Vascular abnormalities correlate with decreased soft tissue volumes in idiopathic clubfoot

The Arterial Supply to the Foot and its Correlation With Return of Capillary Filling Post-Achilles Tenotomy in Congenital Clubfoot

BACKGROUND

Congenital clubfoot is a common idiopathic foot abnormality that manifests in newborns. Vascular deficiencies have been suggested as one of the underlying etiologies of clubfoot. The question in hand was: "Is the return of capillary filling to the foot post-Achilles tenotomy correlated with both the arterial supply to the foot and degree of ankle equinus"?

METHODS

This clinical study included 30 unilateral idiopathic clubfeet. All patients were assessed clinically using the Pirani score, then manipulation using the Ponseti technique, followed by examination of the infragenicular arterial system using Doppler ultrasound in both the affected and the normal control limbs. After Achilles tenotomy and reaching dorsiflexion of 10 to 20 degrees, the time-lapse till complete return of capillary filling to the foot was recorded. Both the radiologist and the surgeon were blinded to each other's assessment.

RESULTS

The mean postoperative time-lapse to complete return of capillary filling after the maintenance of dorsiflexion at the start of cast application was 3.53±5.56 minutes (range: 0 to 26.59). The anterior tibial artery (ATA) on the affected side was found to be completely attenuated distally in 24 out of 30 feet (80%), while the mean caliber of the posterior tibial artery (PTA) (1.09±0.18 mm) on the affected side was found to be increased compared with the normal side (0.99±0.20 mm) (P=0.042). Also, cases with hypoplastic PTAs needed more time for the return of capillary filling (mean: 8.71±8.88 min) compared with those with normal PTAs (mean: 1.95±2.83 min), (P=0.007). Also, there was a direct positive correlation between postoperative complete return of capillary filling and preoperative degree of equinus (P<0.001).

CONCLUSION

Delay of the postoperative complete return of capillary filling to the foot after maximum dorsiflexion post Achilles tenotomy is related to both the degree of preoperative equinus and insufficiency/hypoplasia of the posterior tibial artery. This expected delay should not rush the surgeons to remove the cast before the lapse of 30 minutes.

LEVEL OF EVIDENCE

Level III.

Alternative Methods of Fixation for Anterior Tibialis Transfer in Residual Clubfoot Deformity

The preferred treatment for congenital clubfoot is the Ponseti method, which involves weekly manipulation and casting followed by tendoachilles tenotomy and abduction bracing. Depending on patient age and deformity location, 5%-35% of patients experience recurrent deformities and require additional treatment, including casting or surgery. Dynamic supination during the swing phase of gait represents a common sequela; it can be managed with anterior tibialis transfer to the lateral foot. Variations in this technique include how much tendon is transferred, the use of 2 or 3 incisions, the recipient location of the transferred tendon, and fixation methods. Ponseti preferred the transfer of the entire anterior tibialis tendon into the ossified 3rd cuneiform and securing the transferred tendon with absorbable stitches tied over a plantar button and sterile felt. With this method, the senior author has had soft tissue complications, namely skin maceration and, on one occasion, full-thickness necrosis down to the plantar fascia. As a result, variations on this technique have evolved with resultant mitigation of these complications. These methods are described here.

Key Concepts

(1)Anterior tibialis transfer (ATT) is a commonly utilized method of addressing residual deformity following the Ponseti method(2)The classic fixation method includes using an absorbable suture tied over felt and a plantar button under the cast. While uncommon, this method can lead to significant pressure sores.(3)For patients who undergo isolated ATT, we now tie the button on the outside of the cast to avoid a pressure sore.(4)In patients who undergo ATT with additional treatment of posterior contracture, one can secure the anterior tibialis into the recipient site by tying it to a K-wire used to maintain the hindfoot correction.

Reliability of Percutaneous Achilles Tenotomy in the Treatment of Idiopathic Clubfoot

BACKGROUND

Talipesequinovarus is a congenital ankle/foot malformation that commonly affects newborns. In its treatment using the Ponseti method, an Achilles tenotomy is frequently needed to correct residual equinus deformity. Percutaneous (PC) tenotomy is the most commonly used technique and needs to be thoroughly evaluated. The question we needed to answer was: "Does PC Achilles tenotomy result in complete tendon sectioning"?

METHODS

This clinical study included 56 idiopathic clubfeet in 36 patients who presented during the first 6 months of life and were treated with Ponseti manipulation and casting followed by PC Achilles tenotomy. PC tenotomy was done under general anesthesia, and Thompson's calf squeeze test was performed intraoperatively just after tenotomy. In case of a negative test (ie, ankle plantar flexion with calf squeeze), the percutaneous incision was extended to assess the cause of the negative test.

