ABSTRACT

CORRESPONDING AUTHOR:
Dr. K. G. Gopalakrishna,
#106, Ideal Apts, 16th Cross,
Rajarajeshwari Nagar, Bangalore – 98.
Email: gopalkgortho@gmail.com

ABSTRACT: BACKGROUND: Surgical correction of congenital talipes equino varus (ctev) is to address adequately all aspects of this complex foot deformity. Various exposures have been elucidated with varying results and complications. This prospective study discusses the cincinnati approach advocated by Mackay to address the various aspects of clubfoot correction. Objective: To study the adequacy of exposure, wound healing and problems related to Cincinnati approach. To study the effectiveness of primary surgical correction. METHODS: The present prospective study includes treatment of 24 feet in 21 patients with clubfoot treated with posteromedial and lateral soft tissue release by Cincinnati approach and followed up with an average follow up of 6.9 months. 3 (12.5%) were followed up for 1 year and 3 (12.5%) lost for the follow up. 18 (75%) were followed up to 6 months. All were resistant to correction by conservative method. Age at operation averaged 1.6 year, ranged from 9 months to 3 years. RESULTS: Results were evaluated using Laaveg and Ponseti functional rating system of clubfoot. Postoperatively the average arc of movement in ankle joint was 370, which was 50% of normal limb. Inversion, eversion movement of subtalar joint was 230, bimalleolar angle was 770.The functional results were excellent in 6 feet (25%), good in 12 feet (50%), fair in 5 feet (20.83%) and poor in 1 foot (4.17%). In our series complications encountered were post-operative focal necrosis in 3 feet (12.5%) and marginal necrosis in 3 feet (12.5%). CONCLUSION: Cincinnati incision provides an adequate exposure for extensive surgical release under direct vision, there by bony realignment of talus over calcaneus was restored and hence the restoration of normal bimalleolar angle. Skin closure is not found to be a problem in achieving a primary closure. Wound healing leaves only a thin and cosmetically acceptable scar.
KEYWORDS: CTEV, cincinnati incission, subtalar release, bimalleolar angle.

INTRODUCTION: Idiopathic clubfoot is one of the oldest and commonest congenital deformities of mankind. Hippocrate (460 BC -377BC)1 was the first person to describe club foot. The initial treatment of clubfoot is non-operative. It was concluded that most of the club foot can be successfully managed by a series of Plaster casts and wedging without the use anesthetics, or operative procedures with better results.2,3
In neglected, resistant, recurrent, relapsed, failed conservatively treated CTEV pathological contractures of the soft tissues prevented the reduction of the navicular on the head of talus and calcaneum and surgical correction becomes necessary.4
The comprehensive soft tissue release in current favor is posteromedial release of Turco. Mukhopadhyay procedure with its variants and circumferential release as described by McKay, Carrol and Simons, etc. are some of more than hundred surgeries described.
The conventional Turcos approach, although widely practiced, is associated with non-acceptable scar something keloid, difficult visualization of the other side of ankle and subtalar joint, incomplete soft tissue release, incomplete peritalar release, incomplete subtalar release and incomplete correction of rotation deformity of calcaneum. This could lead on to either persistence or recurrence of deformity.
To predicate the above mentioned problem circumferential Cincinnati approach has been practiced worldwide. A significantly lower incidence of wound complications was seen in the Cincinnati treatment group when compared with the modified Turco.5 so we intend to study the surgical management of CTEV by Cincinnati approach in light of the published literature.

OBJECTIVES OF STUDY:

RELATED TO APPROACH: To study the adequacy of exposure, wound healing and problems related to Cincinnati approach.

RELATED TO PROCEDURE: To study the effectiveness of primary surgical correction.
Surgery in the treatment of clubfoot must be tailored to the age of the child and to the deformity to be corrected.
A modified McKay procedure through a transverse circumferential (Cincinnati) incision is our preferred technique
Any approach should be able to address the release in all quadrants, which are as follows:
Plantar: Plantar fascia, abductor hallucis, flexor digitorum brevis, long and short plantar ligaments
Medial: Medial structures, tendon sheaths, talonavicular and subtalar release, tibialis posterior, FHL, and FDL lengthening
Posterior: Ankle and subtalar capsulotomy, especially releasing post talofibular and tibiofibular ligaments and the calcaneofibular ligaments
Lateral: Lateral structures, peroneal sheath, calcaneocuboid joint, and completion of talonavicular and subtalar release
Any approach should afford adequate exposure. Structures to be released or lengthened are the following:
Achilles tendon.
Tendon sheaths of the muscles crossing the subtalar joint.
Posterior ankle capsule and deltoid ligament.
Inferior tibiofibular ligament.
Fibulocalcaneal ligament.
Capsules of the talonavicular and subtalar joints.
Division of associated ligaments around the subtalar joint.
Plantar fascia and intrinsic muscles.

MATERIALS AND METHODS: The present prospective clinical study includes treatment of 24 feet in 21 patients with clubfoot treated with posteromedial and lateral soft tissue release by Cincinnati approach from the period November 2007 to October 2009. Conducted in department of Orthopaedics, Bangalore Medical College and research institute, Victoria, Bowring & Lady Curzon Hospitals, Bangalore between November 2007 to October 2009 A prior consent was obtained from all the patients and the study was approved by the Ethical Committee of the Hospital.
METHODOLOGY: Required data was collected from patients admitted in Victoria Hospital, Bowring and Lady Curzon hospitals. All patients included in study were assessed pre-operatively and post operatively (clinical and functional) as per Laaveg and Ponseti functional rating system score.
    Children with idiopathic CTEV, more than 6 months of age (Neglected CTEV)-<3years, Rigid CTEV, partially corrected CTEV (failed conservative)/recurrent CTEV were included for the study. X-rays of foot, routine Blood investigations, weight recording done. Cases were followed up at 2 weeks, 6 weeks, 6months and 1year.

EXCLUSION CRITERIA: less than 6 months
•    Flexible CTEV.
•    Aquired talipes equino varus (trauma, burns, neurogenic, muscular dystrophies-, AMC, Teratological-etc).
•    >3 years where bony procedures were needed.

OBSERVATION AND RESULTS: The present study includes treatment of 24 feet in 21 patients with clubfoot treated with posteromedial and lateral soft tissue release by Cincinnati approach from the period November 2007 to October 2009 and followed up with an average follow up of 6.9 months. 3 (12.5%) were followed up for 1 year and 3 (12.5%) lost for the follow up. 18 (75%) were followed up to 6 months. Age at operation averaged 1.6 year ranged from 9 months to 3 years.

Age distribution:

Sex distribution:

CASE 1: BILATERAL NEGLECTED CTEV

Pre op photographs