Interventions for congenital talipes equinovarus (clubfoot)

Management of neglected clubfoot in children using Ilizarov external fixator and minimal invasive surgery, Sub-Saharan Africa experience

PURPOSE

To evaluate the outcomes of Ilizarov external fixator (IEF) and minimal invasive surgery (MIS) in correction of neglected club foot (NCF).

METHODS

Thirty-seven feet in 24 child, between five and 15 years old were diagnosed as NCF. All were treated with Achilles tendon lengthening (ATL) and IEF for gradual correction. After IEF removal, cast was applied for six weeks to maintain correction of the deformity.

RESULTS

There were 20 boys and four girls. Seven children had left (Lt), four children had right (Rt) while 13 children had bilateral foot deformity. The mean age at surgery was 10.3 (range 5-15) years with an average follow-up of 32.5 (range 24-96) months. All feet were graded as severe according to Pirani score. All feet were corrected after an average six weeks in IEF. After two years follow-up, 23 feet (16 patients) showed good results, five feet (3 patients) showed fair results and four feet (2 patients) had Rt side foot fair result while the Lt foot had good result in both patients. Five feet (3 patients) showed poor results. Eight patients had pin site infection. One case had infected skin and subcutaneous tissue and needed debridement. Two cases developed skin sloughing, changes in color and needed close follow-up.

CONCLUSION

We recommend combined IEF and MIS as a suitable, efficient and successful salvage procedure in the management of severe idiopathic NCF in children especially in developing countries.

Plantar Pressure Distribution of Right and Left Foot in Bilateral Clubfoot Treated by Ponseti Method: A Correlation Analysis

Background

Congenital clubfoot is a common pediatric orthopedic deformity that can be corrected by Ponseti method, and pedobarographic analysis has been used to assess the outcomes. However, the relationship between the plantar pressure distribution of the right and left foot in children with bilateral clubfoot has not been studied. In this study, the pedobarographic data of patients with bilateral clubfoot who were treated by the Ponseti method were reviewed, and a correlation analysis was conducted to clarify the relationship between the right and left foot.

Material/Methods

A retrospective cross-sectional study of children with bilateral clubfoot who were treated by the Ponseti method in infancy was performed, in which all the patients were available for clinical evaluation, and pedobarographic analysis was conducted on each patient after treatment. The Pearson’s correlation coefficient (r) were calculated for all the measurements of the left and right foot.

Results

A total of 20 children (mean age 6.9±1.07 years, range 4–8 years) with bilateral clubfoot who were treated by the Ponseti method were included. The Dimeglio and Pirani scores before and after treatment between the right and left foot were significantly correlated. All the pedobarographic measurements between the left and right foot were correlated, indicating different degrees of positive correlation.

Conclusions

The plantar pressure measurements between the 2 feet in patients with bilateral clubfoot were highly correlated before treatment, and a correlation was also observed after those patients were treated by the Ponseti method. We should take these correlations into consideration during study design and analysis of clubfoot cases.

Interventions for congenital talipes equinovarus (clubfoot)

BACKGROUND

Congenital talipes equinovarus (CTEV), also known as clubfoot, is a common congenital orthopaedic condition characterised by an excessively turned-in foot (equinovarus) and high medial longitudinal arch (cavus). If left untreated it can result in long-term disability, deformity and pain. Interventions can be conservative (such as splinting or stretching) or surgical. Different treatments might be effective at different stages: at birth (initial presentation); when initial treatment does not work (resistant presentation); when the initial treatment works but the clubfoot returns (relapse/recurrent presentation); and when there has been no early treatment (neglected presentation). This is an update of a review first published in 2010 and last updated in 2014.

OBJECTIVES

To assess the effects of any intervention for any type of CTEV in people of any age.