RESULTS

Forty-nine feet (87.5%) had a complete tenotomy, as evidenced by a positive Thompson's calf squeeze test. While 7 feet (12.5%) showed a negative test, and therefore the percutaneous incision was extended and all were found to have an incompletely divided Achilles tendon. The tendons were then completely divided, after which Thompson's test became positive in all.

CONCLUSION

Percutaneous Achilles tenotomy is a reliable procedure, but was found to result in incomplete tendon sectioning in 12.5% of cases, affecting the range of ankle dorsiflexion. Thompson's squeeze test is reliable in picking up cases of incomplete tenotomy after the PC technique, and in these cases the incision should be extended for complete sectioning.

LEVEL OF EVIDENCE

Level I.

Clinical Characteristics and Whole Exome Sequencing Analysis in Serbian Cases of Clubfoot Deformity-Single Center Study

BACKGROUND

Recognized as one of the most serious musculoskeletal deformities, occurring in 1-2 per 1000 newborns, 80% of clubfeet are idiopathic while 20% present with associated malformations. The etiopathogenesis of clubfoot is described as multifactorial, including both genetic and environmental risk factors. The aim of this study was to analyze possible genetic causes of isolated and syndromic clubfoot in Serbian children, as well as to correlate clinical and genetic characteristics that would provide insight into clubfoot etiopathogenesis and possibly contribute to global knowledge about clinical features of different genetically defined disorders.

METHODS

We evaluated 50 randomly selected, eligible children with clubfoot aged 3 to 16 years that were initially hospitalized and treated at University Children's Hospital between November 2006 and November 2022. The tested parameters were gender, age, dominant foot, affected foot, degree of deformity, treatment, neuromuscular disorders, positive family history, and maternal smoking. According to the presence of defined genetic mutation/s by whole exome sequencing (WES), patients were separated into two groups: positive (with genetic mutation/s) and negative (without genetic mutation/s).

RESULTS

Seven patients were found to be positive, i.e., with genetic mutation/s. A statistically significant difference between categorical variables was found for families with a history of clubfoot, where more than half (57.14%) of patients with confirmed genetic mutation/s also had a family history of genetic mutation/s (p = 0.023).

CONCLUSIONS

The results from this study further expand the genetic epidemiology of clubfoot. This study contributes to the establishment of genetic diagnostic strategies in pediatric patients with this condition, which can lead to more efficient genetic diagnosis.

The evaluation of vascular flow in clubfoot: a resistive index and peak systolic velocity study

Resistive index (RI) and peak systolic velocity (PSV) are important Color doppler ultrasonography (CDU) parameters indicating the microcirculation and flow velocity in tissues. We aim to determine the changes in vascular flow characteristics in clubfoot after Ponseti treatment. There were three groups: the clubfoot group, the healthy group (the unaffected feet with unilateral deformities) and the control group. The Pirani severity scoring and CDU examinations of the foot were performed at initial admission and the 6th-month follow-up after Ponseti treatment. A total of 34 feet of 24 patients were included in the study. The mean age at initial treatment was 20.9 ± 22.5 days. The RI and PSV values of the clubfeet and the healthy group were similar. Resistive index values were significantly lower, and PSV values were significantly higher in the control group. After Ponseti treatment, only RI of the dorsalis pedis artery decreased, but PSV increased for all of the arteries. Recurrence of the deformity deteriorates the improvement in vascular development. Resistive index and PSV values were not related to the initial severity of the deformity. The RI values were higher, and PSV values were lower in clubfoot patients compared with the normal control group. Vascular pathology is a component of clubfoot, and treatment success improves vascular development. The improvement of microcirculation and blood flow velocity together was detected only in the dorsalis pedis artery. The effect of vascular flow change on prognosis was not detected.

Bilateral Pseudoaneurysms Following Percutaneous Achilles Tenotomy for Congenital Talipes Equinovarus

Pseudoaneurysm following percutaneous tendoachilles (TA) tenotomy is a rare complication found in children with congenital talipes equinovarus (CTEV). It is postulated that associated aberrant vascular anatomy in combination with CTEV may be the underlying aetiology. In this case report, we describe a case of a toddler who developed bilateral pseudoaneurysms following percutaneous tendoachilles tenotomy and explore the management and outcome in relation to this. Based on this case report and a review of the literature, the consistent clinical findings of swelling and/or discolouration due to pseudoaneurysm occur at three weeks post-tenotomy, and should raise suspicion for the diagnosis. Furthermore to the best of our knowledge, this is the first case report of bilateral pseudoaneurysms in the same setting, and we propose the possibility of an aberrant vessel arising from the peroneal artery that may be prone to injury.

