Surgical techniques

Talectomies were performed mainly as salvage procedures but in some cases were used as primary procedures mainly in neglected clubfeet associated with either spina bifida or arthrogryposis. A trial of Ponseti casting was usually performed in the neglected non-operative cases but if it failed, the surgical correction typically started with posterior soft-tissue release (STR). If the STR was not sufficient to correct the hind foot deformity, talectomy was chosen as the primary procedure. Conversely, if a child with spina bifida or arthrogryposis also presented with failed or severely relapsed congenital talipes equinovarus (CTEV) after STR procedures, talectomy was carried out without posterior STR.

Initially, talectomy began in our center utilizing a modified skin incision that was medial to the one described by Menelaus [4]; this approach helped to isolate the dorsal neurovascular bundle. This incision started anterior to the medial malleolus and ended distal to the level of the midfoot between the first and second metatarsal. This medial incision makes exposure of the subtalar joint very difficult, which often results in failure to remove the talus as one piece; thus, the talus is mostly removed in fragments. After excision of the talus, the Achilles tendon was resected, and the posterior ankle capsule and anterior deltoid ligament that holds the navicular in the adducted position were released.

Reduction of the calcaneum was then attempted, and if the calcaneum was not set in the mortise properly, release of the anterior syndesmotic ligament and resection of the tip of the lateral malleolus was carried out to achieve the proper contact between the calcaneum and tibial pilon. The proper position of the calcaneum should include 5° of the valgus, sufficient posterior translation, and 20–40° of calcaneal pitch angle, which were monitored with intraoperative images. If proper calcaneal reduction was achieved, it was fixed with one or two retrograde calcaneotibial K-wires.

The next step was the reduction of the midfoot to the reduced and stabilized hindfoot. Initially, we were very conservative when adding midfoot bony procedures to achieve midfoot full correction due to concerns about the reduction in foot size. Residual mild midfoot adduction equivalent to a Pirani Score [17] of 0.5 for the lateral foot border was accepted and not considered an indication for midfoot bony procures. Occasionally, an additional midfoot stabilizing K-wire was added to hold the midfoot in the best achieved position. This initial group of patients receiving the talectomy procedures utilizing the medial modified approach and accepted residual adduction were labeled as group A.

The surgical approach of talectomy changed at the end of 2014 to the initially classically described incision. This incision starts over the anterolateral aspect of the ankle joint, just anterior to the lateral malleolus, passes through the sinus tarsi, and ends over the prominently subluxated talar head, which is at the level of the 4th intermetatarsal space. Using this approach, the talus was excised as one piece in all cases in this subgroup. The accepted position was a straight lateral foot border (Pirani score of 0 for the lateral border) dictating a lower threshold to perform midfoot bony procedures, mainly calcaneocuboid fusion [10]. This group of patients was labeled as group B.

In both subgroups, above knee casts were applied at the end of the procedure to maintain the position of the foot.