Rev. bras. ortop. vol.49 número6

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w w w . r b o . o r g . b r

Original

Article

Surgical

treatment

for

myelodysplastic

clubfoot

夽

,

夽夽

Alexandre

Zuccon

∗

_,

_Sérgio

_Inácio

_Cristiano

_Cardoso,

_Fábio

_Peluzo

_Abreu,

Antonio

Carlos

Fernandes

Associac¸ãodeAssistênciaàCrianc¸aDeficiente(AACD),SãoPaulo,SP,Brazil

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e

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o

Articlehistory:

Received19July2013 Accepted29October2013 Availableonline22October2014

Keywords:

Myelomeningocele Clubfoot

Acquireddeformitiesofthefoot

a

b

s

t

r

a

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t

Objective:To analyze the results from surgical treatment of69 casesof clubfoot in43 patientswithmyelodysplasiaaccordingtoclinicalandradiographiccriteria,atour insti-tutionbetween1984and2004.

Methods:Thiswasa retrospectivestudy involvinganalysisofmedicalfiles,radiographs andconsultationsrelatingtopatientswhounderwentsurgicalcorrectionofclubfoot.The surgicaltechniqueconsistedofradicalposteromedialandlateralreleasewithorwithout associatedtalectomy.

Results:Thepatients’meanageatthetimeofthesurgerywasfouryearsandtwomonths, andthemeanlengthofpostoperativefollow-upwassevenyearsandtwomonths. Sat-isfactoryresults wereachievedin73.9%ofthefeetandunsatisfactoryresults in26.1% (p<0.0001).

Conclusion: Residualdeformityintheimmediatepostoperativeperiodwasassociatedwith unsatisfactoryresults.OpeningoftheKite(talocalcaneal)angleinfeetthatonly under-wentposteromedialandlateralrelease,alongwithappropriatepositioningofthecalcaneus incasesthatunderwenttalectomy,wastheradiographicparameterthatcorrelatedwith satisfactoryresults.

Tratamento

cirúrgico

do

pé

equinovaro

mielodisplásico

Palavras-chave:

Mielomeningocele Pétorto

Deformidadesadquiridasdopé

r

e

s

u

m

o

Objetivo:Analisarosresultadosentre1984e2004emnossainstituic¸ãodotratamento cirúr-gico de 69 pésequinovaros em 43 pacientes portadores de mielodisplasia segundo os critériosclínicoeradiográfico.

Métodos:Estudo retrospectivo com análise de prontuário, radiografias e consulta com pacientesportadoresdemielomeningocelequeforamsubmetidosacorrec¸ãocirúrgicade pésequinovaros.Atécnicacirúrgicafoialiberac¸ãoposteromediolateral(LPML)radical asso-ciadaounãoatalectomia.

夽

Pleasecitethisarticleas:ZucconA,CardosoSIC,AbreuFP,FernandesAC.Tratamentocirúrgicodopéequinovaromielodisplásico.Rev BrasOrtop.2014;49:653–660.

夽夽

WorkdevelopedattheAssociationforDisabledChildren’sCare(AACD),SãoPaulo,SP,Brazil. ∗ _{Corresponding}_author_.

E-mail:[email protected](A.Zuccon). http://dx.doi.org/10.1016/j.rboe.2014.10.006

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Resultados: Amédiadeidadenaépocada cirurgiafoidequatroanosedoismeseseo seguimentomédiopós-operatório,deseteanosedoismeses.Foramencontradosresultados satisfatóriosem73,9%dospéseinsatisfatóriosem26,1%(p<0,0001).

Conclusão: Adeformidaderesidualnopós-operatórioimediatoestárelacionadacom result-adosinsatisfatórioseaaberturadoângulodeKite(talocalcaneano)nospéssubmetidos somenteaLPML,alémdoposicionamentoadequadodocalcâneo,noscasosemquefoi feitaatalectomia,éoparâmetroradiográficorelacionadoaosresultadossatisfatórios.

Introduction

Thereareseveralformsofpresentationofneuraltubeclosure defects,suchasmyelomeningocele,myelocele,meningocele andlipomeningocele.Theseconditionshavethecommon fea-tureofdeficientfusionofposteriorelementsofthespine,in associationwithmedullarydysplasia.1

Theworldwideincidenceofmyelomeningoceleis1:1000 livebirths,onaverage.1

Medullarydysplasia,ormyelodysplasia,mayoccurto vary-ingdegreesandmaycompromisevariousorgansandsystems, suchasthemusculoskeletal,genitourinary,digestiveand neu-rologicalsystems.Hydrocephalyoccursduringthecourseof 90%ofmyelomeningocelecases.1,2

Theinnervationofthelowerlimbsiscompromisedandthis givesrisetomotorandsensoryparalysis,muscleimbalance anddeformities.

