Correcting residual deformity following clubfoot releases

The perspectives of caregivers and health service providers on barriers to clubfoot management in Puri-Urban health facility in Ghana

Purpose

Clubfoot is a common disabling condition that is prevalent across all populations. Approximately, one out of 750 children globally suffers from clubfoot, and around 150,000 to 200,000 children are born with clubfoot every year with 80% of the cases occurring in developing countries. Clubfoot can result in mobility impairments when not properly managed and researchers have argued that understanding knowledge and perceptions are key components to early identification and effective management of clubfoot. The study explored the barriers to clubfoot management from the perspectives of caregivers and healthcare providers in Duayaw Nkwanta, Ghana.

Methods

A total of 26 participants made up of 22 caregivers of children with clubfoot and six healthcare providers were purposively sampled for the study guided by a set of inclusion and exclusion criteria. Qualitative data were collected using a semi-structured interview guide through in-depth face-to-face interviews. Interviews were transcribed and analyzed thematically and presented as findings.

Results

High cost of treatment, long travel distance, long hours spent at the treatment facility, non-availability of clubfoot treatment services, late reporting of clients for treatment, and non-compliance of parents/caregivers with treatment protocols were identified as the barriers to effective management of clubfoot.

Conclusion

These findings have substantial implications for current interventions to effectively manage clubfoot in Ghana.

Talipes Equinovarus in Loeys-Dietz Syndrome

BACKGROUND

Loeys-Dietz syndrome (LDS) commonly presents with foot deformities, such as talipes equinovarus (TEV), also known as "clubfoot." Although much is known about the treatment of idiopathic TEV, very little is known about the treatment of TEV in LDS. Here, we summarize the clinical characteristics of patients with LDS and TEV and compare clinical and patient-reported outcomes of operative versus nonoperative treatment.

METHODS

We identified 47 patients with TEV from a cohort of 252 patients with LDS who presented to our academic tertiary care hospital from 2010 to 2016. A questionnaire, electronic health records, clinical photos and radiographs, and telephone calls were used to collect baseline, treatment, and outcome data. The validated disease-specific instrument was used to determine patient-reported foot/ankle functional limitations after treatment. Patients were categorized into nonoperative and operative groups, with the operative group subcategorized according to whether the posteromedial release was performed.

RESULTS

Within our TEV cohort, bilateral TEV was present in 40 patients (85%). Thirty-seven patients underwent surgery (14 involving posteromedial release), and 10 were treated nonoperatively. The operative group had a higher incidence of posttreatment foot/ankle functional limitation (71%) than the nonoperative group (25%) ( P =0.04). The pain was the most common functional limitation (54%). The posteromedial release was associated with a higher incidence of developing hindfoot valgus compared with surgery not involving posteromedial release (43% vs. 8.7%, P =0.04) and compared with nonoperative treatment (43% vs. 0.0%, P =0.02).

CONCLUSIONS

We found that patients with LDS have a high incidence of bilateral TEV. Operative treatment was associated with posttreatment foot/ankle functional limitations, and posteromedial release was associated with hindfoot valgus overcorrection deformity. These findings could have implications for the planning of surgery for TEV in LDS patients.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Cavovarus With a Twist: Midfoot Coronal and Axial Plane Rotational Deformity in Charcot-Marie-Tooth Disease

BACKGROUND

The cavovarus deformity of Charcot-Marie-Tooth (CMT) disease is often characterized by a paradoxical relationship of hindfoot varus and forefoot valgus. The configuration of the midfoot, which links these deformities, is poorly understood. Accurate assessment of 3-dimensional alignment under physiologic loadbearing conditions is possible using weightbearing computed tomography (WBCT). This is the first study to examine the rotational deformity in the midfoot of CMT patients and, thus, provide key insights to successful correction of CMT cavovarus foot.

METHODS

A total of 27 WBCT scans from 21 CMT patients were compared to control WBCTs from 20 healthy unmatched adults. CMT patients with a history of bony surgery, severe degenerative joint disease, or open physes in the foot were excluded. Scans were analyzed using 3-dimensional software. Anatomic alignment of the tarsal bones was calculated relative to the anterior-posterior axis of the tibial plafond in the axial plane, and weightbearing surface in the coronal plane.