Congenital talipes equinovarus: A literature review

Congenital talipes equinovarus (CTEV) is a congenital disability characterized by leg deformities in the cavus, adducts, varus, and equinus. The etiology of CTEV is poorly understood, despite its incidence ranging from 0.76 to 3.49 cases per 1000 live births in Indonesia. CTEV involves the fixation of the foot in the adducts, varus, and equinus with concurrent soft tissue anomalies. Despite advances in treatment, disability often persists. Theoretical models have been proposed for neurological, vascular, connective tissue, bone, and muscular causes; however, the currently available data suggests that mild cases are associated with intrauterine position. CTEV's etiology appears to involve a hereditary component, as its prevalence varies by ethnic group. Genetic factors have been identified in 24-50% of cases, depending on the community studied. Based on a complex segregation analysis, the most plausible inheritance pattern is a single large-effect gene interacting with a polygenic background.

Congenital Clubfoot - Is the Ponseti Method the Definitive Solution?

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.

Muscle volume evaluation using 3DCT for congenital clubfoot

Background

In congenital clubfoot, the lower leg is very thin and the calf muscles are hypoplasic. However, there are few studies reporting real muscle volume.

Purpose

The purpose of this study is to assay the muscle volume in congenital clubfoot using 3DCT and to quantify the degree of the hypoplasia.

Material and methods

From January 2015 to December 2016, nine consecutive patients, seven male and two female, with unilateral congenital clubfeet were recruited for CT scans. Axial transverse sectional CT scans were acquired from the delineation of the fibular head to the tibial plafond. From the data, we rendered the entire muscle in 3D for muscle volume assay, and further segmented the posterior musculature for comparison between the normal and affected sides.

Results

The whole muscle volume on the normal side was 291.23 cm³ (181.23–593.49) and that on the affected side was 225.08 cm³ (120.71–429.08), for an affected side to normal side ratio of 0.79 (0.72–0.9), which was significantly smaller (p < .01). Posterior muscle volume on the normal side was 175.81 cm³ (103.72–376.32) and that on the affected side was 106.52 cm³ (58.3–188.39). The ratio of posterior muscle to whole muscle on the normal side was 0.62 (0.46–0.75), and that on the affected side was 0.48 (0.4–0.55), such that the affected side was significantly smaller (p < .01)

Conclusion

This study contributes quantitative data supporting the longstanding observations that the posterior calf muscles are significantly smaller on the affected side compared to the normal side in congenital clubfoot, and further underscores the importance of the extending the excursion of these muscles.

Variations in arterial pedal circulation in idiopathic congenital talipes equinovarus: a systematic review

Variations in pedal circulation in congenital talipes equinovarus (CTEV) are well documented. There is a reported risk of vascular injury to the posterior tibial artery (PTA) during operative procedures for CTEV, potentially leading to necrosis and amputation. The aim of this systematic review was to identify the most common anomalies in arterial pedal circulation in CTEV and to determine the relevance of these to clinical practice. The systematic review was registered on PROSPERO and was carried out according to Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines by two independent reviewers. Studies that examined pedal circulation in idiopathic CTEV were included. Articles that studied nonidiopathic CTEV and those not published in English were excluded. Data extracted included patient demographics, imaging modalities, and findings. A total of 14 articles satisfied the inclusion criteria, including 192 patients (279 clubfeet), aged 0-13.5 years, at various stages in their treatment. Imaging modalities included arteriography (n = 5), duplex ultrasound (n = 5), magnetic resonance angiography (n = 2), and direct visualization intraoperatively (n = 2). The dorsalis pedis was most frequently reported as absent (21.5%), and the anterior tibial artery (ATA) was most frequently reported as hypoplastic (18.3%). Where reported (n = 36 feet), 61% of patients were noted to have a dominant supply from the PTA. The most common variation in pedal circulation in CTEV is diminished supply from ATA and dorsalis pedis, although there are documented anomalies in all of the vessels supplying the foot. We therefore recommend routine Doppler ultrasound imaging prior to operative intervention in CTEV.

Resistive index and peak systolic velocity for congenital talipes equinovarus: A color Doppler ultrasonography study

Objectives

This study aims to investigate whether resistive index (RI) and peak systolic velocity (PSV) are suitable parameters to determine if a clubfoot differs from feet of the normal population.

