Congenital Clubfoot: Early Recognition and Conservative Management for Preventing Late Disabilities

Application of pedobarographic analysis in neglected congenital clubfoot patients following Ponseti treatment for recurrence prediction

Background

Neglected congenital clubfoot (NCCF) is a birth deformity that remains untreated until the child begins to walk. Irrespective of the treatment protocols employed, children with NCCF face an elevated risk of recurrence following the initial correction. Predicting this recurrence could enable early intervention for high-risk children, ultimately diminishing the likelihood of invasive surgery.

Methods

From January 2006 to January 2022, a total of 33 unilateral NCCF patients were enrolled in this study at Xijing Hospital. Pedobarographic tests were performed at three distinct time points: after the initial Ponseti treatment, before recurrence treatment, and after recurrence treatment. Four derivative parameters were developed for predicting recurrence, namely the difference of the contact time% (DCT%), difference of the contact area% (DCA%), difference of the peak pressure (DPP), and difference of the pressure-time integral (DPTI) between the two feet. ROC curves, Kaplan-Meier survival analysis, and Cox regression were employed to identify potential prognostic factors.

Results

Out of the 33 unilateral NCCF patients, recurrence occurred in 8 individuals, with an average follow-up period of 109.8 months. The predictive parameter for recurrence is the midfoot (MF) zone's DCT% (MF-DCT%). When the contact time (CT)% of the affected side was 20.69% higher than that of the unaffected side, the hazard ratio (HR) of recurrence increased by 7.404 times. Another predictive plantar pressure parameter is the DPP in the MF zone (MF-DPP). If the PP of the affected side was 159% higher than that of the unaffected side, the HR of recurrence increased by 9.229 times. The MF-DCT% and MF-DPP of recurrence patients were assessed at three time points for comparisons, further validating their predictive ability for recurrence.

Conclusion

Although satisfactory clinical outcomes were achieved in patients with unilateral NCCF after the initial Ponseti treatment, the plantar pressure distribution does not return to normal levels, which may indicate future recurrence. DCT% and DPP in the MF zone can be used as plantar pressure predictors of recurrence in patients with NCCF.

Barriers and facilitators to lower extremity orthotic compliance in the pediatric population: A scoping review of the literature

Despite the purported benefits of lower extremity orthotics in the literature, pediatric compliance rates remain low. This scoping review synthesized the available literature regarding barriers and facilitators to lower extremity orthotic compliance in the pediatric population using the framework of the International Classification of Functioning, Disability and Health: Children and Youth (ICF). A comprehensive search of MEDLINE, EMBASE, and CINAHL was conducted on May 11, 2021, and of PsycInfo on May 12, 2021. Article reference lists and gray literature were also searched. A total of 81 articles were included. Factors described in at least four articles were labeled as universal barriers or facilitators. In the International Classification of Functioning, Disability and Health: Children and Youth domain of Body Functions/Body Structures, universal barriers were present in the global mental functions, experience of self and time, sensory functions, function of joints and bones, and structures related to the skin subcategories, with no universal facilitators identified. For the Activity Limitations/Participation Restrictions domain, one universal facilitator was identified in the mobility subcategory. In the Environmental Contextual Factors domain, universal barriers were found in the attitudes of immediate and extended family and societal attitude subcategories, with both universal barriers and facilitators found in support & relationships: immediate and extended family, support and relationships: health professionals, services, systems, and policies, and products and technology. The reviewed literature strongly emphasizes the importance of proper orthotic fit and comfort, and the child's experience of self, for lower extremity orthotic compliance, along with multiple environmental factors.

Results of Cross-Sectional Study of the Opinion from Parents of Children with Clubfoot on Medical Care via Ponseti Method in Outpatient Center of Surgery, Traumatology and Orthopedics

Background. Patients with clubfoot can have pain and functional disorders that lead to disability. Familiarity of obstetrician-gynecologists, general practitioners, surgeons with its early diagnosis and timely management may prevent disablement.

Objective. The aim of the study is to analyze the opinion from parents of children with clubfoot on medical care via Ponseti method in outpatient center of surgery, traumatology and orthopedics.

Methods. Cross-sectional study in the form of sociological survey (questionnaire) was carried out in N.F. Filatov Children’s City Hospital from March to December 2021 among parents of children with the following diagnoses: congenital bilateral clubfoot, congenital right clubfoot, congenital left clubfoot.

