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Addar A, Bouchard M. Clinically Detected Leg Length Discrepancy in Patients With Idiopathic Clubfoot Deformity: Prevalence and Outcomes. J Pediatr Orthop 2022; 42:e772-e776. [PMID: 35543605 DOI: 10.1097/bpo.0000000000002178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study evaluates the prevalence and outcomes of patients with idiopathic clubfoot and clinically detected limb length discrepancy (LLD). METHODS This is a retrospective cohort study of idiopathic clubfoot patients in a Research Ethics Board-approved clubfoot registry. Patients with LLD ≥0.5 cm (LLD+) were compared with those with no or <0.5 cm LLD (LLD-). LLD was determined by documented clinical examination. Exclusion criteria included nonidiopathic clubfoot deformity, <2-year follow-up, and incomplete records. RESULTS Of the 300 patients included, 27 (9.0%) had an LLD, of whom 23 patients had a unilateral clubfoot deformity. The prevalence of LLD was 15.3% and 2.67% in unilateral and bilateral clubfoot patients, respectively. The mean LLD was 1.21 cm (0.5 to 3.5 cm, SD: 0.78 cm) in LLD+ patients, with a mean of 1.27 cm (SD: 0.79 cm) in unilateral clubfoot patients and 0.88 cm (SD: 0.75 cm) in bilateral patients. The total number of casts applied in LLD+ unilateral clubfoot patients was significantly higher than in LLD- unilateral patients (9.5 vs. 6.8 casts; P =0.015). The overall relapse rate in all patients was 30.3% and was significantly higher in the unilateral only LLD+ group [relative risk (RR)=2.89] and the total LLD+ patient cohort (RR=1.68). The risk of repeat casting for relapse was also higher in the unilateral LLD+ group (RR=2.45) and the total LLD+ group (RR=1.87). The risk of surgery for relapse was significantly higher in the unilateral LLD+ group for any surgery ( P =0.046), and most specifically for open tendo-Achilles tenotomy ( P =0.008) and tibialis anterior tendon transfer ( P =0.019). There was no correlation between the severity of LLD and Pirani score at presentation. CONCLUSIONS LLD was present in 9% of idiopathic clubfoot patients, and most were <2 cm. There is a significantly higher risk of relapse in patients with unilateral clubfoot and LLD. The risk of surgery overall was higher in all patients with a unilateral LLD. Assessment of LLD should be routinely performed in clubfoot patients. LEVEL OF EVIDENCE Level III.
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Manousaki E, Andriesse H, Hägglund G, Ström A, Esbjörnsson AC. The foot drawing method: reliability of measuring foot length and outward rotation in children with clubfoot. BMC Musculoskelet Disord 2022; 23:506. [PMID: 35624496 PMCID: PMC9145159 DOI: 10.1186/s12891-022-05465-9] [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: 01/23/2022] [Accepted: 05/19/2022] [Indexed: 11/15/2022] Open
Abstract
Background The Ponseti method is the gold standard for clubfoot treatment. However, relapse and residual gait deviations are common, and follow-up until 7 years of age is recommended. We evaluated the reliability of the foot drawing method, a new instrument for the follow-up of clubfoot. The method uses drawings of the foot in the neutral position and external rotation to measure foot length and outward rotation. Methods Nineteen children aged 2.5–7 years who were treated with the Ponseti method for congenital clubfoot were included. Two raters made the drawings twice (D1 and D2). Each rater measured foot length, foot rotation, and foot–tibial rotation independently (D1). Later, the raters repeated the measurements (D2). Interrater reliability was assessed using the D1 from each rater. Intrarater reliability was assessed using the measurements from each rater’s D1 and D2. Bland–Altman plots were used to visualize the limits of agreement (LoA). The mean, 95% confidence interval, and one standard deviation of the differences in all measurements were calculated. Results The mean differences between and within raters were: foot length < 1 mm, foot rotation < 1°, and foot–tibia rotation < 2°, which indicated no systematic differences. The LoA for foot length were: 4.5 mm and 5.9 mm between raters for D1, − 4.8 mm and 5.9 mm for rater 1 (D1–D2), and − 5.1 mm and 5 mm for rater 2 (D1–D2). The LoA for foot rotation: were − 12° and 10.6° between raters (D1), − 8.4° and 6.6° for rater 1 (D1–D2), and − 14° and 14.1° for rater 2 (D1–D2). The LoA for foot–tibia rotation were: − 17.8° and 14.3° between raters (D1), − 12° and 12.2° for rater 1 (D1–D2), and − 12.7° and 13.6° for rater 2 (D1– D2). Conclusions The absence of systematic differences between and within raters, and LoA observed indicate that the foot drawing method is applicable in clinical practice and research. However, the results of the foot and foot–tibia rotation analyses imply that caution is needed when interpreting changes in foot rotation in feet with higher degrees of rotation. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05465-9.