Patients and methods

Fifty-four feet of 27 clubfoot patients (22 males, 5 females; mean age 30.4±16.3 months; range, 5 to 72 months) were included in this retrospective study conducted between December 2017 and January 2019. Twenty-seven feet were conservatively treated, 19 had surgical treatment, and eight feet were healthy in patients with unilateral clubfoot. In addition, 22 feet of 11 normal controls (6 males, 5 females; mean age 33.4±15.3 months; range, 15 to 60 months) were studied. Color Doppler ultrasonography examinations were performed to evaluate the three major arteries of the leg and foot: dorsalis pedis (dp), tibialis posterior (tp), and popliteal (pop). Color filling, flow direction, spectral analysis, velocity, and RI were examined.

Results

With the exception of the dp artery RI, the PSV and RI values for all arteries differed significantly from those of the control group. There were no significant differences among the conservative, surgical, and healthy groups, while there were significant differences between each of the treated groups and the control group. Tibialis posterior artery PSV and pop artery RI were the best parameters to identify clubfoot and the cut-off points were 54 cm/second and 0.77, respectively.

Conclusion

Peak systolic velocity and RI may be accepted as important parameters for identification of clubfoot deformity. Tibialis posteriorartery PSV and pop artery RI are the best- detailed parameters for this examination.

TAZ and myostatin involved in muscle atrophy of congenital neurogenic clubfoot

BACKGROUND

Muscular atrophy is the basic defect of neurogenic clubfoot. Muscle atrophy of clubfoot needs more scientific and reasonable imaging measurement parameters to evaluate. The Hippo pathway and myostatin pathway may be directly correlated in myogenesis. In this study, we will use congenital neurogenic clubfoot muscle atrophy model to verify in vivo. Further, the antagonistic mechanism of TAZ on myostatin was studied in the C2C12 cell differentiation model.

AIM

To identify muscle atrophy in fetal neurogenic clubfoot by ultrasound imaging and detect the expression of TAZ and myostatin in gastrocnemius muscle. To elucidate the possible mechanisms by which TAZ antagonizes myostatin-induced atrophy in an in vitro cell model.

METHODS

Muscle atrophy in eight cases of fetal unilateral clubfoot with nervous system abnormalities was identified by 2D and 3D ultrasound. Western blotting and immunostaining were performed to detect expression of myostatin and TAZ. TAZ overexpression in C2C12 myotubes and the expression of associated proteins were analyzed by western blotting.

RESULTS

The maximum cross-sectional area of the fetal clubfoot on the varus side was reduced compared to the contralateral side. Myostatin was elevated in the atrophied gastrocnemius muscle, while TAZ expression was decreased. They were negatively correlated. TAZ overexpression reversed the diameter reduction of the myotube, downregulated phosphorylated Akt, and increased the expression of forkhead box O4 induced by myostatin.

CONCLUSION

Ultrasound can detect muscle atrophy of fetal clubfoot. TAZ and myostatin are involved in the pathological process of neurogenic clubfoot muscle atrophy. TAZ antagonizes myostatin-induced myotube atrophy, potentially through regulation of the Akt/forkhead box O4 signaling pathway.

Functional physiotherapy method results for the treatment of idiopathic clubfoot

BACKGROUND

Idiopathic clubfoot is a congenital deformity of multifactorial etiology. The initial treatment is eminently conservative; one of the methods applied is the Functional physiotherapy method (FPM), which includes different approaches: Robert Debré (RD) and Saint-Vincent-de-Paul (SVP) among them. This method is based on manipulations of the foot, bandages, splints and exercises adapted to the motor development of the child aimed to achieve a plantigrade and functional foot. Our hypothesis was that the SVP method could be more efficient than the RD method in correcting deformities, and would decrease the rate of surgeries.

AIM

To compare the RD and SVP methods, specifically regarding the improvement accomplished and the frequency of surgery needed to achieve a plantigrade foot.

METHODS

Retrospective study of 71 idiopathic clubfeet of 46 children born between February 2004 and January 2012, who were evaluated and classified in our hospital according to severity by the Dimeglio-Bensahel scale. We included moderate, severe and very severe feet. Thirty-four feet were treated with the RD method and 37 feet with the SVP method. The outcomes at a minimum of two years were considered as very good (by physiotherapy), good (by percutaneous heel-cord tenotomy), fair (by limited surgery), and poor (by complete surgery).

RESULTS

Complete release was not required in any case; limited posterior release was done in 23 cases (74%) with the RD method and 9 (25%) with the SVP method (P < 0.001). The percutaneous heel-cord tenotomy was done in 2 feet treated with the RD method (7%) and 6 feet (17%) treated with the SVP method (P < 0.001). Six feet in the RD group (19%) and twenty-one feet (58%) in the SVP group did not require any surgery (P < 0.001).

