Ankle Range of Motion After Posterior Subtalar and Ankle Capsulotomy for Relapsed Equinus in Idiopathic Clubfoot

What is the optimal treatment for equinus deformity in walking-age children with clubfoot? A systematic review

Equinus contracture is the most common deformity at clubfoot relapse and causes pain and functional limitation. It presents a challenge to the orthopaedic surgeon throughout childhood.A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies included were: (i) original articles, (ii) investigating management of relapsed idiopathic clubfoot, (iii) with at least a partial study population of primarily equinus deformity, and (iv) a paediatric study population of independent walking age.Nine studies were included with a total of 163 patients (207 feet). Studies presented five management paradigms: gastrocnemius-soleus complex release, extensive posterior soft tissue and joint release, anterior distal tibial hemi-epiphysiodesis, distal tibial osteotomy, and circular frame distraction.All approaches reported success in at least one of our selected outcome domains: plantigrade status, range of motion, clinical outcome scores, functional status, radiographic outcomes, patient-reported outcomes, and complications. Younger children tend to be managed with soft tissue release while older children tend to require more extensive bone/joint procedures. Relapse in surgically treated feet is harder to treat.Comparison across treatment approaches is limited by the small size and low evidence level of the literature, as well as a lack of consistent outcome reporting. It is therefore not possible to recommend any one treatment option in any age group.This review highlights the need for a validated core outcome set to enable high-quality research into the management of equinus deformity. Cite this article: EFORT Open Rev 2021;6:354-363. DOI: 10.1302/2058-5241.6.200110.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III.

Effect of Achilles tendon on kinematic coupling relationship between tarsal bones: a pilot finite element study

BACKGROUND

The procedure of percutaneous Achilles tenotomy (PAT) is an important component of the Ponseti method. However, few studies reported the influence of Achilles tendon on kinematic coupling relationship between tarsal bones. The purpose of present study was to demonstrate the effect of Achilles tendon on the kinematic coupling relationship between tarsal bones, and to illustrate how kinematic coupling relationship between tarsal bones works in term of finite element analysis.

METHODS

A three-dimensional finite element model of foot and ankle was constructed based on the Chinese digital human girl No.1 (CDH-G1) image database using the software of mimics, Geomagic studio, HyperMesh, and Abaqus. The last manipulation of the Ponseti method before the procedure of PAT was simulated. The talus head and the proximal tibia and fibula bone were fixed in all six degrees of freedom, and the outward pressure was added on the first metatarsal head to investigate the kinematic coupling relationship between tarsal bones.

RESULTS

The least relationship of kinematic coupling between tarsal bones was found in calcaneus. Stress concentration was mainly observed at the navicular, talus and the medial malleolus. The difference in displacement of the navicular was only found with the Achilles tendon stiffness of 0 N/mm and others. No difference in the navicular displacement was found in the stiffness of Achilles tendon between 40, 80, 200, 400, and 1000 N/mm. The maximum displacement of navicular was observed at the ankle position of PF-20° (plantar flexion-20°). The difference in displacement of the navicular was greater at the ankle position of PF-20° with the Achilles tendon stiffness of 0 N/mm than that at the ankle position of PF-40° with the Achilles tendon stiffness of 40 N/mm.

CONCLUSIONS

Based on the findings from this study, it was demonstrated that the Achilles tendon existence or not and ankle position had great influence, while increased stiffness of Achilles tendon had no influence on kinematic coupling relationship between tarsal bones. For the cases with severe equinus, earlier implementation of PAT procedure (with the purpose of release the Achilles tendon and reduce the degree of ankle plantar flexion) may be beneficial to the deformity correction.

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.

Treatment of relapsed, residual and neglected clubfoot: adjunctive surgery

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

LEVEL OF EVIDENCE

V.

What is new in idiopathic clubfoot?

Idiopathic clubfoot has a tremendous worldwide prevalence. If left untreated, the deformity has severely disabling effects on mobility and quality of life. Given its prevalence and significance, numerous studies are published on this condition every year. In this article, we attempt to highlight important themes and findings of studies published on idiopathic clubfoot over the past 3 years.