Orthopedics - Oleksa A.P. 2006

Congenital and Acquired Deformities of the Lower Extremity
Orthopedic Deformities of the Foot
Congenital Clubfoot (talipes aequino-varus congenita)

Clubfoot (talipes equinovarus) is a severe FOOT deformity that distorts its shape and severely impairs static and dynamic function (Fig. 193).

Among congenital orthopedic deformities, clubfoot, alongside developmental Dysplasia of the hip, holds a leading position. L.E. Rukhman and Bessel-Hagen note that one case of clubfoot occurs per 1,000–1,100 births, occurring twice as often in boys (62%) as in girls.

Congenital clubfoot can be unilateral, but is more frequently bilateral (59%). In 10 percent of cases, clubfoot is associated with other anomalies (Syndactyly, amniotic bands, Torticollis, etc.), which points to it being a sign of a congenital developmental defect that may be caused by multiple factors: genetic, endogenous, and exogenous.

It is worth noting that attempts to determine the cause of clubfoot date back to the time of Hippocrates, who attributed it to dislocations in the JOINTS OF THE foot. Later, other theories emerged, among which the biomechanical, neurogenic, and vascular theories, as well as genetically determined inheritance, remained plausible.

Among the biomechanical Factors influencing the intrauterine position of the feet can be the pressure exerted by amniotic bands (which is why clubfoot may be combined with such bands), pressure from the umbilical cord wrapped around the foot, pressure of the uterine walls on the lateral surfaces of the fetus's feet when Amniotic Fluid is scarce, and uterine tumors, among others.

The neurogenic theory explains the occurrence of the neurogenic form of clubfoot by Spina bifida and myelodysplasia, as well as irritation of the Spinal Cord resulting from its tethering by adhesions and tension during fetal growth. This, in turn, leads to clubfoot because the center of innervation for the Muscles that supinate and flex the foot is located lower than that of their antagonists. Neurogenic clubfoot may be accompanied by lumbosacral hypertrichosis, a sacrococcygeal dimple (fovea coccigea), sensory disturbances in the lower extremities, and pelvic organ dysfunction.

M.I. Kuslik identifies delayed Development of the peroneal Muscle group as one of the etiological factors of clubfoot. When their function is impaired, the antagonistic Muscles Attached to the medial border of the foot (m. tibialis post.) cause adduction and supination of the foot, while the m. triceps surae, having a mechanical advantage over the extensors at that time, causes equinus of the foot.

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Fig. 193. Congenital bilateral clubfoot.

D.R. Hootnick et al. (1994) point to underdevelopment of the anterior tibial artery (a. tibialis anterior) as a factor in The Development of clubfoot, whereas Ippolito and Ponsetti (1980) attribute the deformity to fibrositis of the fascia and muscles.

Toxoplasmosis and other harmful factors are also considered to play a role in the onset of clubfoot (N.A. Balakina, 1960).

It is known that congenital clubfoot can be inherited, a fact pointed out by S.L. Tregubov in his 1938 monograph "Orthopedics," where he illustrated this statement with a photograph of patients with clubfoot across three generations.

The aforementioned theories regarding the Etiology of clubfoot are valid, as correctly emphasized by A.Ye. Frumina, K.N. Kornilova, Kirmisson, and others. They should not be set in opposition, as each explains a particular form of clubfoot. For instance, the biomechanical theory applies to mild and moderate forms. Severe and recurrent forms are explained by primary developmental defects, as well as amniotic and neurogenic origins.

Consequently, congenital clubfoot can stem from various etiological and pathogenetic origins, which is confirmed by the wide variety of deformity forms.

Clinically, clubfoot is characterized by a foot deformity comprising three main components:

1) adduction — inversion of the forefoot;

2) supination — inward Rotation of the foot around its longitudinal axis;

3) equinus — plantar flexion of the foot.

Adduction is the inward rotation of the forefoot in the Lisfranc and Chopart joints; hence, the medial border of the foot is concave, shortened, and sometimes features a pronounced Adams crease. Conversely, the lateral border of the foot is convexly arched and elongated.

As a result of supination, the medial edge of the sole is elevated, while the lateral edge is depressed. Equinus results from the shortening of the triceps surae muscle and its tendon, which pulls the heel upward and drops the forefoot.

The center of the deformity is the talus, which articulates with other bones and undergoes deformation. The severity of clubfoot is determined primarily by THE POSITION OF the talus relative to the calcaneus and the hindfoot (Fig. 194). As B.I. Popov (1935) stated, "until the talus is reduced into the ankle mortise during manipulation, neither supination, equinus, nor varus will be properly corrected." Restoring the position of the talus leads to the restoration of the foot's shape and function.

Clinical manifestations of clubfoot vary depending on the severity of individual components, associated deformities (such as a transverse crease of the sole at the level of the Chopart joint, knee valgus, the degree of muscle atrophy, and nerve status, etc.).

In untreated children, the foot deformity increases sharply when they begin to walk. Under METABOLISM/18.html">The Influence of gravity, all deformity components progress, leading to a gradual bone transformation. The compressed bones on the medial side of the foot fail to grow and remain flat, whereas on the opposite lateral side they are unconstrained and grow rapidly, losing their normal anatomical dimensions and shape.

