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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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Johansson A, Wallander H, Esbjörnsson AC. Initial clubfoot treatment in Sweden from 2016 to 2019: A national register study. PLoS One 2024; 19:e0305900. [PMID: 38924021 PMCID: PMC11207129 DOI: 10.1371/journal.pone.0305900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND This study aimed to describe the initial treatment of clubfoot deformity in Sweden using a national cohort. Secondarily we aimed to analyse the results of the initial treatment in relation to foot severity and additional diseases. METHODS A national register, the Swedish Pediatric Orthopedic Quality Register, was used to extract data on children born with clubfoot in 2016-2019. Children with a registered evaluation after initial treatment were included. Data on deformity severity (Pirani score), casting treatment, and achillotenotomy were extracted. For children with bilateral clubfeet, one foot was included in the analysis. RESULTS A total of 565 children were included in the analysis. Of these, 73% were boys and 47% had bilateral clubfeet. Children with isolated clubfoot required a median of six casts to correct the deformity, while children with non-isolated clubfoot needed a median of eight casts. Seventy-seven percent underwent an achillotenotomy. Residual deformities of 0.5 or above (often soft-tissue issues) according to the Pirani score were noted in 23% (isolated clubfoot) and 61% (non-isolated clubfoot) after initial treatment. CONCLUSIONS We have described the initial clubfoot treatment of children born with isolated or non-isolated clubfoot in Sweden based on data from a national register. The initial treatment was performed to a large extent according to the Ponseti method and international recommendations. Moreover, we discuss the usefulness of the Pirani score in classifying clubfoot deformity after treatment.
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Affiliation(s)
- Arne Johansson
- Department of Orthopaedics, Skaraborg Hospital, Skövde, Sweden
| | - Henrik Wallander
- Departments of Orthopedic Surgery, Gävle Hospital, Gävle, Sweden
| | - Anna-Clara Esbjörnsson
- Department of Clinical Sciences Lund, Orthopaedics, Skane University Hospital, Lund University, Lund, Sweden
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Li J, Xun F, Xu C, Li Y, Xu H, Canavese F, Xia H. Early Radiographic Characteristics of the Lateral Talocalcaneal Angle and its Predictive Significance for Relapse in Patients With Idiopathic Clubfoot Treated With the Ponseti Method. J Foot Ankle Surg 2024:S1067-2516(24)00108-X. [PMID: 38866200 DOI: 10.1053/j.jfas.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 04/16/2024] [Accepted: 05/19/2024] [Indexed: 06/14/2024]
Abstract
In order to evaluate the early radiographic characteristics of the lateral talocalcaneal (L-TC) angle in patients with idiopathic clubfoot (ICF) and to investigate its prognostic significance for relapse after initial treatment with the Ponseti method. We retrospectively included 151 patients (96 males and 55 females; 227 feet) with ICF treated at our Institution between January 2005 and December 2014. The age at initial treatment was less than 6 months, and radiographs were obtained within 3 months of the Achilles tenotomy (mean age: 2.3 months; range: 0.77-6.8). All patients were followed up for at least 7 years (range, 7-18). The participants' feet were classified into 3 groups: relapsed (Group A), not relapsed (Group B), and normal foot groups which consisted of healthy feet in patients with unilateral ICF (Group C). All angle measurements were expressed in degrees. Forty-seven ICF feet in 33 patients relapsed, while 180 feet in 118 patients did not, and the age at relapse was 5.92 ± 1.91 years. Seventy-five normal feet were included in Group C. The average L-TC angle in Group A and B patients was 33.57° ± 12.05° and 39.37° ± 12.55°, respectively, while Group C was 49.61° ± 9.11°. A significant difference was found among the 3 groups of patients (F = 31.48, p < .001). The L-TC angle cut-off value below which a recurrence could be predicted was 36.1° (sensitivity, 74.47%). The L-TC angle of ICF patients treated using the Ponseti method were reduced compared to normal feet. An L-TC angle of <36.1° has relative value in predicting ICF relapse.
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Affiliation(s)
- Jingchun Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Fuxing Xun
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Chenchen Xu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yiqiang Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hongwen Xu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Federico Canavese
- Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre Hospital, Lille, France; Orthopedic and Traumatology Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy; DISC-Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, University of Genova, Viale Benedetto XV N°6, 16132, Genova, Italy
| | - Huimin Xia
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China.
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Naili JE, Lindeberg M, Esbjörnsson AC. Duration and outcome of orthotic treatment in children with clubfoot - a four-year follow-up national register study of Swedish children born between 2015 and 2017. BMC Musculoskelet Disord 2024; 25:425. [PMID: 38822269 PMCID: PMC11143618 DOI: 10.1186/s12891-024-07544-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/27/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND The Ponseti method for treating clubfoot consists of initial treatment with serial casting accompanied by achillotenotomy if needed, followed by the maintenance phase including treatment with a foot abduction orthosis (FAO) for at least four years. This study aimed to examine the duration, course, and outcome of orthotic treatment in children with clubfoot. METHODS 321 children with clubfoot, born between 2015 and 2017, registered in the Swedish Pediatric Orthopedic Quality Register (SPOQ), were included in this prospective cohort study. Data on deformity characteristics and orthotic treatment were extracted. For children with bilateral clubfoot, one foot was included in the analysis. RESULTS Of the 288 children with isolated clubfoot, 274 children (95.5%) were prescribed an FAO, and 100 children (35%) changed orthosis type before 4 years of age. Of the 33 children with non-isolated clubfoot, 25 children (76%) were prescribed an FAO, and 21 children (64%) changed orthosis type before 4 years of age. 220 children with isolated clubfoot (76%), and 28 children with non-isolated clubfoot (84%) continued orthotic treatment until 4 years of age or longer. Among children with isolated clubfoot, children ending orthotic treatment before 4 years of age (n = 63) had lower Pirani scores at birth compared to children ending orthotic treatment at/after 4 years of age (n = 219) (p = 0.01). It was more common to change orthosis type among children ending orthotic treatment before 4 years of age (p = 0.031). CONCLUSIONS The majority of children with clubfoot in Sweden are treated with an FAO during the maintenance phase. The proportion of children changing orthosis type was significantly greater and the Pirani score at diagnosis was lower significantly among children ending orthotic treatment before 4 years of age. Long-term follow-up studies are warranted to fully understand how to optimize, and individualize, orthotic treatment with respect to foot involvement and severity of deformity. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Josefine Eriksson Naili
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
- Motion Analysis Lab, Karolinska University Hospital, Stockholm, Sweden.
