J Korean Orthop Assoc JKOA Journal of the Korean Orthopaedic Association 1226-2102 The Korean Orthopaedic Association 10.4055/jkoa.2009.44.6.642 Original Article Treatment of the Resistant Idiopathic Clubfoot with Toe-in Gait Lee Jong Seo M.D. Kim Hui Taek M.D. Seong Yoon Jae M.D. Bae Seong Ho M.D. Department of Orthopedic Surgery, Pusan National University Hospital, Busan, Korea. Correspondence to Hui Taek Kim, M.D. Department of Orthopaedic Surgery, Pusan National University Hospital, 1-10, Ami-dong, Seo-gu, Busan 602-739, Korea. Tel: +82.51-240-7247, Fax: +82.51-247-8395, kimht@pusan.ac.kr 12 2009 21 12 2009 44 6 642 650 02 11 2009 05 11 2009 Copyright © 2009 The Korean Orthopaedic Association 2009 Purpose

We evaluated the degree of femoral and tibial torsion in, and the efficacy of two operative procedures for, resistant idiopathic clubfoot with toe-in gait.

 Materials and Methods

Thirty one feet in 23 patients (average age at the time of revision surgery 4.3 years) were studied. CT was used to determine femoral anteversion and tibial torsion. Two different operative procedures were applied, depending on the degree of toe-in gait: group 1 (10 feet whose toe-in gait was not severe) - soft tissue release, anterior tibial tendon transfer and mid-foot (cuboid closing and cuneiform opening) osteotomy; group 2 (21 feet which had relatively severe toe-in gait) - supramalleolar external rotation osteotomy of the distal tibia (SEROT), along with the same procedure as group 1. Mean follow-up period after revision surgery was 6.3 years. Results were assessed radiologically and clinically with the Dimeglio classification and Clubfoot Assessment Protocol.

 Results

The mean femoral anteversion and external-tibial torsion of the affected side were increased. Twenty eight of 31 feet (90.3%) demonstrated excellent or good results. In group 2, we obtained 19 excellent (90.5%) and 2 good (9.5%) results. Group 1 had 6 excellent (60%), one good (10%) and 3 fair (30%) results.

 Conclusion

Surgical treatment of the relapsed clubfoot with toe-in gait including soft-tissue release, tendon transfer and mid-foot osteotomy, along with SEROT in cases of severe toe-in gait, is effective in correcting residual clubfoot deformities.

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(A) Three-dimensional illustrations showing midfoot osteotomy. The lateral wedge resection from the cuboid is applied to the medial cuneiform. (B) Improved forefoot adduction and correction of toe-in foot position is seen following the wedge transfer and SEROT.

Weight-bearing AP radiographs of the left clubfoot in a 5-year-old boy who underwent midfoot osteotomy and SEROT: (A) before the secondary surgery (4 years after the initial PMLR) and (B) at the last follow up (3 years after secondary treatment). Reduced forefoot adduction is evident.

(A) shows how the osteotomy cut in SEROT may be made incorrectly in the sagittal plane: a cut along line a will result in a varus ankle deformity (B, left side); a cut along line b will result in a valgus ankle deformity (B, right side). The correct cut in Fig. A is indicated by the horizontal line, at right angles to the bone (parallel to the joint line in both the coronal and sagittal planes).

Patients' Data

*MOT, midfoot osteotomy; †COT, calcaneal displacement osteotomy; ‡TAL, Tendo-Achilles lengthening; §SEROT, supramalleolar external rotation osteotomy; ∥TA, Tibialis anterior transfer; PMR, Posteromedial release; **PMLR, Posteromedial and lateral release.

Comparison of Radiologic Outcomes

Values, means±SD: unit, degrees.

Comparison of Functional Results (Expressed as Percentages of the Normal Values)