| Abstract|| |
Introduction : Postero-medial release is the most common surgical procedure used to correct the deformity of clubfoot. It has been seen that despite a good correction immediately following the surgery, the long-term results are not satisfactory.
Material and methods : A retrospective study was carried out in a total number 52 clubfeet in 36 patients treated by posteromedial release to assess the causes of failures. The mean duration after surgery was 5.1±1.2 years, mean age at operation was 1.1±0.5 years and mean age of patient at final follow up was 6.9±2.1 years. The results were plotted and compared with different variables.
Results : The results were successful in 36 and failure in 16 patients. A significantly high failure rate of 80% was found when postero-medial release was done after 3 years of age as a sole procedure as compared to 25.5% only if age was less than 3 years (p<0.05). The patient compliance to follow bracing protocol showed significantly high failure rate of 52.4% in non-compliant patients versus 16.1% in compliant patients (p<0.05). A significantly high failure rate was also seen when bracing was not continued beyond 3 years after surgery (p<0.05). Neurological clubfoot had a significantly high failure rate (80%) compared to idiopathic clubfoot (25.5%) (p<0.05). A significantly high failure rate was also noted when infection and skin necrosis lead to skin grafting or flap coverage as compared to those healed with dressings alone (p<0.05).
Conclusion : Postero-medial release achieves best results in patients of less than 3 years of age and patients with compliance for bracing for at least up to 3-4 years following surgery and idiopathic clubfoot. Infection in clubfoot does not increase the failure rate unless it is severe enough to require plastic coverage. Any deviations from the above significantly increase the chances of failure of the procedure and hence can be labeled as the causes of failures of postero-medial release.
Keywords: Postero-medial release; Failures; Clubfoot.
|How to cite this article:|
Sanghvi A V. Postero-medial release in clubfoot - A retrospective study of causes of failures. Indian J Orthop 2006;40:191-5
| Introduction|| |
Clubfoot is one of the most common congenital deformities affecting about 1 infant in every 1000 births. Worldwide approximately 1,00,000 new cases of clubfoot occur each year which if uncorrected leaves infant to face a life of disability  .
Postero-medial release is the most common surgical procedure used to correct a clubfoot deformity. It has been seen that despite a good immediate surgical correction, the long-term results of the procedure are not satisfactory. Poor results have been reported in 13 to 50% patients undergoing postero-medial release ,,,,,,,,,,,, . This is probably because other than dealing with the complex pathological anatomy and its correction, one has to also deal with an element of skeletal growth. The effect of growth upon these deformities adds a special dimension to the subject that does not exist in the adult foot  . All these deformities once corrected must be followed by some form of therapy to maintain the correction throughout the entire period of child's growth and development.
| Material and methods|| |
A retrospective study was carried out in 52 clubfeet (20 unilateral, 16 bilateral) in 36 patients (23 male, 13 female) to determine the effect of various factors on the outcome of postero-medial release. Only the patients treated by single stage postero-medial release alone without any bony surgeries were included in the study. The mean duration of follow up was 5.1 years (standard deviation, 1.2 years); the mean age at operation was 1.1 years (standard deviation, 6 months) and the mean age of patient at final follow up was 6.9 years (standard deviation, 2.1 years).
The patients were assessed clinically, functionally and radiologically. Clinical assessment included residual/ recurrent deformities, passive range of motion, and appearance of foot, muscle power testing, calf atrophy, foot size and occurrence of complications. Functional assessment included gait, functional limitation, shoe wear, pain and patient satisfaction.
Radiological assessment included measurements of talocalcaneal angles, talo-1 st metatarsal angle and talo-calcaneal index , . According to Beatson and Pearson, talo-calcaneal index is the sum of talo-calcaneal angles in anteroposterior and lateral views  .
The final results were plotted according to the scoring system of Atar et al  Results were graded as excellent for score 85-100 points, good for 70-84 points, fair for 60-69 points and failure for < 60 points.
The results of the procedure were variable among all patients because of the presence of different risk factors in different patients. The patients were then accordingly grouped into two categories of presence or absence of each factor assumed to be the cause of failure. The results were then compared between them for each factor to decide the impact of that particular factor on the outcome of treatment. The different factors had different risks of failure of procedure. The factor was considered a significantly high risk in the failure of postero-medial release for the 'p' value<0.05 calculated by chi-square test. These factors were considered as the causes of failures of postero-medial release and hence must be watched for and taken care in order to prevent a bad long-term surgical outcome.
| Results|| |
The excellent and good results were grouped together to calculate the success rate while the poor and fair results were designated as failures. In the series of 52 feet operated, 36 feet had successful outcome while 16 were failures. All failures needed further management of the residual/ recurrent deformities.
To find out the causes of failures the results were plotted in relation to different factors and difference in the outcome was assessed statistically by chi-square test with 'p'<0.05 level of significance.
On comparison with age at operation as one of the causes of failure, it was observed that although there were higher chances of failure as the age increased, the differences in the outcome were statistically not significant (p>0.05) till the age of 36 months at the time of operation.
Failure rate was significantly high in patients operated at the age more than 36 months (80%) as compared to less than 36 months (25.5%) ('p'<0.05 by chi-square test). This indicates a very important role of age less than 36 months for a better outcome of the procedure [Table - 1].
