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

Clubfoot patients show more anterior-posterior displacement during one-leg-standing and less ankle power and plantarflexor moment during one-leg-hopping than typically developing children

BACKGROUND

Clubfoot patients show good-to-excellent foot correction after the Ponseti method. Nevertheless, underlying functional problems that limit motor abilities such as one-leg-standing and one-leg-hopping still persist. These restrictions have been proposed to arise due to problems with maintaining balance and the limited force-generating capacity of clubfoot patients. More insight is needed to understand the underlying limiting factors to improve overall motor ability in clubfoot patients.

RESEARCH QUESTION

The aim of this study was to determine the differences between clubfoot patients and typically developing children (TDC) in force and balance parameters during walking, one-leg-standing and hopping.

METHODS

Three-dimensional motion analysis was performed in 19 TDC and 16 idiopathic Ponseti-treated clubfoot patients between 5-9 years old. Kinematic and kinetic parameters were calculated during walking and one-leg-hopping. To describe the balance parameters, center of pressure (CoP) data was assessed during walking, one-leg-hopping and one-leg-standing. Mean group values were calculated and compared using nonparametric statistical tests. A general linear model with repeated measures was used to determine which activity showed the largest group differences.

RESULTS

Clubfoot patients showed lower peak plantarflexor moment and peak ankle power absorption and generation during one-leg-hopping compared to TDC. Furthermore, clubfoot patients showed a lower hop length and velocity than TDC. The difference in peak plantarflexor moment and ankle power between the study groups was larger during one-leg-hopping than during walking. Finally, clubfoot patients showed a higher anterior-posterior CoP range during one-leg-standing.

SIGNIFICANCE

Deviations in force parameters seemed to limit one-leg-hopping in clubfoot patients, and impaired anterior-posterior static balance was thought to be the underlying cause of problems with one-leg-standing. Furthermore, one-leg-hopping was more sensitive to distinguish between clubfoot patients and TDC than walking. Individualized physiotherapy targeting static balance and force parameters, with extra emphasis on including eccentric contractions, might improve the overall motor abilities of clubfoot patients.

Kinematic Gait Impairments in Children with Clubfeet Treated by the Ponseti Method: A Systematic Review and Meta-Analysis

BACKGROUND

Being aware of possible gait impairments in Ponseti-treated clubfoot children might be useful for optimizing initial and additional treatment. Therefore, this systematic review and meta-analysis aimed to identify kinematic gait abnormalities in children with clubfoot treated with the Ponseti method (with and without relapse).

METHODS

A systematic search was conducted. Studies comparing kinematic gait parameters of Ponseti-treated clubfoot children to healthy controls were included. Meta-analyses and qualitative analyses were conducted on the extracted data.

RESULTS

Twenty studies were identified. Twelve of the 153 reported kinematic outcome measures could be included in the meta-analysis. Plantarflexion at push-off, maximum ankle dorsiflexion during the swing, maximal plantarflexion, and ankle range of motion was significantly lower in Ponseti-treated clubfoot children. Ponseti-treated clubfoot children showed more internal foot progression. Qualitative analysis revealed 51 parameters in which pre-treatment relapse clubfeet deviated from healthy controls.

CONCLUSIONS

Ponseti-treated clubfoot children showed several kinematic gait differences from healthy controls. In future studies, homogeneity in measured variables and study population and implementation of multi-segmental foot models will aid in comparing studies and understanding clubfoot complexity and treatment outcomes. The question remains as to what functional problems gait impairments lead to and whether additional treatment could address these problems.

Participation and Motor Abilities in Children Aged 5 to 9 Years With Idiopathic Clubfeet After Treatment With the Ponseti Method

BACKGROUND

Functioning in children consists of different aspects, including their ability to execute activities and participate in life situations. Several studies on children with clubfeet showed limited motor abilities and walking capacity compared with healthy control children, while other studies showed comparable athletic abilities and gross motor development. Although participation in activities of daily life plays an important role in the development of children, this has not yet been investigated in children with clubfeet. The study aims to determine the level of parents' perceived motor ability and participation in Ponseti-treated children with clubfeet compared with age-matched healthy controls.

