Inferior results with unilateral compared with bilateral brace in Ponseti-treated clubfeet

Club Foot with Contralateral Congenital Amniotic Band Syndrome Amputation Successfully Treated with Ponseti Method: Case Report

Introduction

Constriction amniotic band syndrome (CABS) is a rare condition associated with the fibrous amniotic bands that restrict and ensnare the fetus in utero resulting in malformations at birth in one per around 15,000 live births. CABS associated with clubfoot, historically required extensive soft-tissue release due to its propensity for relapse.

Case Report

A 2-day-old Caucasian male infant born at 27 weeks gestation through emergency cesarean section due to concern for placental abruption and premature rupture of membranes in the setting of a prenatal history significant for oligohydramnios. The patient presented with non-viable tissue in the right leg requiring amputation with a left-sided clubfoot deformity. Following amputation of the right leg, the clubfoot was corrected with Ponseti method of serial casting and Achilles tenotomy. Three-week post-tenotomy and 6 months of age, a custom fit prosthesis of the right leg allowed for the application of a left abduction foot orthosis which maintained the correction.

Conclusion

This case study supports recent literature that CABS-associated clubfoot can be corrected with the Ponseti method. While a contralateral amputation can prevent the use of a traditional bilateral abduction foot orthosis, a custom fitted prosthesis can allow for its use and prevention of a relapse of deformity.

What is New in Pediatric Orthopaedic Foot and Ankle

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III.

Unilateral limb orthosis for maintenance of deformity correction following treatment of clubfoot with Ponseti technique: a systematic review

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.

Two-year retrospective cohort results on use of a dynamic unilateral brace for treatment of clubfoot: Can compliance and prevention of recurrence both be achieved?

Objectives

The Ponseti method has led to vast improvements in outcomes for infants born with clubfoot deformity, but challenges with compliance during the bracing phase of the protocol remain. Unilateral braces promise higher compliance but often have led to unacceptably high recurrence.

Methods

We have developed a novel unilateral brace for clubfoot deformity that strategically applies patient-specific, anatomically-targeted forces to the lower limb to maintain correction. We retrospectively reviewed the cases of 26 patients with minimum follow-up of 24 months. The data were analyzed for recurrence rates, caregiver-reported compliance, and differences in Pirani score, dorsiflexion, abduction, hindfoot eversion, and resting rotation between initial and final follow-up.

Results

Most patients (N = 23, 88%) were compliant with the bracing protocol. Two patients showed recurrence of deformity (8%). There were statistically significant improvements in Pirani score, dorsiflexion, abduction, hindfoot eversion, and resting external rotation. A subset of patients with sub-optimal correction at baseline showed improvement in all parameters across the course of bracing.

Conclusions

This novel unilateral brace for maintenance of clubfoot correction after Ponseti treatment demonstrates rates of recurrence rates and caregiver-reported compliance at 2 years of follow up that are comparable to outcomes with traditional bilateral foot abduction orthoses.

The Treatment of Recurrent Congenital Clubfoot

The Ponseti method for treatment of congenital clubfoot is well established and has been introduced in most pediatric orthopedic centers worldwide. However, reported rates of recurrence are largely variable and open joint surgery is still performed frequently, even in the age group younger than 6 years of age. Preventing recurrence and residual deformity can be achieved by strict adherence to the Ponseti method, ensuring and enforcing brace compliance, frequent follow-up, and early treatment of recurrence. This review discusses reasons for clubfoot recurrence, prevention of clubfoot recurrence, and the treatment of recurrent congenital clubfoot within the realm of the Ponseti method.

The foot external rotation above-knee (FERAK) brace versus the Denis Browne brace for management of idiopathic clubfoot following Ponseti casting: a randomized controlled trial

PURPOSE

To compare the foot external rotation above-knee (FERAK) brace and the Denis Browne boot (DBB) brace in terms of relapse prevention and parents' compliance after successful correction with Ponseti casting.

