Ponseti method is superior to surgical treatment in clubfoot - Long-term, randomized, prospective trial

Early radiographic characteristics of the lateral talocalcaneal angle and its predictive significance for relapse in patients with idiopathic clubfoot treated with the Ponseti method

In order to evaluate the early radiographic characteristics of the lateral talocalcaneal (L-TC) angle in patients with idiopathic clubfoot (ICF) and to investigate its prognostic significance for relapse after initial treatment with the Ponseti method. We retrospectively included 151 patients (96 males and 55 females; 227 feet) with ICF treated at our Institution between January 2005 and December 2014. The age at initial treatment was less than 6 months, and radiographs were obtained within 3 months of the Achilles tenotomy (mean age: 2.3 months; range: 0.77-6.8). All patients were followed up for at least 7 years (range, 7-18). The participants' feet were classified into three groups: relapsed (Group A), not relapsed (Group B), and normal foot groups which consisted of healthy feet in patients with unilateral ICF (Group C). All angle measurements were expressed in degrees. Forty-seven ICF feet in 33 patients relapsed, while 180 feet in 118 patients did not, and the age at relapse was 5.92±1.91 years. Seventy-five normal feet were included in Group C. The average L-TC angle in Group A and B patients was 33.57°±12.05° and 39.37°±12.55°, respectively, while Group C was 49.61°±9.11°. A significant difference was found among the three groups of patients (F=31.48, P<0.001). The L-TC angle cut-off value below which a recurrence could be predicted was 36.1° (sensitivity, 74.47%). The L-TC angle of ICF patients treated using the Ponseti method were reduced compared to normal feet. An L-TC angle of <36.1° has relative value in predicting ICF relapse. LEVEL OF EVIDENCE: III.

Determining the Optimal Treatment for Idiopathic Clubfoot: A Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Clubfoot, or congenital talipes equinovarus deformity, is a common anomaly affecting the foot in infants. However, clinical equipoise remains between different interventions, especially those based on the Ponseti method. The aim of this study was to examine the clinical outcomes of the various interventions for treating idiopathic clubfoot.

METHODS

Searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Scopus, and CINAHL were conducted. Randomized controlled trials comparing different interventions, including the Ponseti method, accelerated Ponseti method, Ponseti method with botulinum toxin type A (Botox) injection, Ponseti method with early tibialis anterior tendon transfer (TATT), Kite method, and surgical treatment, were included. Network meta-analyses (NMAs) were conducted according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) reporting guidelines. The primary outcomes were the change in total Pirani score and maximal ankle dorsiflexion. Secondary outcomes were the number of casts, time in casts, and rates of tenotomy, total complications, relapse, adverse events, and additional required major surgery.

RESULTS

Eleven randomized controlled trials involving 740 feet were included. According to the SUCRA (surface under the cumulative ranking curve)-based relative ranking, the Ponseti method was associated with the best outcomes in terms of Pirani score changes, maximal ankle dorsiflexion, number of casts, adverse events, and total complications, whereas the accelerated Ponseti method was associated with the best outcomes in terms of time in casts and tenotomy rate. Early TATT ranked best in terms of relapse rate. The Ponseti method with Botox injection was associated with the best outcomes in terms of the need for additional major surgery.

CONCLUSIONS

The NMAs suggest that the Ponseti method is the optimal treatment overall, despite potential drawbacks such as longer time in casts and higher rates of tenotomy, relapse, and the need for additional surgery compared with other modified approaches. Therefore, clinicians should consider how treatments can be tailored individually.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Conventional Versus Accelerated Ponseti in the Management of Cases of Idiopathic Clubfoot: A Systematic Review and Meta-Analysis