| | - Malin Lindeberg
- Department of Orthopedics, Skane University Hospital, Lund, Sweden
| | - Anna-Clara Esbjörnsson
- Department of Clinical Sciences and Infectious Diseases, Skane University Hospital, Lund University, Lund, Sweden
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Hedley PL, Lausten-Thomsen U, Conway KM, Hindsø K, Romitti PA, Christiansen M. Trends in congenital clubfoot prevalence and co-occurring anomalies during 1994-2021 in Denmark: a nationwide register-based study. BMC Musculoskelet Disord 2023; 24:784. [PMID: 37789312 PMCID: PMC10548612 DOI: 10.1186/s12891-023-06889-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/15/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Congenital talipes equinovarus (clubfoot) is a common musculoskeletal anomaly, with a suspected multifactorial etiopathogenesis. Herein, we used publicly available data to ascertain liveborn infants with clubfoot delivered in Denmark during 1994-2021, and to classify co-occurring congenital anomalies, estimate annual prevalence, and compare clubfoot occurrence with maternal smoking rates, a commonly reported risk factor. Characterizing this nationwide, liveborn cohort provides a population-based resource for etiopathogenic investigations and life course surveillance. METHODS This case-cohort study used data from the Danish National Patient Register and Danish Civil Registration System, accessed through the publicly available Danish Biobank Register, to identify 1,315,282 liveborn infants delivered during 1994-2021 in Denmark to Danish parents. Among these, 2,358 infants (65.1% male) were ascertained with clubfoot and classified as syndromic (co-occurring chromosomal, genetic, or teratogenic syndromes) and nonsyndromic (isolated or co-occurring multiple congenital anomalies [MCA]). Annual prevalence estimates and corresponding 95% confidence intervals (CIs) for children with nonsyndromic clubfoot were estimated using Poisson regression and compared with population-based, maternal annual smoking rates obtained from publicly available resources. RESULTS Infants most often presented with nonsyndromic clubfoot (isolated = 88.6%; MCA = 11.4%); limb and heart anomalies were the most frequently identified MCAs. Prevalence (per 1,000 liveborn infants) was 1.52 (CI 1.45-1.58) for isolated and 0.19 (CI 0.17-0.22) for MCA clubfoot. Prevalence estimates for both isolated and MCA clubfoot remained relatively stable during the study period, despite marked decreases in population-based maternal smoking rates. CONCLUSIONS From 1994 to 2021, prevalence of nonsyndromic clubfoot in Denmark was relatively stable. Reduction in population-level maternal smoking rates did not seem to impact prevalence estimates, providing some support for the suspected multifactorial etiopathogenesis of this anomaly. This nationwide, liveborn cohort, ascertained and clinically characterized using publicly available data from the Danish Biobank Register, provides a population-based clinical and biological resource for future etiopathogenic investigations and life course surveillance.
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Affiliation(s)
- Paula L Hedley
- Department for Congenital Disorders, Statens Serum Institut, 5 Artillerivej DK2300S, Copenhagen, Denmark.
| | | | - Kristin M Conway
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Klaus Hindsø
- Pediatric Section, Department of Orthopedic Surgery, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Paul A Romitti
- Department for Congenital Disorders, Statens Serum Institut, 5 Artillerivej DK2300S, Copenhagen, Denmark
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Michael Christiansen
- Department for Congenital Disorders, Statens Serum Institut, 5 Artillerivej DK2300S, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
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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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Anastasia M, Pramantha B, Kholinne E, Anestessia IJ. Tibialis anterior tendon transfer using suture anchor provides excellent alternative treatment for relapse clubfoot: A case report. Int J Surg Case Rep 2023; 106:108270. [PMID: 37156200 DOI: 10.1016/j.ijscr.2023.108270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/19/2023] [Accepted: 04/22/2023] [Indexed: 05/10/2023] Open
Abstract
INTRODUCTION Relapsed clubfoot is defined as the recurrence of any component of deformity after a complete correction. While the Ponseti method has been known to have excellent outcomes, several relapse cases have been reported. Thus, further surgical intervention is needed to achieve a good and reliable long-term outcome. PRESENTATION OF THE CASE We report a presentation of a 5-year-old boy who came to the clinic with a relapsed bilateral clubfoot after serial Ponseti casting. Plantar fascia release, Achilles tendon lengthening, and tibialis anterior tendon transfer (TATT) were performed respectively followed by an above-knee cast. The patient gained acceptable walking balance and ability to perform high impact sports at one year follow-up. CLINICAL DISCUSSION There are several factors contributing to the relapse clubfoot including adherence to post op foot abduction brace (FAB) protocol, muscle imbalance or inadequate correction of initial deformities. The current case report described a relapse clubfoot following serial Ponseti casting caused by non-compliance of the use of foot abduction brace. Further surgical interventions must be performed in the presence of relapse case of clubfoot. CONCLUSION Relapse clubfoot is the presence of any recurring deformity following correction. Surgical intervention, especially TATT procedure provides a favorable outcome in treating patients with relapse clubfoot.
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Affiliation(s)
- Maria Anastasia
- Faculty of Medicine, Universitas Katolik Indonesia Atma Jaya, Jakarta, Indonesia
| | - Bagus Pramantha
- Carolus Bone & Joint Center, St. Carolus Hospital, Jakarta, Indonesia; Adhyaksa General Hospital, Indonesia
| | - Erica Kholinne
- Carolus Bone & Joint Center, St. Carolus Hospital, Jakarta, Indonesia; Faculty of Medicine, Universitas Trisakti, Jakarta, Indonesia.
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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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Prospective, Randomized Ponseti Treatment for Clubfoot: Orthopaedic Surgeons Versus Physical Therapists. J Pediatr Orthop 2023; 43:e93-e99. [PMID: 36607913 DOI: 10.1097/bpo.0000000000002291] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Clubfoot is a common congenital foot deformity in children. The Ponseti method of serial casting has become the standard of care in clubfoot treatment. Clubfoot casting is performed in many centers by both orthopaedic surgeons and physical therapists (PTs); however, direct comparison of outcomes and complications of this treatment between these providers is limited. This study prospectively compared the outcomes of patients with clubfoot treated by these 2 groups of specialists. METHODS Between January 2010 and December 2014, all patients under the age of 12 months with a diagnosis of clubfoot were included. Patients were randomized to an orthopaedic surgeon (MD) group or a PT group for weekly serial casting. Main outcome measures included the number of casts required to achieve correction, clinical recurrence of the deformity, and the need for additional surgical intervention. RESULTS One hundred twenty-six infants were included in the study. Patient demographics and characteristics (sex, race, family history of clubfoot, laterality, and severity of deformity) were similar between treatment groups, with the only significant difference being the mean age of entry into the study (5.2 weeks in the MD group and 9.2 weeks in the PT group, P=0.01). Mean length of follow-up was 2.6 years. The number of casts required trended to a lower number in the MD group. There was no significant difference in the rates of clinical recurrence or additional surgical intervention between groups. CONCLUSIONS Ponseti casting for treatment of clubfoot performed by orthopaedic surgeons and PTs results in equivalent outcomes without any difference in complications. Although the number of casts required trended to a lower number in the MD group, this likely did not result in any clinical significance, as the difference in cast number equaled <1 week's difference in the overall duration of serial casting. LEVEL OF EVIDENCE Level I-therapeutic.
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Muhammad H, Haryana SM, Magetsari R, Kurniawan A, Baikuni B, Saraswati PA. Genetic Role in Recurrence of Idiopathic CTEV: A Systematic Review. Orthop Res Rev 2023; 15:19-25. [PMID: 36926520 PMCID: PMC10010973 DOI: 10.2147/orr.s400243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
Background Congenital Talipes Equinovarus (CTEV) is a multitude of deformities involving equinus, varus, adductus, and cavus deformities. Clubfoot affects 1 in every 1000 infants born worldwide, with various incidences according to geographical areas. It has been previously hypothesized that the possible genetic role in Idiopathic CTEV (ICTEV) might have a treatment-resistant phenotype. However, the genetic involvement in recurrent ICTEV cases is yet to be determined. Aim To systematically review existing literature regarding the discovery of genetic involvement in recurrent ICTEV to date to further understand the etiology of relapse. Methods A comprehensive search was performed on medical databases, and the review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A comprehensive search was performed on several medical databases: PubMed (MEDLINE), Scopus, the Cochrane Library, and European PMC on May 10, 2022. We included studies reporting patients with recurring idiopathic CTEV or CTEV of unknown cause after treatment, reporting whole-genetic sequencing, whole-exome sequencing, Polymerase Chain Reaction, or Western blot analysis as methods of genetic analysis (intervention) and providing results of idiopathic CTEV genetic involvement. Non-English studies, literature reviews, and irrelevant articles were excluded. Quality and risk of bias assessments were performed using Newcastle-Ottawa Quality Assessment Scale for non-randomized studies where appropriate. The authors discussed data extracted with the primary outcome of gene(s) frequency being reported of their involvement in recurrent ICTEV cases. Results Three pieces of literature were included in this review. Two studies analyzed the genetic involvement in CTEV occurrence, while one analyzed the protein types found. Discussion With included studies of less than five, we could not perform other forms of analysis apart from qualitatively. Conclusion The rarity of literature exploring the genetic etiology of recurrent ICTEV cases has been reflected in this systematic review, giving opportunities for future research.