METHODS

A single-centre, randomized controlled study was conducted between 2016 and 2020. A total of 60 feet in 38 patients with idiopathic clubfoot initially corrected with the Ponseti method were included. They were randomized into two equal groups: the FERAK group and the DBB group. The primary outcome was the efficacy in maintaining correction measured by the Pirani score. The secondary outcomes were parents' compliance and complications (e.g., relapses, skin complications).

RESULTS

The follow-up period was 24 months for each patient. The mean final Pirani score was 0.42 ± 0.76 in the FERAK group and 0.57 ± 0.82 in the DBB group. This difference was statistically insignificant (p-value = 0.411). Regarding parents' compliance in the FERAK group, 86.7% of parents had good and intermediate compliance while 13.3% had bad compliance. In the DBB group, 66.7% had good and intermediate compliance while 33.3% had bad compliance. This difference was also statistically insignificant (p-value = 0.118).

CONCLUSION

Both braces achieved good comparable outcomes after Ponseti casting. However, the FERAK brace yielded slightly better parents' compliance with a less recurrence rate.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A novel prophylactic Chinese parachute ankle brace

Background

The objective is to compare the effects of a self-designed and self-manufactured novel prophylactic ankle brace [Chinese parachute ankle brace (CPAB)] and two ordinary ankle braces on the ankle joint during a half-squat parachute landing (HSPL) via biomechanical assessment.

Methods

Twenty elite paratroopers were in four different conditions: no brace, elastic brace, semi-rigid brace, and CPAB. Each participant was instructed to jump off a platform with three different heights, 40, 80, and 120 cm, and land on the force plate in a half-squat posture. The vertical ground reaction forces (vGRFs), joint angles, moments, powers, and works were calculated. After the experiment, every participant completed the questionnaires designed for this study.

Results

Increasing the dropping height increased all of the parameters significantly (P<0.01), except for time to peak vGRF (T-PvGRF). Applying three braces can all slightly increase vGRF (P=0.237) and reduce T-PvGRF by 6–10 ms, as well as decrease the joint angles, velocities, and moments on the sagittal and coronal planes. Wearing CPAB and a semi-rigid brace more efficiently restricted dorsiflexion and inversion (P<0.05), and they both significantly reduced ankle work (t=5.107, P<0.01; t=3.331, P<0.01) and peak power (t=7.237, P<0.01; t=6.711, P<0.01) at 120 cm. The total scores from low-to-high were semi-rigid brace (19.20±2.99), elastic brace (21.91±3.25), and CPAB (23.37±3.08).

Conclusions

The CPAB was more effective at restricting ankle joint motion on the coronal and sagittal planes than the other two prophylactic ankle braces. Therefore, the CPAB had the advantages of a novel appearance, high efficiency, and superior comfort, providing a reliable choice for parachute jumping and training in China.

Ilizarov technique combined with limited adjunctive surgical procedures for correction of relapsed talipes equinovarus in children

Objective To evaluate the efficacy and safety of using the Ilizarov invasive distraction technique combined with limited surgical operations in the treatment of relapsed talipes equinovarus in children. Methods This retrospective study analysed the outcomes of paediatric patients with relapsed talipes equinovarus who were treated with the Ilizarov technique with moderate open limited soft tissue or bony operations. The International Clubfoot Study Group (ICFSG) classification system score was used to evaluate the deformities before and after surgery. Results The study evaluated 16 feet in 14 patients (nine boys). The correction time ranged from 6 to 12 weeks. The mean duration of frame application was 5.9 months. The gait was improved significantly in all patients. At final follow-up, the mean ankle dorsiflexion and plantarflexion ranges were 8.3° and 34.6°, respectively. The talocalcaneal angle improved from 10.0° preoperatively to 28.3° postoperatively in the anteroposterior plane; and from 4.1° preoperatively to 42.1° postoperatively in the lateral plane. The differences in the angle of plantarflexion, dorsiflexion, range of motion of the ankle joint and talocalcaneal angles pre- and postoperation were significant. Conclusions These current findings suggest that the Ilizarov technique combined with limited surgery effectively corrects relapsed talipes equinovarus in children.