiform (plantar flexion) plantar-based closing wedge osteotomy, or medial cuneiform (plantar flexion) dorsal-based opening wedge osteotomy (see Chapter 8)—based on the coexistence of abduction or adduction of the midfoot (see Management Principle #19, Chapter 4)
ii. Transfer anterior tibialis to the 2nd (middle) cuneiform (see Chapter 7)
iii. Reverse Jones transfer of the FHL to the 1st MT neck (see Chapter 7)
iv. Possible plantar capsulotomy of the 1st MTP joint
b. Often, the hindfoot is stiff, but well-aligned. If not, correct the hindfoot deformity with the appropriate osteotomy (see Chapter 8)
Figure 5-23. A. AP x-ray shows good alignment of the talonavicular joint. B. Lateral x-ray shows good alignment of the subtalar joint, but hyperdorsiflexion of the 1st ray. Purple triangle represents a plantar-based closing wedge osteotomy of the medial cuneiform that was used to correct the forefoot deformity. The black line represents a capsulotomy of the contracted plantar capsule of the 1st MTP joint. C and D. Matching preop clinical photos. E. Post-op AP x-ray shows the internal fixation staple used for the medial cuneiform osteotomy. The purple dots represent the original and transfer locations for the anterior tibialis tendon. F. Ten years post-op lateral x-ray shows the internal fixation staple used for the medial cuneiform osteotomy. The purple dots represent the original and transfer locations for the FHL (reverse Jones transfer). G. and H. Matching clinical photos of the foot 10 years later.