During walking, weight-bearing areas on the dorsolateral surface — over the tuberosity of the fifth metatarsal, the cuboid, and the HEAD of the tarsal bone, i.e., along the axis of the lower leg — develop callosities (thickening of the Skin resembling a sole) enclosing an enlarged bursa.

Fig. 194. Normally, the axis of the talus passes through the middle of the navicular bone, whereas in clubfoot, it passes along its lateral side.

Patients with clubfoot exhibit a peculiar, unsteady, and awkward gait. They walk in short steps, swinging their arms and keeping their trunk and lower limbs straight; they swing the adducted feet one over the other while their hips are somewhat abducted and laterally rotated. Over time, the knee joints also become valgus and hyperextended.

The human center of gravity is normally located between the ankle joint and the third metatarsal bone. In patients with clubfoot, it shifts to the middle of the ankle joint or 1–2 cm posterior to it. This leads to an upright posture of the entire body, increased lumbar lordosis, and recurvatum of the knee joints.

The lower part of the leg is slightly medially rotated, the lateral malleolus (malleolus lateralis) is turned anteriorly, and the medial one posteriorly. Movements in the ankle joint occur not in the sagittal, but almost in the frontal plane (Zatsepin T.S., 1947) and are severely restricted. The leg muscles are markedly atrophied, and during walking, the patient pushes off the ground by exerting not only the calf muscles, but also the anterior and posterior tibial muscles and the long toe flexors. Continuous overstrain of the flexor hallucis longus and loading of the anterolateral border of the foot cause a transverse bend—an inflection of the foot.

Radiographic examination clarifies the spatial relationships of the foot bones in clubfoot, the degree of talar subluxation, etc. (USA 806, Matzen 303, 304).

Classification of clubfoot.

The various types of clubfoot need to be differentiated, as their clinical course and Treatment outcomes vary.

As early as 1937, G.S. Bohm proposed a clinical classification dividing congenital clubfoot into nine groups: 1) late form; 2) neurogenic form; 3) form with an elevated and underdeveloped heel; 4) amniotic form; 5) defective form (bone defect); 6) metatarsus varus (adductus); 7) clubfoot associated with Arthrogryposis; 8) clubfoot associated with Achondroplasia; 9) recurrent clubfoot.

This classification is based on heterogeneous signs of clubfoot, which is its main drawback.

The most convenient and straightforward is the classification by T.S. Zatsepin (1947). He distinguishes two main forms of congenital clubfoot: typical and atypical. The typical form accounts for 75–80% of all clinical cases. It includes clubfoot without other developmental defects and congenital anomalies. Figure 195 schematically illustrates the arrangement of the foot bones in typical clubfoot.

Atypical forms of congenital clubfoot are combined with other congenital anomalies and account for 25% of cases. These include arthrogrypotic clubfoot, amniotic defects, clubfoot with bone defects, etc.

T.S. Zatsepin believed that atypical forms of clubfoot stem from pathological embryonic development or primary primordium defects, making them harder to treat, with a higher probability of recurrence.

Zatsepin divides typical forms of congenital clubfoot into: 1) mild contracture-type cases; 2) rigid bone forms that are more difficult to correct by manipulation; 3) soft-tissue (ligamentous) forms, in which the skin remains mobile and pliable when attempting to correct the deformity.

Fig. 195. Schematic arrangement of the foot bones in typical congenital clubfoot: A — first metatarsal bone, B — talus, C — navicular bone, D — cuboid bone.

This classification also has several drawbacks: it is sometimes difficult to determine the form of clubfoot in older children; the soft-tissue form transitions into the bone form as the child grows; inherited forms of clubfoot are not accounted for, etc.

V.F. Luchko (1963) supplemented this classification with a grading system for the severity of clubfoot manifestations, specifically its main components:

1) mild clubfoot — adduction of the distal foot up to 150°, supination up to 150°, equinus up to 120°. Patients step on the anterolateral part of the foot and toes;

2) moderate deformity — clubfoot with adduction within 150–120°, supination 150–130°, and equinus 120–130°. Patients typically step on the anterolateral border of the foot;

3) severe clubfoot — deformities with adduction of less than 120°, supination of less than 130°, and equinus of more than 130°. Patients with this degree of deformity step on the rear part of the foot, the region of the tuberosity of the fifth metatarsal bone, the cuboid bone, and the head of the talus.

Since the center of deformity in clubfoot is the talus, which is in a sub talo subluxation, early restoration of its normal position is a prerequisite for eliminating the Other components of the deformity and restoring foot function.

The choice of treatment method depends on the severity of the clubfoot. Overstretched and weakened pronators must be strengthened for a long time after the deformity is corrected; sometimes they need to be reinforced by tendon transfer of the tibialis anterior muscle to the third or fourth metatarsal bone.

A variant of congenital clubfoot is pes metatarso-varus. In this deformity, the hindfoot and tarsus remain unchanged, and the heel may even be in pronation. The cuneiform bones are displaced laterally, the bases of the Metatarsal Bones are brought closer together, and their heads are deflected medially, sometimes dorsally.

Pes adductus also deserves attention, manifesting solely as metatarsal adduction (Bogdanov F.R., 1963).

These two deformity forms can be bilateral and are more frequently observed in boys.

