Case 1. A newborn infant with bilateral idiopathic clubfoot was
initially treated with serial manipulations and corrective casts. The
application of the casts started when the patient was two weeks of age and
continued on a weekly basis until the patient was ten weeks of age. Incomplete
correction was obtained, and the patient was scheduled for a bilateral
complete soft-tissue release at nine months of age. Preoperative clinical
evaluation revealed the absence of a palpable dorsalis pedis pulse bilaterally
and the absence of a palpable posterior tibial pulse on the right side.
The operation was begun on the right foot with use of the Cincinnati
incision9 under a
tourniquet pressure of 200 mm Hg. The tibial nerve was identified in the
sheath posterior to the posterior tibial tendon and was of normal size;
however, the posterior tibial artery was not present. Additionally, an
accessory flexor digitorum longus muscle was present immediately adjacent to
the tibial nerve. The Achilles tendon was then lengthened with use of a
z-lengthening technique. After medial, posterior, and lateral release of the
ankle and subtalar joints, a small artery (1 mm in diameter) located on the
posterior surface of the ankle joint was noted to have been transected. The
tourniquet was immediately deflated, and circulation to the foot returned
instantaneously. Intraoperative consultation with a vascular surgeon was
obtained, and repair of this small artery was not attempted because of the
technical difficulty and the unlikelihood of maintaining patency after repair.
The remaining surgical release was completed without difficulty. After the
release, the talonavicular joint was held reduced with a Kirschner wire. The
same procedure was then performed on the left foot, where normal vascular
anatomy was noted. An accessory flexor muscle was not present. Both feet
healed uneventfully and the correction was found to have been maintained at
the time of the most recent follow-up, seventeen years postoperatively.
Case 2. A two-week-old boy with bilateral idiopathic clubfoot
was treated with serial manipulations and corrective casts. Incomplete
correction was obtained, and the patient underwent bilateral complete
soft-tissue release operations at the age of ten months. Clinical examination
revealed the absence of a palpable dorsalis pedis pulse bilaterally and the
absence of a palpable posterior tibial pulse in the left limb. The left foot
was operated on first with use of the Cincinnati incision under a tourniquet
pressure of 200 mm Hg. An accessory flexor digitorum longus muscle was
identified immediately adjacent to the tibial nerve and attaching distally to
the flexor digitorum longus tendon. The posterior tibial artery was noted to
be absent from the sheath containing the tibial nerve. However, a vascular
bundle was identified just anterior to the Achilles tendon and adjacent to the
posterior ankle capsule, and it was protected. The soft-tissue release was
completed without incident. Full correction of the equinus deformity was not
attempted because of the amount of stretch that would have been placed on the
seemingly important posterior vascular structures. The same procedure was then
performed on the right foot, in which normal vascular and muscular anatomy was
noted. Postoperatively, the serial application of casts was used to gradually
dorsiflex the left foot.
Hindfoot varus and equinus deformities as well as forefoot adduction
recurred on the left side, and revision clubfoot surgery was performed under
tourniquet control when the patient was seven years of age. Again, the
complete absence of a posterior tibial artery was observed. During the medial,
posterior, and lateral releases of the ankle and subtalar joints, the
anomalous vascular structures overlying the posterior aspect of the ankle
joint were carefully preserved. The tourniquet was deflated, the extremity had
excellent perfusion distally, and the pulse over the anomalous vasculature was
good. Intraoperative continuous-wave Doppler assessment indicated the absence
of the anterior tibial artery. A planned concomitant midfoot osteotomy was
deferred until the exact vascular anatomy could be delineated with use of
arteriography.
Arteriography was performed the next day with use of the Seldinger
technique and a left femoral artery approach. Frontal and lateral digital
arteriograms of both lower extremities were made. No complications occurred.
Arteriography of the left lower extremity showed that the external iliac,
common femoral, deep femoral, superficial femoral, and popliteal arteries were
normal. A hypoplastic anterior tibial artery was shown originating from the
popliteal artery and terminating as a small branch to the ankle. No posterior
tibial artery was identified on either the frontal or the lateral projection
(Figs. 1-A and 1-B). Lastly, a
dominant peroneal artery, originating from the distal popliteal artery, was
found to cross the ankle posterior to the distal tibiofibular joint to form a
lateral plantar arch. No vessel posterior to the medial malleolus was
visualized. No anomalous venous structures were seen.
Arteriography of the right lower extremity showed normal arterial anatomy
superior to the knee. A hypoplastic anterior tibial artery was noted. The
posterior tibial artery arose from a normal popliteal artery, crossed the
ankle posterior to the medial malleolus, and formed a normal plantar arch. The
peroneal artery was normal in its origin and course. There was no additional
surgical management. At the time of this writing, the patient had persistent,
mild metatarsus adductus of the left foot.