Joint laxity and the risk of clubfoot

Collagen I in the Hip Capsule Plays a Role in Postoperative Clinical Function in Patients With Developmental Dysplasia of the Hip

The aims of the present study is to evaluate the roles of collagen I and III in the hip capsule in the postoperative clinical function of patients with developmental dysplasia of the hip (DDH). Hip capsules from 155 hips of 120 patients were collected during surgery. The patients were divided into three groups according to age: I: 2-3.5 years; II: 3.5-5 years; and III: 5-6 years. Patient clinical function and radiographic outcomes were evaluated with the McKay scores and Severin classification. The expression of collagen I and III was detected through immunohistochemistry and quantitative reverse transcription polymerase chain reaction (RT-PCR) and analyzed according to age, sex, degree of dislocation and McKay classification. All patients received open reduction and pelvic osteotomy and/or femoral shortening osteotomy and achieved good results on the basis of postoperative X-ray imaging. The average follow-up time was 3.4 years (range 2-4.3 years). There were no changes in the expression of collagen III in the different groups. The expression of collagen I according to age and sex was not significantly different. Lower expression of collagen I was observed in DDH patients with a higher degree of dislocation according to the Tonnis grade. The highest expression of collagen I was detected in the group with poor clinical function according to the McKay classification. Collagen I is correlated with the degree of dislocation and is a risk factor for poor clinical function in DDH patients. Collagen I is correlated with the degree of hip dislocation and poor clinical function in DDH patients.

Objective analysis of intermediate-term outcome of the Ponseti technique: a review of the experience from Los Angeles

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.

Does generalized joint hypermobility influence the Ponseti treatment of clubfoot patients?

Previous investigators have suggested a role for generalized joint hypermobility (GJH) in the etiology of clubfoot deformity, while others have suggested its presence may influence treatment outcomes. We sought to determine if GJH was associated with the demographics, treatment, or propensity to relapse of patients whose clubfeet were managed using the Ponseti method. Fifty-seven patients with Ponseti-treated clubfeet comprised the cohort; median age 61 months (range, 38-111 months). A physical therapist evaluated each patient using the nine-point Beighton scale to quantify hypermobility. The scores were then correlated with patient sex, laterality, Dimeglio severity score, treatment, relapse, and surgery. The median Beighton score was 5; 49 of 57 patients (86%) had Beighton scores ≥4. All feet were plantigrade without symptomatic overcorrection at the time of evaluation. Although there was a slightly lower probability of relapse in patients with higher Beighton scores, this was not statistically significant (P = 0.10). Accordingly, the sex, laterality, initial severity, number of pretenotomy casts, need for tenotomy, relapse, and need for tendon transfer surgery were not significantly influenced by the Beighton score. The outcome of Ponseti clubfoot treatment is not altered by the presence of GJH in young children. Joint hypermobility does not appear to influence the likelihood of relapse or surgery. Unlike clubfeet reportedly treated with release surgery, Ponseti-treated clubfeet were not prone to excessive overcorrection regardless of joint laxity. Last, the distribution of Beighton scores in the study's cohort supports an association between GJH and clubfoot deformity.

Clubfoot Etiology: A Meta-Analysis and Systematic Review of Observational and Randomized Trials

BACKGROUND

Clubfoot is a common congenital anomaly with multiple potential risk factors. Identification of modifiable risk factors may minimize future incidence of clubfoot. The aim of this meta-analysis was to systematically review and analyze the best clinical evidence regarding risk factors associated with clubfoot.

METHODS

Medline, Embase, and Cochrane databases were systematically searched from 1967 to May 11, 2016 for studies reporting risk factors for clubfoot. Randomized trials and observational studies were eligible for inclusion, and assessed in duplicate. Study quality was assessed with the Newcastle-Ottawa Scale or Cochrane risk of bias tool; low quality studies were excluded, all randomized trials were included. Two reviewers extracted data independently. This meta-analysis was conducted in accordance with PRISMA guidelines. Pooled effect estimates for the odds of clubfoot were calculated using random or fixed-effects models based on heterogeneity.

RESULTS

Forty-two studies (28 case-control, 10 cohort, 4 randomized trials) comprising 31,844 clubfoot cases and 6,604,013 controls were included. Risk factors associated with increased odds of clubfoot included maternal smoking [odds ratio (OR)=1.65; 95% confidence interval (CI), 1.54-1.78], paternal smoking (OR=1.72; 95% CI, 1.05-2.84), maternal body mass index >30 (OR=1.46; 95% CI, 1.29-1.65), family history (OR=7.80; 95% CI, 4.04-15.04), amniocentesis (OR=2.08; 95% CI, 1.34-3.21), selective serotonin reuptake inhibitor exposure (OR=1.78; 95% CI, 1.34-2.37) maternal single status (OR=1.17; 95% CI, 1.11-1.23), gestational diabetes (OR=1.40; 95% CI, 1.13-1.72), nulliparity (OR=1.32; 95% CI, 1.19-1.45), male sex (OR=1.68; 95% CI, 1.48-1.94), and aboriginal Australian race (OR=2.35; 95% CI, 1.63-3.38).

