Lokman KARAKURT, Erhan YILMAZ, Murat İNCİ, Erhan SERİN, Mehmet ÖZTÜRK

Doğuştan çarpık ayaklı olgularda komplet subtalar gevşetme uygulamalarımızın erken dönem sonuçları

Amaç: Komplet subtalar gevşetme yaptığımız doğuştan çarpık ayaklı olgularda erken dönem klinik ve radyolojik sonuçlan değerlendirdik. Çalışma planı: Yirmi olgunun (14 erkek, 6 kız; ort. yaş 8 ay; dağılım 3.5-18.5 ay) 30 ayağına komplet subtalar gevşetme uygunladı. Olguların hepsinde Cincinnati kesişi kullanıldı. Sonuçlar Simons'un klinik ve radyolojik ölçütlerine göre değerlendirildi. Tarsal kemik patolojileri ayrıca değerlendirildi. Ortalama takip süresi 24.6 ay (dağılım 12-41 ay) idi. Sonuçlar: Klinik olarak 24 ayakta (%80) başarılı, altı ayakta (%20) başarısız sonuç alındı. Radyolojik sonuçlar 19 ayakta (%63) başarılı, 11 ayakta (%37) başarısız bulundu. On üç ayakta (%43.3) yetersiz, bir ayakta (%1.4) aşırı düzeltme saptandı. Yetersiz düzeltilmiş ayaklardan, klinik ve radyolojik sonucu başarısız bulunan beş ayak (%16.6) için revizyon cerrahisi önerildi; bunların dördüne (%13.3) revizyon yapılabildi. Derin cilt nekrozu gelişen iki ayağın birinde Asil tendon nekrozu da saptandı; bu ayaklarda cerrahi tedavi uygulandı. Beş ayakta yüzeyel cilt nekrozu, bir ayakta da yumuşak doku enfeksiyonu gelişti ve tıbbi tedaviyle sorunsuz iyileşme sağlandı. Bir ayakta talus başında, bir ayakta navikülada hipoplazi saptandı. Çıkarımlar: Komplet subtalar gevşetme, bir seansta deformitenin tüm komponentlerinin düzeltilmesine olanak sağlayan ve deneyim kazanıldıkça daha iyi sonuçlar alınabileceğine inandığımız başarılı bir cerrahi yöntemdir.

Anahtar Kelimeler:

Hareket açıklığı, eklem, Ayak bileği eklemi, Çocuk, Çarpık ayak, Süt çocuğu, Tendonlar, para-artiküler, Tedavi sonucu

Early results of complete subtalar release in congenital clubfoot deformity

Objectives: We evaluated the radiological and clinical results of complete subtalar release in patients with congenital clubfoot deformity. Methods: We performed complete subtalar release in 30 feet of 20 patients (14 boys, 6 girls; mean age 8 months; range 3.5 to 18.5 months). We employed the Cincinnati incision in all cases. The results were evaluated according to the Simon's clinical and radiological criteria. Tarsal bone problems were analyzed separately. The mean follow-up period was 24.6 months (range 12 to 41 months). Results: Clinical results were satisfactory in 24 feet (80%) and unsatisfactory in six feet (20%). Radiologically, satis factory and unsatisfactory results were encountered in 19 feet (63%) and 11 feet (37%), respectively. Undercorrection occurred in 13 feet (43.3%) and overcorrection in one foot (1.4%). Revision surgery which was recommended for five undercorrected feet (16.6%) with unsatisfactory clinical and radiological results could be performed in four feet (13.3%). Deep skin necrosis that occurred in two feet (one with Achilles tendon necrosis) was treated surgically. Superficial skin necrosis developed in five feet and soft tissue infection in one feet, all of which responded well to conservative treatment. Other complications included talar head hypoplasia and navicular hypoplasia in two feet, respectively. Conclusion: Complete subtalar release allows to correct all components of clubfoot deformity in a single session. The results may appreciably be improved with enhanced surgical experience.