A clubfoot is not merely a cosmetic defect. Affected children struggle with squatting and walking on their toes, and while running, the deformed foot catches against the opposite leg.

Treatment. The therapeutic approach to congenital clubfoot has evolved and been refined alongside scientific advancements and the accumulation of clinical experience.

Treatment in infancy focuses on restoring the shape of a typical clubfoot. Atypical forms require an individualized choice of method, although they also begin with correcting the foot's alignment.

In the past, A. Ye. Frumina (1948) and M. S. Myasnikov (1958) insisted that adduction and supination of the foot must be corrected first, and only then equinus. However, this view is untenable, as clinical experience demonstrates that all components of clubfoot must be corrected simultaneously—primarily supination and equinus—while correcting the adduction of the distal foot does not strictly require addressing equinus first.

Treatment should be initiated as early as possible. According to Osten-Sacken (1926), "the functional adaptation of muscles and ligaments is particularly evident in the corrected clubfoot During the first weeks of an infant's life." This is facilitated by intensive growth, tissue plasticity, and their capacity for subsequent remodeling when the foot is held in the correct position. The older the child, the more challenging the treatment becomes.

Conservative treatment Methods have progressed through several stages. While Hippocrates treated clubfoot through gradual, gentle manipulation, the Introduction of anesthesia to eliminate pain and technological advancements—particularly in the late 19th century—led to the development of mechanical redressors (Velpeau, Putti, Szulze, Lorenz, and others). Lorenz's osteoclast-redressor, the Schultze board, König's wedge, and Thomas's wrench gained widespread use in correcting clubfoot.

Mechanical redressors were used to forcefully correct neglected clubfeet in adolescents, sometimes until a crunching sound was heard—indicating compression fractures of the bones—followed by the application of a plaster cast. This approach frequently led to complications such as epiphyseal Displacement of the Tibia, skin necrosis, and joint stiffness.

S. F. Godunov (1940) even described a case of forced amputation following a single-stage mechanical redressase. This method was condemned by Turner, V. A. Sturm (1947), H. Debrunner (1957), and essentially all orthopedic surgeons, retaining today only historical significance.

Modern practice relies exclusively on atraumatic treatment methods for clubfoot, avoiding anesthesia and force through gentle, manual progressive redressments of the foot, starting right in the maternity ward during every feeding and diaper change.

It is essential to explain The Nature of the deformity to the mother, along with the principles of correcting the deformed foot and bandaging it in the corrected position. Once the infant's skin becomes fully normal and resilient, typically around 2 to 3 weeks of age, redressment is performed by an orthopedist.

Technique of Redressment. Using the hand opposite to the affected limb, the practitioner holds and depresses the heel, while the other hand grasps and corrects the distal foot—eliminating supination by rotating the foot and abducting the adducted forefoot with the palm. Simultaneously, the thumb presses against the sole at the PROJECTION OF THE cuboid bone (Fig. 196) to enhance foot pronation and correct equinus, assisting the other hand in depressing the heel. To correct equinus, pressure must not be applied to the area of the metatarsal heads, as this can create a "rocker-bottom foot" due to buckling at the Lisfranc and Chopart joints. A rocker-bottom foot is a severe secondary deformity with poor outcomes, as it is notoriously difficult to treat.

Redressment must be performed without damaging soft Tissues, merely stretching them. Through repeated, uniform, and targeted Movements of the foot, the deformity is gradually corrected until a reduction in resistance is felt. It is crucial to immobilize and maintain the achieved correction.

In the past, Eitingen secured the foot using flannel bandages coated with mastisol. Kuslik supplemented this by anchoring a bandage from the thigh to a torso vest. The Fink-Cindepen bandaging method was also employed. T. S. Zatsepin (1947) applied this type of fixation after the umbilical wound healed. Fixation of the corrected foot using bandages alone as an independent method failed to yield satisfactory results, as success was achieved in only 18–20% of children.

A. Ye. Frumina (1947) began immobilizing feet with plaster casts (booties) following manual clubfoot redressment, starting at four weeks of age. She dispelled groundless preconceptions and fears regarding the application of plaster casts to infants. Progressive redressments, frequent changes of the plaster booties, and proper infant care effectively prevent any complications.

Fig. 196. Correction of clubfoot with simultaneous pressure applied to the cuboid bone.

Plaster booties were applied following foot redressment from the second month of life at the Turner Institute, starting on the 20th day according to V. P. Yevdakova (1958), and on the 14th day after birth according to T. F. Ganzhulevich (1957).

Following redressment, we apply a padded plaster boot cast to infants between two and three weeks of age, depending on the General condition of the child and the state of the limb skin. Additionally, starting in the maternity ward, we recommend immobilizing the feet with bandages after each redressment session.

During the application of the plaster cast, the physician maintains the foot in the corrected position with the knee flexed to minimize equinus. To correct the adduction of the distal foot, a clamp or hook is used to pull the hardening plaster cast outward near the fifth toe and slightly into pronation (Fig. 197). The toes must remain visible beyond the edge of the boot cast so parents can monitor Blood Circulation and ensure the foot does not slip upward, given that treatment is conducted on an outpatient basis.

To prevent infants with tiny feet from "slipping out" of the cast, it is sometimes necessary to extend the plaster immobilization up to the middle third of the thigh with the knee flexed.

