Bilateral flatfoot before Surgery and  Bilateral flatfoot after Surgery
Ankle Arthroscopy and Subtalar Arthroscopy
Ankle Arthritis in Rhuematoid patient and Ankle Replacement in Rhuematoid Arthritis
Diabetic foot before Surgery and Diabetic foot after Surgery
Claw toe deformity in Rhuematoid patient and Claw toe deformity in Rhuematoid patient after surgery
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Relapsed Club Foot


  Treatment of resistant & residual clubfoot in older children  
     
 
The appropriate procedures and combination of procedures depend on;  
 
  • The age of the child.
  • The severity of the deformity.
  • The pathological processes involved.
 
     

Common components of resistant clubfoot deformity are:

 
   
  1. Adduction or supination, or both, of the forefoot.
  2. A short medial column or long lateral column of the foot.
  3. Internal rotation and varus of the calcaneus.
  4. Equinus.
 
       
 
 
Forefoot deformities:  
   
  1. Dynamic deformities – tendon balancing procedure (split or complete transfer of tibialis anterior to lateral cuneiform or cuboid).
 
   
   

Split Anterior Tibialis Transfer

 
2. Rigid deformity (<5years): Multiple MTPJ capsulotomies.  
   
3. Rigid deformity (>5years): – Bony procedures like dome osteotomies of metatarsal bases and cuneiform-cuboid osteotomy.
 
   
Metatarsal base  Osteotomy
 
Rigid Deformity
 
   
   

Cunieform Cuboid Osteotomy for correcting forefoot adduction deformity

 
     
 
Cunieform Cuboid Osteotomy
 
     
 

Hindfoot Deformities

 
  • <2-3 years: - modified McKay procedure
 
 
Modified McKay Procedure
 
     
 
Picture showing Cincinnati incision for pantalar release
 
     
     
 
  • 3-10 years:
 
 
Its important to find out if hindfoot deformity is because of isolated heel varus, short medial column or long lateral column.
 
 
 
   

Isolated Heel Varus

         Dwyer osteotomy is the treatment.

 
     
Dwyer Osteotomy
Dwyer Osteotomy Fixed
Tecnique Dwyer Osteotomy
 
 
   
   
 
 
   

Short lateral column 

Dillwyn-Evans procedure is the treatment

 
Dilwyn Evan Procedure
 
 
 
   

Long lateral Column

 

Lichtblau procedure is the treatment

 
 
Lichtblau procedure
 
 
 
   
10-12 years: triple arthrodesis  
   
   
       
     
Triple Arthrodesis for Neglected Clubfoot
       
 
 
   
   
Heel Equinus  
   
     
 
  1. Achilles tendon lengthening plus posterior capsulotomy of subtalar joint, ankle joint (mild-to-moderate deformity)
 
     
 
      1.    
 
       
 
Tendoachilles lengthening
   
 
 
   
   
     
 
  1. Lambrinudi procedure (severe deformity, skeletal immaturity)
 
     
     
 
       
 
Lambrinudi Procedure
   
 
 
     
     
  All Three Deformities  
     
  Triple Arthrodesis is done children more than 12 years. Upto 12 years one should try Ponseti treatment first.  
     
     
 

External Fixator

 
  Has been used successfully in relapsed and resistant clubfoot  
     
     
 

Case 1

 
 

Relapsed club foot after posteromedial release in a five year old child.

 
     
 
Relapsed Clubfoot 1
 
Relapsed Clubfoot 2
 
 
     
     
 

Treatment with JESS External Fixator.

 
     
 
Relapsed Clubfoot treated with External Fixator
 
Relapsed Clubfoot treated with External Fixator 2
 
 
     
     
 

Result – Maintenance of correction 8 years later at the age of 13 years

 
 
   
 
Maintenance of relapsed Clubfoot correction 8 years after surgery 2
 
 
Maintenance of relapsed Clubfoot correction 8 years after surgery 4
 
       
 
 
     
 

Result at the age of 13 years

 
     
 

Internal Tibial Torsion

 
     
 

De-rotational Osteotomy of tibia is rarely required. Foot deformities should be excluded before undertaking tibial osteotomy.