A Longitudinal Review of Gait Following Treatment for Idiopathic Clubfoot: Gait Analysis at 2 and 5 Years of Age

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.

Three-dimensional gait analysis in children with recurrent idiopathic clubfoot undergoing complete tibialis anterior tendon transfer

This study was aimed to evaluate the kinetics and kinematics of the foot and ankle using three-dimensional gait analysis in children with recurrent clubfoot treated with tibialis anterior tendon transfer (TATT). Three-dimensional gait analysis of 17 children with dynamic supination (24 feet; 12 males; mean age: 6.34 years) was performed pre- and post-TATT. Spatial, temporal and kinematic parameters, as well as the gait deviation index (GDI), were recorded for all patients. Moreover, to evaluate the severity of dynamic supination during walking, we also measured the angle between the plane of the foot and the X-axis during the swing phase (V-angle-S). The postoperative step length (38.95 ± 8.36 cm) and stride length (76.73 ± 15.92 cm) were significantly smaller than their preoperative values (40.68 ± 9.35 cm and 80.57 ± 17.51 cm; P = 0.0316 and P = 0.0028, respectively). The postoperative peak internal ankle rotation angle in the frontal plane (20.45° ± 14.44) was significantly lower than the preoperative value (25.93° ± 9.84; P = 0.029). The postoperative peak internal foot progression angle in the transverse plane (0.96° ± 5.83) was significantly lower than the preoperative value (4.34° ± 8.88; P = 0.026). However, both the peak ankle varus moment and GDI were not significantly different between the pre- and postoperative data. Postoperative V-angle-S values (28.55° ± 7.56) were reduced compared to their preoperative values (32.52° ± 6.53; P = 0.0094). TATT to the lateral cuneiform can correct dynamic supination in patients with a recurrent clubfoot; however, it has limited or no effects on hindfoot varus deformity. Level of evidence: Level III.

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.

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.

Clinical examination and classification systems of congenital clubfoot: a narrative review

Clinical examination of the newborn's foot is a complex exercise that requires a lot of sensitivity, practice and deep understanding of normal and pathological anatomy, and the clinical assessment of a child with congenital talipes equinovarus, or congenital clubfoot, must be complete and it should not be limited to a simple orthopedic evaluation of the foot; the search for a cause is a pressing concern. This narrative review article aims to provide the key information about clinical examination of children with congenital clubfoot; classification systems are also described. Clinical examination of children with congenital clubfoot is essential. In particular, it is important to evaluate the mental age of the child (developmental milestones), to rule out the presence of a spinal dysraphism, to eliminate a mild form of neurological disease (congenital myopathy or arthrogryposis), as well as to carefully examine the face and hands of the patient. The examination of the foot and the classification of the clubfoot deformity complete the clinical evaluation. In the end, the pediatric orthopedic surgeon must not underestimate any clinical signs, and must act as a pediatrician. This narrative review summarizes the key points in taking a history and performing a comprehensive clinical examination for patients with congenital clubfoot; the review also briefly describes the normal foot anatomy and growth as to give the reader the opportunity to better understand the morphological and functional modifications secondary to congenital clubfoot.

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.

Plantar Pressures Following Surgical Release in Children With Clubfoot: Comparison of Posterior Release, Posteromedial Release, and Nonoperative Correction

BACKGROUND

Functional deficits observed at long-term follow-up in surgically released clubfeet have led to the adoption of a nonoperative approach. Gait results reported at age 5 years found ankle motion was limited in clubfeet treated by posteromedial release (PMR), compared with those that required posterior release (PR) or remained nonoperative. The purpose of this study was to assess plantar pressures in clubfeet that required surgical correction by 5 years of age.

METHODS

Pedobarograph data were collected at age 5 years on patients with clubfeet that underwent surgical correction due to residual deformity or recurrence. Plantar pressures were assessed by subdividing the foot into the medial/lateral hindfoot, midfoot, and forefoot regions. Variables included maximum force, contact area%, contact time% (CT%), the hindfoot-forefoot angle, and displacement of the center of pressure line. Surgical feet were divided into those that underwent an isolated PR versus PMR. A group of 72 clubfeet that remained nonoperative were matched by initial severity and used for comparison.