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Affiliation(s)
- Hilmi Muhammad
- Department of Surgery, Orthopaedics and Traumatology Division, Sardjito General Hospital, Yogyakarta, Indonesia.,Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Sofia Mubarika Haryana
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Rahadyan Magetsari
- Department of Surgery, Orthopaedics and Traumatology Division, Sardjito General Hospital, Yogyakarta, Indonesia.,Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Aryadi Kurniawan
- Department of Orthopaedic and Traumatology, Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Bima Baikuni
- Department of Surgery, Orthopaedics and Traumatology Division, Sardjito General Hospital, Yogyakarta, Indonesia.,Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Paramita Ayu Saraswati
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
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Participation and Motor Abilities in Children Aged 5 to 9 Years With Idiopathic Clubfeet After Treatment With the Ponseti Method. J Pediatr Orthop 2023; 43:e36-e42. [PMID: 36253894 DOI: 10.1097/bpo.0000000000002278] [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: 02/07/2023]
Abstract
BACKGROUND Functioning in children consists of different aspects, including their ability to execute activities and participate in life situations. Several studies on children with clubfeet showed limited motor abilities and walking capacity compared with healthy control children, while other studies showed comparable athletic abilities and gross motor development. Although participation in activities of daily life plays an important role in the development of children, this has not yet been investigated in children with clubfeet. The study aims to determine the level of parents' perceived motor ability and participation in Ponseti-treated children with clubfeet compared with age-matched healthy controls. METHODS Parents of children aged 5 to 9 years with and without idiopathic Ponseti-treated clubfeet were asked to complete an online questionnaire about their child's motor abilities and participation level using the Dutch version of the Assessment of Life Habits for Children (LIFE-H) version 3 to assess participation and the Dutch Movement Assessment Battery for Children-2 Checklist (MABC-2 Checklist) to assess motor abilities. Statistical analysis focused on differences between groups and the relationship between motor abilities and level of participation. RESULTS Questionnaires of 86 children with clubfeet (mean age 7.1, 73% boys) and 62 controls (age 6.7, 53% boys) were analyzed. Despite a large variation, results showed no significant differences between groups on the total scores of the LIFE-H and the MABC-2 Checklist. Children with clubfeet, however, scored lower on Mobility and better on the categories Communication and Responsibility of the LIFE-H. Furthermore, children with clubfeet showed lower scores on the MABC-2 Checklist subscale "movement in a static and/or predictable environment." High levels of the parents' perceived participation correlate with good results, as perceived by the parents, in motor ability. CONCLUSIONS Although differences on some aspects of motor ability and participation existed, children with clubfeet in general showed high levels of parents' perceived motor ability and participation. High levels of participation correlated with good results in motor ability. LEVEL OF EVIDENCE Level II.
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Li J, Xu C, Li Y, Liu Y, Xu H, Canavese F. Response the comments on the article "Are early antero-posterior and lateral radiographs predictive of clubfoot relapse requiring surgical intervention in children treated by Ponseti method?" by Li et al. J Child Orthop 2022; 16:425-426. [PMID: 36238142 PMCID: PMC9550995 DOI: 10.1177/18632521221113425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Jingchun Li
- Department of Paediatric Orthopaedics,
Guangzhou Women and Children’s Medical Centre, Guangzhou Medical University, Guangzhou,
China
- Jingchun Li, Department of Paediatric Orthopaedics,
Guangzhou Women and Children’s Medical Centre, Guangzhou Medical University, 9th Jinsui
Road, Guangzhou 510623, China.
| | - Chenchen Xu
- Department of Paediatric Orthopaedics,
Guangzhou Women and Children’s Medical Centre, Guangzhou Medical University, Guangzhou,
China
| | - Yiqiang Li
- Department of Paediatric Orthopaedics,
Guangzhou Women and Children’s Medical Centre, Guangzhou Medical University, Guangzhou,
China
| | - Yuanzhong Liu
- Department of Paediatric Orthopaedics,
Guangzhou Women and Children’s Medical Centre, Guangzhou Medical University, Guangzhou,
China
| | - Hongwen Xu
- Department of Paediatric Orthopaedics,
Guangzhou Women and Children’s Medical Centre, Guangzhou Medical University, Guangzhou,
China
| | - Federico Canavese
- Department of Pediatric Orthopedic Surgery,
Lille University Center, Jeanne de Flandre Hospital, Lille, France
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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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Akinyoola LA, Gunderson Z, Sun S, Fitzgerald R, Caltoum CB, Christman TW, Bielski R, Loder RT. Association of Socioeconomic Status With Relapse After Ponseti Method Treatment of Idiopathic Clubfeet. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221119180. [PMID: 36046551 PMCID: PMC9421036 DOI: 10.1177/24730114221119180] [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] [Indexed: 12/04/2022] Open
Abstract
Background: The Ponseti method is today’s standard treatment of idiopathic talipes equinovarus (ITEV). Compliance with foot abduction bracing (FABO) and socioeconomic factors have been shown to impact treatment outcome. We wished to further study socioeconomic factors using the Area Deprivation Index (ADI), a more comprehensive way to evaluate socioeconomic status, which has not been done before. Methods: All TEV patients from 2010 through 2019 treated with the Ponseti method were reviewed. Standard demographic variables, as well as the number of casts to complete initial correction, FABO compliance, and occurrence of relapse were tabulated. Socioeconomic level was quantified with the 2018 ADI. Results: There were 168 children; 151 had typical and 17 complex TEV. Average follow-up was 4.3 ± 1.8 years; relapse occurred in 46%. There were no significant differences in the percentage of relapse by sex, race, or ADI. FABO noncompliance was present in 46%. Relapse increased with increasing time of follow-up and FABO noncompliance (76% vs 21%, P < 10−6). Multivariate logistic regression analysis revealed that only FABO compliance and length of follow-up were associated with relapse. The OR of relapse for FABO noncompliance was 17.9 (7.6, 42.4, P < 10–6) and for follow-up >4 years the OR was 4.97 (2.1, 11.70, P = .0003). Conclusion: The outcome of the Ponseti method for TEV treatment is dependent on local circumstances. In our state, socioeconomic status, as determined by the ADI, was not associated with the occurrence of relapse. Thus, each center needs to assess its results, and analyze its own reasons for relapse. There were no other demographic variables associated with relapse except FABO compliance and length of follow-up. Parents should be strongly advised that FABO compliance and follow-up appears paramount to achieving the best results, and that complex TEV are at greater risk for relapse. Level of Evidence: Level IV, case series
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Affiliation(s)
| | | | - Seungyup Sun
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ryan Fitzgerald
- University of South Florida College of Medicine, Tampa, FL, USA
| | | | - Tyler W. Christman
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Robert Bielski
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Randall T. Loder
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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Li J, Xun F, Li Y, Liu Y, Xu H, Canavese F. Three-dimensional gait analysis in children with recurrent idiopathic clubfoot undergoing complete tibialis anterior tendon transfer. J Pediatr Orthop B 2022; 31:397-406. [PMID: 34908029 DOI: 10.1097/bpb.0000000000000941] [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: 11/27/2022]
Abstract
This study was aimed to evaluate the kinetics and kinematics of the foot and ankle using three-dimensional gait analysis in children with recurrent clubfoot treated with tibialis anterior tendon transfer (TATT). Three-dimensional gait analysis of 17 children with dynamic supination (24 feet; 12 males; mean age: 6.34 years) was performed pre- and post-TATT. Spatial, temporal and kinematic parameters, as well as the gait deviation index (GDI), were recorded for all patients. Moreover, to evaluate the severity of dynamic supination during walking, we also measured the angle between the plane of the foot and the X-axis during the swing phase (V-angle-S). The postoperative step length (38.95 ± 8.36 cm) and stride length (76.73 ± 15.92 cm) were significantly smaller than their preoperative values (40.68 ± 9.35 cm and 80.57 ± 17.51 cm; P = 0.0316 and P = 0.0028, respectively). The postoperative peak internal ankle rotation angle in the frontal plane (20.45° ± 14.44) was significantly lower than the preoperative value (25.93° ± 9.84; P = 0.029). The postoperative peak internal foot progression angle in the transverse plane (0.96° ± 5.83) was significantly lower than the preoperative value (4.34° ± 8.88; P = 0.026). However, both the peak ankle varus moment and GDI were not significantly different between the pre- and postoperative data. Postoperative V-angle-S values (28.55° ± 7.56) were reduced compared to their preoperative values (32.52° ± 6.53; P = 0.0094). TATT to the lateral cuneiform can correct dynamic supination in patients with a recurrent clubfoot; however, it has limited or no effects on hindfoot varus deformity. Level of evidence: Level III.