This study aimed to compare the outcomes of the accelerated and standard Ponseti method for clubfoot pathology by constructing a systematic review and meta-analysis of relevant randomized controlled trials and nonrandomized comparative studies. A systematic search was conducted to identify the relevant studies through PubMed, Google Scholar, and Cochrane depending on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The keywords used included "accelerated" AND "standard" AND "Ponseti" AND "clubfoot" AND "Congenital Talipes Equinovarus" AND "CTEV" AND "prospective comparative design" AND "randomized trial." We conducted this analysis among 13 studies that met the criteria adopted in this review where eight studies were prospective comparative studies, and five studies were randomized prospective comparative studies which were published in the period between 2015 and 2022. Statistically, accelerated Ponseti showed superior impact over standard Ponseti considering the duration of treatment (22.53 days vs. 40.61 days, p<0.001). No significant difference was reported between the two methods considering final Pirani score (0.64 vs. 0.56, p=0.194), number of casts (5.23 vs. 5.25, p=0.425), rate of tenotomy (66.2% vs. 63.1%, OR=1.246, 95% CI: 0.86-1.80, p=0.245), relapse rate (9.51% vs. 8.54%, OR=1.126, 95% CI: 0.68-1.86, p=0.642) and complication rate (14.4% vs. 13.1%, OR=1.130, 95% CI: 0.58-2.19, p=0.717). We concluded that the accelerated Ponseti method could achieve comparable efficacy to the standard method in terms of post-procedure Pirani score, tenotomy rate, relapse rate, complications rate, and number of casts needed by the patients with advantage of requiring shorter duration of treatment which is associated with more patient's compliance.

What is New in Pediatric Orthopaedic Foot and Ankle

BACKGROUND

This paper aims to report on the last 5 years of relevant research on pediatric foot and ankle pathology with specific focus on clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans.

METHODS

The Browzine platform was used to review the table of contents for all papers published in the following target journals related to the treatment of pediatric foot and ankle conditions. Search results were further refined to include clinical trials and randomized controlled trials published from March 1, 2015 to November 15, 2021.

RESULTS

A total of 73 papers were selected for review based on new findings and significant contributions in treatment of clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans. Also included were several papers that did not fit into any of these categories but provided new insight into specific foot and ankle pathologies.

CONCLUSIONS

Treatment strategies for children with foot and ankle pathology are continually evolving. We review many of the most recent publications with the goal of improving understanding of these pathologies and highlighting current best practices.

LEVEL OF EVIDENCE

Level III.

The outcomes of idiopathic congenital talipes equinovarus : a core outcome set for research and treatment

Aims

To identify the minimum set of outcomes that should be collected in clinical practice and reported in research related to the care of children with idiopathic congenital talipes equinovarus (CTEV).

Methods

A list of outcome measurement tools (OMTs) was obtained from the literature through a systematic review. Further outcomes were collected from patients and families through a questionnaire and interview process. The combined list, as well as the appropriate follow-up timepoint, was rated for importance in a two-round Delphi process that included an international group of orthopaedic surgeons, physiotherapists, nurse practitioners, patients, and families. Outcomes that reached no consensus during the Delphi process were further discussed and scored for inclusion/exclusion in a final consensus meeting involving international stakeholder representatives of practitioners, families, and patient charities.

Results

In total, 39 OMTs were included from the systematic review. Two additional OMTs were identified from the interviews and questionnaires, and four were added after round one Delphi. Overall, 22 OMTs reached ‘consensus in’ during the Delphi and two reached ‘consensus out’; 21 OMTs reached ‘no consensus’ and were included in the final consensus meeting. In all, 21 participants attended the consensus meeting, including a wide diversity of clubfoot practitioners, parent/patient representative, and an independent chair. A total of 21 outcomes were discussed and voted upon; six were voted ‘in’ and 15 were voted ‘out’. The final COS document includes nine OMTs and two existing outcome scores with a total of 31 outcome parameters to be collected after a minimum follow-up of five years. It incorporates static and dynamic clinical findings, patient-reported outcome measures, and a definition of CTEV relapse.

Conclusion

We have defined a minimum set of outcomes to draw comparisons between centres and studies in the treatment of CTEV. With the use of these outcomes, we hope to allow more meaningful research and a better clinical management of CTEV.

Cite this article: Bone Jt Open 2022;3(1):98–106.

