Talocalcaneonavicular Realignment: The Foundation for Comprehensive Reconstruction of Severe, Resistant Neurologic Cavovarus, and Equinocavovarus Foot Deformities in Children and Adolescents.

Introduction: The progression of neurologic cavovarus (NCV) and equinocavovarus (NECV) foot deformities during growth can eventually lead to non-reducible severe talonavicular (TN) and subtalar (ST) joint rotational malalignments. This study aimed to describe a technique to correct severe, resistant inversion deformity of the ST joint complex as the foundational procedure in comprehensive reconstruction of multi-segmental NCV and NECV deformities in pediatric patients and to analyze mid-term radiologic, functional, and satisfaction outcomes.

Methods: This prospective study included children with severe NCV and NECV foot deformities who underwent TCNR between 2019 and 2022, with a minimum follow-up of 2 years. Talocalcaneal angle, talus-1 metatarsal angles, and TN coverage angle were measured in preoperative and postoperative weight-bearing foot radiographs. The foot and ankle disability index, foot function index, and Maryland foot score evaluated functionality. Qualitative questions assessed perceived improvement, satisfaction, and expectations of patients/caregivers. Descriptive, comparative pre-post, subgroup, correlation, and satisfaction analysis were performed.

Results: Twenty-six patients (36 feet: 16 unilateral and 10 bilateral) were included; 50% were female, median age was 12.1 years (IQR, 3.21) and median follow-up was 32.9 months (IQR, 18.7). Fifty-four percent had cerebral palsy, and 23% had charcot-marie-tooth disease; 84.6% were ambulatory. Significant improvements were found in radiologic parameters and functional outcomes ( P <0.01), with no relevant differences between unilateral or bilateral procedures, pathology, functional level, or ambulatory capacity ( P >0.05). Correlations between radiologic parameters or functional scales with age were generally low. Most reported significant functional improvements, outcomes exceeding expectations, and high satisfaction; they would recommend the surgery and undergo the procedure again. There were 3 minor complications: hypersensitivity, partial recurrence, and undercorrection.

Conclusions: The TCNR technique enables realignment of severe, resistant inversion deformity of the ST joint complex in NCV and NECV foot deformities. When combined with procedures to correct the other foot deformities and muscle imbalances, functional outcomes are enhanced, high patient/caregiver satisfaction is achieved, and low complication rates are possible. This approach represents an important modification and extension of an already described technique, the deep plantar-medial release.

Level of evidence: Level III, therapeutic prospective cohort study.