Research Article
Results of Bone and Soft Tissue Surgery Combined with Arthrodesis of the Talocalcaneal and Calcaneocuboid Joints for Equinovarus Associated with Spina Bifida
Takashi Fukushima1*, Hideyuki Watanabe2*, Kayo Hagiwara2, Akira Murayama3, Jiro Machida1, Kikuo Kameshita1 and Ichiro Kikkaw1
1Department of Orthopedic Surgery, Jichi Medical University, Japan
2Department of Pediatric Orthopedic Surgery, Jichi Children’s Medical Center, Japan
3Department of Orthopedics, Kanagawa Children’s Medical Center, Japan
*Corresponding author: Takashi Fukushima, Department of Pediatric Orthopedic Surgery, Jichi Children’s Medical Center, Tochigi, 3311-1 Yakushiji, Shimotsuke, Tochigi 3290498, Japan Hideaki Watanabe, Department of Pediatric Orthopedic Surgery, Jichi Children’s Medical Center, Tochigi, 3311-1 Yakushiji, Shimotsuke, Tochigi 3290498, Japan
Published: 07 Feb, 2017
Cite this article as: Fukushima T, Watanabe H, Hagiwara K,
Murayama A, Machida J, Kameshita K,
et al. Results of Bone and Soft Tissue
Surgery Combined with Arthrodesis of
the Talocalcaneal and Calcaneocuboid
Joints for Equinovarus Associated with
Spina Bifida. Clin Surg. 2017; 2: 1288.
Abstract
Whether arthrodesis is necessary for correcting equinovarus associated with spina bifida in
children to prevent its recurrence is controversial. In this retrospective study we determined the
outcomes of bone and soft tissue surgery combined with arthrodesis of the talocalcaneal and
calcaneocuboid joints for equinovarus associated with spina bifida. The subjects were five patients,
with a mean age of 6 years, who underwent surgery. Complications, the presence or absence of
callus, reverse deformation, clinical assessment, evidence of osteoarthritis, and range of motion of
the ankle (assessed by plain radiography) were investigated. A fracture occurred postoperatively
in the proximal tibia during below-knee casting of one foot. No callus formed in any patient, and
mild reverse deformation was observed in three feet. The clinical assessment was good in all cases.
There was no osteoarthritis. The tibiocalcaneal and tibiatalar angles in maximum dorsiflexion
were significantly less after surgery than before it. Bone and soft tissue surgery combined with
arthrodesis of the talocalcaneal and calcaneocuboid joints may be necessary to prevent recurrence
of equinovarus.
Keywords: Ankle joint; Arthrodesis; Equinovarus; Foot; Spina bifida
Introduction
Equinovarus associated with spina bifida is caused by a flaccid paralysis-induced imbalance of muscle strength and malpositioning. Surgery for this condition is necessary when intractable calluses are formed because of the inability to contact the ground with the soles of the feet (plantigrade) and rigid equinovarus. Imbalance of muscle strength, however, changes with growth, and deformation recurs in many cases after soft tissue release alone. Deformation seldom recurs after triple arthrodesis, but the talocrural joint develops osteoarthritis during growth [1,2] because it cannot preserve talocalcaneal, calcaneocuboid, and talonavicular joint motion. Treatment of equinovarus associated with spina bifida is difficult. At our hospital, bone and soft tissue surgery combined with arthrodesis of the talocalcaneal and calcaneocuboid joints is performed in patients with equinovarus associated with spina bifida. We retrospectively investigated the postoperative outcomes of this condition.
Methods
In this case series, the subjects were patients who had undergone bone and soft tissue surgery
combined with arthrodesis of the talocalcaneal and calcaneocuboid joints for equinovarus associated
with spina bifida at our hospital between March 2006 and August 2012. Inclusion criteria were as
follows: The surgery had been performed at least 1 year previously at levels 4 and 5, according to
Sharrard [3] in patients who [1] had been able to walk but had difficulty wearing shoes and orthoses,
[2] were unable to contact the ground with the soles of the feet despite attachment of an orthosis,
and [3] had intractable callus formation causing rigid equinovarus. The exclusion criteria were as
follows: Surgery had been performed less than 1 year previously at levels 1–3, according to Sharrard
[3], indicating an inability to walk and flexible equinovarus. Six feet of five patients were investigated
(four right feet and two left feet).