Keywords:

Range of Motion, Articular, Ankle Joint, Child, Clubfoot, Infant, Tendons, Para-Articular, Treatment Outcome,

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1. Bursalı A, Erçetin Ö, Haklar U, Yurtoğlu C. Pes ekinovarus cerrahi tedavisinde posteromedial ve komplet subtalar gevßetmenin erken dönem sonuçları. Artroplasti Artroskopik Cerrahi 1993;4:49-52.
2. Carroll NC. Clubfoot: what have we learned in the last quarter century? J Pediatr Orthop 1997;17:1-2.
3. Centel T, Bagatur AE, Öğüt T, Aksu T. Comparison of the soft-tissue release methods in idiopathic clubfoot. J Pediatr Orthop 2000;2:648-51.
4. Hersh A. The role of surgery in the treatment of club feet. J Bone Joint Surg [Am] 1967;49:1684-96.
5. Muratlı HH, Yağmuroğlu MF, Tabak AY, Biçimoğlu A, çelebi L. Pes ekinovarusta komplet subtalar gevşetme uygula- dığımız olguların klinik ve radyolojik sonuçları. Artroplasti Artroskopik Cerrahi 2001;12:22-31.
6. Napiontek M. Clinical and radiographic appearance of congenital talipes equinovarus after successful nonoperative treatment. J Pediatr Orthop 1996;16:67-72.
7. Nimityongskul P, Anderson LD, Herbert DE. Surgical treatment of clubfoot: a comparison of two techniques. Foot Ankle 1992;13:116-24.
8. Ponseti IV. Treatment of congenital club foot. J Bone Joint Surg [Am] 1992;74:448-54.
9. Ponseti IV. Clubfoot management. J Pediatr Orthop 2000;20: 699-700.
10. Porat S, Milgrom C, Bentley G. The history of treatment of congenital clubfoot at the Royal Liverpool Children's Hospital: improvement of results by early extensive posteromedial release. J Pediatr Orthop 1984;4:331-8.
11. Rumyantsev NJ, Ezrohi VE. Complete subtalar release in resistant clubfeet: a critical analysis of results in 146 cases. J Pediatr Orthop 1997;17:490-5.
12. Tibrewal SB, Benson MK, Howard C, Fuller DJ. The Oxford club-foot programme. J Bone Joint Surg [Br] 1992;74:528-33.
13. Turco VJ. Surgical correction of the resistant club foot. Onestage posteromedial release with internal fixation: a preliminary report. J Bone Joint Surg [Am] 1971;53:477-97.
14. Uglow MG, Clarke NM. The functional outcome of staged surgery for the correction of talipes equinovarus. J Pediatr Orthop 2000;20:517-23.
15. Bensahel H, Guillaume A, Czukonyi Z, Desgrippes Y. Results of physical therapy for idiopathic clubfoot: a longterm follow-up study. J Pediatr Orthop 1990;10:189-92.
16. van Mulken JM, Bulstra SK, Hoefnagels NH. Evaluation of the treatment of clubfeet with the Dimeglio score. J Pediatr Orthop 2001;21:642-7.
17.Cummings RJ, Bashore CJ, Bookout CB, Elliott MJ. Avascular necrosis of the talus after McKay clubfoot release for idiopathic congenital clubfoot. J Pediatr Orthop 2001;21: 221-4.
18. Cummings RJ, Lovell WW. Operative treatment of congenital idiopathic club foot. J Bone Joint Surg [Am] 1988;70: 1108-12.
19. Haasbeek JF, Wright JG. A comparison of the long-term results of posterior and comprehensive release in the treatment of clubfoot. J Pediatr Orthop 1997;17:29-35.
20. Joseph B, Ajith K, Varghese RA. Evaluation of the hemi- Cincinnati incision for posteromedial soft-tissue release in clubfoot. J Pediatr Orthop 2000;20:524-8.
21. Osterman K, Merikanto J. Critical aspects of neonatal surgery in clubfoot. Pediatr Orthop B 1996;5:55-6.
22. Pancrossa M. Clubfoot. In: Jay RM, editor. Pediatric foot & ankle surgery. 1st ed. Philadelphia: W.B. Saunders; 1999. p. 244-60.
23. Simons GW. Complete subtalar release in club feet. Part I-A preliminary report. J Bone Joint Surg [Am] 1985;67:1044-55.
