Promising results in a 3-year follow-up for adults undergoing a one-stage surgery for residual talipes equinovarus as part of a humanitarian mission in Vietnam

Fixed TEV is a complex deformity that severely impairs mobility. That, in turn, has far-reaching implications for all aspects of daily life, including the ability to commute, study, or work. In developing countries, these limitations can impair the ability to lead an independent and self-sustaining life, putting a strain on the family. While new, sophisticated, and often expensive operative modalities have been demonstrated as effective tools for correcting these deformities, patients living in countries with limited medical access cannot benefit from such “advancements.” This study presents a basic “low-tech” surgical technique for correcting rigid TEV feet and restoring the ability to walk independently. Patients presented to our team with deformities that significantly affected gait and general function. Their deformities forced them to walk on the lateral aspect of their feet, which imposed a slow, disturbed and painful gait. Feet were often non-shoeable. This complex of functional limitation affected many aspects of their lives. Following surgery, although patients did not have a completely normal gait, nor could they qualify for sporting activities, their feet were shoeable and they were able to walk in a way that enabled normal daily activities. The patients also reported that the improvement in their mobility has helped them find work and maintain financial stability.

A few authors have previously described surgical techniques for treating rigid TEV [8, 9, 13]. These are classified based on the type of surgery (bony or soft tissue) and the type of fixation, which can be either internal (plates, screws) or external (K-wires, Steinmann pins, or external fixators). It is common to use a combination of these procedures. The treatment strategy is determined by the configuration of the deformity and its specific components, the patient's needs and preferences, and the surgeons' experience. When developing a treatment strategy, it is critical to consider the local healthcare capabilities in terms of surgical conditions, follow-up availability, and access to rehabilitation. Recent literature indicates that external fixators are becoming the modality of choice for rigid TEV, with promising results [1, 14,15,16,17]. Nonetheless, these modalities are expensive and require a high level of surgical expertise as well as strict follow-up and rehabilitation plans. As a result, this technique was inapplicable for treating our patients in developing countries. Another salvage alternative for fixed clubfoot is talectomy [18]. This procedure allows to orient the calcaneopedal unit properly under the tibiofibular mortise. The reduction obtained is maintained by Kirschner wires for 6 weeks before being removed. This procedure is relatively inexpensive and corrects the deformity while enables to avoid possible vascular complications during reduction.

Bony procedures range from single-stage corrective osteotomies to triple arthrodesis. The Cole osteotomy is a lateral closing wedge. The first cut is made vertically, near the center of the navicular and cuboid bones. The second cut is based on the dimensions of the wedge to be removed, beginning anterior to the first cut and connecting the plantar edge [19]. Japas et al. described another technique [20] that employs an anteromedial approach and a V-shape osteotomy between the midtarsal and tarsometatarsal joints, with its apex proximal and at the base of the deformity center (near the navicular). This technique shortens the foot and eliminates the slow healing process of the osteotomy [20]. For the forefoot deformity, Japas et al. described the tarsometatarsal truncated-wedge arthrodesis [20]. The goal of the treatment is to restore the plantigrade foot to allow mobility. In our series of patients, osteotomy was indicated during the preoperative evaluation because the deformities were fixed. Due to the subtalar involvement and the center of the deformity being in the midfoot, a variation of Cole osteotomy [19, 20] was performed. The modification of the technique includes a subtalar approach within the same skin incision and the midtarsal bone. At the final follow-up visit, all patients displayed a plantigrade foot and improved mobility.

Soft tissue procedures aim to prevent deformity progression by reorienting, shortening, or lengthening tendons and ligaments, which can have a balancing effect on distorted joints [21]. Before conducting these procedures, it is essential to assess the involved tendons with a thorough physical examination to determine their competency. Hindfoot equinus originates from the tibiotalar joint and can be addressed by a TAL procedure. The tibialis anterior (TA) tendon functions as a midfoot supinator, dorsiflexor, and forefoot adductor. The transfer of this tendon to the peroneus tertius, or the fifth metatarsal base [21,22,23,24], eliminates its effect as a supinator and dorsiflexor while improving the peroneus' ability to pronate and evert the foot into a more plantigrade position. In our series, 10 (83.3%) patients underwent TAL in addition to bony procedures, and none underwent a TA transfer. Although not implemented in this series, a posterior release could be added in cases where both an osteotomy and TAL procedure were not sufficient in correcting the equinus.

In developing countries, such as Vietnam, medical equipment is scarce. The procedures were conducted without fluoroscopy, plates, screws, or external fixators. Furthermore, postoperative physical therapy is frequently unavailable to patients. Traditionally, treatment of fixed clubfoot deformities includes extensive soft tissue release in children and osteotomies in older patients [1, 8,9,10,11]. All of the patients in our study had mature bones with fixed deformities. As a result, a combination of soft tissue and bony procedures was carried out, as shown in Table 1. Many studies have described various fixation methods for osteotomies [1, 8,9,10]. We used Steinmann pins and casts for fixation. Despite using these antiquated methods, all surgeries resulted in fixed plantigrade feet, and all patients reported improved mobility and quality of life. One disadvantage of this technique is the lengthy period of cast immobilization. The non-weight-bearing period in our series was 1.5 months in a circular cast and an additional 1.5 months in a removable walking boot. We could have shortened the duration of immobilization by using new locking plates and/or screws, allowing patients to switch to a boot after only six weeks. Another disadvantage is the inability to perform pre-planned monitored corrections, which are possible when using more modern techniques (Table 2).

Table 2 Pre- and post-operative AOFAS scores of patients who underwent surgery for rigid talipes equinovarus (n = 8)

There are several limitations to this study. The short duration of follow-up for some of the patients is probably the most problematic aspect of this study. Another significant issue was the lack of serial physical therapy, which would have been a significant aspect of treatment in any other setting. We did not evaluate the different types of deformities or the degree of improvement. Overall improvement was measured in terms of mobility and plantigrade foot maintenance. There was no radiographic follow-up available. Although it has been argued in the past that there is only a weak correlation between radiographic findings and clinical outcomes [25], if this modality had been readily available, we would have used it to further evaluate the surgical outcomes. Another significant issue was that none of the patients reported any pain before or after the surgery, which could be attributed to a Vietnamese cultural trait. This proclivity affected the AOFAS results, increasing the score by at least 40 points in all tests. Furthermore, scores obtained during follow-up visits or by phone may have been higher due to the patients' willingness to express gratitude to their caregivers. The AOFAS score had been developed in western countries where demographic, cultural, and socioeconomic features are inherently different than in developing countries. This difference can influence health perception, and health services-related expectations, and deeply affect patient-reported outcome scores. Moreover, the inaccessibility to medical care, and the difference that exists between a surgeon–patient relationship in a regular hospital and in a humanitarian mission could significantly distort validated scores. Despite this limitation, it is important to have an evaluation of the functional outcomes, and the extent at which these surgeries improved patient’s quality of life. A more descriptive approach for evaluating patient’s function before and after surgery could add significant and valuable information and could allow a better understanding of the value of these procedures in underserved and remote communities. We therefore added to the results a description of the way patients have been affected by their pathology both before and after surgery. This approach aimed to allow a more profound description of patients function and satisfaction, with both measurable and non-measurable means (Table 3).

Table 3 Postoperative AOFAS scores of patients who underwent surgery for rigid talipes equinovarus (n = 12)

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