1
|
Gelfer Y, Cavanagh SE, Bridgens A, Ashby E, Bouchard M, Leo DG, Eastwood DM. The Core outcome Clubfoot (CoCo) study: relapse, with poorer clinical and quality of life outcomes, affects 37% of idiopathic clubfoot patients. Bone Joint J 2024; 106-B:735-743. [PMID: 38945546 DOI: 10.1302/0301-620x.106b7.bjj-2023-1258.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Aims There is a lack of high-quality research investigating outcomes of Ponseti-treated idiopathic clubfeet and correlation with relapse. This study assessed clinical and quality of life (QoL) outcomes using a standardized core outcome set (COS), comparing children with and without relapse. Methods A total of 11 international centres participated in this institutional review board-approved observational study. Data including demographics, information regarding presentation, treatment, and details of subsequent relapse and management were collected between 1 June 2022 and 30 June 2023 from consecutive clinic patients who had a minimum five-year follow-up. The clubfoot COS incorporating 31 parameters was used. A regression model assessed relationships between baseline variables and outcomes (clinical/QoL). Results Overall, 293 patients (432 feet) with a median age of 89 months (interquartile range 72 to 113) were included. The relapse rate was 37%, with repeated relapse in 14%. Treatment considered a standard part of the Ponseti journey (recasting, repeat tenotomy, and tibialis anterior tendon transfer) was performed in 35% of cases, with soft-tissue release and osteotomies in 5% and 2% of cases, respectively. Predictors of relapse included duration of follow-up, higher initial Pirani score, and poor Evertor muscle activity. Relapse was associated with poorer outcomes. Conclusion This is the first multicentre study using a standardized COS following clubfoot treatment. It distinguishes patients with and without relapse in terms of clinical outcomes and QoL, with poorer outcomes in the relapse group. This tool allows comparison of treatment methods and outcomes, facilitates information sharing, and sets family expectations. Predictors of relapse encourage us to create appropriate treatment pathways to reduce relapse and improve outcome.
Collapse
Affiliation(s)
- Yael Gelfer
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's University of London, London, UK
| | - Sean E Cavanagh
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's University of London, London, UK
| | - Anna Bridgens
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Maryse Bouchard
- The Hospital for Sick Children, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Donato G Leo
- St George's University Hospitals NHS Foundation Trust, London, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Deborah M Eastwood
- Great Ormond Street Hospital, London, UK
- University College London, London, UK
| |
Collapse
|
2
|
Johansson A, Wallander H, Esbjörnsson AC. Initial clubfoot treatment in Sweden from 2016 to 2019: A national register study. PLoS One 2024; 19:e0305900. [PMID: 38924021 PMCID: PMC11207129 DOI: 10.1371/journal.pone.0305900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND This study aimed to describe the initial treatment of clubfoot deformity in Sweden using a national cohort. Secondarily we aimed to analyse the results of the initial treatment in relation to foot severity and additional diseases. METHODS A national register, the Swedish Pediatric Orthopedic Quality Register, was used to extract data on children born with clubfoot in 2016-2019. Children with a registered evaluation after initial treatment were included. Data on deformity severity (Pirani score), casting treatment, and achillotenotomy were extracted. For children with bilateral clubfeet, one foot was included in the analysis. RESULTS A total of 565 children were included in the analysis. Of these, 73% were boys and 47% had bilateral clubfeet. Children with isolated clubfoot required a median of six casts to correct the deformity, while children with non-isolated clubfoot needed a median of eight casts. Seventy-seven percent underwent an achillotenotomy. Residual deformities of 0.5 or above (often soft-tissue issues) according to the Pirani score were noted in 23% (isolated clubfoot) and 61% (non-isolated clubfoot) after initial treatment. CONCLUSIONS We have described the initial clubfoot treatment of children born with isolated or non-isolated clubfoot in Sweden based on data from a national register. The initial treatment was performed to a large extent according to the Ponseti method and international recommendations. Moreover, we discuss the usefulness of the Pirani score in classifying clubfoot deformity after treatment.
Collapse
Affiliation(s)
- Arne Johansson
- Department of Orthopaedics, Skaraborg Hospital, Skövde, Sweden
| | - Henrik Wallander
- Departments of Orthopedic Surgery, Gävle Hospital, Gävle, Sweden
| | - Anna-Clara Esbjörnsson
- Department of Clinical Sciences Lund, Orthopaedics, Skane University Hospital, Lund University, Lund, Sweden
| |
Collapse
|
3
|
Sharma L, Agarwal A, Garg V, Ankitha K, Sachdeva K. Parent reported outcomes for idiopathic clubfoot children treated with the Ponseti technique: An analysis of 140 feet followed minimum 5 years. J Clin Orthop Trauma 2024; 53:102432. [PMID: 38947857 PMCID: PMC11209628 DOI: 10.1016/j.jcot.2024.102432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/15/2024] [Accepted: 06/05/2024] [Indexed: 07/02/2024] Open
Abstract
Objective The treated clubfoot children are often evaluated clinically during follow-up. However, patient reported outcomes (PROM) are seldom analysed for these children. We investigated 87 idiopathic clubfoot children (140 feet) treated by the Ponseti method and followed minimum 5 years to study their clinical outcomes and PROM. Material and methods This was a cross-sectional study, based on evaluating treated clubfoot children clinically (Pirani score) and PROM (Oxford Ankle and Foot Questionnaire - Parent Version) and comparing them with the age-matched healthy controls (n = 60). The questionnaire has four main domains related to the child's physical, school and play, emotional and footwear profile. The children having persistent deformity (residual/relapse) were specifically studied for their PROM scores. Results The mean child age at initial treatment was 2.3 months and the mean follow-up duration was 6.9 years. The PROM score of clubfoot children was statistically lower than the healthy controls (p < 0.001). Of the individual domains, the physical domain was the most affected. On calculating the Pirani scores, 10 out of 140 feet (7 %) had some form of persistent deformity. The children with persistent deformity had lower Oxford scores than healthy children or those with corrected feet. The physical domain followed by the emotional domain scored low when persistent deformity was present. Conclusions Most children (98 %) had a plantigrade foot following Ponseti treatment at follow-up. However, PROM score of the clubfoot children did not correspond to the clinical outcome. Persistent deformity, even minor, was a cause of parental concern and resulted in a low PROM score.
Collapse
Affiliation(s)
- Lokesh Sharma
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India
| | - Anil Agarwal
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India
| | - Varun Garg
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India
| | - K.S. Ankitha
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India
| | - Kishmita Sachdeva
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India
| |
Collapse
|
4
|
Naili JE, Lindeberg M, Esbjörnsson AC. Duration and outcome of orthotic treatment in children with clubfoot - a four-year follow-up national register study of Swedish children born between 2015 and 2017. BMC Musculoskelet Disord 2024; 25:425. [PMID: 38822269 PMCID: PMC11143618 DOI: 10.1186/s12891-024-07544-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/27/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND The Ponseti method for treating clubfoot consists of initial treatment with serial casting accompanied by achillotenotomy if needed, followed by the maintenance phase including treatment with a foot abduction orthosis (FAO) for at least four years. This study aimed to examine the duration, course, and outcome of orthotic treatment in children with clubfoot. METHODS 321 children with clubfoot, born between 2015 and 2017, registered in the Swedish Pediatric Orthopedic Quality Register (SPOQ), were included in this prospective cohort study. Data on deformity characteristics and orthotic treatment were extracted. For children with bilateral clubfoot, one foot was included in the analysis. RESULTS Of the 288 children with isolated clubfoot, 274 children (95.5%) were prescribed an FAO, and 100 children (35%) changed orthosis type before 4 years of age. Of the 33 children with non-isolated clubfoot, 25 children (76%) were prescribed an FAO, and 21 children (64%) changed orthosis type before 4 years of age. 220 children with isolated clubfoot (76%), and 28 children with non-isolated clubfoot (84%) continued orthotic treatment until 4 years of age or longer. Among children with isolated clubfoot, children ending orthotic treatment before 4 years of age (n = 63) had lower Pirani scores at birth compared to children ending orthotic treatment at/after 4 years of age (n = 219) (p = 0.01). It was more common to change orthosis type among children ending orthotic treatment before 4 years of age (p = 0.031). CONCLUSIONS The majority of children with clubfoot in Sweden are treated with an FAO during the maintenance phase. The proportion of children changing orthosis type was significantly greater and the Pirani score at diagnosis was lower significantly among children ending orthotic treatment before 4 years of age. Long-term follow-up studies are warranted to fully understand how to optimize, and individualize, orthotic treatment with respect to foot involvement and severity of deformity. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Josefine Eriksson Naili
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
- Motion Analysis Lab, Karolinska University Hospital, Stockholm, Sweden.
| | - Malin Lindeberg
- Department of Orthopedics, Skane University Hospital, Lund, Sweden
| | - Anna-Clara Esbjörnsson
- Department of Clinical Sciences and Infectious Diseases, Skane University Hospital, Lund University, Lund, Sweden
| |
Collapse
|
5
|
Tabard-Fougère A, Bonnefoy-Mazure A, Dayer R, Vazquez O, De Coulon G. The Importance of Having a Single, Dedicated Medical Team to Treat Congenital Talipes Equinovarus Using the Ponseti Method: A Retrospective Analysis of Treatment Outcomes After 3 Years of Follow-up. J Pediatr Orthop 2024; 44:e361-e368. [PMID: 38189483 PMCID: PMC10913856 DOI: 10.1097/bpo.0000000000002613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Congenital talipes equinovarus (CTEV) is a relatively common pediatric orthopaedic disorder and a frequent cause of disability in adult populations. The Ponseti method has emerged as the generally preferred for treating children with CTEV. Strict adherence to this technique's basic principles is critical to achieving favorable outcomes. In 2013, our institution decided that every case of pediatric CTEV would be treated by a single dedicated medical team. The present study aimed to compare the treatment outcomes of children with CTEV treated using the Ponseti method in period I (multiple surgeons) versus those in period II (single dedicated team). PATIENTS AND METHODS We included respectively the children with CTEV treated using the Ponseti method in Geneva University Hospitals' pediatric units from 2007 to 2018. Data on patient demographics, clinical characteristics, and the treatment outcomes were collected. The primary outcome was the number of relapsed feet (treatment failure) after 3 years of follow-up. The 2 periods' outcomes were compared using χ 2 and independent Student t -tests. Run charts were used to report yearly rates of complications, minor and major recurrences, treatment failure, brace noncompliance, and feet that underwent tenotomy. RESULTS A total of 48 feet (32 patients) and 42 feet (29 patients) in periods I and II were included. The periods showed similar rates for participants' characteristics. The run charts illustrated the overall improvements in treatment outcomes in period II. A total of 8 relapsed feet (5 patients) were reported, all during period I. CONCLUSIONS Since all the pediatric CTEV patients at our institution began to be treated by a single dedicated medical team, we have observed a decrease in all recurrences and complications and an absence of treatment failure. These results highlight the importance of the continuity of care and strict adherence to the Ponseti method. LEVEL OF EVIDENCE Level-III Retrospective comparative study.
