- Discussion:
    - most common foot deformity in myelomeningocele;
    - teratological club-foot deformity in children w/ myelomeningocele is often more severe and more rigid than seen in 
           congenital club foot deformity;
    - secondary foot deformities may also develop as a result of muscle imbalance and/or spasticity;
    - goals of treatment:
           - these children will usually have insensate feet, and it is therefore important to keep the foot in a plantigrade position;
           - the initial emphasis should be placed on achieving a mobile plantigrade foot, but arthrodesis may be required in order to achieve a 
                   plantigrade surface & foot that can be braced;
           - most children w/ mylelomenigocele club foot will require lower-extremity bracing on a long-term basis;

- Non Operative Treatment:
    - serial plaster casts should be begun as early as possible;
           - slow but persistent correction should be gained over first year of life;
           - special care is be taken to avoid pressure sores under cast in insensitive feet;
    - recurrence of deformity is frequent because of muscle imbalance, & surgical release is often needed for lasting correction;

- Operative Treatment:
    - timing of surgery:
          - because of common neurological & urological problems & high risk of recurrence in these children, an operation is done later 
                  than it would be in a child who has idiopathic congenital club foot;
          - generally, operative intervention should be delayed until the child is 12 to 18 months old.
    - treatment options:
          - tenotomy and/or tendon transfers may be used prevent recurrence;
                  - complex tendon transfers should be avoided because of lack of selective muscle control & tendency to create new deformity.
                  - contracted tendons should be resected rather than lengthened;
                  - to correct an equinus deformity consider heel cord tenotomy rather than lengthening to prevent recurrence;
          - talectomy:
                  - severe equino-varus deformities related to arthrogryposis or myelomeningocele, can be managed w/ talectomy;
                  - in most cases, talectomy is indicated for management of severe equinovarus deformities which have been resistant to 
                         previous attempts at operative correction;
                  - in cases of bilateral rigid clubfoot, primary bilateral talectomy may be an option;
                         - desired outcome is bilateral plantigrade feet, which transmit wt bearing eveningly over the foot;
                         - in the study by Letts and Davidson (1999), 10 out of 14 feet had a good or satisfactory result from bilateral talectomy;
                         - essential technical details include need for complete talar removal and relocation of the talus;
                  - bracing is needed after correction to prevent recurrent equinus;

- Revision Surgery:
    - residual deformities after correction of club foot may require additional surgery;
    - talectomy:
          - in revision cases, but it can effective to return the foot to a neutral position;
          - in younger children, the Verebelyi-Ogston procedure (talar decancellation) may be preferred over talectomy;
          - w/ severe scarring, enucleation of navicular, talus, & cuboid as well as the talectomy may be required;
    - osteotomy:
          - closing-wedge osteotomy (Dwyer procedure): indicated for persistent varus angulation of hind part of foot;
          - sliding osteotomy of the calcaneus: indicated for valgus overcorrection of the hindfoot;
          - residual adduction of fore part of foot may necessitate metatarsal osteotomies or shortening of the lateral border of the foot;
    - arthrodesis:
          - arthrodesis of ankle & triple arthrodesis should be avoided

Equinovarus deformity in arthrogryposis and myelomeningocele: evaluation of primary talectomy.

The role of bilateral talectomy in the management of bilateral rigid clubfeet.