The adult sequelae of treated congenital clubfoot

The perspectives of caregivers and health service providers on barriers to clubfoot management in Puri-Urban health facility in Ghana

Purpose

Clubfoot is a common disabling condition that is prevalent across all populations. Approximately, one out of 750 children globally suffers from clubfoot, and around 150,000 to 200,000 children are born with clubfoot every year with 80% of the cases occurring in developing countries. Clubfoot can result in mobility impairments when not properly managed and researchers have argued that understanding knowledge and perceptions are key components to early identification and effective management of clubfoot. The study explored the barriers to clubfoot management from the perspectives of caregivers and healthcare providers in Duayaw Nkwanta, Ghana.

Methods

A total of 26 participants made up of 22 caregivers of children with clubfoot and six healthcare providers were purposively sampled for the study guided by a set of inclusion and exclusion criteria. Qualitative data were collected using a semi-structured interview guide through in-depth face-to-face interviews. Interviews were transcribed and analyzed thematically and presented as findings.

Results

High cost of treatment, long travel distance, long hours spent at the treatment facility, non-availability of clubfoot treatment services, late reporting of clients for treatment, and non-compliance of parents/caregivers with treatment protocols were identified as the barriers to effective management of clubfoot.

Conclusion

These findings have substantial implications for current interventions to effectively manage clubfoot in Ghana.

Talar neck rotation angle in adults with clubfoot deformity: Observed values and intra- and inter-observer reliability using weightbearing CT

INTRODUCTION

Adults presenting with symptomatic clubfoot represent a challenging cohort of patients. An appreciation of the location and degree of deformities is essential for management. Talar anatomy is often abnormal with varus within the talar neck, however, there are few reproducible methods which quantify talar neck deformity in adults. We describe a technique of assessing talar neck deformity, and report on observed values and intra- / inter-observer reliability.

METHODS

This was a single-centre, retrospective study including 96 feet from 56 adult patients with clubfeet (82 feet had clubfoot deformity, 14 were normal). Mean age was 34.3 ± 16.9 years and 31 (55.3%) were male. Weight-bearing CT scans captured as part of routine clinical care were analysed. Image reformats were oriented parallel to the long axis of the talus in the sagittal plane. In the corresponding axial plane two lines were drawn (on separate slices): 1) a line perpendicular to the intermalleolar axis, 2) a line connecting the midpoints of the talar head and narrowest part of the talar neck. The talar neck rotation angle (TNR angle) was the angle formed between these lines. Intraclass correlation coefficients (ICC) were performed for intra- and inter-observer reliability.

RESULTS

Mean TNR angle in clubfeet was 27.6 ± 12.2 degrees (95%CI = 25.0 to 30.2 degrees). Mean TNR angle in normal feet was 18.7 ± 5.1 degrees (95%CI = 16.0 to 21.4 degrees) (p < 0.001). The ICC for clubfeet was 0.944 (95%CI = 0.913 to 0.964) for intra-observer agreement, and 0.896 (95%CI = 0.837 to 0.932) for inter-observer agreement.

CONCLUSION

This measurement technique demonstrated excellent intra- and inter-observer agreement. It also demonstrated that compared to normal feet, clubfeet had about 9 degrees of increased varus angulation of the talar neck. This technique and data may be used for future research into clubfoot deformity and in planning treatment.

LEVEL OF CLINICAL EVIDENCE

3.

Biomechanical application of finite elements in the orthopedics of stiff clubfoot

BACKGROUND

The purpose of this study was to evaluate the effect of varying the different correction angles of hindfoot osteotomy orthosis on the biomechanical changes of the adjacent joints after triple arthrodesis in adult patients with stiff clubfoot to determine the optimal hindfoot correction angle and provide a biomechanical basis for the correction of hindfoot deformity in patients with stiff clubfoot.

METHODS

A 26-year-old male patient with a stiff left clubfoot was selected for the study, and his ankle and foot were scanned using dual-source computed tomography. A three-dimensional finite element model of the ankle was established, and after the validity of the model was verified by plantar pressure experiments, triple arthrodesis was simulated to analyze the biomechanical changes of the adjacent joints under the same load with "3°" of posterior varus, "0°" of a neutral position and "3°, 6°, 9°" of valgus as the correction angles.