Early developmental milestones in patients with idiopathic clubfoot treated by Ponseti method

BACKGROUND

Idiopathic clubfoot, also referred to as congenital talipes equinovarus (CTEV), is one of the most common lower limb deformities observed in newborns, leading to significant functional impairment if untreated. The aims of this study were to (1) assess the developmental milestones in patients with CTEV treated by the Ponseti technique, and to compare them to the unaffected controls; (2) evaluate the possible correlation between developmental milestones, severity of the deformity, and number of casts.

MATERIALS AND METHODS

Seventy-nine subjects were divided into two groups, CTEV group (43 patients; 72 feet) and control group (36 patients). Age, sex, affected side, attainment of babbles (BAL), independent gait (IG), and combined word (CW) were recorded for all patients. In patients with CTEV, Pirani Score (PRS), number of casts (NC), and clinical outcome were collected according to the Clubfoot Assessment Protocol (CAP), The American Orthopedic Foot and Ankle Score (AOFAS), and Foot and Ankle Disability Index (FADI).

RESULTS

IG was achieved later later than the unaffected controls by 12/43 patients (27.9%) with CTEV and 3/36 patients in the control group (8.3%) (p = 0.04) and in a mean time of 16.8 ± 3.5 months and 13.2 ± 2.7 months, respectively (p = 0.001). In the CTEV group the mean value of CAP was 98.6 ± 4.7, of AOFAS of 98.4 ± 4.4 and of FADI equal to 99.9 ± 0.44. There were no statistically significant differences for BAL and CW; and no correlation with PRS, NC, or clinical score were identified.

CONCLUSION

CTEV patients managed by the Ponseti technique achieve independent gait later than the unaffected controls, although they do so within the age limit of developmental. On the other hand, the Ponseti treatment has no impact on attainment of language development.

Long-term outcomes of the Ponseti method for treatment of clubfoot: a systematic review

PURPOSE

The Ponseti method has revolutionized the clubfoot treatment and has been adopted globally in the past couple of decades. However, most reported results of the Ponseti method are either short or midterm. Studies reporting long-term outcomes of the Ponseti method are limited. The following systematic review aimed to provide a comprehensive overview of the published articles on long-term outcomes of the Ponseti method.

MATERIAL AND METHODS

A literature search was performed for articles published in electronic database PubMed (includes Medline) and Cochrane for broad keywords: "Clubfoot"; "Ponseti method/technique"; "long term outcomes/results." Studies selected included full-text articles in English language on children less than one year with primary idiopathic clubfoot treated by the Ponseti method with mean ten year follow-up. Non-idiopathic causes or syndromic clubfoot and case reports/review articles/meta-analyses were excluded. The following parameters were included for analysis: number of patients/clubfeet, male/female, mean age at treatment, mean/range of follow-up, relapses, additional surgery, range of motion, various outcome scores, and radiological variables.

RESULTS

Fourteen studies with 774 patients/1122 feet were included. The male:female ratio was 2.4:1. Mean follow-up recorded in studies was 14.5 years. Relapses occurred in 47% patients with additional surgery being required in 79% patients with relapses. Of these, 86% of surgery were extra-articular while 14% were intra-articular. Plantigrade foot was achieved in majority patients with mean ankle dorsiflexion of 11 degrees. The outcome scores were in general good in contrast to radiological angles which were mostly outside normal range with talar flattening/navicular wedging/degenerative osteoarthritis changes occurring in 60%, 76%, and 30%, respectively.

CONCLUSIONS

Long-term follow-up of infants with primary idiopathic clubfeet treated by the Ponseti method revealed relatively high relapse and additional surgery rates. Radiologically, the various angles were inconsistent compared to normal ranges and anatomical deformations/degenerative changes were present in treated feet. Moreover, the relapse rates and requirement of additional surgery increased on long-term follow-up. Despite this, majority feet were plantigrade and demonstrated good clinical results as measured by various outcome tools. There should be emphasis on long-term follow-up of children with clubfeet in view of late relapses and secondary late changes.

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.