Collapse
Affiliation(s)
| | - Alice Bonnefoy-Mazure
- Kinesiology Laboratory, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | | | | |
Collapse
|
6
|
Novintan S, Campioni-Norman D, Hulme A. Investigations and management of complex congenital talipes equinovarus. BMJ Case Rep 2024; 17:e256114. [PMID: 38373814 PMCID: PMC10882447 DOI: 10.1136/bcr-2023-256114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
Congenital talipes equinovarus (CTEV) is a congenital deformity affecting the feet, commonly idiopathic in nature. We present a previously unreported cause of a non-idiopathic clubfoot and highlight the importance of poor response to initial treatment.A poor response to Ponseti serial casting for CTEV should alert a clinician to the fact that the foot may not be in the 'idiopathic' group and be of a more complex nature. Idiopathic clubfoot should correct with a maximum of eight serial manipulations, cast applications and Achilles tendon tenotomy. If this is not the case, a repeat careful history, full examination, further investigations and review of the treatment method are required.
Collapse
|
7
|
Maghfuri HB, Alshareef AA. The Efficacy of the Ponseti Method in the Management of Clubfoot: A Systematic Review. Cureus 2024; 16:e52482. [PMID: 38371124 PMCID: PMC10873899 DOI: 10.7759/cureus.52482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Clubfoot is a congenital abnormality of the lower extremities, and it may be unilateral or bilateral. Left untreated, it may lead to issues with walking. Additionally, inappropriate treatment or the lack of treatment can result in functional damage. The goal of clubfoot treatment is to correct the deformities of the involved components. The Ponseti method has been regarded as the gold standard for the treatment of clubfoot as it is safe and effective. In this review, we aimed to assess the success of the Ponseti method in the treatment of clubfoot by reviewing the previous studies on this subject. We searched electronic databases, including PubMed, Scopus, Science Direct, and Google Scholar, for relevant articles spanning the period from 2018 to 2023. The keywords used in the search were "Ponseti method, Treatment, Outcomes, Success, Relapse, Failure, and Rates." The inclusion criteria were original articles in English on clubfoot patients treated with the Ponseti method. While our search yielded a total of 1,037 articles, only nine were deemed eligible for analysis based on the inclusion criteria. The articles involved a total of 537 feet of 358 patients and the age of the patients ranged from one day to five years. The success rate ranged between 55% and 100%, and the relapse rate ranged between 3.2% and 34.2%. Based on our findings, the Ponseti method has a high success rate in the treatment of idiopathic clubfoot, and hence it is an excellent conservative method of treatment. However, there are additional factors that may affect the treatment outcomes, which need to be taken into account.
Collapse
Affiliation(s)
- Hassan B Maghfuri
- Orthopedic Surgery, Ministry of Health, Jizan, SAU
- Pediatric Orthopedics, Abha Maternity and Children Hospital, Abha, SAU
| | - Ali A Alshareef
- Orthopedic Surgery, Armed Forces Hospital Southern Region, Khamis Mushait, SAU
| |
Collapse
|
8
|
Hussain SA, Russell A, Cavanagh SE, Bridgens A, Gelfer Y. A 'Hub and Spoke' Shared Care initiative for CTEV Ponseti service. Bone Jt Open 2023; 4:865-872. [PMID: 37963491 PMCID: PMC10645486 DOI: 10.1302/2633-1462.411.bjo-2023-0076.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
Aims The Ponseti method is the gold standard treatment for congenital talipes equinovarus (CTEV), with the British Consensus Statement providing a benchmark for standard of care. Meeting these standards and providing expert care while maintaining geographical accessibility can pose a service delivery challenge. A novel 'Hub and Spoke' Shared Care model was initiated to deliver Ponseti treatment for CTEV, while addressing standard of care and resource allocation. The aim of this study was to assess feasibility and outcomes of the corrective phase of Ponseti service delivery using this model. Methods Patients with idiopathic CTEV were seen in their local hospitals ('Spokes') for initial diagnosis and casting, followed by referral to the tertiary hospital ('Hub') for tenotomy. Non-idiopathic CTEV was managed solely by the Hub. Primary and secondary outcomes were achieving primary correction, and complication rates resulting in early transfer to the Hub, respectively. Consecutive data were prospectively collected and compared between patients allocated to Hub or Spokes. Mann-Whitney U test, Wilcoxon signed-rank test, or chi-squared tests were used for analysis (alpha-priori = 0.05, two-tailed significance). Results Between 1 March 2020 and 31 March 2023, 92 patients (139 feet) were treated at the service (Hub 50%, n = 46; Spokes 50%, n = 46), of whom nine were non-idiopathic. All patients (n = 92), regardless of allocation, ultimately achieved primary correction, with idiopathic patients at the Hub requiring fewer casts than the Spokes (mean 4.0 (SD 1.4) vs 6.9 (SD 4.4); p < 0.001). Overall, 60.9% of Spokes' patients (n = 28/46) required transfer to the Hub due to complications (cast slips Hub n = 2; Spokes n = 17; p < 0.001). These patients ultimately achieved full correction at the Hub. Conclusion The Shared Care model was found to be feasible in terms of providing primary correction to all patients, with results comparable to other published services. Complication rates were higher at the Spokes, although these were correctable. Future research is needed to assess long-term outcomes, parents' satisfaction, and cost-effectiveness.
Collapse
Affiliation(s)
- Sabba A. Hussain
- Trauma and Orthopaedics Department, St George’s University Hospitals NHS Foundation Trust, London, UK
- St George’s University of London, London, UK
| | - Aisling Russell
- Paediatric Physiotherapy Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Sean E. Cavanagh
- Trauma and Orthopaedics Department, St George’s University Hospitals NHS Foundation Trust, London, UK
- St George’s University of London, London, UK
| | - Anna Bridgens
- Trauma and Orthopaedics Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Yael Gelfer
- Trauma and Orthopaedics Department, St George’s University Hospitals NHS Foundation Trust, London, UK
- St George’s University of London, London, UK
| |
Collapse
|
9
|
Quinlan R, Pacey V, Ilhan E, Gibbons P, Gray K. Subgroups of Idiopathic Clubfoot Can Predict Short-term Outcomes. J Pediatr Orthop 2023; 43:326-331. [PMID: 36914260 DOI: 10.1097/bpo.0000000000002382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND The Pirani scale is used for the assessment of Ponseti-managed clubfoot. Predicting outcomes using the total Pirani scale score has varied results, however, the prognostic value of midfoot and hindfoot components remains unknown. The purpose was to (1) determine the existence of subgroups of Ponseti-managed idiopathic clubfoot based on the trajectory of change in midfoot and hindfoot Pirani scale scores, (2) identify time points, at which subgroups can be distinguished, and (3) determine whether subgroups are associated with the number of casts required for correction and need for Achilles tenotomy. METHODS Medical records of 226 children with 335 idiopathic clubfeet, over a 12-year period, were reviewed. Group-based trajectory modeling of the Pirani scale midfoot score and hindfoot score identified subgroups of clubfoot that followed statistically distinct patterns of change during initial Ponseti management. Generalized estimating equations determined the time point, at which subgroups could be distinguished. Comparisons between groups were determined using the Kruskal-Wallis test for the number of casts required for correction and binary logistic regression analysis for the need for tenotomy. RESULTS Four subgroups were identified based on the rate of midfoot-hindfoot change: (1) fast-steady (61%), (2) steady-steady (19%), (3) fast-nil (7%), and (4) steady-nil (14%). The fast-steady subgroup can be distinguished at the removal of the second cast and all other subgroups can be distinguished at the removal of the fourth cast [ H (3) = 228.76, P < 0.001]. There was a significant statistical, not clinical, difference in the total number of casts required for correction across the 4 subgroups [median number of casts 5 to 6 in all groups, H (3) = 43.82, P < 0.001]. Need for tenotomy was significantly less in the fast-steady (51%) subgroup compared with the steady-steady (80%) subgroup [ H (1) = 16.23, P < 0.001]; tenotomy rates did not differ between the fast-nil (91%) and steady-nil (100%) subgroups [ H (1) = 4.13, P = 0.04]. CONCLUSIONS Four distinct subgroups of idiopathic clubfoot were identified. Tenotomy rate differs between the subgroups highlighting the clinical benefit of subgrouping to predict outcomes in Ponseti-managed idiopathic clubfoot. LEVEL OF EVIDENCE Level II, prognostic.
Collapse
Affiliation(s)
| | | | - Emre Ilhan
- Macquarie University
- The Children's Hospital at Westmead
| | - Paul Gibbons
- The Children's Hospital at Westmead
- University of Sydney, NSW, Australia
| | | |
Collapse
|
10
|
Grin L, van Oorschot L, Vanwanseele B, Wijnands SDN, Kars HJJC, Besselaar AT, van der Steen MCM. Kinematic Gait Impairments in Children with Clubfeet Treated by the Ponseti Method: A Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050785. [PMID: 37238333 DOI: 10.3390/children10050785] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/20/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023]
Abstract
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.
Collapse
Affiliation(s)
- Lianne Grin
- Department of Health Innovations and Technology, Fontys University of Applied Sciences, Dominee Theodoor Fliednerstraat 2, 5361 BN Eindhoven, The Netherlands
- Department of Movement Sciences, Katholieke Universiteit Leuven, Tervuursevest 101, 3001 Heverlee, Belgium
| | - Lisa van Oorschot
- Department of Health Innovations and Technology, Fontys University of Applied Sciences, Dominee Theodoor Fliednerstraat 2, 5361 BN Eindhoven, The Netherlands
| | - Benedicte Vanwanseele
- Department of Health Innovations and Technology, Fontys University of Applied Sciences, Dominee Theodoor Fliednerstraat 2, 5361 BN Eindhoven, The Netherlands
- Department of Movement Sciences, Katholieke Universiteit Leuven, Tervuursevest 101, 3001 Heverlee, Belgium
| | - Saskia D N Wijnands
- Department of Movement Sciences, Katholieke Universiteit Leuven, Tervuursevest 101, 3001 Heverlee, Belgium
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, 5600 PD Eindhoven, The Netherlands
| | - H J J Cojanne Kars
- Department of Health Innovations and Technology, Fontys University of Applied Sciences, Dominee Theodoor Fliednerstraat 2, 5361 BN Eindhoven, The Netherlands
| | - Arnold T Besselaar
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, 5600 PD Eindhoven, The Netherlands
| | - M C Marieke van der Steen
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, 5600 PD Eindhoven, The Netherlands
- Department of Orthopaedic Surgery & Trauma, Catharina Hospital Eindhoven, 5602 ZA Eindhoven, The Netherlands
| |
Collapse
|
11
|
Prospective, Randomized Ponseti Treatment for Clubfoot: Orthopaedic Surgeons Versus Physical Therapists. J Pediatr Orthop 2023; 43:e93-e99. [PMID: 36607913 DOI: 10.1097/bpo.0000000000002291] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Clubfoot is a common congenital foot deformity in children. The Ponseti method of serial casting has become the standard of care in clubfoot treatment. Clubfoot casting is performed in many centers by both orthopaedic surgeons and physical therapists (PTs); however, direct comparison of outcomes and complications of this treatment between these providers is limited. This study prospectively compared the outcomes of patients with clubfoot treated by these 2 groups of specialists. METHODS Between January 2010 and December 2014, all patients under the age of 12 months with a diagnosis of clubfoot were included. Patients were randomized to an orthopaedic surgeon (MD) group or a PT group for weekly serial casting. Main outcome measures included the number of casts required to achieve correction, clinical recurrence of the deformity, and the need for additional surgical intervention. RESULTS One hundred twenty-six infants were included in the study. Patient demographics and characteristics (sex, race, family history of clubfoot, laterality, and severity of deformity) were similar between treatment groups, with the only significant difference being the mean age of entry into the study (5.2 weeks in the MD group and 9.2 weeks in the PT group, P=0.01). Mean length of follow-up was 2.6 years. The number of casts required trended to a lower number in the MD group. There was no significant difference in the rates of clinical recurrence or additional surgical intervention between groups. CONCLUSIONS Ponseti casting for treatment of clubfoot performed by orthopaedic surgeons and PTs results in equivalent outcomes without any difference in complications. Although the number of casts required trended to a lower number in the MD group, this likely did not result in any clinical significance, as the difference in cast number equaled <1 week's difference in the overall duration of serial casting. LEVEL OF EVIDENCE Level I-therapeutic.
