Treatment of Severe Recurrent Clubfoot

Anterior tibial tendon transfer in idiopathic clubfoot: pull-out vs. other fixations - a systematic review

PURPOSE

Review the literature and describe the complications associated with each of the anterior tibial tendon transfer (ATTT) techniques described.

METHODS

A systematic review of the literature was performed with the keywords ''clubfoot'', ''Ponseti'' and ''anterior tibial''. Studies in patients with clubfoot recurrence, who underwent ATTT, whose method of tendon fixation was different from the classical method, were included.

RESULTS

Six studies were included in this systematic review, which described multiple techniques for tibialis anterior fixation: bone anchors, interference screws, endobotton, K-wires, transosseous suture, and suture to the plantar fascia. In the papers that described postoperative complications, no major complications were reported, however the samples are generally small.

CONCLUSION

Several options have now emerged for tendon fixation in tendon transfers around the foot and ankle, including ATTT for treatment of relapsed clubfoot. To our knowledge this is the first paper that questioned the potential complications associated with the use of these new techniques. Due to the scarcity of published works in favor of other fixation methods, we believe that the traditional method is the optimal one for the transfer of the tendon of the tibialis anterior muscle.

Outcomes of Eight-Plate Epiphysiodesis for Residual Clubfoot Deformities

OBJECTIVE

The outcome of congenital clubfoot treatment is still challenging if the feet deformities are not completely corrected. Here we explore a minimal invasive procedure with an eight-plate implant to correct the residual forefoot adduction deformity after treatment of neglected or relapsed clubfoot.

METHODS

We retrospectively reviewed patients with residual forefoot adduction deformity after clubfoot treatment between January 2013 and June 2016. The patients underwent temporary epiphysiodesis of the lateral column of the mid-foot, which in detail, an eight-plate was placed on each side of the calcaneocuboid joint. The foot deformities were recorded according to the weight-bearing radiographic measurements including talo-first metatarsal angle, calcaneo-fifth metatarsal angle and medial-to-lateral column length.

RESULTS

A total of 13 patients (20 feet) with an average age of 7.8 years old were located with an average duration of 40.8 months follow-up (range, 28 to 54 months). The average talo-first metatarsal angle improved from 28.3° (range, 19° to 47°) preoperatively to 8.3° (range, 3° to 18°) and the calcaneo-fifth metatarsal angle improved from 29.1° (range, 19° to 40°) preoperatively to 8.4° (range, 0° to 21°) at final follow-up. The mean ratio of the medial-to-lateral column length improved from 1.14 ± 0.06 to 1.55 ± 0.09 with statistical significance (t = 3.566; P < 0.001).

CONCLUSIONS

Eight-plate epiphysiodesis is an easy and effective method for the correction of residual forefoot adduction deformity after clubfoot treatment in growing children without the need of osteotomy.

The relation between clinical and objective gait scores in clubfoot patients with and without a relapse

BACKGROUND

Objective gait analysis that fully captures the multi-segmental foot movement of a clubfoot may help in early identification of a relapse clubfoot. Unfortunately, this type of objective measure is still lacking in a clinical setting and it is unknown how it relates to clinical assessment.

RESEARCH QUESTION

The aim of this study was to identify differences in total gait and foot deviations between clubfoot patients with and without a relapse clubfoot and to evaluate their relationship with clinical status.

METHODS

In this study, Ponseti-treated idiopathic clubfoot patients were included and divided into clubfoot patients with and without a relapse. Objective gait analysis was done resulting in total gait and foot scores and clinical assessment was performed using the Clubfoot Assessment Protocol (CAP). Additionally, a new clubfoot specific foot score, the clubFoot Deviation Index (cFDI*), was calculated to better capture foot kinematics of clubfoot patients.

RESULTS

Clubfoot patients with a relapse show lower total gait quality (GDI*) and lower clinical status defined by the CAP than clubfoot patients without a relapse. Abnormal cFDI* was found in relapse patients, reflected by differences in corresponding variable scores. Moderate relationships were found for the subdomains of the CAP and total gait and foot quality in all clubfoot patients.

