Journal of Limb Lengthening & Reconstruction

: 2020  |  Volume : 6  |  Issue : 2  |  Page : 137--141

An external fixator and limited release in the treatment of neglected, recurrent, relapsed and resistant talipes equinovarus deformity of the feet

Aditya K Agrawal1, Manish R Shah1, Malkesh D Shah1, Neel H Patel2, Takshay Gandhi2, Sarvang M Desai1, Jagdish J Patwa1,  
1 Department of Orthopaedics, Dhiraj Hospital, Smt. BK Shah Medical Institute and Research Centre, Sumandeep, Vidyapeeth, Deemed to be University, Piparia, Waghodia, Vadodara, Gujarat, India
2 LG Hospital, Ellisbridge, Ahmedabad Gujarat, India

Correspondence Address:
Dr. Aditya K Agrawal
MS Ortho, MCh (UK), Associate Professor, Department of Orthopaedics, Dhiraj Hospital, Smt. BK Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth Deemed to be University, Piparia Waghodia Vadodara - 391 760, Gujarat


Introduction: The existence of resistant and neglected talipes equinovarus deformity of the foot is still prevalent in many parts of the world, serving as a challenge to an orthopedic surgeon to convert this complex deformity into a normal functioning foot. Our study aims to evaluate the results of our mid-path treatment in neglected, resistant, relapsed, and rigid clubfoot. Our treatment protocol's objectiveswere (1) the foot must become plantigrade at the end of the treatment. (2) Patient must be able to wear normal shoes. Patients and Methods: Our study included 35 feet belonging to 29 patients (six cases of bilateral congenital talipes equinovarus) aged between 2 years and 8 years with an average age of 4.8 ± 2.5 years. Our protocol includes soft-tissue release and frame fixation using a mini external fixator at the same time. After frame removal, an above-knee cast was given for 3 weeks. The average follow-up period was 3.8 ± 1.2 years. Results: We achieved excellent results in 30 cases, 3 cases had a fair result, and 2 cases had a poor result using Pirani score. Two cases had superficial infection and two cases required additional procedures. The average fixator duration was 10 weeks. Conclusion: Our mid-path protocol for managing neglected and rigid talipes equinocavovarus deformity has excellent outcomes with satisfactory patient compliance to the treatment with added advantages of rapid correction and decreased pain during and reduced external fixator duration. Level of Evidence: Level IV.

How to cite this article:
Agrawal AK, Shah MR, Shah MD, Patel NH, Gandhi T, Desai SM, Patwa JJ. An external fixator and limited release in the treatment of neglected, recurrent, relapsed and resistant talipes equinovarus deformity of the feet.J Limb Lengthen Reconstr 2020;6:137-141

How to cite this URL:
Agrawal AK, Shah MR, Shah MD, Patel NH, Gandhi T, Desai SM, Patwa JJ. An external fixator and limited release in the treatment of neglected, recurrent, relapsed and resistant talipes equinovarus deformity of the feet. J Limb Lengthen Reconstr [serial online] 2020 [cited 2021 Mar 1 ];6:137-141
Available from:

Full Text


Congenital talipes equinovarus (CTEV) deformity of the foot is a condition, the cause of which is unknown, the patho-anatomy of which is uncertain, the behavior of which is unpredictable, and the treatment remains controversial.[1] Although we have achieved a high success rate with Ponseti technique, we still come across many cases with recurrent, resistant, and neglected talipes equinovarus deformity of the foot in patients who have either not completed or defaulted during Ponseti cast treatment. If proper technique is not used, it can lead to complications like rocker bottom foot. The task is to convert these complex deformities of the foot into a normal-looking and optimally functional foot. Therefore, we have used a mini external fixator, which is especially useful to correct the foot and ankle deformities for patients with age between 2 and 8 years.[2] It will act as a minimally invasive mid-path treatment modality between various plaster techniques and corrective osteotomy surgical procedures.

Aims and objectives

Our study aimed to evaluate our mid-path treatment results in neglected, resistant, relapsed, and rigid clubfoot. Our treatment protocol's objectives are as follows: (1) the foot must become plantigrade at the end of the treatment. (2) Patient must be able to wear normal shoes.