Relapses in clubfoot treated with Ponseti technique and standard bracing protocol- a systematic analysis

PURPOSE

The analysis determined the relapses in clubfoot children treated with Ponseti technique and standard bracing protocol and their correlation with overall follow up duration using pooled data from various series. It also tested the prescribed timelines of 5 and 7 years for slow-down/cessation of relapses in clubfoot children.

METHODS

A systematic literature search was performed for articles published in "Pubmed (includes Medline indexed journals)" electronic databases using key words: "Clubfoot or CTEV or congenital talipes equinovarus", "Ponseti" for years 1^st January 2001 to 15^th November 2020. Included were studies that addressed treatment of idiopathic clubfoot using the standard Ponseti technique, followed a well defined brace protocol (maintenance of corrected deformity using a central bar based brace and prescribed duration mentioned), reported a minimum mean follow up of 4 years and having relapse as one of their outcome measure. Studies reporting Ponseti technique for non-idiopathic clubfoot, child's age older than 1 year at the time of primary treatment, clubfoot with previous interventions before Ponseti treatment, where relapse and residual deformities were not identified distinctly in follow up, abstract only publications, letter to the editors, case reports, technique papers and review articles were excluded. The following characteristics of clubfoot patients in the selected articles were included for analysis: Patient numbers/feet treated with Ponseti technique; follow up years (<5; 5-7 and >7 years; overall) and corresponding relapse percentages for patients.

RESULTS

There were total 2206 patients in the included 24 studies. Average follow up was 6 years. The average relapse rates for clubfoot patients in the pooled data stood at 30%. The overall relapse rates increased with a longer follow up and the curve befitted a linear regression equation with weak positive correlation (Pearson correlation coefficient = 0.08). The relapse rates in follow up categories of <5 years (26.6 ± 15.6%), 5-7 years (30.8 ± 16.3%) and >7 years (28.4 ± 6.2%) were similar statistically (Analysis of variance, ANOVA).

CONCLUSIONS

Approximately 1 in 3 clubfoot patients suffer relapse post Ponseti technique and standard bracing protocol. A weak positive correlation was observed for relapses when correlated with increasing follow up years. The relapses however tend to slow down after initial growth years. There is a need to educate the care receivers regarding the possibility of late relapses despite proper Ponseti treatment and accordingly to keep them under supervised follow up for longer periods.

Gross motor skill development is similar in children post Ponseti casting for congenital talipes equinovarus compared to typically developing children: a systematic review

This review aimed to investigate gross motor skill development in children with congenital talipes equinovarus (CTEV) following the Ponseti method of casting and bracing. Summary of evidence revealed through a systematic search of electronic databases completed in May 2019. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used to report and conduct the study. The McMaster Critical Review Form was used to critically appraise included studies and a descriptive synthesis of the results is reported. Inclusion criteria for studies included participants aged above 4 years, with a diagnosis of CTEV, treated via the Ponseti method and followed up with valid gross motor outcome measures. The comparator was a control group of typically developing children, or reference data. The searches resulted in 619 unique articles. Eight studies (retrospective cohort/case control studies) met inclusion criteria. There were nine different outcome measures used with 29 domains being relevant to this review. Synthesis of the findings found no significant difference between the gross motor skills of children with CTEV treated with Ponseti and typically developing children. The balance domains of three measures were consistently lower for the CTEV group versus controls/normative data. Yet, it is still demonstrated that most gross motor skills are within the typically developing range. It must be considered, however, that there is a spectrum of severity of CTEV and overall gross motor function should be monitored.

Radiological tarsal bone morphology in adolescent age of congenital clubfeet treated with the Ponseti method

BACKGROUND

Major abnormalities of tarsal bone shape after surgical clubfoot treatment are well known from the literature. The Ponseti method has gained widespread acceptance in primary treatment of congenital clubfeet. Despite the longtime experience, data regarding the development of tarsal bones after this treatment are still rare. The aim of the study was therefore to evaluate radiographic parameters describing tarsal bone shape of clubfeet after Ponseti treatment and compare them to age-matched healthy feet.