RESULTS

Pedobarograph data from 53 patients (72 clubfeet; 25 PR and 47 PMR) showed minimal differences between the PR and PMR feet. Compared with the nonoperative group, both surgical groups had increased CT% in the medial hindfoot and medial midfoot regions. An increase in lateral hindfoot CT% was observed in the PMR group. In addition, CT% in the first metatarsal region in the PMR group was reduced compared with the nonoperative group. Lateralization is present across both surgical groups in the center of pressure line and hindfoot-forefoot angle.

CONCLUSION

While there were minimal differences between surgical groups, patients who underwent PR exhibited pressure variables that were more comparable to the nonoperative group while the PMR group had greater deviations.

LEVEL OF EVIDENCE

Level II-therapeutic.

The 5-Year Outcome of the Ponseti Method in Children With Idiopathic Clubfoot and Arthrogryposis

BACKGROUND

The Ponseti method effectively treats idiopathic clubfoot, but its effectiveness in treating the stiffer clubfoot associated with arthrogryposis is less clear. The purpose of this study was to assess the comparative effectiveness of the Ponseti method in 5-year-old children with either idiopathic clubfoot or clubfoot due to arthrogryposis.

METHODS

The outcomes of the Ponseti method were retrospectively evaluated in children with idiopathic clubfoot and clubfoot associated with arthrogryposis. The children with clubfoot were seen at our hospital between 2012 and 2019 and were 4.0 to 6.9 years old at the time of their evaluation. Outcomes of the 2 groups of children with clubfoot were assessed using passive range of motion, foot pressure analysis, the Gross Motor Function Measure Dimension-D, and parent report using the Pediatric Outcomes Data Collection Instrument. These results were also compared with the same measures from a group of typically developing children. Surgical and bracing history was also recorded.

RESULTS

A total of 117 children were included (89 idiopathic clubfoot and 28 associated with arthrogryposis) with an average age of 4.8±0.8 years. The historical gait analyses of 72 typically developing children were used as a control, with an average age of 5.2±0.8 years. Significant residual equinovarus was seen in both children with idiopathic clubfoot and associated with arthrogryposis according to passive range of motion and foot pressure analysis when compared with normative data. Children with arthrogryposis demonstrated limited transfer and basic mobility, sports functioning, and global functioning while children with idiopathic clubfoot were significantly different from their typically developing peers in only transfer and basic mobility.

CONCLUSIONS

Although children with idiopathic clubfoot continue with some level of residual deformity, the Ponseti method is effective in creating a pain-free, highly functional foot. In children with clubfoot associated with arthrogryposis, the Ponseti method is successful in creating a braceable foot that can delay the need for invasive surgical intervention.

LEVEL OF EVIDENCE

Level III, Therapeutic Studies-Investigating the Results of Treatment.

In-toeing gait in children with clubfoot and the effect of tibial rotation osteotomy

In-toeing gait is common after treatment for clubfoot deformity and is often secondary to residual internal tibial torsion. The purpose of the current study was to characterize the gait pattern in children with an intoeing gait pattern associated with talipes equinovarus (TEV) deformity, identify secondary changes at the hip that occur with intoeing, and determine if these secondary effects resolve after correction of tibial torsion. Patients with a diagnosis of TEV deformity, in-toeing gait secondary to residual internal tibial torsion corrected with tibial rotation osteotomy (TRO) and complete preoperative and postoperative motion analysis studies obtained approximately 1 year apart, were included in the study. Nineteen children (19 left extremities) with a TRO at a mean age of 8.2 years met inclusion criteria. Clinical examination showed improvement in tibial torsion assessment by measure of the thigh foot axis and transmalleolar axis. Kinematically, an abnormal internal FPA was present in all cases preoperatively, was corrected to normal in 12 (63%), remained internal in 5 (26%), and was abnormally external in 2 (11%). External hip rotation was identified in 13 (68%) cases preoperatively. Hip rotation was normalized postoperatively in 7 (54%), and was unchanged in the remaining 6 (46%). TRO provides effective correction of excessive internal tibial torsion, resolution of kinematic internal knee rotation, and normalization of the internal foot progression angle in the majority of patients with TEV deformity. External hip rotation resolved in approximately 50% of cases. Overcorrection of the internal FPA is possible when secondary changes at the hip do not resolve.

