Surgical Treatment of Overcorrected Clubfoot Deformity

Abstract

Introduction: In our experience, a supramalleolar osteotomy with or without calcaneal osteotomy and midfoot osteotomy has been an effective treatment for sequelae resulting from overcorrected clubfoot deformity.

Step 1 preoperative assessment and planning: Determine the treatment using the decisional algorithm in Figure 3.

Step 2 patient positioning: Use spinal or general anesthesia, administer intravenous antibiotics, position the patient supine, apply a tourniquet.

Step 3 medial approach to the distal part of the tibia: Use a medial approach to expose the distal part of the tibia.

Step 4 supramalleolar osteotomy: Remove the bone wedge, close the osteotomy, and use rigid plate fixation to secure the correction.

Step 5 additional procedures if necessary: If necessary, perform fibular osteotomy, calcaneal osteotomy, and/or plantar flexion osteotomy of the first cuneiform.

Step 6 closure of all incisions and postoperative care: A short leg splint is worn for two days, followed by partial weight-bearing with the ankle protected in a splint at night and a walking boot during the day for eight weeks.

Results: Between 2002 and 2009, fourteen adult patients (mean age, thirty-seven years; range, nineteen to sixty-six years) who presented with a symptomatic overcorrected clubfoot deformity were treated with a supramalleolar osteotomy.

What to watch for: IndicationsContraindicationsPitfalls & Challenges.

Fig. 1

Illustration of subfibular impingement in a patient with overcorrected clubfoot deformity.

Fig. 2

Illustration of anterior impingement in the ankle joint due to the flattened dome of the talus in a patient with clubfoot deformity.

Fig. 3

Decisional algorithm for the treatment of overcorrected clubfoot deformity. TAS = tibial articular surface angle, OT = osteotomy, and SMOT= supramalleolar osteotomy.

Fig. 4-A

Preoperative anteroposterior weight-bearing radiograph showing valgus deviation.

Fig. 4-B

Preoperative lateral weight-bearing radiograph showing a flat-top talus.

Fig. 4-C

Preoperative hindfoot weight-bearing radiograph showing lateral offset of the calcaneus.

Fig. 5

Preoperative radiograph used for the planning of a medial closing-wedge osteotomy in a patient with an overcorrected flatfoot deformity. The angle of the distal tibial joint surface (α) and the tibiotalar angle are shown. The angle α₁ is the planned surgical correction.

Fig. 6

Preoperative radiograph showing the tibial lateral surface angle (β) and the planned anterior wedge removal (gray wedge).

Fig. 7

Marking of the location of the approach to the distal part of the tibia.

Fig. 8

Intraoperative radiograph of the guidewires for the tibial osteotomy.

Fig. 9

Intraoperative image of the guides and the subperiosteal placement of the Hohmann retractors.

Fig. 10

Removal of the bone wedge after the osteotomy.

Fig. 11

Fixation of the correction with a plate with interlocking screws.

Fig. 12-A

Intraoperative radiograph showing correction of the distal articular surface angle in the patient shown in Figs. 4-A, 4-B, and 4-C.

Fig. 12-B

Intraoperative lateral radiograph showing the correction of the distal part of the tibia in dorsiflexion.

Fig. 12-C

Intraoperative lateral radiograph showing the correction of the distal part of the tibia in plantar flexion.

Fig. 13

Orientation of the fibular osteotomy.

Fig. 14

Marking of the location of the approach for the calcaneal displacement osteotomy.

Fig. 15

Intraoperative image showing the medial displacement of the calcaneal tuberosity.