Midterm Follow-Up of Talectomy for Severe Rigid Equinovarus Feet

The Journal of Foot & Ankle Surgery 54 (2015) 1093–1098

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The Journal of Foot & Ankle Surgery

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Midterm Follow-Up of Talectomy for Severe Rigid Equinovarus Feet

Mostafa H. El-Sherbini, MD, PhD 1, Ahmed A. Omran, MD, MSc 2

1 Assistant Professor, Department of Orthopaedics, National Institute of Neuromotor System (NINMS, GOTHI), Imbaba, Giza, Great Cairo, Egypt 2 Senior Specialist, Department of Orthopaedics, National Institute of Neuromotor System (NINMS, GOTHI), Imbaba, Giza, Great Cairo, Egypt article info abstract

Level of Clinical Evidence: 4 Rigid equinovarus foot is a challenging problem. Talectomy has been advocated as a salvage procedure to achieve a plantigrade painless foot in the treatment of rigid equinovarus deformity. The present prospective Keywords: arthrogryposis observational study evaluated the effectiveness of talectomy in the treatment of Dimeglio grade IV rigid calcaneal osteotomy equinovarus feet. Nineteen feet in 13 patients were treated by talectomy from September 2001 through Dimeglio grade January 2012 (10-year, 2-month period). Of the 13 patients, 9 (69.23%) had a foot deformity due to arthrog- equinovarus deformity ryposis multiplex congenita and 1 (7.69%) each due to sacral agenesis, spastic cerebral palsy, neglected navicular excision congenital talipes equinovarus, and post-traumatic contracture. Of the 13 patients, 9 (69.23%) were male and 4 (30.77%) were female. Their mean age was 7.7 (range 3 to 26) years. The mean follow-up duration was 6.4 (range 2 to 11) years. Along with talectomy, excision of the navicular was performed in 8 feet (42.11%), calcaneal osteotomy with a laterally based wedge in 8 (42.11%), and calcaneocuboid fusion in 3 feet (15.79%). Postoperatively, all the feet improved to Dimeglio grade II and were painless, and 16 feet (84.22%) were plantigrade; 1 foot (5.26%) had residual equinus resulting from incomplete removal of the talus and 2 (10.53%) had residual varus. Also, 3 feet (15.79%) had forefoot adduction (2 residual and 1 recurrent) that required a second surgery to correct the deformity. From our experience, talectomy is an effective procedure for correction of severe rigid equinovarus feet, provided that the talus is completely removed and the calcaneus is positioned correctly in the ankle mortise. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.

The goal of management of a rigid foot deformity is to provide a imbalances (1). Complications of the external ﬁxation techniques used plantigrade, painless foot that can be shod with standard footwear in the treatment of rigid equinovarus feet include pin tract infection, (1,2). The treatment options for rigid equinovarus foot deformity early consolidation, incomplete osteotomy, articular subluxation, include soft tissue release, triple arthrodesis, correction with Ilizarov deformity recurrence, acute tarsal tunnel syndrome, and, in some principles, and talectomy (1,3). Soft tissue release alone does not cases, persistent foot pain (1,6,7). In Menelaus, Whitman described usually provide adequate correction, and residual deformity and talectomy (astragalectomy) for the treatment of paralytic calcaneus recurrence are common with such an approach. Secondary bony pro- deformity, and the operation has since been used for a variety of other cedures are usually needed to sustain the correction (3,4), and triple deformities (4). Talectomy has been successfully used as a salvage arthrodesis has been used for severe deformities in the mature foot. procedure and, occasionally, as a primary procedure for the treatment The complications associated with bony procedures include smaller of severe, rigid, and resistant equinovarus deformity (4,8). We under- feet (due to disruption and premature closure of growth plates), took a prospective investigation to assess the effectiveness of tale- wound healing problems, possible neurovascular complications, and ctomy in the treatment of severe, rigid equinovarus feet, with an early degenerative osteoarthritis in adjacent joints (3,5). The applica- interest in identifying factors associated with unsatisfactory surgical tion of Ilizarov principles and techniques allows simultaneous outcomes. correction of all deformity components of rigid equinovarus, without bone resection or foot shortening (1,6), although arthrodesis and/or Patients and Methods tendon transfer are usually required to eliminate neuromuscular Study Population and Evaluation