Technique
Plans for bone and soft tissue surgery combined with arthrodesis
of the talocalcaneal and calcaneocuboid joints were designed by one
of the authors. The surgery included posteromedial release [4-6],
which was applied through the medial side of the foot, after which
the talocalcaneal and calcaneocuboid joints were released through the
lateral side of the foot. The operation began with a medial incision at
the medial cuneiform. The cut passed through a medial malleolus and
was extended until it was just distal to the calf, thereby exposing the
Achilles tendon, similar to the medial Turco incision. The Achilles
tendon sheath was incised to expose the Achilles tendon, which was
lengthened by Z-lengthening. Similarly, the posterior tibial (PT)
and flexor digitorum longus (FDL) tendons’ sheaths were incised
to expose the PT and FDL, which then underwent Z-lengthening.
After the posterior tibial neurovascular bundle was identified and
protected posteromedially, the flexor hallucis longus (FHL) tendon
was identified and protected as well. The ankle capsule was exposed
and incised from the posteromedial to the posterolateral corners. The
posterior tibiofibular and calcaneofibular ligaments were exposed and
released to allow maximum dorsiflexion of the talus. The superficial
tibionavicular, spring, bifurcate, and plantar calcaneocuboid
ligaments were released through the medial side of the foot. If the
hallux was tightly flexed, the FHL was lengthened by Z-lengthening.
Next, the incision was made from the end of the lateral malleolus
through the upper edge of the calcaneocuboid joint to the base of
the third metatarsal bone. The extensor digitorum brevis muscle was
identified and incised, and the lateral calcaneocuboid joint and the
sinus tali were exposed. The articular cartilage in the calcaneocuboid
joint and the sinus tali were resected to allow bone union. After these
releases were complete, the foot was corrected in sequence using
the modified Ponseti method [7,8]. First, the pronated forefoot was
supinated while plantarflexing the cuboid, with the foot stabilized by
the thumb and index finger over the heel. The calcaneocuboid joint
was then fixed using a pin. Second, with counter pressure by the
thumb against the head of the talus, the forefoot was abducted and
dorsiflexed with the foot stabilized using the thumb and index finger
over the heel. The talonavicular joint was fixed using a pin. Finally,
the talocrural joint was fixed with a pin.
After this sequence, arthrodesis was performed in those joints
through the lateral side of the foot. Additionally, tenodesis was
applied to the Achilles tendon and the PT, FDL, and FHL tendons
on the posterior side of the ankle through the medial side of the foot
(Figure 1). Casting was applied for 8 weeks after surgery, and an
ankle−foot orthosis was attached thereafter for 1 year.
The outcomes of the patients were evaluated at the final followup
more than 1 year after surgery, including the following items:
complications, presence or absence of callus, reverse deformation,
clinical assessment according to Neto et al. [9], evidence of
osteoarthritis, and the range of motion (ROM) of the ankle joint as
assessed on plain radiographs. We defined reverse deformation as
valgus deformity of the heel, even if it was only slight. For this clinical
assessment [9], “good” indicated that the condition was favorable in
the posterior and anterior regions of the foot, “fair” indicated that
the condition was favorable in the posterior region but unfavorable
in the anterior region, requiring surgery and “poor” indicated that
the condition was unfavorable in the posterior and anterior regions
and required secondary surgery. For assessing the ROM of the ankle
joint, the tibiocalcaneal (TiCa) and tibiotalar (TiTa) angles [10]
were measured on plain lateral radiographs of the foot in maximum
dorsiflexion before and after surgery.
For statistical analysis, we used IBM SPSS version 20 software
(Chicago, IL, USA). TiCa and TiTa angles before and after surgery
were compared using the Wilcoxon rank-sum test. A value of p = 0.05
was regarded to indicate statistical significance.
Table 1
Table 2
Figure 1
Figure 1
Bone and soft tissue surgery combined with arthrodesis of the talocalcaneal and calcaneocuboid joints. TP: posterior tibial tendon; FHL: flexor halluces longus tendon; FDL: flexor digitorum longus tendon; AT: Achilles tendon.