RESULTS

Maximal rotational deformity in CMT patients occurred at the transverse tarsal joints, averaging 61 degrees of external rotation (supination), compared to 34 degrees among controls (P < .01). The talonavicular joint was also the site of peak adduction deformity in the midfoot, with an average talonavicular coverage angle measuring 12 degrees compared with -11 degrees in controls (P < .01).

CONCLUSION

This 3-dimensional WBCT analysis is the first to isolate and quantify the multiplanar rotational deformity in the midfoot of CMT patients. Compared with healthy unmatched control cases, CMT patients demonstrated increased axial plane adduction and coronal plane rotation at the talonavicular (TN) joint. These findings support performing soft tissue release at the TN joint to abduct and derotate the midfoot as a first step for targeted deformity correction.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Updates in the Surgical Management of Recurrent Clubfoot Deformity: a Scoping Review

PURPOSE OF REVIEW

This article focuses on the current advances in surgical management for clubfoot deformity, supported by up-to-date longitudinal studies on each approach.

RECENT FINDINGS

Long-term analysis following primary and repeated soft tissue releases has demonstrated good results in young patients with low relapse rates. Tibialis anterior transfer following the Ponseti method shows no difference in long-term pedographic analysis in comparison to the Ponseti method alone. Furthermore, tibialis anterior transfer following surgical relapses provides good long-term results with improved correction in talus-first metatarsal angle. Bony osteotomies may also play a role in addressing surgical relapses in older children. However, talar neck osteotomy may result in avascular necrosis of the talar dome. Hexapod external fixation may be considered by experienced surgeons to correct rigid clubfoot deformities in older patients with good long-term results and drastic improvements in pain perception. Long-term analysis of anterior distal tibial epiphysiodesis (ADTE) for recurrent equinus deformity following surgical correction has demonstrated statistical improvements in the anterior distal tibial angle (ADTA) and ankle dorsiflexion. Talectomy and naviculectomy are rarely used in today's practice as long-term studies have demonstrated high relapse rates and residual pain impeding patient mobility. Surgical correction following failure of the conservative approaches can be implemented to achieve full correction in clubfoot deformity. It is difficult to achieve a plantigrade feet with pain-free gait with repeated surgical interventions. Therefore, proper choice of the initial surgical technique is essential for achieving satisfactory long-term outcomes.

Is there a correlation between static radiographs and dynamic foot function in pediatric foot deformities?

BACKGROUND

Idiopathic flexible flatfeet, congenital clubfeet and pes cavovarus are the most common foot deformities in children. Accurate assessment to quantify the severity of these deformities by clinical examination alone can be challenging. Radiographs are a valuable adjunct for accurate diagnosis and effective treatment. However, static radiographs during relaxed standing may not reflect the dynamic changes in the foot skeleton during functional activities such as walking. Therefore, the aim of this study is to predict dynamic foot movements during walking from planar standing radiographs to reveal the significance of the radiographic analysis for the assessment of foot function.

METHODS

Patients 8-17 years with flexible flatfeet (FFF, n=217) recurrent clubfeet (RCF n=38) and overcorrected clubfeet (OCCF, n=71) of non-neurogenic or syndromic origin and pes cavovarus due to peripheral neuropathy (PNP, n=48) were retrospectively included. Patients underwent gait analysis with the Oxford Foot Model and radiographic examination in anterior-posterior and lateral view during standing. Multilinear predictor analysis of selected gait parameters was performed based on radiographic measures.

RESULTS

The variance that was explained by radiography was greatest for the transverse plane forefoot abduction with 33% for OCCF, 50% for RCF and 59% for PNP. Flatfeet and foot kinematics in the other planes or between rearfoot and tibia showed little or no relation.

CONCLUSIONS

The static measures of foot deformities by radiography could explain only a small amount of variance in foot kinematics during walking, in particular for FFF. An explanation may be that the forces during weight bearing bear little resemblance to those during gait in terms of neither magnitude nor direction. These findings suggest that foot function cannot be accurately assessed solely from static radiographic observations of the foot, commonly undertaken in clinical practice.