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Affiliation(s)
- Jingchun Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Fuxing Xun
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yiqiang Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yuanzhong Liu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hongwen Xu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Federico Canavese
- Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre Hospital, Lille
- University of Lille, Faculty of Medicine, Loos, France
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The Predictive Value of Radiographs and the Pirani Score for Later Additional Surgery in Ponseti-Treated Idiopathic Clubfeet, an Observational Cohort Study. CHILDREN 2022; 9:children9060865. [PMID: 35740802 PMCID: PMC9221593 DOI: 10.3390/children9060865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 02/08/2023]
Abstract
There are few validated predictors of the need for additional surgery in idiopathic clubfeet treated according to the Ponseti method. Our aim was to examine if physical examination (Pirani score) and radiographs at the age of three months (after initial correction of the clubfeet) can predict the future need for additional surgery. In this retrospective cohort study, radiographs of idiopathic clubfeet were made at the age of three months. The Pirani score was determined at the first cast, before tenotomy, and at the age of three months. Follow-up was at least five years. The correlation between the radiograph, Pirani score, and the need for additional surgery was explored with logistic regression analysis. Parent satisfaction was measured with a disease-specific instrument. The study included 72 clubfeet (50 children) treated according to the Ponseti method. Additional surgery was needed on 27 feet (38%). A larger lateral tibiocalcaneal angle (i.e., equinus) and a smaller lateral talocalcaneal angle (i.e., hindfoot varus) at the age of three months were correlated with the need for additional surgery. Higher Pirani scores before tenotomy and at the age of three months also correlated with additional surgery. Parent satisfaction was lower in patients who needed additional surgery. Both the Pirani scores and the lateral radiographs are predictive for future additional surgery.
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Li S, Myerson MS. Surgical Management of the Undercorrected and Overcorrected Severe Club Foot Deformity. Foot Ankle Clin 2022; 27:491-512. [PMID: 35680301 DOI: 10.1016/j.fcl.2021.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Managing complications of clubfoot deformities can be very challenging. Some patients present with recurrent clubfoot and residual symptoms, and some present with overcorrection leading to a severe complex flatfoot deformity. Both can lead to long-term degenerative changes of the foot and ankle joints owing to deformity caused by unbalanced loading. This article only focuses on severe complications caused by recurrence and overcorrection in both children and adult patients.
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Affiliation(s)
- Shuyuan Li
- Department of Orthopaedic Surgery, University of Colorado School of Medicine; Steps2Walk.
| | - Mark S Myerson
- Department of Orthopaedic Surgery, University of Colorado School of Medicine; Steps2Walk
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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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Laliotis N, Chrysanthou C, Konstandinidis P, Anastasopoulos N. Anatomical Structures Responsible for CTEV Relapse after Ponseti Treatment. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9050581. [PMID: 35626758 PMCID: PMC9139296 DOI: 10.3390/children9050581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/03/2022] [Accepted: 04/15/2022] [Indexed: 11/30/2022]
Abstract
Relapse of deformity after a successful Ponseti treatment remains a problem for the management of clubfoot. An untreated varus heel position and restricted dorsal flexion of the ankle are the main features of recurrences. We analyze the anatomical structures responsible for these recurrences. Materials and methods: During 5 years, 52 children with CTEV (Congenital Talipes Equino Varus) were treated with casts according to the Ponseti method, with a mean number of 7 casts. Closed percutaneous tenotomy was performed in 28 infants. Children were followed monthly and treated with the continuous use of a molded cast. We had 9 children with relapsed clubfeet. During the standing and walking phase, they had a fixed deformity with a varus position of the heel and dorsal flexion of the ankle <10 d. They were surgically treated with the posterolateral approach. Results: In all patients, we found a severe thickening of the paratenon of the Achilles in the medial side, with adhesions with the subcutaneous tissue. The achilles after the previous tenotomy was completely regenerated. The achilles was medially displaced. Conclusions: A severe thickening of the paratenon of the achilles and adhesions with the subcutaneous tissue are anatomical structures in fixed relapsed cases of clubfoot. We treated our patients with an appropriate surgical release.
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Affiliation(s)
- Nikolaos Laliotis
- Orthopaedic Department, Inter Balkan Medical Center, Asklipiou 10 Pilea, 57001 Thessaloniki, Greece; (C.C.); (P.K.)
- Correspondence:
| | - Chrysanthos Chrysanthou
- Orthopaedic Department, Inter Balkan Medical Center, Asklipiou 10 Pilea, 57001 Thessaloniki, Greece; (C.C.); (P.K.)
| | - Panagiotis Konstandinidis
- Orthopaedic Department, Inter Balkan Medical Center, Asklipiou 10 Pilea, 57001 Thessaloniki, Greece; (C.C.); (P.K.)
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Li J, Xu C, Li Y, Liu Y, Xu H, Canavese F. Are early antero-posterior and lateral radiographs predictive of clubfoot relapse requiring surgical intervention in children treated by Ponseti method? J Child Orthop 2022; 16:35-45. [PMID: 35615392 PMCID: PMC9124919 DOI: 10.1177/18632521221080478] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/05/2022] [Indexed: 02/03/2023] Open
Abstract
Purpose To investigate the value of antero-posterior and lateral radiographs in predicting clubfoot relapse after treatment with the Ponseti method. Methods This was a retrospective review of 104 children (157 feet) younger than 3 months of age with idiopathic clubfoot treated using the Ponseti method at our institution between January 2007 and December 2014. All patients underwent Achilles tenotomy and were divided into two groups according to the need for further surgery to correct the deformity: relapsed group (24 patients; 36 feet) and non-relapsed group (80 patients; 121 feet). All antero-posterior and lateral foot radiographs were performed less than 3 months after Achilles tenotomy. The talo-calcaneal (TC-AP) and talus-first metatarsal (TM-AP) angles were measured in the antero-posterior view, while the tibio-calcaneal (TIC-L), talus-first metatarsal (TM-L), and talo-calcaneal (TC-L) angles were measured in the lateral view. The multi-factor logistic regression model of the stepwise selection method was used to predict the relapse of clubfoot deformity from the potential predictive values. Results The mean age at initial plain radiography examination was 99.45 ± 21.54 days. Differences in TC-AP, TM-AP, TC-L, and TIC-L between the two groups were statistically significant. However, only TM-AP and TIC-L were included in the "risk of relapse" formula using the multi-factor logistic stepwise selection method. Conclusion Early antero-posterior and lateral radiographs in children younger than 3 months of age at initial Ponseti treatment have positive predictive value for relapse. Reduced TM-AP angle and increased TIC-L were associated with an increased risk of relapse. Level of evidence level III.