CONCLUSIONS

Smoking, maternal obesity, family history, amniocentesis, and some selective serotonin reuptake inhibitor exposures are the most clinically relevant exposures associated with increased odds of clubfoot, with family history representing the greatest risk. Recognition of modifiable risk factors may help in counseling patients, and minimizing clubfoot incidence.

LEVEL OF EVIDENCE

Level II.

Association between maternal age at conception and risk of idiopathic clubfoot

Background and purpose - Results from case-control studies of maternal age at conception and risk of idiopathic clubfoot have been inconsistent. We conducted a meta-analysis to determine whether there is any association between maternal age at conception and the morbidity of idiopathic clubfoot. Methods - We searched PubMed-MEDLINE, EMBASE, and the Cochrane Library up to June 2015 and supplemented the search with manual searches of the reference lists of the articles identified. 11 studies published between 1990 and 2015 were pooled. We investigated heterogeneity in maternal age and whether publication bias might have affected the results. Results - Compared to a control group, maternal age at conception of between 20 and 24 years old was associated with an increased risk of occurrence of clubfoot (OR = 1.2, 95% CI: 1.1-1.4). No such association was found for the age groups of ≥ 35, 30-34, 25-29, and < 20 years. There was no heterogeneity in the age groups of ≥ 35, 30-34, and 20-24 years, moderate heterogeneity in the 25- to 29-year age group, and a large degree of heterogeneity in the group that was < 20 years of age. The prediction intervals for the age groups of 25-29 and < 20 years were 0.56 to 1.3 and -0.39 to 2.4, respectively. We found no evidence of significant publication bias. Interpretation - From the results of this meta-analysis of 11 studies, maternal age at conception between 20 to 24 years of age appears to be associated with an increased risk of occurrence of clubfoot.

Consanguineous marriage and increased risk of idiopathic congenital talipes equinovarus: a case-control study in a rural area

BACKGROUND

The purpose of this study is to evaluate if there is any relationship between consanguineous marriages and idiopathic congenital talipes equinovarus (CTEV).

METHODS

A case-control study on CTEV screening was conducted in a rural eastern city of Turkey between 2009 and 2011 and a total of 28 cases (infants with idiopathic CTEV) and 575 controls (healthy infants) were recruited. Sociodemographic status of the infants, including gestational age and birth weights, maternal characteristics and, if any, the degree of consanguinity, were recorded. As an inclusion criterion, only singleton, full-term, live births were accepted. A backward stepwise logistic regression model was used to evaluate the relationship between idiopathic CTEV and parental consanguinity. Unadjusted and adjusted odds ratios (OR) with 95% confidence interval (CI) were calculated.

RESULTS

Among maternal and infant characteristics, significant risk factors for idiopathic CTEV in the regression analysis were work status (employed), consanguineous marriage, sex (male), and gestational age (>42 wk). Babies born to first-cousin parents had >4 times the risk of idiopathic CTEV [OR, 4.138, (95% CI, 1.484, 11.538)] and the risk for those born to distant relatives was 2.9 times higher [OR, 2.941, (95% CI, 1.070, 8.087)] than for children of unrelated parents.

CONCLUSIONS

Consanguineous marriage was significantly associated with an increased risk of idiopathic CTEV. This association remained significant even after adjusting for potential confounding variables. To obtain more accurate results, a population-based screening study with an increased number of cases and controls should be performed in future studies.

LEVEL OF EVIDENCE

Case-control study investigating the effect of a patient characteristic on the outcome of disease (level-III).

Epidemiology of congenital idiopathic talipes equinovarus in Iowa, 1997-2005

Congenital idiopathic talipes equinovarus (ITEV), also known as clubfoot, is a well-recognized foot deformity. To date, prevalence estimates and descriptive data reported for ITEV have varied due to differences in study methodology. Using population-based surveillance data collected by the Iowa Registry for Congenital and Inherited Disorders, we examined isolated ITEV births delivered from 1997 through 2005 and compared to live births in Iowa during the same time period. An overall prevalence was calculated for live, singleton full-term births only. Prevalence odds ratios (POR)s and 95% confidence intervals (CI)s were examined for selected infant and parental characteristics. The prevalence of isolated ITEV was 11.4 per 10,000 live, singleton full-term births (95% CI = 10.3, 12.6), with no significant variation in prevalence during the study period. Increased PORs were found for males (POR 1.8; 95% CI = 1.5, 2.3) and maternal smoking during pregnancy (POR = 1.5, 95% CI = 1.2, 1.9); low birth weight (<2,500 g) showed an increase among females (POR = 3.2, 95% CI = 1.5, 6.9) but not males (POR = 0.9, 95% CI = 0.3, 2.8). Elevated, but non-significant, PORs were found for season of birth, maternal education, and trimester prenatal care was initiated; decreased PORs were found for fetal presentation, maternal race/ethnicity, parity, area of residence, and parental age at delivery. Our study of a well-defined, homogenous sample suggested that prevalence of isolated ITEV in Iowa was similar to that reported in other population-based studies and provided support for some, but not all, previously reported associations with infant and parental characteristics. More detailed, longitudinal studies of isolated ITEV are recommended.