METHODS

Twenty two consecutive severe clubfeet in 14 patients were investigated by repeated diagnostic ultrasound during the corrective process. Extent and temporal course of correction were documented with standardized X-rays after a mean follow-up of 12 years (between the ages of 10-14 years) and compared to a group of age-matched normal feet.

RESULTS

Reliability testing for all X-ray parameters showed good to excellent results. In comparison to the control group, all parameters except the radius of the trochlea (RT) were significantly altered in clubfeet with highest differences shown for the anterior talar motion segment (ATM), talonavicular coverage (TNC) and the talometatarsal index (TMT-Index). Differentiation between minor and major deformities showed significant differences only for the front tarsal index (FTI).

CONCLUSIONS

Tarsal bone shape of clubfeet treated by the Ponseti method differs significantly from normal feet. One of the most pronounced and clinically relevant difference of the clubfoot talus compared to the normal talus is the markedly reduced anterior talar motion segment.

Sport Ability during Walking Age in Clubfoot-Affected Children after Ponseti Method: A Case-Series Study

Background: The Ponseti method (PM) of manipulative treatment for congenital talipes equinovarus (CTEV) or clubfoot became widely adopted by pediatric orthopedic surgeons at the beginning of the mid-1990s with reports of long-term successful outcomes. Sports are crucial for children’s development and for learning good behavior. This study aimed to evaluate the sports activity levels in children treated with PM and to assess the different outcomes, according to gender and bilaterality. Methods: A total of 25 patients (44 feet) with CTEV treated by the PM were included in the study. The patients were clinically evaluated according to the Clubfoot Assessment Protocol, American Orthopedic Foot and Ankle Society, Ankle–Hindfoot score, the Foot and Ankle Disability Index (CAP, AOFAS, and FADI, respectively), and FADI Sport scores. Results: The overall mean CAP, AOFAS, FADI, and FADI Sport scores were 97.5 ± 6.4 (range 68.75–100), 97.5 ± 5.8 (range 73.00–100), 99.9 ± 0.6 (range 97.1–100), and 100, respectively. Gender and bilaterality did not affect outcome (p > 0.05). Conclusions: The data confirmed good-to-excellent outcomes in children with CTEV managed by PM. No limitations in sport performance or activity could be observed. In particular, male and female patients and patients with unilateral or bilateral involvement performed equally well.

Foot function during gait and parental perceived outcome in older children with symptomatic club foot deformity

Aims

To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population.

Methods

In all, 73 children with idiopathic club foot were included: 31 children treated with the Ponseti method (mean age 8.3 years; 24 male; 20 bilaterally affected, 13 left and 18 right sides analyzed), and 42 treated with primary surgical correction (mean age 11.6 years; 28 male; 23 bilaterally affected, 18 left and 24 right sides analyzed). Foot function data was collected during walking gait and included Oxford Foot Model kinematics (Foot Profile Score and the range of movement and average position of each part of the foot) and plantar pressure (peak pressure in five areas of the foot). Oxford Ankle Foot Questionnaire, Disease Specific Index for club foot, Paediatric Quality of Life Inventory 4.0 were also collected. The gait data were compared between the two club foot groups and compared to control data. The gait data were also correlated with the data extracted from the questionnaires.

Results

Our findings suggest that symptomatic children with club foot deformity present with similar degrees of gait deviations and perceived disability regardless of whether they had previously been treated with the Ponseti Method or surgery. The presence of sagittal and coronal plane hindfoot deformity and coronal plane forefoot deformity were associated with higher levels of perceived disability, regardless of their initial treatment.

Conclusion

This is the first paper to compare outcomes between Ponseti and surgery in a symptomatic older club foot population seeking further treatment. It is also the first paper to correlate foot function during gait and perceived disability to establish a link between deformity and subjective outcomesCite this article: Bone Joint Open 2020;1-7:384-391.