The present study was prospective in design and included all consecutive patients Financial Disclosure: None reported. with severe, rigid equinovarus feet admitted to our institution from September 2001 to Conﬂict of Interest: None reported. January 2012. A deformity assessment was conducted according to the Dimeglio scale Address correspondence to: Mostafa H. El-Sherbini, MD, PhD, 36 Teba Street, originally devised for the idiopathic clubfoot (9), and only patients with feet with Elmohandesen Doki, Giza 12311, Egypt. Dimeglio grade IV were included. The assessment was performed by 1 of us (M.E.). The E-mail address: [email protected] (M.H. El-Sherbini). Dimeglio score measures 4 particular foot deformities (i.e., equinus, heel varus, forefoot

1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.07.004 1094 M.H. El-Sherbini, A.A. Omran / The Journal of Foot & Ankle Surgery 54 (2015) 1093–1098

Table 1 deformity that requires surgical correction. The radiologic evaluation was performed Patient population (N ¼ 19 feet in 13 patients) using plain ﬁlm radiographic measurement of the standing lateral tibiocalcaneal angle.

Etiology of Rigid Patients/Feet (n) Age (y) Sex (M/F) Surgical Technique of Talectomy Equinovarus AMC 9 (69.23)/14 (73.68) 5.3 (3 to 10) 7 (53.84)/2 (15.38) The approach used in the present series was anterolateral after the method Old neglected CTEV 1 (7.69)/1 (5.26) 26 1 (7.69) (M) described by Green et al (13). The operation was performed with the patient under Sacral agenesis 1 (7.69)/1 (5.26) 6 1 (7.69) (F) general anesthesia combined with a caudal block, with a thigh tourniquet on the ipsi- CP spastic diplegia 1 (7.69)/2 (10.53) 12 1 (7.69) (M) lateral extremity. An anterolateral incision was made over the ankle and extended Post-traumatic 1 (7.69)/1 (5.26) 10 1 (7.69) (F) distally to the level of the navicular, and the head and neck of the talus were exposed starting from the anterior aspect of the ankle. The Achilles tendon was lengthened using Abbreviations: AMC, arthrogryposis multiplex congenital; CP, cerebral palsy; CTEV, Z-plasty by way of a second incision made directly over the tendon. In cases with a congenital talipes equinovarus; F, female; M, male. fibrotic, adherent Achilles tendon, excision of a portion of the tendon was performed. Data presented as n (%); for age, the data in parentheses are the range. Thereafter, complete removal of the talus was performed, and the foot was easily corrected to the neutral, plantigrade position. Posterior displacement of the foot was un- dertaken until the middle facet of the calcaneus was situated directly under the tibial adduction, and foot supination). The reducibility of each deformity is determined and plafond and, if needed to achieve this alignment, the navicular was also excised. After scored (0 to 4) in terms of the angulation of deformity: 20 to <0 is given a score of 1; ascertainment of the desired position was visualized directly and using an intraoperative 0 to <20, a score of 2; 20 to <45, a score of 3; and 45 to 90, a score of 4. Thus, the image intensifier, 2 tibiocalcaneal Kirschner wires or a Steinmann pin was used to severity of the deformity is graded from 1 to 4 points. Other clinical findings are also temporarily stabilize the correction, with the wires or pin directed from plantarly to considered, including the presence of a posterior or medial crease, pes cavus, and poor proximally (intramedullary). Adjunct midfoot and forefoot procedures were also per- muscle function. When any of these additional conditions is present, an additional formed on an as-needed basis, and a below-the-knee plaster cast was applied for the first point is added to the score for each additional finding. A final score, ranging from <5to 8 postoperative weeks. Thereafter, a custom-fitted, below-the-knee ankle-foot orthosis 20, is determined and the foot graded from I (least deformity) to IV (most deformity). A (a plastic, custom, below-the-knee, foot and ankle orthosis without a custom foot insole) score of 1 to <5 is categorized as a grade I deformity (least severe), a score of 5 to <10 as was used for 1 year after the surgery. One of us (M.E.) performed all the operations. a grade II deformity, a score of 10 to <15 as a grade III deformity, and a score of 15 to 20 is categorized as a grade IV deformity (most severe). Statistical Analysis The clinical evaluation of each patient was also described in terms modified by Ò Ò Legaspi et al (12), and the feet were graded as good, fair, or poor. A grade of “good” Statistical analyses were conducted using IBM SPSS Statistics software, version indicates a painless, plantigrade foot without deformity and a satisfied patient. In 22 (IBM Corp., Armonk, NY). Data are presented as the median and range and counts contrast, a grade of “fair” indicates a painless foot with residual deformity that requires and percentages for nonparametric measures and categorical data. Tests of the null surgical correction. Finally, “poor” indicates a painful foot with residual or recurrent hypothesis between 2 independent groups for nonparametric data were conducted

