CTEV SURGICAL THERAPY

Surgical indication:
o

Tachdjian:

resistant, persistent, or relapsed clubfoot deformity (that does not

respond to further nonoperative treatment) will be required to
obtain a plantigrade foot

first indication for surgical management of clubfoot is failure to

correct the deformity by conservative methods within the first year
of life

Lovell: In more severe clubfeet, Dimeglio grades 3 and 4, and in the

syndromic or neuropathic clubfoot, surgical treatment remains necessary
in a number of cases.

Apley: The objectives of club-foot surgery are:

1.

the complete release of joint tethers (capsular and ligamentous

contractures and fibrotic bands)

2. lengthening of tendons so that the foot can be positioned normally

without undue tension

Kapankah waktu operasi terbaik (timing) pada kasus CTEV?

o

Tachdjian:

If nonoperative treatment fails, surgery should be performed before

the age of 12 months (once the child has achieved walking status)

therefore little advantage to performing the surgery before 9 to

10 months, an age that ensures that the child will be weight
bearing when the postoperative cast immobilization is completed.

Apley

Delaying surgery until the child is near walking age has the
advantages of operating on a larger foot (making surgery easier)
and using the forces in normal walking to help maintain the
correction obtained at surgery.

This delayed operative approach is suitable for severe, rigid

deformities; however, for less severe cases it may be preferable to

operate at around 6 months of age, but manipulation and splintage

must still be continued until the child is walking.

Why does ASAP surgery in CTEV cases is not recommended?

Lovell: Ponseti has documented the high cellular nature of medial ligaments in
the infant clubfoot, and Zimny and others have documented the presence of
myofibroblasts that might well be stimulated by early surgery, leading to a more
rigid foot and unsatisfactory outcome

Sebutkan approach pada kasus CTEV (Apley):

o

Turco extended posteromedial incision

Cincinatti Crawford (McKay) extended anterior both medial and lateral

side (Circumferential)

Caroll posterolateral incision combined with separate curved medial

incision

ATL pada kasus CTEV. Kaki dari Z incision pada bagian distal mengarah ke medial (Campbell)

Surgical technique (Campbell):

o

Turco:

Only in mild deformities

no severe internal rotational deformity of the calcaneus DO NOT

requires extensive posterolateral release

McKay:

For more extensive release that includes the posterolateral

ligament. The procedure described by McKay takes into
consideration the three-dimensional deformity of the subtalar joint
and allows correction of the internal rotational deformity of the
calcaneus and release of the contractures of the posterolateral and
posteromedial foot.

Modified McKay procedure through a transverse circumferential

(Cincinnati) incision is our preferred technique for the initial surgical
management of most clubfeet

Urutan release (Apley ):

o

The tendo Achillis and tibialis posterior tendons (Z-divisions)

Posterior capsules of the ankle and subtalar joints often have to be divided
to allow adequate correction of hindfoot equinus

Sometimes flexor digitorum longus and flexor hallucis longus also require
attention.

The calcaneo-fibular ligament, a key structure in keeping the calcaneum

malrotated, is then released.

A complete subtalar release is performed to allow the hindfoot to be

corrected.

Superficial deltoid ligament (the deep part is preserved ankle

instability)

Tachdjian: Frequently, a posterior release consisting of Achilles tendon

lengthening and posterior capsulotomies of the tibiotalar and subtalar joints will
be sufficient to correct the equinus and, if present, minimal hindfoot varus

TURCO

Complete, one-stage posteromedial release

Supine position

curved posteromedial incision beginning alongside the Achilles tendon above the
ankle joint

the posterior tibialis tendon being lengthened or released, the talonavicular joint
opened dorsally, medially, and inferiorly, and the calcaneonavicular spring
ligament released. The Achilles tendon and long toe flexors are lengthened and
repaired. The talonavicular joint is reduced and pinned

talonavicular joint is reduced and pinned

Release of the interosseous talocalcaneal ligament so that the calcaneus can be

everted and rotated by moving the anterior end laterally and the posterior
tuberosity downward was part of Turco's original description, although it is
generally avoided in other techniques.

Immobilized his patients for a total of 4 months and removed the K-wires at 6
weeks. Night splints were used for an additional year after the end of cast
immobilization.

CARROL (Tachdjian)

Position: prone/supine

Modiff of Turcos basic procedure

Posteromedial:

Plantar fascial release and capsulotomy of the calcaneocuboid joint because

forefoot adduction and supination (actual cavus) were not addressed by Turco's
procedure.

The abductor hallucis is identified and released

plantar fascia is divided

calcaneocuboid joint is opened from the medial side and fully released

Posterolateral:

Posterior longitudinal incision paralleling the lateral edge of the heel cord

Achilles tendon is Z-lengthened and a posterior capsulotomy of the ankle joint,

including the medial and lateral ligaments

Reduce the talonavicular joint, by internally rotating the talus with a longitudinal
K-wire as the handle to perform this derotation

CINCINNATI (McKay and Simons)

More extensive procedure, supine position

Incision (Lovell) circumferential incision around the posterior aspect of the foot
several millimeters above the posterior crease

INCISION DESIGN (Campbell):

Begin on medial aspect of foot in (level of naviculocuneiform)

Carry incision posteriorly, curve beneath the distal end of the medial malleolus
and ascending slightly to pass transversely over the Achilles tendon
approximately at the level of the tibiotalar joint

Continue the incision in a gentle curve over the lateral malleolus, and end it just
distal and slightly medial to the sinus tarsi

Extend the incision distally medially or laterally, depending on the requirements

of the operation

RELEASE (Tachdian):

Release all peritalar structures

The majority of peritalar structures, including all hindfoot and midfoot joints,

Release lateral talocalcaneus from from the attachment of the calcaneocuboid

joint laterally to the sheath of the flexor hallucis longus.

Complete release of the talonavicular and calcaneocuboid is included, and both

these structures are pinned.

The subtalar interosseous ligament release.

Once the calcaneus has been adequately derotated by pushing the anterior end
laterally and the posterior tuberosity medially and downward, the interosseous
ligament is internally fixed.

McKay also introduced the concept of an articulated cable cast in which the
hinge is centered at the ankle joint for immediate postoperative movement, with
the connection between the foot and leg portions of the cast being large-gauge
telephone wire. This was intended to increase hindfoot (ankle) motion, with 30 to
60 degrees of total motion being reported

Wound complications from early motion of the cable cast have decreased
acceptance of this method of postoperative management.