Neglected clubfoot treated by serial casting: a narrative review on how possibility takes over disability

Application of pedobarographic analysis in neglected congenital clubfoot patients following Ponseti treatment for recurrence prediction

Background

Neglected congenital clubfoot (NCCF) is a birth deformity that remains untreated until the child begins to walk. Irrespective of the treatment protocols employed, children with NCCF face an elevated risk of recurrence following the initial correction. Predicting this recurrence could enable early intervention for high-risk children, ultimately diminishing the likelihood of invasive surgery.

Methods

From January 2006 to January 2022, a total of 33 unilateral NCCF patients were enrolled in this study at Xijing Hospital. Pedobarographic tests were performed at three distinct time points: after the initial Ponseti treatment, before recurrence treatment, and after recurrence treatment. Four derivative parameters were developed for predicting recurrence, namely the difference of the contact time% (DCT%), difference of the contact area% (DCA%), difference of the peak pressure (DPP), and difference of the pressure-time integral (DPTI) between the two feet. ROC curves, Kaplan-Meier survival analysis, and Cox regression were employed to identify potential prognostic factors.

Results

Out of the 33 unilateral NCCF patients, recurrence occurred in 8 individuals, with an average follow-up period of 109.8 months. The predictive parameter for recurrence is the midfoot (MF) zone's DCT% (MF-DCT%). When the contact time (CT)% of the affected side was 20.69% higher than that of the unaffected side, the hazard ratio (HR) of recurrence increased by 7.404 times. Another predictive plantar pressure parameter is the DPP in the MF zone (MF-DPP). If the PP of the affected side was 159% higher than that of the unaffected side, the HR of recurrence increased by 9.229 times. The MF-DCT% and MF-DPP of recurrence patients were assessed at three time points for comparisons, further validating their predictive ability for recurrence.

Conclusion

Although satisfactory clinical outcomes were achieved in patients with unilateral NCCF after the initial Ponseti treatment, the plantar pressure distribution does not return to normal levels, which may indicate future recurrence. DCT% and DPP in the MF zone can be used as plantar pressure predictors of recurrence in patients with NCCF.

Neglected Clubfoot- a Community Health Challenge in Rural Odisha, India

Introduction

Neglected clubfoot deformities are very rigid & stiff that need surgical correction. Unlike countries like china, Uganda, and Malawi, no dedicated National program has been implemented for clubfoot management in India. The burden of disability from untreated or partly treated clubfoot is relatively high. With the existing issues, it has been observed that untreated clubfoot is a public health problem in most low and middle-income countries.

Objective

To conduct an observational analysis of the community approach to the correction of neglected clubfoot by corrective rehabilitation surgery camps.

Methods

The study included the retrospective data of all the neglected clubfoot children who had undergone clubfoot corrective surgery in 13 different remote districts of Odisha, held every year between February 2014 to October 2022 except during covid 19 pandemic period (2020 and 2021). A total of 993 clubfeet of 731 children were corrected through community approach-based corrective camp surgery. Follow-up was done for all the operated children with post-op plaster and orthosis till they returned back to the community.

Results

About 46.78% of study participants were within the age group of 5 years. Male presentation [454 males (62.10%)] was reportedly found 1.6 times higher than the female [277 females (37.89%)]. Most of them belonged to minor communities, socially and economically backward classes from various rural districts of eastern India. The Association of different socially backward categories of clubfoot children with the district they belonged to, was found significant statistically (p value < 0.001). When gender distribution was compared among the district where surgical camps were conducted, the association was statistically not significant (p value = 0.676).

Conclusion

Neglected clubfoot in rural areas can be managed by camp approach. The establishment of a robust standard operating procedure for the conduction of community-based surgical camps may be required to reduce the morbidity level in children with neglected clubfoot.

Treating Older Children with Clubfoot: Results of a Cross-Sectional Survey of Expert Practitioners

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.

Can Below-Knee Casts be Effective for Clubfoot Management in Walking-Age Children? A Prospective Cohort Study

Purpose

Above-knee casts pose a major challenge in the day-to-day activities among walking age clubfoot patients due to complete restriction of knee movement. This current study investigates the effectiveness of below-knee casts compared to above-knee casts for managing walking age clubfoot deformity.

Methods

After approval from the institutional ethical committee, we enrolled walking age clubfoot patients for deformity correction through corrective manipulation and casting through below-knee casts over 2 years. The corrective manipulation was performed using the Ponseti technique. The patients were followed for a minimum of 2 years period. To compare the effectiveness of below-knee casts over above-knee casts, we enrolled equal numbers of walking age clubfeet matched for age and gender. We compared the two groups in terms of initial and post-correction Dimeglio scores, individual deformities corrections (maximum ankle dorsiflexion, heel varus correction, foot abduction), failure rates, relapses, and complication rates.

Results

56 patients with 80 clubfeet with a mean follow-up of 39.98 months were considered for the final analysis. There were 29 patients in the below-knee cast group and 27 in the above-knee cast group, with 40 clubfeet each. The patients in the above-knee casting group had significantly better post-correction Dimeglio scores and individual deformity components corrections than the below-knee cast group. There were nil failures in the above-knee casting group and 7.5% in the below-knee cast group. The relapse rate was 15% in both groups, with none requiring any extensive soft tissue procedure. We did not encounter any major complications during the treatment and follow-up.

Conclusion

The deformity correction and maintenance are suboptimal with the below-knee casts. Therefore, above-knee casts should be the preferred management modality for correction of walking age clubfoot deformities.

Outcomes of Eight-Plate Epiphysiodesis for Residual Clubfoot Deformities

OBJECTIVE

The outcome of congenital clubfoot treatment is still challenging if the feet deformities are not completely corrected. Here we explore a minimal invasive procedure with an eight-plate implant to correct the residual forefoot adduction deformity after treatment of neglected or relapsed clubfoot.

METHODS

We retrospectively reviewed patients with residual forefoot adduction deformity after clubfoot treatment between January 2013 and June 2016. The patients underwent temporary epiphysiodesis of the lateral column of the mid-foot, which in detail, an eight-plate was placed on each side of the calcaneocuboid joint. The foot deformities were recorded according to the weight-bearing radiographic measurements including talo-first metatarsal angle, calcaneo-fifth metatarsal angle and medial-to-lateral column length.

RESULTS

A total of 13 patients (20 feet) with an average age of 7.8 years old were located with an average duration of 40.8 months follow-up (range, 28 to 54 months). The average talo-first metatarsal angle improved from 28.3° (range, 19° to 47°) preoperatively to 8.3° (range, 3° to 18°) and the calcaneo-fifth metatarsal angle improved from 29.1° (range, 19° to 40°) preoperatively to 8.4° (range, 0° to 21°) at final follow-up. The mean ratio of the medial-to-lateral column length improved from 1.14 ± 0.06 to 1.55 ± 0.09 with statistical significance (t = 3.566; P < 0.001).

CONCLUSIONS

Eight-plate epiphysiodesis is an easy and effective method for the correction of residual forefoot adduction deformity after clubfoot treatment in growing children without the need of osteotomy.