SIGNIFICANCE

A new total foot score was introduced in this study, which was more relevant for the clubfoot population. The use of this new foot score (cFDI*) besides the GDI*, is recommended to identify gait and foot motion deviations. Along with clinical assessment, this will give an overview of the overall status of the complex, multi-segmental aspects of a (relapsed) clubfoot. The relationships found in this study suggest that clinical assessment might be indicative of a deviation in total gait and foot pattern, therefore hinting towards personalised screening for better treatment decision making.

The Predictive Value of Radiographs and the Pirani Score for Later Additional Surgery in Ponseti-Treated Idiopathic Clubfeet, an Observational Cohort Study

There are few validated predictors of the need for additional surgery in idiopathic clubfeet treated according to the Ponseti method. Our aim was to examine if physical examination (Pirani score) and radiographs at the age of three months (after initial correction of the clubfeet) can predict the future need for additional surgery. In this retrospective cohort study, radiographs of idiopathic clubfeet were made at the age of three months. The Pirani score was determined at the first cast, before tenotomy, and at the age of three months. Follow-up was at least five years. The correlation between the radiograph, Pirani score, and the need for additional surgery was explored with logistic regression analysis. Parent satisfaction was measured with a disease-specific instrument. The study included 72 clubfeet (50 children) treated according to the Ponseti method. Additional surgery was needed on 27 feet (38%). A larger lateral tibiocalcaneal angle (i.e., equinus) and a smaller lateral talocalcaneal angle (i.e., hindfoot varus) at the age of three months were correlated with the need for additional surgery. Higher Pirani scores before tenotomy and at the age of three months also correlated with additional surgery. Parent satisfaction was lower in patients who needed additional surgery. Both the Pirani scores and the lateral radiographs are predictive for future additional surgery.

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.

Staged Correction of Severe Recurrent Clubfoot Deformity With Dislocation of the Chopart Joint Using a Hexapod External Fixator and Unconventional Arthrodesis

Despite success of the Ponseti method, a subset of patients with clubfeet experience residual deformity. Surgical release after unsuccessful serial casting can lead to residual clubfoot deformities, including a flat-top talus. We present a case of a 17-year-old boy with a dysmorphic ankle and a complete dorsal dislocation of the Chopart joint. Because of pain with activities and functional limitations, the patient underwent a staged correction of the dislocation. The deformity was corrected through a staged approach using a Taylor Spatial Frame, navicular excision, talocuneiform arthrodesis, and calcaneocuboid arthrodesis. One year postoperatively, the patient is pain free with notable functional gains.

Updates in the Surgical Management of Recurrent Clubfoot Deformity: a Scoping Review

PURPOSE OF REVIEW

This article focuses on the current advances in surgical management for clubfoot deformity, supported by up-to-date longitudinal studies on each approach.

RECENT FINDINGS

Long-term analysis following primary and repeated soft tissue releases has demonstrated good results in young patients with low relapse rates. Tibialis anterior transfer following the Ponseti method shows no difference in long-term pedographic analysis in comparison to the Ponseti method alone. Furthermore, tibialis anterior transfer following surgical relapses provides good long-term results with improved correction in talus-first metatarsal angle. Bony osteotomies may also play a role in addressing surgical relapses in older children. However, talar neck osteotomy may result in avascular necrosis of the talar dome. Hexapod external fixation may be considered by experienced surgeons to correct rigid clubfoot deformities in older patients with good long-term results and drastic improvements in pain perception. Long-term analysis of anterior distal tibial epiphysiodesis (ADTE) for recurrent equinus deformity following surgical correction has demonstrated statistical improvements in the anterior distal tibial angle (ADTA) and ankle dorsiflexion. Talectomy and naviculectomy are rarely used in today's practice as long-term studies have demonstrated high relapse rates and residual pain impeding patient mobility. Surgical correction following failure of the conservative approaches can be implemented to achieve full correction in clubfoot deformity. It is difficult to achieve a plantigrade feet with pain-free gait with repeated surgical interventions. Therefore, proper choice of the initial surgical technique is essential for achieving satisfactory long-term outcomes.