Collapse
|
12
|
Common Errors in the Management of Idiopathic Clubfeet Using the Ponseti Method: A Review of the Literature. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10010152. [PMID: 36670703 PMCID: PMC9856779 DOI: 10.3390/children10010152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/20/2022] [Accepted: 01/04/2023] [Indexed: 01/15/2023]
Abstract
Congenital talipes equinovarus is one of the most prevalent birth defects, affecting approximately 0.6 to 1.5 children per 1000 live births. Currently, the Ponseti method is the gold-standard treatment for idiopathic clubfeet, with good results reported globally. This literature review focuses on common errors encountered during different stages of the management of idiopathic clubfeet, namely diagnosis, manipulation, serial casting, Achilles tenotomy, and bracing. The purpose is to update clinicians and provide broad guidelines that can be followed to avoid and manage these errors to optimize short- and long-term outcomes of treatment of idiopathic clubfeet using the Ponseti method. A literature search was performed using the following keywords: "Idiopathic Clubfoot" (All Fields) AND "Management" OR "Outcomes" (All Fields). Databases searched included PubMed, EMBASE, Cochrane Library, Google Scholar, and SCOPUS (age range: 0-12 months). A full-text review of these articles was then performed looking for "complications" or "errors" reported during the treatment process. A total of 61 articles were included in the final review: 28 from PubMed, 8 from EMBASE, 17 from Google Scholar, 2 from Cochrane Library, and 6 from SCOPUS. We then grouped the errors encountered during the treatment process under the different stages of the treatment protocol (diagnosis, manipulation and casting, tenotomy, and bracing) to facilitate discussion and highlight solutions. While the Ponseti method is currently the gold standard in clubfoot treatment, its precise and intensive nature can present clinicians, health care providers, and patients with potential problems if proper diligence and attention to detail is lacking. The purpose of this paper is to highlight common mistakes made throughout the Ponseti treatment protocol from diagnosis to bracing to optimize care for these patients.
Collapse
|
13
|
Participation and Motor Abilities in Children Aged 5 to 9 Years With Idiopathic Clubfeet After Treatment With the Ponseti Method. J Pediatr Orthop 2023; 43:e36-e42. [PMID: 36253894 DOI: 10.1097/bpo.0000000000002278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
Collapse
|
14
|
Ayub AAA, Firth GB, Green GL, Bijlsma P, Ramachandran M. Tibialis anterior tendon transfer using bone anchor for dynamic supination in congenital talipes equinovarus. J Pediatr Orthop B 2023; 32:15-20. [PMID: 35834789 DOI: 10.1097/bpb.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Tibialis anterior tendon transfer (TATT) is a recognised procedure for the treatment of recurrent congenital talipes equinovarus. The most common technique in use requires three skin incisions and breaching of the plantar tissues, risking pressure areas and damage to neurovascular structures. There have been no studies showing the clinical results of the use of a bone anchor to secure the tendon without drilling through the lateral cuneiform. This study presents the largest series of outcomes for such a procedure. Retrospective case series. Electronic records for all children under 18 undergoing TATT with anchor fixation included. Outcomes recorded were a failure of the tendon transfer and complications. Seventy-seven feet were identified in 61 children with a male-to-female ratio of 2.5:1, the average age at surgery of 5.6 years, and an average follow-up of 4.4 years. There were no cases of pullout of the anchor. Seventy-six cases (98.7%) had no recurrence of dynamic supination on follow-up. No revision surgery was required. Consistently reliable, reproducible and safe fixation of the tibialis anterior tendon in TATT can be achieved using a bone anchor for the treatment of dynamic supination in children with clubfeet following correction using the Ponseti method and is a quick and straightforward alternative method to traditional techniques.
Collapse
|
15
|
Pinto D, Leo DG, Aroojis A, Eastwood D, Gelfer Y. The Impact of Living with Clubfoot on Children and Their Families: Perspectives from Two Cultural Environments. Indian J Orthop 2022; 56:2193-2201. [PMID: 36507216 PMCID: PMC9705620 DOI: 10.1007/s43465-022-00748-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 09/06/2022] [Indexed: 02/04/2023]
Abstract
Purpose To study the physical, emotional and social impact of clubfoot on the lives of affected children and their families. Methods A purposive sample of children with treated idiopathic clubfoot and their parents was recruited from two geographical locations-the United Kingdom (UK) and India. Children were divided into age groups of 5-7 and 8-11 years. Questionnaires were administered separately to children and parents; the former comprised multiple-choice questions scored using an 'emoji' system, and the latter included open-ended questions divided into pre-defined themes of daily limitations, social life, general health, emotional barriers and family impact. Results Thirty-four children and parents participated from UK; 96 children and parents participated from India. The majority of children (> 80%) reported no problems in daily activities, although 32.8% reported having pain. Difficulty finding appropriate footwear and limitation in sports were more common among UK children, whereas difficulty in squatting was more problematic for Indian children. Self and emotional perceptions regarding their appearance/condition were lower among older as compared to younger children in both countries. Parents' responses mirrored those of children; additionally they reported emotional and financial difficulties during initial treatment phase, and ongoing concerns about the future during the maintenance phase. Conclusion Treated clubfoot continues to impact the lives of affected children and families. Perceptions of the condition and its impact vary between population groups; this needs to be appreciated when collecting and analysing outcomes.
Collapse
Affiliation(s)
- Deepika Pinto
- Department of Orthopaedics, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH UK
| | - Donato Giuseppe Leo
- St George’s Healthcare NHS Trust, London, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Yael Gelfer
- St George’s Hospital, St George’s University of London, London, UK
| |
Collapse
|
16
|
Vahidi K, Shamabadi A, Nabian MH, Vosoughi F, Panjavi B, Zargarbashi R. Clinical, radiological, pedobarographic, and quality of life outcomes of the Ponseti treatment for clubfoot: a prospective study. Foot (Edinb) 2022; 52:101921. [PMID: 36037761 DOI: 10.1016/j.foot.2022.101921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 01/28/2022] [Accepted: 03/13/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Talipes equinovarus, also known as clubfoot, is a congenital anomaly that affects one newborn per 1000 live births. Its standard treatment strategy is Ponseti casting management. This study aims to report the long-term outcomes of the Ponseti treatment in Iran. METHODS A prospective cohort study was enrolled to evaluate clinical outcomes, radiological results, pedobarographic measurements, and quality of life after the Ponseti treatment in patients with clubfoot who were followed for at least five years. RESULTS In this study, 25 clubfeet of 18 patients were included. Significant reductions in Pirani, Dimeglio, and CAP scores, improved ankle dorsiflexion, and acceptable pedobarographic indices were observed in this study. From the radiological evaluation indices, the calcaneal pitch and lateral talus-first metatarsal angles were significantly reduced. After five years of treatment, patients' quality of life was favorable, which was better in females. This study showed that the results of the Ponseti treatment remained acceptable after five years. CONCLUSIONS The Ponseti management for clubfoot in the long term appears to maintain significant improvements. However, the recurrence rate - albeit without disruption to daily activities - cannot be ignored.
Collapse
Affiliation(s)
- Kamyar Vahidi
- Department of Orthopedics, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Shamabadi
- Department of Orthopedics, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Nabian
- Department of Orthopedics, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; Department of Pediatric Surgery and Orthopedics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fardis Vosoughi
- Department of Orthopedics, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Panjavi
- Department of Orthopedics, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; Department of Pediatric Surgery and Orthopedics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Ramin Zargarbashi
- Department of Orthopedics, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; Department of Pediatric Surgery and Orthopedics, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
17
|
Akinyoola LA, Gunderson Z, Sun S, Fitzgerald R, Caltoum CB, Christman TW, Bielski R, Loder RT. Association of Socioeconomic Status With Relapse After Ponseti Method Treatment of Idiopathic Clubfeet. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221119180. [PMID: 36046551 PMCID: PMC9421036 DOI: 10.1177/24730114221119180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: The Ponseti method is today’s standard treatment of idiopathic talipes equinovarus (ITEV). Compliance with foot abduction bracing (FABO) and socioeconomic factors have been shown to impact treatment outcome. We wished to further study socioeconomic factors using the Area Deprivation Index (ADI), a more comprehensive way to evaluate socioeconomic status, which has not been done before. Methods: All TEV patients from 2010 through 2019 treated with the Ponseti method were reviewed. Standard demographic variables, as well as the number of casts to complete initial correction, FABO compliance, and occurrence of relapse were tabulated. Socioeconomic level was quantified with the 2018 ADI. Results: There were 168 children; 151 had typical and 17 complex TEV. Average follow-up was 4.3 ± 1.8 years; relapse occurred in 46%. There were no significant differences in the percentage of relapse by sex, race, or ADI. FABO noncompliance was present in 46%. Relapse increased with increasing time of follow-up and FABO noncompliance (76% vs 21%, P < 10−6). Multivariate logistic regression analysis revealed that only FABO compliance and length of follow-up were associated with relapse. The OR of relapse for FABO noncompliance was 17.9 (7.6, 42.4, P < 10–6) and for follow-up >4 years the OR was 4.97 (2.1, 11.70, P = .0003). Conclusion: The outcome of the Ponseti method for TEV treatment is dependent on local circumstances. In our state, socioeconomic status, as determined by the ADI, was not associated with the occurrence of relapse. Thus, each center needs to assess its results, and analyze its own reasons for relapse. There were no other demographic variables associated with relapse except FABO compliance and length of follow-up. Parents should be strongly advised that FABO compliance and follow-up appears paramount to achieving the best results, and that complex TEV are at greater risk for relapse. Level of Evidence: Level IV, case series
Collapse
Affiliation(s)
| | | | - Seungyup Sun
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ryan Fitzgerald
- University of South Florida College of Medicine, Tampa, FL, USA
| | | | - Tyler W. Christman
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Robert Bielski
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Randall T. Loder
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| |
Collapse
|
18
|
Correction results of atypical clubfeet managed with modified Ponseti technique: A meta-analysis of 354 feet. J Clin Orthop Trauma 2022; 31:101939. [PMID: 35818375 PMCID: PMC9270237 DOI: 10.1016/j.jcot.2022.101939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND/PURPOSE Atypical clubfeet are distinct from idiopathic clubfeet. It is resistant to correction by conventional casting methods and often requires a modification of Ponseti's casting technique. Although the initial correction rates are reasonable, relapse and complications are frequent. There is limited literature on the results of modified Ponseti casting of these feet. We conducted this meta-analysis to study a few important aspects of atypical/complex clubfeet treatment by the modified Ponseti technique. RESEARCH QUESTION What are the results of atypical or complex clubfeet after treatment by the modified Ponseti technique? METHODOLOGY Five electronic databases (PubMed, Embase, Scopus, Ovid, and Cochrane Library) were searched for articles reporting on the results of atypical/complex clubfeet treated by the modified Ponseti technique. Details of the number of casts required for correction, rate of percutaneous Achilles tenotomy (PAT), other soft tissue procedures required, complications, and relapse rates were extracted into spreadsheets, and meta-analysis was carried out using OpenMeta Analyst software. RESULTS Ten studies were included for analysis with a total of 240 patients with 354 clubfeet. The initial correction was achieved in all feet. A pooled analysis of the data showed that a mean of six casts was required for the initial correction. The rate of PAT was 98.3%. The overall complication rate was 16.8%. 7.2% required an additional soft tissue procedure apart from the PAT, and relapse of the deformity was observed in a mean of 19.8% cases. CONCLUSION Modified Ponseti technique is effective in the initial management of atypical/complex clubfeet. Although the PAT rate is slightly higher in the Modified Ponseti technique, the remaining result parameters are comparable with the results of idiopathic clubfoot managed with the Ponseti method of casting. However, these children should be kept under follow-up for a longer duration to find the exact relapse rates.