METHODS

Parents of children aged 5 to 9 years with and without idiopathic Ponseti-treated clubfeet were asked to complete an online questionnaire about their child's motor abilities and participation level using the Dutch version of the Assessment of Life Habits for Children (LIFE-H) version 3 to assess participation and the Dutch Movement Assessment Battery for Children-2 Checklist (MABC-2 Checklist) to assess motor abilities. Statistical analysis focused on differences between groups and the relationship between motor abilities and level of participation.

RESULTS

Questionnaires of 86 children with clubfeet (mean age 7.1, 73% boys) and 62 controls (age 6.7, 53% boys) were analyzed. Despite a large variation, results showed no significant differences between groups on the total scores of the LIFE-H and the MABC-2 Checklist. Children with clubfeet, however, scored lower on Mobility and better on the categories Communication and Responsibility of the LIFE-H. Furthermore, children with clubfeet showed lower scores on the MABC-2 Checklist subscale "movement in a static and/or predictable environment." High levels of the parents' perceived participation correlate with good results, as perceived by the parents, in motor ability.

CONCLUSIONS

Although differences on some aspects of motor ability and participation existed, children with clubfeet in general showed high levels of parents' perceived motor ability and participation. High levels of participation correlated with good results in motor ability.

LEVEL OF EVIDENCE

Level II.

Retrospective Case Analysis of 104 Cases of Talipes Equinus

A retrospective study of 104 patients (81 male and 23 females, the age range from 2 to 288days) with talipes equinus was conducted to explore the case factors associated with it. We analyzed and discussed the correlation of plaster correction times, age of first visit, gender, and birthplace of patients in the department and understood their correlation and causality. The data were analyzed using frequency analysis, normality test, chi-square goodness-of-fit test, chi-square test, and PLS regression. The findings are set out below. All the distributions of the number of plaster casts in the samples did not have normality. Therefore, we used the nonparametric test and partial least squares regression (PLS regression) and found that the number of plaster casts was more closely related to the age at first visit, gender, and birthplace and had a strong positive correlation. There was a negative correlation between the times of plaster correction and the compliance of braces. The lower the compliance of patients with braces, the more times the plaster correction will be conducted.

Quality of life of clubfoot patients during the brace period of the Ponseti method

PURPOSE

Quantifying the quality of life in clubfoot patients during bracing following the Ponseti method compared with healthy controls.

METHODS

Data collected during the brace period of the Ponseti method and of a reference sample was retrospectively analyzed to investigate health-related quality of life scale (TAPQOL) in clubfoot patients compared with healthy controls. The TAPQOL instrument consists of 12 subscales comprising the 4 domains of health-related quality of life namely physical, social, emotional and cognitive functioning.

RESULTS

Responses of 80 parents of clubfoot patients and 238 parents of healthy controls were analyzed. On average both study groups scored high on the 4 domains of the TAPQOL instrument. The clubfoot group scored significantly (p<0.0125) lower on the subscales motor functioning, sleep, lung and skin problems during bracing. No difference was observed between the study groups in the year the bracing had ended.

CONCLUSION

Dutch clubfoot patients show an overall good health related quality of life. However, during the brace phase of the Ponseti treatment they score lower in subscales in the physical functioning domain. These results can be used in the counselling of parent and might alleviate some concerns that parents have about the bracing period.

LEVEL OF EVIDENCE

Level III, Case control study.

The foot drawing method: reliability of measuring foot length and outward rotation in children with clubfoot

Background

The Ponseti method is the gold standard for clubfoot treatment. However, relapse and residual gait deviations are common, and follow-up until 7 years of age is recommended. We evaluated the reliability of the foot drawing method, a new instrument for the follow-up of clubfoot. The method uses drawings of the foot in the neutral position and external rotation to measure foot length and outward rotation.

