Can selective soft tissue release and cuboid osteotomy correct neglected clubfoot?

Can Below-Knee Casts be Effective for Clubfoot Management in Walking-Age Children? A Prospective Cohort Study

Purpose

Above-knee casts pose a major challenge in the day-to-day activities among walking age clubfoot patients due to complete restriction of knee movement. This current study investigates the effectiveness of below-knee casts compared to above-knee casts for managing walking age clubfoot deformity.

Methods

After approval from the institutional ethical committee, we enrolled walking age clubfoot patients for deformity correction through corrective manipulation and casting through below-knee casts over 2 years. The corrective manipulation was performed using the Ponseti technique. The patients were followed for a minimum of 2 years period. To compare the effectiveness of below-knee casts over above-knee casts, we enrolled equal numbers of walking age clubfeet matched for age and gender. We compared the two groups in terms of initial and post-correction Dimeglio scores, individual deformities corrections (maximum ankle dorsiflexion, heel varus correction, foot abduction), failure rates, relapses, and complication rates.

Results

56 patients with 80 clubfeet with a mean follow-up of 39.98 months were considered for the final analysis. There were 29 patients in the below-knee cast group and 27 in the above-knee cast group, with 40 clubfeet each. The patients in the above-knee casting group had significantly better post-correction Dimeglio scores and individual deformity components corrections than the below-knee cast group. There were nil failures in the above-knee casting group and 7.5% in the below-knee cast group. The relapse rate was 15% in both groups, with none requiring any extensive soft tissue procedure. We did not encounter any major complications during the treatment and follow-up.

Conclusion

The deformity correction and maintenance are suboptimal with the below-knee casts. Therefore, above-knee casts should be the preferred management modality for correction of walking age clubfoot deformities.

Evaluation of a surgical treatment algorithm for neglected clubfoot in low-resource settings

Purpose

Idiopathic clubfoot affects approximately 1/1000 alive-born infants, of whom 80–91% are born in low- or middle-income countries (LMICs). This retrospective study aimed to evaluate the morphological, functional, and social outcomes in patients with neglected clubfoot in rural Bangladesh, after receiving surgical treatment.

Methods

Patients received a posteromedial release (PMR) with or without an additional soft tissue intervention (group 1), a PMR with an additional bony intervention (group 2), or a triple arthrodesis (group 3) according to our surgical algorithm. Patients were followed until two year post-intervention. Evaluation was done using a modified International Clubfoot Study Group Outcome evaluation score and the Laaveg-Ponseti score.

Results

Twenty-two patients with 32 neglected clubfeet (ages 2–24 years) received surgical treatment. Nineteen patients with 29 clubfeet attended follow-up. At two year follow-up an excellent, good, or fair Laaveg-Ponseti score was obtained in 81% (group 1), 80% (group 2), and 0% (group 3) of the patients (p value 0.0038). Age at intervention is inversely correlated with the Laaveg-Ponseti score at two year follow-up (p < 0.0001). All patients attended school or work and were able to wear normal shoes.

Conclusion

Our treatment algorithm is in line with other surgical algorithms used in LMICs. Our data reconfirms that excellent results can be obtained with a PMR regardless of age. Our algorithm follows a pragmatic approach that takes into account the reality on the ground in many LMICs. Good functional outcomes can be achieved with PMR for neglected clubfoot. Further research is needed to investigate the possible role of triple arthrodesis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00264-021-05058-6.

Ponseti Method After Walking Age - A Multi-Centric Study of 429 Feet: Results, Possible Treatment Modifications and Outcomes According to Age Groups

OBJECTIVE

Ponseti method is suitable to treat neglected clubfoot after the walking age. However, limited evidence exists on its effectiveness, outcomes and rate of relapse. Methods: 429 clubfeet in 303 patients with no previous treatment and older than one-year were treated with the Ponseti method in 15 centers from seven countries. The median age at treatment onset was three years, and the median follow-up of 1.3 years. Standard Ponseti Method was applied. Bilateral abduction brace was recommended after casting. Patients were classified according to group ages (<2 years, 2-4 years, >4-8years, >8 years). Feet were evaluated by Pirani score and a clinical outcome classification. Relapses were described in a subset of 103 clubfeet with minimal follow-up of two years.