Fig. 197. Pulling the hardening plaster cast laterally (into abduction) and into pronation of the redressed foot.

At two to three months of age, redressments with cast changes are performed every 5–6 days, and later every 8–10 days or longer. Prior to each redressment, a warm bath and massage of the calf muscles are administered.

Redressments are continued until hypercorrection of all Components of the former deformity is achieved. However, achieving hypercorrection does not yet indicate the complete resolution of the clubfoot.

According to A. Ye. Frumina, treatment is considered complete only when the child is independently able to actively dorsiflex, abduct, and pronate the foot.

Since clubfoot can recur, children are prescribed orthopedic footwear—specifically, high-top shoes with firm counters and toe boxes (on the medial side), thickened lateral soles, and no heels.

Children are given muscle massage and thermal treatments, and overnight application of plaster or plastic splints is recommended to hold the feet in hypercorrection. Due to the possibility of deformity relapse, children must wear orthopedic shoes for 4–5 years.

Treating infants with clubfoot in rural areas remains a challenge, especially in winter. In such cases, patients must be hospitalized and undergo

manual redressement in a hospital Setting. Once the primary components of clubfoot are corrected, treatment is continued on an outpatient basis.

Timely application of this clubfoot treatment method achieves success in 97% of children.

Western European, particularly British, orthopedists are critical of treating clubfoot with plaster casts. We agree with them that weakened foot pronators and extensors atrophy even further from inactivity inside a plaster cast. Therefore, the functional method proposed by Browne (Browne D., 1952) and its modifications could be implemented in Ukraine, provided they are first refined and industrial production of the necessary treatment devices is established.

The Essence of these methods lies in The Use of functional splints, such as those by Thompson or Kendrick, which feature a mobile sole with lateral flanges to correct foot supination and adduction (Fig. 198), as well as mobility at the ankle joint projection to correct equinus.

According to Browne, his treatment method stimulates the active function of the pronators and gradually stretches the soft Tissues of the medioposterior aspect of the foot. The SOLE OF THE splint is fixed to the foot with the adduction corrected. Supination is corrected by a connecting bar attached to the soles of the splints. Abduction and lateral rotation of the feet in the splints can be progressively increased. Such fixation allows for limited foot movement in all correction planes.

It should be noted that treating clubfoot with a duralumin sole has certain drawbacks. Treves (Treves A., 1952) points out that treating unilateral clubfoot deforms the healthy foot, while Rettig (Rettig H., 1956) observed skin irritation on the lower leg caused by the adhesive plaster used to secure the splint to the foot. Another disadvantage is the need to frequently replace splint sizes as the child grows.

Following functional treatment, children must also wear orthopedic shoes.

It is worth noting that functional treatment for clubfoot was previously used in Kharkiv by M. H. Zelenin and described by E. H. Raskina and A. D. Dolynska in 1935.

The essence of the method consisted of applying a splint to the sole and securing it to the lower leg with a flannel bandage using mastic adhesive, hence the name "tar bandage."

In the 1980s, other functional splints were proposed (such as Vilensky's polymer splint, Feoktistov's, and others), which ensure active movement in the ankle joints and direct Muscle Action toward correcting the deformity.

However, because these functional splints are not yet mass-produced or widely used in clinical practice today, manual redressement combined with foot fixation using plaster boots remains the standard approach.

We consider the timing of the initiation of foot redressement—and ultimately the restoration of pronator function—to be decisive for the outcomes of conservative clubfoot treatment.

Fig. 198. Right-sided functional splint for clubfoot correction.

However, complete correction of all clubfoot components, especially equinus, is not achieved in all patients.

Relapses of equinus and, occasionally, foot supination also occur in clinical practice. In such cases, Surgical treatment is applied after appropriate preparation. Untreated children with neglected clubfoot cases are also operated on, although this is extremely rare nowadays.

All surgical interventions are divided into three groups:

1) soft-tissue surgeries (lengthening of the Achilles tendon, relocation of the tibialis posterior muscle insertion, Operations on the tendo-ligamentous and capsular apparatus, muscle tendon transposition).

2) bone surgeries;

3) combined bone and soft-tissue surgeries.

Lengthening of the Achilles tendon is the most frequently performed Procedure.

Achilles tendon lengthening is performed after adduction and supination of the foot have been corrected, provided that equinus does not respond to conservative correction for a certain period of time.

According to Debrunner (1957), a four-month failure to correct equinus deformity through manual repositioning is an indication for achillotomy. He considers 4 to 8 months of age to be the optimal time for this procedure. Frumina performed Achilles tendon lengthening at the end of the child's first half-year of life, Fonaryov B.M. (1939) and Bakov P.I. (1936) at the end of the first year, while Zatsepin T.S., Kornilova K.N., and many others allowed it to be performed at later dates.

Surgical technique. Under anesthesia, a linear skin incision is made along the Achilles tendon, and the tendon is exposed via a longitudinal incision of its sheath. Some orthopedic surgeons perform a Z-lengthening of the tendon in the sagittal plane according to Bayer, justifying this by the ability not only to precisely dose the lengthening, but also to detach its medial half inferiorly above the heel, which facilitates the lateral displacement of the traction vector on the calcaneus. If necessary, achillotomy is supplemented with capsulotomy. Fig. 199 shows a sagittal section of the Achilles tendon with the detachment of its half from the calcaneus (A) and following capsulotomy (B).