Collapse
|
19
|
The Predictive Value of Radiographs and the Pirani Score for Later Additional Surgery in Ponseti-Treated Idiopathic Clubfeet, an Observational Cohort Study. CHILDREN 2022; 9:children9060865. [PMID: 35740802 PMCID: PMC9221593 DOI: 10.3390/children9060865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 02/08/2023]
Abstract
There are few validated predictors of the need for additional surgery in idiopathic clubfeet treated according to the Ponseti method. Our aim was to examine if physical examination (Pirani score) and radiographs at the age of three months (after initial correction of the clubfeet) can predict the future need for additional surgery. In this retrospective cohort study, radiographs of idiopathic clubfeet were made at the age of three months. The Pirani score was determined at the first cast, before tenotomy, and at the age of three months. Follow-up was at least five years. The correlation between the radiograph, Pirani score, and the need for additional surgery was explored with logistic regression analysis. Parent satisfaction was measured with a disease-specific instrument. The study included 72 clubfeet (50 children) treated according to the Ponseti method. Additional surgery was needed on 27 feet (38%). A larger lateral tibiocalcaneal angle (i.e., equinus) and a smaller lateral talocalcaneal angle (i.e., hindfoot varus) at the age of three months were correlated with the need for additional surgery. Higher Pirani scores before tenotomy and at the age of three months also correlated with additional surgery. Parent satisfaction was lower in patients who needed additional surgery. Both the Pirani scores and the lateral radiographs are predictive for future additional surgery.
Collapse
|
20
|
Gelfer Y, Davis N, Blanco J, Buckingham R, Trees A, Mavrotas J, Tennant S, Theologis T. Attaining a British consensus on managing idiopathic congenital talipes equinovarus up to walking age. Bone Joint J 2022; 104-B:758-764. [PMID: 35638218 PMCID: PMC9948433 DOI: 10.1302/0301-620x.104b6.bjj-2021-1687.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AIMS The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV. METHODS The consensus process followed an established Delphi approach with a predetermined degree of agreement. The process included the following steps: establishing a steering group; steering group meetings, generating statements, and checking them against the literature; a two-round Delphi survey; and final consensus meeting. The steering group members and Delphi survey participants were all British Society of Children's Orthopaedic Surgery (BSCOS) members. Descriptive statistics were used for analysis of the Delphi survey results. The Appraisal of Guidelines for Research & Evaluation checklist was followed for reporting of the results. RESULTS The BSCOS-selected steering group, the steering group meetings, the Delphi survey, and the final consensus meeting all followed the pre-agreed protocol. A total of 153/243 members voted in round 1 Delphi (63%) and 132 voted in round 2 (86%). Out of 61 statements presented to round 1 Delphi, 43 reached 'consensus in', no statements reached 'consensus out', and 18 reached 'no consensus'. Four statements were deleted and one new statement added following suggestions from round 1. Out of 15 statements presented to round 2, 12 reached 'consensus in', no statements reached 'consensus out', and three reached 'no consensus' and were discussed and included following the final consensus meeting. Two statements were combined for simplicity. The final consensus document includes 57 statements allocated into six successive stages. CONCLUSION We have produced a consensus document for the treatment of idiopathic CTEV up to walking age. This will provide a benchmark for standard of care in the UK and will help to reduce geographical variability in treatment and outcomes. Appropriate dissemination and implementation will be key to its success. Cite this article: Bone Joint J 2022;104-B(6):758-764.
Collapse
Affiliation(s)
- Yael Gelfer
- St George's Hospital, London, UK,St George's University of London, London, UK,Correspondence should be sent to Yael Gelfer. E-mail:
| | - Naomi Davis
- Royal Manchester Children's Hospital, Manchester, UK
| | - Jose Blanco
- North West Anglia NHS Foundation Trust, Peterborough, UK
| | | | - Amanda Trees
- James Cook University Hospital, Middlesbrough, UK
| | | | - Sally Tennant
- Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Tim Theologis
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| |
Collapse
|
21
|
Laliotis N, Chrysanthou C, Konstandinidis P, Anastasopoulos N. Anatomical Structures Responsible for CTEV Relapse after Ponseti Treatment. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9050581. [PMID: 35626758 PMCID: PMC9139296 DOI: 10.3390/children9050581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/03/2022] [Accepted: 04/15/2022] [Indexed: 11/30/2022]
Abstract
Relapse of deformity after a successful Ponseti treatment remains a problem for the management of clubfoot. An untreated varus heel position and restricted dorsal flexion of the ankle are the main features of recurrences. We analyze the anatomical structures responsible for these recurrences. Materials and methods: During 5 years, 52 children with CTEV (Congenital Talipes Equino Varus) were treated with casts according to the Ponseti method, with a mean number of 7 casts. Closed percutaneous tenotomy was performed in 28 infants. Children were followed monthly and treated with the continuous use of a molded cast. We had 9 children with relapsed clubfeet. During the standing and walking phase, they had a fixed deformity with a varus position of the heel and dorsal flexion of the ankle <10 d. They were surgically treated with the posterolateral approach. Results: In all patients, we found a severe thickening of the paratenon of the Achilles in the medial side, with adhesions with the subcutaneous tissue. The achilles after the previous tenotomy was completely regenerated. The achilles was medially displaced. Conclusions: A severe thickening of the paratenon of the achilles and adhesions with the subcutaneous tissue are anatomical structures in fixed relapsed cases of clubfoot. We treated our patients with an appropriate surgical release.
Collapse
Affiliation(s)
- Nikolaos Laliotis
- Orthopaedic Department, Inter Balkan Medical Center, Asklipiou 10 Pilea, 57001 Thessaloniki, Greece; (C.C.); (P.K.)
- Correspondence:
| | - Chrysanthos Chrysanthou
- Orthopaedic Department, Inter Balkan Medical Center, Asklipiou 10 Pilea, 57001 Thessaloniki, Greece; (C.C.); (P.K.)
| | - Panagiotis Konstandinidis
- Orthopaedic Department, Inter Balkan Medical Center, Asklipiou 10 Pilea, 57001 Thessaloniki, Greece; (C.C.); (P.K.)
| | | |
Collapse
|
22
|
Scanlan E, Grima-Farrell K, IIhan E, Gibbons P, Gray K. Initiating Ponseti management in preterm infants with clubfoot at term age. J Child Orthop 2022; 16:141-146. [PMID: 35620121 PMCID: PMC9127881 DOI: 10.1177/18632521221080476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/15/2022] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Currently, the optimal time to initiate treatment among preterm infants with clubfoot is unknown. The aim of this study was to describe treatment outcomes up to 1 year post-correction following Ponseti management in infants who were born preterm but treated at term age. METHODS A retrospective chart audit was conducted at a major pediatric hospital on preterm infants with clubfoot who commenced Ponseti management at term age (≥37 weeks of gestation). Data are expressed as mean values (±standard deviation) or 95% confidence intervals (95% CIs). RESULTS Twenty-six participants (40 feet) born at 32.6/40 (±3.1) weeks of gestation were identified. Thirteen (50%) were male, 14 (54%) presented bilaterally, and 7 (27%) presented with syndromic clubfoot. Ponseti management was initiated at 41.4/40 (±2.8) weeks gestation. Baseline Pirani scores were 5.2 (95%CI: 4.8-5.6) in the idiopathic group and 5.7 (95%CI: 5.0-6.4) in the syndromic group. The number of casts to correction was 5.9 (95% CI: 5.1-6.6) for those with idiopathic clubfoot and 6.1 (95%CI: 5.0-7.3) for those with syndromic clubfoot. Achilles tenotomies were required in 13 (21 feet) with idiopathic clubfoot and five (7 feet) with syndromic clubfoot. Recurrence occurred in four infants (5 feet): 4 feet required further casting and bracing, and 1 foot required additional surgery. CONCLUSION Ponseti management at term age in preterm-born infants yields comparable 1-year outcomes to term-born infants. Further research is required to determine whether outcomes beyond 1 year of age align with growth and development demonstrated by term-born infants who are managed with the Ponseti method. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Emily Scanlan
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, NSW, Australia
| | - Kate Grima-Farrell
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, NSW, Australia
| | - Emre IIhan
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, NSW, Australia
| | - Paul Gibbons
- Department of Orthopaedic Surgery, The Children’s Hospital at Westmead, Westmead, NSW, Australia
| | - Kelly Gray
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, NSW, Australia,Department of Orthopaedic Surgery, The Children’s Hospital at Westmead, Westmead, NSW, Australia,Kelly Gray, Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Road, Macquarie Park, NSW 2109, Australia.
| |
Collapse
|
23
|
Bergamasco JMP, Costa MT, Ferreira RC, Fucs PMDMB. Anterior tibial tendon transfer in idiopathic clubfoot: does the outcome differ with the initial treatment? Proposed classification to surgical indication. INTERNATIONAL ORTHOPAEDICS 2022; 46:1361-1366. [PMID: 35344056 DOI: 10.1007/s00264-022-05309-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/09/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To establish parameters and propose a radiographic classification for foot adduction/supination deformities to assist the indication of Garceau procedure. Secondly, to investigate whether the outcome of Garceau surgery depends on the initial treatment used, peritalar release, or the Ponseti method, and verify the maintenance of correction until skeletal maturity. METHODS Prospective cohort study, with follow-up evaluations in 2009 and 2019. Fifty-three consecutive patients (71 feet) with idiopathic congenital clubfoot (ICCF) were divided into two groups according to the initial treatment used: peritalar release (group I) or Ponseti method (group II). All patients underwent Garceau procedure. The patients were evaluated clinically and radiographically using the American Orthopedic Foot Association (AOFAS) score for ankle and hindfoot. A radiographic classification is proposed based on the adduction by talo-first metatarsal angle on dorsoplantar view and supination by the elevation of the head of the first metatarsal on lateral view, both weight-bearing. RESULTS In the first clinical evaluation, the mean score on the AOFAS was 87 points in group I and 86 points in group II. In the second evaluation, group I had mean AOFAS of 92 points and group II of 94 points. No statistical differences were found between the two groups, neither between the first and the second evaluation. In the radiographic evaluation, the adduction deformity obtained an average correction of 4° in group I and 3.6° in group II; in supination deformity, the average depression of the first metatarsal head in relation to the ground was 6.7 mm in group I and 7.5 mm in group II, with no statistical difference between the two evaluations, indicating the correction was maintained until skeletal maturity. CONCLUSION Garceau transfer is capable of correcting residual deformities in adduction/supination of mild and moderate degrees, regardless of the initial treatment, and maintaining the correction until skeletal maturity. The proposed radiographic classification might help to objectively indicate the surgical procedure.
