- See:
Myelomeningocele:
- Discussion:
- most common foot deformity in myelomeningocele;
- teratological club-foot deformity in children w/ myelomeningocele is often more severe and
more rigid than seen in
congenital club foot deformity;
- secondary foot deformities may also develop as a result of muscle imbalance and/or spasticity;
-
goals of treatment:
- these children will usually have insensate feet, and it is therefore important to keep the foot
in a plantigrade position;
- the initial emphasis should be placed on achieving a mobile plantigrade foot, but arthrodesis
may be required inorder to achieve a plantigrade surface & foot that can be braced;
- most children w/ mylelomenigocele club foot will require lower-extremity bracing on a long-term basis;
- Non Operative Treatment:
- serial plaster casts should be begun as early as possible;
- slow but persistent correction should be gained over first year of life;
- special care is be taken to avoid pressure sores under cast in insensitive feet;
- recurrence of deformity is frequent because of muscle imbalance, & surgical release is often
needed for lasting correction;
- Operative Treatment:
-
timing of surgery:
- because of common neurological & urological problems & high risk of recurrence in these children,
an operation is done later than it would be in a child who has idiopathic congenital club foot;
- generally, operative intervention should be delayed until the child is 12 to 18 months old.
-
treatment options:
- tenotomy and/or tendon transfers may be used prevent recurrence;
- complex tendon transfers should be avoided because of lack of selective muscle control & tendency to create new deformity.
- contracted tendons should be resected rather than lengthened;
- to correct an equinus deformity consider heel cord tenotomy rather than lengthening to prevent recurrence;
- talectomy:
- severe equino-varus deformities related to
arthrogryposis or myelomeningocele, can be managed w/ talectomy;
- in most cases, talectomy is indicated for management of severe equinovarus deformities which have been
resistant to previous attempts at operative correction;
- in cases of bilateral rigid clubfoot, primary bilateral talectomy may be an option;
- desired outcome is bilateral plantigrade feet, which transmit wt bearing eveningly over the foot;
- in the study by Letts and Davidson (AJO Feb 1999), 10 out of 14 feet had a good or satisfactory result from bilateral talectomy;
- essential technical details include need for complete talar removal and relocation of the talus;
- bracing is needed after correction to prevent recurrent equinus;
- Revision Surgery:
- residual deformities after correction of club foot may require additional surgery;
- talectomy:
- in revision cases, but it can effective to return the foot to a neutral position;
- in younger children, the Verebelyi-Ogston procedure (talar decancellation) may be preferred over talectomy;
- w/ severe scarring, enucleation of navicular, talus, & cuboid as well as the talectomy may be required;
- osteotomy:
- closing-wedge osteotomy (Dwyer procedure): indicated for persistent varus angulation of hind part of foot;
- sliding osteotomy of the calcaneus: indicated for valgus overcorrection of the hindfoot;
- residual adduction of fore part of foot may necessitate metatarsal osteotomies or shortening of the
lateral border of the foot;
- arthrodesis:
- arthrodesis of ankle &
triple arthrodesis should be avoided;
Talectomy for equinovarus deformity in myelodysplasia.
Equinovarus deformity in arthrogryposis and myelomeningocele: evaluation of primary talectomy.
The role of bilateral talectomy in the management of bilateral rigid clubfeet.
Merv Letts MD and Darin Davidson.
The American Journal of Orthopedics. Feb 1999. p 106.