Posteromedial Release versus Ponseti Treatment of Congenital Idiopathic Clubfoot: A Long-Term Retrospective Follow-Up Study into Adolescence

Purpose

Although many short-term studies have shown the superiority of Ponseti treatment to surgical treatment, studies with long-term follow-up of patients into adolescence are lacking. The aim of this study was to compare the morphological, functional and radiological results of the two methods into and during adolescent age, when both soft tissue and bony procedures can be performed to correct residual deformities.

Patients and Methods

We retrospectively evaluated two groups of patients diagnosed with congenital idiopathic clubfoot and treated with either the Ponseti method (34 clubfeet) and surgery in the form of posteromedial release (31 clubfeet). All included clubfeet were clinically fully corrected after initial treatment and final plaster removal. Evaluation was performed with the International Clubfoot Study Group (ICFSG) score.

Results

The age at follow-up was 12.8±1.6 years in the Ponseti group and 13.5±1.7 years in the surgical group. Excellent or good results were obtained in 26 feet (76%) of the Ponseti group and in 14 feet (45%) in the surgical group. The Ponseti treatment was significantly superior to posteromedial release in terms of the final score (10.58±6.49 versus 17.26±8.83, p<0.001), functional score (p<0.001) and radiological score (p<0.001). Residual deformities were clinically present in both groups but were less frequent and less severe in Ponseti-treated patients. Flat-top talus was found to be present in both groups, but the Ponseti method was more protective than surgical treatment against this outcome (relative risk=0.494, p=0.002). The overall foot and ankle mobility was significantly better in the Ponseti group (p<0.001).

Conclusion

The Ponseti method was superior to surgery for treatment of clubfoot and achieved better long-term morphological, functional and radiological results. It preserves better mobility of the foot and ankle, and results in less frequent and less severe residual deformities than surgical treatment.

Late Effects of Clubfoot Deformity in Adolescent and Young Adult Patients Whose Initial Treatment Was an Extensive Soft-tissue Release: Topic Review and Clinical Case Series

Children with congenital clubfoot often have residual deformity, pain, and limited function in adolescence and young adulthood. These patients represent a heterogeneous group that often requires an individualized management strategy. This article reviews the available literature on this topic while proposing a descriptive classification system based on a review of patients at our institution who underwent surgery for problems related to previous clubfoot deformity during the period between January 1999 and January 2012. Seventy-two patients (93 feet) underwent surgical treatment for the late effects of clubfoot deformity at an average age of 13 years (range 9 to 19 years). All patients had been treated at a young age with serial casting, and most had at least one previous surgery on the affected foot or feet. Five common patterns of pathology identified were as follows: undercorrection, overcorrection, dorsal bunion, anterior ankle impingement, and lateral hindfoot impingement. Management pathways for each group of the presenting problems is described. To our knowledge, this topic review represents the largest report of adolescent and young adult patients with residual clubfoot deformity in the literature.

Does an overcorrected clubfoot caused by surgery or by the Ponseti method behave differently?

BACKGROUND

Overcorrection is a recognized problem following surgical treatment of congenital clubfoot. Recently this complication has also been mentioned following Ponseti treatment.

RESEARCH QUESTION

Do overcorrected clubfeet (OCCF) caused by surgery behave differently from those caused by Ponseti treatment in terms of segmental motion of the feet and show differences in the severity of deformity on X-rays?

METHODS

Children between 7 and 12 years with OCCF were included in this study. Depending on the aetiology causing them, the feet were divided into 2 groups (Ponseti and peritalar release surgery). 25 typically developing children served as controls. All subjects were subjected to clinical and radiological examination and 3-Dimensional gait analysis using the Oxford Foot Model.

RESULTS

Thirty-two children with OCCF, of these 18 feet in the surgical and 14 feet in the Ponseti group, were included in the study. No radiological differences were seen in the flatfoot parameters between OCCF groups except in the calcaneal inclination angle that was more pathological in the Ponseti group. The clinical ankle plantar flexion was significantly reduced in the surgical group. During walking the range motion of the hindfoot in the frontal plane was significantly reduced in surgically treated feet compared to the Ponseti group. The other parameters did not show any significant difference between groups.