Plantar Pressure Distribution of Right and Left Foot in Bilateral Clubfoot Treated by Ponseti Method: A Correlation Analysis

Background

Congenital clubfoot is a common pediatric orthopedic deformity that can be corrected by Ponseti method, and pedobarographic analysis has been used to assess the outcomes. However, the relationship between the plantar pressure distribution of the right and left foot in children with bilateral clubfoot has not been studied. In this study, the pedobarographic data of patients with bilateral clubfoot who were treated by the Ponseti method were reviewed, and a correlation analysis was conducted to clarify the relationship between the right and left foot.

Material/Methods

A retrospective cross-sectional study of children with bilateral clubfoot who were treated by the Ponseti method in infancy was performed, in which all the patients were available for clinical evaluation, and pedobarographic analysis was conducted on each patient after treatment. The Pearson’s correlation coefficient (r) were calculated for all the measurements of the left and right foot.

Results

A total of 20 children (mean age 6.9±1.07 years, range 4–8 years) with bilateral clubfoot who were treated by the Ponseti method were included. The Dimeglio and Pirani scores before and after treatment between the right and left foot were significantly correlated. All the pedobarographic measurements between the left and right foot were correlated, indicating different degrees of positive correlation.

Conclusions

The plantar pressure measurements between the 2 feet in patients with bilateral clubfoot were highly correlated before treatment, and a correlation was also observed after those patients were treated by the Ponseti method. We should take these correlations into consideration during study design and analysis of clubfoot cases.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

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.

Gross Motor Skills in Children With Idiopathic Clubfoot and the Association Between Gross Motor Skills, Foot Involvement, Gait, and Foot Motion

BACKGROUND

Little is known regarding gross motor skills (GMS) in children with idiopathic clubfoot (IC). This study describes GMS, specifically foot involvement and asymmetries, and analyses the association between GMS, gait, and foot status in children with IC.

METHODS

Gross motor tasks and gait were analyzed in children with IC and typically developed (TD) children. GMS were assessed using videotapes and the Clubfoot Assessment Protocol (CAP). The Gait Deviation Index (GDI) and GDI-Kinetic were calculated from gait analyses. Children were divided into bilateral, unilateral clubfoot, or TD groups. To analyze asymmetries, feet within each group were further classified into superior or inferior foot, depending on their CAP scores. Correlations identified associations between CAP and GDI, GDI-Kinetic, passive foot motion, and Dimeglio Classification Scores at birth in the clubfeet.

RESULTS

In total, 75 children (mean age, 5 years) were enrolled (bilateral n=22, unilateral clubfoot n=25, TD=28). Children with clubfeet demonstrated significantly lower GMS, gait, and foot motion compared with TD children. One leg standing and hopping deviated in 84% and 91%, respectively, in at least one foot in children with clubfoot. Gross motor asymmetries were evident in both children with bilateral and unilateral involvement. In children with unilateral clubfoot, contralateral feet showed few deviations in GMS compared with TD; however, differences existed in gait and foot motion. The association between GMS and gait, foot motion, and initial foot status varied between poor and moderate.

CONCLUSIONS

Gross motor deficits and asymmetries are present in children with both bilateral and unilateral IC. Development of GMS of the contralateral foot mirrors that of TD children, but modifies to the clubfoot in gait and foot motion. The weak association with gait, foot motion, and initial clubfoot severity indicates that gross motor measurements represent a different outcome entity in clubfoot treatment. We therefore, recommend gross motor task evaluation for children with IC.

LEVEL OF EVIDENCE

Level II-prognostic studies.

Functional physiotherapy method results for the treatment of idiopathic clubfoot

BACKGROUND

Idiopathic clubfoot is a congenital deformity of multifactorial etiology. The initial treatment is eminently conservative; one of the methods applied is the Functional physiotherapy method (FPM), which includes different approaches: Robert Debré (RD) and Saint-Vincent-de-Paul (SVP) among them. This method is based on manipulations of the foot, bandages, splints and exercises adapted to the motor development of the child aimed to achieve a plantigrade and functional foot. Our hypothesis was that the SVP method could be more efficient than the RD method in correcting deformities, and would decrease the rate of surgeries.

AIM

To compare the RD and SVP methods, specifically regarding the improvement accomplished and the frequency of surgery needed to achieve a plantigrade foot.