Thefeet are frequentlyaffected bydeformitiesin these cases.3–6_In_a_study_conducted_in_the_{myelomeningocele}_clinic

ofour hospital,the mostprevalent deformity was equino-varus,whichwasobservedin31%ofthe480feetthatwere evaluatedrandomly.1

Myelodysplasticequinovarusfootisoneofthemost fre-quent abnormalities. It is difficult to treat and has high complicationrates.3–5

Conservativetreatmentofmyelodysplasticfeetusingserial plaster casts in accordance with the Ponseti method has increasedinpopularityamongpediatricorthopedists. How-ever, so far, there is still no scientific evidence regarding long-termmaintenanceofthecorrectionachievedand there-foresurgicaltreatmentisstillused.1,7–9_In_the_literature,_there

arereportsonproceduresgoingfromsoft-tissuereleasewith tendonstretchingtobonesurgeryofamoreaggressivenature, suchastalectomy.3,10–13

Theobjective ofthe present study was to evaluatethe resultsfrom surgical treatmentofmyelodysplastic equino-varusfeetatourinstitutionfromOctober1984toOctober2004 andtocorrelatethedeformities,surgicaltechniqueusedand resultsobtained.

Material

and

method

Aretrospective study was conducted,withanalysis onthe medicalfilesofpatientspresentingmyelodysplasticclubfoot. Subsequently,patientswhounderwentsurgicaltreatmenton

theirfeet atourservicebetweenOctober1984andOctober 2004, asshown inourdatabase, were invited toreturnfor clinicalassessment.

Noclassificationregardingtheseverityofthedeformities wasmade.

Theinclusioncriteriawerethatthepatientsneededtohave hadthefollowing:(1)myelodysplasiawithequinovarusfeet from thetimeofbirththathadnotbeen treatedsurgically priortothetreatmentatourinstitutionand(2)aminimum postoperativefollow-upoftwoyears.

Patientswhowewereunabletocontact,thosewhosedata wereinsufficientandthosewhodidnotcomeforclinical eval-uationwereexcluded.

The surgical technique used was posteromedial lateral release(PMLR),withorwithoutassociatedtalectomy.Insome feet, shorteningofthe lateral columnwasalso performed. Twoaccessincisionsused(oneposteromedialandtheother, lateral) andtheCincinnatiroute wasusedinfeet that pre-sentedequinus≤30◦(24.6%).Tenotomywasperformedwith

resection of around 2cm of the tendons ofthe calcaneus, longflexorofthehallux,commonflexorofthetoes,posterior andanteriortibialisand abductorofthehallux. Posterome-diallateralcapsulotomyofthetibiotarsalandsubtalarjoints wasthenperformed,includingtheinterosseous, talonavicu-lar,calcaneocuboid,naviculocuneiformandcuneometatarsal ligaments.Whenreductionofthedeformityofthehindfoot throughtheseprocedureswasnotpossible,orwhenthetalus wasverydeformed,talectomywaschosen.Incasesinwhich deformityinadductionpersistedaftertheprocedures, short-eningofthelateralcolumnwasalsoperformed(36feet).The location wasat the level ofthe cuboid in 33 casesand at thelevelofthecalcaneocuboidinthreecases.Fixationwith Kirschnerwireswasperformedaftercorrectionofthe defor-mity, with placement ofa retrograde wire inthe hindfoot (calcaneus-talus-tibia),awireinthemedialcolumntokeep themedialjointsopenandanotherwireinthelateralcolumn toclosethejointsinthiscolumn.Thewireswerethreaded, becauseuponperformingthereleaseandthecapsulotomies and reducing thedeforming, therewasa needtokeepthe jointsinthemedialregionopen.

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Table1–Generaldistributionofthepatients.