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Affiliation(s)
- Jingchun Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Chenchen Xu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yiqiang Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yuanzhong Liu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hongwen Xu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Federico Canavese
- Department of Paediatric Orthopaedics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre Hospital, Lille, France
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VAN SCHELVEN H, MOERMAN S, VAN DER STEEN M, BESSELAAR AT, GREVE C. Prognostic factors for recurrent idiopathic clubfoot deformity: a systematic literature review and meta-analysis. Acta Orthop 2022; 93:11-28. [PMID: 34607499 PMCID: PMC8815420 DOI: 10.1080/17453674.2021.1982576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - After initial clubfoot correction through Ponseti treatment, recurrence rates range from 26% to 48%. Even though various factors have been associated with increased recurrence risk, systematic assessments of the prognostic capacity of recurrence risk factors and their clinical relevance are lacking. Therefore we assessed clinically relevant prognostic factors for recurrent idiopathic clubfoot deformity after initial correction through Ponseti treatment. Methods - PubMed, Embase, Cinahl, and Web of Science were systematically searched for studies investigating the association between clinically relevant factors and recurrence rates. Prognostic factors were qualitatively assessed and included in the meta-analysis if ≥ 2 studies investigated the same factor and methods were comparable. Results - 34 articles were included in the qualitative synthesis, of which 22 were also included in the meta-analysis. Meta-analysis revealed that poor evertor muscle activity (OR = 255, 95% CI 30-2,190), brace non-compliance (OR = 10, CI 5-21), no additional stretching (OR = 31, CI 10-101), more casts (OR = 3.5, CI 1.6-7.8), lower education level of parents (OR = 1.8, CI 1.2-2.6), non-marital status of parents (OR = 1.8, CI 1.1-3.0), and higher Dimeglio scores (OR = 1.9, CI 1.2-3.3) were associated with higher recurrence rates. Interpretation - Brace non-compliance and poor evertor muscle activity have been identified as main recurrence risk factors and are therefore important to be closely monitored during clinical follow-up of clubfoot patients. Adding additional stretching during the bracing protocol might be promising in the quest to prevent relapse, but scientific evidence for clear clinical treatment recommendations is still limited.
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Affiliation(s)
- Heleen VAN SCHELVEN
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen
| | - Sophie MOERMAN
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen
| | - Marieke VAN DER STEEN
- Department of Orthopaedic Surgery & Trauma, Catharina Hospital, Eindhoven,Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Veldhoven
| | - Arnold T BESSELAAR
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Veldhoven
| | - Christian GREVE
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen,Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Abstract
Clubfoot or talipes equinovarus deformity is one of the most common anomalies affecting the lower extremities. This review provides an update on the outcomes of various treatment options used to correct clubfoot. The ultimate goal in the treatment of clubfoot is to obtain a fully functional and pain-free foot and maintain a long-term correction. The Ponseti method is now considered the gold standard of treatment for primary clubfoot. Relapse is common after primary treatment with the Ponseti method, and other interventions are discussed that are used to provide for long-term successful outcomes.
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Cordeiro FG, Macedo RS, Massa BSF, Grangeiro PM, Godoy-Santos AL, Fernandes TD. Congenital Clubfoot - Is the Ponseti Method the Definitive Solution? Rev Bras Ortop 2021; 56:683-688. [PMID: 34900094 PMCID: PMC8651437 DOI: 10.1055/s-0041-1735833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 04/23/2021] [Indexed: 11/11/2022] Open
Abstract
Congenital clubfoot is one of the most common deformities at birth. The inadequacy or absence of treatment causes serious limitations for people with this condition. The initial treatment using the Ponseti method ensures functional results superior to other treatment modalities previously proposed. However, recurrences and neglected feet are still a challenge today. An understanding of the pathophysiology of the disease, as well as of the anatomy and local biomechanics and a thorough clinical and radiological evaluation of patients are essential to understanding the limits of the method and choosing the best treatment.
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Affiliation(s)
- Felippi Guizardi Cordeiro
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Rodrigo Sousa Macedo
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Bruno Sérgio Ferreira Massa
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Patricia Moreno Grangeiro
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Alexandre Leme Godoy-Santos
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Túlio Diniz Fernandes
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Myerson MS, Haje DP. An Approach to the Management of Severe Clubfoot Deformities on Global Humanitarian Programs: The Role of Talectomy. Foot Ankle Clin 2021; 26:727-745. [PMID: 34752236 DOI: 10.1016/j.fcl.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The approach to treatment of severe untreated or recurrent congenital talipes equinovarus deformities is very different in the world where patients are mobile, have access to repeated return visits for follow-up treatment, and where more sophisticated options for gradual correction with external fixation are available. For treatment, talectomy may be the only option to treat certain neglected clubfoot deformities during humanitarian programs and it may still have to be used as a salvage procedure used in modern foot surgery. Our extensive experience with these deformities has been on global humanitarian programs.
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Affiliation(s)
| | - Davi P Haje
- Centro Clinico Orthopectus e IGESDF, SMHN Bloco A Ed. Clínicas, Sala 804-806, Brasília, DF 70710-904, Brazil
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Recordon JAF, Halanski MA, Boocock MG, McNair PJ, Stott NS, Crawford HA. A Prospective, Median 15-Year Comparison of Ponseti Casting and Surgical Treatment of Clubfoot. J Bone Joint Surg Am 2021; 103:1986-1995. [PMID: 34547011 DOI: 10.2106/jbjs.20.02014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND In 2010, 2 authors of this current study reported the results of Ponseti treatment compared with primary posteromedial release (PMR) for congenital talipes equinovarus in a cohort of 51 prospective patients. This current study shows outcomes recorded at a median of 15 years after the original treatment. METHODS Patient health records were available for all 51 patients at a median of 15 years (range, 13 to 17 years) following treatment of congenital talipes equinovarus with either the Ponseti method (25 patients [38 feet]) or PMR (26 patients [42 feet]). Thirty-eight of 51 patients could be contacted, and 33 patients (65%) participated in the clinical review, comprising patient-reported outcomes, clinical examination, 3-dimensional gait analysis, and plantar pressures. RESULTS Sixteen (42%) of 38 Ponseti-treated feet and 20 (48%) of 42 PMR-treated feet had undergone a further surgical procedure. The PMR-treated feet were more likely to undergo osteotomies and intra-articular surgical procedures (15 feet) than the Ponseti-treated feet (5 feet) (p < 0.05). Of the 33 patients reviewed with multimodal assessment, the Ponseti group, compared with the PMR group, demonstrated better Dimeglio scores (5.8 compared with 7.0 points; p < 0.05), Disease Specific Instrument (80.7 compared with 65.6 points; p < 0.05), Functional Disability Inventory (1.1 compared with 5.1; p < 0.05), and American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire scores (52.2 compared with 46.6 points; p < 0.05), as well as improved total sagittal ankle range of motion in gait and ankle plantar flexion range at toe-off. The PMR group with clinical hindfoot varus displayed higher pressures in the lateral midfoot and the forefoot. CONCLUSIONS Although the numbers of repeat surgical interventions following Ponseti treatment and primary PMR were similar, the PMR-treated feet had greater numbers of osteotomies and intra-articular surgical procedures. Functional outcomes were improved at a median of 15 years for feet treated with the Ponseti method compared with feet treated with PMR, with advantages seen in the Ponseti group over several domains. This study provides the most comprehensive evaluation of outcomes close to skeletal maturity in prospective cohorts, reinforcing the Ponseti method as the initial treatment of choice for idiopathic clubfeet. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- James A F Recordon