RESULTS

Ponseti method was able to correct the deformity in 87% (373 of 429) of neglected clubfeet, after a mean of 6.8 casts. Residual equinus was treated with percutaneous sectioning of the Achilles tendon in 356 (83%) of 429 clubfeet. A bilateral foot abduction brace was prescribed and used in 70% of children. Relapses occurred in 31% (32 of 103) of clubfeet and were associated with age less than 4 years at treatment onset, and bracing noncompliance.

CONCLUSION

The Ponseti method is effective to correct neglected clubfeet. Relapses occurred in one-third of clubfeet, mainly in children younger than four years and in noncompliance with the brace. Our study reinforces the recommendation for the Ponseti method with no major modification to treat neglected clubfoot in patients after walking age.Level of Evidence: IV.

An Analysis of the Mechanical Properties of the Ponseti Method in Clubfoot Treatment

Congenital clubfoot is a complex pediatric foot deformity, occurring in approximately 1 in 1000 live births and resulting in significant disability, deformity, and pain if left untreated. The Ponseti method of manipulation is widely recognized as the gold standard treatment for congenital clubfoot; however, its mechanical aspects have not yet been fully explored. During the multiple manipulation-casting cycles, the tendons and ligaments on the medial and posterior aspect of the foot and ankle, which are identified as the rate-limiting tissues, usually undergo weekly sequential stretches, with a plaster of Paris cast applied after the stretch to maintain the length gained. This triggers extracellular matrix remodeling and tissue growth, but due to the viscoelastic properties of tendons and ligaments, the initial strain size, rate, and loading history will affect the relaxation behavior and mechanical strength of the tissue. To increase the efficiency of the Ponseti treatment, we discuss the theoretical possibilities of decreasing the size of the strain step and interval of casting and/or increasing the overall number of casts. This modification may provide more tensile stimuli, allow more time for remodeling, and preserve the mechanical integrity of the soft tissues.

Pedobarographic Analysis following Ponseti Treatment for Unilateral Neglected Congenital Clubfoot

Recent trends have led to an interest in Ponseti treatment for correcting neglected congenital clubfoot. Although good clinical and functional outcomes have been reported, the plantar pressure distribution after the treatment of neglected clubfoot has not been explored yet. The present study aimed to investigate whether plantar pressures normalized following Ponseti treatment in patients with neglected congenital clubfoot. Pedobarographic, clinical, and functional examinations were performed in 22 children (aged, 91.0 ± 40.3 months) with unilateral neglected congenital clubfeet, treated using Ponseti method at 27.8 ± 12.1 months of age. Plantar pressure parameters were recorded using a Footscan pressure plate. The contact time, contact area, peak pressure, and pressure-time integral were determined. The data of the affected feet were compared with those of the unaffected feet and healthy controls. Although clinical and functional examinations showed satisfactory results according to the Dimeglio and Pirani scores, considerable differences in plantar pressure parameters were identified among the affected feet, unaffected feet, and healthy controls. Internal foot progression angle and a load transfer from the medial forefoot and hindfoot to the lateral forefoot and midfoot were observed in the affected feet. Future studies should attempt to investigate the factors accounting for plantar pressure deviations and the possible effect of these deviations on the lower limb musculoskeletal development of children.

What is new in idiopathic clubfoot?

Idiopathic clubfoot has a tremendous worldwide prevalence. If left untreated, the deformity has severely disabling effects on mobility and quality of life. Given its prevalence and significance, numerous studies are published on this condition every year. In this article, we attempt to highlight important themes and findings of studies published on idiopathic clubfoot over the past 3 years.