SEARCH METHODS

On 28 May 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus, AMED and Physiotherapy Evidence Database. We also searched for ongoing trials in the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (to May 2019). We checked the references of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs evaluating interventions for CTEV, including interventions compared to other interventions, sham intervention or no intervention. Participants were people of all ages with CTEV of either one or both feet.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risks of bias in included trials and extracted the data. We contacted authors of included trials for missing information. We collected adverse event information from trials when it was available. When required we attempted to obtain individual patient data (IPD) from trial authors for re-analysis. If unit-of-analysis issues were present and IPD unavailable we did not report summary data, MAIN RESULTS: We identified 21 trials with 905 participants; seven trials were newly included for this update. Fourteen trials assessed initial cases of CTEV (560 participants), four trials assessed resistant cases (181 participants) and three trials assessed cases of unknown timing (153 participants). The use of different outcome measures prevented pooling of data for meta-analysis, even when interventions and participants were comparable. All trials displayed high or unclear risks of bias in three or more domains. Twenty trials provided data. Two trials reported on the primary outcome of function using a validated scale, but the data were not suitable for inclusion because of unit-of-analysis issues, as raw data were not available for re-analysis. We were able to analyse data on foot alignment (Pirani score), a secondary outcome, from three trials in participants at initial presentation. The Pirani score is a scale ranging from zero to six, where a higher score indicates a more severe foot. At initial presentation, one trial reported that the Ponseti technique significantly improved foot alignment compared to the Kite technique. After 10 weeks of serial casting, the average total Pirani score of the Ponseti group was 1.15 points lower than that of the Kite group (mean difference (MD) -1.15, 95% confidence interval (CI) -1.32 to -0.98; 60 feet; low-certainty evidence). A second trial found the Ponseti technique to be superior to a traditional technique, with mean total Pirani scores of the Ponseti participants 1.50 points lower than after serial casting and Achilles tenotomy (MD -1.50, 95% CI -2.28 to -0.72; 28 participants; very low-certainty evidence). One trial found evidence that there may be no difference between casting materials in the Ponseti technique, with semi-rigid fibreglass producing average total Pirani scores 0.46 points higher than plaster of Paris at the end of serial casting (95% CI -0.07 to 0.99; 30 participants; low-certainty evidence). We found no trials in relapsed or neglected cases of CTEV. A trial in which the type of presentation was not reported showed no evidence of a difference between an accelerated Ponseti and a standard Ponseti treatment in foot alignment. At the end of serial casting, the average total Pirani score in the accelerated group was 0.31 points higher than the standard group (95% CI -0.40 to 1.02; 40 participants; low-certainty evidence). No trial assessed gait using a validated assessment. Health-related quality of life was reported in some trials but data were not available for re-analysis. There is a lack of evidence for the addition of botulinum toxin A during the Ponseti technique, different types of major foot surgery or continuous passive motion treatment following major foot surgery. Most trials did not report on adverse events. Two trials found that further serial casting was more likely to correct relapse after Ponseti treatment than after the Kite technique, which more often required major surgery (risk differences 25% and 50%). In trials evaluating serial casting techniques, adverse events included cast slippage (needing replacement), plaster sores (pressure areas), and skin irritation. Adverse events following surgical procedures included infection and the need for skin grafting.

AUTHORS' CONCLUSIONS

From the evidence available, the Ponseti technique may produce significantly better short-term foot alignment compared to the Kite technique. The certainty of evidence is too low for us to draw conclusions about the Ponseti technique compared to a traditional technique. An accelerated Ponseti technique may be as effective as a standard technique, but results are based on a single small comparative trial. When using the Ponseti technique semi-rigid fibreglass casting may be as effective as plaster of Paris. Relapse following the Kite technique more often led to major surgery compared to relapse following the Ponseti technique. We could draw no conclusions from other included trials because of the limited use of validated outcome measures and the unavailability of raw data. Future RCTs should address these issues.

Can pedobarography predict the occurrence of heel rocker in children with lower limb spasticity?

BACKGROUND

Pedobarography software calculates the centre-of-pressure trajectory in relation to the foot to quantify foot contact patterns. This study presents two new pedobarography measures using the centre-of-pressure trajectory to assess heel rocker.

