Open Journal of Orthopedics, 2013, 3, 314-320
Published Online November 2013 (http://www.scirp.org/journal/ojo)
http://dx.doi.org/10.4236/ojo.2013.37058
Open Access OJO
Treatment of Resistant Clubfoot with Soft Tissue Release
and Alkhooly External Fixator*
Ali Zein A. A. Al-Khooly#, Mohamed Ali Ahmed Mohamed, Ebrahim El-Hawary Ali
Department of Orthopedic and Trauma, El-Minia University Hospital, El-Minia, Egypt.
Received September 10th, 2013; revised October 15th, 2013; accepted October 29th, 2013
Copyright © 2013 Ali Zein A. A. Al-Khooly et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
After the first research with this technique done by the first author, ten operations on the foot and ankle were performed
on five patients (two boys and three girls) suffering from severe club foot deformity all with bilateral foot affection.
Their ages ranged from five to fourteen years. All of them were treated by soft tissue release, skin flap (rotational flap),
supplemented with Alkhooly external fixator. The follow up period ranged from two to seven years. The results ac-
cording to Mittal (1987) [1] were excellent in eight feet (80%) and good in two feet (20%).
Keywords: Clubfoot-External Fixator; Soft Tissue Release
1. Introduction
The treatment of clubfoot is controversial, because its
cause remains unknown, its pathological anatomy is un-
certain and its behavior is unpredictable [2].
Some authors concluded that there are different etio-
logical factors responsible for resistance to correction or
recurrence after correction [3-8].
A high incidence of recurrence ranging from 36% to
68% with conservative and operative treatment has been
reported by many authors [8-10]. Recently there has been
a trend towards very early soft-tissue release procedures
on the basis that this congenital abnormality is best
treated early in order to prevent affection of uncorrected
deformity on normal bone growth [11-14].
The uneven wound closure and the difficulty with skin
coverage that may follow the operative correction of se-
vere congenital and acquired deformities of the foot and
ankle are well-recognized problems. These complications
may result in wound infection, skin sloughing, fibrosis,
recurrence of the deformity and a generalized increase in
morbidity [15]. Moreover, the long medial curvilinear
incision that extends across joints is subjected either to
hypertrophic scarring or keloid formation or both. The
scarring and fibrosis lead to skin contracture on pos-
tero-medial aspect which is a potent deforming element
and an important factor in recurrence. Therefore, it must
be avoided to reduce the danger of medial tethering from
secondary scarring.
The early postoperative management and the required
degree of correction of the deformity can not be achieved
completely by plaster cast alone. Therefore, the use of an
external fixator was found more reliable.
The principles of extern al fixation for treatment of late
deformed club foot are well established and there are
many papers which testify to the use of an Ilizarov frame
in management. Certainly the frame described by Mr.
ALKHOOLY is novel and simple (Michael K.D. Benson,
December 1995, personal letter).
In this research the authors follow the same technique
of the first author in the first research and the results
were encouraging so the aim of this work is to conclude
the validity of this technique in the treatment of resistant
and severe neglected cases of club foot.
*NB. The first research with this technique was done by prof. Ali Zein
A.A. Alkhooly and published in German Journal of Foot and Ankle
Surgery, August 2003, A.Z.A.A.Al-Khooly (2003): eight year’s ex-
p
erience with soft tissue release and Alkhooly external fixator in the
treatment of resistant clubfoot, German Journal of Foot and Ankle
Surgery. Band 1. Heft 3. August 2003-(199-207).
#Corresponding author.
2. Material and Methods
The studied series includes ten feet in five patients, two
boys and three girls, their ranged from five to fourteen,
all have severe bilateral deformity, eight of them were

Treatment of Resistant Clubfoot with Soft Tissue Release and Alkhooly External Fixator 315
treated from birth by repeated manipulation and repeated
plaster cast but not corrected, and two of them were ne-
glected.
Follow up period from two to seven years.
2.1. Preoperative Assessment
Clinically: All children were examined clinically be-
fore operation, and the degree of various components of
deformity and the cond ition of the sk in and muscles were
recorded. All cases were idiopathic congenital clubfeet.
Radiologically: A-P and lateral X-rays were made for
assessment of the degree of deformity.
2.2. Operative Procedure
2.2.1. Skin In cision
The incision had two parts: the foot and the leg part
(Figure 1).
The foot part: Semi-circular incision extending from
the base of the 5th metatarsal at the dorso-lateral aspect
of the foot to the dorso-medial aspect, extending to the
plantar aspect and then straight back to the insertion of
tendo-Achillis.
The leg part: Longitudinal incision extending proxi-
mally from the insertion of tendo-Achillis to the lower
third of the leg. Then a thick skin flap is raised for about
2 cm.
2.2.2. Soft Tissue Release
Medial, Posterior and Subtalar Release. All tight struc-
tures on the medial and poster medial side were released
posterior capsulotomy of the ankle, tenotomy of abductor
hallucis (at its insertion in the big toe) and release of the
plantar fascia.