RESULTS

The peak plantar pressure calculated by the finite element model of the clubfoot was in good agreement with the actual plantar pressure measurements, with an error of less than 1%. In triple arthrodesis, the peak von Mises stress in the adjacent articular cartilage was significantly different and less than the preoperative stress when the corrected angle of the hindfoot was valgus "6°". In comparison, the peak von Mises stress in the adjacent articular cartilage was not significantly different in varus "3°", neutral "0°", valgus "3°" and valgus "9°" compared with the preoperative stress.

CONCLUSION

The results of this study showed that different angles of hindfoot correction in triple arthrodesis did not increase the peak von Mises stress in the adjacent joints, which may not lead to the development of arthritis in the adjacent joint, and a hindfoot correction angle of "6°" of valgus significantly reduced the peak von Mises stress in the adjacent joints after triple arthrodesis.

Symmetry of Shoe Size and Calf Girth in Children With Treated Idiopathic Clubfoot: A Longitudinal Study

BACKGROUND

Treatments for idiopathic clubfoot focus on obtaining a functional foot, typical gait pattern, and activity participation. Patients and families are also concerned about practical considerations regarding shoe wear and the appearance of the calf. The purpose of this study was to quantify whether children treated for idiopathic clubfoot have symmetry differences in shoe size and calf girth when presenting with unilateral versus bilateral involvement.

METHODS

Participants with a diagnosis of idiopathic clubfoot (treated with Ponseti or French functional methods) were prospectively recruited along with children who are typically developing. Shoe size and calf girth were measured at 5, 7, and 10 years of age.

RESULTS

Sixty-five participants, 45 with a diagnosis of idiopathic clubfoot (26 unilateral and 19 bilateral) and 20 who were typically developing, began the study at age 5. Children with clubfoot treated with the Ponseti versus French methods showed no differences in shoe size asymmetry, calf girth asymmetry, or absolute calf girth at age 5. Participants with unilateral clubfoot demonstrated an average of 1.5 size smaller shoes for the involved side at all 3 ages. Participants with bilateral clubfeet had a significantly smaller, <0.75 size difference between both feet. Participants with unilateral clubfoot demonstrated about a 2 cm smaller calf girth on the involved side compared with the uninvolved side at all 3 ages. Participants with bilateral clubfeet had a smaller, <0.5 cm calf difference between sides. Calf girths for involved limbs were significantly smaller than for uninvolved limbs.

CONCLUSIONS

Children with unilateral clubfeet can expect to need a smaller shoe on their involved side. Children with bilateral clubfeet can expect a minimal shoe size discrepancy between limbs. All limbs with clubfoot involvement can expect to have a smaller calf girth than limbs that are typically developing.

LEVEL OF EVIDENCE

Level II. This is considered a prognostic study-investigating the effect of a treated clubfoot on shoe size and calf girth. This is a lesser-quality prospective study in which <80% of persons completed follow-up.

Surgical Management of the Undercorrected and Overcorrected Severe Club Foot Deformity

Managing complications of clubfoot deformities can be very challenging. Some patients present with recurrent clubfoot and residual symptoms, and some present with overcorrection leading to a severe complex flatfoot deformity. Both can lead to long-term degenerative changes of the foot and ankle joints owing to deformity caused by unbalanced loading. This article only focuses on severe complications caused by recurrence and overcorrection in both children and adult patients.

Cavovarus With a Twist: Midfoot Coronal and Axial Plane Rotational Deformity in Charcot-Marie-Tooth Disease

BACKGROUND

The cavovarus deformity of Charcot-Marie-Tooth (CMT) disease is often characterized by a paradoxical relationship of hindfoot varus and forefoot valgus. The configuration of the midfoot, which links these deformities, is poorly understood. Accurate assessment of 3-dimensional alignment under physiologic loadbearing conditions is possible using weightbearing computed tomography (WBCT). This is the first study to examine the rotational deformity in the midfoot of CMT patients and, thus, provide key insights to successful correction of CMT cavovarus foot.

