Patient-based outcomes after clubfoot surgery

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.

This is a narrative review of the functional evaluation of clubfoot treatment with gait analysis

Clinicians worldwide have embraced Ponseti’s nonoperative approach in the treatment of clubfoot, primarily due to ubiquitous reports of successful outcomes. A crucial component in this measured success, has come from researchers assessing long-term physical function following nonoperative treatment. Gait analysis has been instrumental in objectively evaluating lower extremity kinematics and kinetics while plantar pressures demonstrate the load bearing patterns experienced in the foot. As technology improves, our ability to evaluate function can take place both in the laboratory setting, and in the community. For over 20 years, our institution has been studying the gait patterns of children treated for clubfoot. After adopting the nonoperative approach, we established a prospective research program that has allowed us to study functional outcomes in the very young walker, through growth to adolescents, and finally at skeletal maturity. We have seen over 450 children treated for clubfoot in the Movement Science Lab, for over 1,250 gait assessments over the span of this study. Early results in 105 children (154 feet) treated nonoperatively for clubfoot, showed 56% of children had normal sagittal plane ankle kinematics, however an incidence of 48% of Ponseti feet had increased dorsiflexion in stance phase, leading us to wonder if this was the result of the tenotomy. Intermediate follow up at age 5 years, showed that the incidence of increased dorsiflexion was reduced (24%) and ankle power did not appear to be affected (P>0.05 compared to controls). The research highlighted in this paper presents the application of functional evaluation through growth and the long-term effects of nonoperative treatment on gait and function. This is a review of the functional outcome studies from our experience at Scottish Rite for Children.

Long-term outcomes of the Ponseti method for treatment of clubfoot: a systematic review

PURPOSE

The Ponseti method has revolutionized the clubfoot treatment and has been adopted globally in the past couple of decades. However, most reported results of the Ponseti method are either short or midterm. Studies reporting long-term outcomes of the Ponseti method are limited. The following systematic review aimed to provide a comprehensive overview of the published articles on long-term outcomes of the Ponseti method.

MATERIAL AND METHODS

A literature search was performed for articles published in electronic database PubMed (includes Medline) and Cochrane for broad keywords: "Clubfoot"; "Ponseti method/technique"; "long term outcomes/results." Studies selected included full-text articles in English language on children less than one year with primary idiopathic clubfoot treated by the Ponseti method with mean ten year follow-up. Non-idiopathic causes or syndromic clubfoot and case reports/review articles/meta-analyses were excluded. The following parameters were included for analysis: number of patients/clubfeet, male/female, mean age at treatment, mean/range of follow-up, relapses, additional surgery, range of motion, various outcome scores, and radiological variables.

RESULTS

Fourteen studies with 774 patients/1122 feet were included. The male:female ratio was 2.4:1. Mean follow-up recorded in studies was 14.5 years. Relapses occurred in 47% patients with additional surgery being required in 79% patients with relapses. Of these, 86% of surgery were extra-articular while 14% were intra-articular. Plantigrade foot was achieved in majority patients with mean ankle dorsiflexion of 11 degrees. The outcome scores were in general good in contrast to radiological angles which were mostly outside normal range with talar flattening/navicular wedging/degenerative osteoarthritis changes occurring in 60%, 76%, and 30%, respectively.

CONCLUSIONS

Long-term follow-up of infants with primary idiopathic clubfeet treated by the Ponseti method revealed relatively high relapse and additional surgery rates. Radiologically, the various angles were inconsistent compared to normal ranges and anatomical deformations/degenerative changes were present in treated feet. Moreover, the relapse rates and requirement of additional surgery increased on long-term follow-up. Despite this, majority feet were plantigrade and demonstrated good clinical results as measured by various outcome tools. There should be emphasis on long-term follow-up of children with clubfeet in view of late relapses and secondary late changes.

A survey on idiopathic congenital talipes equinovarus (ICTEV) managed by the Ponseti technique at Mulago Hospital - Uganda

Introduction

Ponseti technique is the treatment of choice for idiopathic congential talipes equino varus (ICTEV) since 1950s with excellent treatment outcomes reported worldwide. However, despite the popularity of this technique, Uganda adapted it as a treatment modality for ICTEV in May 2005. Since then, the effectiveness of delivered Ponseti care to children with this very common orthopaedic deformity under the supervision of an orthopaedic surgeon was unknown. The implication of this undertaking was that, satisfactory outcomes would then support the Ministry of Health (MOH)-Uganda´s decision to embrace this mode of treatment and if the outcomes were unsatisfactory, MOH would then consider a policy revision in this regard. To assess the midterm treatment outcomes of children with ICTEV who had been enrolled for treatment at Mulago National Referral Hospital in the period of 2006-2009.

Methods

in November/December 2013, a cross-sectional study was conducted to assess the treatment outcomes of 68 feet of 45 children using the designed questionnaire and the PBS score; a pilot study of 10 neonates was performed prior to research. A good treatment outcome meant having a foot or feet that did not require any major or minor surgery.

