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Posts Tagged ‘clubfoot’

Case Study: Calf Implants in Bilateral Clubfeet

Saturday, August 3rd, 2013

 

Background: Calf augmentation using either a synthetic implant or fat injections is a well known surgical procedure to increase the prominence of the calf muscle. While many people think of the typical calf augmentation patient as a body builder or an athlete, aesthetic enhancement of normal calf muscles is only one reason to have the procedure. The other reason calf implants are done is for congenital deformities or obvious developmental asymmetries. Such deformities can include club foot, spina bifida and even polio.

Clubfoot is a well recognized lower leg deformity which is reported to be the most common birth defect. Medically known as congenital talipes equinovarus, the involved foot looks like it has been turned inward at the ankle. It occurs half the time in both feet at birth and more frequently in males. The calf (gastrocnemius) muscle is always smaller on the affected foot. Besides the issue of less functional use, studies have shown that the smaller size of the gastrocnemius muscle is due to wasting of the calf muscle from a reduction in the number of muscle fibers rather than their size.

When occurring on one side, clubfeet patients have a much smaller muscle than on the normal leg. When occurring in both feet, the calfs (as well as the entire leg) can be extremely thin. The calf muscle is so atrophic that there is a straight line from the inner knee straight down to the ankle without the usual calf muscle bulge seen in the frontal view. This is a source of embarrassment for many patients and will often prevent them from wearing shorts or otherwise exposing their calfs in public.

Case Study: This 23 year-old male was born with bilateral clubfeet and had been through many years of physical therapy, splints and achilles release surgery. He had thin upper thighs and very thin calfs that tapered inward from below the knee to the ankle. His skin was very tight around his calfs. While he ideally could have aesthetically benefited by both medial and lateral calf implants for both legs, the tightness of his tissues made that consideration too risky for fear of a compartment syndrome after surgery.

Under general anesthesia in the prone position, 3.5 cms long incisions were made in skin creases behind the knees at the inner half. Dissection was carried down to the muscle fascia where, in a stairstep fashion, fascial incisions were made well below the level of the skin incisions. An instrument dissected out a subfascial plane over the medial gastrocnemius muscle where solid soft silicone elastomer calf implants (15cm long x 5 cm wide, 135cc volume) were placed. the fascia and skin were closed in separate layers. He was dressed with tapes for his incisions and ace wraps for his calfs. The procedure was completed in one hour.

He rested his legs for the first few days, keeping his legs elevated. His recovery occurred over the next 3 weeks during which the calf muscles became used to having an implant sitting on top of it and the overlying skin stretched a bit. Returning to normal walking gradually occurred although a bit slower in the club foot patient who already had comfortable walking issues beforehand. His results showed a visible enlargement in his inner calf size that was proportionate to his thighs.

Calf implants in the clubfoot patient provide an immediate improvement in calf size. Fat injections are often not an option if they do not have any significant amount of fat to harvest in thinner patients. It is tempting to use larger sizes of calf implant or even two implants per leg but the tightness of the surrounding skin makes this a more risky approach in the patient with an atrophic overall calf. A larger size or an additional implant can be placed at a later date if desired.

Case Highlights:

1) For the clubfoot patient, calf augmentation with implants can provide a immediate and visible change in atrophic calf size.

2) Calf implants are placed on top of the muscle under the fascia in the inner calf muscle to get the most visible effect.

3) Calf implant augmentation is a very straightforward procedure that is accompanied by a longer recovery than the simplicity of the operation would suggest due to lower extremity dependency and function.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Implant Augmentation in Calf Asymmetry in Clubfoot

Saturday, June 22nd, 2013

 

Background:  Augmentation of deficient calf muscles is done for a variety of reasons. These include naturally small calfs, in bodybuilders who want their calfs to match the muscular look of the rest of their body and for congenital leg defects in which calf muscle development is small and ill-defined either on one leg or both legs.

One of the most common congenital lower leg defects that affects the calf muscles is that of clubfoot. Clubfoot is a well known birth defect, also called talipes equinovarus, as it occurs in about one in every 1,000 births. In about half of those so affected, it will occur on both sides. It is a birth defect that is far more common in males than females. The appearance of the foot so affected is unmistakeable with the foot turned inward on its side. The involved foot, calf and overall leg length is smaller and shorter.  If clubfoot is limited to one side, the calf asymmetry compared to that of the normal side is very apparent. Circumferential calf measurements are often 2 to 5 cms smaller than that of the unaffected leg.

Calf augmentation is most commonly done by synthetic implants. Commercially available calf implants offer immediate and permanent changes in calf size and are made of a very soft durometer solid (spongy) silicone material.  They are shaped like long fat cigars in various lengths, widths and volumes. These implants are placed in a subfascial location on top of the calf muscles. Complications can include infection and inadequate positioning whose risks are very low. The biggest issue with calf implants is the recovery, particularly if both calfs are treated.

Case Study: This 16 year-old female was born with a right clubfoot deformity. Her leg leg and foot were unaffected. She had been treated by serial casting as an infant and had a fairly normal gait. She was bothered by the difference in her calf sizes which was very visible in shorts. The difference in circumferential calf size measurement was 3.7 cms at the mid-calf area.

Under general anesthesia and in the prone position, a 3 cm incision above the medial gastocnemius muscle head was made in the popliteal skin crease of the right leg. Dissection was carried down to the gastrocnemius fascia which was horizontally incised. An instrument was used to develop the subfascial pocket over the muscle. A small silicone calf implant, measuring 16cms in length by 5.5cms in width (70cc volume) was inserted. The fascia and skin was closed with dissolveable sutures and taped. No other dressing was used.

Her recovery included some calf pain, swelling and inability to comfortably fully flex the ankle for a few weeks. By six weeks after surgery she had returned to all normal activities. Her calf asymmetry was improved, although not perfect, with a change to only a 1.5 cm difference in circumferential mid-calf measurement from that of the left normal side.

Gastrocnemius muscle augmentation using implants can provide an effective improvement in calf asymmetry due to clubfoot. The congenital shortness of tissue around the calf makes for tight skin. This limits the size of the calf implant that can be placed and dual muscle augmentation (medial and lateral heads) is not usually advised.

Case Highlights:

1) Calf augmentation by synthetic implants is the most reliable method of permanent volume enhancement

2) Congenital clubfoot deformity is associated with other lower leg issues of which small calf muscle development also occurs.

3) Calf augmentation (reconstruction) in club foot with synthetic implants must take into consideration the tightness and shortage of circumferential skin when selecting implant size.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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