Long-term follow-up of children with a surgically treated clubfoot: Assessing the multi-segment-foot motions, dynamic plantar pressures, and functional outcomes

OBJECTIVE

The purpose of this study was to compare surgically treated clubfoot with typically developing (TD) children using plantar pressure, multi-segment-foot kinematic analysis, and multiple functional outcomes in comprehensive and long-term study. Methods: 26 patients with 45 clubfeet and 23 TD children with 45 normal feet were evaluated. Most clubfoot patients had a complete subtalar release and a few patients had a posterior medial-lateral release at the mean age of 5 years and 6 months. The mean age at follow-up for clubfoot was 12 years and 5 months. Subjects underwent physical and radiographic examination, plantar pressure analysis, multi-segment-foot motion analysis, AAOS Foot & Ankle Questionnaire (AAOS-FAQ), the Pediatric Outcomes Data Collection Instrument (PODCI), and the Child Behavior Checklist (CBCL).

RESULTS

Clubfoot patients scored significantly worse than TD on the AAOS-FAQ (90.9 vs.99.9 for pain and comfort), the CBCL Problems scale (23.1 vs.6.3), and several subscales of the PODCI (86.5 vs.96.7 for Sports and Physical Functioning) (P<0.05). Peak pressure at the lateral heel (25.6 vs.29.6 N/cm²), contact area at the 1 st metatarsal head (1 st MT) (6.0 vs. 7.2 cm²) and the pressure time integral at the 1 st MT (5.2 vs. 11.0 N/cm² ∗ s) were significantly lower for the clubfoot group compared to the TD foot group (P<0.05). Maximum dorsiflexion of the 1 st metatarsal-hallux (1 st MT-Hal) (17.5° vs. 34.8°) during stance phase (ST), supination of the 1 st MT-Hal during swing phase (SW) (4° vs. 7°), maximum plantarflexion of the ankle during ST (-6.8° vs.-11.2°), and maximum varus of the ankle during SW (4.4° vs. 6.9°) were also lower for clubfoot except for maximum dorsiflexion of the navicular-1 st MT (P<0.05).

CONCLUSION

This study supports evidence that surgically treated clubfoot continues to have residual deformity of forefoot, overcorrection of hindfoot, stiffness, and a decrease in physical functioning. This comprehensive study accurately portrays postsurgical clubfoot function with objective means through appropriate technologies. A plantar pressure redistributed and finite element analysis designed orthosis may be of importance in the improvement of the foot and ankle joint function for ambulatory children with a relapse of clubfoot deformity.

The Treatment of Recurrent Congenital Clubfoot

The Ponseti method for treatment of congenital clubfoot is well established and has been introduced in most pediatric orthopedic centers worldwide. However, reported rates of recurrence are largely variable and open joint surgery is still performed frequently, even in the age group younger than 6 years of age. Preventing recurrence and residual deformity can be achieved by strict adherence to the Ponseti method, ensuring and enforcing brace compliance, frequent follow-up, and early treatment of recurrence. This review discusses reasons for clubfoot recurrence, prevention of clubfoot recurrence, and the treatment of recurrent congenital clubfoot within the realm of the Ponseti method.

An Approach to the Management of Severe Clubfoot Deformities on Global Humanitarian Programs: The Role of Talectomy

The approach to treatment of severe untreated or recurrent congenital talipes equinovarus deformities is very different in the world where patients are mobile, have access to repeated return visits for follow-up treatment, and where more sophisticated options for gradual correction with external fixation are available. For treatment, talectomy may be the only option to treat certain neglected clubfoot deformities during humanitarian programs and it may still have to be used as a salvage procedure used in modern foot surgery. Our extensive experience with these deformities has been on global humanitarian programs.