24. Simons GW. Complete subtalar release in club feet. Part IIComparison with less extensive procedures. J Bone Joint Surg [Am] 1985;67:1056-65.
25. Lubicky JP, Altiok H. Regional fasciocutaneous flap closure for clubfoot surgery. J Pediatr Orthop 2001;21:50-4.
26. Tachdjian MO. The foot and leg. In: Wickland EH, editor. Tachdjian's pediatric orthopaedics. Vol. 4, 2nd ed. Philadelphia: W.B. Saunders; 1990. p. 2405-3012.
27.Vanderwilde R, Staheli LT, Chew DE, Malagon V. Measurements on radiographs of the foot in normal infants and children. J Bone Joint Surg [Am] 1988;70:407-15.
28. Crawford AH, Marxen JL, Osterfeld DL. The Cincinnati incision: a comprehensive approach for surgical procedures of the foot and ankle in childhood. J Bone Joint Surg [Am] 1982;64:1355-8.
29. Herring JA. Disorders of the foot. In: Herring JA, editor. Tachdjian's pediatric orthopaedics. Vol. 2, 3rd ed. Philadelphia: W.B. Saunders; 2002. p. 891-1037.
30. Thompson GH, Simons GW. Congenital talipes equinovarus (clubfeet) and metatarsus adductus. In: Drennan JC, editor. The child's foot and ankle. 1st ed. New York: Raven Press; 1992. p. 97-133.
31. Ferlic RJ, Breed AL, Mann DC, Cherney JJ. Partial wound closure after surgical correction of equinovarus foot deformity. J Pediatr Orthop 1997;17:486-9.
32. Napiontek M. Transposed skin graft for wound closure after Cincinnati incision. Experience in 7 patients with severe foot deformities. Acta Orthop Scand 1996;67:280-2.
33. Lehman WB, Atar D. Complications in the management of talipes equinovarus. In: Drennan JC, editor. The child's foot and ankle. 1st ed. New York: Raven Press; 1992. p. 135-53.
34. Beaty JH. Congenital anomalies of lower extremity. In: Canale ST, editor. CampbellÕs operative orthopaedics. Vol. 1, 9th ed. St. Louis: Mosby; 1998. p. 925-1019.
35.Yamamoto H, Muneta T, Ishibashi T, Furuya K. Posteromedial release of congenital club foot in children over five years of age. J Bone Joint Surg [Br] 1994;76:555-8.
36. Moses W, Allen BL Jr, Pugh LI, Stasikelis PJ. Predictive value of intraoperative clubfoot radiographs on revision rates. J Pediatr Orthop 2000;20:529-32.
37. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop B 1995;4:129-36.
38. Magone JB, Torch MA, Clark RN, Kean JR. Comparative review of surgical treatment of the idiopathic clubfoot by three different procedures at Columbus Children's Hospital. J Pediatr Orthop 1989;9:49-58.
39. Tözün R, Hamzaoğlu A, Pınar H, Seyhan F. Complete subtalar release in clubfeet. J Foot Surg 1990;29:436-8.
40. Joseph B, Bhatia M, Nair NS. Talo-calcanea relationship in clubfoot. J Pediatr Orthop 2001;21:60-4.
41. Lourenco AF, Dias LS, Zoellick DM, Sodre H. Treatment of residual adduction deformity in clubfoot: the double osteotomy. J Pediatr Orthop 2001;21:713-8.
42. Yngve DA, Gross RH, Sullivan JA. Clubfoot release without wide subtalar release. J Pediatr Orthop 1990;10:473-6.
43. Lau JH, Meyer LC, Lau HC. Results of surgical treatment of talipes equinovarus congenita. Clin Orthop 1989;248:219-26.
44. Hofmann AA, Constine RM, McBride GG, Coleman SS. Osteotomy of the first cuneiform as treatment of residual adduction of the fore part of the foot in club foot. J Bone Joint Surg [Am] 1984;66:985-90.
45. Cohen-Sobel E, Caselli M, Giorgini R, Giorgini T, Stummer S. Long-term follow-up of clubfoot surgery: analysis of 44 patients. J Foot Ankle Surg 1993;32:411-23.
46. Thometz JG, Simons GW. Deformity of the calcaneocuboid joint in patients who have talipes equinovarus. J Bone Joint Surg [Am] 1993;75:190-5.