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Abstract: A 15-year-old patient with severe foot deformity, horseshoe clubfoot, difficulty in standing, slow walking, and even limping was diagnosed with rigid clubfoot after examination. This type belongs to a kind of clubfoot which is difficult to treat, and it is easy to recur, so conservative treatment is not effective, so surgery is recommended.
Basic information】Female, 15 years old
Disease Type】Stiff clubfoot
Hospital】Harbin First Hospital
Date of Consultation】04/2021
Treatment plan】Surgery (Achilles tendon release + Achilles tendon lengthening + internal fixation of the dorsal wedge of the first metatarsal bone)
Treatment Period】7 days of inpatient treatment, 1 month of outpatient follow-up, and 3 months of return to the hospital for review
Treatment effect] The foot deformity is well corrected and the normal walking ability is basically restored.
I. Initial consultation
The patient was 15 years old and had a severe foot deformity, with a horseshoe inversion pattern, significant plantarflexion deformity of the ankle and subtalar joint, and the prominent talar bone could be felt from the dorsum of the foot under the skin, and the Achilles tendon contracture was also serious. This type of foot is relatively difficult to treat, and it is easy to recur, and the effect of conservative treatment is not good. Since the patient is 15 years old, has a relatively long history of the disease, has obvious claudication, and has serious soft tissue and joint stiffness, surgery is recommended.
II. Treatment after
The patient was recommended to undergo surgical treatment, including Achilles tendon release, Achilles tendon lengthening, and internal fixation of the dorsal wedge osteotomy of the first metatarsal. During the procedure, the Achilles tendon is released and lengthened by an open method, 2.5 cm depending on the patient’s age and deformity, to ensure proper tension of the Achilles tendon. The tense metatarsal fascia was also severed, the posterior tibial tendon was displaced and the long peroneal tendon was simultaneously disconnected and the short peroneal tendon was strengthened. A wedge-shaped osteotomy was performed on the dorsal aspect of the first metatarsal and was internally fixed with titanium plate screws. After soft tissue and bone management, the clubfoot was corrected. A long-leg cast was used for postoperative immobilization to relieve pain and ensure bony healing and soft tissue repair. After surgery, the patient’s general condition was closely monitored and the affected limb was elevated to observe the peripheral blood circulation in the foot and to see if any local swelling or overtightening of the cast occurred. The patient recovered well after 7 days of hospitalization and was discharged.
III. Treatment effect
After comprehensive treatment, the patient’s clubfoot was corrected. Due to the relatively small surgical trauma, the patient’s pain symptoms were not serious in the initial postoperative period, and the pain symptoms improved significantly in about 1 week. The blood supply and innervation of the lower extremity were fully protected, and no deep vein thrombosis of the lower extremity was formed or numbness of the extremity was produced. There was no persistent exudation from the Achilles tendon lengthening site, no significant increase of white blood cells in the blood routine, and no signs of infection. The patient was instructed to follow up at the outpatient clinic for one month, remove the cast after 6 weeks, and return to the hospital for a review in about 3 months.
IV. Notes
I was very pleased to see that the patient recovered well. During the fixation of the long leg cast, the patient should not stand to prevent the surgical effect from deteriorating. Normally, the cast is removed 6 weeks after surgery and the X-ray is reviewed. It takes about 3 months for the fracture to heal completely before the patient can walk normally with weight. In addition to strengthening nutrition, the patient should also perform functional exercises for the muscles and joints of the lower limbs before the fracture heals to avoid the formation of adhesions and joint stiffness and other surgical complications, and take oral medications such as rivaroxaban tablets to prevent deep vein thrombosis in the lower limbs. The risk of lower extremity DVT can persist until 4-6 weeks after surgery and needs to be given high priority. Avoid strenuous exercise for 1 year to prevent injury to the Achilles tendon, ankle joint and foot joints.
V. Personal insight
For patients with clubfoot, especially stiff clubfoot, early diagnosis and timely treatment will lead to improvement of deformity in most patients. Prolonged non-treatment can lead to significant lameness, stiffness of soft tissues and joints, significant atrophy of calf muscles, and even foot ulcers. Patients are advised to undergo surgery in a timely manner, and post-surgical rehabilitation is also crucial. Patients need to clarify the treatment cycle and actively cooperate with the rehabilitation physician to achieve the best recovery results.