SIGNIFICANCE

The overcorrected clubfeet following surgery and Ponseti showed similar appearance and showed no significant differences in 11/12 radiological parameters. The segmental motion of the feet showed no significant differences between groups except the in the range of motion of the subtalar eversion. A considerable subtalar joint motion was present even in the surgical group. These findings might help plan the treatment of these feet.

Limitation of flatfoot surgery in overcorrected clubfeet after extensive surgery

INTRODUCTION

Flatfoot is a severe complication of extensive clubfoot surgery. In this retrospective study, we evaluated our results following flatfoot surgery in overcorrected clubfeet. The aim was to analyze the success of different surgical techniques, including tarsal osteotomies and arthrodesis, in correcting different types of flatfeet.

MATERIAL AND METHOD

Between January 1, 2011 and December 31, 2015 we treated 25 severe cases of flatfeet after extensive clubfoot surgery. We classified the hindfoot deformities into rotational valgus, hinge valgus or translatory valgus based on AP standing X-rays. Tarsal osteotomies (Mitchell, Evans, Cotton) and arthrodesis were adapted based on age and severity. Age, gender, pain, hindfoot valgus and function were documented. Function and X-rays were compared pre- and postoperatively.

RESULTS

There were 17 male and 4 female patients. Age at operation ranged from 11 to 26 years with an average age of 14.3 years. The mean follow-up was 27.6 months (7-60 months). Primary surgical treatment was a tarsal osteotomy in 19 cases and in six cases it was arthrodesis. Hindfoot valgus (Ø 18.6°-3.2°), calcaneal pitch (Ø 6.2°-14.6°), Costa Bartani angle (Ø155°-142°) and Meary angle (Ø 2.0°-8.8°) improved pre- to postoperatively. Range of motion did not improve after surgical correction. 81% were satisfied with the postoperative results. All flatfeet with translatory valgus, initially treated with a tarsal osteotomy, needed further arthrodesis due to primary undercorrection.

CONCLUSION

Tarsal osteotomies are successful methods for correcting flatfeet following extensive clubfoot surgery with rotational valgus and mild hinge valgus. Tarsal osteotomies are unable to successfully correct flatfeet that have a translatory valgus. In such cases, we recommend double or triple arthrodesis. The functional outcome is limited by the preop range of motion and the appearance of talus deformities.

Ponseti Treatment of Rigid Residual Deformity in Congenital Clubfoot After Walking Age

BACKGROUND

There is no established treatment for rigid residual deformity of congenital clubfoot (CCF) after walking age. Soft-tissue procedures, osseous procedures, and external fixation have been performed with unpredictable results. We applied the Ponseti method to patients with this condition in order to improve the outcomes of treatment.

METHODS

We retrospectively reviewed the cases of 44 patients (68 feet) with congenital clubfoot whose mean age (and standard deviation) at treatment was 4.8 ± 1.6 years. All patients had been previously treated in other institutions by various conservative and surgical protocols. Residual deformity was evaluated using the International Clubfoot Study Group Score (ICFSGS), and stiffness was rated by the number of casts needed for deformity correction. Ponseti manipulation and cast application was performed. Equinus was usually treated with percutaneous heel-cord surgery, while the cavus deformity was treated with percutaneous fasciotomy when needed. Tibialis anterior tendon transfer (TATT) was performed in patients over 3 years old. At the time of follow-up, the results were evaluated using the ICFSGS.

RESULTS

Before treatment, 12 feet were graded as fair and 56, as poor. Two to 4 casts were applied, with each cast worn for 4 weeks. Stiffness was moderate (2 casts) in 23 feet, severe (3 casts) in 30 feet, and very severe (4 casts) in 15 feet. Percutaneous heel-cord surgery was performed in 28 feet; open posterior release, in 5 feet; plantar fasciotomy, in 30 feet; and TATT, in 60 feet. The mean length of follow-up was 4.9 ± 1.8 years. Eight feet had an excellent result; 49 feet, a good result; and 11 feet, a fair result. No patient had pain. All of the feet showed significant improvement.