Non-compliance was defined as any patient who didn't wear braces for at least up to 3 years after surgery. The failure rate increased significantly to as high as 52.4% in patients non-compliant to bracing protocol as compared to the 16.1% only in compliant ones ('p'<0.05 by chi-square test). The success rate increased from 47.8% in the non-compliant patients to as high as 83.9% if the patients were compliant to bracing indicating a significant contribution of this factor in the outcome of postero-medial release [Table - 2].
The etiology of clubfoot significantly influenced the outcome of postero-medial release as indicated by a very high failure rate of 4 out of 5 cases in case of non-idiopathic clubfoot as compared to the idiopathic ones where only 12 feet failed out of 47 feet ('p'<0.05 by chi-square test).
The occurrence of infection in a patient didn't lead to significant increase in the failure rate ('p'>0.05 by chi-square test) [Table - 3].
The infections were graded into two categories according to the treatment required for healing them. This comparison showed a remarkable finding that any infection ultimately ending into some type of plastic surgical procedure significantly hampers the outcome of treatment. The infections healed by dressings alone had a significantly better result (83.3%) as compared to 100% failure when the infection ended into either skin grafting or flap coverage ('p'<0.05 by chi-square test) [Table - 4].
The results were also compared with regard to sex and laterality. The result was found to be successful in 16 males, 9 females, 14 unilateral patients and 11 bilaterally deformed patients. Although the results were poorer in females and in bilateral deformities the differences were statistically not significant enough ('p'>0.05) to label them as the causes of failure of postero-medial release.
| Discussion|| |
The study has projected the impact of various factors on the outcome of postero-medial release, so that the causes of failures can be properly identified and corrected. On comparison with similar series of Turco , (16% failures) and another by Thompson et al  (14% failures), the present series had higher percentage of failures (30.8%).
The postero-medial release is always considered only after the conservative management of clubfoot is unable to achieve the correction for at least within 4-6 months of trial , . The foot is usually operated just before the walking age of around 9 months to 1 year to take the advantages of physiological stimulus to the corrected foot during walking helping to maintain the correction as well as for better identification of structures of foot. The study shows that up to 3 years of age, although the failure rate increases as the age at operation increases, the differences are never significant enough (p>0.05) to contraindicate postero-medial release as a sole procedure to correct clubfoot. But when the patient is more than 3 years of age, postero-medial release alone gives significantly high failures (p<0.05).
In Turco's series  , the number of excellent results diminished as the surgical age increased beyond 2-3 years, which correlates with similar finding in present series when the surgical age increased beyond 3 years, giving supplementary evidence of effect of surgical age on final outcome. Because of this reason, age more than 3 years should be considered as a contraindication to postero-medial release as a sole procedure to correct the deformity. This is probably because as the age increases, it increases the bony deformities by constant bone remodeling in the persistently deformed position. To correct these deformities, in addition to postero-medial release, bony surgeries are also required after the age of 3 years.
The results were significantly poor if the patients were non-compliant to bracing. Any patient not using the bracing at least up to 3 years after surgery has significantly high chances of failure of postero-medial release despite initial good correction.
Similar experience with regard to patient compliance has been reported by Turco  who mentioned that feet completely corrected 2 years after surgery stay corrected. Importance of patient compliance to bracing is therefore must as we are dealing with a foot that is under constant remodeling due to skeletal growth. Any failure to maintain the correction will allow the foot to remodel once again in the deformed position making it further difficult to maintain. A strict adherence to bracing schedule is therefore must at least up to 3 years after surgery for a good outcome.
The etiology of clubfoot is also very important in planning the treatment. It has been proven by the study that nonidiopathic clubfoot is a significantly high risk for failure of postero-medial release. The results are significantly better in idiopathic clubfoot. However, a non-idiopathic clubfoot due to various causes is altogether a different entity from idiopathic one and usually requires multiple surgeries instead of single stage postero-medial release alone to achieve a plantigrade foot. This is similar to experience of Gibson et al  and Guidera et al  , who did studies on postero-medial release in patients of Arthrogryposis multiplex congenita and had unacceptably high failures in such patients.
The study had 21.6% infection rate and although statistically insignificant, the results were slightly inferior in the infected ones as compared to their counterparts. A remarkable observation of the study is that among the infected ones the failure rate increases to 100% if it requires plastic procedure for their healing. So mere occurrence of infection by itself is not a significant risk for failure as compared to its severity that accounts for a significant risk for failure of postero-medial release. In a large series of Turco  involving 273 operations, 11 had infection; 10 out of 11 feet did not require plastic surgical procedure and had satisfactory result in all of them, while the one which had severe gaping needed plastic procedure to cover it up and ended in to severe contracture of scar and failure which correlates to our experience in present series with effect of severity of infection on final result.
The female sex and bilateral deformity have poorer results but not significant enough to consider them as the causes of failure of postero-medial release.
In conclusion, the causes of failure of postero-medial release are multiple, including the age of the child at the time of surgery, compliance to wear braces for the prescribed duration, non-idiopathic clubfeet and the severity of infective complications. The mere occurrence of infective complication, female sex and a bilateral deformity although have a poorer outcome as compared to their counterparts, cannot be labeled as the causes of failure of the procedure as they are statistically insignificant.
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A V Sanghvi
‘AVSAR’, 4/4, Patel colony, Jamnagar- 361008, Gujarat
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]