METHODS

A total of 27 WBCT scans from 21 CMT patients were compared to control WBCTs from 20 healthy unmatched adults. CMT patients with a history of bony surgery, severe degenerative joint disease, or open physes in the foot were excluded. Scans were analyzed using 3-dimensional software. Anatomic alignment of the tarsal bones was calculated relative to the anterior-posterior axis of the tibial plafond in the axial plane, and weightbearing surface in the coronal plane.

RESULTS

Maximal rotational deformity in CMT patients occurred at the transverse tarsal joints, averaging 61 degrees of external rotation (supination), compared to 34 degrees among controls (P < .01). The talonavicular joint was also the site of peak adduction deformity in the midfoot, with an average talonavicular coverage angle measuring 12 degrees compared with -11 degrees in controls (P < .01).

CONCLUSION

This 3-dimensional WBCT analysis is the first to isolate and quantify the multiplanar rotational deformity in the midfoot of CMT patients. Compared with healthy unmatched control cases, CMT patients demonstrated increased axial plane adduction and coronal plane rotation at the talonavicular (TN) joint. These findings support performing soft tissue release at the TN joint to abduct and derotate the midfoot as a first step for targeted deformity correction.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Jones Fracture: A Late Sequelae of Undercorrected or Recurrent Congenital Talipes Equinovarus: A Report of 2 Cases

CASE

We present 2 cases in which patients previously treated for congenital talipes equinovarus (CTEV) presented with residual cavovarus deformity and lateral foot pain and were found to have Jones fractures. Both patients were indicated for surgical correction of their residual cavovarus deformity, although neither elected to proceed. These 2 patients were treated conservatively for their fractures with cast immobilization. At the final follow-up, both were clinically and radiographically healed.

CONCLUSION

Residual cavovarus foot deformities after the treatment of CTEV are at risk for proximal fifth metatarsal or Jones fractures. Although conservative management may lead to healing of these fractures, the underlying stresses persist after conservative management increasing the risk for recurrent fracture. Correction of the residual deformity should be the main goal.

The Novel Application of Three-Dimensional Printing Assisted Patient-Specific Instrument Osteotomy Guide in the Precise Osteotomy of Adult Talipes Equinovarus

Objective

This current research is aimed at assessing clinical efficacy and prognosis of three-dimensional (3D) printing assisted patient-specific instrument (PSI) osteotomy guide in precise osteotomy of adult talipes equinovarus (ATE).

Methods

We included a total of 27 patients of ATE malformation (including 12 males and 15 females) from June 2014 to June 2018 in the current research. The patients were divided into the routine group (n = 12) and 3D printing group (n = 15) based on different operative methods. The parameters, including the operative time, intraoperative blood loss, complications, time to obtain bony fusion, functional outcomes based on American Orthopedic Foot and Ankle Society (AOFAS), and International Congenital Clubfoot Study group (ICFSG) scoring systems between the two groups were observed and recorded regularly.

Results

The 3D printing group exhibits superiorities in shorter operative time, less intraoperative blood loss, higher rate of excellent, and good outcomes presented by ICFSG score at last follow-up (P < 0.001, P < 0.001, P = 0.019) than the routine group. However, there was no significant difference exhibited in the AOFAS score at the last follow-up and total rate of complications between the two groups (P = 0.136, P = 0.291).

Conclusion

Operation assisted by 3D printing PSI osteotomy guide for correcting the ATE malformation is novel and feasible, which might be an effective method to polish up the precise osteotomy of ATE malformation and enhance the clinical efficacy.

Late Effects of Clubfoot Deformity in Adolescent and Young Adult Patients Whose Initial Treatment Was an Extensive Soft-tissue Release: Topic Review and Clinical Case Series

Children with congenital clubfoot often have residual deformity, pain, and limited function in adolescence and young adulthood. These patients represent a heterogeneous group that often requires an individualized management strategy. This article reviews the available literature on this topic while proposing a descriptive classification system based on a review of patients at our institution who underwent surgery for problems related to previous clubfoot deformity during the period between January 1999 and January 2012. Seventy-two patients (93 feet) underwent surgical treatment for the late effects of clubfoot deformity at an average age of 13 years (range 9 to 19 years). All patients had been treated at a young age with serial casting, and most had at least one previous surgery on the affected foot or feet. Five common patterns of pathology identified were as follows: undercorrection, overcorrection, dorsal bunion, anterior ankle impingement, and lateral hindfoot impingement. Management pathways for each group of the presenting problems is described. To our knowledge, this topic review represents the largest report of adolescent and young adult patients with residual clubfoot deformity in the literature.

