Both of our cases have constriction rings on their right legs, mild lymphoedema in the distal region and club foot deformity on the same side (Zone 2 and Grade 3). They were 6 months old Turkish boy and 8 months old Turkish girl respectively. Initially foot deformities of both patients have been corrected by Ponceti casting method (Figure 1). Start was given by correcting cavus component of the deformity, through serial castings forefoot was rendered to supination and the first metatarsi to dorsiflexion. As a result of corrected arcus, forefoot and hindfoot were observed to be in the same alignment. Pronation of the forefoot was carefully avoided. For the correction of varus and adduction deformity, the foot was brought to abduction by asserting a force with our thumb to the talar head in the supination position over the cast.
In the following castings, it was observed that talar head has been reducted and covered by os naviculare and that supination also decreased as the foot was put in abduction position. However, the foot was never brought to pronation.
It was also observed that the foot was plantigrade just as it was brought to complete abduction and that heel varus was corrected with coming of evertion simultaneously. During the manipulation, for the complete correction of the calcaneal alignment, an extra care was given to not to touch to calcaneocuboid joint or the heel. The casting was applied after hand correction, which lasted for 2-3 minutes. In both cases, synthetic cast (soft cast 3M) was used as above the knee. The family was informed about the circulation control and was told to remove the casting in a suspicious situation. The serial casting was performed in 7 days period. For each case seven castings were used. After the correction of foot adduction and heel varus, equinus deformity was corrected by making dorsiflexion of the ankle. Upon the permanent equinus deformity, we performed tenotomy of achilles tendon under general anesthesia.
The casting applied following the tenotomy remained for 3 weeks. After the removal of the last casting, specially designed shoes for the prevention of relapse, we applied Dennis Brown foot braces in the position of abduction at 70° and dorsiflexion at 15-20°. The brace was initially used all day long for a period of 3 months and then after, only during sleep [4].
Six months following the tenotomies we performed the operation of constriction bands. After the resection of soft tissue and deep fascia, both of two constriction bands were released at the same session and corrected by Z plasty procedure with multiple parallel incision of 60° to each other [2].
Tissue necrosis was observed in none of our patients and after 1 month from the operation constriction bands healed without any wound complication (Figures 2,3 and 4). The patients after 1 year of follow up had good results.