Talipes equinovarus

Sir,

I read with interest the article entitled `Relapse in staged surgery for congenital talipes equinovarus' by Uglow and Clarke1 in the July 2000 issue. I appreciate and agree with their concern for problems of wound healing in the surgical management of club feet, the need for a reproducible classification for pre- and postoperative comparison, and the use of separate plantar medial and posterolateral incisions, as described by Carroll, McMurty and Leete.2 I was uncertain how they managed to correct the composite deformities by using an initial limited medial release which included structures such as the talonavicular and calcaneocuboid capsules, but excluded the crucial tibialis posterior, flexor hallucis, flexor digitorum longus, tendo Achillis, and the anterior portion of the deltoid ligament. Unless these structures, commonly found to be very tight in operable club feet, are divided, it is difficult to determine the adequacy of any limited medial release. Also, it may not be possible to reduce the navicular on to the talus and to restore the talocalcaneonavicular relationship in the horizontal, coronal and sagittal planes, which are considered to be essential elements of successful surgical correction of club feet.2-6 If these are to be divided through a posterolateral incision, after two to four weeks, despite an adequate, staged release, it would still be difficult to obtain a satisfactory talocalcaneonavicular reduction, with a medial incision in an advanced stage of healing. Singlestage surgery allows the precise assessment of the adequacy of soft-tissue release, which in turn is essential if we are to obtain a satisfactory radiological correction. This is the reason why all such procedures described, including thoes by Carroll et al,2 McKay3 and Turco6 are recommended as single-stage procedures to allow simultaneous multiplanar, bony and soft-tissue correction. The authers, however, have given neitherdirect reference to the radiological outcome of the staged surgery as described by them, nor to its effect on relapse.

K. B. MUKHERJEE, Diplomate, NB(Orth), D Orth St Stephen's Hospital, Delhi, India.

1. Uglow MG, Clarke NMP. Relapse in staged surgery for congenital talipes equinovarus. J Bone Joint Surg [BrI 2000;82-B:739-43.

2. Carroll NC, McMurty R, Leete SF. The pathoanatomy of congenital clubfoot. Orthop Clin North Am 1978;9:225-32.

3. McKay DW. New concept of correction of and approach to clubfoot treatment. Section II. Correction of clubfoot. J Pediatr Orthop 1983;3:10.

4. Pavlovcic V, Pecak F. Surgical treatment of clubfoot: the significance of talocalcaneonavicular malposition correction. J Paediatr Orthop B 1999;8:1-4.

5. Song HR, Carroll NC, Neyt J, et al. Clubfoot analysis with threedimensional foot models. J Pediatr Orthop B 1999;8:5-11.

6. Turco VJ. Resistant congenital clubfoot: one stage posteromedial release with internal fixation. J Bone Joint Surg [Am] 1979;61-A:80514.

Authors' reply:

Sir,

We thank Dr Mukherjee for his interest in our paper and the issues which he has addressed.

The radiological outcome of our series and the effect on relapse, together with the functional results, have been published separately.1 The overall rate of relapse in our series was similar to that of the other series mentioned in this article. We therefore believe that the results of staged surgery are comparable with those of other authors.

We wish to reiterate that by classifying the deformities appropriately it is possible to identify in which group of patients the rate of relapse is unacceptably high. It is for these patients that further methods should be explored and Dr Mukherjee's comments may be of relevance. Until, however, other series are published with a compatible classification, it is not possible to compare treatment regimes. At present, staged surgery produces comparable results to other peer-reviewed series and may even be advantageous for grades II and III as classified by Dimeglio et al.2

M. G. UGLOW, FRCS (Tr & Orth) N. M. P. CLARKE, FRCS Southampton General Hospital, UK.

1. Uglow MG, Clarke NMP. The functional outcome of staged surgery for the correction of talipes equinovarus. J Pediatr Orthop 2000;20:517-23.

2. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop B 1995;4:129-36.

Copyright British Editorial Society of Bone & Joint Surgery Mar 2001
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