Complex Clubfoot Treatment With Ponseti Method: A Latin American Multicentric Study

BACKGROUND

Complex clubfoot is a term used to describe those feet that present after treatment with a short first metatarsal, severe plantar flexion of all metatarsals, rigid equinus, and deep folds through the sole of the foot and above the heel. Ponseti has described a modification of his original technique for the treatment of the deformity. Few series have reported the treatment outcomes of this group of patients. The purpose of this study is to analyze mid-term results and complications of a large multicenter cohort.

METHODS

Patients with complex clubfoot treated at 6 tertiary-care institutions with a minimum of 1-year follow-up were retrospectively analyzed. Demographic data, previous treatment, number of casts, Achilles tenotomy, recurrences, complications, and additional procedures were documented. The patients were clinically evaluated at the time of presentation, after treatment, and at the last follow-up according to the Pirani score. All variables had a nonparametric distribution and are thus described as median (interquartile range (IQR), minimum-maximum). A comparison between the variables was performed using a Mann-Whitney U test, the change within each group was performed with a Wilcoxon-designated range test. A P-value <0.05 was used to indicate statistical significance.

RESULTS

One hundred twenty-four feet (79 patients) were evaluated. The median age at initial treatment was 7 months (IQR, 15; min-max, 1 to 53 mo). The mean follow-up was 49 months (IQR, 42; min-max, 12 to 132 mo). A median of 5 casts (IQR, 5; min-max, 3 to 13) was required for correction. Percutaneous tenotomy of the Achilles tendon was performed in 96% of the feet. One hundred twenty-two feet (98%) were initially corrected; 2 feet could not be corrected and required a posteromedial release. The Pirani score improved significantly from a pretreatment mean of 6 points (IQR, 1; min-max, 4.5 to 6) to 0.5 (IQR, 0.5; min-max, 0 to 2.5) at the last follow-up (P <0.001). Seven feet (6%) presented minor complications related to casting. Relapses occurred in 29.8% (37/124). In this subgroup, the number of casts required at initial treatment was higher (6; IQR, 5; min-max, 1 to 12 vs. 4 IQR, 4; min-max, 1 to 13; P<0.001), and follow-up was significantly longer (62 mo; IQR, 58; min-max, 28 to 132 vs. 37 mo; IQR, 48, min-max, 7 to 115; P<0.001).

CONCLUSIONS

Ponseti method is safe and effective for the correction of complex clubfeet. Early diagnosis and strict adherence to the Ponseti principles are key to achieve deformity correction. Patients with complex clubfoot require frequent follow-up because of a higher recurrence rate.

LEVEL OF EVIDENCE

Level III-therapeutic study.

A systematic review of reported outcomes following Ponseti correction of idiopathic club foot

AIMS

To analyze outcomes reported in studies of Ponseti correction of idiopathic clubfoot.

METHODS

A systematic review of the literature was performed to identify a list of outcomes and outcome tools reported in the literature. A total of 865 studies were screened following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 124 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Each outcome tool was assigned to one of the five core areas defined by the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT). Bias assessment was not deemed necessary for the purpose of this paper.

RESULTS

In total, 20 isolated outcomes and 16 outcome tools were identified representing five OMERACT domains. Most outcome tools were appropriately designed for children of walking age but have not been embraced in the literature. The most commonly reported isolated outcomes are subjective and qualitative. The quantitative outcomes most commonly used are ankle range of motion (ROM), foot position in standing, and muscle function.

CONCLUSIONS

There is a diverse range of outcomes reported in studies of Ponseti correction of clubfoot. Until outcomes can be reported unequivocally and consistently, research in this area will be limited. Completing the process of establishing and validating COS is the much-needed next step.Cite this article: Bone Joint Open 2020;1-8:457-464.

Interventions for congenital talipes equinovarus (clubfoot)

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

AUTHORS' CONCLUSIONS

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

Early Radiographic Changes in the Lateral Talocalcaneal Angle Following Achilles Tenotomy in Children With Idiopathic Clubfoot

BACKGROUND

Percutaneous Achilles tenotomy (PAT) is an important component of the Ponseti method and is performed in 85% to 90% of patients. However, there is a lack of objective data assessing early radiographic changes in children undergoing PAT.