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | | | - Mark G Boocock
- Department of Physiotherapy, Auckland University of Technology, Auckland, New Zealand
| | - Peter J McNair
- Department of Physiotherapy, Auckland University of Technology, Auckland, New Zealand
| | - Ngaire S Stott
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Haemish A Crawford
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
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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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Sheta RA, El-Sayed M, Abdel-Ghani H, Saber S, Mohammed ASE, Hassan TGT. A modification of the Ponseti method for clubfoot management: a prospective comparative study. J Child Orthop 2021; 15:433-442. [PMID: 34858529 PMCID: PMC8582604 DOI: 10.1302/1863-2548.15.210038] [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: 02/22/2021] [Accepted: 06/11/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE We aimed to compare our parent-based exercise programem's efficacy with the foot abduction brace (FAB) Ponseti manipulation as a retention programme. METHODS We conducted this prospective multicentre cohort study between August 2009 and November 2019. The included children were allocated into one of two groups according to the retention protocol. The Pirani and Laaveg-Ponseti scores were used to assess the feet clinically and functionally. Radiological assessment was performed using standing anteroposterior and lateral radiographs of the feet. We assessed the parents' satisfaction and adherence to the retention method. SPSS version 25 was used for the statistical analysis. RESULTS A total of 1265 feet in 973 children were included. Group A included 637 feet managed with FAB, while group B included 628 feet managed with our retention programme. All patients were followed up to the age of four years. At the final follow-up, Pirani scores in group A participants were excellent, good and poor in 515, 90, and 32 feet, respectivel, while in group B the scores were excellent, good and poor in 471, 110 and 44 feet, respectively. The mean total score of Laaveg-Ponseti was 87.81 (sd 19.82) in group A and 90.55 (sd 20.71) in group B (p = 0.02). Group B participants showed higher satisfaction with the treatment method (p = 0.011) and more adherence to the treatment (p = 0.013). CONCLUSION The deformity's recurrence related to the brace's non-compliance in the Ponseti method might be reduced by substituting the brace with our home-based daily stretching exercises. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Reda Ali Sheta
- Professor of Orthopaedics, Al-Ahrar Specialist Hospital, Zagazig, Al-Sharkia, Egypt
| | - Mohamed El-Sayed
- Professor of Pediatric Orthopedics & Limb Reconstructive Surgeries, Tanta University, Egypt
| | - Hisham Abdel-Ghani
- Professor of Pediatric Orthopedics; Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sameh Saber
- Assistant Professor of Radiology, Faculty of Medicine, Zagazig University, Al-Sharkia, Egypt
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Zionts LE, Ebramzadeh E, Sangiorgio SN. Objective analysis of intermediate-term outcome of the Ponseti technique: a review of the experience from Los Angeles. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1101. [PMID: 34423013 PMCID: PMC8339808 DOI: 10.21037/atm-20-7774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/12/2021] [Indexed: 12/04/2022]
Abstract
The Ponseti method of manipulative treatment for clubfoot deformity became widely adopted by pediatric orthopaedic surgeons beginning in the mid-1990s. The technique allows correction of most idiopathic clubfeet using gentle manipulation and cast application. The treatment represents a marked advance over past efforts to gain correction of the foot through extensive release surgery. In 2006, we began a Clubfoot Clinic at the Orthopaedic Institute for Children in Los Angeles, California dedicated to managing clubfoot patients using Ponseti’s method. An IRB-approved database of patient-related, treatment related, and demographic variables was assembled and used to ascertain the outcome of treatment as well as to address parental questions regarding certain aspects of treatment. Here, we present a review of our body of work, which has improved clinical decision making as well as our ability to better inform our patients’ parents regarding the treatment and prognosis of the Ponseti method. Studies from our institution showed that while relapses and the need for extra-articular tibialis anterior tendon transfer (TATT) surgery remain common to the Ponseti method, these events do not adversely affect overall patient function or satisfaction. These findings were not unlike those of classic studies reported from Ponseti’s institution. We conclude that the Ponseti method is not only a technique to achieve initial correction of an idiopathic clubfoot, but also how to manage relapses that will inevitably occur in many patients. While relapses and tendon transfer surgery are likely to remain common with this treatment method, these events do not adversely affect overall patient function or satisfaction. The parents of infants whose clubfeet are managed using the Ponseti method should be counselled accordingly.
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Affiliation(s)
- Lewis E Zionts
- The J. Vernon Luck, Sr., MD Orthopedic Research Center, Orthopaedic Institute for Children and the Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Edward Ebramzadeh
- The J. Vernon Luck, Sr., MD Orthopedic Research Center, Orthopaedic Institute for Children and the Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sophia N Sangiorgio
- The J. Vernon Luck, Sr., MD Orthopedic Research Center, Orthopaedic Institute for Children and the Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Alves C, Batlle AE, Rodriguez MV. Neglected clubfoot treated by serial casting: a narrative review on how possibility takes over disability. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1103. [PMID: 34423015 PMCID: PMC8339819 DOI: 10.21037/atm-21-65] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/04/2021] [Indexed: 11/29/2022]
Abstract
The Ponseti Method is recognized as the best treatment for congenital idiopathic clubfoot in newborns and its principles became also adopted for treating older children with neglected deformity. This review aims to evaluate the role and effectiveness of serial casting in the treatment of neglected clubfoot, worldwide. Clubfoot is a complex tridimensional congenital foot deformity that can be easily treated after birth by correct manipulation of the foot and serial casting, with a great majority of cases requiring a percutaneous Achilles tenotomy, which can be organized as an ambulatory day procedure, without need for general anesthesia. However, in many low-income countries, treatment is not readily available, and many children grow up with disabling foot deformities. When compared to a newborn’s clubfoot, a neglected clubfoot is different and more challenging to treat, as bones become ossified while malaligned and exposed to abnormal forces. Application of the Ponseti method in children with untreated idiopathic clubfoot older than walking age leads to satisfactory outcomes, has a low cost, and avoids surgical procedures likely to cause complications. The upper age limit for the use of Ponseti Method in clubfoot treatment is yet to be established. Success of clubfoot treatment is mostly defined as a pain-free, aesthetically acceptable plantigrade foot, with no need for extensive surgical tissue release after casting and tenotomy. The results of the Ponseti method for the treatment of clubfoot in children after the walking age are encouraging, with more than 80% of success in achieving initial correction and 18–62.5% of relapses. If Ponseti casting is not successful, any further interventions should be carefully selected and planned, in order to maintain the length of the foot and avoid intracapsular scarring or bony fusions.