Results

forty-five (45) children with 68 ICTEV feet were evaluated; males 29 (64.4%) and 16 (35.6%) females with a mean age of 73.22 months (SD 11.364, range 48-96 months). Among the feet assessed, 46 (68%) had good to excellent outcomes while 22 (32%) had a relapse of moderate and severe deformity. Good functionality was seen in 61.8% out of which, 69% and 55.9% had no limitation in walking or running respectively.

Conclusion

Ponseti treatment technique in children with ICTEV under the care of predominantly orthopaedic officers with some supervision from orthopaedic surgeons had fair to good midterm outcomes even in low resource settings like Uganda. Public health approach should be embraced in the management of clubfoot in Uganda by enhancing adequate comprehensive support supervision and establishment of reliable institutionalized systems for patient follow up which will lead to early detection and treatment of relapsed ICTEV cases or neglected clubfeet in the communities.

Foot function during gait and parental perceived outcome in older children with symptomatic club foot deformity

Aims

To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population.

Methods

In all, 73 children with idiopathic club foot were included: 31 children treated with the Ponseti method (mean age 8.3 years; 24 male; 20 bilaterally affected, 13 left and 18 right sides analyzed), and 42 treated with primary surgical correction (mean age 11.6 years; 28 male; 23 bilaterally affected, 18 left and 24 right sides analyzed). Foot function data was collected during walking gait and included Oxford Foot Model kinematics (Foot Profile Score and the range of movement and average position of each part of the foot) and plantar pressure (peak pressure in five areas of the foot). Oxford Ankle Foot Questionnaire, Disease Specific Index for club foot, Paediatric Quality of Life Inventory 4.0 were also collected. The gait data were compared between the two club foot groups and compared to control data. The gait data were also correlated with the data extracted from the questionnaires.

Results

Our findings suggest that symptomatic children with club foot deformity present with similar degrees of gait deviations and perceived disability regardless of whether they had previously been treated with the Ponseti Method or surgery. The presence of sagittal and coronal plane hindfoot deformity and coronal plane forefoot deformity were associated with higher levels of perceived disability, regardless of their initial treatment.

Conclusion

This is the first paper to compare outcomes between Ponseti and surgery in a symptomatic older club foot population seeking further treatment. It is also the first paper to correlate foot function during gait and perceived disability to establish a link between deformity and subjective outcomesCite this article: Bone Joint Open 2020;1-7:384-391.

A systematic review of reported outcomes following Ponseti correction of idiopathic club foot

AIMS

To analyze outcomes reported in studies of Ponseti correction of idiopathic clubfoot.

METHODS

A systematic review of the literature was performed to identify a list of outcomes and outcome tools reported in the literature. A total of 865 studies were screened following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 124 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Each outcome tool was assigned to one of the five core areas defined by the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT). Bias assessment was not deemed necessary for the purpose of this paper.

RESULTS

In total, 20 isolated outcomes and 16 outcome tools were identified representing five OMERACT domains. Most outcome tools were appropriately designed for children of walking age but have not been embraced in the literature. The most commonly reported isolated outcomes are subjective and qualitative. The quantitative outcomes most commonly used are ankle range of motion (ROM), foot position in standing, and muscle function.

CONCLUSIONS

There is a diverse range of outcomes reported in studies of Ponseti correction of clubfoot. Until outcomes can be reported unequivocally and consistently, research in this area will be limited. Completing the process of establishing and validating COS is the much-needed next step.Cite this article: Bone Joint Open 2020;1-8:457-464.

Clubfoot treatment with Ponseti method-parental distress during plaster casting

Background

Clubfoot is one of the most prevalent musculoskeletal congenital defects. Gold standard treatment of idiopathic clubfoot is the conservative Ponseti method, including the reduction of deformity with weekly serial plaster casting and percutaneous Achilles tenotomy. It is well known that parents of children with severe and chronic illnesses are mentally stressed, but in recent studies regarding clubfoot treatment, parents were only asked about their satisfaction with the treatment. Largely unknown is parental distress before and during plaster casting in clubfoot.

Therefore, we want to determinate first, how pronounced the parents’ worries are before treatment and if they decrease during the therapy. Second, we hypothesized that parents faced with an extreme deformity (high Pirani score), reveal more distress, than parents whose children have a less pronounced deformity (low Pirani score). Therefore, we wanted to investigate whether the Pirani score correlates with the parents’ mental resilience in relation to the therapy of the child as a global distress parameter.

Methods

To answer this question, we developed a questionnaire with the following emphases: Physical capacity, mental resilience, motion score, parents score, and child score with point scores 1 (not affected) to 6 (high affected). Subsequently, we interviewed 20 parents whose children were treated with clubfeet and determined the Pirani score of the infants at the beginning (T₀) and at the end (T_E) of the treatment with plaster casting.

Results

High values were obtained in child score (Mean (M) = 3.11), motion score (M = 2.63), and mental resilience (M = 2.25). During treatment, mental resilience improved (p = 0.015) significantly. Spearman correlation coefficient between Pirani score (T₀) and mental resilience (T₀) is 0.21, so the initial hypothesis had to be rejected.