Arthrodesis of the Foot or Ankle in Adult Patients with Congenital Clubfoot

Background

Although clubfoot that was corrected in childhood rarely recurs in adulthood, persistent deformities or arthritic pain may require further treatment during adulthood. Little evidence exists on the operative procedures utilized in adult clubfoot patients, who were previously treated for congenital clubfoot in childhood, for residual or recurrent deformity or pain.

Objective

The objective of this study is to characterize the types and frequencies of procedures utilized in adult clubfoot patients, who were previously treated for congenital clubfoot in childhood.

Methods

A two-pronged approach was employed to describe the operative procedures used in adult clubfoot patients. First, a literature review of all reported cases of operative treatment in adult clubfoot patients who were previously treated in childhood was performed. Second, an analysis of the operative treatments used in adult patients with a diagnosis of congenital clubfoot was conducted using a large, administrative claims database.

Results

In the literature review, arthrodesis was the most cited operative treatment and reported in four out of the eight studies included. Osteotomies were also reported in the literature. In the database analysis, 94 hindfoot arthrodesis procedures were identified in 73 patients, out of 1,198 adult patients in the database with a diagnosis of congenital clubfoot. Sixty-two patients out of 1,198 adult clubfoot patients received osteotomies. An insufficient number of total ankle arthroplasties were reported for further analysis.

Conclusions

Operative treatment in adult clubfoot patients who were treated for congenital clubfoot in childhood includes hindfoot arthrodesis and osteotomy procedures. Total ankle arthroplasty has not been reported in the literature for these patients.

Trimorphic extreme clubfoot deformities and their management by triple surgical skin expanders- DOLAR, DOLARZ and DOLARZ-E (evidence based mega-corrections without arthrodesis)

AIM/PURPOSE

Extreme congenital club foot deformities are common in developing countries, presenting at birth, persisting in children, adolescents and adults; as untreated/under-corrected by conservative and/or surgical means. Scores of confusing names exist in literature for such deformities with no good treatment available; mostly advocating unacceptable arthrodesis. The author researched this grey area for more than 40 years and successfully innovated improved surgical corrections, more acceptable to patients.

METHODS

All were given a generic name: "extreme deformities", with 3 hierarchic grades. each 3D (trimorphic) because of their common aim: a good correction. The author started with anatomical dissections in clubfeet (zero cost), consistently reinforced with solid clinical background. Heterogeneous skin contractures, congenital with/without scars, were discovered as the primary cause with cramped deeper tissues and evolved, evidence based, 3D enlargement of skin chamber by triple expanding incisions: DOrso-LAteral Rotation skin flap (DOLAR- acronym) for grade I, DOLAR + Z-plasty (DOLARZ) for grade II and DOLAR + Z + VY-plasty (DOLARZ-E) for grade III, E means Extended. Patient satisfaction level (excellent, good, fair/poor) had been considered for grading results, rather than scoring systems because each clubfoot is different with countless variables.

RESULTS & CONCLUSIONS

The author operated 1080 feet during the last 40 years with long term follow up, six months to 30 years, with an average of 12½ years. The results obtained were: excellent/good (96%) and fair/poor (4% including superficial skin necrosis only in 3%, evidence based). Triple surgical skin expansion consistently resulted in longer, flexible, joints sparing, good shaped, better functioning foot; even in adults.

The 2017 ABJS Nicolas Andry Award: Advancing Personalized Medicine for Clubfoot Through Translational Research

BACKGROUND

Clubfoot is one of the most common pediatric orthopaedic disorders. While the Ponseti method has revolutionized clubfoot treatment, it is not effective for all patients. When the Ponseti method does not correct the foot, patients are at risk for lifelong disability and may require more-extensive surgery.