No. Side Age Surgicaltechnique Result Lengthoftimeafteroperation

1 R/L 1Y PMLR +/+ 19Y+3M

2 R/L 6Y PMLR+TAL+SLC +/+ 6Y

3 L 2Y+8M PMLR+SLC + 18Y

4 R/L 2Y+2M PMLR +/+ 16Y

5 R/L 3Y+2M PMLR +/− 11Y

6 L 5Y+7M PMLR+TAL − 9Y

7 R 6Y PMLR+TAL + 10Y+10M

8 L 4Y PMLR+TAL − 10Y

9 L 2Y+9M PMLR+TAL+SLC − 7Y

10 R/L 3Y PMLR+SLC −/+ 7Y+6M

11 R/L 2Y+5M PMLR+TAL+SLC +/− 7Y

12 R/L 1Y+8M PMLR+TAL+SLC +/+ 6Y+4M

13 R/L 3Y+1M PMLR −/− 5Y

14 R 1Y+9M PMLR+TAL+SLC +/+ 4Y+1M

15 R/L 9Y+8M PMLR+TAL+SLC +/+ 6Y

16 R/L 3Y+2M PMLR +/+ 8Y+6M

18 R 6Y PMLR+TAL+SLC + 4Y+11M

19 R/L 7Y+4M PMLR +/+ 3Y+8M

21 R/L 1Y+6M PMLR+SLC +/+ 5Y

22 R/L 1Y+7M PMLR+TAL+SLC +/+ 3Y+10M

23 L 3Y+9M PMLR+SLC − 8Y+9M

24 R/L 2Y+6M PMLR+SLC −/− 8Y

25 R/L 2Y+1M PMLR+TAL+SLC−D +/+ 8Y+10M

26 R 1Y+2M PMLR − 7Y

27 R/L 2Y PMLR +/+ 3Y

28 R/L 1Y+6M PMLR+TAL +/+ 2Y

29 L 11Y+5M PMLR+TAL − 2Y+2M

30 R 4Y+6M PMLR+TAL+SLC + 2Y

31 L 6Y PMLR+SLC + 9Y

32 L 2Y PMLR+TAL+SLC + 19Y

33 R/L 4Y+3M PMLR+TAL−D +/− 7Y

34 L 1Y+5M PMLR + 2Y

35 R/L 2Y+6M PMLR +/− 8Y

36 R/L 2Y PMLR +/+ 2Y

37 R/L 3Y PMLR +/+ 2Y+4M

38 L 13Y PMLR+SLC + 2Y+1M

39 R 6Y PMLR+TAL+SLC + 3Y+6M

40 R 7Y PMLR + 3Y

41 L 7Y+2M PMLR+SLC + 2Y

42 R/L 2Y PMLR+TAL+SLC +/− 3Y+6M

43 R/L 5Y+8M PMLR+SLC −/− 4Y+2M

Results:(+),satisfactory;(−),unsatisfactory;SLC,shorteningoflateralcolumn;TAL,talectomy.

Thecaseswereanalyzedusingclinicalandradiographic criteria. According to the clinical criteria, we divided the resultsintosatisfactoryandunsatisfactory,ascanbeseenin thefollowing:

• Satisfactory result–feetthatpresentedthecriterialisted

below:

1. Plantigradefeet;

2. Feetcompatiblewithuseofabraceintheneutral posi-tion;

3. Feetwithoutskinlesionsorpressureulcers.

• Unsatisfactoryresult–atleastoneofthefollowingcriteria:

1. Non-plantigradefeet;

2. Feetincompatiblewithuseofabraceintheneutral posi-tion;

3. Feetwithskinlesions(ulcers)duetopressure;

4. Feetrequiringsubsequentsurgicalprocedures.

Thepatientsweregroupedaccordingtonumericalorder, initials oftheirname,sideofthebody affected,ageatthe timeofthesurgery,surgicaltechniqueused,resultobtained andlengthofpostoperativefollow-up(Table1).

We evaluated the immediate complications (those that occurredduringtheimmediatepostoperativeperiodorupto twoweeksafterthesurgicalprocedure)andthelate compli-cations(morethantwoweeksafterthesurgery),withregard tofrequencyandtype.

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(giventhatthismeasurementwouldbeimpossibleincases oftalectomy).Thisanglemeasurestheopeningbetweenthe talusandcalcaneusandnormalvaluesarebetween20◦_and

40◦_._It_is_greatly_used_in_the_literature_for_evaluating_talipes

equinovarusandfrequentlyisdiminished(<20◦₎_in_cases_of

thisdeformity.5 _We_also_analyzed_the_position_of_the

calca-neusinthefeetthatunderwenttalectomyandconsideredthe radiographicresulttobeacceptablewhenthecalcaneuswas positionedbelowthetibia,inaneutralpositionandslightly posteriorizedinrelationtoit,andifnoresidualfragmentof thetaluswasidentifiedbetweenthecalcaneusandthetibia.