Collapse
Affiliation(s)
| | - Marco Túlio Costa
- Orthopaedic Department, Ankle and Foot Clinic, Santa Casa Medical School and Hospitals, São Paulo, Brazil
| | - Ricardo Cardenuto Ferreira
- Orthopaedic Department, Ankle and Foot Clinic, Santa Casa Medical School and Hospitals, São Paulo, Brazil
| | | |
Collapse
|
24
|
Agarwal A, Rastogi A, Talwar J, Deo NB, Rastogi P. Unilateral limb orthosis for maintenance of deformity correction following treatment of clubfoot with Ponseti technique: a systematic review. J Pediatr Orthop B 2022; 31:e195-e201. [PMID: 34267168 DOI: 10.1097/bpb.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The systematic review study aimed to investigate the following details in the clubfoot children treated with the Ponseti technique: (1) to review the various designs and prescriptions of unilateral limb orthosis described in literature; (2) to find the outcome following use of this orthosis, especially patient adherence and recurrence; (3) comparison with standard bilateral limb foot abduction orthosis. A literature search was performed for articles published in 'Pubmed (includes Medline indexed journals)' electronic databases for broad key words: 'Clubfoot or CTEV or congenital talipes equinovarus', 'orthosis or brace or splint'. Included were studies that addressed the treatment of idiopathic clubfoot in children up to 2 years of age using the Ponseti technique and use of unilateral limb orthosis for the subsequent maintenance phase. We excluded studies reporting Ponseti technique for nonidiopathic clubfoot, child age older than 2 years at the time of primary treatment, studies where unilateral limb orthosis was used as a tool for primary correction of all or some components of clubfoot and design descriptions of orthosis without practical usage data. Of the 1537 articles from the database, 10 articles were included in the final review. Most studies were retrospective, underpowered and had a short term follow-up. In some series, the use of this orthosis was driven by personal experiences and regional preferences rather than a just scientific explanation. The tested designs were variable and nonstandardized. Being less restrictive, unilateral limb orthosis may have an edge over bilateral limb orthosis in terms of patient adherence. The available comparative studies however showed inferiority of unilateral orthoses when compared to the bilateral limb orthosis in preventing recurrences in clubfoot treatment. There is insufficient evidence to support use of unilateral limb orthosis for maintenance of deformity correction following treatment of clubfoot with the Ponseti technique. Their use was found associated with high recurrence rates.
Collapse
Affiliation(s)
- Anil Agarwal
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Delhi
| | - Anuj Rastogi
- Department of Orthopaedics, Integral Institute of Medical Sciences and Research, Integral University, Lucknow, Uttar Pradesh
| | - Jatin Talwar
- Central Institute of Orthopaedics Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Nitish Bikram Deo
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Delhi
| | - Prateek Rastogi
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Delhi
| |
Collapse
|
25
|
Li J, Xu C, Li Y, Liu Y, Xu H, Canavese F. Are early antero-posterior and lateral radiographs predictive of clubfoot relapse requiring surgical intervention in children treated by Ponseti method? J Child Orthop 2022; 16:35-45. [PMID: 35615392 PMCID: PMC9124919 DOI: 10.1177/18632521221080478] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/05/2022] [Indexed: 02/03/2023] Open
Abstract
Purpose To investigate the value of antero-posterior and lateral radiographs in predicting clubfoot relapse after treatment with the Ponseti method. Methods This was a retrospective review of 104 children (157 feet) younger than 3 months of age with idiopathic clubfoot treated using the Ponseti method at our institution between January 2007 and December 2014. All patients underwent Achilles tenotomy and were divided into two groups according to the need for further surgery to correct the deformity: relapsed group (24 patients; 36 feet) and non-relapsed group (80 patients; 121 feet). All antero-posterior and lateral foot radiographs were performed less than 3 months after Achilles tenotomy. The talo-calcaneal (TC-AP) and talus-first metatarsal (TM-AP) angles were measured in the antero-posterior view, while the tibio-calcaneal (TIC-L), talus-first metatarsal (TM-L), and talo-calcaneal (TC-L) angles were measured in the lateral view. The multi-factor logistic regression model of the stepwise selection method was used to predict the relapse of clubfoot deformity from the potential predictive values. Results The mean age at initial plain radiography examination was 99.45 ± 21.54 days. Differences in TC-AP, TM-AP, TC-L, and TIC-L between the two groups were statistically significant. However, only TM-AP and TIC-L were included in the "risk of relapse" formula using the multi-factor logistic stepwise selection method. Conclusion Early antero-posterior and lateral radiographs in children younger than 3 months of age at initial Ponseti treatment have positive predictive value for relapse. Reduced TM-AP angle and increased TIC-L were associated with an increased risk of relapse. Level of evidence level III.
Collapse
Affiliation(s)
- Jingchun Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Chenchen Xu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yiqiang Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yuanzhong Liu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hongwen Xu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Federico Canavese
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre Hospital, Lille, France
| |
Collapse
|
26
|
Hu W, Ke B, Niansu X, Li S, Li C, Lai X, Huang X. Factors associated with the relapse in Ponseti treated congenital clubfoot. BMC Musculoskelet Disord 2022; 23:88. [PMID: 35081931 PMCID: PMC8790874 DOI: 10.1186/s12891-022-05039-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/17/2022] [Indexed: 12/31/2022] Open
Abstract
Objectives We retrospectively investigated the clinical materials to seek the factors that lead to relapse after using the Ponseti method. Methods We retrospectively reviewed all children with congenital clubfoot treated with the Ponseti method in our hospital from June 2008 to June 2013. The data included the following factors: age, gender, initial Pinari score, number of casts, number of feet (unilateral or bilateral), age at the first casting, age of mother, tenotomy, walking age, and compliance with using bracing. All investigations were conducted in conformity with ethical standards. This study was approved by Guilin Peoples’ Hospital Ethics Committee. Results In this study, there were 148 cases (164 ft) in total that underwent the Ponseti method, with the follow–up period at least 5 years. Of them, 64 children presented with left side, 58 with right side, and 26 with bilateral cases. This study included 75 males and 73 females; sex did not affect the outcomes. The mean age of the first casting was 2.50 ± 2.15 months. The average initial Pirani score was 4.98 ± 1.33, and the average number of casts was 5.71 ± 2.28 times. The mean age of mothers at birth was 25.81 ± 2.38 years old. The walking age of children was at a mean of 14.83 ± 1.18 months. Forty-nine cases could not tolerate using braces, namely the rate of noncompliance in this study was 33.1%. Tenotomy was performed on 113 ft (76.4%). The average follow–up period was 7.27 ± 1.29 years (from 5 to 10 years). The rate of relapse was 21.6% (32 cases) at the end of the follow-up. The rate of relapse in the noncompliance with using bracing group was significantly higher compared to the compliance group . Conclusion The initial Pirani score, compliance with the foot abduction brace and the age at the first casting are three independent factors for relapse in clubfoot.
Collapse
Affiliation(s)
- Wei Hu
- Department of Spine and Osteopathy Ward, Guilin Peoples' Hospital, No 12 Wenming road, Guilin, 540021, Guangxi, China.
| | - Baoyi Ke
- Department of Spine and Osteopathy Ward, Guilin Peoples' Hospital, No 12 Wenming road, Guilin, 540021, Guangxi, China
| | - Xiao Niansu
- Department of Spine and Osteopathy Ward, Guilin Peoples' Hospital, No 12 Wenming road, Guilin, 540021, Guangxi, China
| | - Sen Li
- Department of Spine and Osteopathy Ward, Guilin Peoples' Hospital, No 12 Wenming road, Guilin, 540021, Guangxi, China
| | - Cheng Li
- Department of Spine and Osteopathy Ward, Guilin Peoples' Hospital, No 12 Wenming road, Guilin, 540021, Guangxi, China
| | - Xingming Lai
- Department of Spine and Osteopathy Ward, Guilin Peoples' Hospital, No 12 Wenming road, Guilin, 540021, Guangxi, China
| | - Xinyu Huang
- Department of Spine and Osteopathy Ward, Guilin Peoples' Hospital, No 12 Wenming road, Guilin, 540021, Guangxi, China
| |
Collapse
|
27
|
Aly AS, Samir S, Mahmoud S, El-Sobky TA. Naviculectomy With Limited Soft-Tissue Releases as a Third Way Beyond Manipulative Treatment and Extensive Soft-Tissue Releases for Ambulatory Children With Complex Congenital Vertical Talus: A Technical Note. Foot Ankle Spec 2022:19386400211068265. [PMID: 35043723 DOI: 10.1177/19386400211068265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Level IV case series.
Collapse
Affiliation(s)
- Ahmad S Aly
- Division of Paediatric Orthopaedics, Department of Orthopaedic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt (ASA, SS, SM, TAES)
| | - Shady Samir
- Division of Paediatric Orthopaedics, Department of Orthopaedic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt (ASA, SS, SM, TAES)
| | - Shady Mahmoud
- Division of Paediatric Orthopaedics, Department of Orthopaedic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt (ASA, SS, SM, TAES)
| | - Tamer A El-Sobky
- Division of Paediatric Orthopaedics, Department of Orthopaedic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt (ASA, SS, SM, TAES)
| |
Collapse
|
28
|
VAN SCHELVEN H, MOERMAN S, VAN DER STEEN M, BESSELAAR AT, GREVE C. Prognostic factors for recurrent idiopathic clubfoot deformity: a systematic literature review and meta-analysis. Acta Orthop 2022; 93:11-28. [PMID: 34607499 PMCID: PMC8815420 DOI: 10.1080/17453674.2021.1982576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - After initial clubfoot correction through Ponseti treatment, recurrence rates range from 26% to 48%. Even though various factors have been associated with increased recurrence risk, systematic assessments of the prognostic capacity of recurrence risk factors and their clinical relevance are lacking. Therefore we assessed clinically relevant prognostic factors for recurrent idiopathic clubfoot deformity after initial correction through Ponseti treatment. Methods - PubMed, Embase, Cinahl, and Web of Science were systematically searched for studies investigating the association between clinically relevant factors and recurrence rates. Prognostic factors were qualitatively assessed and included in the meta-analysis if ≥ 2 studies investigated the same factor and methods were comparable. Results - 34 articles were included in the qualitative synthesis, of which 22 were also included in the meta-analysis. Meta-analysis revealed that poor evertor muscle activity (OR = 255, 95% CI 30-2,190), brace non-compliance (OR = 10, CI 5-21), no additional stretching (OR = 31, CI 10-101), more casts (OR = 3.5, CI 1.6-7.8), lower education level of parents (OR = 1.8, CI 1.2-2.6), non-marital status of parents (OR = 1.8, CI 1.1-3.0), and higher Dimeglio scores (OR = 1.9, CI 1.2-3.3) were associated with higher recurrence rates. Interpretation - Brace non-compliance and poor evertor muscle activity have been identified as main recurrence risk factors and are therefore important to be closely monitored during clinical follow-up of clubfoot patients. Adding additional stretching during the bracing protocol might be promising in the quest to prevent relapse, but scientific evidence for clear clinical treatment recommendations is still limited.