METHODS

Retrospective study of 71 idiopathic clubfeet of 46 children born between February 2004 and January 2012, who were evaluated and classified in our hospital according to severity by the Dimeglio-Bensahel scale. We included moderate, severe and very severe feet. Thirty-four feet were treated with the RD method and 37 feet with the SVP method. The outcomes at a minimum of two years were considered as very good (by physiotherapy), good (by percutaneous heel-cord tenotomy), fair (by limited surgery), and poor (by complete surgery).

RESULTS

Complete release was not required in any case; limited posterior release was done in 23 cases (74%) with the RD method and 9 (25%) with the SVP method (P < 0.001). The percutaneous heel-cord tenotomy was done in 2 feet treated with the RD method (7%) and 6 feet (17%) treated with the SVP method (P < 0.001). Six feet in the RD group (19%) and twenty-one feet (58%) in the SVP group did not require any surgery (P < 0.001).

CONCLUSION

Our study provides evidence of the superiority of the SVP method over the RD method, as a variation of the FPM, for the treatment of idiopathic clubfoot.

Correlations between the Gait Profile Score and standard clinical outcome measures in children with idiopathic clubfoot

BACKGROUND

Measures of overall gait deviations such as the Gait Profile Score (GPS) and the Gait Variable Score (GVS) are used to evaluate gait in clinical practice and for research purposes. In the clinical setting, gait deviations are often visually assessed and classified using structured protocols such as the Clubfoot Assessment Protocol (CAP).

RESEARCH QUESTION

Determine the relationship between measures of overall gait deviations and clinical assessments.

METHODS

This cross-sectional study evaluated the usability of GPS and GVS in children with idiopathic clubfoot. Twenty consecutively born children with idiopathic clubfoot participated in this study. At 7 years of age, the children were referred for three-dimensional gait analysis and, on the same day, they also underwent a clinical examination according to the CAP.

RESULTS

The overall gait deviations, expressed as the GPS (overall and affected side) and the GVS for nine key variables were calculated. The correlations between the GPS and values from CAP, its domains, and a single item called walking and between the item walking and the GVS values were analyzed using the Spearman's rank correlation coefficient (r_s). The item walking correlated significantly with the GPS (r_s = -0.62), and the GVS for foot progression (r_s = -0.61) and foot dorsiflexion/plantarflexion (r_s = -0.50). The domain "morphology" correlated with the GPS (r_s = 0.64).

SIGNIFICANCE

These findings indicate that the GPS index along with the GVS reflects gait deviations observed clinically in children with clubfoot.

Functional Outcomes Following Treatment for Clubfoot: Ten-Year Follow-up

BACKGROUND

The purpose of this study was to assess function, at the age of 10 years, of children initially treated nonoperatively for clubfoot with either the Ponseti or French physiotherapy program and to compare outcomes in feet that had undergone only nonoperative treatment with those that required subsequent surgery.

METHODS

Gait analysis, isokinetic ankle strength, parent-reported outcomes, and daily step activity data were collected when patients who had been treated for idiopathic clubfoot reached the age of 10 years. Patients who had undergone only nonoperative treatment were compared with those who subsequently underwent extra-articular surgery or intra-articular surgery (posterior release or posteromedial release). The clubfoot groups were compared with age-matched controls.

RESULTS

Of 263 treated clubfeet in 175 patients, 148 had only been treated nonoperatively, 29 underwent extra-articular surgery, and 86 underwent intra-articular surgery (posterior release in 42 and posteromedial release in 44). Significant abnormalities were found in ankle kinetics and isokinetic ankle strength in the feet treated with intra-articular surgery compared with the nonoperatively treated feet (p < 0.017). Compared with controls (n = 40 feet), all groups showed reduced ankle plantar flexion during gait, resulting in a deficit of 9% to 14% for dynamic range of motion, 13% to 20% for ankle moment, and 13% to 23% for power (p < 0.013). Within the intra-articular group, feet that underwent posteromedial release had decreased plantar flexion strength (15%; p = 0.008), dorsiflexion strength (6%; p = 0.048), and parent-reported global function scores (p = 0.032) compared with the posterior release group. The patients with clubfoot took 10% fewer steps (p = 0.015) and had 11% less total ambulatory time (p = 0.001) than the controls.