METHODS

Forty-nine patients with idiopathic clubfoot treated by Ponseti casting were prospectively enrolled between October 2017 and October 2018. Preoperative and postoperative ankle dorsiflexion (pre-ADF^max, post-ADF^max) and lateral talocalcaneal angle (pre-LTCA^max, post-LTCA^max) values with the ankle in maximal dorsiflexion as well as postoperative LTCA values with the ankle in the neutral position (post-LTCA^neutral) were measured. The relationship between the preoperative and postoperative ADF and LTCA values was studied using Pearson or Spearman correlation coefficients. Forty-nine patients (72 feet) were included; the mean age at initial treatment was 32.2 ± 24.1 days.

RESULTS

Post-LTCA^max improved significantly from 18.6 ± 9.2 degrees to 25.1 ± 10.5 degrees (P < .0001). Pre-ADF and pre-LTCA^max showed a positive correlation in both the less than 28-day group (r = 0.42; P = .015) and the Dimeglio III group (r = 0.29; P = .035). However, post-ADF and post-LTCA^max showed a positive correlation in the Dimeglio III group (r = 0.30; P = .028). The degree of improvement in post-LCTA^max in the Dimeglio III group was similar to that in the Dimeglio IV group (P = .28).

CONCLUSION

The LTCA increased immediately after PAT in clubfoot, although the improvement seemed to be unrelated to the severity of the disease. PAT led to an increase in both ADF and the LTCA, and it contributed to the improvements in subtalar joint motion and alignment.

LEVEL OF EVIDENCE

Level III, comparative study.

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.

Outcomes of the Ponseti Method for Untreated Clubfeet in Nepalese Patients Seen Between the Ages of One and Five Years and Followed for at Least 10 Years

BACKGROUND

To our knowledge, there are no reports of the Ponseti method initiated after walking age and with >10 years of follow-up. Our goal was to report the clinical findings and patient-reported outcomes for children with a previously untreated idiopathic clubfoot who were seen when they were between 1 and 5 years old, were treated with the Ponseti method, and had a minimum follow-up of 10 years.

METHODS

A retrospective review of medical records was supplemented by a follow-up evaluation of physical findings (alignment and range of motion) and patient-reported outcomes using the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C). The initial treatment was graded as successful if a plantigrade foot was achieved without the need for an extensive soft-tissue release and/or osseous procedure.

RESULTS

We located 145 (91%) of 159 patients (220 clubfeet). The average age at treatment was 3 years (range, 1 to 5 years), and the average duration of follow-up was 11 years (range, 10 to 12 years). The initial scores according to the systems of Pirani et al. and Diméglio et al. averaged 5 and 17, respectively, and an average of 8 casts were required. Surgical treatment, most commonly a percutaneous Achilles tendon release (197 feet; 90%), was required in 96% of the feet. A plantigrade foot was achieved in 95% of the feet. Complete relapse was rare (3%), although residual deformities were common. Patient-reported outcomes were favorable.

CONCLUSIONS

A plantigrade foot was achieved in 95% of the feet initially and was maintained in most of the patients, although residual deformities were common. Patient-reported outcomes were satisfactory, and longer-term follow-up with age-appropriate outcome measures will be required to evaluate function in adulthood.

LEVEL OF EVIDENCE

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

[Treatment of knee flexion contracture with Ilizarov technology after burns]

Objective

To summarize the effectiveness of Ilizarov technique in the correction of flexion contracture deformity of the knee after burn.

Methods

Between April 2012 and July 2017, Ilizarov technique was used to treat 14 cases (17 knees) of knee flexion contracture patients. There were 11 males (13 knees) and 3 females (4 knees), with an age of 20-48 years (mean, 37 years). The duration of scar formation was 8 months to 24 years (mean, 5 years). The scar ranged from the upper part of the thigh, down to the middle part of the leg, from both sides to the inside and outside of the popliteal fossa, without ulceration. The area after scar contracture was 12 cm×10 cm to 30 cm×22 cm. Preoperative total activity of motion (TAM) was 30-115° (mean, 69°). There were 4 cases in wheelchair, 5 cases walking with double crutches, 3 cases with limp, and 2 cases with half squat walking. According to the knee function evaluation criteria by QIN Sihe, the preoperative knee function was fair in 3 knees, poor in 5 knees, and very poor in 9 knees.