CONCLUSIONS

Ponseti treatment with TATT, which was performed in 88% of the feet, was effective, and satisfactory results were achieved in 84% of the feet. At the time of follow-up, no patient showed an abnormal gait, all feet were plantigrade and flexible, but 2 feet (2.9%) had relapsed.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical treatment of neglected congenital idiopathic talipes equinovarus after walking age in Eritrea: an Italo-Eritrean cooperation

An Italian team of orthopaedic surgeons joined Eritrean colleagues to perform a clinical study in ambulating children affected by neglected idiopathic congenital talipes equinovarus (clubfoot). This study reports the surgical strategy as well as clinical outcomes, early complications and relapse at a mid-term follow-up. Four expeditions of 7 days were organized between 2012 and 2015 from Italy to the Halibet Hospital of Asmara in Eritrea. In each expedition were included two experienced surgeons, two assistants and one anaesthesiologist. During these expeditions, a total of 468 patients were evaluated together with Eritrean colleagues and 45 cases of neglected talipes equinovarus in ambulating children were diagnosed and selected for surgery. Follow-up range was 1-3 years. During the four expeditions, the Eritrean team of orthopaedic surgeons learned to manage most cases of neglected talipes equinovarus. No major complications were reported. Sixteen feet were considered excellent, 25 good and four poor. No overcorrections were observed. Neglected congenital talipes equinovarus is the result of delayed treatment of congenital deformity in developing countries, and its treatment often requires extensive surgery. Collaboration with foreign expert surgeons may help local doctors to learn how to treat this disease. The current study demonstrates that surgical expeditions in developing countries, when organized in collaboration with local doctors, help to manage on site this severe deformity.

Congenital idiopathic talipes equinovarus before and after walking age: observations and strategy of treatment from a series of 88 cases

BACKGROUND

We reviewed a series of newborns, toddlers and ambulating children affected by idiopathic congenital talipes equinovarus (clubfoot). Taking into account the time of diagnosis, stiffness of the deformity and walking age, nonsurgical or surgical treatment was considered. This study reports clinical outcomes, early complications and relapse at mid-term follow-up.

MATERIALS AND METHODS

Fifty-two clubfeet were diagnosed at birth, 12 in non-ambulating children aged between 4 and 12 months and 24 in ambulating children. Feet were classified using the Pirani score. Newborns and toddlers were treated with serial casting (Ponseti); however, toddlers also underwent open Achilles tendon lengthening (2 feet) and posteromedial release (3 feet). In all ambulating children, surgical treatment was always performed: selective medial release combined with cuboid subtraction osteotomy (1 foot), posteromedial release (6 feet), and posteromedial release combined with cuboid subtraction osteotomy (17 feet).

RESULTS

The average follow-up was 5 years (1-6 years). In newborns treated with Ponseti, the results were excellent in 42 feet, good in 6, and poor in 4. In non-ambulating children, the results were excellent in 9 feet, and good in 3. In ambulating children, the results were excellent in 5 feet, good in 16, and poor in 3. No major complications were reported. No overcorrections were observed. The need for open surgery was higher in cases of delayed treatment. In cases of relapse, re-casting and/or more extensive surgery was considered.

CONCLUSIONS

Early treatment enables a high rate of good correction to be obtained with serial casting and limited surgery. Conversely, if the deformity is observed after walking age surgery should be considered. Serial casting in cases of late observation and relapse have demonstrated encouraging results.

LEVEL OF EVIDENCE

IV.

Plantar pressures following anterior tibialis tendon transfers in children with clubfoot

BACKGROUND

Relapses following nonoperative treatment for clubfoot occur in 29% to 37% of feet after initial correction. One common gait abnormality is supination and inversion of the foot caused by an imbalance of the anterior tibialis tendon muscle. The purpose of this study was to determine if plantar pressures are normalized following an anterior tibialis tendon transfer (ATTT).