Fig. 1. Preoperative clinical photograph and standing plain radiographs of the patient with cerebral palsy (patient 9). (A) Anterior view. (B) Posterior view. (C) Plain film lateral radiograph of the right foot. (D) Plain film lateral radiograph of the left foot. Tibio/Calc A, tibiocalcaneal angle; Calca/1st Met. A, calcaneus–first metatarsal angle. M.H. El-Sherbini, A.A. Omran / The Journal of Foot & Ankle Surgery 54 (2015) 1093–1098 1095

Fig. 2. Views of patient 9 at the 6-year follow-up point. (A) Anterior view. (B) Posterior view. (C) Plain film radiographic lateral view of right foot. (D) Plain film radiographic lateral view of left foot. using the Wilcoxon rank sum test or chi-square test. Differences between the Dimeglio All 19 feet underwent talectomy performed by the same surgeon scores and radiographic measurements were compared using Student’s paired t test. (M.E.). Complete subtalar release (CSTR) was performed as the pri- Statistical significance was defined at the 5% (p .05) level. mary (index) procedure in 2 (10.53%) of the 19 feet, and the decision to undertake talectomy was made during the course of the surgery ac- Results cording to the operative findings (Figs. 3 and 4; Table 2). Talectomy was performed as a primary intervention in just 2 of the 19 feet Our patient population included 19 feet in 13 patients, and their (10.53%). Furthermore, adjunct surgical procedures were performed in mean age was 7.7 (range 3 to 26) years. Of the 19 feet, 14 (73.68%) had 15 of the 19 feet (78.95%), including naviculectomy in 8 feet (42.11%), resulted from arthrogryposis multiplex congenita (AMC), 1 (5.26%) calcaneocuboid fusion in 3 (15.79%), calcaneal osteotomy in 8 (42.11%), from neglected congenital talipes equinovarus, 1 (5.26%) from sacral and PMR in 3 feet (15.79%). The mean follow-up duration was 6.4 agenesis, and 2 (10.53%) from cerebral palsy with spastic diplegia; 1 (range 2 to 11) years, and postoperative clinical and radiographic (5.26%) was post-traumatic (Table 1). Of the 13 patients, 12 (92.31%) evaluations were conducted at 6-month intervals after talectomy. had previously undergone posteromedial release (PMR), and 1 patient Using the Dimeglio scale, all feet had improved from grade IV with (7.69%; 2 [10.53%] operated feet) had not previously undergone PMR. a preoperative mean score of 16.1 1.76 to grade II with a post- Four feet (21.05%) had also undergone previous revision PMR. All operative mean score of 7.89 1.1 (p .0001) after talectomy (with or patients were ambulatory; however, 4 (30.77%) required bilateral without adjunct surgery; Table 3). Clinically, 16 feet (84.21%) were handheld support (crutches or walker) preoperatively (patients 5, 6, 9, plantigrade. We observed a good outcome in 13 feet (68.42%) and a and 13). The patient with cerebral palsy (patient 9) had been classified fair outcome in 6 (31.58%). Three feet (15.79%) had a residual hindfoot as grade III according to the Gross Motor Function Classification deformity (1 with equinus and 2 with varus), and 3 feet (15.79%) had System (GMFCS) (10,11). Patient 9 with cerebral palsy improved from adduction (2 residual and 1 recurrent), which necessitated additional grade III to grade II. At the final follow-up visit, all patients had operative correction. Radiologically, the mean preoperative lateral painless feet, with independent ambulation without handheld sup- tibiocalcaneal angle was 130 20.5 (range 90 to 146 ). Post- port (no crutches or walker required), and all the patients were operatively, it was 88 27.5 (range 60 to 118 ), and the difference satisfied (Figs. 1 to 4). Furthermore, the natural progression of the was statistically significant (p < .001). interface between the tibia and the residual tarsal bones after tale- Regarding complications, residual deformities occurred in 6 feet ctomy primarily entails the development of a functional pseu- (31.58%) in 4 patients (30.77%; 3 with AMC and 1 with cerebral palsy; doarthrosis consisting primarily of scar tissue (Figs. 2C and D and 4C patients 1, 5, 9, and 13). One foot (5.26%) had residual equinus (15 and D). This requires the use of the custom ankle–foot orthosis to plantar flexion) owing to incomplete removal of the talus, 2 feet minimize instability and guide alignment. (10.53%) had residual varus of 5 , 2 (10.53%) had residual adduction 1096 M.H. El-Sherbini, A.A. Omran / The Journal of Foot & Ankle Surgery 54 (2015) 1093–1098