Forefoot adduction and forefoot supination as kinematic indicators of relapse clubfoot

BACKGROUND

Understanding the kinematic characteristics of relapse clubfoot compared to successfully treated clubfoot could aid early identification of a relapse and improve treatment planning. The usage of a multi segment foot model is essential in order to grasp the full complexity of the multi-planar and multi-joint deformity of the clubfoot.

RESEARCH QUESTION

The purpose of this study was to identify differences in foot kinematics, using a multi-segment foot model, during gait between patients with Ponseti treated clubfoot with and without a relapse and age-matched healthy controls.

METHODS

A cross-sectional study was carried out including 11 patients with relapse clubfoot, 11 patients with clubfoot and 15 controls. Gait analysis was performed using an extended Helen Hayes model combined with the Oxford Foot Model. Statistical analysis included statistical parametric mapping and discrete analysis of kinematic gait parameters of the pelvis, hip, knee, ankle, hindfoot and forefoot in the sagittal, frontal and transversal plane.

RESULTS

The relapse group showed significantly increased forefoot adduction in relation with the hindfoot and the tibia. Furthermore, this group showed increased forefoot supination in relation with the tibia during stance, whereas during swing increased forefoot supination in relation with the hindfoot was found in patients with relapse clubfoot compared with non-relapse clubfoot.

SIGNIFICANCE

Forefoot adduction and forefoot supination could be kinematic indicators of relapse clubfoot, which might be useful in early identification of a relapse clubfoot. Subsequently, this could aid the optimization of clinical decision making and treatment planning for children with clubfoot.

Concomitant Talocalcaneal Coalition as a Risk Factor for Early Relapse Following Ponseti Treatment of Idiopathic Clubfoot

Concomitant talocalcaneal coalition (TCC) in idiopathic clubfeet is not well documented in the literature. The purpose of this study was to describe our experience with very early relapsing idiopathic clubfeet associated with TCC. Although cases have been successfully treated with the Ponseti casting method, all recurred within 2 months of removing the final cast. A single-centre cohort of twelve feet in eight patients treated by a single surgeon between 2006 and 2020 was investigated retrospectively. Recurred cavus with variable degrees of equinus was the earliest findings noted. TCC was incidentally detected during the open reduction of the earliest three feet in our series. Afterwards, ultrasonography was advised as a screening tool for detecting an associated anomaly; however, only the use of magnetic resonance imaging (MRI) was 100% accurate in diagnosing concurrent TCC. All coalitions were cartilaginous and the posterior facet was most commonly involved facet. The average age was 18 months for the coalition resection and open reduction of a dislocated talonavicular joint, and the average duration of follow-up was 52 months. None of the patients showed clinical signs of relapse at the latest follow-up. We recommend that an associated TCC should be considered in very early relapsing idiopathic clubfoot cases.

Narrative review of the management of a relapsed clubfoot

The management of idiopathic clubfoot has transformed over the past several decades as the Ponseti method for the correction of this deformity became the standard of care, and surgical release has almost all but been abandoned. The Ponseti method has shown very high initial success rate and excellent long-term functional results. Relapse of the deformity, however, continues to be a major problem, occurring in up to 40% of patient, and there is no consensus on the definition and management of the relapsed clubfoot. This review discusses the available management options for the treatment of a relapsed clubfoot deformity following initial treatment with the Ponseti method [including repeat casting, tendo-Achilles lengthening, plantar fascia release, and tibialis anterior tendon transfer (TATT)] as well as following initial surgical treatment with posteromedial release (including casting, hemiepiphysiodesis, revised posteromedial release, osteotomies, fusion, and the use of gradual distraction with external fixators). These are discussed from the least to the most invasive. Available evidence, and limitations of the literature, for the management of relapses following both the Ponseti method and initial surgical release is reviewed along with along with the reported outcomes. Future efforts should be geared towards standardizing the definition of a relapse with objective criteria for its management.

Successful Ponseti-treated Clubfeet at Age 2 Years: What Is the Rate of Surgical Intervention After This?