CONCLUSION

Our study provides evidence of the superiority of the SVP method over the RD method, as a variation of the FPM, for the treatment of idiopathic clubfoot.

Quantifying joint stiffness in clubfoot patients

BACKGROUND

In clinical practice, clubfeet feel stiffer compared to healthy feet. Furthermore, the clinical impression is that stiffer clubfeet have a higher tendency to relapse. Until now, no objective measure has been available to determine the stiffness of clubfeet. The goal of the current project was to objectively quantify ankle and subtalar joint stiffness in clubfeet patients and to compare this stiffness between clubfeet patients and healthy controls using a newly developed measurement device.

METHODS

The newly developed Torque-Displacement-Handpiece in combination with an adjusted Abduction Dorsiflexion Mechanism clubfoot-brace, made it possible to move a foot over two rotational axis, while continuously capturing the applied torque and the achieved angulation. Based on this information, stiffness of the ankle and subtalar joint were assessed for 11 clubfoot patients with 17 clubfeet and 11 healthy subjects with 22 healthy feet.

FINDINGS

With the Torque-Displacement-Handpiece measuring device it was possible to measure torque, angulation and stiffness in a reliable and precise manner. Clubfoot patients showed less angulation and a higher stiffness for measurements over the ADM subtalar axis compared to controls. After adjusting for shoe size, the stiffness for measurements over the ADM tibiotalar axis was also significantly higher in clubfeet than controls.

INTERPRETATION

Overall, these results indicate that clubfoot patients have a higher ankle and subtalar joint stiffness in the affected joint compared to healthy controls. In the future, the Torque-Displacement-Handpiece could be used to monitor stiffness of clubfeet during treatment, and as such, play a potential role in the early detection of relapsing clubfeet.

Arterial tree anomalies in patients with clubfoot: an investigation carried out at Soba University Hospital

Vascular deficiencies and reduced perfusion of the anterior tibial artery and the dorsalis pedis artery were suggested as causes of congenital talipes equino varus (CTEV). In this study, we assessed the prevalence of arterial abnormalities in patients with CTEV (50 patients; 74 feet) compared with a normal control group (16 patients; 32 feet) by Doppler ultrasound and Ankle Brachial Index. The flow was normal in the control group and was deficient in 39.19% of clubfoot patients. In severe clubfoot cases, the deficiency was found to an extent of 76.67%. In conclusion, the anterior tibial artery and dorsalis pedis artery are deficient in CTEV patients; to avoid postoperative skin sloughing, arterial supply must be protected using a judicious incision.

Deficient dorsalis pedis flow in severe idiopathic clubfeet: Does Ponseti casting affect the outcome?

BACKGROUND

Arterial deficiency in congenital clubfoot or congenital talipes equinovarus (CTEV) was postulated as either the primary cause of deformity or secondary manifestation of other bony and soft tissue abnormalities. The objectives of the study were to find any association between arterial deficiency with severity of CTEV and its treatment.

METHOD

This prospective study conducted on 24 feet with CTEV (18 babies) with Pirani score ranging between 2 to 6. Eighteen normal babies (36 feet) were selected as control. We used Color Doppler Ultrasound to assess dorsalis pedis and posterior tibial arteries before initiating the treatment. Second ultrasound was performed in study group upon completion of Ponseti treatment.

RESULTS

The patients were from one week to 15 weeks of life. Dorsalis pedis arterial flows were absent in 7 clubfeet (29.1%) while the remaining 17 clubfeet (70.8%) had normal flow. There was a significant association between Pirani severity score and vascular status in congenital clubfoot. There was a higher proportion of clubfeet having abnormal vascularity when the Pirani severity score was 5 and more. In study group, posterior tibial arteries were detectable and patent in all feet. All normal feet in control group had normal arterial flow. There was a significant difference in vascular flow before and after the Ponseti treatment (p 0.031).

CONCLUSION

The study concludes that there is an association between Pirani severity score and arterial deficiency in CTEV. Ponseti treatment is safe in CTEV with arterial deficiency and able to reconstitute the arterial flow in majority of cases.

The 2017 ABJS Nicolas Andry Award: Advancing Personalized Medicine for Clubfoot Through Translational Research

BACKGROUND

Clubfoot is one of the most common pediatric orthopaedic disorders. While the Ponseti method has revolutionized clubfoot treatment, it is not effective for all patients. When the Ponseti method does not correct the foot, patients are at risk for lifelong disability and may require more-extensive surgery.