Results. Respondents rated the quality of provided medical care and its availability, the hospital stay conditions by 10.0 points on the scale from 0 to 10. Territorial accessibility of medical care was estimated by 9.0 (7.0; 10.0) points, 30 out of 99 respondents (30.3%) required improvement in territorial accessibility (7 points out of 10 and below). Only 36.4% (36 out of 99) of children were sent to N.F. Filatov Children’s City Hospital for treatment by doctor of out-patient clinic. Others learned about this variant from the Internet, from acquaintances, etc. 10 out of 15 (15.2%) children with disabilities included in the study had difficulties in learning socially necessary skills. None of 10 children who have been diagnosed antenatally had any difficulties in learning socially necessary skills or disabilities. Mean age of disability was 10.6 ± 7.3 months. Children with disease diagnosed since birth had difficulties in learning socially necessary skills in 7.1% (2 out of 28) cases, and in 13.3% (8 out of 60) cases if diagnosed after birth (p = 0.356). Disability did not affect conditions in which children received treatment (14.6% and 20.0% of children under outpatient and inpatient treatment, respectively, had disabilities; p = 0.646). 26.7% of children with disabilities and only 11.9% of children without disabilities received treatment in hospital before the treatment (p = 0.218). 5.9% of children treated on outpatient basis had difficulties with learning socially necessary skills. Children treated on inpatient basis had difficulties with learning socially necessary skills in 35.7% cases (p = 0.005). The choice of outpatient or inpatient treatment did not depend on the presence of spina bifida (p = 0.276), children age (2.1 (0.7; 3.6) months vs 3.65 (0.6; 4.975) months, respectively; p = 0.309).

Conclusion. Treatment can be delayed statistically significantly in case of late diagnosis, which is associated with the observed low awareness of doctors (working by the district principle) about specialized medical care. Ratio of children with disabilities and difficulties in learning socially necessary skills or disabilities is lower among patients with antenatal diagnosis. However, further studies are required for evaluation of these factors’ association.

An investigation of maternal psychological status of children with congenital talipes equinovarus treated with the Ponseti method

Objectives:

To investigate maternal psychological status of children with congenital talipes equinovarus in different periods, and to clarify the influence on maternal psychological status of congenital talipes equinovarus treated with the Ponseti method.

Methods:

Sixty-seven mothers of children with congenital talipes equinovarus were investigated. Self-rating Depression Scale and Self-rating Anxiety Scale were used to evaluate the psychological stress of the mothers at different periods. Paired-samples t-test was used to analyze the results.

Results:

The mothers of 67 children with congenital talipes equinovarus ranged from 25 to 38 years old, with an average of 33.5 years old. Before prenatal diagnosis of congenital talipes equinovarus, the average score of Self-rating Anxiety Scale was 42.537 ± 10.476, and the average score of Self-rating Depression Scale was 47.254 ± 12.846; after prenatal diagnosis of congenital talipes equinovarus, the average score of Self-rating Anxiety Scale was 54.224 ± 13.050, and the average score of Self-rating Depression Scale was 57.403 ± 13.649 points. Before the postpartum treatment of congenital talipes equinovarus, the average score of Self-rating Anxiety Scale was 53.388 ± 12.716, the average score of Self-rating Depression Scale was 56.284 ± 13.617; after the treatment of congenital talipes equinovarus with the Ponseti method, the average score of Self-rating Anxiety Scale was 47.731 ± 12.259, and the average score of Self-rating Depression Scale was 51.910 ± 13.878 points. The above differences were statistically significant (P < 0.001).

Conclusion:

The prenatal diagnosis of congenital talipes equinovarus will increase the maternal psychological stress, and the maternal psychological status will be significantly improved after the deformity of congenital talipes equinovarus is corrected effectively by the Ponseti method.

Level of evidence:

level III, retrospective study.

Anterior tibial tendon transfer in idiopathic clubfoot: does the outcome differ with the initial treatment? Proposed classification to surgical indication

PURPOSE

To establish parameters and propose a radiographic classification for foot adduction/supination deformities to assist the indication of Garceau procedure. Secondly, to investigate whether the outcome of Garceau surgery depends on the initial treatment used, peritalar release, or the Ponseti method, and verify the maintenance of correction until skeletal maturity.

METHODS

Prospective cohort study, with follow-up evaluations in 2009 and 2019. Fifty-three consecutive patients (71 feet) with idiopathic congenital clubfoot (ICCF) were divided into two groups according to the initial treatment used: peritalar release (group I) or Ponseti method (group II). All patients underwent Garceau procedure. The patients were evaluated clinically and radiographically using the American Orthopedic Foot Association (AOFAS) score for ankle and hindfoot. A radiographic classification is proposed based on the adduction by talo-first metatarsal angle on dorsoplantar view and supination by the elevation of the head of the first metatarsal on lateral view, both weight-bearing.