CONCLUSIONS

Examination of patients when they had reached the age of 10 years showed better ankle power and isokinetic strength for clubfeet treated without surgery compared with those that underwent intra-articular surgery for residual deformity or recurrence. Compared with controls, both nonoperatively and surgically treated clubfeet had significant limitations in ankle plantar flexion resulting in decreased range of motion, moment, and power. Gastrocnemius-soleus complex strength was decreased after both nonoperative and surgical treatment of clubfeet. Although activity was diminished in the clubfoot population, no differences in function were perceived by the patients' parents.

LEVEL OF EVIDENCE

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

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.

Clubfoot Does Not Impair Gross Motor Development in 5-Year-Olds

PURPOSE

To evaluate the gross motor development of 5-year-olds using the Peabody Developmental Motor Scales, 2nd Edition (PDMS-2), test after initial nonoperative management of clubfoot as infants.

METHODS

The PDMS-2 Stationary, Locomotion, and Object Manipulation subtests were assessed on 128 children with idiopathic clubfeet at the age of 5 years. Children were categorized by their initial clubfoot severity as greater than 13, unilateral or bilateral involvement, and required surgery.

RESULTS

Children with treated clubfeet had average gross motor scores (99 Gross Motor Quotient) compared with age-matched normative scores. Children with more severe clubfeet required surgery significantly more than children with less severe scores (P < .01). Peabody scores were not significantly different according to initial clubfoot severity, unilateral versus bilateral involvement, and surgical versus nonsurgical outcomes.

CONCLUSIONS

Clubfoot does not significantly impair gross motor development in 5-year-olds.

Gait in 5-year-old children with idiopathic clubfoot: A cohort study of 59 children, focusing on foot involvement and the contralateral foot

Background and purpose - Idiopathic clubfoot can be bilateral or unilateral; however, most studies of gait have assessed clubfoot cases as one uniform group. The contralateral foot in children with unilateral clubfoot has shown deviations in pedobarographic measurements, but it is seldom included in studies of gait. We evaluated gait in children with idiopathic clubfoot, concentrating on foot involvement. Patients and methods - Three-dimensional gait analyses of 59 children, mean age 5.4 years, with bilateral (n = 30) or unilateral (n = 29) idiopathic clubfoot were stratified into groups of bilateral, unilateral, or contralateral feet. Age-matched controls (n = 28) were evaluated for comparison. Gait assessment included: (1) discrete kinematic and kinetic parameters, and (2) gait deviation index for kinematics (GDI) and kinetics (GDI-k). Results - No differences in gait were found between bilateral and unilateral idiopathic clubfoot, but both groups deviated when compared to controls. Compared to control feet, contralateral feet showed no deviations in discrete gait parameters, but discrepancies were evident in relation to unilateral clubfoot, causing gait asymmetries in children with unilateral involvement. However, all groups deviated significantly from control feet according to GDI and GDI-k. Interpretation - Bilateral and unilateral idiopathic clubfoot cases show the same persistent deviations in gait, mainly regarding reduced plantarflexion. Nevertheless, knowledge of foot involvement is important as children with unilateral clubfoot show gait asymmetries, which might give an impression of poorer deviations. The results of GDI/GDI-k indicate global gait adaptations of the contralateral foot, so the foot should preferably not be used as a reference for gait.

Functional Assessment of the Foot Undergoing Percutaneous Achilles Tenotomy in Term of Gait Analysis

Background. This study was designed to evaluate the function of the foot undergoing the procedure of percutaneous Achilles tenotomy (PAT) in case of clubfoot management in terms of gait analysis. Methods. Nineteen patients with unilateral clubfeet were retrospectively reviewed from our database from July 2012 to June 2016. The result in all the cases was rated as excellent according to the scale of International Clubfoot Study Group (ICSG). The affected sides were taken as Group CF and the contralateral sides as Group CL. Three-dimensional gait analysis was applied for the functional evaluation of the involved foot. Results. Statistical difference was found in physical parameters of passive ankle dorsiflexion and plantar-flexion. No statistical difference was found in temporal-spatial parameters. There was statistical difference in kinematic parameters of total ankle rotation, ankle range of motion, and internal foot progression angle and in kinetic parameters of peak ankle power. No statistical difference was found in other kinematic and kinetic parameters. Conclusions. It is demonstrated that the procedure of PAT is safe and efficient for correcting the equinus deformity in case of clubfoot management and preserving the main function of Achilles tendon at the minimum of four-year follow-up.