BACKGROUND

In recent decades, nonoperative Ponseti casting has become the standard of care in the treatment of idiopathic clubfoot. However, the rate of recurrence, even after successful Ponseti treatment is not insignificant. The purpose of this study was to determine the future rate, timing, and type of surgery needed in patients whose idiopathic clubfeet treated by Ponseti casting were considered successful at the age of 2 years.

METHODS

Inclusion criteria for this retrospective study were patients under 3 months with idiopathic clubfoot treated exclusively by Ponseti casting, who had successful outcomes at 2 years of age without surgery, and who had at least 5 years of follow-up. The total number of surgical interventions in the age range 2 to 5 and above 5 years, the number and type of procedures performed, and the timing of surgery were reviewed.

RESULTS

Three hundred thirty-six patients with a total of 504 clubfeet fulfilled the inclusion criteria. One hundred twenty-two of these 336 patients (36.3%) eventually underwent surgical intervention. Between 2 and 5 years of age, 79 patients (23.5%) with 104 feet (20.6%) underwent surgery. The most common procedures performed between 2 and 5 years were limited (a la carte) in scope: tibialis anterior tendon transfer, posterior release, plantar fascia release, and repeat tendo-Achilles lengthening. At age above 5 years, 53 patients (20.1%) with 65 feet (16.9%) underwent surgery. Ten of these 53 patients had already undergone surgery between 2 and 5 years of age. The procedures most commonly performed were similar.

CONCLUSIONS

In patients with idiopathic clubfoot who reached 2 years of age with successful outcomes from Ponseti cast treatment, ∼35% eventually underwent surgical intervention, mostly limited (a la carte), to regain or maintain a plantigrade foot. The most commonly performed procedures include tibialis anterior tendon transfer, posterior capsular release, plantar fascia release and repeat tendo-Achilles lengthening, either in isolation or in combination. However, before considering surgery, the need for these procedures can, and should, be minimized by recasting recurrent deformities using Ponseti method.

LEVEL OF EVIDENCE

Level III.

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.

Poor Evertor Muscle Activity Is a Predictor of Recurrence in Idiopathic Clubfoot Treated by the Ponseti Method: A Prospective Longitudinal Study With a 5-Year Follow-up

BACKGROUND

After successful primary correction of the deformity in idiopathic clubfoot with the Ponseti method, recurrence has been reported to affect up to 40% of children. So far, it has been difficult to predict which feet are at risk of recurrence, despite numerous studies investigating various potential risk factors. The foot abduction brace (FAB) has been the standard of care in preventing recurrence but, even with excellent compliance, recurrences still occur. Increasingly, evidence points to a congenital neuromuscular imbalance constituting the deforming forces present in clubfoot. Poor evertor muscle activity has been cited specifically as a potential risk factor for recurrence. The aim of this study is to evaluate whether poor evertor muscle activity on clinical examination can predict recurrence in idiopathic clubfoot at 5-year follow-up.

METHODS

Data were collected prospectively on patients treated at our tertiary physiotherapy-led Ponseti service between 2010 and 2015. Hospital ethical approval was obtained. Sex, age, laterality, Pirani score, number of casts, brace compliance, and evertor activity were recorded. Evertor muscle activity was scored in a semiquantitative repeatable manner: 0, 0.5, or 1 as previously described. Recurrence was defined as deterioration of any of the 4 components of the deformity following a previously complete correction.

RESULTS

In total, 104 patients (172 feet) were included in the study, 76 patients had good evertor activity, and 28 demonstrated poor evertor activity. The mean follow up was 62 months (range, 41 to 71 mo); 18.3% of the patients (19/104) had recurrence treated with repeat casting; 13.5% (14/104) of the patients required additional surgery following recasting. Recurrence was highly associated with poor evertor activity (P<0.01).

CONCLUSIONS

Results at 5 years confirm that a semiquantitative evertor muscle activity assessment can predict recurrence and should be added to the routine clinical assessment in order to assist with individualizing patient's treatment strategies.