METHODS

To validate these pedobarography measures against 3D gait analysis, emed_®-x and Vicon Nexus gait analysis data were captured from 25 children aged 8-16 years (11 male) with unilateral (n = 18) and bilateral (n = 7) cerebral palsy or acquired brain injury. 3D gait analysis identified whether heel rocker was intact (n = 22 feet) or absent (n = 28 feet) based on centre-of-pressure at initial contact and the ankle kinematic curve between 0 and 2% of the gait cycle. Pedobarography measures calculated from the initial centre-of-pressure point were the distance to the heel (point of initial contact) and to the most posterior point of the trajectory (rollback), reported as a percentage of foot length.

FINDINGS

The median point of initial contact in limbs with an intact heel rocker was 9% (range 7-12%) and median rollback was 0% (range 0-0.2%), whereas the median point of initial contact in limbs with an absent heel rocker was 58% (range 8-78%) and rollback was 18% (range 0-40%). Point of initial contact is the more accurate method for predicting heel rocker, with a threshold of 14% of foot length identifying the correct heel rocker status in 94% of cases.

INTERPRETATION

Point of initial contact can assess heel rocker with high accuracy. Both point of initial contact and rollback provide sensitive information on foot strike pattern, enhancing the utility of pedobarography.

Results of Modified Ponseti Technique in Difficult Clubfoot and a review of literature

INTRODUCTION

Serial Ponseti casting achieves deformity correction in early presenting idiopathic clubfoot cases normally in around 7 casts. However, there are resistant patients where correction requires more casts than usual. In such patients a modification in standard technique might be required right from the beginning. Such patients were collectively called as difficult clubfoot. The aim of this study was to assess the outcome of our modification to Ponseti technique in difficult clubfoot.

METHODS

All idiopathic clubfoot cases who were 75th percentile or more in WHO age for weight chart (chubby infants) or untreated clubfoot patients presenting for first time to our clinic at more than 5 months age (late presenters and neglected cases) were included in the study. Patients who had been previously surgically intervened elsewhere, patients over 7 years of age, patients with syndromic clubfoot or clubfoot associated with neurological conditions were excluded from the study. The patients were treated by early tenotomy of tendoachillis and a plantar fascia release before starting serial casting by Ponseti technique. Post correction, strict bracing protocol was followed with regular follow up. Pirani scoring was done at each stage. Measurement of Talocalcaneal angle on AP radiograph, maximum degree of abduction and dorsiflexion was noted once every year.

RESULTS

There were total 28 patients in our study. In all, 47 feet were subjected to modified Ponseti protocol. There were 21 male patients. Median age at presentation was 4 months. Mean centile of weight for age as per WHO growth chart was 64. Mean Pirani score at presentation was 5.86 (S.D. ± 0.34). Mean number of casts required for correction was 3.75 ± 1.10. Maximum followup period was 25 months.

CONCLUSION

This modification of Ponseti casting for difficult clubfoot patients achieves correction in shorter duration with less number of casts.

A silent massive ossification of Achilles tendon as a suspected rare late effect of surgery for club foot

We report the case of a 66-year-old male patient with massive ossification of the distal portion of the Achilles tendon, as a late consequence of a surgical release for club foot conducted in his childhood. The singularity of the case report derives from its clinical features: the bone mass was of abnormal dimensions, almost substituting the entire tendon; the condition had always been asymptomatic, without deficits in range of motion, in absence of either pain or biomechanical defects with age. In fact, the condition was diagnosed just recently as a consequence of a tear. Despite an ultrasound diagnosis after the injury, only during the surgical treatment, a proper evaluation of the entity of the pathology was possible. Although the ossification of Achilles tendon is a rare clinical condition with a complex multifactorial etiology, in our case report, some of the elements in the patient's medical history could be useful for the pathogenesis and early diagnosis of the disease. The aim of this case report is to emphasize the importance both of a correct evaluation of clinical history and of an accurate diagnosis, in order to conduct a proper management of this pathology.

Can the Pirani Score Predict the Number of Casts and the Need for Tenotomy in the Management of Clubfoot by the Ponseti Method?

Introduction: We assessed the role of the Pirani score in determining the number of casts and its ability to suggest requirement for tenotomy in the management of clubfoot by the Ponseti method.