Frumina, Debrunner, and Matzen performed Z-lengthening of the tendon in the frontal plane.

To avoid damaging the bone epiphyses, the calcaneus is depressed using a single-hook retractor. Suturing the tendon with the foot at a 90° angle relative to the lower leg is considered optimal for Muscle Function. Excessive lengthening leads to Atrophy of the gastrocnemius muscle and sometimes The formation of a calcaneal foot. If the foot cannot be brought into the correct position during surgery, a posterior capsulotomy of the ankle joint must be performed. The displaced ends of the tendon are connected with several sutures, and the wound is closed. A short-leg plaster cast is applied at a 90° angle with slight pronation of the foot.

It is worth noting that in the past M.I. Kuslik, and even today some orthopedic surgeons, perform closed achillotomy. It is believed that this method preserves the tendon sheath and, consequently, its blood supply, while avoiding constrictive scarring. In addition, this is a minimally invasive intervention (the skin is incised to the width of an "eye" scalpel) that can be used in the youngest children.

If foot supination does not respond to conservative correction, surgery is required: transposition of the insertion site of the tibialis posterior tendon, which supinates the foot, Supports the longitudinal arch, and acts as a plantar flexor.

Under anesthesia, a linear incision is made along the Medial surface of the foot distally from the tip of the medial malleolus. The tendon of m. tibialis posterior is exposed along with its broad insertion (Fig. 199), which attaches to the medioplantar surface of the navicular and first cuneiform bones.

The tendon is then sharply detached from these bones, supination is corrected (with capsulotomy between them if necessary), and the tendon is sutured to the dorsal aspect of the navicular bone. Afterward, a plaster or plastic short-leg cast is applied with the foot in the corrected position.

This procedure can be performed in one-year-old children in whom foot supination could not be fully corrected by manual manipulation.

Back in 1939, T.S. Zatsepin developed a surgical method targeting the tendoligamentous apparatus, which was subsequently updated in 1954. It is performed in cases of conservative treatment failure and clubfoot recurrence.

Surgical technique. The operation is performed under anesthesia with a thigh tourniquet while the patient is in the prone position. The first linear tissue incision according to Turco (Turco V.J., 1979) is made through the middle of the medial malleolus, starting from the transition of the sole to the medial surface and ending 2-4 cm above the malleolus. The flexor retinaculum is divided, and the tendons of the tibialis posterior and flexor hallucis longus are lengthened. Next, the entire Ligamentous apparatus of the medial side of the ankle joint is transected.

Through a second incision along the posteromedial surface, the Achilles tendon is lengthened via a Z-cut in the sagittal plane. It is advisable to detach the medial part of the tendon near the calcaneus and the lateral part near the muscle.

Protecting the neurovascular bundle and retracting the ends of the tendon, the surgeon reaches the talocalcaneal and posterior talotibial ligaments. These ligaments and the Joint Capsule are then incised.

During foot repositioning, any remaining intact ligaments (such as the interosseous talocalcaneal ligament) are ruptured.

If the talocalcaneal ligament does not rupture on its own, it must be surgically divided. All of this makes it possible to release the talus along the posteromedial surface and achieve its complete correction. If significant adduction of the forefoot persists, the tendons of the abductor hallucis and flexor hallucis brevis are lengthened. Only after the foot is fully corrected are the tendons and wounds sutured. A padded plaster cast is then applied.

Fig. 199. Diagram of exposing the insertion site of the m. tibialis posterior tendon (a), and lengthening transection of the Achilles tendon (b).

A drawback of Zatsepin's procedure is the close proximity of the incisions, which sometimes compromises the Blood supply to the Skin bridge between them. Blood circulation is especially impaired due to the tension of the sutured wounds and the corrected position of the foot. This can lead to Necrosis of the wound edges and slow healing by secondary intention. Scars resulting from granulating wounds along the medial surface of the ankle joint may cause a recurrence of the deformity.

To increase the width of the skin bridge, the skin incision is made not through the middle of the medial malleolus, but along its anterior border. Naturally, the greater distance between postoperative scars improves the gliding conditions for the lengthened tendons.

Similar to Zatsepin's operation in its principle of eliminating obstacles in the medioposterior region of the clubfoot is the procedure by B.A. Sturm (1951), designated by the author as tenoligamentocapsulotomy. It is also performed using two incisions.

The first tissue incision begins 1.5-2 cm above and posterior to the tip of the medial malleolus, extends forward, and reaches the joint between the first cuneiform and metatarsal bones. The tibialis anterior tendon is Z-lengthened or transected if its transposition is planned. The tendons of the tibialis posterior and flexor digitorum longus are also lengthened.

Following this, the ligament apparatus and capsules of the ankle, talonavicular, naviculocuneiform, and cuneometatarsal joints are incised. Diastasis—gaping gaps—forms between the bones in these joints.

Where bones remain in contact due to mutual pressure, they grow more slowly, whereas areas of diastasis exhibit a sharp increase in bone growth, which helps align the foot.