QUESTIONS/PURPOSES

(1) What genetic and morphologic abnormalities contribute to the development of clubfoot? (2) How can this information be used to devise personalized treatment paradigms for patients with clubfoot?

METHODS

Human gene sequencing, molecular genetic engineering of mouse models of clubfoot, MRI of clubfoot, and development of new treatment methods all have been used by our group to understand the biological basis and improve therapy for this group of disorders.

RESULTS

We gained new insight into clubfoot pathogenesis from our discovery that mutations in the PITX1-TBX4-HOXC transcriptional pathway cause familial clubfoot and vertical talus in a small number of families, with the unique lower limb expression of these genes providing an explanation for the lack of upper extremity involvement in these disorders. MRI studies revealed corresponding morphologic abnormalities, including hypomorphic muscle, bone, and vasculature, that are not only associated with these gene mutations, but also are biomarkers for treatment-resistant clubfoot.

CONCLUSIONS

Based on an understanding of the underlying biology, we improved treatment methods for neglected and syndromic clubfoot, developed new treatment for congenital vertical talus based on the principles of the Ponseti method, and designed a new dynamic clubfoot brace to improve strength and compliance.

Factors associated with recurrence of clubfoot treated by the Ponseti method

AIM

To assess several associated factors on the recurrence of clubfoot after successful correction by the Ponseti method.

METHODS

A total of 115 children with 196 clubfeet deformities, treated by the Ponseti method, were evaluated. Demographic data, family history of clubfoot in first-degree relatives, maternal educational level and brace compliance were enquired. Based on their medical files, the characteristics of the patients at the time of presentation such as age, possible associated neuromuscular disease or especial syndrome, severity of the deformity according to the Dimeglio grade and Pirani score, residual deformity after previous Ponseti method and number of casts needed for the correction were recorded.

RESULTS

There were 83 boys (72.2%) and 32 girls (27.8%) with a male to female ratio of 2.6. The mean age at the initiation of treatment was 5.4 d (range: 1 to 60 d). The average number of casts applied to achieve complete correction of all clubfoot deformities was 4.2. Follow-up range was 11 to 60 mo. In total, 39 feet had recurrence with a minimum Dimeglio grade of 1 or Pirani score of 0.5 at the follow-up visit. More recurrence was observed in non-idiopathic clubfoot deformities (P = 0.001), non-compliance to wear braces (P < 0.001), low educational level of mother (P = 0.033), increased number of casts (P < 0.001), and more follow-up periods (P < 0.001). No increase in the possibility of recurrence was observed when the previous unsuccessful casting was further treated using the Ponseti method (P = 0.091). Also, no significant correlation was found for variables of age (P = 0.763), Dimeglio grade (P = 0.875), and Pirani score (P = 0.624) obtaining at the beginning of the serial casting.

CONCLUSION

Using the Ponseti method, non-idiopathic clubfoot, non-compliance to wear braces, low educational level of mother, increased number of casts and more follow-up periods had more association to possible increase in recurrence rate after correction of clubfoot deformity.

What is the fate of clubfoot patients treated by posteromedial release?

INTRODUCTION

Management and long-term results of operatively treated clubfoot deformity still remains controversial. The aim of this study was to evaluate the radiological and clinical results of adult clubfoot patients treated with posteromedial release.

MATERIALS AND METHODS

Between 2005 and 2012, we evaluated patients with congenital foot deformities regarding clubfoot who were operatively treated with complete posteromedial release. Out of 320 patients evaluated, 29 patients (40 feet) were included the study. We also included foot radiographies of 40 healthy adults. Talocalcaneal angle on the dorsoplantar projection (TC-DP) and lateral projection (TC-L) and talus-first metatarsal angle on the dorsoplantar projection (TFM-DP) were measured for both clubfeet and control groups. Laaveg-Ponseti functional rating system was used for clinical evaluation and measurement of lower leg circumference was used for detection of atrophy.

RESULTS

The average age was 21.5 years (range 19-34). The mean TC-DP angle was 16.97 in the clubfeet group and 21.03 in the control group. The mean TC-L angle was 23.34 in the clubfeet group and 33.98 in the control group. The mean TFM-DP angle was 9.02 in the clubfeet group and 7.9 in control group. There were statistically significant difference between clubfoot and control groups regarding the TC-DP angle and the TC-L angle. The average Laaveg-Ponseti score was 74 points (range 42-96). While no significant correlations could be detected between the TC-DP angle, the TC-L angle, the TFM-DP angle and the functional score, a significant correlation was detected between circumferential measurement of lower leg and functional score (p = 0.04).