QUESTIONS/PURPOSES

(1) What genetic and morphologic abnormalities contribute to the development of clubfoot? (2) How can this information be used to devise personalized treatment paradigms for patients with clubfoot?

METHODS

Human gene sequencing, molecular genetic engineering of mouse models of clubfoot, MRI of clubfoot, and development of new treatment methods all have been used by our group to understand the biological basis and improve therapy for this group of disorders.

RESULTS

We gained new insight into clubfoot pathogenesis from our discovery that mutations in the PITX1-TBX4-HOXC transcriptional pathway cause familial clubfoot and vertical talus in a small number of families, with the unique lower limb expression of these genes providing an explanation for the lack of upper extremity involvement in these disorders. MRI studies revealed corresponding morphologic abnormalities, including hypomorphic muscle, bone, and vasculature, that are not only associated with these gene mutations, but also are biomarkers for treatment-resistant clubfoot.

CONCLUSIONS

Based on an understanding of the underlying biology, we improved treatment methods for neglected and syndromic clubfoot, developed new treatment for congenital vertical talus based on the principles of the Ponseti method, and designed a new dynamic clubfoot brace to improve strength and compliance.

Soft-Tissue Abnormalities Associated with Treatment-Resistant and Treatment-Responsive Clubfoot: Findings of MRI Analysis

BACKGROUND

Clubfoot treatment commonly fails and often results in impaired quality of life. An understanding of the soft-tissue abnormalities associated with both treatment-responsive and treatment-resistant clubfoot is important to improving the diagnosis of clubfoot, the prognosis for patients, and treatment.

METHODS

Twenty patients with clubfoot treated with the Ponseti method were recruited for magnetic resonance imaging (MRI) of their lower extremities. Among these were seven patients (six unilateral cases) with treatment-responsive clubfoot and thirteen patients (five unilateral cases) with treatment-resistant clubfoot. Demographic information and physical examination findings were recorded. A descriptive analysis of the soft-tissue abnormalities was performed for both patient cohorts. For the patients with unilateral clubfoot, we calculated the percentage difference in cross-sectional area between the affected limb and the unaffected limb in terms of muscle, subcutaneous fat, intracompartment fat, and total area. With use of the Wilcoxon signed-rank test, we compared inter-leg differences in cross-sectional areas and the intracompartment adiposity index (IAI) between treatment-responsive and treatment-resistant groups. The IAI characterizes the cross-sectional area of fat within a muscle compartment.

RESULTS

Extensive soft-tissue abnormalities were more present in patients with treatment-resistant clubfoot than in patients with treatment-responsive clubfoot. Treatment-resistant clubfoot abnormalities included excess epimysial fat and intramuscular fat replacement as well as unique patterns of hypoplasia in specific muscle groups that were present within a subset of patients. Among the unilateral cases, treatment-resistant clubfoot was associated with a significantly greater difference in muscle area between the affected and unaffected limb (-47.8%) compared with treatment-responsive clubfoot (-26.6%) (p = 0.02), a significantly greater difference in intracompartment fat area between the affected and unaffected limb (402.6%) compared with treatment-responsive clubfoot (9%) (p = 0.01), and a corresponding higher inter-leg IAI ratio (8.7) compared with treatment-responsive clubfoot (1.5) (p = 0.01).

CONCLUSIONS

MRI demonstrated a range of soft-tissue abnormalities in patients, including unique patterns of specific muscle-compartment aplasia/hypoplasia that were present in patients with treatment-resistant clubfoot and not present in patients with treatment-responsive clubfoot. Correlations between MRI, physical examination, and treatment responsiveness may aid in the development of a prognostic classification system for clubfoot.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical Treatment of Overcorrected Clubfoot Deformity

Introduction

In our experience, a supramalleolar osteotomy with or without calcaneal osteotomy and midfoot osteotomy has been an effective treatment for sequelae resulting from overcorrected clubfoot deformity.

Step 1 Preoperative Assessment and Planning

Determine the treatment using the decisional algorithm in Figure 3.

Step 2 Patient Positioning

Use spinal or general anesthesia, administer intravenous antibiotics, position the patient supine, apply a tourniquet.

