Treatment of residual deformities in resistant clubfoot remains challenging. Many patients have undergone prior surgical procedures, leading to scarring of the skin and soft tissues. Complications such as skin necrosis, difficulty in manipulating the medial side due to scarring, cartilage, or physeal damage to the growing bone can occur following reoperations [10
]. We describe how correction of forefoot adduction and midfoot supination can be achieved without medial osteotomy for children younger than 5 years when the cuneiform ossific nucleus is not well-developed and provide short-term clinical and radiographic findings.
The limitations observed in this study include the small number of patients and the short duration of followup with mean follow up of 2.6 years (range, 2–3.2 years). The long-term outcome of this procedure therefore remains unknown. Pohl and Nicol reported one case of recurrence at 2 years, attributed to the collapse of the medial graft [15
], however, Schaefer and Hefti observed a tendency to adduction deformity with longer followup [17
]. Another limitation arises from the qualitative clinical outcome measures based on parents’ perceptions and visual assessments. These qualitative assessments were, however, supplemented by the more objective radiographic measures.
The essential deformity in residual clubfoot is the length disproportion between medial and lateral columns of the foot [1
]. Although the Ponseti serial casting technique has been effective in correcting even neglected clubfeet [13
], surgical procedures may be needed to correct more rigid and structural deformities. We chose not to perform the medial opening wedge osteotomy since all of the children were younger than 5 years old with a less than well-developed medial cuneiform ossific nucleus. In addition, we believe that it would be difficult to locate the exact site for the medial osteotomy and would possibly disturb the medial column growth plate as well as increase the risk of medial graft extrusion in a cartilaginous area. Nonetheless, correction of adduction deformity in our series was comparable to others radiographically [5
] (Table ).
Data comparison with other series
We believe the medial cuneiform opening wedge osteotomy should still be performed in older children once the ossific nucleus is well-defined, for a better correction of forefoot adduction deformities. Addressing the medial side for older children may have the benefit of handling the following issues: (1) the abductor hallucis longus, which can be a deforming force; (2) cavus component of the deformity is often present, thus the ability to perform a plantar fascia release from the medial side; (3) a Z-plasty can be performed at the medial scar if the previous scar is contributing to the deformity; (4) performing a medial cuneiform—1st metatarsal capsulotomy which may help correct the forefoot adduction deformity; (5) lengthening the medial column with an opening wedge medial cuneiform osteotomy may improve long-term results in the older child (> 4 years of age); and (6) as noted by Ponseti [16
], the anterior tibial tendon can often be a supination deforming force, therefore, the anterotibial tendon transfer to the mid-foot (Garceau procedure) at the time of the double-tarsal osteotomy can be performed [16
The minimal access was an added advantage to our procedure whereby only a small lateral incision was made for cuboidal wedge osteotomy. Using the same approach, the trans-midfoot osteotomy was subsequently performed under an image intensifier using a Kirschner wire and osteotome. This ensured minimal disruption to the soft tissue on the medial side of the foot.
Numerous types of osteotomies and their combinations have previously been described for correction of forefoot adduction and midfoot supination. Johanning in 1958 described wedge resection and enucleation of the cuboid to shorten the lateral column, followed by manipulation and casting as treatment of resistant clubfoot [9
]. Lengthening of the short medial column had also been described by Hofmann et al. where medial wedge cuneiform osteotomy corrected the forefoot adduction but did not easily address the supination [8
In 1991, McHale and Lenhart [14
] first described the combination of a shortening osteotomy of cuboid and elongation of cuneiform. Supported by cadaveric study, they suggested the cuboid closing wedge corrected the midfoot, whereas the cuboid and cuneiform osteotomies both contributed to the correction in the forefoot [14
]. Kose et al., using cadaveric and clinical studies, reported a combination of three procedures namely transmidtarsal, closing cuboidal, and opening cuneiform wedge osteotomy [10
]. The added advantage of the trans-midfoot procedure was to allow correction of the rotational component as it was centered at the apex of the deformity. Therefore, these combinations allowed corrections of three planes to be made simultaneously. However, this method did not address the residual hindfoot varus. Pohl and Nicol adapted the technique by exiting the osteotome at the apex of cuboid osteotomy and reported similar results with a reliable correction of adduction and supination [15
] (Table ).
Lourenco et al. subsequently reported their series of treatment of residual adduction deformity in clubfoot by double osteotomy and advocated that surgery should be reserved for children older than 4 years of age when the medial cuneiform ossific nucleus is well-developed [12
]. Using similar techniques, Gordon et al. [5
] stated a success rate of 90% improvement in both clinical and radiographic evaluation. They, too, recommended that the procedure should be reserved for patients age 5 years or older.
We found the combined closing wedge cuboid and trans-midfoot rotation osteotomy had a low rate of complications and reasonably corrected residual forefoot adduction and midfoot supination. We believe this combination is useful for children younger than 5 years of age in whom a medial cuneiform ossification center is not well-developed.