CTEV is a three-dimensional deformity that must be understood before attempting corrective measures. Medial and plantar displacement of the navicular, cuboid, and calcaneus around the talus result in an inverted or varus hind-foot, and the entire complex rests in quines .
Nowadays, although there is almost a universal agreement on non-surgical management of CTEV [15–19], and also reports of trials of application of the Ponseti technique in severe arthrogrypotic club feet , there are still reports of early recurrence of the deformity, and it is likely that a small number of clubfeet will require surgery even after expertly applied non-operative treatment .
Along with other complications of poor parents compliance, long duration of casting, incomplete correction of the deformity, recurrence of the deformity, difficulty of treatment of old neglected cases with severe deformity and finally parents refusing proposed non-operative trials, surgical treatment will be the indicated line of treatment in few relapsed severely deformed feet.
The parents of all the patients included in this study refused the non-operative technique, although it was strongly recommended, even in severe relapsed cases after failure of previous surgical management, especially in the younger age group.
Transfixion of the talonavicular joint with a fine Kirschner wire ensures that this correction will be maintained . Some of the failures after previous soft-tissue surgery resulted from a loss of the initial correction when only a plaster cast was used to stabilize the reduction .
Here it is of value to mention that, although the calcaneus is not as deformed as the talus, displaying only slight shortening and widening with mild medial bowing. It is integral to the positional deformities of CTEV: quines, varus, and adduction .
We believe that the equino-varus deformity of the calcaneus is the most difficult to correct in relapsed severe cases. In infants under three months of age, manipulative treatment by conventional methods is usually successful; but in infants over four months of age, it may not be possible by manipulative treatment to get the calcaneus into the exact position desired, even when lengthening of the Achilles tendon is performed. Recurrent deformities, the so-called rocker-bottom deformities, caused by poor treatment, and untreated deformities in older children are particularly difficult to treat by manipulative methods. This was also approved by many authors and various techniques have been suggested for the treatment of these more complicated deformities [23–25].
It was also noted that residual hind-foot varus and/or cavus deformities of the heel were among the most common complications after surgical treatment of CTEV, even after the use of the traditional (talonavicular, and subtalar wires), pins for stabilization of the corrected feet .
We paid special attention to the hind-foot deformity, and introduced a transverse (coronal plane) wire into the calcaneus to use it as a joystick to control the adequately released bone into the coronal plane to precisely correct the supination and varus deformities into the normal desired position. This wire also provided better correction of the quines deformity of the calcaneus, which was proved by the immediate improvement of the lateral talo-calcaneal and the lateral tibio-calcaneal angles. Finally this wire was of great help during casting after closure of the wound as it allowed better handling and grip of the small slippery heel within the cast.
Early clinical and radiological assessment of all the cases at periodic intervals showed comparable favorable results in accordance with other studies using the Ponseti method [27, 28], as well as, after surgical soft tissue release [29–31]. In addition we paid special attention to the hind-foot axis at the final follow-up and modified a classification system for our patients based on the clinical angle measured using a goniometer (Table 4). There was a favorable hind foot positioning in about 95% of the studied cases at the final follow-up visit. Only 3 feet ended with a 0° hind-foot axis and was considered as a varus heel, and non-favorable result. All those complicated cases with residual final varus deformity presented with very severe deformity, had had previous surgical intervention, and were older than 36 month.
This modified suggested pinning technique provided better control and correction of the hind-foot deformity. During casting this was of particular importance as it enabled the surgeon to have a good grip on the small sized calcaneus in all planes possible. By the end of the follow-up period, all the patients showed excellent functional rating scores. We think that we should follow the cases for longer durations to provide a long-term results of this technique, but we believe that our early clinical and radiographic values are promising to manage this severe recurrent deformity when surgical intervention is considered in very severe CTEV cases.