Step 3 Medial Approach to the Distal Part of the Tibia

Use a medial approach to expose the distal part of the tibia.

Step 4 Supramalleolar Osteotomy

Remove the bone wedge, close the osteotomy, and use rigid plate fixation to secure the correction.

Step 5 Additional Procedures If Necessary

If necessary, perform fibular osteotomy, calcaneal osteotomy, and/or plantar flexion osteotomy of the first cuneiform.

Step 6 Closure of All Incisions and Postoperative Care

A short leg splint is worn for two days, followed by partial weight-bearing with the ankle protected in a splint at night and a walking boot during the day for eight weeks.

Results

Between 2002 and 2009, fourteen adult patients (mean age, thirty-seven years; range, nineteen to sixty-six years) who presented with a symptomatic overcorrected clubfoot deformity were treated with a supramalleolar osteotomy.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

Reconstructive surgery for overcorrected clubfoot in adults

BACKGROUND

A known complication of the surgical treatment of clubfoot deformity is hindfoot valgus deformity of the ankle and/or the subtalar joint leading to calcaneofibular and/or anterior ankle impingement and flatfoot deformity. The purpose of this prospective study was to assess the radiographic outcome, pain relief, and functional improvement in patients with symptomatic overcorrected clubfoot deformity who were managed with a supramalleolar osteotomy.

METHODS

Fourteen patients with an overcorrected clubfoot deformity and a mean age of 36.9 ± 14.0 years were managed with a supramalleolar osteotomy. The mean duration of follow-up was 50.6 months. Radiographic assessment included comparison of the preoperative and postoperative distal tibial joint surface angle, tibiotalar angle, and amount of calcaneal offset on the hindfoot alignment view. Clinical outcomes were quantified with use of a visual analog score for pain and the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score.

RESULTS

No perioperative complications occurred. Radiographically, all osteotomy sites healed within eight weeks and the orientation of the distal tibial articular surfaces was normalized in all cases. Clinically, calcaneofibular and anterior ankle impingement resolved in all patients and the mean visual analog score for pain decreased significantly from 4.1 ± 1.7 to 2.2 ± 1.5 (p < 0.05). The mean AOFAS hindfoot score increased significantly from 51.6 ± 12.3 preoperatively to 77.8 ± 11.8 postoperatively (p < 0.05). The ankle motion increased significantly from 25° ± 12° preoperatively to 29° ± 9° postoperatively (p < 0.05). All patients walked in normal shoes.

CONCLUSIONS

Supramalleolar osteotomy is an effective surgical procedure for the treatment of ankle impingement in patients with an overcorrected congenital clubfoot deformity. The correction is associated with a low risk of perioperative complications and leads to significant reduction of pain, increased ankle motion, and improved clinical outcome (p < 0.05).

Assessment of talipes equinovarus treated by Ponseti technique: three-year preliminary report

BACKGROUND

The Ponseti method has become increasingly popular in the treatment of congenital talipes equinovarus (CTEV). Current methods of assessment focus on clinical, functional and radiological outcomes which are subjective and often difficult to repeat. However, integration of biomechanical evaluation can provide objective and quantifiable analysis. This study aims to evaluate the treatment outcome of CTEV patients on the basis of long-term clinical, functional and biomechanical assessment.

METHODS

Following treatment, five children with CTEV were reviewed annually for the period 2008-2010. Clinical and functional outcomes were graded using parental questionnaires and clinical examination. Biomechanical parameters were evaluated using digital foot pressure studies.

RESULTS

The study group recorded good clinical and functional outcomes. However, biomechanical studies have been able to identify subtle abnormalities that would be unapparent otherwise on clinical examination.

CONCLUSIONS

It is recommended that biomechanical assessment be integrated into the overall evaluation of the outcome of CTEV after treatment.

Triple arthrodesis

Triple arthrodesis is largely used to restore painful hindfoot deformity. However, the procedure has been connected to several postoperative complications. Therefore, an isolated fusion of the talonavicular and the subtalar joint through a single medial approach has gained popularity. This "diple" arthrodesis provides effective correction of deformities and reduces the risk of wound healing problems on the lateral side of the foot.