LEVEL OF EVIDENCE

Level II.

Treatment of relapsed, residual and neglected clubfoot: adjunctive surgery

Over the past two decades, the Ponseti 'conservative' (non-surgical) method of clubfoot treatment has been almost universally adopted worldwide. As a result, the need for operative treatment for clubfoot has decreased dramatically. However, even Ponseti himself routinely used surgery for certain patients: at least 90% of feet need percutaneous tenotomy, and 15% to 40% may require tibialis anterior tendon transfer. Additionally, relapses are common, sometimes necessitating further surgical intervention. Relapses are recurrent deformities in previously well corrected feet. Residual deformities may be defined as persistent deformities in incompletely corrected feet. In addition, in many parts of the developing world, neglected clubfoot is still a major challenge. Many neglected feet can be treated with Ponseti principles, particularly in younger children. However, in older children and adults, surgical approaches are more likely to be needed. Major reasons for relapsed/residual clubfoot include incomplete application of the Ponseti principles, inability to adhere to the foot abduction brace protocol, failure to recommend a complete course of bracing and inadequate follow-up. Sometimes, despite excellent treatment, and perfect adherence to the bracing protocols, there are still relapses, related to intrinsic muscle imbalance. We describe several solutions that include reinstitution of Ponseti casting and 'á la carte' operative treatment. As an alternative for particularly stubborn cases, application of a hexapod external fixator can be a powerful tool. In order to be a full-service clubfoot specialist, and not only a Ponseti practitioner, one must have in their toolbox the full gamut of adjunctive surgical options.

LEVEL OF EVIDENCE

V.

Quantifying joint stiffness in clubfoot patients

BACKGROUND

In clinical practice, clubfeet feel stiffer compared to healthy feet. Furthermore, the clinical impression is that stiffer clubfeet have a higher tendency to relapse. Until now, no objective measure has been available to determine the stiffness of clubfeet. The goal of the current project was to objectively quantify ankle and subtalar joint stiffness in clubfeet patients and to compare this stiffness between clubfeet patients and healthy controls using a newly developed measurement device.

METHODS

The newly developed Torque-Displacement-Handpiece in combination with an adjusted Abduction Dorsiflexion Mechanism clubfoot-brace, made it possible to move a foot over two rotational axis, while continuously capturing the applied torque and the achieved angulation. Based on this information, stiffness of the ankle and subtalar joint were assessed for 11 clubfoot patients with 17 clubfeet and 11 healthy subjects with 22 healthy feet.

FINDINGS

With the Torque-Displacement-Handpiece measuring device it was possible to measure torque, angulation and stiffness in a reliable and precise manner. Clubfoot patients showed less angulation and a higher stiffness for measurements over the ADM subtalar axis compared to controls. After adjusting for shoe size, the stiffness for measurements over the ADM tibiotalar axis was also significantly higher in clubfeet than controls.

INTERPRETATION

Overall, these results indicate that clubfoot patients have a higher ankle and subtalar joint stiffness in the affected joint compared to healthy controls. In the future, the Torque-Displacement-Handpiece could be used to monitor stiffness of clubfeet during treatment, and as such, play a potential role in the early detection of relapsing clubfeet.

Incidence of congenital idiopathic clubfoot in the Netherlands

The incidence of clubfoot patients is an important factor for centralization of care. Medical records of 21 accredited clubfoot centers were selected using the diagnosis treatment codes and checked to confirm diagnosis. All idiopathic clubfoot cases born during 2013-2014 were analyzed with respect to sex, affected foot, regional distribution, and seasonal variation. Among the 346 522 live births, 377 idiopathic clubfoot cases were registered. The incidence of the congenital idiopathic clubfoot in the Netherlands during 2013 and 2014 was 1.09 per 1000 live births, indicating that every year, ~200 children with one or two clubfeet are born in the Netherlands. On the basis of this finding, we can start to refine clubfoot care.