Fig. 3. Preoperative clinical photograph and plain film radiographic image of patient 13 with arthrogryposis multiplex congenita. (A) Anterior view. (B) Posterior view. (C) Plain film lateral radiograph of the right foot. (D) Plain film lateral radiograph of the left foot. of 10 and cavus (patient 9), and 1 foot (5.26%) had recurrent subjective outcomes despite the deterioration of function over time adduction of 15 (patient 5). Additional operative correction at a mean and arthritic changes on plain radiographs (5,15). Triple arthrodesis is duration of 58.67 2.3 months after talectomy was performed for not the first choice for patients with a neurologic foot deformity, patients 5 and 9. The other 2 patients (patients 1 and 13) declined especially in patients with myelomeningocele, because of the danger additional operative correction. Radiographically, we did not observe of joint degeneration and skin ulceration caused by the stiffness of any cases of spontaneous tibiocalcaneal ankylosis during the obser- the foot, according to some investigators (16). In skeletally immature vation period. patients, Ilizarov correction is an alternative that has resulted in satisfactory outcomes reported in the published data. Ilizarov Discussion correction was reported in patients with AMC, with an average treatment duration of 18.5 weeks and an average of 2 operations for Experience has shown that isolated soft tissue release is an each of 12 patients, only 3 of whom had Dimeglio grade IV (1).We inadequate procedure for the treatment of a severe, rigid equi- believe a patient population with more severe deformities would novarus foot. Despite the improvements gained with serial post- have resulted in an even longer treatment duration. In another report operative casting after soft tissue release, the incidence of residual of patients with neurologic feet, the average treatment duration was and/or recurrent deformity is usually high (3,4). In skeletally mature 10 weeks (7 weeks in an external fixation frame and 3 weeks in a patients, triple arthrodesis is an option, although talectomy is gaining below-the-knee cast). In their subset of patients with more severe favor compared with triple arthrodesis. However, no clear-cut ben- deformities, concomitant hindfoot and midfoot osteotomies were efits have yet been confirmed. Some investigators have reported a performed during the index procedure (7). relatively high incidence of complications with long-term follow-up Menelaus (4) described the first long-term follow-up period of of triple arthrodesis, including residual deformities requiring addi- talectomy in a large series of patients with AMC and spina bifida tional surgery, pain due to secondary degenerative osteoarthritis, with rigid talipes equinovarus. He stated that talectomy succeeded and pseudoarthrosis (14). Others have reported satisfactory where soft tissue release had failed, because it provided sufficient M.H. El-Sherbini, A.A. Omran / The Journal of Foot & Ankle Surgery 54 (2015) 1093–1098 1097