CONCLUSION

Functional outcome may be affected by lower leg muscular atrophy instead of foot alignment disturbance. Lastly we believe that results for treatment of clubfoot-a three-dimensional deformity-need to be evaluated with three-dimensional imaging techniques.

Does the Ponseti technique affect the vascular development in patients with congenital talipes equinovarus?

In this study, we have evaluated the changes observed in the main arteries of the foot before and after the Ponseti technique. Arterial structures of seven patients were examined using Doppler ultrasound and the parameters studied included the course of the arteries, lumen filling, flow direction, pattern, and velocity. Before the treatment, the side with congenital talipes equinovarus deformity showed decreased blood flow in all arteries, except for the posterior tibial artery. At the second examination, the increase in the flow velocity of both arteries except tibialis anterior arteries was statistically significant. The Ponseti method results in normalization of the arterial structures in extremities with congenital talipes equinovarus.

Soft-Tissue Abnormalities Associated with Treatment-Resistant and Treatment-Responsive Clubfoot: Findings of MRI Analysis

BACKGROUND

Clubfoot treatment commonly fails and often results in impaired quality of life. An understanding of the soft-tissue abnormalities associated with both treatment-responsive and treatment-resistant clubfoot is important to improving the diagnosis of clubfoot, the prognosis for patients, and treatment.

METHODS

Twenty patients with clubfoot treated with the Ponseti method were recruited for magnetic resonance imaging (MRI) of their lower extremities. Among these were seven patients (six unilateral cases) with treatment-responsive clubfoot and thirteen patients (five unilateral cases) with treatment-resistant clubfoot. Demographic information and physical examination findings were recorded. A descriptive analysis of the soft-tissue abnormalities was performed for both patient cohorts. For the patients with unilateral clubfoot, we calculated the percentage difference in cross-sectional area between the affected limb and the unaffected limb in terms of muscle, subcutaneous fat, intracompartment fat, and total area. With use of the Wilcoxon signed-rank test, we compared inter-leg differences in cross-sectional areas and the intracompartment adiposity index (IAI) between treatment-responsive and treatment-resistant groups. The IAI characterizes the cross-sectional area of fat within a muscle compartment.

RESULTS

Extensive soft-tissue abnormalities were more present in patients with treatment-resistant clubfoot than in patients with treatment-responsive clubfoot. Treatment-resistant clubfoot abnormalities included excess epimysial fat and intramuscular fat replacement as well as unique patterns of hypoplasia in specific muscle groups that were present within a subset of patients. Among the unilateral cases, treatment-resistant clubfoot was associated with a significantly greater difference in muscle area between the affected and unaffected limb (-47.8%) compared with treatment-responsive clubfoot (-26.6%) (p = 0.02), a significantly greater difference in intracompartment fat area between the affected and unaffected limb (402.6%) compared with treatment-responsive clubfoot (9%) (p = 0.01), and a corresponding higher inter-leg IAI ratio (8.7) compared with treatment-responsive clubfoot (1.5) (p = 0.01).

CONCLUSIONS

MRI demonstrated a range of soft-tissue abnormalities in patients, including unique patterns of specific muscle-compartment aplasia/hypoplasia that were present in patients with treatment-resistant clubfoot and not present in patients with treatment-responsive clubfoot. Correlations between MRI, physical examination, and treatment responsiveness may aid in the development of a prognostic classification system for clubfoot.

LEVEL OF EVIDENCE

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

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.

3D MRI analysis of the lower legs of treated idiopathic congenital talipes equinovarus (clubfoot)

Background

Idiopathic congenital talipes equinovarus (CTEV) is the commonest form of clubfoot. Its exact cause is unknown, although it is related to limb development. The aim of this study was to quantify the anatomy of the muscle, subcutaneous fat, tibia, fibula and arteries in the lower legs of teenagers and young adults with CTEV using 3D magnetic resonance imaging (MRI), and thus to investigate the anatomical differences between CTEV participants and controls.

Methodology/Principal Findings

The lower legs of six CTEV (2 bilateral, 4 unilateral) and five control young adults (age 12–28) were imaged using a 3T MRI Philips scanner. 5 of the CTEV participants had undergone soft-tissue and capsular release surgery. 3D T1-weighted and 3D magnetic resonance angiography (MRA) images were acquired. Segmentation software was used for volumetric, anatomical and image analysis. Kolmogorov-Smirnov tests were performed. The volumes of the lower affected leg, muscle, tibia and fibula in unilateral CTEV participants were consistently smaller compared to their contralateral unaffected leg, this was most pronounced in muscle. The proportion of muscle in affected CTEV legs was significantly reduced compared with control and unaffected CTEV legs, whilst proportion of muscular fat increased. No spatial abnormalities in the location or branching of arteries were detected, but hypoplastic anomalies were observed.