The second incision is made along the lateral margin of the Achilles tendon, which is isolated, Z-lengthened in the frontal plane, and its ends are separated. Taking care not to damage the neurovascular bundle and the flexor hallucis longus tendon, the posterior ligaments and capsule of the ankle joint are transversely divided. Once the foot is brought into the corrected position, the tendons and skin are sutured. Foot correction is performed with the patient's knee fully extended. A long-leg plaster cast extending to the upper third of the thigh is applied for a period of 4-6 months.

Zatsepin allowed children to walk and bear weight on the leg while in the plaster cast, which, in his opinion, promoted the remodeling of the foot bones, the restoration of their anatomical shape, and the balance of muscle groups.

These surgeries were performed on children aged 8–12 years, representing neglected cases that required preoperative preparation with sequential redressions over a period of 1.5–2 months.

Frumina A.E. (1945), Luchko V.F. (1963), and others rarely saw the need to section the medial ligaments and tendons, but considered it necessary to lengthen the Achilles tendon and divide the ligaments and capsule of the posterior ankle joint.

Codivilla's procedure was widespread in Italy, performed at two years of age following conservative treatment failures or clubfoot recurrences.

Codivilla (1907) suggested dividing the soft tissues on the medioposterior aspect of the ankle joint. This was performed through a single incision extending from the midpoint of the first metatarsal bone in an arch below and behind the medial malleolus up to the lower third of the leg. The deltoid ligament and the ligaments on both sides of the navicular bone were then sectioned. Similarly, the tendons of both the tibialis anterior and posterior, flexor hallucis longus, flexor digitorum longus, and Achilles tendon were lengthened. The ankle joint was opened from the medial and posterior aspects. If the deformed talus did not fit into the mortise between the malleoli, a bone wedge of the required shape and size was excised from it. Subsequent treatment remained unchanged. The plaster cast was kept in place for up to 6 months.

In short, so many variations of soft-tissue Procedures for clubfoot have been described that even an experienced orthopedist encounters difficulties in choosing a specific method, given that unsatisfactory outcomes occur in nearly 35% of children operated on under the age of ten.

Sotirow V. (1976) believes that the cause of such surgical outcomes in most cases is the failure to properly reduce the navicular bone onto the head of the talus, which in turn prevents the correction of foot equinus and heel supination in children.

To seat the navicular bone onto the head of the talus, it is essential to derotate the calcaneus relative to the talus, thereby eliminating foot adduction and supination.

Derotation in the subtalar joint and reduction of the navicular bone onto the talar head are performed in the Garlicki clinic via a lateral approach to the foot.

The soft-tissue operation is performed through four incisions in a single stage under general anesthesia using a thigh tourniquet.

Surgical technique. The first incision, up to 1.5 cm in length, is made on the medial side of the heel to reach the plantar aponeurosis, which is isolated and detached from the calcaneus. The tendons of the flexor digitorum brevis and flexor hallucis brevis should not be detached to avoid disturbing the balance between them and the toe extensors, and to prevent the development of Hammer Toes. The wound is closed without drainage.

Through a second incision, up to 4 cm long behind the medial malleolus, the m. tibialis posterior is exposed and lengthened using a Z-plasty. One or two temporary sutures are placed in the wound.

A third incision in the lower third of the leg above the ankle joint reaches the m. tibialis anterior, which is lengthened by Z-plasty. The wound is temporarily closed with one or two sutures.

The fourth approach, passing along the lateral malleolus, reaches the prominence of the lateral cuneiform bone. After dividing the skin and subcutaneous tissue, the lig. talocalcaneum laterale, lig. talocalcaneum anterius, and lig. talocalcaneum interosseum are sectioned, along with the capsule of the subtalar joint laterally and dorsally. The tendons of the extensor digitorum brevis together with a bone fleck are then detached from the calcaneus and retracted upward. Next, the scalpel is used to divide the lig. calcaneocuboideum dorsale and the capsule of the calcaneocuboid joint. Afterward, the lig. talonaviculare, lig. deltoideum, and the capsule of the talonavicular joint are sectioned from the medial side.

When opening the joint cavities, it is essential not to damage the articular Cartilage. Once all the specified ligaments are divided, the joints become supple. Manual derotation of the calcaneus is then performed in the subtalar joint, and the navicular bone is shifted onto the head of the talus. To achieve this, the heel is grasped with four fingers of one hand and pulled laterally, while the thumb of the same hand presses the head of the talus in a medial direction. The other hand grasps the forefoot, first correcting the supination of the foot and then abducting the forefoot, thereby positioning the navicular bone onto the head of the talus. To prevent redisplacement of the navicular bone in Chopart's joint, it is fixed with a Kirschner wire inserted through the navicular and the joint into the talus. The wound is closed.

In this manner, supination and adduction of the foot are corrected, accompanied by pronation of the calcaneal tuberosity.

The operation is concluded by isolating the Achilles tendon through the second incision and lengthening it via Z-plasty, bringing the foot into 90 degrees of extension. In this position, the Achilles tendon and the tibialis posterior tendon are sutured. The wound is closed.

Next, the tibialis anterior tendon is sutured, and the wound is closed.

Following surgery, a boot-type plaster cast is applied up to the middle third of the thigh. After three weeks, the Kirschner wire is removed by pulling on its end protruding above the skin.