Our initial hypothesis was that if the deformities were notcompletelycorrectedthroughthesurgicalprocedure,i.e. iftherewas someresidualdeformityafterthe surgery,the chanceofobtaininganunsatisfactoryresultwouldbegreater. Toassess whethertheresidual deformitywasrelatedto theresults,weusedtheFisherexacttest.Situationsof sat-isfactoryresultswiththe presenceofresidualdeformityor unsatisfactoryresultswithoutresidualdeformityweretaken tobediscordant.

Statistical values from the radiographic analyses were obtainedusingtheMcNemartest.

Inall cases,therejectionlevelforthenullityhypothesis wassetatavalue≤0.05(5%).

Whenthestatisticscalculatedpresentedsignificance,we used an asterisk (*) to denote this. If otherwise, i.e. non-significant,weusedtheabbreviationNS.

Results

Weanalyzed90 medicalfilesand attemptedtocontactthe individualsconcernedbymeansofthetelephone,inorderto invitethemforclinicalassessmentandfinalradiography.Out ofthese90patients,weobtaineddataonandattendanceby 43.

Weincluded69feet(43patients)inthestudy.Thus, defor-mities in both feet were observed in 26 patients (60.4%). Regarding gender, there were slightly more females: 22 patients(51.1%).

Thepatients’meanageatthetimeofthesurgerywasfour yearsandtwomonths.Theminimumagewasoneyearand themaximumwas13years.

Theminimumpostoperativelengthoffollow-upwastwo yearsandthemaximumwas19yearsandthreemonths.The meanwassevenyearsandtwomonths.

Outofthe69feetevaluated,wefoundthattheresultwas satisfactoryin51(73.9%)andunsatisfactoryin18(26.1%),in accordance withtheclinical criteriastated inthe methods section(p<0.0001).

In31feet(44.9%),posteromediallateral releasewas per-formed in association with talectomy, whilein 38 (55.1%), posteromediallateralreleasealonewasperformed.

Immediate (I)and late (T) complicationswere observed in34feet(49.2%).Suturedehiscence(16feet)occurredmost frequently and, later on, hypercorrection showing valgus deformity(ninefeet)(Table2).

– Partialortotalrecurrenceoccurredin12feet(17.4%ofthe cases).

Table2–Frequenciesofpostoperativecomplications.

Complication Numberoffeet Percentage

Suturedehiscencea ₁₆ _39.1%

Superficialinfectiona ₆ _14.6%

Deepinfectiona ₃ _7.3%

Migrationofwires 3 7.3%

Skindistressa_{(circulatory)} ₃ _7.3%

Hypercorrection 9 22%

Asepticnecrosisoftalus 1 2.4%

Total 41 100%

a _Note_:_In_seven_feet,_more_than_one_complication_occurred.

– Reoperationwasperformedon12feet(17.4%).

Inanalyzingthefeetthatpresentedresidualdeformity,i.e. which presenteddeformity intheimmediatepostoperative period(ninefeet),weidentifiedunsatisfactoryresultsineight cases(88.9%). When weanalyzedthefeet without residual deformities(60),weidentifiedsatisfactoryresultsin50(83.3%) andunsatisfactoryresultsinonly10(16.7%)(Table3).

Weobservedrecurrenceofthedeformityin12feet.Eight (66.6%)hadresidualdeformityintheimmediatepostoperative periodandfour(33.3%)didnotpresentthis.

Regardingtheradiographicevaluation,weobtained com-pletedocumentationfor45feetand,amongthese,wefound that thepreoperativeAPKite anglewasclosed(<20◦₎_in₄₁

(91.1%).InthefeetthatunderwentPMLRforwhich satisfac-toryresultswereobtained(22),theKiteangleincreasedin21 cases(95.4%),whileinthefeetwithunsatisfactoryresultsthat underwent PMLR(six),the Kiteangleincreasedinonlyone (16.6%)(Table4).InthefeetthatunderwentPMLR+talectomy forwhichsatisfactoryresultswereobtained(15),14(93.3%) presentedcorrectpositioningofthecalcaneusandonlyone didnot.Ontheotherhand,amongthefeetthatunderwent

Table3–Relationshipbetweentheresultsandresidual deformity.

Result Residualdeformity

Present Absent Total

Unsatisfactory 8feet* ₁₀_feet ₁₈_feet

Satisfactory 1foot 50feet 51feet

Total 9feet 60feet 69feet

∗ _p₌_0.00004_(Fisher_test).

Table4–RelationshipbetweenpostoperativeKiteangle andfinalresult.