 Patients and Methods

This study has been carried out at a tertiary care hospital taken into account from January 2003 to December 2015. The study was conducted after the institutional ethics committee approval. A single surgeon performed all the surgeries. Inclusion criteria: the current study includes cases of nontreated neglected clubfoot of children with age more than 2 years (n = 20), relapsed club foot after cast application (n = 13), and recurrent clubfoot after previous surgery (n = 2). All patients had idiopathic CTEV. The study comprises 35 feet belonging to 29 patients (six were bilateral) aged between 2 years and 8 years were included in the study (average age of patients, 4.8 ± 2.5 years). Twenty-one feet had a Pirani score of 6 while 14 feet had a Pirani score of 5. The exclusion criteria were as follows: all the patients with neglected club foot secondary to trauma or cerebral palsy and all patients with neglected club foot older than 8 years. Instruments used [Figure 1]: the external fixator techniques include a mini fixator (based on the differential distraction with nontensioned wire) leading to tissue genesis and growth.{Figure 1}


Our mid-path treatment protocol consists of minimum soft-tissue release combined with a mini fixator in the same stage. The soft-tissue release consists of closed tenotomy of the abductor hallucis longus done on the medial aspect of the great toe, followed by a closed fractional release of tendo-Achilles, medial plantar fasciotomy performed over the mid-sole area. The frame fixation method includes the insertion of two 1.5 mm Kirschner wires each from lateral to medial side on proximal tibia, calcaneum, and metatarsals. A Z-bar was applied on two K-wires of the tibia, and an L-bar was applied from metatarsal to calcaneum. Differential distraction is carried out till overcorrection is achieved [Figure 2] and [Figure 3].{Figure 2}{Figure 3}

Distraction was performed medially at the rate of 1 mm/day (4 × 0.25 turns/day), and lateral side distraction was at 0.5 mm/day, 6 weeks. Caregivers passively manipulated toes to prevent contracture. Overcorrection was determined clinically, and the fixators were removed under anesthesia, and an above-knee plaster cast is applied and kept for 6 weeks, followed by CTEV shoes.[3],[4] The CTEV shoes were continued for 2 years along with night splint as per the Ponseti bracing protocol. Patients were evaluated using the Pirani score [Figure 4] and [Figure 5].{Figure 4}{Figure 5}


The average follow-up was 3.8 ± 1.2 years. Excellent-to-good results were seen in 28 cases, while 2 cases had good, 3 cases fair, and 2 cases had poor results using Pirani score[5] [Table 1]. Poor results were mainly due to other deformities like metatarsus adductus and with late presentation leading to bony changes and altered gait. These patients required corrective osteotomy procedures to correct the deformity. Superficial pin infection was seen in two cases. One patient required reapplication of the fixator due to loosening and one required reinsertion of the calcaneal pin. Additional procedures (n = 2) were done in two cases with recurrence, as shown in [Table 1]c.{Table 1}


Neglected clubfoot is defined as a case in which no treatment for deformity correction was taken. Relapsed clubfoot is seen in those who drop out of cast treatment. Many of these patients presented to us with late and complex manifestations. Recurrent clubfoot is one in which deformity recurs after casting, soft-tissue release, and deformity correction.

A deformed foot can alter the gait and contribute to leg length discrepancy (LLD). LLD may be attributed to limb hypoplasia or decrease foot height.[6] Complete correction of foot deformity is essential to make the foot plantigrade and cosmetically acceptable. The patient should be able to wear normal shoes to bear weight without any pain. Uncorrected feet may develop arthritic changes in the ankle and subtalar joint.

Some surgeons believe that deformity correction occurs at the level of abnormal tissue. They follow the technique of posteromedial release only. Others believe tissue, but it may occur by stretching normal tissue. Correction can be achieved either by casting or by differential distraction; the level of correcting pivot for which is controversial.[3]

The drawbacks of Ponseti casting are that it requires multiple casts, making it a prolonged treatment. It can lead to thigh and heel sores, Recurrence is common due to noncompliance with bracing.

In older children presenting with resistant and rigid clubfeet, one may attempt either Ponseti treatment or PMSTR. PMSTR is an acute procedure only to cut fibrotic bands, thereby neutralizing the contractile forces.[8],[9],[10] It is complex and traumatic surgery and may lead to stiffness and shortening of the foot. Damage to the articular surface and blood supply to the bone may lead to avascular necrosis of bone and recurrence of deformity. Forceful correction may lead to rocker bottom foot.[11] The mini fixator is atraumatic, preserves the articular surface, with fewer recurrences.[11],[12]

We have noted lengthening of the first metatarsal in a few cases, which increases the medial border's length, reducing the chance of recurrence. Bethem and Weiner[4] and Turco[13] performed PMSTR. Oganesian and Istomina,[14] Galante et al.,[7] and Joshi et al. (1998–1999)[12] used external fixator device. Our results are comparable to Suresh[15] and Oganesian and Istomina[14] Marthya[1] and Reddy et al[16] [Table 2] and [Table 3].{Table 2}{Table 3}

Our soft-tissue release is less extensive than the PMSTR and does not lead to fibrosis and recurrence. It reduces the resistance to the external fixator device's correction and reduces the duration of fixator wear and enables complete correction.[14],[17],[18],[19],[20]