Methods

Nineteen children aged 2.5–7 years who were treated with the Ponseti method for congenital clubfoot were included. Two raters made the drawings twice (D1 and D2). Each rater measured foot length, foot rotation, and foot–tibial rotation independently (D1). Later, the raters repeated the measurements (D2). Interrater reliability was assessed using the D1 from each rater. Intrarater reliability was assessed using the measurements from each rater’s D1 and D2. Bland–Altman plots were used to visualize the limits of agreement (LoA). The mean, 95% confidence interval, and one standard deviation of the differences in all measurements were calculated.

Results

The mean differences between and within raters were: foot length < 1 mm, foot rotation < 1°, and foot–tibia rotation < 2°, which indicated no systematic differences. The LoA for foot length were: 4.5 mm and 5.9 mm between raters for D1, − 4.8 mm and 5.9 mm for rater 1 (D1–D2), and − 5.1 mm and 5 mm for rater 2 (D1–D2). The LoA for foot rotation: were − 12° and 10.6° between raters (D1), − 8.4° and 6.6° for rater 1 (D1–D2), and − 14° and 14.1° for rater 2 (D1–D2). The LoA for foot–tibia rotation were: − 17.8° and 14.3° between raters (D1), − 12° and 12.2° for rater 1 (D1–D2), and − 12.7° and 13.6° for rater 2 (D1– D2).

Conclusions

The absence of systematic differences between and within raters, and LoA observed indicate that the foot drawing method is applicable in clinical practice and research. However, the results of the foot and foot–tibia rotation analyses imply that caution is needed when interpreting changes in foot rotation in feet with higher degrees of rotation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05465-9.

Muscle-tendon properties and functional gait outcomes in clubfoot patients with and without a relapse compared to typically developing children

BACKGROUND

Altered muscle-tendon properties in clubfoot patients could play a role in the occurrence of a relapse and negatively affect physical functioning. However, there is a lack of literature about muscle-tendon properties of clubfoot relapse patients.

RESEARCH QUESTION

The aim of this study was to determine whether the muscle architecture of the medial gastrocnemius and the morphology of the Achilles tendon differ between typically developing children (TDC) and clubfoot patients with and without a relapse clubfoot and to determine the relationships between morphological and functional gait outcomes.

METHODS

A cross-sectional study was carried out in clubfoot patients treated according to the Ponseti method and TDC aged 4-8 years. A division between clubfoot patients with and without a relapse was made. Fifteen clubfoot patients, 10 clubfoot relapse patients and 19 TDC were included in the study. Morphologic properties of the medial head of the Gastrocnemius muscle and Achilles tendon were assessed by ultrasonography. Functional gait outcomes were assessed using three-dimensional gait analysis. Mean group differences were analysed with ANOVA and non-parametric alternatives. Relationships between functional and morphologic parameters were determined for all clubfoot patients together and for TDC with Spearman's rank correlation.

RESULTS

Morphological and functional gait parameters did not differ between clubfoot patients with and without a relapse, with exception of lower maximal dorsiflexor moment in clubfoot relapse patients. Compared to TDC, clubfoot and relapse patients did show lower functional gait outcomes, as well as shorter and more pennate muscles with a longer Achilles tendon. In all clubfoot patients, this longer relative tendon was related to higher ankle power and plantarflexor moment.

SIGNIFICANCE

In clubfoot and relapse patients, abnormalities in morphology did not always relate to worse functional gait outcomes. Understanding these relationships in all clubfoot patients may improve the knowledge about clubfoot and aid future treatment planning.

This is a narrative review of the functional evaluation of clubfoot treatment with gait analysis

Clinicians worldwide have embraced Ponseti’s nonoperative approach in the treatment of clubfoot, primarily due to ubiquitous reports of successful outcomes. A crucial component in this measured success, has come from researchers assessing long-term physical function following nonoperative treatment. Gait analysis has been instrumental in objectively evaluating lower extremity kinematics and kinetics while plantar pressures demonstrate the load bearing patterns experienced in the foot. As technology improves, our ability to evaluate function can take place both in the laboratory setting, and in the community. For over 20 years, our institution has been studying the gait patterns of children treated for clubfoot. After adopting the nonoperative approach, we established a prospective research program that has allowed us to study functional outcomes in the very young walker, through growth to adolescents, and finally at skeletal maturity. We have seen over 450 children treated for clubfoot in the Movement Science Lab, for over 1,250 gait assessments over the span of this study. Early results in 105 children (154 feet) treated nonoperatively for clubfoot, showed 56% of children had normal sagittal plane ankle kinematics, however an incidence of 48% of Ponseti feet had increased dorsiflexion in stance phase, leading us to wonder if this was the result of the tenotomy. Intermediate follow up at age 5 years, showed that the incidence of increased dorsiflexion was reduced (24%) and ankle power did not appear to be affected (P>0.05 compared to controls). The research highlighted in this paper presents the application of functional evaluation through growth and the long-term effects of nonoperative treatment on gait and function. This is a review of the functional outcome studies from our experience at Scottish Rite for Children.