Collapse
Affiliation(s)
- Heleen VAN SCHELVEN
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen
| | - Sophie MOERMAN
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen
| | - Marieke VAN DER STEEN
- Department of Orthopaedic Surgery & Trauma, Catharina Hospital, Eindhoven,Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Veldhoven
| | - Arnold T BESSELAAR
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Veldhoven
| | - Christian GREVE
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen,Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
29
|
Gelfer Y, Leo DG, Russell A, Bridgens A, Perry DC, Eastwood DM. The outcomes of idiopathic congenital talipes equinovarus : a core outcome set for research and treatment. Bone Jt Open 2022; 3:98-106. [PMID: 35084212 PMCID: PMC9047079 DOI: 10.1302/2633-1462.31.bjo-2021-0192.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Yael Gelfer
- St George's Hospital, London, UK.,St George's University of London, London, UK
| | - Donato G Leo
- St George's Hospital, London, UK.,University of Liverpool, Liverpool, UK
| | | | | | - Daniel C Perry
- University of Liverpool, Liverpool, UK.,Alder Hey Hospital, Liverpool, UK.,University of Oxford, Oxford, UK
| | - Deborah M Eastwood
- University College London, London, UK.,Great Ormond Street Hospital, London, UK
| |
Collapse
|
30
|
Hemo Y, Yavor A, Kalish M, Segev E, Wientroub S. Ponseti treated idiopathic clubfoot - outcome predictive factors in the test of time: analysis of 500 feet followed for five to 20 years. J Child Orthop 2021; 15:426-432. [PMID: 34858528 PMCID: PMC8582614 DOI: 10.1302/1863-2548.15.210156] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/07/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To investigate a set of risk factors on the outcome of Ponseti treated idiopathic clubfeet (ICF). METHODS This study was approved by the institutional review board. A retrospective analysis of prospectively gathered data over a 20-year period, at a single dedicated clubfoot clinic. Records of 333 consecutive infants with 500 ICF were analyzed. Initial Pirani score, number of casts, need for tenotomy, foot abduction brace compliance and functional score had been documented. The need for surgery after initial correction was the outcome measure. All children were followed by the same team throughout the study period. Descriptive statistics, chi-squared and multivariate analysis were performed. RESULTS In total, 82 children (24%) with 119 feet (23.8%) were operated on, with 95.1% of feet being operated up to the age of nine years. There was a significant correlation between the Pirani score at presentation and the number of surgical procedures (chi-squared = 79.32; p < 0.001). Achilles tenotomy was done in 94.8% of patients. Pirani score of > 4.5 before casting was strongly associated with increased surgical risk (odds ratio = 1.95). When six to eight cast changes were needed, surgical prospect was 2.9 more, increasing to 11.9 when nine or more casts were needed. CONCLUSION Foot severity and number of cast changes were the strongest predictors for future surgery. Estimation of the risk of deformity recurrence after initial correction may help in tailoring a cost-effective personal treatment and follow-up protocol. Personalized focused protocol will help patients and caregivers and will reduce expenses. LEVEL OF EVIDENCE Level II - prognostic study.
Collapse
Affiliation(s)
- Yoram Hemo
- Department of Pediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Correspondence should be sent to Yoram Hemo, MD, Senior Paediatric Orthopaedic Surgeon, Department of Paediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel.
| | - Ariella Yavor
- Department of Pediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Meirav Kalish
- Department of Pediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eitan Segev
- Department of Pediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomo Wientroub
- Department of Pediatric Orthopaedic Surgery, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
31
|
Sheta RA, El-Sayed M, Abdel-Ghani H, Saber S, Mohammed ASE, Hassan TGT. A modification of the Ponseti method for clubfoot management: a prospective comparative study. J Child Orthop 2021; 15:433-442. [PMID: 34858529 PMCID: PMC8582604 DOI: 10.1302/1863-2548.15.210038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/11/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE We aimed to compare our parent-based exercise programem's efficacy with the foot abduction brace (FAB) Ponseti manipulation as a retention programme. METHODS We conducted this prospective multicentre cohort study between August 2009 and November 2019. The included children were allocated into one of two groups according to the retention protocol. The Pirani and Laaveg-Ponseti scores were used to assess the feet clinically and functionally. Radiological assessment was performed using standing anteroposterior and lateral radiographs of the feet. We assessed the parents' satisfaction and adherence to the retention method. SPSS version 25 was used for the statistical analysis. RESULTS A total of 1265 feet in 973 children were included. Group A included 637 feet managed with FAB, while group B included 628 feet managed with our retention programme. All patients were followed up to the age of four years. At the final follow-up, Pirani scores in group A participants were excellent, good and poor in 515, 90, and 32 feet, respectivel, while in group B the scores were excellent, good and poor in 471, 110 and 44 feet, respectively. The mean total score of Laaveg-Ponseti was 87.81 (sd 19.82) in group A and 90.55 (sd 20.71) in group B (p = 0.02). Group B participants showed higher satisfaction with the treatment method (p = 0.011) and more adherence to the treatment (p = 0.013). CONCLUSION The deformity's recurrence related to the brace's non-compliance in the Ponseti method might be reduced by substituting the brace with our home-based daily stretching exercises. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Reda Ali Sheta
- Professor of Orthopaedics, Al-Ahrar Specialist Hospital, Zagazig, Al-Sharkia, Egypt
| | - Mohamed El-Sayed
- Professor of Pediatric Orthopedics & Limb Reconstructive Surgeries, Tanta University, Egypt
| | - Hisham Abdel-Ghani
- Professor of Pediatric Orthopedics; Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sameh Saber
- Assistant Professor of Radiology, Faculty of Medicine, Zagazig University, Al-Sharkia, Egypt
| | | | | |
Collapse
|
32
|
Gelfer Y, Blanco J, Trees A, Davis N, Buckingham R, Peek AC, Wright E, Rajan R, Atherton WG, Watson D, Easton V, Garg N, Mavrotas J, Tennant S, Theologis T. Attaining a British consensus statement on managing idiopathic congenital talipes equinovarus (CTEV) through a Delphi process: a study protocol. BMJ Open 2021; 11:e049212. [PMID: 34475168 PMCID: PMC8413928 DOI: 10.1136/bmjopen-2021-049212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Idiopathic congenital talipes equinovarus (CTEV) is the most common congenital limb deformity. Non-operative intervention using the Ponseti method has shown to be superior to soft tissue release and has become the gold standard for first-line treatment. However, numerous deviations from the Ponseti protocol are still reported following incomplete correction or deformity relapse. Significant variation in treatment protocols and management is evident in the literature. Reducing geographical treatment variation has been identified as one of The James Lind Alliance priorities in children's orthopaedics. For this reason, the British Society of Children's Orthopaedic Surgery (BSCOS) commissioned a consensus document to form a benchmark for practitioners and ensure consistent high quality care for children with CTEV. METHODS AND ANALYSIS The consensus will follow an established Delphi approach aiming at gaining an agreement on the items to be included in the consensus statement for the management of primary idiopathic CTEV up to walking age. The process will include the following steps: (1) establishing a steering group, (2) steering group meetings, (3) a two-round Delphi survey aimed at BSCOS members, (4) final consensus meeting and (5) dissemination of the consensus statement. Degree of agreement for each item will be predetermined. Descriptive statistics will be used for analysis of the Delphi survey results. ETHICS AND DISSEMINATION No patient involvement is required for this project. Informed consent will be assumed from participants taking part in the Delphi survey. Study findings will be published in an open access journal and presented at relevant national and international conferences. Charities and associations will be engaged to promote awareness of the consensus statement.
Collapse
Affiliation(s)
- Yael Gelfer
- Trauma and Orthopaedic Department, St George's Hospital, London, UK
| | - Jose Blanco
- Paediatric Orthopaedics, North West Anglia NHS Foundation Trust, Peterborough, UK
| | - Amanda Trees
- Physiotherapy, James Cook University Hospital, Middlesbrough, UK
| | - Naomi Davis
- Paediatric Orthopaedic Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Rachel Buckingham
- Paediatric Orthopaedics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anna C Peek
- Paediatric Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Rohan Rajan
- Orthopaedics, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - Denise Watson
- Physiotherapy, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Vicky Easton
- Paediatric Physiotherapy, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Neeraj Garg
- Orthopaedics, Alder Hey Children's Hospital, Liverpool, UK
| | - Jason Mavrotas
- Core Surgical Trainee, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Sally Tennant
- Paediatric Orthopaedics, Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Tim Theologis
- Paediatric Orthopaedic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
33
|
Masrouha K, Chu A, Lehman W. Narrative review of the management of a relapsed clubfoot. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1102. [PMID: 34423014 PMCID: PMC8339836 DOI: 10.21037/atm-20-7730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/14/2021] [Indexed: 11/29/2022]
Abstract
The management of idiopathic clubfoot has transformed over the past several decades as the Ponseti method for the correction of this deformity became the standard of care, and surgical release has almost all but been abandoned. The Ponseti method has shown very high initial success rate and excellent long-term functional results. Relapse of the deformity, however, continues to be a major problem, occurring in up to 40% of patient, and there is no consensus on the definition and management of the relapsed clubfoot. This review discusses the available management options for the treatment of a relapsed clubfoot deformity following initial treatment with the Ponseti method [including repeat casting, tendo-Achilles lengthening, plantar fascia release, and tibialis anterior tendon transfer (TATT)] as well as following initial surgical treatment with posteromedial release (including casting, hemiepiphysiodesis, revised posteromedial release, osteotomies, fusion, and the use of gradual distraction with external fixators). These are discussed from the least to the most invasive. Available evidence, and limitations of the literature, for the management of relapses following both the Ponseti method and initial surgical release is reviewed along with along with the reported outcomes. Future efforts should be geared towards standardizing the definition of a relapse with objective criteria for its management.
Collapse
Affiliation(s)
- Karim Masrouha
- Division of Pediatric Orthopedics, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Alice Chu
- Division of Pediatric Orthopedics, Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Wallace Lehman
- Division of Pediatric Orthopedics, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| |
Collapse
|
34
|
Long-term outcomes of the Ponseti method for treatment of clubfoot: a systematic review. INTERNATIONAL ORTHOPAEDICS 2021; 45:2599-2608. [PMID: 34415418 DOI: 10.1007/s00264-021-05189-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
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.
Collapse
|
35
|
Fantasia I, Dibello D, Di Carlo V, Colin G, Barbieri M, Belcaro C, Magni E, Faletra F, Laura T, Stampalija T. Prenatal diagnosis of isolated clubfoot: Diagnostic accuracy and long-term postnatal outcomes. Eur J Obstet Gynecol Reprod Biol 2021; 264:60-64. [PMID: 34273754 DOI: 10.1016/j.ejogrb.2021.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/01/2021] [Accepted: 07/04/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate concordance between prenatal and postnatal diagnosis of congenital talipes equinovarus (cTEV), rates of surgery and postnatal outcomes in relation to the prenatal classification of severity. STUDY DESIGN This is a retrospective observational cohort study on fetuses with a prenatal diagnosis of cTEV between 2004 and 2018. All cases of isolated cTEV in singleton pregnancies were included. Postnatally, the Ponseti method was applied. Children were followed-up postnatally for at least two years, with a specific focus on neurodevelopmental outcome. RESULTS The cohort included 81 fetuses with a prenatal diagnosis of cTEV confirmed postnatally in 86.4% of cases. Concordance between prenatal and postnatal assessment was good for both laterality and degree of severity (k = 0.61 and 0.66, respectively). The average Pirani score, number of casts and rates of Achilles tendon tenotomy were higher for III degree cTEV (p < 0.001). Within this group only, the rate of relapse was 11% and the rates of major surgery was 6%. The postnatal outcome was normal in 68.6% newborns, while 14% of cases had a diagnosis of minor additional findings and 17% had an impairment of neurological development. None of the outcome was statistically correlated to the prenatal assessment of laterality or degree. CONCLUSIONS The accuracy of prenatal ultrasound for isolated cTEV is 86% with a false positive diagnosis of 14%. The grade of cTEV assigned prenatally correlates to postnatal severity and longer orthopedic rehabilitation in terms of number of casts and need of surgery. The assessment of the correlation between cTEV and neurological impairment requires further prospective studies on larger cohorts.