The advantages of our mid-path treatment are the following: (1) simultaneous correction of all components of deformities. (2) Bloodless technique. (3) Small incisions leading to small scars and less fibrosis. (4) Recurrence is lesser. (5) Less pain during and after treatment leading to better patient compliance. (6) Reduced fixator duration. (7) Overcorrection can be achieved to prevent recurrences. (8) Complications of skin, neurovascular deficit, and edema are easily visible with the frame and can be corrected and resolved. (9) Osteotomies, arthrodesis, compression, and distraction can be done along with limb lengthening. (10) lesser chances of growth plate damage. (11) Three-dimensional correction is possible.

Our study's limitation is that we have neither evaluated patients based on radiographs nor computerized gait analysis performed small sample size. We have also not compared and a our results with those of studies that have used the Ilizarov fixator, which gives better. We have also not compared our results with that of Ponseti protocols used in older children.


Management of neglected and rigid talipes equinocavovarus deformity in early childhood using mid-path protocol gives good-to-excellent results with a high rate of compliance.

Level of evidence: Level IV.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Anwar Marthya H, Arun B. Short term results of results of correction of CTEV with JESS distractor. J Orthopaedics 2004;1:3.
2Atar D, Lehman WB, Grant AD, Strongwater A. Revision surgery in clubfeet. Bull Hosp Jt Dis Orthop Inst 1990;50:149-59.
3Atar D, Lehman WB, Grant AD, Strongwater A, Frankel V, Golyakhovsky V. Treatment of complex limb deformities in children with the ilizarov technique. Orthopedics 1991;14:961-7.
4Bethem D, Weiner D. Radical one-stage posteromedial release for the resistant clubfoot. Clin Orthop Relat Res 1978;14:214-23.
5Bradish CF, Noor S. The Ilizarov method in the management of relapsed club feet. JBJS (Br) 2000;82B: 387-91.
6Kite JH. Principles involved in the treatment of congenital clubfoot. The results of treatment. J Bone Joint Surg 1939;21:595-606.
7Galante VN, Molfetta L, Simone C. The treatment of clubfoot with external fixation: A review of results. Curr Orthop 1995;9:185-8.
8Garg S, Dobbs MB. Use of the Ponseti method for recurrent clubfoot following posteromedial release. Indian J Orthop 2008;42:68-72.
9Grant AD, Atar D, Lehman WB. The ilizarov technique in correction of complex foot deformities. Clin Orthop 1992;280:94-103.
10Grill F, Franke J. The Ilizarov distractor for the correction of relapsed or neglected clubfoot. J Bone Joint Surg Br 1987;69:593-7.
11Ippolito E, Farsetti P, Valentini MB. Management of clubfoot. In: Bentley G, editors. European Surgical Orthopaedics and Traumatology. Berlin, Heidelberg: Springer; 2014.
12Joshi BB, Laud NS, Warrier S, Kanaji BG, Joshi AP, Dabake H. Treatment of CTEV by Joshi's external stabilization system. In: Kulkarni GS, editor. Textbook of Orthopaedics and Trauma. 1st ed. New Delhi: Jaypee Brothers Medical Publishers; 1999.
13Turco VJ. Resistant congenital club foot- One stage posteromedial release with internal fixation; a follow up report of a fifteen years' experience. J Bones Joint Surg Am 1979;61(6A):805-14.
14Oganesian OV, Istomina IS. Talipes equinocavovarus deformities corrected with the aid of a hinged-distraction apparatus. Clin Orthop Relat Res 1991;4:42-50.
15Suresh S, Ahmed A, Sharma VK. Role of Joshi's external stabilisation system fixator in the management of idiopathic clubfoot. J Orthop Surg 2003;11:194-201.
16Reddy KR, Rathod J, Koneru Rao T. Study of Joshi's external stabilization system in old neglected, recurrent and resistant congenital talipes equino varus in children of 1-3 year age group. Int J Contemp Med Res 2016;3:2017-9.
17Noonan KJ, Meyers AM, Kayes K. Leg length discrepancy in unilateral congenital clubfoot following surgical treatment. Iowa Orthop J 2004;24:60-4.
18Pirani S, Outerbridge HK, Sawatzky B, Stothers K. A reliable method of clinically evaluating a virgin clubfoot evaluation. Sydney, Australia: 21st SICOT Congress; 1999.
19Ponseti IV. The treatment of congenital clubfoot. [Editorial] J Orthop Sports Phys Ther 1994;20:1.
20Rajacich N, Bell DF, Armstrong PF. Pediatric applications of the Ilizarov method. Clin Orthop Relat Res 1992;3:72-80.