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Affiliation(s)
- Cristina Alves
- Serviço de Ortopedia Pediátrica do Hospital Pediátrico - CHUC, EPE, Coimbra, Portugal
| | - Anna Ey Batlle
- Hospital Sant Joan de Déu, Barcelona, Spain.,Equipo Internacional Ortopedia Pediatrica Dra Ey, Barcelona, Spain
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Long-term outcomes of the Ponseti method for treatment of clubfoot: a systematic review. INTERNATIONAL ORTHOPAEDICS 2021; 45:2599-2608. [PMID: 34415418 DOI: 10.1007/s00264-021-05189-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The Ponseti method has revolutionized the clubfoot treatment and has been adopted globally in the past couple of decades. However, most reported results of the Ponseti method are either short or midterm. Studies reporting long-term outcomes of the Ponseti method are limited. The following systematic review aimed to provide a comprehensive overview of the published articles on long-term outcomes of the Ponseti method. MATERIAL AND METHODS A literature search was performed for articles published in electronic database PubMed (includes Medline) and Cochrane for broad keywords: "Clubfoot"; "Ponseti method/technique"; "long term outcomes/results." Studies selected included full-text articles in English language on children less than one year with primary idiopathic clubfoot treated by the Ponseti method with mean ten year follow-up. Non-idiopathic causes or syndromic clubfoot and case reports/review articles/meta-analyses were excluded. The following parameters were included for analysis: number of patients/clubfeet, male/female, mean age at treatment, mean/range of follow-up, relapses, additional surgery, range of motion, various outcome scores, and radiological variables. RESULTS Fourteen studies with 774 patients/1122 feet were included. The male:female ratio was 2.4:1. Mean follow-up recorded in studies was 14.5 years. Relapses occurred in 47% patients with additional surgery being required in 79% patients with relapses. Of these, 86% of surgery were extra-articular while 14% were intra-articular. Plantigrade foot was achieved in majority patients with mean ankle dorsiflexion of 11 degrees. The outcome scores were in general good in contrast to radiological angles which were mostly outside normal range with talar flattening/navicular wedging/degenerative osteoarthritis changes occurring in 60%, 76%, and 30%, respectively. CONCLUSIONS Long-term follow-up of infants with primary idiopathic clubfeet treated by the Ponseti method revealed relatively high relapse and additional surgery rates. Radiologically, the various angles were inconsistent compared to normal ranges and anatomical deformations/degenerative changes were present in treated feet. Moreover, the relapse rates and requirement of additional surgery increased on long-term follow-up. Despite this, majority feet were plantigrade and demonstrated good clinical results as measured by various outcome tools. There should be emphasis on long-term follow-up of children with clubfeet in view of late relapses and secondary late changes.
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Al-Mohrej OA, Alshaalan FN, Alhussainan TS. Is the modified Ponseti method effective in treating atypical and complex clubfoot? A systematic review. INTERNATIONAL ORTHOPAEDICS 2021; 45:2589-2597. [PMID: 34114108 DOI: 10.1007/s00264-021-05092-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE In 2006, Ponseti modified the standard technique to treat cases of "atypical" and "complex" clubfoot. To determine the outcomes of Ponseti's modified method to treat complex idiopathic clubfoot patients, we asked the following: (1) What is the deformity correction success rate? (2) What is the relapse rate after the correction? (3) What is the incidence of complications? MATERIALS AND METHODS We performed a systematic review by searching the EMBASE, MEDLINE, Cochrane Library, and Web of Science databases from inception to March 1, 2021. All studies on idiopathic, complex, and atypical clubfoot that assessed Ponseti's modified technique were included. Of 699 identified articles, ten met the inclusion criteria. The mean index for non-randomized studies score for the included studies was 11.8 ± 1.7. RESULTS Early detection of the deformity and modifying the standard protocol, as described by Ponseti, resulted in a high rate of success. Initial correction occurred in all children, with a mean ankle dorsiflexion of 15°. Relapse occurred often ranging between 10.5 and 55%. The incidence of complications associated with the modified Ponseti method ranged from 6 to 30%. CONCLUSIONS Studies using the modified Ponseti technique have shown high initial correction rates and a smaller number of relapses. However, studies with prospective designs and long-term follow-up are required to conclude whether these observations are due to properly performing the modified method or if higher rates of relapse increase with further follow-up.
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Affiliation(s)
- Omar A Al-Mohrej
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON, Canada. .,Section of Orthopedic Surgery, Department of Surgery, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia.
| | - Fawaz N Alshaalan
- Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Thamer S Alhussainan
- Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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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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Li J, Zhu G, Kang X, Shen X, Chen S, Tang S, Gong Q, Li Y, Xu H. Association Between TPM1 Gene Polymorphisms and Idiopathic Congenital Talipes Equinovarus Risk in a Chinese Population. Genet Test Mol Biomarkers 2021; 25:355-360. [PMID: 33945307 DOI: 10.1089/gtmb.2020.0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Idiopathic congenital talipes equinovarus (ICTEV) is one of the most common congenital deformities of children, and dysplasia of the striated muscle may be one of the causes of ICTEV. Previous studies have shown that polymorphisms of the rs4075583 SNP in the tropomyosin gene 1 (TPM1) were associated with ICTEV in Caucasian children. However, there are no studies investigating the correlations of TPM gene polymorphisms with the risk of ICTEV in Chinese children. Methods: We conducted a case-control study, including 430 children with ICTEV and 891 ICTEV-free children. We explored the potential correlations of three TPM gene polymorphisms (TPM1/rs4075583 G>A, tropomyosin gene 2 (TPM2)/rs2145925 C>T, and TPM2/rs2025126 G>A) with ICTEV risk. The three single nucleotide polymorphisms (SNPs) were genotyped using a TaqMan method. We calculated the odds ratios (ORs) and adjusted ORs and their 95% confidence intervals (CIs) to explore the associations between these selected SNP polymorphisms and ICTEV. Results: TPM1 rs4075583 A was found to be associated with an increased ICTEV risk (AA vs. GG: adjusted OR = 1.70, 95% CI = 1.15-2.49, p = 0.007; and GG/GA vs. AA: adjusted OR = 1.62, 95% CI = 1.14-2.31, p = 0.0071) after adjusting for age and sex. In addition, a risk effect of rs4075583 GA/AA with ICETV was observed for patients with affected right feet (adjusted OR = 1.62, 95% CI = 1.10-2.39, p = 0.014) in the stratified analysis. However, there were no significant differences in the risk for ICTEV associated with the rs2145925 and rs2025126 polymorphisms. Conclusion: These results indicate that the TPM1 rs4075583 G > A polymorphism is associated with ICTEV risk in a southern Chinese population; however, this finding needs to be confirmed in larger studies and through mechanistic studies.
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Affiliation(s)
- Jingchun Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, China
| | - Guanghui Zhu
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Changsha, China
| | - Xiaopeng Kang
- Department of Pediatric Orthopedics, Kunming Children's Hospital, Kunming, China
| | - Xiantao Shen
- Department of Pediatric Orthopedics, Wuhan Medical and Healthcare Center for Women and Children, Wuhan, China
| | - Shunyou Chen
- Department of Pediatric Orthopedics, Fuzhou second Hospital of Xiamen University, Fuzhou, China
| | - Shengping Tang
- Department of the First Orthopaedics, Shenzhen Children's Hospital, Shenzhen, China
| | - Qian Gong
- Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yiqiang Li
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, China
| | - Hongwen Xu
- Department of Paediatric Orthopaedics, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, China
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Agarwal A, Rastogi A, Rastogi P. Relapses in clubfoot treated with Ponseti technique and standard bracing protocol- a systematic analysis. J Clin Orthop Trauma 2021; 18:199-204. [PMID: 34026487 PMCID: PMC8122108 DOI: 10.1016/j.jcot.2021.04.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/11/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022] Open
Abstract
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 1st January 2001 to 15th 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.