Surgical treatment of neglected clubfoot using external fixator

The definition of neglected clubfoot (NC) includes a variable range of complex deformities of the foot that are refractory to conventional treatments or are treated inappropriately. Several etiologies may be related to this. The Ilizarov method has become established as a tool for treating these deformities. It minimizes soft-tissue damage through gradual correction of the deformity, with a high success rate in relation to achieving a plantigrade foot, with low incidence of recurrence. The indications for treatment include severe rigid deformities (Dimeglio III and IV), or adverse skin conditions. Careful clinical and radiological examination is fundamental for proper planning and installation of the external fixator. The techniques used include selection of external fixation assemblies, which can be closed when there is a connection between the leg, hindfoot and forefoot. This closed assembly may or may not be constricted, according to whether hinges are provided or whether use of the natural anatomical hinges during correction of the deformity is envisaged. An open assembly makes it possible to add flexibility to the foot through histogenesis, while allowing closed corrections of greater precision later on. Hexapod fixators are an innovation with high potential for accuracy in correcting deformities. Procedures associated with external fixation include soft-tissue release and bone procedures. These procedures enable corrections that are more anatomical, for different degrees of severity and stiffness of deformity. It can be concluded from analyzing this case series that treatment of neglected clubfoot using an external fixator has a high rate of good and excellent results, with low frequency of complications.

Surgical treatment of neglected congenital idiopathic talipes equinovarus after walking age in Eritrea: an Italo-Eritrean cooperation

An Italian team of orthopaedic surgeons joined Eritrean colleagues to perform a clinical study in ambulating children affected by neglected idiopathic congenital talipes equinovarus (clubfoot). This study reports the surgical strategy as well as clinical outcomes, early complications and relapse at a mid-term follow-up. Four expeditions of 7 days were organized between 2012 and 2015 from Italy to the Halibet Hospital of Asmara in Eritrea. In each expedition were included two experienced surgeons, two assistants and one anaesthesiologist. During these expeditions, a total of 468 patients were evaluated together with Eritrean colleagues and 45 cases of neglected talipes equinovarus in ambulating children were diagnosed and selected for surgery. Follow-up range was 1-3 years. During the four expeditions, the Eritrean team of orthopaedic surgeons learned to manage most cases of neglected talipes equinovarus. No major complications were reported. Sixteen feet were considered excellent, 25 good and four poor. No overcorrections were observed. Neglected congenital talipes equinovarus is the result of delayed treatment of congenital deformity in developing countries, and its treatment often requires extensive surgery. Collaboration with foreign expert surgeons may help local doctors to learn how to treat this disease. The current study demonstrates that surgical expeditions in developing countries, when organized in collaboration with local doctors, help to manage on site this severe deformity.

Congenital idiopathic talipes equinovarus before and after walking age: observations and strategy of treatment from a series of 88 cases

BACKGROUND

We reviewed a series of newborns, toddlers and ambulating children affected by idiopathic congenital talipes equinovarus (clubfoot). Taking into account the time of diagnosis, stiffness of the deformity and walking age, nonsurgical or surgical treatment was considered. This study reports clinical outcomes, early complications and relapse at mid-term follow-up.

MATERIALS AND METHODS

Fifty-two clubfeet were diagnosed at birth, 12 in non-ambulating children aged between 4 and 12 months and 24 in ambulating children. Feet were classified using the Pirani score. Newborns and toddlers were treated with serial casting (Ponseti); however, toddlers also underwent open Achilles tendon lengthening (2 feet) and posteromedial release (3 feet). In all ambulating children, surgical treatment was always performed: selective medial release combined with cuboid subtraction osteotomy (1 foot), posteromedial release (6 feet), and posteromedial release combined with cuboid subtraction osteotomy (17 feet).

RESULTS

The average follow-up was 5 years (1-6 years). In newborns treated with Ponseti, the results were excellent in 42 feet, good in 6, and poor in 4. In non-ambulating children, the results were excellent in 9 feet, and good in 3. In ambulating children, the results were excellent in 5 feet, good in 16, and poor in 3. No major complications were reported. No overcorrections were observed. The need for open surgery was higher in cases of delayed treatment. In cases of relapse, re-casting and/or more extensive surgery was considered.

CONCLUSIONS

Early treatment enables a high rate of good correction to be obtained with serial casting and limited surgery. Conversely, if the deformity is observed after walking age surgery should be considered. Serial casting in cases of late observation and relapse have demonstrated encouraging results.

LEVEL OF EVIDENCE

IV.