Materials and Methods: Prospective analysis of 66 (110 feet) cases of idiopathic clubfoot up to one year of age was done. Exclusion criteria included children more than one year of age at the start of treatment, non-idiopathic cases and previously treated or operated cases.

Results: The initial Pirani score was (5.5±0.7) for the tenotomy group and the initial Pirani score was (3.3±1.6) for the non-tenotomy group. There was a significant difference between the initial Pirani score for the tenotomy and the non-tenotomy group with t= -7.9, df= 64 p<0.0001. The tenotomy group had a significantly higher number of casts (four to seven) compared to non-tenotomy group (two to five) t=-10.4, df=64, p<0.0001. Spearman’s rank correlation coefficient was significant and confirmed positive correlation between the initial Pirani score and the number of casts required to correct the deformity (r = 0.931, p<0.0001).

Conclusion: Initial high Pirani score suggests the need for greater number of casts to achieve correction and probable need for tenotomy. The number of casts required in achieving complete correction increases with increase in the initial Pirani score. The initial high hindfoot score (2.5-3) signifies the probable need of a minor surgical intervention of percutaneous tendoachilles tenotomy. Based on the initial Pirani score, parents can be informed about the probable duration of treatment and the need for tenotomy.

Cost-effectiveness of the Ponseti method for treatment of clubfoot in Pakistan

BACKGROUND

Clubfoot is disabling, with an incidence of 0.9/1,000 live births to 7/1,000 live births. It affects mobility, productivity, and quality of life. Patients are treated surgically or non-surgically using the Ponseti method. We estimated the cost per patient treated with both methods and the cost-effectiveness of these methods in Pakistan.

METHODS

Parents of patients treated, either surgically or with the Ponseti method, at the Indus Hospital's free program for clubfoot were interviewed between February and May 2012. We measured the direct and indirect household expenditures for pre-diagnosis, incomplete treatment, and current treatment until the first brace for Ponseti method and the first corrective surgery for surgically treated patients. Hospital expenditure was measured by existing accounts.

RESULTS

Average per-patient cost was $349 for the Ponseti method and $810 for patients treated surgically. Of these, the Indus hospital costs were $170 the for Ponseti method and $452 for surgically treated patients. The direct household expenditure was $154 and $314 for the Ponseti and surgical methods, respectively. The majority of the costs were incurred pre-diagnosis and after inadequate treatment, with the largest proportion spent on transportation, material, and fee for service. The Ponseti method is shown to be the dominant method of treatment, with an incremental cost-effectiveness ratio of $1,225.

CONCLUSIONS

The Ponseti method is clearly the treatment of choice in resource-constrained settings like Pakistan. Household costs for clubfoot treatment are substantial, even in programs offering free diagnostics and treatments and may be a barrier to service utilization for the poorest patients.

Bilateral clubfeet are highly correlated: a cautionary tale for researchers

BACKGROUND

Congenital talipes equinovarus, or clubfoot, is a common pediatric orthopaedic condition of unknown origin. In many clubfoot clinical trials, interventions are assigned to a patient, but response to treatment is assessed separately in each foot. Trials commonly report x patients with y feet where y is greater than x (eg, 35 patients with 56 feet). However, common statistical tests assume that each data point is independent. Although data from unilateral cases of clubfoot are independent, it is unknown if each foot of patients with bilateral clubfeet are correlated.

QUESTIONS/PURPOSES

The purpose of this study was to assess the correlation in the feet of patients with bilateral clubfeet by (1) evaluating the degree of severity between lower limbs of each patient with bilateral clubfeet at baseline; (2) determining if right and left feet of each patient responded to intervention in the same way; (3) determining the proportion of bilateral relapse; and (4) determining the proportion of right and left feet which required the same intervention to correct bilateral relapse.

METHODS

We performed a chart review of the records of 33 patients with bilateral clubfeet (66 feet). Baseline severity was assessed using the Pirani score. The number of Ponseti serial casts to correct the deformity, the proportion of patients who underwent bilateral Achilles tenotomy, the proportion of bilateral relapse, and the treatment to correct bilateral relapse were examined.