Conclusion

The issues of the children are in the focus of parental worries concerning clubfoot treatment, especially the assumed future motion and the assumed ability to play with other children. Particular emphasis should be placed on educating parents about the excellent long-term results in the function of the treated feet especially as this topic shows the greatest parental distress.

Nwdps protocol - A simple functional outcome assessment tool for clubfoot correction and a review of literature

INTRODUCTION

Various clubfoot severity scoring systems are known to us. Dimeglio and Pirani Scoring systems are most widely used. Also, various treatment outcome measures have been proposed by researchers to assess patient satisfaction and results of treatment. None of the available methods are widely popular and amenable for routine use. A "nwdps protocol" was proposed for functional assessment of patients with clubfoot correction, where "n" was no pain during walking or running; "w" was ability to wear normal shoes; "d" was no significant difference in foot/shoe size of both sides; "p" was plantigrade foot and "s" was ability of the child to squat without heel lift-off. The aim of this study was to test this functional outcome assessment tool for easy day to day use post clubfoot correction.

METHODS

The nwdps protocol was applied to all the children at followup on a yearly basis who underwent clubfoot deformity correction in Department of Orthopaedics of our Institute between March 2016 and January 2018.

RESULTS

Eighty children were enrolled for the study, 45 had bilateral affection while 35 had unilateral affection. In all 125 feet were treated for clubfoot correction and evaluated using nwdps protocol. Each child was assessed by 2 researchers independently. There was no difference in functional assessment of 2 observers. Fifty-nine children were nwdp positive, one was nwps positive, while 2 were dwps positive at the end of 1 year. 79 children became nwdps positive at the end of 2nd year of followup.

CONCLUSION

Nwdps protocol is a very easy to remember and easy to use functional outcome assessment tool post clubfoot correction with high degree of objectivity and interobserver reliability.

LEVEL OF EVIDENCE

Level IV.

Plantar flexion, dorsiflexion, range of movement and hindfoot deviation are important determinants of foot function in children

PURPOSE

Paediatric foot surgery is often performed to restore anatomical shape or range of movement (ROM). The purpose of this study was to determine how foot morphology and ROM are associated with foot function in children aged five to 16 years of age.

METHODS

Participants included 89 patients with foot disorders and 58 healthy controls. In addition to measuring children's foot alignment and ankle ROM, children and parents completed the Oxford Ankle and Foot Questionnaire (OxAFQ).

RESULTS

Mean age was 10.3 years for patients and 10.6 years for controls; 53 of 89 patients had clubfoot. All foot measurements and scores on the OxAFQ significantly differed (p < 0.001) between patients and controls. Patients and their parents significantly differed on the physical (p = 0.03) and emotional (p = 0.02) domains of the OxAFQ, with parents' ratings being lower than their children. Moderate correlations (r = 0.54 to 0.059; p < 0.001) were found between physical domain (reported by parents on the OxAFQ) and dorsiflexion-knee flexed, and foot- arc-of-movement. Moderate correlations were found between physical domain (reported by children on OxAFQ) and foot-arc-of-movement (r = 0.56; p < 0.001). Patients in the surgical group showed moderate correlations (r = 0.57;, p < 0.001) between physical domain (reported by children on OxAFQ) and plantar flexion, and foot arc-of-movement. The control group and the patients in non-surgical subgroup showed no significant correlations.

CONCLUSION

Plantar flexion, arc of ankle ROM and hindfoot alignment impact foot function in children with foot deformities. Parents report significantly lower scores on the OxAFQ when judging foot functioning.

LEVEL OF EVIDENCE

Level II. Prognostic Studies.

Additional challenges in children with idiopathic clubfoot: is it just the foot?

PURPOSE

Treatment of idiopathic clubfoot (IC) has improved since the introduction of the Ponseti method. However, relapses are still common and primarily related to non-adherence to the brace regime. Our hypothesis was that IC might be more than just a structural deformity. Based on three studies, the aim of this paper was to provide an overview of findings regarding additional challenges within IC.

METHODS

In total, 153 children with IC and 137 control children participated in the studies. The first study assessed gross motor skills in six motor tasks using the Clubfoot Assessment Protocol. The second and third studies surveyed neurodevelopmental difficulties (NDDs) using the Five to Fifteen (FTF) questionnaire and health-related quality of life (HRQoL) using the EuroQol-5D youth.

RESULTS

A high percentage of gross motor deviations were found in children with IC compared with controls, and those correlated poorly with clubfoot severity and foot movement. Children with IC had a higher prevalence of NDDs on the FTF compared with the control group, including the domains: motor skills, perception and language. One-third of children with IC were defined as at risk of developmental disorders. In this subgroup, parents were less satisfied with the outcome of clubfoot treatment and the children reported worse HRQoL than those without NDDs.

CONCLUSION

The findings suggest additional challenges in children with IC, such as NDDs, apparently affecting both clubfoot treatment outcome and HRQoL. Thus, awareness of these challenges could be vital to further optimize treatment and support, for example, with regards to brace adherence.

LEVEL OF EVIDENCE

II - Prognostic study.