Fig. 4. Views of patient 13 at the 2-year follow-up point. The surgical procedure included bilateral talectomy and bilateral complete subtalar release, with naviculectomy of the left side. (A) Anterior view. (B) Posterior view. (C) Plain ﬁlm lateral radiograph of the right foot. (D) Plain ﬁlm lateral radiograph of the left foot. laxity for the equinovarus deformity to be corrected without ten- depends on a careful assessment of the deformity and the details of sion. The tibiocalcaneal pseudoarthrosis that was created remained the surgical technique. Talectomy is an effective procedure for stable and relatively congruous in the plantigrade feet. Moreover, correction of hindfoot deformities, and surgeons need to under- the foot had no tendency to relapse owing to the stable position stand that the associated forefoot problems need to be treated as and the absence of medial tension (4). The outcome of talectomy separate entities (12,17).

Table 2 Study population characteristics, procedures, and outcome (N ¼ 19 feet in 13 patients)

Patient Age (y) Sex Diagnosis Side Deformity Previous Operation Associated Operations Complications Follow-Up Duration (y) Result* No. 1 10 Male AMC Right E,V,A,S PMR d Residual E (15) 11 Fair AMC Left E,C,V,A,S PMR Nav Residual V (5) 10 Fair 2 10 Male AMC Right E,C,V,A,S PMR (twice) Nav þ CCF þ STR d 9 Good AMC Left V,C,A PMR Nav þ CCF d 9.6 Good 3 26 Male Neglected CTEV Left E,C,V,A,S PMR Nav þ CCF d 8 Good 4 6 Female Sacral agenesis Left E,C,V,A,S PMR (twice) CalO þ STR d 8 Good 5 4 Female AMC Right E,C,V,A,S PMR Nav þ CalO d 7 yr, 7 mo Good AMC Left E,C,V,A,S PMR CalO Recurrent A 6 yr, 3 mo Fair 6 3 Male AMC Right E,C,V,A,S PMR Nav þ CalO d 7 Good 7 8 Male AMC Left E,C,V,A,S PMR CalO d 7 Good 8 3 Male AMC Right E,V,A,S PMR dd5 yr, 3 mo Good 9 12 Male CP spastic Left E,C,V,A,S PMR d Residual A þ C 6 Fair GMFCS III Right E,C,V,A,S PMR d Residual A þ C 6 Fair 10 3 Male AMC Right V,C,A PMR CalO d 5.3 Good AMC Left E,C,V,A,S PMR CalO d 5.3 Good 11 10 Female Post-traumatic Right E,V PMR (twice) dd3 Good 12 3 Male AMC Left E,C,V,A,S PMR Nav þ CalO d 2.2 Good 13 3 Female AMC Right E,C,V,A,S CSTR 2 Good AMC Left E,C,V,A,S Nav þ CSTR Varus 2 Fair

Abbreviations: A, adduction; C, cavus; CalO, calcaneal osteotomy; CCF, calcaneocuboid fusion; CSTR, complete subtalar release; CTEV, congenital talipes equinovarus; E, equinus; GMFCS, Gross Motor Function Classiﬁcation System; Nav, naviculectomy; PMR, posteromedial release; S, supination; STR, soft tissue release; V, varus. * Good indicates a painless, plantigrade foot without deformity and a satisﬁed patient; fair indicates a painless foot with residual or recurrent deformity that requires surgical correction; and poor indicates a painful foot requiring surgical correction. 1098 M.H. El-Sherbini, A.A. Omran / The Journal of Foot & Ankle Surgery 54 (2015) 1093–1098