Results

All patients were followed up 6 months to 5 years (mean, 2 years). No local skin necrosis, needle tract infection, limb numbness, and other complications occurred. Knee flexion deformities were all corrected. The postoperative TAM was 70-145° (mean, 125°). All patients were able to walk with plantar weight-bearing, and their gait improved when compared with that before operation. Five cases could walk without a crutch and only slightly claudication after operation. At last follow-up, according to the knee function evaluation criteria, the results were excellent in 9 knees, good in 5 knees, and fair in 3 knees, all were significantly improved when compared with that before operation ( Z=-3.677, P=0.000).

Conclusion

Ilizarov technique has the advantages of minimally invasive, safe, and easy to operate for the treatment of flexion contracture deformity of the knee after burn.

Gait kinetics in children with clubfeet treated surgically or with the Ponseti method: A meta-analysis

BACKGROUND

Currently, the Ponseti method is the gold standard for treatment of clubfeet. For long-term functional evaluation of this method, gait analysis can be performed. Previous studies have assessed gait differences between Ponseti treated clubfeet and healthy controls.

RESEARCH QUESTION/PURPOSE

The aims of this systematic review were to compare the gait kinetics of Ponseti treated clubfeet with healthy controls and to compare the gait kinetics between clubfoot patients treated with the Ponseti method or surgically.

METHODS

A systematic search was performed in Embase, Medline Ovid, Web of Science, Scopus, Cochrane, Cinahl ebsco, and Google scholar, for studies reporting on gait kinetics in children with clubfeet treated with the Ponseti method. Studies were excluded if they only used EMG or pedobarography. Data were extracted and a risk of bias was assessed. Meta-analyses and qualitative analyses were performed.

RESULTS

Nine studies were included, of which five were included in the meta-analyses. The meta-analyses showed that ankle plantarflexor moment (95% CI -0.25 to -0.19) and ankle power (95% CI -0.89 to -0.60, were significantly lower in the Ponseti treated clubfeet compared to the healthy controls. No significant difference was found in ankle dorsiflexor and plantarflexor moment, and ankle power between clubfeet treated with surgery compared to the Ponseti method.

SIGNIFICANCE

Differences in gait kinetics are present when comparing Ponseti treated clubfeet with healthy controls. However, there is no significant difference between surgically and Ponseti treated clubfeet. These results give more insight in the possibilities of improving the gait pattern of patients treated for clubfeet.

[Effectiveness of Ilizarov technique in treatment of clubfoot after burns]

Objective

To investigate the effectiveness of Ilizarov technique in treatment of the clubfoot after burns.

Methods

Between March 2012 and February 2017, 12 patients (17 feet) with clubfoot after burns were treated with Ilizarov technique. There were 10 males (14 feet) and 2 females (3 feets) with an average age of 38 years (range, 18-52 years). There were 3 cases of left foot, 4 cases of right foot, and 5 cases of both feet. According to the Qin's classification of clubfoot deformity, there were 5 feet of degreeⅠ, 9 feet of degreeⅡ, and 3 feet of degree Ⅲ.

Results

All clubfeet were completely corrected without local skin necrosis, needle tract infection, or acroanesthesia. All patients could walk with a heavy load. Pationts were followed up from 4 months to 3 years (mean, 10 months). At last follow-up, according to the International Clubfoot Study Group (ICFSG) score, the effectiveness was rated as excellent in 7 feet, good in 7 feet, and fair in 3 feet, with the excellent and good rate of 82.4%.

Conclusion

Using Ilizarov technique can gradually correct the clubfoot deformity with the advantages of minimal invasion, safeness, and simpleness.