Result Kite

Open Closed Total

Satisfactory 21feet 1foot 22feet

Unsatisfactory 1foot 5feet 6feet

Total 22feet 6feet 28feet

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Table5–Relationshipbetweenthepositionofthe calcaneusandthefinalresult.

Result Radiography

Position+ Position− Total

Satisfactory 14 1 15

Unsatisfactory 1 1 2

Total 15 2 17

p=0.7500NS.Concordance=88.23%(McNemartest). Position+:correctpositionforcalcaneus.

Position−:incorrectpositionforcalcaneus.

PMLR+talectomywithunsatisfactoryresults(two),one pre-sentedcorrectpositioningofthecalcaneusandone,incorrect positioning(Table5).

Discussion

Equinovarusdeformityoffeetincasesofmyelodysplasiais difficult to manage, with high rates of complications and recurrenceduetothespecificcharacteristicsofthis patholog-icalcondition, whichpresentsparalysis,muscleimbalance, insensitivityandstiffness.3–5,8

Thepreferredtreatmentforthisdeformityhashistorically beensurgical.Thus,thetechniqueusedisimportant,because itmayinfluencethefinalresult.7

Althoughconservative treatmentfor casesofidiopathic clubfootiswellestablishedintheliterature,thistreatment isstillnotcompletelyreproducibleandtherearestillno long-termstudiesrelatingtomyelodysplasticfeet.

Morestudiesandclinicaltrialsusingplaster-casttreatment arenowappearing,especiallyusingtheprinciplesofthe Pon-setimethodforcorrectionofthesedeformities.However,the recurrenceratesinnon-idiopathicfeetarestillhigh.14_In

ana-lyzingoursample,particularlywithregardtoageatthetime ofthetreatment,thechoiceofsurgicaltreatmentwasmore viable.

Thepatients’ ageatthe timeofthe surgerywasa deci-sivefactor,giventhattheirmeanageasfouryearsandtwo months.Thisisanadvancedagefortreatingthispathological condition, giventhat the feetalready present greater stiff-ness,alterationstotheboneformatandjointincongruence (Figs.1and2).

Theincisionsusedinsurgicaltreatmentsforclubfootvary widely.Turcodescribedastraightincision fromthebaseof thefirstmetatarsaltotheAchillestendon,without subcuta-neousdissection.15_Crawford_et_al._described_the_incision_that

hadbeenconceptualizedbyGiannestrasandisknownasthe Cincinnatirouteinhomagetotheplacewheretheyworked.16

Inthisstudy,adoubleroutewasused(oneposteromedialand theother,lateral)inthegreatmajorityofthepatientsandthe Cincinnatiroutewasusedinthefeetthatpresentedan equi-nuscomponentoflessthan30◦_;_in_this_manner,_there_was_no

difficultyinclosingtheskin.

Someauthorshaveemphasizedtheimportanceofusing an appropriatesurgical technique, withthe use oftendon resectionratherthansimplestretching,andthiswasalsoour

Fig.1–Patientwithmyelodysplasia,presentingstiff clubfootbeforeoperationconsistingofPMLR+talectomy.

preference.1,4,12_Through_doing_this,_we_rebalanced_the_forces

actingonthefootandavoidedrecurrence.

Posteromediallateralreleaseisdonetotreatclubfootand broadcapsulotomyisimportant,alongwithtendonrelease withresection,asalreadymentioned.2,3

Another pointcitedintheliteratureiscorrectionofthe rotationofthetalus.12_In_our_study,_there_was_an_increase_in

theKiteangleinalltheradiographicallydocumentedfeetthat evolvedsatisfactorilyandwhichdidnotundergotalectomy, whichindicatestheimportanceofthistechnicaldetail.

Talectomy is a procedure that has been performed for a long time in orthopedic practice, with reports dating back to1608,from Fabricus.10 _Many _authors _have_reported

good resultsfrom this technique for surgicaltreatment of myelodysplasticequinovarusfoot.6,7,10,17,18

Someauthorshavehighlightedtheimportanceofcorrect positioningofthecalcaneusintalectomizedcases.Wealso believe that a poorly positioned calcaneus may lead toan unsatisfactoryresult,althoughwedidnotprovethis statis-ticallyinpourstudy,probablybecauseofthesmallsample size.13,19

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Fig.2–Patientwiththeabilitytowalkwithinthecommunity,withmyelodysplasticclubfootwithalesioninthe dorsolateralskin(theweight-bearingareaofthisfoot).

ofthemidfootandforefoot.Therefore,itdoesnotprovidefull correctionofthedeformitiesandincreasesthepossibilityof recurrence.

