The Cincinnati Approach To Ctev Correction; A Study On 43 Feet Treated By The Modified Mckay Procedure

摘要

Aim: Adequate surgical correction of congenital talipes equinovarus (CTEV) is a challenge to orthopedicians aiming to address all aspects of this complex foot deformity. Various exposures have been elucidated with varying results. This study discusses the Cincinnati approach advocated by McKay and whether it addresses the various aspects of clubfoot correction.Materials and methods: Pantalar release using the circumferential Cincinnati incision was done in 43 feet of 30 patients aged between 9 months to 3 years. The right side was involved in 11, the left in 6 and bilateral involvement present in 13 cases. All cases were found to be resistant to correction by the conservative method proposed by Ponseti.Results: The patients were followed up for a minimum period of 2 years. Excellent results were seen in 18%, good in 46%, fair in 20% and poor in 14% cases. More than half of the cases had a preop talocalcaneal index of 21-30 percent which converted to 51-60 percent after surgery.Conclusion: The Cincinnati approach is ideal to achieve pantalar reduction, is cosmetically more acceptable and gives a better range of motion. Introduction Congenital talipes equinovarus (CTEV) or clubfoot is one of the commonest foot deformities and its incidence is approximately one in every 1000 live births.1 It is a complex deformity that is notoriously difficult to correct. Corrected, it has a tendency to recur until the age of six or seven years.2 Manipulative treatment, though effective when instituted early, has also resulted in increased cavus deformity, rocker bottom deformity, longitudinal breech, flattening of the proximal surface of talus, lateral rotation of the ankle and increased stiffness of the ligaments and joints.3, 4, 5 Some authors advise early and primary operative treatment of clubfoot.2 In 1978, Turco introduced the one stage soft tissue posteromedial release.6 The posteromedial release of Turco has been used for a long time with good results in most CTEV cases but it was always felt that this procedure did not address the deformities on the lateral aspect i.e. the peroneal tendons and retinaculum, sural nerve, calcaneofibular ligament, bifurcate ligament, lateral joint capsule, dorsal calcaneocuboid ligament, EDB origin etc. which remain unexposed. These structures must be released to reverse the tethering of the posterior calcaneus to the fibula and to allow calcaneocuboid relocation to correct the midfoot and forefoot adduction and varus as well as talar relocation into the medial column7. Carroll and Gross advocated a twin-incision approach using a posterolateral and a medial incision to improve access, especially on the lateral side13 but the cosmesis and correction were less desirable. Douglas McKay introduced a circumferential release of the posterior, medial, lateral and plantar aspects of the foot which is now the preferred exposure at the Mayo Clinic as well7.The advantages with this approach are that it provides excellent exposure of the subtalar joint and is useful in patients with a severe internal rotation deformity of the calcaneus and allows increased visualization of the medial,lateral, plantar and posterior structures with simultaneous evaluation of the released structures in a sagittal, frontal and transverse fashion7,8. The lateral extension of the incision allows clear access to the lateral structures, thus avoiding the inability of the hockey stick incision to address the lateral deformities. Material and Methods This study was conducted on 30 children (aged between 9 months to 3 years ) and 43 feet and the results assessed 2-4 years postoperatively. The purpose was to assess the efficiency of the Cincinnati incision in providing surgical access to the main affectations and the success measured in functional terms 2 years after the procedure.In our study, all children operated had idiopathic CTEV. Children with deformities secondary to neuromuscular deformities were excluded. For the purpose of this study,