1. Neglected clubfoot deformity in a 4 year old Mongolian boy Soo-Sung Park M.D Department of Orthop. Surgery AMC Children’s hospital Seoul KOREA

2. Introduction  Late-presenting clubfoot deformity is rarely found, but still common in developing countries  Non-op tx. usually fails and is no longer an option  Surgery is necessary but can lead to problems of poor wound healing and infection  Variety of skin incision & rotation flaps  Staged surgery – tissue expanders, partial wound closure with healing by secondary intention, casting with suboptimal correction after surgery followed by serial manipulation  Ilizarov technique w/ or w/o preliminary surgery

3. Case (4Y/M)  C.C: nelected clubfoot deformities  P/E: Rigid Talipes equinocavovarus deformity (Lt>Rt)

4. Operation  Rt : SSTR(achilles tenotomy, TPAL, PF, AHR) + Ilizarov inst.  Lt (Staged Op): SSTR(achilles tenotomy, TPAL, PF, AHR) Ilizarov instrumentation 1wk later

5. 6 weeks after deformity correction

6. Removal of EF & CAST (DC 6w) Cast for 3 weeks AFO (day & night)

7. Post Op 3M before leaving to Mongolia

8. Discussion (recent papers)  Ponseti Method (JBJS-B 2007)  17 children (24 feet), mean age 3.9 yrs. cast for 3.9 mos.  Painless plantigrade foot in 16 feet ; effective method  But 7/16 recurred, 8 feet failed  Circumferential release & fasciocut. flap (JPO-B 2007)  Case report  Single staged tech. w/ double zigzag incision  Age 6M~4Y, very safe and cost-effective method (J of Foot & Ankle Surg. 2006)

9. Discussion  Ilizarov External Fixator  Role of soft tissue release before or after correction of the deformity ?  Ilizarov inst. alone w/o preliminary surgery ischemic necrosis after preliminary extensive dissection (Tachdjian’s Pediatric orthop. 4 th Ed.)

10.  Ilizarov External Fixator  Ilizarov inst. w/ minimal release recurrent arthrogrypotic clubfoot after prev. PMR  Medial TN joint release ± TP tenotomy, PC (Choi el al. JBJS-B 2001) Neglected clubfoot in pts. with mean age of 19 (5~39) yrs.  Limited soft tiss. dissection achilles tenot., plantar fasciotomy ; high recurrence(50%) and ankylosis(74%) ; reduce risk of NV Cx. & avoid excessive shortening of foot (Foot & Ankle international 2006) Discussion

11. Conclusion  STAGED Operation; SSTR followed by Ilizarov inst. is thought to be a useful method in a 4 yrs old boy  Based on literature review, Ponseti method also seems to be a effective and low-cost strategy in older children

12. Thank you for your attention