RESULTS

In the first clinical evaluation, the mean score on the AOFAS was 87 points in group I and 86 points in group II. In the second evaluation, group I had mean AOFAS of 92 points and group II of 94 points. No statistical differences were found between the two groups, neither between the first and the second evaluation. In the radiographic evaluation, the adduction deformity obtained an average correction of 4° in group I and 3.6° in group II; in supination deformity, the average depression of the first metatarsal head in relation to the ground was 6.7 mm in group I and 7.5 mm in group II, with no statistical difference between the two evaluations, indicating the correction was maintained until skeletal maturity.

CONCLUSION

Garceau transfer is capable of correcting residual deformities in adduction/supination of mild and moderate degrees, regardless of the initial treatment, and maintaining the correction until skeletal maturity. The proposed radiographic classification might help to objectively indicate the surgical procedure.

Finite element analysis of the kinematic coupling effect of the joints around talus when Ponseti manipulation

Background

Little information was obtained from the published papers about the kinematic coupling effect between tarsal bones during Ponseti manipulation. The aim was to explore the kinematic coupling effect of the joints around talus, to investigate the kinematic rhythm and coupling relationship of tarsal joints; to clarify the pulling effect on medial ligament of the ankle during the process of Ponseti manipulation.

Methods

The model of foot and ankle was reconstructed from the Chinese digital human girl No.1 (CDH-G1) image database. Finite element analysis was applied to explore the kinematic coupling effect of the joints around talus. The distal tibia and fibula bone and the head of talus were fixed in all six degrees of freedom; outward pressure was added to the first metatarsal head to simulate the Ponseti manipulation. Kinematic coupling of each tarsal joint was investigated using the method of whole model splitting, and medial ligament pulling of the ankle was studied by designing the model of medial ligament deletion during the Ponseti manipulation.

Results

All the tarsal joints produced significant displacement in kinematic coupling effect, and the talus itself produced great displacement in the joint of ankle. Quantitative analysis revealed that the maximum displacement was found in the joints of talonavicular (12.01mm), cuneonavicular (10.50mm), calcaneocuboid (7.97mm), and subtalar(6.99mm).The kinematic coupling rhythm between talus and navicular, talus and calcaneus, calcaneus and cuboid, navicular and cuneiform 1 were 1:12, 1:7, 1:2 and 1:1.6. The results of ligaments pulling showed that the maximum displacement was presented in the ligaments of tibionavicular (mean 27.99mm), talonavicular (21.03mm), and calcaneonavicular (19.18 mm).

Conclusions

All the tarsal joints around talus were involved in the process of Ponseti manipulation, and the strongest kinematic coupling effect was found in the joints of talonavicular, subtalar, calcaneocuboid, and cuneonavicular. The ligaments of tibionavicular, talonavicular, and calcaneonavicular were stretched greatly. It was suggested that the method of Ponseti management was a complex deformity correction processes involved all the tarsal joints. The present study contributed to better understanding the principle of Ponseti manipulation and the pathoanatomy of clubfoot. Also, the importance of cuneonavicular joint should be stressed in clinical practice.

Difficulties During Ponseti Casting for the Treatment of Idiopathic Clubfoot

The Ponseti method has resulted in excellent outcomes in the treatment of idiopathic clubfoot. To evaluate the process of serial casting, most studies previously used the number of casts required to achieve correction. In contrast, difficulties that occurred during serial casting were rarely studied. We reviewed 47 patients with severe idiopathic clubfoot (Dimeglio score ≥10) and a follow-up period of ≥4 years by focusing on difficulties during the Ponseti casting and their related factors. All events requiring temporary discontinuation and/or delay of scheduled casting were considered difficulties. Among the 47 patients, difficulties occurred in 18 patients (38.3%). Initial Dimeglio score (14.9 ± 2.5 [vs 13.5 ± 2.3, p = .042]), its subcomponent of equinus (3.8 ± 0.4 [vs 3.3 ± 0.6, p = .005]), and the number of casts (6.3 ± 2.0 [vs 4.9 ± 1.2, p = .009]) in the 18 patients with difficulties were greater than those of the remaining 29 patients. In addition, the foot length was shorter (7.2 ± 0.6 cm [vs 7.7 ± 0.8 cm, p = .030]) in patients with difficulties. In the regression analysis, both subcomponents of equinus and foot length showed the significance for the occurrence of difficulties. During 8.7 ± 3.8 years, further surgery was needed in 35 patients (74.5%) because of residual or recurrent deformity. The ratio was higher in patients with difficulties (94.4% [vs 62.1%, p = .017]). In our experience, difficulties frequently occurred in feet with rigid equinus and small length, and further surgery was required after the initial correction in almost all of the feet with difficulties.

