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TALECTOMY
FOR
A.
ARTHROGRYPOSIS
D.
L.
GREEN,
From
J. A.
FIXSEN,
the Hospitalfor
Eighteen
patients
(34 feet) with
equinovarus
deformity
were reviewed.
considered
satisfactory;
the remainder
recurrence
of the deformity,
but finally
history of talectomy
is reviewed and the
in order
to obtain
1970;
a plantigrade
foot
C.
Children,
CONGENITA
LLOYD-ROBERTS
London
arthrogryposis
multiplex
congenita
treated
by talectomy
for rigid
The average follow-up
was 11 years. Twenty-four
feet (71%) were
were improved.
Seven feet required further operations
to correct
all could be fitted with boots or shoes and all patients could walk. The
operative
details described.
(Lloyd-Roberts
Men#{233}laus 1971 ; Drummond
The aim of this
results
of talectomy
equinovarus
deformity
genita.
G.
Sick
Arthrogryposis
multiplex
congenita
is a syndrome,
present
at birth, which usually affects all four limbs and
sometimes
also the spine ; it is associated
with muscular
and ligamentous
abnormalities.
Clinical
studies
have
shown
that the foot and ankle are the most commonly
affected
areas, and rigid equinovarus
is the most frequent
foot deformity
(Friedlander,
Westin
and Wood
1968;
Gibson
and Urs 1970; Lloyd-Roberts
and Lettin 1970).
Treatment
by serial plasters
and soft-tissue
surgery
alone has generally
proved
ineffective
(Fisher et al. 1970;
Menelaus
1971) and talectomy
has therefore
been advised
Lettin
1978).
MULTIPLEX
and
and
Cruess
Evans
(1928)
reported
that talectomy
gave good
results
in the treatment
of paralytic
calcaneovalgus
and
fair results
in the treatment
of equinovarus
deformity
due to spastic
paralysis,
spina
bifida
or progressive
muscular
atrophy.
Leikkonen
(1950)
and son Holmdahl
(1956)
held
conflicting
views on the value of talectomy
in treating
deformity
caused
by poliomyelitis.
Leikkonen
was generally critical
of the operation
whereas
son Holmdahl
reported
good results
in over 80% of those treated
and
found it particularly
valuable
for correcting
equinus.
In 1970 several workers
recommended
talectomy
for
the treatment
of rigid equinovarus
in arthrogryposis
(Gibson
and Urs 1970; Lloyd-Roberts
and Lettin 1970).
study was to assess the long-term
for the treatment
of severe
rigid
in arthrogryposis
multiplex
con-
History
of talectomy
The first known
report
of talectomy
was by Hildanus
(1641)
who described
its successful
outcome
for the
treatment
of a patient
with a compound
dislocation
of
the talus. In 1872, Edward
Lund of Manchester
described
talectomy
for the treatment
of congenital
talipes equinovarus
and
devised
a special
knife
for the operation.
Royal Whitman
published
his first paper on talectomy for paralytic
talipes calcaneovalgus
in 1901. Further
papers followed
in 1908 and 1910, the operation
becoming
known
as Whitman’s
operation.
During
the following
10
to 20 years it was practised
extensively,
particularly
in
the United
States.
A. D. L. Green,
Queen
Elizabeth
FRCS,
Senior
Specialist
Military
Hospital,
Woolwich,
England.
J. A. Fixsen, MCII,
G. C. Lloyd-Roberts,
The Hospital
3JH, England.
Requests
©
VOL.
Children,
for reprints
1984
British
66-8,
SE18
FRCS, Consultant
Orthopaedic
Surgeon
MC1I, FRCS, Consulting
Orthopaedic
for Sick
0301-620X/84/5l48
London
should
Editorial
Great
be sent
Society
1984
Street,
London
to Mr J. A. Fixsen.
of Bone
$2.00
No. 5, NOVEMBER
Ormond
and
Joint
Surgery
6XN,
Surgeon
WC1N
Fig.
Shape
ofthe
feet and legs in infancy;
MATERIAL
AND
1
the deformities
are clearly
seen.
METHODS
Thirty-four
feet in 18 children
with arthrogryposis
were
treated
by talectomy
for rigid equinovarus
; each patient
was personally
reviewed
in a special clinic. The original
diagnosis
(Fig. 1) was made after clinical
examination
by orthopaedic
surgeons
and neurologists.
