Subtalar realignment in congenital clubfoot using the Cincinnati approach.

GOAL OF SURGERY

Surgical correction of clubfoot through an extensive and meticulous posterior, lateral, medial, subtalar, and plantar release.

INDICATIONS

Failed conservative treatment of clubfoot at 6 months of age.

CONTRAINDICATIONS

Previous failed surgery with a different incision.

PREOPERATIVE WORK UP

Radiographs of both foot and ankle in the anterior-posterior and lateral projections.

POSITIONING AND ANAESTHESIA

Supine. Tourniquet. General anaesthesia. Free draping above the knee.

SURGICAL TECHNIQUE

Through a Cincinnati incision the Achilles tendon is exposed and lengthened and the posterior capsule excised. The talofibular and the calcaneofibular ligaments are incised and released. The plantar aponeurosis is divided and the small plantar muscles are detached. Finally a medial release is achieved having excised the abductor hallucis muscles. Release of the dorsal talonavicular joint capsule. In severe cases the calcaneoucuboid joint must also be released. The corrected position is maintained with Kirschner wires.

POSTOPERATIVE MANAGEMENT

Long leg cast with the knee bent at 90 degrees . Cast changed after 10 to 14 days. Eight weeks postoperatively removal of cast and Kirschner wires and prescription of a Dennis-Brown boot to be worn for 12 to 18 months.

POSSIBLE COMPLICATIONS

Injury to neurovascular structures. Pin tract infection. Tightness, loosening or slipping of cast. Inadequate correction and damage to articular surfaces.

RESULTS

From 1985 to 1992 60 infants (70 feet) were operated. Average follow-up was 5 years (1 to 7). Assessment of clinical and functional results was based on the Magone rating system: 60% excellent, 18.6% good, 11% fair results were obtained; 2 infants had a minor skin breakdown, 7 were undercorrected and 2 were overcorrected.