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Wang YY, Su YC, Tu YK, Fang CJ, Hong CK, Huang MT, Lin YC, Hsieh ML, Kuan FC, Shih CA, Lin CJ. Determining the Optimal Treatment for Idiopathic Clubfoot: A Network Meta-Analysis of Randomized Controlled Trials. J Bone Joint Surg Am 2024; 106:356-367. [PMID: 38015923 DOI: 10.2106/jbjs.22.01210] [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: 11/30/2023]
Abstract
BACKGROUND Clubfoot, or congenital talipes equinovarus deformity, is a common anomaly affecting the foot in infants. However, clinical equipoise remains between different interventions, especially those based on the Ponseti method. The aim of this study was to examine the clinical outcomes of the various interventions for treating idiopathic clubfoot. METHODS Searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Scopus, and CINAHL were conducted. Randomized controlled trials comparing different interventions, including the Ponseti method, accelerated Ponseti method, Ponseti method with botulinum toxin type A (Botox) injection, Ponseti method with early tibialis anterior tendon transfer (TATT), Kite method, and surgical treatment, were included. Network meta-analyses (NMAs) were conducted according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) reporting guidelines. The primary outcomes were the change in total Pirani score and maximal ankle dorsiflexion. Secondary outcomes were the number of casts, time in casts, and rates of tenotomy, total complications, relapse, adverse events, and additional required major surgery. RESULTS Eleven randomized controlled trials involving 740 feet were included. According to the SUCRA (surface under the cumulative ranking curve)-based relative ranking, the Ponseti method was associated with the best outcomes in terms of Pirani score changes, maximal ankle dorsiflexion, number of casts, adverse events, and total complications, whereas the accelerated Ponseti method was associated with the best outcomes in terms of time in casts and tenotomy rate. Early TATT ranked best in terms of relapse rate. The Ponseti method with Botox injection was associated with the best outcomes in terms of the need for additional major surgery. CONCLUSIONS The NMAs suggest that the Ponseti method is the optimal treatment overall, despite potential drawbacks such as longer time in casts and higher rates of tenotomy, relapse, and the need for additional surgery compared with other modified approaches. Therefore, clinicians should consider how treatments can be tailored individually. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ying-Yu Wang
- Chang Gung Memorial Hospital at Linkuo, Taoyuan City, Taiwan
- National Cheng Kung University Hospital, School of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Cheng Su
- Chang Gung Memorial Hospital at Linkuo, Taoyuan City, Taiwan
- National Cheng Kung University Hospital, School of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Ju Fang
- Department of Secretariat, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Medical Library, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Kai Hong
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Orthopedics, National Cheng Kung University Hospital Dou-Liou Branch, Tainan, Taiwan
| | - Ming-Tung Huang
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yung-Chieh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Min-Ling Hsieh
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Fa-Chuan Kuan
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chien-An Shih
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Medical Device R&D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chii-Jeng Lin
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- President's Office, Joint Commission of Taiwan, New Taipei City, Taiwan
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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.
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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
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Gait Analysis Characteristics in Relapsed Clubfoot. J Pediatr Orthop 2023; 43:65-69. [PMID: 36607915 DOI: 10.1097/bpo.0000000000002314] [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: 01/07/2023]
Abstract
BACKGROUND Relapse rates of clubfoot deformity after initial correction range between 19% and 68% regardless of treatment approach. Most studies focus on relapse before age 4. Little research has focused on late clubfoot relapse. The purpose of this study was to compare the gait characteristics of children with late clubfoot relapse (age ≥5 y) following treatment with the Ponseti method only compared with intra-articular and extra-articular surgeries. METHODS A retrospective review was conducted of all patients with idiopathic clubfoot ≥5 years old who underwent computerized gait analysis for clubfoot relapse between 2001 and 2021. Joint range of motion, muscle strength, gait kinematics, and kinetics were compared among 3 groups based on prior clubfoot treatment: (1) Ponseti casting, (2) Extra-articular (EA) surgery, and (3) Intra-articular (IA) surgery. RESULTS Sixty-eight subjects (107 feet) were included (39 bilateral). Thirty-one percent of feet had been treated with Ponseti casting alone; 57% had IA surgery, and 12% had EA surgery. The average age when presenting with late relapse was 8.2 years, 9.0 years and 10.7 years for the Ponseti, and IA and EA groups, respectively. The IA group had greater passive dorsiflexion than the other 2 groups (P<0.002), greater inversion weakness than the other 2 groups (P<0.0001), greater dorsiflexion during the stance phase of gait compared with the Ponseti group (P=0.001), and lower maximum power production at push-off compared with the other 2 groups (P=0.009). CONCLUSION Late relapse can occur after all types of clubfoot correction. Consistent with existing literature, patients who have undergone posteromedial release surgery have significantly greater plantarflexor weakness resulting in poorer plantarflexor moment and power production during gait. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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