Evaluation of a simple tool to assess the results of Ponseti treatment for use by clubfoot therapists: a diagnostic accuracy study

Background

We aimed to develop and evaluate a tool for clubfoot therapists in low resource settings to assess the results of Ponseti treatment of congenital talipes equinovarus, or clubfoot, in children of walking age.

Method

A literature review and a Delphi process based on the opinions of 35 Ponseti trainers in Africa were used to develop the Assessing Clubfoot Treatment (ACT) tool and score. We followed up children with clubfoot from a cohort treated between 2011 and 2013, in 2017. A full clinical assessment was conducted to decide if treatment was successful or if further treatment was required. The ACT score was then calculated for each child. Inter-observer variation for the ACT tool was assessed. Sensitivity, specificity, positive and negative predictive values were calculated for the ACT score compared to full clinical assessment (gold standard). Predictors of a successful outcome were explored.

Results

The follow up rate was 31.2% (68 children). The ACT tool consisted of 4 questions; each scored from 0 to 3, giving a total from 0 to 12 where 12 is the ideal result. The 4 questions included one physical assessment and three parent reported outcome measures. It took 5 min to administer and had excellent inter-observer agreement.

An ACT score of 8 or less demonstrated 79% sensitivity and 100% specificity in identifying children that required further intervention, with a positive predictive value of 100% and negative predictive value of 90%. Children who completed two or more years of bracing were four times more likely to achieve an ACT score of 9 or more compared to those who did not (OR: 4.08, 95% CI: 1.31–12.65, p = 0.02).

Conclusions

The ACT tool is simple to administer, had excellent observer agreement, and good sensitivity and specificity in identifying children who need further intervention. The score can be used to identify those children who definitely need referral and further treatment (score 8 or less) and those with a definite successful outcome (score 11 or more), however further discrimination is needed to decide how to manage children with a borderline ACT score of 9 or 10.

Level of evidence

Level II, Diagnostic Study.

Electronic supplementary material

The online version of this article (10.1186/s13047-019-0323-4) contains supplementary material, which is available to authorized users.

A comparison of outcome measures used to report clubfoot treatment with the Ponseti method: results from a cohort in Harare, Zimbabwe

Background

There are various established scoring systems to assess the outcome of clubfoot treatment after correction with the Ponseti method. We used five measures to compare the results in a cohort of children followed up for between 3.5 to 5 years.

Methods

In January 2017 two experienced physiotherapists assessed children who had started treatment between 2011 and 2013 in one clinic in Harare, Zimbabwe. The length of time in treatment was documented. The Roye score, Bangla clubfoot assessment tool, the Assessing Clubfoot Treatment (ACT) tool, proportion of relapsed and of plantigrade feet were used to assess the outcome of treatment in the cohort. Inter-observer variation was calculated for the two physiotherapists. A comparative analysis of the entire cohort, the children who had completed casting and the children who completed more than two years of bracing was undertaken. Diagnostic accuracy was calculated for the five measures and compared to full clinical assessment (gold standard) and whether referral for further intervention was required for re-casting or surgical review.

Results

31% (68/218) of the cohort attended for examination and were assessed. Of the children who were assessed, 24 (35%) had attended clinic reviews for 4–5 years, and 30 (44%) for less than 2 years. There was good inter-observer agreement between the two expert physiotherapists on all assessment tools. Overall success of treatment varied between 56 and 93% using the different outcome measures. The relapse assessment had the highest unnecessary referrals (19.1%), and the Roye score the highest proportion of missed referrals (22.7%). The ACT and Bangla score missed the fewest number of referrals (7.4%). The Bangla score demonstrated 79.2% (95%CI: 57.8–92.9%) sensitivity and 79.5% (95%CI: 64.7–90.2%) specificity and the ACT score had 79.2% (95%CI: 57.8–92.9%) sensitivity and 100% (95%CI: 92–100%) specificity in predicting the need for referral.

Conclusion

At three to five years of follow up, the Ponseti method has a good success rate that improves if the child has completed casting and at least two years of bracing. The ACT score demonstrates good diagnostic accuracy for the need for referral for further intervention (specialist opinion or further casting). All tools demonstrated good reliability.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2365-3) contains supplementary material, which is available to authorized users.

Casting Is Effective for Recurrence Following Ponseti Treatment of Clubfoot

BACKGROUND

Up to 40% of patients with idiopathic clubfoot who are treated with the Ponseti method experience recurrence of deformity. Many of these patients receive surgery (e.g., anterior tibial tendon transfer). An alternative approach for recurrent clubfoot is repeat Ponseti casting. The purpose of this study was to evaluate the outcome of repeat Ponseti casting in the treatment of recurrent clubfoot.

METHODS

Patients with recurrent idiopathic clubfoot who were treated at our hospital, between 2004 and 2012, with repeat serial casting and bracing (the recurrent group) were eligible for inclusion in the study. The recurrent group and a control group of randomly selected patients seen during the same period who had not had recurrence were compared with respect to demographic data, age at the time of treatment, number of casts, subsequent surgical intervention(s), and the Disease-Specific Instrument (DSI) clubfoot scale. Patients were deemed to have a successful outcome if they had a well-corrected foot (defined as dorsiflexion of ≥10°, hindfoot in valgus, and a straight lateral border) at the time of follow-up.

