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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.
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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
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Drury G, Nunn TR, Dandena F, Smythe T, Lavy CBD. Treating Older Children with Clubfoot: Results of a Cross-Sectional Survey of Expert Practitioners. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6846. [PMID: 37835115 PMCID: PMC10572625 DOI: 10.3390/ijerph20196846] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023]
Abstract
Treating clubfoot in walking-age children is debated, despite studies showing that using the Ponseti casting principles can correct the midfoot effectively. We aimed to explore techniques and approaches for the management of older children with clubfoot and identify consensus areas. A mixed-methods cross-sectional electronic survey on delayed-presenting clubfoot (DPC) was sent to 88 clubfoot practitioners (response rate 56.8%). We collected data on decision-making, casting, imaging, orthotics, surgery, recurrence, rehabilitation, multidisciplinary care, and contextual factors. The quantitative data were analysed using descriptive statistics. The qualitative data were analysed using conventional content analysis. Many respondents reported using the Pirani score and some used the PAVER score to aid deformity severity assessment and correctability. Respondents consistently applied the Ponseti casting principles with a stepwise approach. Respondents reported economic, social, and other contextual factors that influenced the timing of the treatment, the decision to treat a bilateral deformity simultaneously, and casting intervals. Differences were seen around orthotic usage and surgical approaches, such as the use of tibialis anterior tendon transfer following full correction. In summary, the survey identified consensus areas in the overall principles of management for older children with clubfoot and the implementation of the Ponseti principles. The results indicate these principles are well recognised as a multidisciplinary approach for older children with clubfoot and can be adapted well for different geographical and healthcare contexts.
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Affiliation(s)
- Grace Drury
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7HE, UK
| | - Timothy R. Nunn
- CURE Children’s Hospital of Ethiopia, P.O. Box 21634, Addis Ababa 1000, Ethiopia
| | - Firaol Dandena
- CURE Children’s Hospital of Ethiopia, P.O. Box 21634, Addis Ababa 1000, Ethiopia
| | - Tracey Smythe
- International Centre for Evidence in Disability, Department of Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town 7602, South Africa
| | - Christopher B. D. Lavy
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7HE, UK
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3
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Fijany AJ, Olsson SE, Givechian BK, Zago I, Bishay AE, Troia T, Page TS, Barnett A, Downey MW, Pekarev M. A Novel Orthoplastic Reconstruction of Relapsed Clubfoot With Total Ankle Arthroplasty. Cureus 2023; 15:e44796. [PMID: 37809200 PMCID: PMC10558358 DOI: 10.7759/cureus.44796] [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: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Congenital clubfoot is addressed in infancy and rarely persists into adulthood. Ankle arthroplasty is an increasingly popular surgical intervention for patients with ankle arthritis since it allows a natural ankle range of motion and completely replaces a degenerative hindfoot. Here, we describe the first successful total ankle arthroplasty (TAA) for a patient with previously treated congenital clubfoot that reverted later in life. To address the patient's poor soft-tissue integument and reduce the likelihood of post-surgical complications, a perioperative latissimus muscle-free flap was performed. This two-staged, novel orthoplastic intervention addressed our patient's ankle issues and appears to be a viable option for clubfoot patients.
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Affiliation(s)
- Arman J Fijany
- Plastic Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Sofia E Olsson
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
| | | | - Ilana Zago
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
| | - Anthony E Bishay
- Neurosurgery, Vanderbilt University School of Medicine, Nashville, USA
| | - Thomas Troia
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
| | - Trevor S Page
- Plastic Surgery, Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | | | - Michael W Downey
- Trauma and Reconstructive Surgery, Precision Orthopedics and Sports Medicine, Fort Worth, USA
| | - Maxim Pekarev
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
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4
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Smythe T, Freeze L, Cuthel A, Flowers M, Seghers F, Zia N, Bachani AM. Provision of rehabilitation for congenital conditions. Bull World Health Organ 2022; 100:717-725. [PMID: 36324557 PMCID: PMC9589394 DOI: 10.2471/blt.22.288147] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Considerable progress has been made in saving the lives of children younger than 5 years. Nevertheless, these advances have failed to help all children thrive, particularly children with disabilities. We describe the increasing prevalence of disability among children and adolescents. We evaluate the current situation regarding children with disabilities and rehabilitation in the context of health systems, particularly those in low- and middle-income countries. Within the newborn health agenda, congenital anomalies often require early intervention and rehabilitation. We provide Argentina as an example of a country where rehabilitation for congenital anomalies is integrated into the health system. We argue that congenital anomalies that require rehabilitation have the potential to strengthen rehabilitation systems and policies by: strengthening coordination between primary care and rehabilitation; identifying and understanding pathways that allow families to engage with services; providing human resources for rehabilitation; and building systems and resources that support assistive technology and rehabilitation. We propose ways for countries to prioritize and integrate early identification, referral and care for children with congenital anomalies to strengthen health systems for all. We identify opportunities to expand policy and planning and to design service delivery and workforce strategies through World Health Organization guidelines and frameworks for rehabilitation. We argue that the global health community must act to ensure that rehabilitation services to support functioning from birth are well established, accepted and integrated within health systems, and that disability is prioritized within child health. These steps would strengthen health systems, ensure functioning from birth and make rehabilitation accessible to all.