The average
age at talectomy
was 2 years 5 months.
Halfthe
operations
697
698
A. D. L. GREEN,
,
Fig.2
Shape
J. A. FIXSEN,
Fig.3
#{149}
of the feet and legs in a child
aged five years,
after
were performed
on infants
under the age of 18 months.
The oldest child was over 5 years. Follow-up
was from 4
to 20 years with an average
of 1 1 years ; seven patients
had reached
skeletal
maturity.
Before
talectomy
all the patients
had undergone
conservative
treatment.
In addition
21 operations
(18
feet) had been
performed
: lengthening
of the tendo
calcaneus
(4); posteromedial
release
(1 5); and Dil!wyn
Evans operation
(2). Only one foot treated
by soft-tissue
release
had a successful
result. Figures
2 and 3 show the
typical appearance
of the feet after lengthening
the tendo
calcaneus.
Operative
technique.
The operation
is performed
under
general
anaesthesia
and with a thigh tourniquet.
The
patient
lies in the supine
position
with a small sandbag
under the buttock
on the side of operation.
An anterolateral
incision
is made
over the ankle and extended
distally
to the
of the
level
of the
navicular.
talus
are exposed
starting
from
ankle ; this is a useful
landmark,
of the
small
foot
where
the
talus
is largely
The
head
the
anterior
particularly
and
cartilaginous.
grow
and
cause
recurrence
this.
after
to remove
all or part
ofthe
calcaneus,
but before
talectomy.
calcaneus
is stabilised
in the corrected
position
by a
Kirschner
wire driven
up through
the skin of the heel
into the tibia. The end of the wire is left protruding
and
is bent
over
to prevent
migration.
Fig. 4
Radiographic
It is
may
of deformity.
navicular
the tendo
neck
The
tendo
calcaneus
should
be lengthened
by
excision
of 1 to 2 cm, rather
than by “Z” lengthening
which can predispose
to recurrence
of the equinus.
The
lengthening
is carried
out through
a second
incision
made directly
over the tendon.
After complete
removal
of the talus and excision
of a portion
of the tendo
calcaneus,
the foot should
be easily correctable
to the
neutral
plantigrade
position.
In some patients
it may be
necessary
lengthening
aspect
in a
most important
to remove
the talus completely
; this
be difficult
when
it is adherent
to the surrounding
structures,
but a small fragment
left behind
will almost
invariably
G. C. LLOYD-ROBERTS
to achieve
All equinus
must be corrected
as any remaining
operation
will persist
and tend to increase.
The
appearance
shortly
after
talectomy.
A below-knee
plaster is applied
with the foot in the
corrected
position.
This plaster
is changed
after three
weeks
when
the Kirschner
wire is removed
and the
patient
allowed
to bear weight.
Figure
4 shows
the
radiographic
is retained
appearance
for six to eight
shortly
weeks
after operation.
in all.
Plaster
RESULTS
A painfree
plantigrade
foot which would accept normal
boots or shoes or specially
fitted boots, was considered
satisfactory
(Figs
5 to 7). Twenty-four
feet (71%) were
satisfactory
at review ; 19 of these had talectomy
alone
and 5 had required
further
operative
treatment.
Ten feet
(29%)
were
considered
unsatisfactory
THE JOURNAL
(Table
I).
OF BONE AND JOINT
SURGERY
TALECTOMY
This man had a talectomy
Table I. Results after
subsequent
operations
Satisfactory
talectomy
alone
or after
FOR
when
combined
with
Number
%
Talectomy
alone
Talectomy
19
5
24
71
8
2
10
29
Unsatisfactory
further
operations
by
Walking
ability. All patients
were able to walk without
pain ; eight walked
without
aids, four with calipers,
and
six with calipers
and crutches.
Two patients
were able to
wear normal
shoes, two required
specially
fitted boots
and the rest were able to wear standard
boots.
Clinical assessment.
The shape of the foot, at final review,
was assessed
clinically
and from anteroposterior
and
lateral radiographs
of the foot and lower tibia. Twentyfour feet (71%) were found to be plantigrade,
except for
slight supination
of the forefoot.
Equinus
deformity
of
the whole
foot was present
in four,
and plantaris
deformity
in six. The most common
residual
deformity
was supination
of the forefoot
which was present
in 31
feet. This was mild and limited
neither
walking
nor the
use of standard
footwear.