2.2.3. Alkho oly Extern al Fi x at or (Fig ure 2 )
A K. wire 2 mm in diameter was introduced transversely
through the distal part of all metatarsal shafts. Ano ther K.
wire was passed transversely through the calcaneus par-
allel to the first one.
The ends of both K. wires were placed in the holes of
the fixator according to the degree of correction of the
deformity. The first K. wire was passed in the distal half
ring, the second K. wire in the proximal ha lf-ring and the
joint of the fixator was adapted according to correction of
the deformity.
The upright bars of the fixator were included in the
above-knee plaster cast. With the knee joint in 90° of
flexion, the foot and leg were in slight external rotation
to correct internal tibial torsion.
2.2.4. Skin Closure
The skin was closed by rotation of the flap medially and
posteriorly (Figure 1).
Figure 1. Diagram showing the skin flap. Foot part (a) and
leg part (b). The arrow showing the direction of rotation of
the flap.
Figure 2. Alkhooly external fixator. This Fixator was in-
troduced by Prof. Ali Zein Alabedeen A. Alkhooly and ap-
proved in 29/4/1997 under No. 20089.
2.2.5. Post- O p e rative Care
Post-operative care included the following: observation
of the circulation, correction of the deformity when
needed, (by changing the position of K. from one hole to
the next hole, position of side bar or joint of the fixator)
and avoidance of any circulatory embarrassment and
early movement of the toes.
2.2.6. Time of Remov al of the Fixator
After 4 to 6 weeks and complete healing of wounds, the
K. wires and fixator were removed followed by applica-
tion of an above-knee plaster cast in a well-corrected
position (with the knee at 90 degree of flexion, the leg
portion of the cast, which includes the foot, was held in
slight external rotation) for anther 6 weeks.
2.2.7. Treatment Duration
Overall treatment time ranged from 10 to 12 weeks. Af-
ter removal of the cast, short period of physiotherapy
then the child was allowed to walk.
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Treatment of Resistant Clubfoot with Soft Tissue Release and Alkhooly External Fixator 316
2.3. Post-Operative Assessment
2.3.1. Clinically
Patients were examined clinically for wound healing de-
gree of corr ection of deformity and foot stiffness.
2.3.2. Radiological l y
A-P X-rays were made with the foot in 30 plantar-flexion
and the tube directed caudally 30 from perpendicular [10].
Lateral X-rays were taken with the foot in 30 plantar flex-
ion and ano ther with the foot in the neutral position.
2.3.3. Functi o n all y
The evaluation of function included whether the child
had any pain, can walk normally, can walk on uneven
ground, can run normally and can wear normal shoes
(parents of the children gave us most of the above data).
3. Results
3.1. Clinically
The results are classified clinically according to Mittal [1]
as excellent, good, and poor (Criteria of assessment;
clinical results Tables 1(a) and (b)).
Excellent has the following criteria: healthy scar, the
deformity fully corrected, the foot in fully plantgrade
without any hidden equinus (the heel does not touch the
ground while sitting on the feet).
Good has the following criteria: healthy scar, the foot
is fully plantgrade without any equines or minor degree
of deformity.
Poor has the following criteria: moderate deformity,
contracture of the scar and valgus foot deformity (due to
over correction).
Eight from ten had excellent results (80%). Two feet
had good results (20%) with mild residual adduction be-
cause the side bar of the fixator was not fixed in the cor-
rect position early which is corrected by repeated ma-
Table 1. (a) Criteria of assessment; (b) Clinical results.
(a)
Excellent
Healthy scar, the deformity fully corrected, the foot
in fully plantgrade without any hidden equinus (the
heel does not touch the gro un d w h i le sitting on the
feet).
Good Healthy scar, the foot is fully plantgrade without
any equines or min or degree of deformity.
Poor Moderate deformity, contracture of the scar and
valgus foot deformity (due to over correction).
(b)
Degree No. of feet Percent
Excellent 8 80%
Good 2 20%
Total 10 100%
nipulation and cast. Mild superficial infection occurred in
three cases, which healed rapidly without any other com-
plications. After removal of the plaster cast, all feet had a
mild degree of stiffness. However, the normal range of
movement was regained rapidly after a short period of
rehabilitation. No bony operation had been done.
3.2. Radiologically (After Removal of the Cast)
3.2.1. Cav u s Deformity (Figure 3)
Measured on lateral X-ray: the angle between the axis of
the first metatarsal and the axis of the calcaneus, which is
named plantaris angle or forefoot Equinus [16]. In our
cases this angle improved in serial follow up X-ray.
3.2.2. Varus Deformity of the Heel
The angle between long axis of talus and calcaneus in
A-P X-rays [18]. In our cases, this angle improved in
serial follow up X-ray.
3.2.3. Adduction of the Fore Part of the Foot
The angle between axis of calcaneus and fifth metatarsal
bone in A-P X-rays [16]. In our cases, this angle im-
proved in serial fo llow up X-ray.