Collapse
Affiliation(s)
- Ilaria Fantasia
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Via dell'Istria 65/1, 34137 Trieste, Italy.
| | - Daniela Dibello
- Unit of Orthopedics and Traumatology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Via dell'Istria 65/1, 34137 Trieste, Italy
| | - Valentina Di Carlo
- Unit of Orthopedics and Traumatology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Via dell'Istria 65/1, 34137 Trieste, Italy
| | - Giulia Colin
- Department of Medical, Surgical and Health Sciences, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy
| | - Moira Barbieri
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Via dell'Istria 65/1, 34137 Trieste, Italy
| | - Chiara Belcaro
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Via dell'Istria 65/1, 34137 Trieste, Italy
| | - Elena Magni
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", via dell'Istria, 34137 Trieste, Italy
| | - Flavio Faletra
- Department of Medical Genetics, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Via dell'Istria 65/1, 34137 Trieste, Italy
| | - Travan Laura
- Neonatal Intensive Care Unit, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Via dell'Istria 65/1, 34137 Trieste, Italy
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Via dell'Istria 65/1, 34137 Trieste, Italy; Department of Medical, Surgical and Health Sciences, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy
| |
Collapse
|
36
|
Percutaneous Achilles tenotomy under local anaesthetic in the clubfoot clinic was safe during the COVID-19 pandemic, for both children and parents. INTERNATIONAL ORTHOPAEDICS 2021; 45:2271-2276. [PMID: 34218297 PMCID: PMC8254860 DOI: 10.1007/s00264-021-05119-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/14/2021] [Indexed: 12/02/2022]
Abstract
Purpose An Achilles tenotomy is routinely required to correct the equinus deformity in Congenital talipes equinovarus (CTEV) patients as part of the gold standard treatment using the Ponseti method. This procedure can be performed in clinic under local anaesthetic or in theatre under general anaesthetic. The COVID-19 pandemic reduced theatre capacity and caused a delay to CTEV patients’ treatment. A new standard operating procedure that allowed the tenotomies to be performed under local anaesthetic in the clinic was introduced. This study was looking into the safety, feasibility and parents’ perspective of this procedure. Methods The study was prospectively registered as a service improvement project and followed the SQUIRE guidelines (Ogrinc et al. in BMJ Qual Saf 25:986–992, 2016). All consecutive patients requiring a tenotomy were included. Data was collected prospectively including demographics, Pirani score and a carers’ satisfaction questionnaire. Results Twenty five patients (36 tenotomies) were included in the study. The median age was 9 weeks. All patients achieved ankle dorsiflexion of greater than 15° post-op. None of the patients nor their parents contracted the COVID 19 virus. All parents reported a positive experience and 99% felt less anxious about having the tenotomy done in clinic rather than theatre. Conclusions The new service offering clinic tenotomies was found to be safe and clinically successful. This study is the first to show parents preference and excellent satisfaction with a tenotomy performed under local anaesthetic. The service has improved the allocation of resources and due to its success, will continue beyond the pandemic. Supplementary Information The online version contains supplementary material available at 10.1007/s00264-021-05119-w.
Collapse
|
37
|
Cohen E, Katz T, Rozen U, Friesem T, Leibovitz E. The Influence of Achilles Tenotomy and Compliance with Foot Abduction Orthosis on the Relapse Rate of Ponseti Treatment for Idiopathic Clubfoot: A Regional Study. J Foot Ankle Surg 2021; 59:784-787. [PMID: 32307285 DOI: 10.1053/j.jfas.2019.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 11/02/2019] [Accepted: 12/18/2019] [Indexed: 02/03/2023]
Abstract
The Ponseti method for treating idiopathic clubfoot is based on gradual manipulations and corrective plaster castings followed by a years-long period of use of a foot orthosis. The role of surgery is limited. The factors that may affect outcome and their influence are subject of controversy. The aim of the study is to systematically and objectively evaluate the results of Ponseti treatment in our region of Southern Israel and focus on the role of the Achilles tenotomy and compliance to foot orthosis as factors that may influence outcome. The use of Ponseti method was retrospectively studied (level of evidence IV) by searching computerized medical files and clinical photos. The severity of deformity was evaluated by Dimeglio score (D-score) at baseline and at last examination. During 2006-2014, 57 children with idiopathic clubfoot (total 90 feet) were enrolled. An Achilles tenotomy was performed in 55/90 (61.1%) of the feet. If the D-score was 15 or higher there was a 20% increase in the incidence of Achilles tenotomy. The parental compliance had a weak protective effect against relapse. The treatment of idiopathic clubfoot by the Ponseti method was successful and reliable, proving efficiency and universality of the method. A dominant predictor for relapse was not seen. An incidental observation was that extended time in cast may buffer the adverse effects of low compliance rate. Although the initial severity, or compliance to braces are important, there may be other factors that affect the outcome such as, accuracy of the casting technique, time in the cast, access to a dedicated clubfoot clinic, cooperation with nurses and pediatricians, economic status that allows purchase of new generation of braces, cultural perception, and education level of the patient population are some examples.
Collapse
Affiliation(s)
- Eugen Cohen
- Lecturer, Orthopaedic Department, Soroka Medical Center, Ben Gurion University Beer-Sheva, Israel.
| | - Tiberiu Katz
- Lecturer, Orthopaedic Department, Soroka Medical Center, Ben Gurion University Beer-Sheva, Israel
| | - Uri Rozen
- Resident, Meuhedet Health Services, Tel Aviv, Israel
| | - Tai Friesem
- Senior Lecturer, Orthopaedic Department, Soroka Medical Center, Ben Gurion University Beer-Sheva, Israel
| | - Eugene Leibovitz
- Professor, Pediatric Division, Soroka Medical Center, Ben Gurion University Beer-Sheva, Israel
| |
Collapse
|
38
|
Li J, Zhu G, Kang X, Shen X, Chen S, Tang S, Gong Q, Li Y, Xu H. Association Between TPM1 Gene Polymorphisms and Idiopathic Congenital Talipes Equinovarus Risk in a Chinese Population. Genet Test Mol Biomarkers 2021; 25:355-360. [PMID: 33945307 DOI: 10.1089/gtmb.2020.0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Idiopathic congenital talipes equinovarus (ICTEV) is one of the most common congenital deformities of children, and dysplasia of the striated muscle may be one of the causes of ICTEV. Previous studies have shown that polymorphisms of the rs4075583 SNP in the tropomyosin gene 1 (TPM1) were associated with ICTEV in Caucasian children. However, there are no studies investigating the correlations of TPM gene polymorphisms with the risk of ICTEV in Chinese children. Methods: We conducted a case-control study, including 430 children with ICTEV and 891 ICTEV-free children. We explored the potential correlations of three TPM gene polymorphisms (TPM1/rs4075583 G>A, tropomyosin gene 2 (TPM2)/rs2145925 C>T, and TPM2/rs2025126 G>A) with ICTEV risk. The three single nucleotide polymorphisms (SNPs) were genotyped using a TaqMan method. We calculated the odds ratios (ORs) and adjusted ORs and their 95% confidence intervals (CIs) to explore the associations between these selected SNP polymorphisms and ICTEV. Results: TPM1 rs4075583 A was found to be associated with an increased ICTEV risk (AA vs. GG: adjusted OR = 1.70, 95% CI = 1.15-2.49, p = 0.007; and GG/GA vs. AA: adjusted OR = 1.62, 95% CI = 1.14-2.31, p = 0.0071) after adjusting for age and sex. In addition, a risk effect of rs4075583 GA/AA with ICETV was observed for patients with affected right feet (adjusted OR = 1.62, 95% CI = 1.10-2.39, p = 0.014) in the stratified analysis. However, there were no significant differences in the risk for ICTEV associated with the rs2145925 and rs2025126 polymorphisms. Conclusion: These results indicate that the TPM1 rs4075583 G > A polymorphism is associated with ICTEV risk in a southern Chinese population; however, this finding needs to be confirmed in larger studies and through mechanistic studies.
Collapse
Affiliation(s)
- Jingchun Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, China
| | - Guanghui Zhu
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Changsha, China
| | - Xiaopeng Kang
- Department of Pediatric Orthopedics, Kunming Children's Hospital, Kunming, China
| | - Xiantao Shen
- Department of Pediatric Orthopedics, Wuhan Medical and Healthcare Center for Women and Children, Wuhan, China
| | - Shunyou Chen
- Department of Pediatric Orthopedics, Fuzhou second Hospital of Xiamen University, Fuzhou, China
| | - Shengping Tang
- Department of the First Orthopaedics, Shenzhen Children's Hospital, Shenzhen, China
| | - Qian Gong
- Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yiqiang Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, China
| | - Hongwen Xu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
39
|
Murphy D, Raza M, Khan H, Eastwood DM, Gelfer Y. What is the optimal treatment for equinus deformity in walking-age children with clubfoot? A systematic review. EFORT Open Rev 2021; 6:354-363. [PMID: 34150329 PMCID: PMC8183149 DOI: 10.1302/2058-5241.6.200110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Daniel Murphy
- St George's University Hospitals NHS Foundation Trust, London, UK.,St George's, University of London, London, UK
| | - Mohsen Raza
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Hiba Khan
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Deborah M Eastwood
- Great Ormond Street Hospital, London, UK.,University College London (UCL), London, UK
| | - Yael Gelfer
- St George's University Hospitals NHS Foundation Trust, London, UK.,St George's, University of London, London, UK
| |
Collapse
|
40
|
Agarwal A, Rastogi A, Rastogi P. Relapses in clubfoot treated with Ponseti technique and standard bracing protocol- a systematic analysis. J Clin Orthop Trauma 2021; 18:199-204. [PMID: 34026487 PMCID: PMC8122108 DOI: 10.1016/j.jcot.2021.04.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/11/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022] Open
Abstract
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 1st January 2001 to 15th 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.
Collapse
Affiliation(s)
- Anil Agarwal
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India,Corresponding author. Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India.
| | - Anuj Rastogi
- Department of Orthopaedics, Integral Institute of Medical Sciences and Research, Integral University, Lucknow, Uttar Pradesh, India
| | - Prateek Rastogi
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 31, India
| |
Collapse
|
41
|
Leo DG, Russell A, Bridgens A, Perry DC, Eastwood DM, Gelfer Y. Development of a core outcome set for idiopathic clubfoot management. Bone Jt Open 2021; 2:255-260. [PMID: 33882693 PMCID: PMC8085617 DOI: 10.1302/2633-1462.24.bjo-2020-0202.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aims This study aims to define a set of core outcomes (COS) to allow consistent reporting in order to compare results and assist in treatment decisions for idiopathic clubfoot. Methods A list of outcomes will be obtained in a three-stage process from the literature and from key stakeholders (patients, parents, surgeons, and healthcare professionals). Important outcomes for patients and parents will be collected from a group of children with idiopathic clubfoot and their parents through questionnaires and interviews. The outcomes identified during this process will be combined with the list of outcomes previously obtained from a systematic review, with each outcome assigned to one of the five core areas defined by the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT). This stage will be followed by a two round Delphi survey aimed at key stakeholders in the management of idiopathic clubfoot. The final outcomes list obtained will then be discussed in a consensus meeting of representative key stakeholders. Conclusion The inconsistency in outcomes reporting in studies investigating idiopathic clubfoot has made it difficult to define the success rate of treatments and to compare findings between studies. The development of a COS seeks to define a minimum standard set of outcomes to collect in all future clinical trials for this condition, to facilitate comparisons between studies and to aid decisions in treatment. Cite this article: Bone Jt Open 2021;2(4):255–260.
