When is posteromedial release considered for a pediatric patient with Congenital Talipes Equinovarus (CTEV)?

Posteromedial Release for Congenital Talipes Equinovarus (CTEV)

Posteromedial release should be reserved for resistant clubfoot cases that fail conservative treatment with the Ponseti method, particularly in children presenting after walking age or with severe, stiff deformities that cannot be adequately corrected with serial casting alone. 1, 2

Primary Treatment Approach

The Ponseti method is the first-line treatment for CTEV and should be initiated early in newborns and non-ambulatory infants. 3, 4 This conservative approach achieves excellent results in the majority of cases:

• Newborns treated with Ponseti casting achieve excellent results in approximately 81% of cases (42 of 52 feet), with good results in an additional 12% 1
• The Ponseti technique produces significantly better short-term foot alignment compared to the Kite technique, with average total Pirani scores 1.15 points lower (95% CI 0.98 to 1.32) after 10 weeks of serial casting 4
• Open Achilles tendon lengthening may be required as an adjunct for cases with more severe equinus or late presentation 5

Indications for Posteromedial Release

Posteromedial release becomes necessary in specific clinical scenarios where conservative treatment is insufficient:

Late Presentation (After Walking Age)

• Children presenting after walking age require surgical intervention in nearly all cases 1
• In ambulatory children, posteromedial release was performed in 6 feet as a standalone procedure, and combined with cuboid subtraction osteotomy in 17 feet 1
• Results in this late-presenting group showed excellent outcomes in only 21% (5 of 24 feet) and good outcomes in 67% (16 of 24 feet), with 13% poor results 1

Resistant/Stiff Deformities

• Complete one-stage posteromedial plantar release is indicated for resistant deformities that fail incomplete releases or conservative treatment 2
• Patients who underwent complete posteromedial plantar release as the initial surgical procedure achieved 86% satisfactory (excellent or good) long-term results 2
• Those who had failed incomplete releases followed by complete posteromedial release achieved 79% satisfactory results 2

Non-Ambulatory Toddlers (4-12 Months)

• In non-ambulatory children aged 4-12 months with stiff deformities, posteromedial release was required in 3 feet after failed serial casting 1
• This age group achieved excellent results in 75% (9 of 12 feet) and good results in 25% 1

Surgical Technique Considerations

The complete posteromedial plantar release must address all components of the deformity simultaneously to achieve optimal outcomes: 2

• Complete simultaneous release of all pathological anatomical components is essential 2
• Incomplete releases result in only 42% satisfactory long-term results compared to 86% with complete releases 2
• Radiographic measurements that best correlate with clinical success include anteroposterior talocalcaneal overlap, lateral talocalcaneal angle, and positions of the navicular and calcaneus 2

Common Pitfalls

The most critical error is performing incomplete surgical releases, which leads to significantly worse outcomes and often necessitates revision surgery: 2

• Incomplete releases achieve satisfactory results in only 42% of cases 2
• Failed incomplete releases requiring subsequent complete release still achieve only 79% satisfactory results, worse than primary complete release at 86% 2
• Delayed treatment increases the need for more extensive open surgery 1
• Relapse following Ponseti treatment should first be managed with re-casting before considering surgical intervention 1

Treatment Algorithm

1. Newborns and early infants (<4 months): Initiate Ponseti serial casting 1, 3, 4
2. Non-ambulatory toddlers (4-12 months) with stiff deformities: Attempt Ponseti casting; consider posteromedial release if casting fails 1
3. Ambulatory children (walking age): Posteromedial release is typically required, often combined with cuboid subtraction osteotomy for severe cases 1
4. Resistant deformities at any age: Complete one-stage posteromedial plantar release addressing all components simultaneously 2