Treatment of rigid congenital clubfoot with Ilizarov technique in older children

Objective

To investigate the effectiveness of Ilizarov technique in treatment of rigid congenital clubfoot in older children.

Methods

A clinical data of 55 patients (69 feet) with rigid congenital clubfoot (Diméglio grade Ⅳ) between September 2005 and September 2015 were retrospectively analyzed. There were 33 boys and 22 girls with an average age of 11 years (range, 6-14 years). There were 41 cases of unilateral clubfoot and 14 cases of bilateral clubfeet. The degree of foot deformity was rated as fair in 24 feet and as poor in 45 feet according to International Clubfoot Study Group (ICFSG) score before operation. Sixty-nine feet were treated by Ilizarov external fixator combined with limited soft tissue release, and 21 feet were combined with individualized V-shaped osteotomies.

Results

All patients were followed up 2-10 years ( mean, 4.2 years). The incisions healed well after operation. Five cases of needle tract infection occurred and were cured by local dressing change. The effectiveness was excellent in 39 feet, good in 21 feet, and fair in 9 feet according to ICFSG score, with the excellent and good rate of 87.0%. During the follow-up, X-ray films showed that no blood supply disorder or necrosis of talus, scaphoid, cuneiform, metatarsal, calcaneus, and cuboid occurred. No osteomyelitis occurred.

Conclusion

Ilizarov technique combined with limited soft tissue release or V-shaped osteotomy for the older children with rigid congenital clubfeet is safe and can obtain significant orthopedic effectiveness.

Identification and treatment of residual and relapsed idiopathic clubfoot in 88 children

Background and purpose - The Ponseti treatment is successful in idiopathic clubfoot. However, approximately 11-48% of all clubfeet maintain residual deformities or relapse. Early treatment, which possibly reduces the necessity for additional surgery, requires early identification of these problematic clubfeet. We identify deformities of residual/relapsed clubfeet and the treatments applied to tackle these deformities in a large tertiary clubfoot treatment center. Patients and methods - Retrospective chart review of patients who visited our clinic between 2012 and 2015 focused on demographics, deformities of the residual/relapsed clubfoot, and applied treatment. Residual deformities were defined as deformities that were never fully corrected and needed additional treatment. We defined relapse as any deformity of the clubfoot reoccurring, after initial successful treatment, with necessity for additional treatment. Results - We identified 33 patients with residual and 55 patients with relapsed clubfeet. In both groups decreased dorsal flexion and adduction were the most often registered deformities. Furthermore, often equinus/decreased dorsiflexion, active supination, and varus occurred. In more than half, typical profiles of combined deformities were found. Relapses occurred at all stages of treatment and follow-up; half of the residual or relapsed clubfeet were identified before the end of the bracing period. In half of the patients, additional treatment consisted of the Ponseti treatment, one-quarter also required adaptation of the brace protocol, and one-quarter needed additional surgery. The Ponseti treatment was mainly reapplied if feet presented with relapses or residues until the age of 5. Interpretation - Practitioners should especially be aware of equinus/decreased dorsiflexion, adduction, and active supination as a sign of a residual or relapsed clubfoot. Due to the heterogeneous profiles of these clubfeet, treatment strategy should be based on a step-by step approach including recasting, bracing, and if necessary surgical intervention.

[Pediatric clubfoot : Treatment of recurrence]

Over the last 10 years the Ponseti method has become established as the gold standard for initial treatment of clubfeet nearly worldwide. Nevertheless, there are considerable fluctuations regarding the authenticity and quality in the application of the Ponseti method. Especially the efforts to ensure and promote compliance with the foot abduction brace and subsequently the recurrence rate show great variation. As a result, we are still faced with a significant number of recurrent or residual clubfeet. In recent years it has been shown in high-volume clinics that even these can almost always be successfully treated with recasting and with minor interventions, such as anterior tibial tendon transfer and lengthening of the Achilles tendon. More invasive surgical procedures are only very rarely indicated and are reserved for severe recurrence in previously surgically treated and secondary clubfeet.