Ahmet DOĞAN, A. Erdem BAGATUR, Gazi ZORER

Komplet subtalar gevşetme yapılan doğuştan çarpık ayaklarda derin deltoid ligament gevşetmesinin dorsifleksiyon üzerine etkisi

Amaç: Komplet subtalar gevşetme (KSG) ile tedavi edilen doğuştan çarpık ayaklı (DÇA) olgularda, derin deltoid ligamentin posterior yarısının gevşetilmesinin ayak bileği dorsifleksiyon kapasitesi üzerine etkisi araştırıldı. Çalışma planı: Doğuştan çarpık ayak deformitesi nedeniyle KSG ile tedavi edilen 35 hastanın 52 ayağı değerlendirildi. Olgular, posterior deltoid gevşetmesi yapılmayanlar (grup I) ve yapılanlar (grup II) olarak ikiye ayrıldı. Grup I’de 13 hastanın 21 ayağı, grup II’de 22 hastanın 31 ayağı çalışmaya alındı. Olguların tümünde orijinal Cincinnati insizyonu kullanıldı. Klasik KSG işlemine ek olarak, grup II’de deltoid ligamentin derin liflerinin posterior yarısı gevşetildi. Ameliyat sonrası izlemlerde, iki grupta farklı bir işlem uygulanmadı. Ameliyat sonrası ortalama izlem süresi, grup I’de 55.5 ay (dağılım 36-77 ay), grup II’de 24.7 ay (dağılım 10-37 ay) idi. Sonuçlar radyografik olarak talo-tibial ve kalkaneal inklinasyon açıları ölçülerek değerlendirildi. Sonuçlar: Her iki grupta da kalkaneusun hala ekinus pozisyonunda olduğu gözlendi. Derin deltoid ligamentin gevşetilmesinin sağladığı ekstra hareket ameliyat sırasında net bir şekilde gözlenmesine rağmen, gruplar arasında fonksiyonel kazanım açısından anlamlı fark bulunmadı. Çıkarımlar: Deltoid ligamentin derin liflerinin posterior yarısı gevşetildiğinde talusun net bir şekilde dorsifleksiyona gitmesi ve ameliyat sırasında talus kubbesinin posteriordan görünmesine karşın, Aşil tendonunun yeterince uzatılamaması nedeniyle klinik sonuç değişmedi.

Anahtar Kelimeler:

Çarpık ayak, Süt çocuğu, Subtalar eklem, Tendonlar, para-artiküler, Ayak deformitesi, Ligamentler, eklem

The effect of deep deltoid ligament release on dorsiflexion in congenital clubfoot treated with complete subtalar release

We evaluated the effect of releasing the posterior half of the deep branches of the deltoid ligament on dorsiflexion capacity of the ankle in congenital clubfoot treated with complete subtalar release (CSTR). Methods: Fifty-two feet of 35 patients with clubfeet were treated with CSTR. The patients were divided into two groups depending on the absence (group I) or presence (group II) of posterior deltoid ligament release. The groups consisted of 13 patients (21 feet) and 22 patients (31 feet), respectively. The original Cincinnati incision was used in all cases. In addition to the classical CSTR, posterior half of the deep branches of the deltoid ligament was released in group II. Both groups received the same postoperative care. The mean postoperative follow-up period was 55.5 months (range 36-77 months) in group I, and 24.7 months (range 10-37 months) in group II. The results were evaluated radiographically by measuring the talo-tibial and calcaneal inclination angles. Results: It was observed that the calcaneus remained in equinus in both groups. Although posterior deltoid ligament release appreciably increased the dorsiflexion perioperatively, this did not represent a statistically significant functional improvement in group II. Conclusion: Although the foot could be dorsiflexed and the talar dome observed posteriorly upon the release of the posterior half of the deep branches of the deltoid ligament, no beneficial clinical effect was observed because the tendo calcaneus could not be lengthened sufficiently.