Conclusions/Significance

Combining 3D MRI and MRA is effective for quantitatively characterizing CTEV anatomy. Reduction in leg muscle volume appears to be a sensitive marker. Since 5/6 CTEV cases had soft-tissue surgery, further work is required to confirm that the treatment did not affect the MRI features observed. We propose that the proportion of muscle and intra-muscular fat within the lower leg could provide a valuable addition to current clinical CTEV classification. These measures could be useful for clinical care and guiding treatment pathways, as well as treatment research and clinical audit.

Paralytic congenital talipes equinovarus of unknown origin: A new entity. Multicenter study of 42 cases

BACKGROUND

Paralysis of the lateral and/or anterior leg muscles can lead to relapse of treated talipes equinovarus.

HYPOTHESIS

The muscle function impairment is due to isolated permanent paralysis, and early palliative tendon transfer may prevent recurrence of the deformity.

MATERIAL AND METHODS

Forty-two cases of congenital talipes equinovarus that recurred after conservative therapy were reviewed after a mean follow-up of 10 years. In 39 cases, second-line surgery was performed (posteromedial release, n=33; and muscle transfer, n=26). Outcomes were evaluated clinically.

RESULTS

Separating the cases into two groups, based on whether muscle transfer was performed, showed a statistically significant difference: muscle transfer intended to restore eversion and/or dorsal flexion of the foot was associated with significantly better functional outcomes.

DISCUSSION

In addition to providing etiological insights, the identification of paralysis in patients with talipes equinovarus can influence treatment decisions, depending on the nature of the muscle deficiencies, with the goal of preventing recurrences. Early muscle transfer to restore eversion and/or dorsal flexion of the foot may provide the best functional outcomes by minimizing the need for soft-tissue release.

LEVEL OF EVIDENCE

IV, retrospective multicentre study.

Genetics of clubfoot

Modern advances in genetics have allowed investigators to identify the complex etiology of clubfoot. It has become increasingly apparent that clubfoot is a heterogeneous disorder with a polygenetic threshold model explaining its inheritance patterns. Several recent genetic studies have identified a key developmental pathway, the PITX1-TBX4 transcriptional pathway, as being important in clubfoot etiology. Both PITX1 and TBX4 are uniquely expressed in the hindlimb, which helps explain the foot phenotype seen with mutations in these transcription factors. Future studies are needed to develop animal models to determine the exact mechanisms by which these genetic abnormalities cause clubfoot and to test other hypotheses of clubfoot pathogenesis.

Pitx1 haploinsufficiency causes clubfoot in humans and a clubfoot-like phenotype in mice

Clubfoot affects 1 in 1000 live births, although little is known about its genetic or developmental basis. We recently identified a missense mutation in the PITX1 bicoid homeodomain transcription factor in a family with a spectrum of lower extremity abnormalities, including clubfoot. Because the E130K mutation reduced PITX1 activity, we hypothesized that PITX1 haploinsufficiency could also cause clubfoot. Using copy number analysis, we identified a 241 kb chromosome 5q31 microdeletion involving PITX1 in a patient with isolated familial clubfoot. The PITX1 deletion segregated with autosomal dominant clubfoot over three generations. To study the role of PITX1 haploinsufficiency in clubfoot pathogenesis, we began to breed Pitx1 knockout mice. Although Pitx1(+/-) mice were previously reported to be normal, clubfoot was observed in 20 of 225 Pitx1(+/-) mice, resulting in an 8.9% penetrance. Clubfoot was unilateral in 16 of the 20 affected Pitx1(+/-) mice, with the right and left limbs equally affected, in contrast to right-sided predominant hindlimb abnormalities previously noted with complete loss of Pitx1. Peroneal artery hypoplasia occurred in the clubfoot limb and corresponded spatially with small lateral muscle compartments. Tibial and fibular bone volumes were also reduced. Skeletal muscle gene expression was significantly reduced in Pitx1(-/-) E12.5 hindlimb buds compared with the wild-type, suggesting that muscle hypoplasia was due to abnormal early muscle development and not disuse atrophy. Our morphological data suggest that PITX1 haploinsufficiency may cause a developmental field defect preferentially affecting the lateral lower leg, a theory that accounts for similar findings in human clubfoot.