RESULTS

Of a total of 71 eligible patients with clubfeet, 35 patients participated. At the time of follow-up, success rates were 74% for the recurrent group and 83% for the control group. Dorsiflexion past neutral was significantly higher in the control group than the patient group (20° versus 12°, respectively; p < 0.001). Ninety-five percent of the control subjects had a straight lateral border in comparison with 78% in the recurrent group (p = 0.004). Likewise, 97% of controls had the hindfoot in valgus in comparison with 80% of the recurrent group (p = 0.02). There was a significant difference in the ability to squat (76% in the control group and 43% in the recurrent group; p = 0.03). There was no difference between groups in the total outcome of the DSI.

CONCLUSIONS

Recurrence was seen in 19% (71) of 382 children who were eligible for our study who were typically discharged after the age of 5 years from our clinic, indicating the importance of continued follow-up until after that age. Treatment with casting was successful in many patients and may be a reasonable choice for recurrent idiopathic clubfeet.

LEVEL OF EVIDENCE

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

What is a good result after clubfoot treatment? A Delphi-based consensus on success by regional clubfoot trainers from across Africa

BACKGROUND

Congenital talipes equino-varus (CTEV), also known as clubfoot, is one of the most common congenital musculoskeletal malformations. Despite this, considerable variation exists in the measurement of deformity correction and outcome evaluation. This study aims to determine the criteria for successful clubfoot correction using the Ponseti technique in low resource settings through Africa.

METHODS

Using the Delphi method, 18 experienced clubfoot practitioners and trainers from ten countries in Africa ranked the importance of 22 criteria to define an 'acceptable or good clubfoot correction' at the end of bracing with the Ponseti technique. A 10cm visual analogue scale was used. They repeated the rating with the results of the mean scores and standard deviation of the first test provided. The consistency among trainers was determined with the intra-class correlation coefficient (ICC). From the original 22 criteria, ten criteria with a mean score >7 and SD <2 were identified and were rated through a second Delphi round by 17 different clubfoot treatment trainers from 11 countries in Africa. The final definition consisted of all statements that achieved strong agreement, a mean score of >9 and SD<1.5.

RESULTS

The consensus definition of a successfully treated clubfoot includes: (1) a plantigrade foot, (2) the ability to wear a normal shoe, (3) no pain, and (4) the parent is satisfied. Participants demonstrated good consistency in rating these final criteria (ICC 0.88; 0.74,0.97).

CONCLUSIONS

The consistency of Ponseti technique trainers from Africa in rating criteria for a successful outcome of clubfoot management was good. The consensus definition includes basic physical assessment, footwear use, pain and parent satisfaction.

Assessment of success of the Ponseti method of clubfoot management in sub-Saharan Africa: a systematic review

Background

Clubfoot is one of the most common congenital deformities affecting mobility. It leads to pain and disability if untreated. The Ponseti method is widely used for the correction of clubfoot. There is variation in how the result of clubfoot management is measured and reported. This review aims to determine and evaluate how success with the Ponseti method is reported in sub-Saharan Africa.

Methods

Five databases were examined in August 2017 for studies that met the inclusion criteria of: (1) evaluation of the effect of clubfoot management; (2) use of the Ponseti method; (3) original study undertaken in sub-Saharan Africa; (4) published between 2000 and 2017. We used the PRISMA statement to report the scope of studies. The included studies were categorised according to a hierarchy of study methodologies and a 27-item quality measure identified methodological strengths and weaknesses. The definition of success was based on the primary outcome reported.

Results

Seventy-seven articles were identified by the search. Twenty-two articles met the inclusion criteria, of which 14 (64%) reported a primary outcome. Outcomes were predominantly reported though case series and the quality of evidence was low. Clinical assessment was the most commonly reported outcome measure and few studies reported long-term outcome. The literature available to assess success of clubfoot management is characterised by a lack of standardisation of outcomes, with different measures reporting success in 68% to 98% of cases.

Conclusion

We found variation in the criteria used to define success resulting in a wide range of results. There is need for an agreed definition of good outcome (successful management) following both the correction and the bracing phases of the Ponseti method to establish standards to monitor and evaluate service delivery.

Electronic supplementary material

The online version of this article (10.1186/s12891-017-1814-8) contains supplementary material, which is available to authorized users.

Inferior results with unilateral compared with bilateral brace in Ponseti-treated clubfeet

PURPOSE

The Ponseti method for treating clubfoot was introduced in Norway in 2003, and a cohort of children has been followed for 8 to 11 years. In a previous study, we found good results after follow-up of two to five years, with 3% rate of extensive surgery (posterior release or posteromedial release). During 8 to 11 years of follow-up, the rate of extensive surgery increased to 11%. The children had been treated with a bilateral brace or a unilateral brace. In this multicentre study we aimed to compare these two post-corrective treatment methods.

METHODS

In all, 94 children (133 feet) were initially treated according to the Ponseti method, and had post-corrective treatment with either a bilateral foot abduction brace or a unilateral above-the-knee brace. The children were examined at a mean age of 9.3 years (8 to 11) regarding flexibility and deformity of the foot and ankle. Information including type of brace, brace compliance and surgical procedures was -obtained from the patient records. The parents answered questionnaires and radiographs were taken of the feet.