Motor ability in children treated for idiopathic clubfoot. A controlled pilot study

Background

To study motor ability at seven years of age in children treated for idiopathic clubfoot and its relation to clubfoot laterality, foot status and the amount of surgery performed.

Methods

Twenty children (mean age 7.5 years, SD 3.2 months) from a consecutive birth cohort from our hospital catchments area (300.000 inhabitants from southern Sweden) were assessed with the Movement Assessment Battery for Children (MABC) and the Clubfoot Assessment Protocol (CAP).

Results

Compared to typically developing children an increased prevalence of motor impairment was found regarding both the total score for MABC (p < 0.05) and the subtest ABC-Ball skills (p < 0.05). No relationship was found between the child's actual foot status, laterality or the extent of foot surgery with the motor ability as measured with MABC. Only the CAP item "one-leg stand" correlated significantly with the MABC (rs = -0.53, p = 0.02).

Conclusions

Children with idiopathic clubfoot appear to have an increased risk of motor activity limitations and it is possible that other factors, independent of the clinical status, might be involved. The ability to keep balance on one leg may be a sufficient tool for determining which children in the orthopedic setting should be more thoroughly evaluated regarding their neuromotor functioning.

The association between idiopathic clubfoot and increased internal hip rotation

Clinical observation suggests the coexistence of increased internal hip rotation in limbs with clubfoot, thereby providing an additional, and perhaps overlooked, site of deformity to account for an intoeing gait in these limbs. Furthermore, assuming a genetic basis exists for exaggerated femoral and/or acetabular anteversion, which are the possible cause(s) for increased internal hip rotation, this association could provide another key to the multifactorial etiology of clubfoot. We asked whether such an association exists and retrospectively reviewed 114 children (178 clubfeet). We then tested for an association between clubfoot and increased internal hip rotation. These rotational measurements were compared with published normative data on torsion in children. In cases of unilateral clubfoot, an additional analysis compared the rotational profiles of the affected and unaffected extremities. Increased internal hip rotation occurred more frequently in limbs with idiopathic clubfoot. In patients with unilateral clubfoot, the affected extremities manifested greater internal hip rotation than the unaffected extremities, whereas the latter showed no difference in internal hip rotation compared with normative values. Clinical evaluation of intoeing in children with a history of clubfoot should include a rotational profile to determine the level(s) of deformity and guide therapeutic intervention.

LEVEL OF EVIDENCE

Level III, prognostic study (case control study). See Guidelines for Authors for a complete description of levels of evidence.

Hypermobility disorders in children and adolescents

It is well recognized that many if not most children and adolescents attending paediatric rheumatology clinics will have a non-inflammatory origin for their complaints or disorder. Mechanical causes are frequently identified, and hypermobility or ligamentous laxity of joints is increasingly recognized as an aetiological factor in the presentation. Such conditions include 'growing pains', recurrent lower-limb arthralgia, anterior knee pain syndromes, and back pain. Studies of significant cohorts of such patients have now been published supporting the link of ligamentous laxity to particular symptom complexes. However, much disagreement remains as to the validity of hypermobility as an aetiogical factor. What seems clear is that not all hypermobile individuals will be symptomatic or indeed possibly have any risk for specific musculoskeletal disorders in later life. Screening tools such as the Beighton score are likely to be inadequate in many paediatric populations. Along with increasing recognition of these disorders in childhood and adolescence has been the development of a multidisciplinary management approach, which usually involves predominantly allied health professionals such as podiatrists, physiotherapists and occupational therapists. The challenge remains to interpret symptoms correctly as being related to the hypermobility and to predict why such children become symptomatic. The answer is likely to involve physiological and psychosocial factors. In addition, early identification and modification of risk factors may have major implications for subsequent prevalence of many adult medical disorders such as low back pain, chronic pain syndromes and degenerative osteoarthritis.

Overcorrection and generalized joint laxity in surgically treated congenital talipes equino-varus

Fifty patients with 70 previously operated clubfeet were assessed for overcorrection (using Tachdjian's flat foot grade) and generalized joint laxity. Twenty-eight patients (40 feet) had signs of generalized joint laxity using the Biro score and of these 25 feet were overcorrected. Of the 22 patients (30 feet) who did not have signs of joint laxity, only three overcorrected. This difference was statistically significant (P<0.001). A significant correlation exists between flat foot grade and laxity score (P<0.01). Overcorrection is a complication largely ignored in the published literature but we believe it is a serious complication of open release often resulting in poor long-term function. For those patients requiring surgery, the authors urge caution and recommend a limited surgical release, particularly if joint laxity is suspected, or the Ponseti method of treatment, which will probably avoid this complication.