Table 3 more active patient population might have resulted in different out- Preoperative and postoperative Dimeglio scores comes. Other biases that likely influenced our findings were the single Score Feet (n) Mean SD tpValue Significance surgeon series and that the outcome assessments were performed by Overall the operating surgeon and others related to the patients’ treatment. Preoperative 19 16.105 1.7605 Despite these limitations, the findings we have described could be Postoperative 19 7.895 1.1002 17.514 <.0001 HS used in the development of future randomized controlled trials and Supination prospective cohort studies focusing on the surgical care of the rigid Preoperative 19 54.737 30.5266 Postoperative 19 0.263 1.1471 7.767 <.0001 HS equinovarus foot. Adduction In conclusion, talectomy is an effective procedure for the treat- Preoperative 19 34.211 5.5934 ment of rigid, severe equinovarus feet with a grade IV Dimeglio Postoperative 19 1.053 2.0943 24.817 <.0001 HS classification. Talectomy is used primarily to correct hindfoot defor- Varus mity, provided that the talus is completely removed and the calcaneus Preoperative 19 27.895 12.7275 Postoperative 19 1.053 4.2749 9.57 <.0001 HS can be aligned in the ankle mortise. Any associated mid- and/or Equinus forefoot deformity should be addressed with adjunct surgical in- Preoperative 19 24.737 21.6329 terventions. Finally, talectomy is relatively straightforward and does < Postoperative 19 2.895 5.6065 5.473 .0001 HS not require a great amount of surgical time and relieves neurovascular Abbreviations: HS, highly significant (p < .01); SD, standard deviation. tension and allows early mobilization of the operated extremity. From Comparison between 2 dependent groups for parametric data performed using a our experience with talectomy, we believe it is a viable alternative for paired t test; the probability of error at .05 was considered significant and at .01, highly significant. the surgical treatment of rigid, severe, equinovarus foot deformity.