After eight weeks, children are allowed to walk in the cast with weight-bearing, for which a weight-bearing wooden sole ("heel") is incorporated into the plaster. The plaster cast is removed after 3.5–4 months, and rehabilitation therapy is prescribed. To prevent clubfoot recurrence, patients must wear orthopedic shoes for 3–4 years or longer and remain under orthopedic supervision.

Regarding the surgical lengthening of the long toe flexor tendons performed by Zatsepin S. (1949), Marciniak W. (1964), and Boychev and Gertchev (1970), this remains a controversial issue within the described surgical method, while Sotirow S. considers it optional and even unnecessary.

Very frequently, in neglected untreated cases of clubfoot, bone surgery is required to improve foot function and weight-bearing capacity.

Miller W. (1912) proposed transplanting a bone wedge, harvested from the lateral convex border of the foot, into a cleft created in the navicular bone in children. In this way, adduction is corrected without shortening the foot.

Particularly during World War II, the number of untreated clubfoot patients increased sharply, bringing about various age groups of affected children and adolescents. First and foremost, it should be noted that during that time, the number of qualified orthopedists and hospitals grew each year, improving the quality of care for patients with musculoskeletal disorders. In the postwar years, surgery was predominantly performed on untreated children with clubfoot.

Nowadays, early detection (beginning in the maternity hospital) and treatment of congenital anomalies have become standard practice for all physicians. Children undergo early conservative treatment, and soft-tissue surgery for clubfoot has become acceptable—particularly closed lengthening of the Achilles tendon starting from six months of age. Sturm's ligamentocapsulotomy was widely practiced. However, a significant number of adolescents and even adult patients with clubfoot still required soft-tissue and bone reconstructive procedures.

Skeletal surgeries should be performed in patients where bone deformities represent the primary obstacle to restoring the normal shape and weight-bearing capacity of the foot. Such a need arises in cases of severe deformity in neglected clubfeet or their recurrences.

Among the proposed procedures, foot resections (wedge, crescentic, and fragmentary) were most frequently performed in clinical practice, whereas tarsal excochleation was rarely used.

A long time ago (1902), the Ogston excochleation procedure was performed on the Tarsal Bones. Through a dorsolateral approach, the talus and cuboid bones were exposed, and cancellous bone was scooped out from them using a Volkmann spoon through an opening. The articular surfaces of the bones remained undisturbed during foot redressement, as hollowed-out bones compress easily without excessive force, thereby eliminating foot deformity. However, this operation did not become widespread due to frequent relapses of clubfoot and significant deformation of the operated bones (Popov B.P., 1935; Frumina A.Ye., 1936; Debrunner H., 1957).

The correction of the talus was considered more appealing, since its deformation and displacement are particularly often the cause of clubfoot recurrences (Rubinstein B.V., Kornilova K.N., 1951).

Following the modeling reconstruction of the talus (restoring its shape) and the correction of its alignment and proper position within the ankle mortise, normal bone relationships are achieved, and the range of foot motion reaches up to 45. These surgeries were performed in school-aged children. For neglected forms of clubfoot, wedge resection of the foot—originally proposed by Weber and later slightly modified by Kocher—was most commonly applied.

Nowadays, such severe and neglected clubfoot deformities are rarely seen because children are successfully treated in early infancy; nevertheless, we provide a Description of the surgical technique for wedge resection.

Using a semi-arched tissue incision extending from the lateral malleolus to the tendons of the extensor digitorum longus, the BONES OF THE midfoot are exposed.

When calculating the width of the wedge, Wreden proceeded from the assumption that its apex is located at the projection of the navicular tuberosity, while its base lies in the region of the cuboid and cuneiform bones. The size of the wedge base depends on the degree of foot adduction as well as supination. Therefore, the posterior osteotomy plane must be perpendicular to the axis of the hindfoot, while the anterior plane should be perpendicular to the axis of the forefoot. By directing the Base of the wedge dorsolaterally, equinus and foot supination are eliminated, In addition to correcting the adduction of the forefoot.

The resected bone surfaces are adapted and fixed with Kirschner wires, followed by the shortening of the peroneal tendons. A short leg plaster cast is applied for 1.5–2 months.

The drawback of this procedure is the shortening of an already short foot and the persistence of deformity in the hindfoot. Equinus and, to some extent, heel supination remain.

As Frumina points out, consequently, Hohmann proposed a horizontal resection of the calcaneus in order to eliminate supination.

It is also worth mentioning an older procedure—the crescentic midtarsal resection according to M.I. Kuslik (1927). The surgical approach to the tarsal bones is the same as in wedge resection, but it is performed using a spherical osteotome. The proximal osteotomy plane extends laterally and posteriorly, running forward across the entire foot into its medial region. The distal plane is made 0.5 cm posterior to the Chopart joint until it intersects the proximal plane at the medial border of the foot. Thus, the base of the wedge faces superiorly and laterally, while the apex points inferiorly and medially.

Kuslik does not specify the exact width and localization of the wedge. They are determined individually, on a clinical basis, while the Lisfranc and Chopart joints remain unharmed.

After removing the wedge, redressement of the forefoot is performed, and the resected surfaces are approximated. Sutures are placed in the periosteum, and the peroneal tendons are shortened. The foot is immobilized in a plaster cast in a position of overcorrection.