Collapse
Affiliation(s)
- Donato Giuseppe Leo
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Science, University of Liverpool, Liverpool, UK.,St George's Healthcare NHS Trust, London, UK
| | | | | | - Daniel C Perry
- University of Liverpool, Liverpool, UK.,University of Oxford, Oxford, UK.,Institute in the Park, Alder Hey Hospital, Liverpool, UK
| | - Deborah M Eastwood
- Great Ormond Street Hospital, London, UK.,University College London, London, UK
| | - Yael Gelfer
- St George's Healthcare NHS Trust, London, UK.,St George's University of London, London, UK
| |
Collapse
|
42
|
Successful Ponseti-treated Clubfeet at Age 2 Years: What Is the Rate of Surgical Intervention After This? J Pediatr Orthop 2021; 40:597-603. [PMID: 32558742 DOI: 10.1097/bpo.0000000000001614] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
Collapse
|
43
|
Quantification of Ankle Dorsiflexion in Ponseti-managed Unilateral Clubfoot Patients During Early Childhood. J Pediatr Orthop 2021; 41:83-87. [PMID: 33264177 DOI: 10.1097/bpo.0000000000001719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Following the initial correction of a clubfoot using the Ponseti method, diminished passive ankle dorsiflexion may be observed over time, which could represent a possible relapsed deformity. Alternatively, the change may be attributable to patient age or other variables. Our purpose was to quantify passive ankle dorsiflexion in the involved and contralateral unaffected limbs of Ponseti-managed unilateral clubfoot patients, and to determine what patient-related variables influence this finding. METHODS In total, 132 unilateral clubfoot patients were studied. Passive ankle dorsiflexion was measured in both limbs at each visit. Data were excluded from visits in which patients showed clear evidence of a relapse. Mean ankle dorsiflexion for clubfeet and contralateral unaffected limbs were reported for annual age intervals and compared using paired t tests. A general linear model was established to assess the effects of age, severity, sex, and side on ankle dorsiflexion. RESULTS Mean ankle dorsiflexion for unaffected limbs declined with age, measuring 53±6 degrees between 0 and 1 year of age and decreasing to 39±7 degrees by 4 to 5 years of age. Similarly, mean ankle dorsiflexion in treated clubfeet declined with age, measuring 44±7 degrees between 0 and 1 year and 29±7 degrees between 4 and 5 years. Overall, the difference between limbs in these patients averaged ~10 degrees for every age interval through 9 years (P<0.001). Ankle dorsiflexion of clubfeet in 95% of patients aged 0 to 2 years was at least 20 degrees, and in 95% of patients aged 3 to 5 years this was at least 15 degrees. Patient age (P<0.001) and severity of deformity (P<0.001) were found to be the only significant factors affecting ankle dorsiflexion in the affected limbs. CONCLUSIONS Ankle dorsiflexion in the Ponseti-treated clubfeet was influenced by age of the patient and the initial severity of the affected limb. Furthermore, our data suggest that, in patients who showed no relapse, a minimum of 20 degrees of ankle dorsiflexion in the corrected clubfoot is maintained through age 3 years and a minimum of 15 degrees is maintained through age 5 years. LEVEL OF EVIDENCE Level IV-this is a retrospective case series.
Collapse
|
44
|
Sheta RA, El-Sayed M. Is the Denis Browne Splint a Myth? A Long-Term Prospective Cohort Study in Clubfoot Management using Denis Browne Splint Versus Daily Exercise Protocol. J Foot Ankle Surg 2021; 59:314-322. [PMID: 32130997 DOI: 10.1053/j.jfas.2019.08.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 02/03/2023]
Abstract
The Ponseti technique is successful in idiopathic clubfoot management. However, the leading cause of relapse and recurrence is nonadherence to the Denis Brown bracing protocol. This necessitates more extensive soft tissue surgeries. Based on a detailed up-to-date search, we have found that no other studies provide such a modified Ponseti technique. This study is unique, as it depends on using specific stretching exercises instead of bracing during management. Between August 2009 and June 2019, a consecutive series of 194 isolated idiopathic clubfoot patients (251 feet) were included in this study. The mean follow-up was 93 months (range 72 to 146), mean 91.8 months. All patients underwent a clinical and functional assessment using the Laaveg-Ponseti score and radiological assessments. There were 132 boys (68.1%) and 62 girls (31.9%), a male-to-female ratio of 2:1. The mean age at initiation of treatment was 14.9 days. According to the Laaveg-Ponseti score, 51.7% yielded excellent results, 35.3% yielded good results, 11.55% yielded fair results, and 1.59% yielded poor results. Bracing noncompliance has been identified as a major cause for treatment failure. This presented exercise protocol not only eliminates the need for bracing and reduces the cost for the affected individuals but also provides excellent clinical and radiographic end results, comparable to the original treatment protocol using the Denis Brown brace.
Collapse
Affiliation(s)
- Reda Ali Sheta
- Orthopedic Consultant, Al Ahrar Specialist Hospital, Zagazig, Egypt.
| | - Mohamed El-Sayed
- Professor, Pediatric Orthopedics & Limb Reconstructive Surgeries, Tanta University, Tanta, Egypt
| |
Collapse
|
45
|
Variations in arterial pedal circulation in idiopathic congenital talipes equinovarus: a systematic review. J Pediatr Orthop B 2021; 30:59-65. [PMID: 32195760 DOI: 10.1097/bpb.0000000000000724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Variations in pedal circulation in congenital talipes equinovarus (CTEV) are well documented. There is a reported risk of vascular injury to the posterior tibial artery (PTA) during operative procedures for CTEV, potentially leading to necrosis and amputation. The aim of this systematic review was to identify the most common anomalies in arterial pedal circulation in CTEV and to determine the relevance of these to clinical practice. The systematic review was registered on PROSPERO and was carried out according to Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines by two independent reviewers. Studies that examined pedal circulation in idiopathic CTEV were included. Articles that studied nonidiopathic CTEV and those not published in English were excluded. Data extracted included patient demographics, imaging modalities, and findings. A total of 14 articles satisfied the inclusion criteria, including 192 patients (279 clubfeet), aged 0-13.5 years, at various stages in their treatment. Imaging modalities included arteriography (n = 5), duplex ultrasound (n = 5), magnetic resonance angiography (n = 2), and direct visualization intraoperatively (n = 2). The dorsalis pedis was most frequently reported as absent (21.5%), and the anterior tibial artery (ATA) was most frequently reported as hypoplastic (18.3%). Where reported (n = 36 feet), 61% of patients were noted to have a dominant supply from the PTA. The most common variation in pedal circulation in CTEV is diminished supply from ATA and dorsalis pedis, although there are documented anomalies in all of the vessels supplying the foot. We therefore recommend routine Doppler ultrasound imaging prior to operative intervention in CTEV.
Collapse
|
46
|
Gelfer Y, Hughes KP, Fontalis A, Wientroub S, Eastwood DM. A systematic review of reported outcomes following Ponseti correction of idiopathic club foot. Bone Jt Open 2020; 1:457-464. [PMID: 33215139 PMCID: PMC7667221 DOI: 10.1302/2633-1462.18.bjo-2020-0109.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Yael Gelfer
- St George’s University of London, UK
- St George’s Hospital, London, UK
- Sheffield Teaching Hospital NHS Trust, Sheffield, UK
| | | | | | - Shlomo Wientroub
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Orthopaedics, Dana Children’s Hospital – Tel Aviv Medical Center, Tel Aviv, Israel
| | - Deborah M. Eastwood
- Great Ormond Street Hospital, London, UK
- Paediatric Orthopaedics, University College London, London, UK
| |
Collapse
|
47
|
Abstract
Clubfoot is a complex 4-dimensional deformity involving the hindfoot, midfoot, and forefoot. The fourth dimension is time. Treatment aims at achieving a pain-free, plantigrade, and mobile foot but, over time, flexible deformities become fixed and more difficult to manage. The Ponseti method of serial manipulation and casting can be used successfully in older children and may reduce the need for extensive open surgery. Alternatively, gradual correction of by an external device enables simultaneous correction of all components of the deformity without shortening the foot. Combining gradual soft tissue distraction with open releases and/or bony procedures may achieve a pain-free and plantigrade foot.
Collapse
Affiliation(s)
- Nicholas Peterson
- Royal Liverpool & Broadgreen University Hospital, Liverpool, UK; Alder Hey Children's Hospital, East Prescot Road, Liverpool L14 5AB, UK.
| | - Christopher Prior
- Alder Hey Children's Hospital, East Prescot Road, Liverpool L14 5AB, UK
| |
Collapse
|
48
|
Abstract
PURPOSE OF REVIEW This review aims to provide primary care physicians with updates on recent literature regarding clubfoot and answer questions asked by parents and caregivers of children with clubfoot. The topics discussed include prenatal counseling, relapse after Ponseti treatment, long-term outcomes following successful treatment of clubfoot, and the effect of diagnosis and treatment on the parent or caregiver. RECENT FINDINGS Clubfoot is one of the most commonly searched orthopaedic conditions on the internet by parents. There is a lack of evidence-based guidelines on clubfoot worldwide. Recent systematic reviews have identified emerging evidence of genetic and modifiable risk factors that lead to clubfoot. Patients treated by the Ponseti method show better ankle power and strength compared with those treated with surgery for residual deformity or recurrence. SUMMARY The treatment of clubfoot is a long and involved process. Exposure to and familiarity with the Ponseti method will aid primary care physicians and parents in the optimization of children's clubfoot deformity correction using largely nonoperative management.
Collapse
Affiliation(s)
| | - Shevaun M Doyle
- Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| |
Collapse
|
49
|
Hemo Y, Gigi R, Wientroub S. Delayed ossification and abnormal development of tarsal bones in idiopathic clubfoot: should it affect bracing protocol when using the Ponseti method? J Child Orthop 2019; 13:265-270. [PMID: 31312266 PMCID: PMC6598050 DOI: 10.1302/1863-2548.13.190080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/21/2019] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To point out the need to take into account the dysplastic nature of tarsal bones when treating idiopathic clubfoot (CF). METHODS Review the published evidence on the developmental abnormalities of tarsal bones in idiopathic CF. RESULTS The literature review provides abundant proof of the existence of delayed appearance and slower development of ossification centres of tarsal bones in idiopathic clubfoot. CONCLUSION Gentle manipulations and casting are the cornerstone of the Ponseti method. The biological response of all foot elements is critical for a successful outcome. Delayed ossification and abnormal development of tarsal bones in idiopathic CF may affect the results. Development of a personalized tailored bracing protocol based on severity assessment and response to casting treatment will improve results and quality of care in CF management. LEVEL OF EVIDENCE V.
Collapse
Affiliation(s)
- Y. Hemo
- Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R. Gigi
- Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S. Wientroub
- Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center, and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|