Effect of Achilles tendon on kinematic coupling relationship between tarsal bones: a pilot finite element study

BACKGROUND

The procedure of percutaneous Achilles tenotomy (PAT) is an important component of the Ponseti method. However, few studies reported the influence of Achilles tendon on kinematic coupling relationship between tarsal bones. The purpose of present study was to demonstrate the effect of Achilles tendon on the kinematic coupling relationship between tarsal bones, and to illustrate how kinematic coupling relationship between tarsal bones works in term of finite element analysis.

METHODS

A three-dimensional finite element model of foot and ankle was constructed based on the Chinese digital human girl No.1 (CDH-G1) image database using the software of mimics, Geomagic studio, HyperMesh, and Abaqus. The last manipulation of the Ponseti method before the procedure of PAT was simulated. The talus head and the proximal tibia and fibula bone were fixed in all six degrees of freedom, and the outward pressure was added on the first metatarsal head to investigate the kinematic coupling relationship between tarsal bones.

RESULTS

The least relationship of kinematic coupling between tarsal bones was found in calcaneus. Stress concentration was mainly observed at the navicular, talus and the medial malleolus. The difference in displacement of the navicular was only found with the Achilles tendon stiffness of 0 N/mm and others. No difference in the navicular displacement was found in the stiffness of Achilles tendon between 40, 80, 200, 400, and 1000 N/mm. The maximum displacement of navicular was observed at the ankle position of PF-20° (plantar flexion-20°). The difference in displacement of the navicular was greater at the ankle position of PF-20° with the Achilles tendon stiffness of 0 N/mm than that at the ankle position of PF-40° with the Achilles tendon stiffness of 40 N/mm.

CONCLUSIONS

Based on the findings from this study, it was demonstrated that the Achilles tendon existence or not and ankle position had great influence, while increased stiffness of Achilles tendon had no influence on kinematic coupling relationship between tarsal bones. For the cases with severe equinus, earlier implementation of PAT procedure (with the purpose of release the Achilles tendon and reduce the degree of ankle plantar flexion) may be beneficial to the deformity correction.

Can Repeated Ponseti Management for Relapsed Clubfeet Produce the Outcome Comparable With the Case Without Relapse? A Clinical Study in Term of Gait Analysis

BACKGROUND

The prevention and treatment of relapsed clubfoot remained challenging tasks. There were controversies as to treatment options and management, such as complete subtalar release, application of an Ilizarov external frame, or repeated Ponseti method; and different options were available in different treatment centers. This study was designed to evaluate the clinical outcome of relapsed clubfeet treated by repeated Ponseti method in comparison with the cases without relapse in term of gait analysis and to clarify the clinical efficacy of repeated Ponseti method in treating the relapsed clubfeet.

METHODS

Thirty-seven patients (53 feet) were retrospectively identified from our database according to the inclusion and exclusion criteria. Among the 37 patients, 17 cases (25 relapsed clubfeet) were assigned to group I, whereas 20 cases (28 clubfeet without relapse) were assigned to group II. Clinical examination, gait analysis, and kinematic gait deviation criteria from Texas Scottish Rite Hospital for Children were used for evaluation.

RESULTS

There was statistically significant difference in the parameters of foot length, stride length, and single limb support time (%gait cycle) between the 2 groups (P<0.05). No statistically significant difference was found in the kinematic parameters of total hip, knee, and ankle excursion, peak knee and ankle flexion and extension, and internal foot progression (P>0.05). There was no statistically significant difference in peak hip, knee, and ankle flexion moment, peak knee valgus moment, and peak ankle power (P>0.05). No statistically significant difference was found in equinus and calcaneus gait, increased ankle dorsiflexion, foot drop, and internal foot progression angle (P>0.05).

CONCLUSIONS

Repeated Ponseti method for relapsed clubfeet can yield good or excellent clinical results. We recommend repeated Ponseti method as the treatment choice for relapsed clubfeet in the early stage.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

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.