RESULTS

The degree of severity between right (Pirani score mean, 5.2; SD, 0.8) and left (Pirani score mean, 5.2; SD, 0.5) feet for each patient at baseline was highly correlated (r=0.76, p<0.001). Response to intervention between lower limbs was highly correlated for the number of Ponseti casts required for initial correction (right mean, 5.2, SD, 1.1; left mean, 5.2, SD, 1.3) (r=0.89, p<0.001) and the proportion of patients who underwent bilateral Achilles tenotomy (right, 17/18; left, 16/18) (r=0.94, p<0.001). In the nine patients who experienced relapse, eight experienced bilateral involvement. In all cases of bilateral relapse, the right and left foot of each patient required the same intervention to correct the relapse.

CONCLUSIONS

In patients with bilateral clubfeet, baseline severity, response to initial Ponseti treatment, Achilles tenotomy, and relapse outcomes were highly correlated in the right and left feet of each patient. Pooling clinical results of patients who present with bilateral clubfeet is statistically inappropriate, since results in two limbs of the same patient do not represent independent observations. These results support analogous work in other specialties suggesting that patients with bilateral presentations should not be analyzed as independent data points.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Interventions for congenital talipes equinovarus (clubfoot)

BACKGROUND

Congenital talipes equinovarus (CTEV), which is also known as clubfoot, is a common congenital orthopaedic condition characterised by an excessively turned in foot (equinovarus) and high medial longitudinal arch (cavus). If left untreated it can result in long-term disability, deformity and pain. Interventions can be conservative (such as splinting or stretching) or surgical. The review was first published in 2012 and we reviewed new searches in 2013 (update published 2014).

OBJECTIVES

To evaluate the effectiveness of interventions for CTEV.

SEARCH METHODS

On 29 April 2013, we searched CENTRAL (2013, Issue 3 in The Cochrane Library), MEDLINE (January 1966 to April 2013), EMBASE (January 1980 to April 2013), CINAHL Plus (January 1937 to April 2013), AMED (1985 to April 2013), and the Physiotherapy Evidence Database (PEDro to April 2013). We also searched for ongoing trials in the WHO International Clinical Trials Registry Platform (2006 to July 2013) and ClinicalTrials.gov (to November 2013). We checked the references of included studies. We searched NHSEED, DARE and HTA for information for inclusion in the Discussion.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs evaluating interventions for CTEV. Participants were people of all ages with CTEV of either one or both feet.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed risk of bias in included trials and extracted the data. We contacted authors of included trials for missing information. We collected adverse event information from trials when it was available.

MAIN RESULTS

We identified 14 trials in which there were 607 participants; one of the trials was newly included at this 2014 update. The use of different outcome measures prevented pooling of data for meta-analysis even when interventions and participants were comparable. All trials displayed bias in four or more areas. One trial reported on the primary outcome of function, though raw data were not available to be analysed. We were able to analyse data on foot alignment (Pirani score), a secondary outcome, from three trials. Two of the trials involved participants at initial presentation. One reported that the Ponseti technique significantly improved foot alignment compared to the Kite technique. After 10 weeks of serial casting, the average total Pirani score of the Ponseti group was 1.15 (95% confidence interval (CI) 0.98 to 1.32) lower than that of the Kite group. The second trial found the Ponseti technique to be superior to a traditional technique, with average total Pirani scores of the Ponseti participants 1.50 lower (95% CI 0.72 to 2.28) after serial casting and Achilles tenotomy. A trial in which the type of presentation was not reported found no difference between an accelerated Ponseti or standard Ponseti treatment. At the end of serial casting, the average total Pirani scores in the standard group were 0.31 lower (95% CI -0.40 to 1.02) than the accelerated group. Two trials in initial cases found relapse following Ponseti treatment was more likely to be corrected with further serial casting compared to the Kite groups which more often required major surgery (risk difference 25% and 50%). There is a lack of evidence for different plaster casting products, the addition of botulinum toxin A during the Ponseti technique, different types of major foot surgery, continuous passive motion treatment following major foot surgery, or treatment of relapsed or neglected cases of CTEV. Most trials did not report on adverse events. In trials evaluating serial casting techniques, adverse events included cast slippage (needing replacement), plaster sores (pressure areas) and skin irritation. Adverse events following surgical procedures included infection and the need for skin grafting.