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Affiliation(s)
- Anil Agarwal
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India,Corresponding author. Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India.
| | - Anuj Rastogi
- Department of Orthopaedics, Integral Institute of Medical Sciences and Research, Integral University, Lucknow, Uttar Pradesh, India
| | - Prateek Rastogi
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 31, India
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Successful Ponseti-treated Clubfeet at Age 2 Years: What Is the Rate of Surgical Intervention After This? J Pediatr Orthop 2021; 40:597-603. [PMID: 32558742 DOI: 10.1097/bpo.0000000000001614] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In recent decades, nonoperative Ponseti casting has become the standard of care in the treatment of idiopathic clubfoot. However, the rate of recurrence, even after successful Ponseti treatment is not insignificant. The purpose of this study was to determine the future rate, timing, and type of surgery needed in patients whose idiopathic clubfeet treated by Ponseti casting were considered successful at the age of 2 years. METHODS Inclusion criteria for this retrospective study were patients under 3 months with idiopathic clubfoot treated exclusively by Ponseti casting, who had successful outcomes at 2 years of age without surgery, and who had at least 5 years of follow-up. The total number of surgical interventions in the age range 2 to 5 and above 5 years, the number and type of procedures performed, and the timing of surgery were reviewed. RESULTS Three hundred thirty-six patients with a total of 504 clubfeet fulfilled the inclusion criteria. One hundred twenty-two of these 336 patients (36.3%) eventually underwent surgical intervention. Between 2 and 5 years of age, 79 patients (23.5%) with 104 feet (20.6%) underwent surgery. The most common procedures performed between 2 and 5 years were limited (a la carte) in scope: tibialis anterior tendon transfer, posterior release, plantar fascia release, and repeat tendo-Achilles lengthening. At age above 5 years, 53 patients (20.1%) with 65 feet (16.9%) underwent surgery. Ten of these 53 patients had already undergone surgery between 2 and 5 years of age. The procedures most commonly performed were similar. CONCLUSIONS In patients with idiopathic clubfoot who reached 2 years of age with successful outcomes from Ponseti cast treatment, ∼35% eventually underwent surgical intervention, mostly limited (a la carte), to regain or maintain a plantigrade foot. The most commonly performed procedures include tibialis anterior tendon transfer, posterior capsular release, plantar fascia release and repeat tendo-Achilles lengthening, either in isolation or in combination. However, before considering surgery, the need for these procedures can, and should, be minimized by recasting recurrent deformities using Ponseti method. LEVEL OF EVIDENCE Level III.
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Quantification of Ankle Dorsiflexion in Ponseti-managed Unilateral Clubfoot Patients During Early Childhood. J Pediatr Orthop 2021; 41:83-87. [PMID: 33264177 DOI: 10.1097/bpo.0000000000001719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Following the initial correction of a clubfoot using the Ponseti method, diminished passive ankle dorsiflexion may be observed over time, which could represent a possible relapsed deformity. Alternatively, the change may be attributable to patient age or other variables. Our purpose was to quantify passive ankle dorsiflexion in the involved and contralateral unaffected limbs of Ponseti-managed unilateral clubfoot patients, and to determine what patient-related variables influence this finding. METHODS In total, 132 unilateral clubfoot patients were studied. Passive ankle dorsiflexion was measured in both limbs at each visit. Data were excluded from visits in which patients showed clear evidence of a relapse. Mean ankle dorsiflexion for clubfeet and contralateral unaffected limbs were reported for annual age intervals and compared using paired t tests. A general linear model was established to assess the effects of age, severity, sex, and side on ankle dorsiflexion. RESULTS Mean ankle dorsiflexion for unaffected limbs declined with age, measuring 53±6 degrees between 0 and 1 year of age and decreasing to 39±7 degrees by 4 to 5 years of age. Similarly, mean ankle dorsiflexion in treated clubfeet declined with age, measuring 44±7 degrees between 0 and 1 year and 29±7 degrees between 4 and 5 years. Overall, the difference between limbs in these patients averaged ~10 degrees for every age interval through 9 years (P<0.001). Ankle dorsiflexion of clubfeet in 95% of patients aged 0 to 2 years was at least 20 degrees, and in 95% of patients aged 3 to 5 years this was at least 15 degrees. Patient age (P<0.001) and severity of deformity (P<0.001) were found to be the only significant factors affecting ankle dorsiflexion in the affected limbs. CONCLUSIONS Ankle dorsiflexion in the Ponseti-treated clubfeet was influenced by age of the patient and the initial severity of the affected limb. Furthermore, our data suggest that, in patients who showed no relapse, a minimum of 20 degrees of ankle dorsiflexion in the corrected clubfoot is maintained through age 3 years and a minimum of 15 degrees is maintained through age 5 years. LEVEL OF EVIDENCE Level IV-this is a retrospective case series.
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Sheta RA, El-Sayed M. Is the Denis Browne Splint a Myth? A Long-Term Prospective Cohort Study in Clubfoot Management using Denis Browne Splint Versus Daily Exercise Protocol. J Foot Ankle Surg 2021; 59:314-322. [PMID: 32130997 DOI: 10.1053/j.jfas.2019.08.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 02/03/2023]
Abstract
The Ponseti technique is successful in idiopathic clubfoot management. However, the leading cause of relapse and recurrence is nonadherence to the Denis Brown bracing protocol. This necessitates more extensive soft tissue surgeries. Based on a detailed up-to-date search, we have found that no other studies provide such a modified Ponseti technique. This study is unique, as it depends on using specific stretching exercises instead of bracing during management. Between August 2009 and June 2019, a consecutive series of 194 isolated idiopathic clubfoot patients (251 feet) were included in this study. The mean follow-up was 93 months (range 72 to 146), mean 91.8 months. All patients underwent a clinical and functional assessment using the Laaveg-Ponseti score and radiological assessments. There were 132 boys (68.1%) and 62 girls (31.9%), a male-to-female ratio of 2:1. The mean age at initiation of treatment was 14.9 days. According to the Laaveg-Ponseti score, 51.7% yielded excellent results, 35.3% yielded good results, 11.55% yielded fair results, and 1.59% yielded poor results. Bracing noncompliance has been identified as a major cause for treatment failure. This presented exercise protocol not only eliminates the need for bracing and reduces the cost for the affected individuals but also provides excellent clinical and radiographic end results, comparable to the original treatment protocol using the Denis Brown brace.
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Affiliation(s)
- Reda Ali Sheta
- Orthopedic Consultant, Al Ahrar Specialist Hospital, Zagazig, Egypt.
| | - Mohamed El-Sayed
- Professor, Pediatric Orthopedics & Limb Reconstructive Surgeries, Tanta University, Tanta, Egypt
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The diagnosis and management of common childhood orthopedic disorders: An update. Curr Probl Pediatr Adolesc Health Care 2020; 50:100884. [PMID: 33069588 DOI: 10.1016/j.cppeds.2020.100884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Musculoskeletal illness represents a significant portion of office visits to primary and urgent care clinicians. Despite this, little emphasis is placed on learning pediatric orthopaedics during medical school or residency. The focus of this paper is to provide a systematic approach to this general musculoskeletal physical exam and to assist in the recognition of what conditions are normal development and what conditions require observation, workup and referral to an experienced pediatric orthopaedist.
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Abstract
PURPOSE OF REVIEW This review aims to provide primary care physicians with updates on recent literature regarding clubfoot and answer questions asked by parents and caregivers of children with clubfoot. The topics discussed include prenatal counseling, relapse after Ponseti treatment, long-term outcomes following successful treatment of clubfoot, and the effect of diagnosis and treatment on the parent or caregiver. RECENT FINDINGS Clubfoot is one of the most commonly searched orthopaedic conditions on the internet by parents. There is a lack of evidence-based guidelines on clubfoot worldwide. Recent systematic reviews have identified emerging evidence of genetic and modifiable risk factors that lead to clubfoot. Patients treated by the Ponseti method show better ankle power and strength compared with those treated with surgery for residual deformity or recurrence. SUMMARY The treatment of clubfoot is a long and involved process. Exposure to and familiarity with the Ponseti method will aid primary care physicians and parents in the optimization of children's clubfoot deformity correction using largely nonoperative management.
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Affiliation(s)
| | - Shevaun M Doyle
- Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
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