METHODS

Thirty children (37 clubfeet) who underwent an ATTT, were seen for plantar pressure testing preoperatively and postoperatively. Each foot was subdivided into 7 regions: medial/lateral hindfoot and midfoot, and the forefoot (first, second, and third to fifth metatarsal heads). Variables included: contact time as a percentage of stance time (CT%), contact area as a percentage of the total foot (CA%), peak pressure (PP), hindfoot-forefoot angle (H-F), location of initial contact, and deviation of the center-of-pressure line (COP). Paired t tests were used for group comparisons, whereas multiple comparisons were assessed with ANOVA (α set to 0.05 with Bonferroni correction).

RESULTS

Significant changes were seen in preoperative to postoperative comparison. PP, CT%, and CA% had significant increases in the medial hindfoot, midfoot, and first metatarsal regions, whereas the involvement of the lateral midfoot and forefoot were reduced. Compared with controls, postoperative results following ATTT continue to show increased PP, CA%, and CT% in the lateral midfoot, increased CA% and CT% in the lateral forefoot, whereas CA% was decreased in the first metatarsal region. Compared with controls, the COP line continues to move laterally and the H-F angle continues to show forefoot adductus following ATTT. No differences were found between patients treated with an isolated ATTT and those treated with concomitant procedures.

CONCLUSIONS

The changes seen in plantar pressures following ATTT would suggest that the foot is better aligned for a more even distribution of pressure throughout the foot, but is not fully normalized.

LEVEL OF EVIDENCE

Therapeutic level II.

Calcaneocuboid arthrodesis for recurrent clubfeet: what is the outcome at 17-year follow-up?

PURPOSE

Calcaneocuboid arthrodesis was used during revision clubfoot surgery in order to maintain midfoot correction. The purposes of this study were to determine: (1) functional level at 17-year follow-up compared to 5-year follow-up; (2) patients' current functional level, satisfaction, and pain; and (3) current arthropometric measurements.

METHODS

Twenty patients (27 clubfeet) with clubfoot relapse underwent revision soft tissue release and calcaneocuboid fusion between 1991 and 1994. They were previously evaluated at a mean follow-up of 5.5 years. Ten out of 20 patients (13 clubfeet), mean age of 24 years, were reevaluated at mean follow-up of 17.5 years. The Hospital for Joint Diseases Functional Rating System (HJD FRS) for clubfoot surgery, Outcome Evaluation in Clubfoot developed by the International Clubfoot Study Group, the Clubfoot Disease-Specific Instrument, American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire, Laaveg and Ponseti's functional rating system for clubfoot and pain scale were completed by patient and/or surgeon to assess function, patient satisfaction and pain. Foot and ankle radiographs and anthropometric measurements were reviewed. For HJD FRS, scores from original follow-up were compared to current ones.

RESULTS

The HJD FRS score of all feet was 65.9, demonstrating a significant decline from the original mean score of 77.8 (p = 0.03). Excellent/good HJD FRS scores went from 85 to 38 %. Mean AAOS Foot Ankle Outcomes Questionnaire standardized core and shoe comfort scores were 84.6 and 84.5, respectively. Average foot pain was 1.8 on a scale of 1-10. Patients were very/somewhat satisfied with status of foot in 76 % of feet and appearance of foot in 46 % of feet, based on Clubfoot Disease-Specific Instrument questions.

CONCLUSIONS

Revision clubfoot surgery with calcaneocuboid fusion in patients 5-8 years of age showed an expected decline in functional outcome measures over a 17-year follow-up period. It still produced comparable results to other studies for a similar population of difficult, revision cases, and should have a place in current surgical treatment techniques.

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 results of treatment of congenital idiopathic clubfoot in 187 feet: outcome of the functional "French" method, if necessary completed by soft-tissue release

BACKGROUND

Two main options for treatment of congenital idiopathic clubfoot are the "French" functional method and the Ponseti method. The goal of this article was to evaluate the results of the functional treatment method, which, if necessary, is completed by a surgical release.

PATIENTS AND METHODS

A series of 187 feet (129 patients) underwent functional conservative treatment. At first evaluation, the feet were classified according to the classification of Dimeglio. All patients then underwent daily physiotherapy and splintage, which was progressively stopped during childhood. Among these 187 feet, 85 feet (45.5%) required soft-tissue release to correct the remaining deformity. Surgery, when required, consisted of a complete posterolateral and medial release procedure, combined with a lengthening of the tibialis anterior tendon in most cases and a bony lateral procedure in case of forefoot adduction.