Residual
clawing
was present
in 17 feet;
in four
this
required
I would like to thank Brigadier
Jack
Miss Maria Phelan for her secretarial
surgical
MULTIPLEX
he was aged five. These
talectomy
followed
ARTHROGRYPOSIS
correction.
photographs
699
CONGENITA
show the appearance
18 years
later.
Movement
at the tibiocalcaneal
pseudarthrosis
was
severely
limited.
Twenty-four
joints were almost
fused,
none having
more than a few degrees
of movement.
Lateral
radiographs
revealed
bony fusion in 1 1 At the
midtarsaljoint
seven feet were stiff; the other 27 had only
a jog of movement.
Relapse.
All patients
were satisfactory
after the initial
talectomy
; any relapse
intoequinovarus
orcavus
occurred
between
two and six years later. This was a problem
in
seven feet and 1 1 further operations
had to be performed.
In four feet the tendo calcaneus
which had previously
been “Z” lengthened
was now excised.
Remnants
of the
talus
had to be removed
from
four feet. Two
feet
developed
severe
cavus
deformity
and both required
wedge
tarsectomy
; in one a subsequent
release
of the
plantar
fascia and flexor hallucis longus was also required.
.
Conclusion
Talectomy
is a useful
operation
to correct
the rigid
equinovarus
foot in arthrogryposis
multiplex
congenita
and to convert
it into one which,
though
still rigid, is a
functionally
useful plantigrade
foot. It is recommended
either as a primary
procedure
for such feet or as one to
be used after the failure of less radical
treatment.
Coull, Consultant
Advisor
in Orthopaedic
Surgery to the Army, for his help
assistance,
and also Miss Marshall
from the Department
of Medical
Records.
and support
with
this paper,
REFERENCES
Drummond
DS, Cruess RL. The management
of the foot and ankle in arthrogryposis
multiplex
congenita.
J Bone Joint Surg [Br] 1978 ;60-B:
96-9.
Evans EL. Astragalectomy.
In : The Robert
Jones
birthday
volume : a co//ection
of surgical
essays.
London : Oxford
Medical
Publications,
1928:
375-94.
Fisher RL, Johnston
WT, Fisher WH Jr, Goldkamp
0G. Arthrogryposis
multiplex
congenita;
a clinical
investigation.
J Pediatr 1970;76: 255-61.
Friedlander
HL, Westin GW, Wood WL Jr. Arthrogryposis
multiplex
congenita
: a review of forty-five
cases. J Bone Joint Surg [Am]
1968;
50-A:89-l 12.
Gibson
DA, Urs NDK. Arthrogryposis
multiplex
congenita.
J Bone Joint Surg [Br] l970;52-B:
483-93.
Hildanus
F. Observationum
et curationum
medico-chirurgarum
centurae
sex. 1641 . Cited in Bick EM. Source book of orthopaedics.
2nd ed.
Baltimore
: Williams
& Wilkins Co. 1948 : 52.
Leikkonen
0. Astragalectomy
as ankle stabilizing
operation
in infantile
paralysis
sequelae : with special reference
to astragalectomies
and total
arthrodeses
performed
in Finland.
Acta Chir Scand 1950; 100:668-70.
Lloyd-Roberts
GC, Lettin AWF. Arthrogryposis
multiplex
congenita.
J Bone Joint Surg [Br] l970;52-B
: 494-508.
Lund E. Removal
of both astragali
in a case of severe double talipes. Br Med J 1872; II :438.
Menelaus
MB. Talectomy
for equinovarus
deformity
in arthrogryposis
and spina bifida. J Bone Joint Surg [Br] 1971 ;53-B:468-73.
son HOImdahI HC. Astragalectomy
as a stabilising
operation
for foot paralysis
following
poliomyelitis
: results
of a follow-up
investigation
of 153
cases. Acta Orthop Scand 1956;25:207-27.
Whitman
R. The operative
treatment
of paralytic
talipes of the calcaneus
type. Trans Am Orthop Assoc 1901 ; 14: 178-87.
Whitman
R. Further
observations
on the treatment
of paralytic
talipes calcaneus,
by astragalectomy
and backward
displacement
of the foot. Ann
Surg 1908;47: 264-73.
Whitman
R. Further
observations
on the operative
treatment
of paralytic
talipes
of the calcaneus
type. Am J Orthop Surg 1910 ; 8 : 137-45.
VOL. 66-B, No. 5, NOVEMBER
1984