Results
One foot of a boy and five feet of five girls were evaluated. The mean age at the time of surgery was 6 years (4–8 years). Four right feet and two left feet had been treated, and the mean duration of follow-up was 76 months (37–113 months) (Table 1). Regarding complications, a fracture occurred at the site of bone collection in the proximal tibia during below-knee casting of one foot. No callus formed in any patient, and mild reverse deformation was noted in three feet. The clinical assessment established by Neto et al. [9] was “good” in all cases (Table 2) (Figure 2 and 3). There was no evidence of osteoarthritis. The TiCa angles before and after surgery, respectively, were as follows: median 85° and 57.5°, maximum 100° and 75°, minimum 70° and 45°. The TiTa angles before and after surgery, respectively, were as follows: median 110° and 92.5°, maximum 135° and 100°, minimum 95° and 85°. The angles, measured in maximum dorsiflexion, were significantly lower after surgery than before surgery (p = 0.03) (Figure 4-6) [11].
h2 id="anch5" class="text-left article-page-title">Figure 2
Figure 2
Preoperative and postoperative photographs of all six cases. Equinovarus was noted in all of the feet, and the patients walked by contacting the ground with the lateral sides of the feet, leading to callus formation at the base of the fifth metatarsus (arrows). Adduction and varus were observed in the anterior and posterior regions of the feet, respectively.
Figure 3
Figure 4
Figure 4
Lateral radiograph of the normal foot in maximum dorsiflexion. Normal values of the tibiotalar (TiTa) and tibiocalaneal (TiCa) angles in a lateral radiograph of the foot in maximum dorsiflexion are 113.69±11.21 and 67.79±10.63.
Figure 5
Figure 5
Preoperative (top panels) and postoperative (bottom panels)
lateral radiographs of patients 1–3 with the feet in maximum dorsiflexion.
Figure 6
Figure 6
Preoperative (top panels) and postoperative (bottom panels)
lateral radiographs of patients 4–6 with the feet in maximum dorsiflexion.
Discussion
Neto et al. [9] performed posterior mediolateral release, and the
outcomes after a mean of 86 months of follow-up were good in 49
of 63 feet (63%), fair in 9 (14%), and poor in 14 (23%). Flynn et al.
[12] performed posteromedial release, and the outcomes at a mean
of 36 months after surgery were good in 45 of 72 feet (61%), fair in
18 (26%), and poor in 9 (13%). Soft tissue release operations, such
as posteromedial and posterior mediolateral release, have been
performed to correct deformity and equalize muscle strength, but
the deformation recurrence rate is high. The deformation recurrence
rate after surgical arthrodesis, such as triple arthrodesis, is low [1,2],
but this technique is generally avoided because osteoarthritis may
develop in the adjacent talocrural joint, resulting in restriction of
ROM in the talocalcaneal, talonavicular, and calcaneocuboid joints in
the future. Whether arthrodesis is necessary to correct equinovarus
associated with spina bifida in children is controversial. Bone and
soft tissue surgery combined with arthrodesis of the talocalcaneal and
calcaneocuboid joints achieved a “good” result in all of our patients.
However, mild reverse deformation not requiring surgery was
observed in three feet at a mean of 40 months after surgery. Machida
et al. [5] also reported that deformation did not recur in any of 34
feet concomitantly treated with this surgery after a mean of 12.7 years
of follow-up. Based on these reports, we consider that arthrodesis
of the talocalcaneal and calcaneocuboid joints may be necessary, in
addition to soft tissue release operations (e.g., posteromedial release),
to prevent recurrence of equinovarus. Machida et al. [5], however,
reported that osteoarthritis had occurred in the adjacent talocrural
joint in one foot. In our cases, there was no osteoarthritis of the
adjacent talocrural joint. However, because these cases have only
a short-term follow-up, their course should be followed to observe
whether osteoarthritis of the adjacent talocrural joint subsequently
occurs. To prevent reverse deformity, we currently perform tendon
lengthening and suture of the posterior tibial muscle in the medial
side of the foot. We believe that this surgical procedure is necessary
to prevent recurrence of equinovarus associated with spina bifida in
children.
The limitations of this case series is that only six feet were
investigated and these cases had short-term follow-up.
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