Keywords:

Clubfoot, Infant, Subtalar Joint, Tendons, Para-Articular, Foot Deformities, Ligaments, Articular,

PDF

___

1. Main BJ, Crider RJ. An analysis of residual deformity in club feet submitted to early operation. J Bone Joint Surg [Br] 1978;60:536-43.
2. Thompson GH, Richardson AB, Westin GW. Surgical management of resistant congenital talipes equinovarus deformities. J Bone Joint Surg [Am] 1982;64:652-65.
3. Ghali NN, Smith RB, Clayden AD, Silk FF. The results of pantalar reduction in the management of congenital talipes equinovarus. J Bone Joint Surg [Br] 1983;65:1-7.
4. 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.
5. Simons GW. Analytical radiography of club feet. J Bone Joint Surg [Br] 1977;59:485-9.
6. 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.
7. Heywood AW. The mechanics of the hindfoot in clubfoot as demonstrated radiographically. J Bone Joint Surg [Br] 1964; 46:102-7.
8. Simons GW. Complete subtalar release in club feet. Part II Comparison with less extensive procedures. J Bone Joint Surg [Am] 1985;67:1056-65.
9. Stauffer RN, Chao EY, Brewster RC. Force and motion analysis of the normal, diseased, and prosthetic ankle joint. Clin Orthop 1977;(127):189-96.
10. Boone DC, Azen SP. Normal range of motion of joints in male subjects. J Bone Joint Surg [Am] 1979;61:756-9.
11. Giannestras NJ. Foot disorders. Medical and surgical management. 1st ed. Philadelphia: Lea & Febiger; 1967.
12. 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.
13. Perry J. Gait analysis: normal and pathological function. 1st ed. New York: McGraw Hill; 1992.
14. Green AD, Lloyd-Roberts GC. The results of early posterior release in resistant club feet. A long-term review. J Bone Joint Surg [Br] 1985;67:588-93.
15. Tachdjian MO. Pediatric orthopedics. Vol. 4, 2nd ed. Philadelphia: W.B. Saunders; 1990.
16. Coleman SS. Complex foot deformities in children. 1st ed. Philadelphia: Lea & Febiger; 1983.
17. 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.
18. Aronson J, Puskarich CL. Deformity and disability from treated clubfoot. J Pediatr Orthop 1990;10:109-19.
19. Sutherland DH, Cooper L, Daniel D. The role of the ankle plantar flexors in normal walking. J Bone Joint Surg [Am] 1980;62:354-63.
20. Centel T, Bagatur AE, �Ûut T, Aksu T. Comparison of the soft-tissue release methods in idiopathic clubfoot. J Pediatr Orthop 2000;20:648-51.
21. Porter RW. Congenital talipes equinovarus: I. Resolving and resistant deformities. J Bone Joint Surg [Br] 1987;69:822-5.
22. Porter RW. Congenital talipes equinovarus: II. A staged method of surgical management. J Bone Joint Surg [Br] 1987; 69:826-31.
23. De Langh R, Mulier JC, Fabry G, Martens M. Treatment of clubfoot by posterior capsulectomy. Clin Orthop 1975;(106): 248-53.
24. Smith WA Jr, Campbell P, Bonnett C. Early posterior ankle release in the treatment of congenital clubfoot. Orthop Clin North Am 1976;7:889-93.
25. Hutchins PM, Foster BK, Paterson DC, Cole EA. Long-term results of early surgical release in club feet. J Bone Joint Surg [Br] 1985;67:791-9.
26.Hjelmstedt EA, Sahlstedt B. Arthrography as a guide in the treatment of congenital clubfoot. Findings and treatment results in a consecutive series. Acta Orthop Scand 1980;51:321-34.
27. Tayton K, Thompson P. Relapsing club feet. Late results of delayed operation. J Bone Joint Surg [Br] 1979;61:474-80.
28. Scott WA, Hosking SW, Catterall A. Club foot. Observations on the surgical anatomy of dorsiflexion. J Bone Joint Surg [Br] 1984;66:71-6.
29. Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up note. J Bone Joint Surg [Am] 1995;77: 1477-89.
30. Hensinger RN. Standards in pediatric orthopedics. Tables, charts, and graphs illustrating growth. 1st ed. New York: Raven Press; 1986.
31. Dormans JP, Copley LA. Orthopedic approach to treatment. Dormans JP, Pellegrino L, editors. Caring for children with cerebral palsy: a team based approach. Baltimore: Paul H. Brookes Publishing; 1998. p. 143-69.