Thesurgicalcorrectionofthedeformitieswasstartedin thehindfootbymeansoftendonandcapsulereleases(PMLR). Whenthesewereinsufficientforcompletecorrectionofthe deformityofthehindfoot,talectomywasperformed. Adduc-tion deformities of the forefoot were corrected by means of capsule and ligament release. When these procedures wereinsufficientforfullcorrection,shorteningofthelateral columnwasused. Therefore, intraoperativeevaluationand knowledgeofthepathologicalanatomyofthedeformitiesis extremelyimportant,sincethesurgicalproceduresare per-formedonlyasrequired.20

Thirty-onecasesunderwentposteromediallateralrelease inassociationwithtalectomyand38withouttalectomy,and 36ofthesefeet(52.1%)underwentshorteningofthelateral column.Wefoundarateofsatisfactoryresultssimilartothat oftheliteraturethroughtheseprocedures.

Figs. 3 and 4 show illustrative cases of the corrections achievedthroughthesurgicalprocedures.

Complicationsintreatingthisdeformityfrequentlyoccur, asalreadyhighlightedbyotherauthors.1,3,5,8_During_the

post-operativefollow-up, complicationsoccurred in49.2%ofthe cases,ascanbeseeninChart2.

Valgusdeformitywasoneofthemainlong-term compli-cationsand we attribute this to the wide-ranging releases thatwereperformed,includingofthesubtalarinterosseous ligament. There is controversy regarding whether release of this ligament should be performed, even if only partially.21,22

Itwasnotourobjectivetoevaluatefunctionallevel, defor-mities in other segments of the body or gait prognosis, althoughthereisastudyintheliteraturethatcorrelated defor-mityinkneeflexionandsurgicalcorrectionofclubfootamong patientswithmyelodysplasiaandarthrogryposis.7

Table3showsthat,accordingtotheFisherexacttest,the calculatedstatisticalp-valuewas0.0004*andthatthe resid-ual deformitiespresent onlyappeared infrequentlyamong thesatisfactoryresults.Thus,presenceofresidual deformi-tiescorrelatedwithhigherratesofunsatisfactoryresults.This observationisextremelyimportantbecauseattheendofthe surgicalprocedure,ifanydeformitiesstillremaintobe cor-rected,theseshouldnotbeneglectedorelsetheremightbea riskofpoorresults.

Ourstudypresentsseverallimitations,startingwithits ret-rospectivecaseseriesdesign.

Itwasnotpossibletouseaseverityclassificationforthe feetthatweretreatedbecauseofinsufficientdatainthe med-icalfiles.However,fromthehighrateoftalectomyprocedures performed,itcanbeinferredthatdifficultyincorrectingthese feetwasencountered.

Anotherlimitationwasthattherewasnocorrelationwith thesepatients’functionallevel,giventhatpatientswhowere abletowalkmightbemorelikelytohaveunsatisfactoryresults becauseofthegreaterlikelihoodofskinlesionsthroughthe bodyweightborneonafootwithresidualdeformity,evenif thisweremild.

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Fig.3–SamepatientasinFig.1,aftertheoperationonthestiffclubfootconsistingofPMLR+talectomy.

Fig.4–PatientwithmyelodysplasticfeetwhounderwentsurgicalcorrectionbymeansofPMLRattheageofninemonths. Goodevolution,withtheabilitytowalkwithinthecommunity,presentingplantigradefeetcompatiblewithbracersand withoutscars.Preoperativesituation(pre-op),secondyearaftertheoperationand17thyearaftertheoperation.

patientswithmyelodysplasiaandthatthesurgicalprocedure isextensive.Duringtheoperation,ifproceduressuchas talec-tomyandshorteningofthelateralcolumnbecomenecessary, theseshouldbeperformedduringthesameoperation,soas nottoleave residual deformitiesand thus todiminishthe possibilityofrecurrence.

Conclusion

Thesurgical treatment instituted in these myelodysplastic feetofpatientsfollowedupatourinstitutionwaseffectivein correctingthedeformities,withresultssimilartothosefound intheliterature.

– Postoperativecomplicationsoccurfrequently.

– Residualdeformityafterthesurgicalprocedureisafactor contributingtowardlackofsuccessintreatingthesefeet andthereforeshouldbeavoided.

– When posteromediallateralreleaseisperformedwithout talectomy,itseemstobeimportanttoopenupthe talocal-canealangle.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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