3.2.4. Equinus Deformity of the Ankle (Figure 4)
This was measured by the angle formed by the axis of the
shaft of the tibia and long axis of the calcaneus on lateral
X-ray [19] this angle improved in serial follow up X-ray.
Radiological follow up: marked improvement in fol-
low up X-ray (Figures 5(a) and (b)).
3.3. Functional Assessment
 All feet had good flexibility no pain or discomfort
and the gait was good after a short period of rehabili-
tation.
Case study (Figures 6(a) and (b)) case of bil. Con-
genital talipes equino-varus
The same case after operation in the fixator (Figure 7).
The same case post-operative (Figures 8 and 9).
Figure 3. Plantaris angle.
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Treatment of Resistant Clubfoot with Soft Tissue Release and Alkhooly External Fixator
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317
4. Discussion This problem is solved by the Alkhooly external fixa-
tor, so the advantages of this technique are:
Although the treatment of a mild congenital clubfoot
may be easy, the complete and permanent correction of
severe and rigid clubfoot is often difficult [16]. Most
authors still agree that all congenital clubfeet should ini-
tially be treated non-operatively [20 ,2 1].
a Permitting dressing of the wounds
b Maintenance of the correction and g radual correction
c Observation of the circulation and pre vent ion of
neurovascular complications by gradual correction
when needed.
d Good correction of healing inversion
Bensahel et al. [22] recommended in 1987 that the ini-
tial treatment should consist of daily manipulation of the
foot without anesthesia for three months. This was fol-
lowed by adhesive strapping of the foot in the corrected
position. If the deformity did not respond to this regime
after three months surgical interference was advised.
In one of the published reports [29], it was observed
that half of their cases of the series after completion of
treatment had only a false correction of the deformity.
The foot was broken at the talonavicular level, leaving
the heel in inversion although the forefoot was planti-
grade; this meant that plaster cast could not maintain the
correction of inversion of the heel. By using the fixator,
inversion of the heel can be corrected and maintained by
changing the position of K. wire passing through the
calcaneus in the holes of proximal half ring.
Several techniques for surgical treatment of club-foot
were described in the literature [17]. Their indications
varied with the age of the patient and the degree of de-
formity. Some authors reported good results with
soft-tissue release, even at the age of 8 - 10 years [23].
Other author s reported an opposite view [24 ,25].
Turco introduced in 1978 [26] th e one stage so ft tissue
posteromedial release. This is still used widely today
[27,28] He advised that the optimum age of candidates
for this procedure was one to two years, with an upper
limit of six years.
C = Calcaneus E = Equines
N = Neutral
The contracture of the posteromedial skin is an im-
pediment to correction in severe deformities at all ages.
Hence, its release is always indicated [1]. The use of a
rotation skin flap will solve the problem. Mittal [1] de-
scribed the dorsolateral semicircular flap rotated pos-
teromedially, thus allowing the lax skin on the dorso-
lateral aspect to shift planterwards and backwards. The
other problem is the final correction with prevention of
neurovascular complications and good observation of the
foot; this is not achieved completely by repeated chang-
ing of the plaster cast with the possibility of loss of cor-
rection and recurrence of deformity and wound compli-
cations. Figure 4. Diagram showing the tibio-calcaneal angle as
traced. On the lateral X-ray to measure the ankle equines.
(a) (b)
Figure 5. (a) Pre operative X-ray (left foot); (b) Post operative follow up X-ray (left foot).

Treatment of Resistant Clubfoot with Soft Tissue Release and Alkhooly External Fixator 318
(a)
(b)
Figure 6. (a) Case of bil. Congenital talipes equino-varus (Pre-operative photos). (b) The same case while standing (Pre-op-
erative photos).
Figure 7. Post-operative photos in the fixator.
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Treatment of Resistant Clubfoot with Soft Tissue Release and Alkhooly External Fixator
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319
Figure 8. Post-operative follow up, left side operated and right side not ope r ated yet.
Figure 9. Both feet after correction.
Our results are encouraging for using this technique.
Mittal [15] reported that even in a normal looking foot
there was sometimes radiological under-correction of the
talo-calcaneal index and/or calcaneo-metatarsal angle;
however, substantial radiological improvement had oc-
curred in every case whenever X-ray was taken. In addi-
tion, Wynne-Davies [29] in his review of patients after
treatment of talipes equino-varus, radiological assess-
ment revealed that only one fourth of the 121 feet exam-
ined showed normal alignment of the hind foot, another
quarter showed some over-riding of talus and calcaneus
or partial inversion, and one-half of the feet showed
complete over-riding of the talus and calcaneus or full
inversion of the heel, however, on clinical examination
those feet were plantigrade. Most of our cases show ra-
diological correction after two years of follow-up as
shown in the X-ray. Similarly, Sherman and Westin [30]
stated in 1981 that there was no standard method to
measure equinus angulation of the calcaneus. So, clinical
correction was, therefore, always relied upon when as-
sessing the results.
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