RESULTS

Feet treated with a bilateral brace had better dorsal flexion (p = 0.008), plantar flexion (p = 0.02), external rotation (p = 0.001) and less forefoot adduction (p = 0.04) than feet treated with a unilateral brace. Children using a bilateral brace had a better Functional Rating System score (p = 0.005) and Disease Specific Instrument score (p = 0.02).

CONCLUSION

Children treated with a bilateral brace had better parent-reported outcomes and more flexible feet than children treated with a unilateral brace. Our results do not support the use of a unilateral foot abduction brace in clubfoot treatment.

Ponseti method compared to previous treatment of clubfoot in Norway. A multicenter study of 205 children followed for 8-11 years

PURPOSE

Despite few studies comparing Ponseti treatment and traditional treatment of clubfoot (talipes equinovarus), the Ponseti method is now accepted as standard treatment for this deformity. The Ponseti method was introduced in Norway in 2003 and the purpose of this multicenter-study was to compare the results of Ponseti treatment with the results of the previous treatment for clubfoot in Norway.

METHODS

90 children (134 clubfeet) treated with previous treatment (pre-Ponseti group), were compared to 115 Ponseti treated children (160 clubfeet) (Ponseti group). The previous treatment consisted of casting and surgery if needed. At 8-11 years of age, all children were examined by the same orthopaedic surgeon, the parents answered a questionnaire, all feet were X-rayed and information about surgical procedures was obtained from the patient records.

RESULTS

The number of surgeries was higher in the pre-Ponseti group, and the number of extensive surgeries was 119 in the pre-Ponseti group compared to 19 in the Ponseti group. The range of motion in the ankle joint was better in the Ponseti group. Children in this group had better function, higher satisfaction and less pain according to patient and parent reported outcome measures. The incidence of moderate or severe talar flattening was higher in the pre-Ponseti group.

CONCLUSION

Ponseti treatment seems to be superior to the previous treatment in Norway, with regards to number and severity of operations, flexibility of the foot and ankle, parent/patient reported outcome and the presence of talar flattening on X-ray.

The Bangla clubfoot tool: a repeatability study

Background

‘Walk for Life’ (WFL) is the sustainable clubfoot program in Bangladesh, where there are many challenges in implementing the Ponseti technique in a poor and highly populated country. The relapsing tendency of congenital clubfoot deformity means that initial results may well differ from those of the medium and longer term. Over 10000 children with16668 clubfeet have been treated by WFL since its inception in 2009. Such a large project provides both the need to evaluate each individual child’s case, and also the opportunity to evaluate the wider WFL program results. Such systematic review requires a measure that is sufficiently robust, yet contextually practical, hence the aim of this work was to develop a tool for this purpose, and to report the examiner reliability.

Methods

The Bangla clubfoot tool was largely developed from components of existing validated clubfoot assessment measures, and adapted for local use. Three areas of examination are included: parent satisfaction, gait, clinical examination of the clubfoot. A same-subject repeated measures study design was used to assess the intra-rater reliability of a local WFL physiotherapist, and a visiting WFL volunteer. The inter-rater reliability was also assessed, which is relevant for other examiners and other clubfoot projects undertaking evaluation of medium and longer term results.

Results

The reliability study was conducted in 37 children who had commenced treatment for congenital clubfoot deformity using Ponseti method within the previous two years. The mean age of the children was 2.6 years, with gender 28 male: 9 female. The intra-rater reliability results [ICCs (95% CI)] were: 0.87 (0.76 – 0.93) for the local WFL examiner, and 0.82 (0.64 – 0.91) for the visiting examiner. Inter-rater reliability results [ICCs (95% CI)] were: 0.92 (0.88 – 0.96). Hence the tool showed very good intra-rater and inter-rater reliability, rendering it suitable for use.

Conclusions

The Bangla clubfoot tool has been developed to suit the context of the large WFL clubfoot program in Bangladesh, and shown to be a very reliable evaluation instrument.

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.

Is tibialis anterior tendon transfer effective for recurrent clubfoot?

BACKGROUND

Tibialis anterior tendon transfer surgery forms a part of Ponseti management for children with congenital talipes equinovarus who, after initial correction, present with residual dynamic supination. Although retrospective studies support good outcomes, prospective longitudinal studies in this population are lacking.

QUESTIONS/PURPOSES

We assessed strength, plantar loading, ROM, foot alignment, function, satisfaction, and quality of life in patients with clubfoot that recurred after Ponseti casting who met indications for tibialis anterior tendon transfer surgery, and compared them with a group of patients with clubfoot treated with casting but whose deformity did not recur (therefore who were not indicated for tibialis anterior tendon transfer surgery).