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Affiliation(s)
- Evgenia Manousaki
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Skane University Hospital, 221 85, Lund, Sweden. .,Department of Orthopedics, Central Hospital in Växjö, Växjö, Sweden.
| | - Hanneke Andriesse
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Skane University Hospital, 221 85, Lund, Sweden
| | - Gunnar Hägglund
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Skane University Hospital, 221 85, Lund, Sweden
| | - Axel Ström
- Clinical Studies Sweden Forum South, Skane University Hospital, Lund, Sweden
| | - Anna-Clara Esbjörnsson
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Skane University Hospital, 221 85, Lund, Sweden
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Abstract
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.
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Affiliation(s)
- Kali Tileston
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
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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.
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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.
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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.
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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
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Trout SM, Whitaker AT. Management issues of congenital talipes equinovarus in the neonatal intensive care unit: A systematic review. Foot Ankle Surg 2021; 27:480-485. [PMID: 32958391 DOI: 10.1016/j.fas.2020.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/17/2020] [Accepted: 07/10/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The Ponseti method is the standard of care for managing idiopathic congenital talipes equinovarus (clubfoot) in the outpatient setting, but there are no clinical guidelines for inpatient treatment. Children in the neonatal intensive care unit (NICU) with clubfoot often delay treatment initiation due to medical reasons. METHODS We systematically reviewed literature related to the treatment of clubfoot in the NICU, non-idiopathic clubfoot, and older infants, as well as barriers to care. RESULTS In a mixed NICU population of syndromic and idiopathic clubfoot, the Ponseti method has good functional outcomes with minimal interference with medical management. The Ponseti method has good functional outcomes with reduced need for extensive surgical procedures in non-idiopathic clubfoot and idiopathic clubfoot with delayed presentation (under one year of age). CONCLUSIONS It is possible to begin Ponseti treatment in the NICU without compromising medical management. It is not clear if this confers an advantage over waiting for outpatient casting.
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Affiliation(s)
- Sally M Trout
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Amanda T Whitaker
- The Ohio State University College of Medicine, Columbus, OH, USA; Nationwide Children's Hospital, Orthopaedic Surgery, Columbus, OH, USA.
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Manousaki E, Esbjörnsson AC, Hägglund G, Andriesse H. Development of foot length in children with congenital clubfoot up to 7 years of age: a prospective follow-up study. BMC Musculoskelet Disord 2021; 22:487. [PMID: 34044803 PMCID: PMC8161945 DOI: 10.1186/s12891-021-04323-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/05/2021] [Indexed: 11/30/2022] Open
Abstract
Background Clubfeet are typically shorter than normal feet. This study aimed first to describe the development of foot length in a consecutive series of children with congenital clubfoot and second to relate foot length to development of relapse and motion quality. Methods Foot length was measured every 6 months in 72 consecutive children with congenital clubfoot (29 bilateral) aged from 2 to 7 years. The initial treatment was nonsurgical followed by standardized orthotic treatment. Foot length growth rate was calculated every half year. In children with unilateral clubfeet, the difference in foot length between the clubfoot and the contralateral foot was calculated. Motion quality was evaluated by the Clubfoot Assessment Protocol (CAP). Student’s t test, the Mann–Whitney U test and Spearman’s correlation were used for group comparisons. Bonferroni correction was used when multiple comparisons were performed. Results Clubfeet were smaller (P < 0.001) than reference feet at all ages but had a similar growth rate up to age 7. Unilateral clubfeet with greater difference in size compared with the contralateral foot at the first measurement, relapsed more frequently (P = 0.016) and correlated with poorer motion quality (r = 0.4; P = 0.011). Conclusions As previously reported, clubfeet were smaller than reference feet at all ages. The growth rate, however, was similar between clubfeet and reference feet. Children with unilateral clubfeet and greater foot length difference at 2 years of age had a higher tendency to relapse and poorer motion quality at 7 years of age, indicating that foot length could be used as a prognostic tool.
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Affiliation(s)
- Evgenia Manousaki
- Department of Clinical Sciences, Lund University, Orthopedics, 221 85, Lund, Sweden.
| | | | - Gunnar Hägglund
- Department of Clinical Sciences, Lund University, Orthopedics, 221 85, Lund, Sweden
| | - Hanneke Andriesse
- Department of Clinical Sciences, Lund University, Orthopedics, 221 85, Lund, Sweden
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Affiliation(s)
- S. Böhm
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
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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.
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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
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