RESULTS

At the latest follow-up (14.7 y; range, 7.4 to 23 y), results were "good" or "very good" in almost 98% of feet, according to the Ghanem and Seringe score. Severe feet at first consultation showed a worse result and required surgery more often than did the less severe ones. Among nonoperated feet, very good results were found in 99% of feet, and none had a fair or bad result. The average age at surgery was 2.5 years. Feet operated upon had lower results compared with the others. At last follow-up, among the operated feet, the results were excellent or good in 95% of the feet. The results were fair or bad in 4 cases; all 4 feet had been operated upon more than once. The results were not statistically dependent on age at the time of surgery, but feet operated upon before the age of 2 years had statistically more flattening of the talar dome and subtalar stiffness.

CONCLUSIONS

The functional treatment of clubfoot leads to a very good result without the need for surgery in more than half of the patients. The initial severity of the feet is the main factor that influences the final result. The rate of feet not requiring surgery should be increased by recent modifications to the method, including percutaneous Achilles tenotomy.

LEVEL OF EVIDENCE

Level IV-retrospective series.

Reconstructive surgery for overcorrected clubfoot in adults

BACKGROUND

A known complication of the surgical treatment of clubfoot deformity is hindfoot valgus deformity of the ankle and/or the subtalar joint leading to calcaneofibular and/or anterior ankle impingement and flatfoot deformity. The purpose of this prospective study was to assess the radiographic outcome, pain relief, and functional improvement in patients with symptomatic overcorrected clubfoot deformity who were managed with a supramalleolar osteotomy.

METHODS

Fourteen patients with an overcorrected clubfoot deformity and a mean age of 36.9 ± 14.0 years were managed with a supramalleolar osteotomy. The mean duration of follow-up was 50.6 months. Radiographic assessment included comparison of the preoperative and postoperative distal tibial joint surface angle, tibiotalar angle, and amount of calcaneal offset on the hindfoot alignment view. Clinical outcomes were quantified with use of a visual analog score for pain and the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score.

RESULTS

No perioperative complications occurred. Radiographically, all osteotomy sites healed within eight weeks and the orientation of the distal tibial articular surfaces was normalized in all cases. Clinically, calcaneofibular and anterior ankle impingement resolved in all patients and the mean visual analog score for pain decreased significantly from 4.1 ± 1.7 to 2.2 ± 1.5 (p < 0.05). The mean AOFAS hindfoot score increased significantly from 51.6 ± 12.3 preoperatively to 77.8 ± 11.8 postoperatively (p < 0.05). The ankle motion increased significantly from 25° ± 12° preoperatively to 29° ± 9° postoperatively (p < 0.05). All patients walked in normal shoes.

CONCLUSIONS

Supramalleolar osteotomy is an effective surgical procedure for the treatment of ankle impingement in patients with an overcorrected congenital clubfoot deformity. The correction is associated with a low risk of perioperative complications and leads to significant reduction of pain, increased ankle motion, and improved clinical outcome (p < 0.05).

Persistent clubfoot deformity following treatment by the Ponseti method

The Ponseti method of clubfoot correction is now widely practiced worldwide. Initial correction rates are nearly 100%, but subsequent relapses may occur in up to one-third of patients. Very little has been written by anyone other than Dr Ponseti about the characterization and treatment of recurrent clubfoot deformity following use of the Ponseti method. This review paper is the first one which draws together the current literature on the topic.