The advantage of crescentic resection over wedge resection lies in the minimal loss of Bone tissue, while the correction of the forefoot is achieved primarily through lateral displacement and good adaptation of the osteotomy and resection planes.

Furthermore, this operation successfully corrects feet in children, and R.Z. Sheygam (1950) observed no subsequent retardation in foot growth.

Crescentic resection was performed in both adults and children presenting with significant bone alterations and in cases where surgery on the tendo-ligamentous apparatus proved ineffective.

In the treatment of clubfoot, it is essential to restore not only the shape of the foot but also its function. Therefore, surgical interventions should aim for minimal bone tissue loss without damaging the articular surfaces.

To this end, wedge resections of the talar neck and fragmentary resections are performed in adolescents and adults. The resection is indicated in patients where a bony prominence on the dorsolateral surface of the talus impedes the extension of the clubfoot.

The resection is performed extra-articularly. Near the capsule of the ankle joint, the bone is transected with an osteotome from top and side downwards, perpendicular to the body of the talus. The second osteotomy of the neck is performed near the base of the head—externally, superiorly, and anteriorly, i.e., at an angle to the plane of the first osteotomy. Thus, the base of the wedge faces the dorsolateral side of the foot. The size of the wedge depends on the degree of foot deformity and the patient's age.

After removing the wedge, the bone contact planes are adapted through redressement, and forefoot adduction and supination are eliminated. A short leg plaster cast is applied for 1.5–2 months.

A.Ye. Frumina (1936) performed a fragmentary resection, which involved removing small pieces of bone from the talus, calcaneus, and cuboid while preserving their articular surfaces. Although logically sound, this procedure did not gain widespread support because it is laborious and technically demanding to execute.

While preserving the joints in clubfeet is rational during childhood, arthrodesis of the tarsal joints is frequently performed in adulthood. This operation corrects the foot and prevents the development of painful degenerative osteoarthritis of the tarsal bones.

Wedge-shaped triple arthrodesis (the French "T-arthrodesis", resembling a recumbent letter T) has become widely used in adolescents and adults with rigid clubfoot deformities. The following joints are arthrodesed: subtalar, talonavicular, and calcaneocuboid. Depending on the degree of deformity, the required amount of bone tissue is excised along with the articular cartilage in order to eliminate calcaneal supination and forefoot adduction. Following surgery, a short leg plaster cast is applied with the foot in a corrected position until bone fusion occurs.

The question arises as to in which cases it is more appropriate to perform a wedge resection versus a wedge arthrodesis, and when patients with skeletal involvement can be operated on.

Numerous literary sources indicate that there are no universally accepted age limits for surgical interventions on the bones of clubfeet.

H. Debrunner considers the age between 5 and 7 years to be optimal for wedge-shaped foot resections. T. S. Zatsepin operated on the Skeleton of clubfeet starting from the age of ten. A. Ye. Frumina permitted bone interventions from the age of five, Yu. S. Kuzmin performed wedge resections of the dorsolateral border of the foot in three-year-old children, and V. A. Koyava performed them after the age of two. A. P. Nikolayev believes that the age of 13-14 is appropriate for performing a triple arthrodesis. V. F. Luchko asserts that conservative resections of the cuboid bone in significant forefoot adduction assist in clubfoot correction and can be performed starting from the age of three.

It should be remembered that during surgeries in childhood, all articular surfaces of the foot bones must be preserved.

In adolescence and adulthood, the choice of The Nature and scope of surgical intervention is determined individually. The primary objective is to ensure that the surgical method preserves the maximum amount of foot tissue and restores its functional capacity.

Occasionally, cases arise where internal rotation of the lower leg and foot persists after the completion of clubfoot treatment, representing both a cosmetic and functional defect. After clubfoot treatment is completed, correction of lower leg rotation can be performed even at the age of 4–6 years via a corrective osteotomy of both leg bones in their lower third. Lateral rotation of the lower leg is a favorable deformity and does not require correction.

In summary, the established routine practice of early detection of clubfoot in newborns (starting from the maternity hospital) and their proper conservative treatment during the first year of life make it possible to eliminate all components of clubfoot in 87% of treated children. However, children must continue to wear orthopedic shoes for another two to three years to prevent recurrence of the deformity.

In cases of equinus recurrence, which occurs most frequently, it is necessary to lengthen the Achilles tendon and, if required, perform a posterior capsulotomy of the ankle joint.

The anatomical and PHYSIOLOGICAL CHARACTERISTICS OF childhood largely preclude skeletal surgeries in patients under three years of age and limit these interventions until the age of five. At this age, operations are typically performed on the tendo-ligamentous apparatus. To minimize skeletal defects in children over five, bone surgeries are combined with procedures on the tendo-ligamentous apparatus.

In Conclusion, certain shortcomings in the Organization OF TREATMENT for children with clubfoot must be pointed out. First and foremost, mention should be made of the delayed initiation of treatment for children born at home in remote rural areas. Other factors include non-systematic treatment and treatment interruptions, particularly during the winter period when it is difficult to travel with the child to an orthopedist, or when the mother is unable or unwilling to stay in the hospital.

Timeliness and quality of treatment (a proper treatment plan, timely surgical intervention, comprehensive rehabilitation) are of critical importance for treatment outcomes, whereas shortcomings include rough, short-term manual derotation maneuvers and incomplete correction of deformities.