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Complex reconstruction of iatrogenic skew foot deformity

© BMJ Publishing Group Limited 2022. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A 19 yearold male was referred by his primary orthopaedic surgeons with bilateral skew foot deformity, acquired secondary to surgical overcorrection of a congenital talipes equinovarus (clubfoot) deformity. The patient was born with bilateral clubfoot as an isolated musculoskeletal defect and underwent multiple corrective surgeries throughout his childhood and adolescence, with interval evolving deformity between surgeries. Previous operations included an Achilles tendon release, posteromedial release, and a corrective triple foot arthrodesis, which resulted in overcorrection and subsequent formation of skew foot bilaterally. His mobility was impaired secondary to deformity and pain, with a large impact on quality of life. At the time of referral, the patient was considering amputation with prosthesis to restore functional mobility. Examination and Xrays revealed complex bilateral deformity showing skew foot hallmarks of hindfoot valgus, midfoot supination, and forefoot adduction, with longitudinal arch flattening (figure 1). Remnants of clubfoot were present with toes skewed medially with fixed flexion. The patient was planned for and underwent right foot reconstruction using the following methods: calcaneal dome osteotomy through nonunion of subtalar joint with lateral bone block to correct the valgus deformity and the calcaneal pitch; calcaneocuboid joint osteotomy; dorsiflexing osteotomy of the first metatarsal; corrective first metatarsophalangeal joint arthrodesis; flexor tenotomies of lesser toes and transfixation with Kires. The skew deformity of the right foot was successfully corrected, with achievement of a plantigrade foot and restoration of functional anatomy (figure 2). Weekly 3layer compression bandages (Unna boot) were applied. The patient progressed from a nonweight bearing status to weight bearing as tolerated with crutches after 4 weeks. Pain was significantly improved and the patient does not currently require analgesia. The medial incision was initially slow to heal (expected outcome given surgical lengthening of medial side of foot with consequent stretching of already thin tissue over bone). PICO (negative pressure wound therapy device) vacuum dressing was applied with good progress on healing. Following time for healing, similar corrective surgery on the left foot will be planned. The medial and dorsal plates have since been removed after bony healing to aid in closure (figure 3). Clubfoot is the most common musculoskeletal birth defect, with an incidence of 1:1000 (up to 1:250 in Maori and Hawaiian populations). It presents bilaterally in 50%, and as an isolated