Comprehensive review of the functional outcome evaluation of clubfoot treatment: a preferred methodology

Treatment outcome has been a focus of interest in those who manage clubfeet. Because of a lack of a common evaluation protocol, it has become necessary to establish a universally recognized quantitative measurement to compare and better understand the treatment outcome. The outcome is not merely morphological and radiographic, but it should also include functional and quality-of-life measurements. In this article, we will outline the most commonly used methods of long-term evaluation for congenital clubfeet and recommend the data collection parameters that are most appropriate for a comprehensive functional analysis. This will begin with pretreatment classifications that are important in prognosticating the results. The physical examinations and plain radiographs in standing position are also two fundamental evaluations of clubfoot. Several outcome evaluations have been published in the literature and may be useful depending on the desired metrics. Gait analysis is an additional useful technical tool for analyzing the motion of the foot and ankle and its relation to the whole body function; pedobarography added to the dynamics of the evaluation. Functional quality-of-life questionnaires are increasing in popularity for measuring the total body functional status and the quality of life.

Residual clubfoot in children

The deformities encountered in any patient who has residual clubfoot comprise various degrees of equinus, varus, adduction, supination, cavus, and toe deformity. Joint flexibility or stiffness, tarsal dysmorphism, articular incongruence, and progressive degrees of degeneration may be present. Add to this the scars of previous attempts at correction and various etiologic factors, and surgeons can find that treatment solutions are far from straightforward. A philosophy of careful history, examination, investigation, and surgery à la carte will provide a safe foundation for treating patients who have these often complex and difficult problems. A surgical strategy progressing from proximal to distal, performing soft tissue surgery before fixed deformity occurs, extra-articular osteotomies to correct bony deformity, and augmentation with rebalancing of soft tissue-deforming forces will help improve pain and function for many patients. Joint fusions should be reserved as a last salvage option to avoid future degeneration of adjacent joints.

Long-term outcome evaluation in young adults following clubfoot surgical release

BACKGROUND

The aim of this study was to evaluate the long-term outcome of a comprehensive surgical release for congenital talipes equinovarus (CTEV).

METHODS

Gait, strength, segmental foot motion, and outcomes questionnaire data were collected on 24 adults (21.8+/-2.3 y) who were surgically treated for CTEV as infants. These data were statistically compared with of 48-age group matched controls (23.2+/-2.4 y).

RESULTS

The clubfoot group was functional in activities of daily living, although most patients did experience foot pain after a day of typical activities, such as walking, standing, using stairs and doing exercise. Lower extremity gait kinematics was similar to the control group. There were differences in segmental foot motion with the hindfoot in a more plantarflexed position relative to the tibia and the forefoot dorsiflexed, and adducted relative to the hindfoot. Ankle plantarflexion and inversion strength and range of motion was reduced in the clubfoot group in association with an increase in hip power generation during the preswing and initial swing phases of the gait cycle.

CONCLUSIONS

Surgical correction of CTEV was successful in providing a functional plantigrade foot as the patients reached adulthood. However, limitations included foot pain, limited foot range of motion, and weakness.

LEVEL OF EVIDENCE

Level III.

Transfer of the tendon of tibialis anterior in relapsed congenital clubfoot: long-term results in 38 feet

A total of 38 relapsed congenital clubfeet (16 stiff, 22 partially correctable) underwent revision of soft-tissue surgery, with or without a bony procedure, and transfer of the tendon of tibialis anterior at a mean age of 4.8 years (2.0 to 10.1). The tendon was transferred to the third cuneiform in five cases, to the base of the third metatarsal in ten and to the base of the fourth in 23. The patients were reviewed at a mean follow-up of 24.8 years (10.8 to 35.6). A total of 11 feet were regarded as failures (one a tendon failure, five with a subtalar fusion due to over-correction, and five with a triple arthrodesis due to under-correction or relapse). In the remaining feet the clinical outcome was excellent or good in 20 and fair or poor in seven. The mean Laaveg-Ponseti score was 81.6 of 100 points (52 to 92). Stiffness was mild in four feet and moderate or severe in 23. Comparison between the post-operative and follow-up radiographs showed statistically significant variations of the talo-first metatarsal angle towards abduction. Variations of the talocalcaneal angles and of the overlap ratio were not significant. Extensive surgery for relapsed clubfoot has a high rate of poor long-term results. The addition of transfer of the tendon of tibialis anterior can restore balance and may provide some improvement of forefoot adduction. However, it has a considerable complication rate, including failure of transfer, over-correction, and weakening of dorsiflexion. The procedure should be reserved for those limited cases in which muscle imbalance is a causative or contributing factor.