Timing for Ponseti clubfoot management: does the age matter? 90 children (131 feet) with a mean follow-up of 5 years

Background and purpose - There are still controversies as to the age for beginning treatment with the Ponseti method. We evaluated the clinical outcome with different age at onset of Ponseti management for clubfoot. Patients and methods - 90 included children were divided into 3 groups in terms of age at start of treatment. The difference in treatment-related and prognosis-related variables including presentation age, initial Pirani and Dimeglio score, casts required, relapse rates, final Dimeglio score, and international clubfoot study group score (ICFSG) was analyzed. Results - Age between 28 days and 3 months at start of treatment method was associated with fewer casts required, lower relapse rate, and lower final ICFSG score (p < 0.05). Early treatment before 28 days of age required more casts and had a higher relapse rate (p < 0.05). The highest ICFSG scores were found in the ages between 3 and 6 months (p < 0.05). After propensity score matching, age between 28 days and 3 months was demonstrated to have a lower finial ICFSG score. Linear regression models showed that presentation age was positively correlated with final ICFSG score, and was identified as the only independent prognostic risk factor. Interpretation - There was lower rate of relapse and better clinical outcome when treatment was initiated at age between 28 days and 3 months. With the Ponseti method, clubfeet may not need urgent treatment.

The Correlation of Pirani and Dimeglio Scoring Systems for Ponseti Management at Different Levels of Deformity Severity

The Pirani and Dimeglio scoring systems both have excellent inter-observer and intra-observer reliability, but no research has been conducted to determine their inter-observer reliability and their relationship at different levels of deformity. A total of 173 idiopathic clubfoot cases were reviewed using Pirani and Dimeglio scoring systems, and the number of casts needed was also recorded. For clubfeet with a cast number equal to 2 or 7 and 8, the inter-observer reliability of the two scoring systems was poor or moderate, and there was no correlation between the two scoring systems. There was also no correlation between the Dimeglio scoring score with the number of casts for grade II or IV clubfeet. A binary regression of the number of casts on initial Pirani or Dimeglio scores showed that there was a Quadratic or Cubic relation between the scores and the cast numbers. In conclusion, in the case of mild and very severe clubfoot deformity, the interobserver reliability and its ability to predict the number of casts needed for clubfoot deformity correction was poor. A more objective evaluation system may be required.

Filamin B: The next hotspot in skeletal research?

Filamin B (FLNB) is a large dimeric actin-binding protein which crosslinks actin cytoskeleton filaments into a dynamic structure. Up to present, pathogenic mutations in FLNB are solely found to cause skeletal deformities, indicating the important role of FLNB in skeletal development. FLNB-related disorders are classified as spondylocarpotarsal synostosis (SCT), Larsen syndrome (LS), atelosteogenesis (AO), boomerang dysplasia (BD), and isolated congenital talipes equinovarus, presenting with scoliosis, short-limbed dwarfism, clubfoot, joint dislocation and other unique skeletal abnormalities. Several mechanisms of FLNB mutations causing skeletal malformations have been proposed, including delay of ossification in long bone growth plate, reduction of bone mineral density (BMD), dysregulation of muscle differentiation, ossification of intervertebral disc (IVD), disturbance of proliferation, differentiation and apoptosis in chondrocytes, impairment of angiogenesis, and hypomotility of osteoblast, chondrocyte and fibroblast. Interventions on FLNB-related diseases require prenatal surveillance by sonography, gene testing in high-risk carriers, and proper orthosis or orthopedic surgeries to correct malformations including scoliosis, cervical spine instability, large joint dislocation, and clubfoot. Gene and cell therapies for FLNB-related diseases are also promising but require further studies.

Comparison of different conservative treatments for idiopathic clubfoot: Ponseti's versus non-Ponseti's methods

Objective

Various methods are applied in the clinical treatment of idiopathic clubfoot. The purpose of this meta-analysis was to evaluate the efficacy of different conservative treatments.

Methods

Studies were pooled and odds ratio (ORs) with corresponding confidence intervals were calculated for evaluation of the results, relapses, and requirement for major surgery.

Results

A final analysis of 1435 patients from 9 eligible studies was performed. The combined OR indicated that significantly more fair and poor results were achieved and that major surgery was required significantly more often when using non-Ponseti’s methods (OR = 3.33 and OR = 7.32, respectively), but no significant difference was detected in the occurrence of relapse (OR = 1.34). Pooled OR evaluation showed a significantly higher rate of fair and poor results, relapse, and requirement for major surgery when using Kite’s method than when using Ponseti’s method (OR = 3.93, OR = 2.53, and OR = 3.19, respectively), but no significant difference was detected between the French method and Ponseti’s method (OR = 3.01, OR = 0.72, and OR = 1.26, respectively).

Conclusions

This meta-analysis indicates that Ponseti’s method is safe and efficient for conservative treatment of clubfoot and decreases the number of surgical interventions required. It is recommended as the first-choice conservative treatment for idiopathic clubfoot.