METHODS

Twenty children with idiopathic congenital talipes equinovarus indicated for tibialis anterior tendon transfer surgery were recruited. Assessment at baseline (before surgery), and 3, 6, and 12 months (after surgery) included strength (hand-held dynamometry), plantar loading (capacitance transducer matrix platform), ROM (Dimeglio scale), foot alignment (Foot Posture Index(©)), function and satisfaction (disease-specific instrument for clubfoot), and quality of life (Infant Toddler Quality of Life Questionnaire™). Outcomes were compared with those of 12 age-matched children with congenital talipes equinovarus not indicated for tibialis anterior tendon transfer surgery. Followup was 100% in the control group and 95% (19 of 20) in the tibialis anterior transfer group.

RESULTS

At baseline, the tibialis anterior tendon transfer group had a significantly worse eversion-to-inversion strength ratio, plantar loading, ROM, foot alignment, and function and satisfaction. At 3 months after surgery, eversion-to-inversion strength, plantar loading, and function and satisfaction were no longer different between groups. Improvements were maintained at 12 months after surgery (eversion-to-inversion strength mean difference, 8% body weight; 95% CI, -26% to 11%; p = 0.412; plantar loading, p > 0.251; function and satisfaction, p = 0.076). ROM remained less and foot alignment more supinated in the tibialis anterior tendon transfer group between baseline and followup (p < 0.001, p < 0.001).

CONCLUSIONS

Tibialis anterior tendon transfer surgery was an effective procedure, which at 12-month followup restored the balance of eversion-to-inversion strength and resulted in plantar loading and function and satisfaction outcomes similar to those of age-matched children with congenital talipes equinovarus who after Ponseti casting were not indicated for tibialis anterior tendon transfer.

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.

Midterm results of the Ponseti method in the treatment of congenital clubfoot

PURPOSE

The Ponseti method has become the gold standard for clubfoot treatment. Although promising short-term results have been published, only a few studies report results at the end of the bracing period. We aimed to evaluate the functional midterm results, rate of recurrence and need for subsequent surgery.

METHODS

Patients from our prospective database of clubfeet treated with the Ponseti method with a minimum age of three years were identified. Exclusion criteria were syndrome or neurogenic association, address in a foreign country, presentation after six weeks of age, more than three casts applied elsewhere and correction with less than three casts. A total of 125 patients met the inclusion criteria. The Pediatric Outcomes Data Collection Instrument (PODCI), the disease-specific instrument (DSI) questionnaire and an invitation for a clinical examination were sent out. For patients not presenting for evaluation, data from the last follow-up were extracted.

RESULTS

Seventy questionnaires (56 %) of patients with a mean age of 5.7 years (3.3-8.9 years) were returned. The DSI score (n = 65) was 85.3 (± 13.01 SD) and the PODCI score (n = 59) was 95.5 (± 6.3 SD). A total of 113 of 125 patients (90.4 %) with 182 clubfeet were examined in the study or seen in follow-up. During a mean follow-up of 5.2 years (range 3-8.5 years) a repeat tenotomy was performed in 4 % of cases, a percutaneous Achilles tendon lengthening in 3 %, a tibialis anterior tendon transfer in 13 % and open joint surgery in 5 %. The mean dorsiflexion with knee extended was 15.9° (range 0-32°; SD ± 5.5) with 16 feet (9 %) presenting less than 10°.

CONCLUSIONS

The functional scores indicate that the Ponseti method results in mostly pain-free feet not limiting age-appropriate activity. In this consecutive case series open joint surgery could be avoided in 95 % of cases with a good functional and anatomic outcome.

A comprehensive outcome comparison of surgical and Ponseti clubfoot treatments with reference to pediatric norms

PURPOSE

Isolated congenital clubfoot can be treated either operatively (posteromedial release) or conservatively (Ponseti method). This study retrospectively compared mid-term outcomes after surgical and Ponseti treatments to a normal sample and used multiple evaluation techniques, such as detailed gait analysis and foot kinematics.

METHODS

Twenty-six children with clubfoot treated surgically and 22 children with clubfoot treated with the Ponseti technique were evaluated retrospectively and compared to 34 children with normal feet. Comprehensive evaluation included a full gait analysis with multi-segment and single-segment foot kinematics, pedobarograph, physical examination, validated outcome questionnaires, and radiographic measurements.

RESULTS

The Ponseti group had significantly better plantarflexion and dorsiflexion range of motion during gait and had greater push-off power. Residual varus was present in both treatment groups, but more so in the operative group. Gait analysis also showed that the operative group had residual in-toeing, which appeared well corrected in the Ponseti group. Pedobarograph results showed that the operative group had significantly increased varus and significantly decreased medial foot pressure. The physical examination demonstrated significantly greater stiffness in the operative group in dorsiflexion, plantarflexion, ankle inversion, and midfoot abduction and adduction. Surveys showed that the Ponseti group had significantly more normal pediatric outcome data collection instrument results, disease-specific indices, and Dimeglio scores. The radiographic results suggested greater equinus and cavus and increased foot internal rotation profile in the operative group compared with the Ponseti group.

CONCLUSIONS

Ponseti treatment provides superior outcome to posteromedial release surgery, but residual deformity still persists.