AUTHORS' CONCLUSIONS

From the limited evidence available, the Ponseti technique produced significantly better short-term foot alignment compared to the Kite technique and compared to a traditional technique. The quality of this evidence was low to very low. An accelerated Ponseti technique may be as effective as a standard technique, according to moderate quality evidence. Relapse following the Kite technique more often led to major surgery compared to relapse following the Ponseti technique. We could draw no conclusions from other included trials because of the limited use of validated outcome measures and lack of available raw data. Future randomised controlled trials should address these issues.

Results of clubfoot management using the Ponseti method: do the details matter? A systematic review

BACKGROUND

Although the Ponseti method is accepted as the best choice for treatment of clubfoot, the treatment protocol is labor intensive and requires strict attention to details. Deviations in strict use of this method are likely responsible for the variations among centers in reported success rates.

QUESTIONS/PURPOSES

We wished to determine (1) to what degree the Ponseti method was followed in terms of manipulation, casting, and percutaneous Achilles tenotomy, (2) whether there was variation in the bracing type and protocol used for relapse prevention, and (3) if the same criteria were used to diagnose and manage clubfoot relapse.

METHODS

We conducted a systematic review of MEDLINE, EMBASE(TM), and the Cochrane Library. Studies were summarized according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement. Five hundred ninety-one records were identified with 409 remaining after deduplication, in which 278 irrelevant studies and 22 review articles were excluded. Of the remaining 109 papers, 19 met our inclusion criteria. All 19 articles were therapeutic studies of the Ponseti method.

RESULTS

The details of manipulation, casting, or percutaneous Achilles tenotomy of the Ponseti method were poorly described in 11 studies, whereas the main principles were not followed in three studies. In three studies, the brace type deviated significantly from that recommended, whereas in another three studies the bracing protocol in terms of hours of recommended use was not followed. Furthermore no unified criteria were used for judgment of compliance with brace use. The indication for recognition and management of relapse varied among studies and was different from the original description of the Ponseti method.

CONCLUSIONS

We found that the observed clinically important variation may have been the result of deviations from the details regarding manipulation, casting, percutaneous Achilles tenotomy, use of the bar-connected brace, and indication for relapse recognition and management recommended for the classic Ponseti approach to clubfoot management. We strongly recommend that clinicians follow the Ponseti method as it initially was described without deviation to optimize treatment outcomes.

Update on clubfoot

Congental talipes equinovarus, or clubfoot, remains one of the commonest congenital limb deformities. The genetics of this condition are not yet fully understood. It is increasingly being diagnosed on prenatal ultrasound with implications for prenatal counselling. With the widespread acceptance of the Ponseti method of clubfoot treatment major surgical interventions are needed much less frequently and long-term outcomes are improved.

[Clubfoot treatment through the ages: the Ponseti method in comparison to other conservative approaches and operative procedures]

Clubfoot is one of the most common congenital deformities of the musculoskeletal system with incidence rates ranging from 0.6 to 6.8 per 1,000 live births. The treatment of clubfoot historically belongs to one of the oldest orthopedic therapies. By the end of the nineteenth century redressement with various tools, such as clamps, braces and casts was the standard treatment of clubfoot. Through further development of operational capabilities and the fact that soft tissue structures show amore resistant reaction to pressure and strain than the surrounding cartilage and bone, operative therapy was favored in the late twentieth century. Surgical correction involves the release of contracted capsular and ligamentous structures to varying degrees and the lengthening of tendons.In 1963 Ponseti published his method. He recognized that the internal rotation and plantar flexion of the calcaneus is the key deformity. However, his method first became known worldwide at the turn of the millennium as long-term results of release operations showed stiff scar healing and the risk of over-correction as problems in these operations.Many comparative studies have shown the superiority of the Ponseti method regarding invasiveness, primary correction rate, functional outcome and recurrence rate in both idiopathic and non-idiopathic clubfoot. In this article the current literature regarding this will be presented as well as prominent landmarks in the development of clubfoot treatment.