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Affiliation(s)
- Tracey Smythe
- International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Lindsey Freeze
- MiracleFeet, Chapel Hill, United States of America (USA)
| | - Anna Cuthel
- MiracleFeet, Chapel Hill, United States of America (USA)
| | | | | | - Nukhba Zia
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Abdulgafoor M Bachani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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5
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Mustari MN, Faruk M, Bausat A, Fikry A. Congenital talipes equinovarus: A literature review. Ann Med Surg (Lond) 2022; 81:104394. [PMID: 36147065 PMCID: PMC9486628 DOI: 10.1016/j.amsu.2022.104394] [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] [Received: 06/13/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 11/05/2022] Open
Abstract
Congenital talipes equinovarus (CTEV) is a congenital disability characterized by leg deformities in the cavus, adducts, varus, and equinus. The etiology of CTEV is poorly understood, despite its incidence ranging from 0.76 to 3.49 cases per 1000 live births in Indonesia. CTEV involves the fixation of the foot in the adducts, varus, and equinus with concurrent soft tissue anomalies. Despite advances in treatment, disability often persists. Theoretical models have been proposed for neurological, vascular, connective tissue, bone, and muscular causes; however, the currently available data suggests that mild cases are associated with intrauterine position. CTEV's etiology appears to involve a hereditary component, as its prevalence varies by ethnic group. Genetic factors have been identified in 24–50% of cases, depending on the community studied. Based on a complex segregation analysis, the most plausible inheritance pattern is a single large-effect gene interacting with a polygenic background. CTEV is a congenital disability characterized by leg deformities in the cavus, adducts, varus, and equinus. In Indonesia, its incidence ranges from 0.76 to 3.49 cases per 1000 live births. Genetic factors have been identified in 24–50% of cases, depending on the community studied.
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Smolle MA, Svehlik M, Regvar K, Leithner A, Kraus T. Long-term clinical and radiological outcomes following surgical treatment for symptomatic pediatric flexible flat feet: a systematic review. Acta Orthop 2022; 93:367-374. [PMID: 35347339 PMCID: PMC8958850 DOI: 10.2340/17453674.2022.2254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Albeit pediatric flexible flat foot (FFF) is a common condition, only a minority of patients become symptomatic. Long-term outcomes of surgically treated pediatric patients with symptomatic FFF are largely unknown. In this systematic review, studies providing outcomes at a mean follow-up of at least 4 years after the procedure in these patients were analyzed. MATERIAL AND METHODS A PubMed search was undertaken involving original articles published up to July 2021 on outcome in children aged 6 to 14 with surgically treated FFF and mean (or minimum) follow-up of at least 4 years. Radiographic and clinical outcomes were analyzed. RESULTS Of initially 541 entries, 10 could be included in the systematic review (all level IV), involving 846 pediatric patients with 1,536 symptomatic FFF. Pooled mean radiological (n = 8) and clinical follow-up (n = 10) was 5.3 (range 0.5-15) and 7.0 (range 4.1-15) years, respectively. Surgical procedures included arthroereisis (n = 8), lateral column lengthening (n = 1), and Horseman procedure (n = 1). Overall relative frequency of implant-associated complications and wound-healing problems was 3.2% and 1.3%, as well as 2.8% and 1.6% following subtalar arthroereisis only. From preoperative to latest radiological assessment following subtalar arthroereisis (including 3 studies with radiological follow-up < 48 months), pooled median decrease in talonavicular coverage angle (TNCA; -9.2°), anteroposterior talocalcaneal angle (A-TCA; -6.5°), lateral talocalcaneal angle (L-TCA; -3.5°), talar declination angle (TDA; -14°), Moreau Costa Bertani angle (MCB; -13°), and talo-firstmetatarsal angle (L-T1MA; -10°) was observed, as was an increase in calcaneal pitch (4.5°). INTERPRETATION In symptomatic pediatric FFF patients, surgery is associated with a manageable complication profile, and results in satisfactory long-term clinical as well as radiological outcome. Yet scientific evidence is low, warranting larger scaled studies in the future.
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Affiliation(s)
- Maria Anna Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria.
| | - Martin Svehlik
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria.
| | - Katharina Regvar
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria.
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria.
| | - Tanja Kraus
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz.
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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.
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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
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