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.

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.

Normalization of Forefoot Supination After Tibialis Anterior Tendon Transfer for Dynamic Clubfoot Recurrence

BACKGROUND

We aimed to evaluate the effect of tibialis anterior tendon transfer (TATT) on foot motion in children with clubfoot recurrence after initial Ponseti treatment.

METHODS

Children with dynamic clubfoot recurrence after initial Ponseti treatment who underwent TATT between 2014 and 2017 were considered for inclusion. Exclusion criteria were neurological disease, split transfer of the tendon, additional bone or joint invasive surgery, and initial treatment abroad. Of 94 children (143 TATT), 36 met the inclusion criteria. Seventeen (47%) of the 36 children with 25 clubfeet and a mean age at the time of surgery of 6.8 years participated in the study. Gait analysis, including the Oxford foot model, was conducted preoperatively and postoperatively. Furthermore, kinematic and kinetic data were compared with those of age-matched healthy children (n=18).

RESULTS

Forefoot supination in relation to the hindfoot and tibia was reduced during swing and at initial contact after TATT compared with preoperative values. Forefoot supination in relation to the tibia at initial contact decreased from 12.4 to 5.2 degrees after TATT (control group, 6.0 degrees). The heel showed less dynamic varus and adduction movement after TATT compared with preoperatively. Maximum ankle power was reduced preoperatively and postoperatively compared with controls. Maximum ankle dorsiflexion slightly increased after TATT.

CONCLUSIONS

Gait analysis showed normalization of the main components of dynamic clubfoot recurrence after TATT. This joint-sparing surgery efficiently corrects recurrent dynamic deformity.

LEVEL OF EVIDENCE

Level II-therapeutic.

A comparative study of pedobarography and ankle kinematics between children with idiopathic clubfoot after a soft tissue release procedure and controls

PURPOSE

Surgery for idiopathic clubfoot, though limited in indications, should be performed by a selective soft tissue release. Aims of the study were to evaluate the pedobarography and ankle kinematics of the clubfoot post-surgery and compare with controls.

METHODS

Twenty-two patients (33 clubfeet) and 22 normal children (44 feet) were enrolled into the cross-sectional study. Demographic data were recorded. Plantar force measurements and ankle kinematic data were obtained and compared between clubfoot patients and controls by pedobarography and 3-dimensional gait analysis.

RESULTS

Clubfoot patients were operated at an average age of 12.8 ± 8.1 months. The average follow-up was 9.9 ± 3.9 years. Demographic data were comparable between the two groups. The plantar force in clubfoot patients was significantly lower than controls (108.2 ± 86.7 vs. 150.9 ± 73.9 N, p = 0.03). Clubfoot patients demonstrated a longer contact time, larger contact area, lower peak pressure, and force relative to body weight in toe, midfoot, and heel areas. The impulse was comparable between the two groups but the contact area, force, and force time integral concentrated at the midfoot region of the clubfoot. The ankle kinematics in clubfoot patients demonstrated a dorsiflexed position through late toe off. Range of dorsiflexion in the clubfoot was significantly higher than in controls. Foot adduction during stance, limited inversion-eversion, and limited plantar flexion during loading response and toe off were observed.

CONCLUSION

The results underscore the importance of limited soft tissue release during clubfoot surgery. Although the procedure could preserve range of motion at the ankle joint, muscle weakness and flatfoot deformity are prevalent.