Acknowledgments Numerous associated procedures have been reported in published studies at the same time of the index procedure. The tarsal navicular The authors give special thanks to Ahmed Kamal, MD, for his can be excised if necessary to obtain adequate posterior displacement assistance with statistical analyses. of the calcaneus (13,18). Calcaneocuboid fusion was shown to decrease the incidence of recurrent deformity in children (2). The References most commonly reported complication has been residual deformity. 1. Choi IH, Yang MS, Ghung CY, Cho TJ, Sohn YJ. The treatment of recurrent Usually, the deformity results from a technical error during surgery. arthrogrypotic club foot in children by the Ilizarov method. J Bone Joint Surg Br The technical errors include incomplete removal of the talus and 83:731–737, 2001. incorrect positioning of the calcaneus in the ankle mortise (4,8,12,19). 2. Pirpiris M, Ching DE, Kuhns CA, Otsuka NY. Calcaneocuboid fusion in children undergoing talectomy. J Pediatr Orthop 25:777–780, 2005. In contrast to the classic recommendation, Cassis and Capdevila (20) 3. Coleman S. Teratologic equinovarus congenita. In: Complex Foot Deformities in found no correlation between the presence of residual talus and the Children, pp. 255–264, edited by S Coleman, Lea & Feibger, Philadelphia, 1983. outcome. However, the size of the residual talus and whether articular 4. Menelaus MB. Talectomy for equinovarus deformity in arthrogryposis and spina bifida. J Bone Joint Surg Br 53:468–473, 1971. cartilage or bony talus had been left behind was not reported (20). 5. Angus PD, Cowell HR. Triple arthrodesis: a critical long-term review. J Bone Joint Legaspi et al (12) found no correlation between the degree of poste- Surg 68:260–265, 1986. rior displacement of the calcaneus relative to the tibial mid-axis and 6. Kocaoglu M, Eralp L, Atalar AC, Bilen FE. Correction of complex foot deformities fi – talocalcaneal arthritis, and all their patients wore normal shoes. A using the Ilizarov external xator. J Foot Ankle Surg 41:30 39, 2002. 7. Lee DY, Choi IH, Yoo WJ, Lee SJ, Cho TJ. Application of the Ilizarov technique to the similar finding was reported by Cooper and Capella (8) in their long- correction of neurologic equinocavovarus foot deformity. Clin Orthop Relat Res term follow-up study. 469:860–867, 2011. The results of our study have confirmed those of numerous reports 8. Cooper RR, Capello W. Talectomy: a long-term follow-up evaluation. Clin Orthop Relat Res 201:32–35, 1985. that talectomy offers a simple and effective correction of rigid equi- 9. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. novarus feet. The treatment duration was approximately 8 weeks on J Pediatr Orthop B 4:129–136, 1995. average, with follow-up examinations at 4 and 8 weeks postoperatively. 10. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral Subsequently, mobilization was started with the patient in a below-the- palsy. Dev Med Child Neurol 39:214–222, 1997. knee splint. We had good results in 13 of 19 feet (68.42%) and a fair 11. Palisano RJ, Rosenbaum P, Bartlett P. Content validity of the expanded and revised outcome in 6 feet (31.58%). None of our patients experienced a poor gross motor function classification system. Dev Med Child Neurol 50:744–750, 2008. 12. Legaspi J, Li YH, Chow W, Leong JC. Talectomy in patients with recurrent deformity outcome. Furthermore, no cases of foot pain were reported after tale- in club foot: a long-term follow-up study. J Bone Joint Surg Br 83:384–387, 2001. ctomy. Importantly, we must remember the limited demands of these 13. Green ADL, Fixsen JA, Lloyd-Roberts GC. Talectomy for arthrogryposis multiplex patients owing to the associated orthopedic and nonorthopedic dis- congenita. J Bone Joint Surg Br 66:697–699, 1984. 14. Guidera KJ, Drennen JC. Foot and ankle deformities in arthrogryposis multiplex abilities that often accompany the severe, rigid equinovarus foot. We congenita. Clin Orthop 194:93–98, 1985. performed talectomy as a salvage procedure in all but 2 feet (10.53%). In 15. Saltzman CL, Fehrle MJ, Cooper RR, Spencer EC, Ponseti IV. Triple arthrodesis: neglected cases with severe deformity, the operation can be performed twenty-five and forty-four-year average follow-up of the same patients. J Bone – as a primary procedure. We believe that the fair results were related to a Joint Surg Am 81:1391 1402, 1999. 16. Lindseth RE. Myelomeningocele. edited by RT Morrissy, SL Weinstein, Lippincott failure to address all deformity components with concomitant pro- Williams & Wilkins, Philadelphia, 2001. cedures. Also, we undertook adjunct procedures in 14 of the 19 feet 17. Dias LS, Stern LS. Talectomy in the treatment of resistant talipes equinovarus – (73.68%) on which we performed talectomy. deformity in myelomeningocele and arthrogryposis. J Pediatr Orthop 7:39 41, 1987. The limitations of the present observational case series included 18. Trumble T, Banta JV, Raycroft JF, Curtis BH. Talectomy for equinovarus deformity in the small sample size, although we were able to show statistically myelodysplasia. J Bone Joint Surg Am 67:21–29, 1985. significant differences in the outcome measures. More importantly, 19. Hsu LCS, Jaffray D, Leong JCY. Talectomy for club foot in arthrogryposis. J Bone Joint Surg Br 66:694–696, 1984. however, the limited functional demands of our patient population 20. Cassis N, Capdevila R. Talectomy for clubfoot in arthrogryposis. J Pediatr Orthop probably influenced the favorable outcomes we observed. Thus, a 20:652–655, 2000. 本文献由“学霸图书馆-文献云下载”收集自网络，仅供学习交流使用。

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