Functional midterm outcome in 131 consecutive cases of surgical clubfoot treatment

Can selective soft tissue release and cuboid osteotomy correct neglected clubfoot?

BACKGROUND

Neglected clubfoot in older children is characterized by a stiff, nonreducible deformity with relative elongation of the lateral column of the foot with respect to the medial column. Surgical correction often has involved a double osteotomy with elongation of the medial column and shortening of the lateral column, or the use of an external fixator to achieve more gradual correction. Both approaches have shortcomings.

QUESTIONS/PURPOSES

We therefore (1) used objective physical examination measurements and a functional assessment to evaluate the effectiveness of cuboid osteotomy combined with a selective soft tissue release to achieve correction of neglected clubfoot in older children, (2) determined the rate of complications, and (3) ascertained whether the initial correction achieved was maintained.

METHODS

We reviewed 31 patients (56 feet) older than 5 years with severe, neglected nonreducible clubfoot deformity who underwent the index procedure. Minimum followup was 2 years (average, 6 years; range, 2-9 years). Postoperatively, the Laaveg and Ponseti classification and Dimeglio score were used to grade correction. Complication rates were tallied.

RESULTS

According to the Laaveg and Ponseti classification, 24 feet showed excellent correction, 20 good, nine fair, and three poor at 1-year followup. These results were maintained up to the latest followup. Patients showed significant improvement of Dimeglio score after surgery (p < 0.0001). Two patients had postoperative skin-related complications that healed without additional surgery.

CONCLUSIONS

Cuboid subtraction osteotomy combined with posteromedial release is an effective approach to manage a stiff nonreducible neglected clubfoot deformity in older children.

Long-term retrospective study of patients with idiopathic clubfoot treated with posterior medial-lateral release

BACKGROUND

It has been demonstrated that an important component of clubfoot deformity is related to pathologic external rotation of the talus with respect to the remainder of the foot. The purpose of the present study was to review the long-term results for a cohort of patients with idiopathic clubfoot who were managed by a single surgeon with a uniform surgical protocol consisting of extensive posterior medial-lateral release in addition to the use of a temporary Kirschner wire to derotate the talus prior to fixation.

METHODS

Eighty patients (120 clubfeet) with idiopathic clubfoot without previous surgery were managed with posterior medial-lateral release. At an average of twenty-one years postoperatively, patients underwent a detailed physical examination and completed four quality-of-life surveys (the Short Form-36, the Laaveg and Ponseti scale, the Foot Function Index, and the modified Atar scale).

RESULTS

Thirty-two clubfeet (27%) had required additional procedures at the time of follow-up, with only one patient requiring complete revision posterior medial-lateral release and none requiring subtalar or triple arthrodesis. In patients with unilateral clubfoot, clinical examination demonstrated a significant decrease in the range of motion (p < 0.001), foot length (p = 0.045), and calf circumference (p = 0.008) on the affected side as compared with the unaffected, contralateral side. The results on all four quality-of-life scales remained durable, with no decline in relation to the time from the index procedure (p ≥ 0.48). Significantly worse scores were found for patients who required additional surgical procedures (p ≤ 0.03).

CONCLUSIONS

Previous studies have demonstrated inconsistent long-term results following the treatment of clubfoot with extensive soft-tissue releases. With our technique, thirty-two clubfeet (27%) required additional procedures and only one clubfoot required revision posterior medial-lateral release. We demonstrate that our technique, which involves aggressive posterior medial-lateral soft-tissue release in addition to manual derotation of the talus with a Kirschner wire to correct pathologic external rotation, produces acceptable results.

A review of the foot function index and the foot function index - revised

BACKGROUND

The Foot Function Index (FFI) is a self-report, foot-specific instrument measuring pain and disability and has been widely used to measure foot health for over twenty years. A revised FFI (FFI-R) was developed in response to criticism of the FFI. The purpose of this review was to assess the uses of FFI and FFI-R as were reported in medical and surgical literature and address the suggestions found in the literature to improve the metrics of FFI-R.

METHODS

A systematic literature search of PubMed/Medline and Embase databases from October 1991 through December 2010 comprised the main sources of literature. To enrich the bibliography, the search was extended to BioMedLib and Scopus search engines and manual search methods. Search terms included FFI, FFI scores, FFI-R. Requirements included abstracts/full length articles, English-language publications, and articles containing the term "foot complaints/problems." Articles selected were scrutinized; EBM abstracted data from literature and collected into tables designed for this review. EBM analyzed tables, KJC, JM, RMS reviewed and confirmed table contents. KJC and JM reanalyzed the original database of FFI-R to improve metrics.

RESULTS

Seventy-eight articles qualified for this review, abstracts were compiled into 12 tables. FFI and FFI-R were used in studies of foot and ankle disorders in 4700 people worldwide. FFI Full scale or the Subscales and FFI-R were used as outcome measures in various studies; new instruments were developed based on FFI subscales. FFI Full scale was adapted/translated into other cultures. FFI and FFI-R psychometric properties are reported in this review. Reanalysis of FFI-R subscales' confirmed unidimensionality, and the FFI-R questionnaires' response categories were edited into four responses for ease of use.

CONCLUSION

This review was limited to articles published in English in the past twenty years. FFI is used extensively worldwide; this instrument pioneered a quantifiable measure of foot health, and thus has shifted the paradigm of outcome measure to subjective, patient-centered, valid, reliable and responsive hard data endpoints. Edited FFI-R into four response categories will enhance its user friendliness for measuring foot health.