Ponseti treatment for idiopathic clubfoot: minimum 5-year followup

Ponseti clubfoot treatment has become more popular during the last decade. We reviewed the medical records of 74 consecutive infants (117 club feet) who underwent Ponseti treatment. Minimum followup was 5 years (mean, 6.3 years; range, 5-9 years). We studied age at presentation, previous treatment, the initial severity score of the Pirani scoring system, number of casts, need for Achilles tenotomy or other surgical procedures, and brace use. We measured final ankle motion and parents' perception of outcome. Late presentation and previous non-Ponseti treatment were associated with lower initial severity score, fewer casts, and less need for tenotomy. Forty-four percent of patients had poor brace use. We observed better brace use (75%) in babies who presented late for treatment. Good brace use predicted less need for extensive surgical procedures. Twenty-four (32%) babies underwent additional surgical procedures other than tenotomy, including 21% who underwent tibialis anterior tendon transfer. At followup, 89% of feet had adequate dorsiflexion (5 degrees or greater). Parents indicated high satisfaction with the treatment results. Ankle motion was not associated with parents' satisfaction. The Ponseti method is effective, even if treatment starts late or begins after failure at other centers. Brace use influenced the success of treatment.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Evaluation of a disease-specific instrument for idiopathic clubfoot outcome

In 2001, Roye et al. developed a disease-specific instrument (DSI) to measure outcomes of treatment for clubfoot. We assessed this instrument using a cohort of 62 patients, ages 5 through 12 years (mean, 8.6 years), with idiopathic clubfoot who were treated as infants by various methods. Treatment groups were defined by whether the patient received joint-invasive surgery (posterior or posteromedial release surgery) or joint-sparing treatment only (manipulation and casting with or without tendo-Achilles lengthening or anterior tibial tendon transfer). The DSI scales demonstrated internal consistency reliability of 0.74 to 0.85 using Cronbach's alpha. Higher (better) DSI scores were associated with "excellent" general health ratings and better health-related quality of life; lower DSI score were related to special healthcare needs. Patients treated using joint-sparing techniques only (eg, Ponseti technique) had higher DSI scores than those who had received joint-invasive surgery. DSI scores for patients who had received posterior or posterior medial release surgery were very similar to those reported by Roye et al. in New York for a comparable group of patients. Our findings suggest the DSI is sensitive to differences in treatment technique or underlying severity of disease. These data support the use of the Roye DSI as an outcome measure for idiopathic clubfoot in children.

LEVEL OF EVIDENCE

Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Clinico-radiological assessment and their correlation in clubfeet treated with postero-medial soft-tissue release

The controversy regarding the radiographic parameter which best represents the various deformities of clubfoot continues. The aim of our study was to clear up this controversy. Fifty surgically treated (soft-tissue release) congenital clubfeet were studied clinically using Laaveg and Ponseti score and radiologically using twelve different radiographic parameters in weight-bearing AP and lateral views. The talo-calcaneal angle (TCA) in AP and lateral view showed statistically significant correlation with the functional rating, but significant variation in the dimension of the angles among the different functional groups was found with AP angle only. The talo-first metatarsal angle in AP and lateral view averaged 10 degrees and 19 degrees respectively, and showed significant correlation with the functional rating. The talo-navicular subluxation in AP, the calcaneo-fifth metatarsal angle and the first-fifth metatarsal angle in lateral view did not show any significant correlation with function. Talo-calcaneal index averaged 44 degrees in the clubfeet and showed significant correlation. The wide range of parameters representing each of the deformities gives a better radiological assessment of the clubfoot than any single parameter.

Patient-based outcomes after Ilizarov surgery in resistant clubfeet

We present the results of clinical evaluation and patient-based outcomes after Ilizarov surgery in resistant clubfeet (grade D clubfeet, Dimeglio-Bensahel system). This is a retrospective study of 26 resistant clubfeet in 23 children who were managed by the Ilizarov technique. The average age of the patients at the time of the operation was 9 years and the average follow-up period was 47 months. A calcaneal or mid-foot osteotomy followed by bony distraction was undertaken in nine feet and a soft-tissue distraction, with or without soft-tissue release, was undertaken in 17 feet. Clinical evaluation of the degree of correction of the deformity and functional evaluation, using patient-based questionnaires, were used in assessing the outcome in these patients. Patient-based outcomes give useful information about the functional status following surgery, complementing the objective assessment by the surgeon. Clinical evaluation revealed stiff, plantigrade feet in nine patients and a recurrent deformity after initial correction in the remaining 14 patients. The patient-based outcomes were good to excellent in 52% for satisfaction, 57% for cosmesis, 48% for walking and 73% for teasing (made fun of because of the shape of foot), showing that the functional results were better in these patients in spite of a poor surgical outcome.

Validity and responsiveness of the Clubfoot Assessment Protocol (CAP). A methodological study

Background

The Clubfoot Assessment Protocol (CAP) is a multi dimensional instrument designed for longitudinal follow up of the clubfoot deformity during growth. Item reliability has shown to be sufficient. In this article the CAP's validity and responsiveness is studied using the Dimeglio classification scoring as a gold standard.

Methods

Thirty-two children with 45 congenital clubfeet were assessed prospectively and consecutively at ages of new-born, one, two, four months and two years of age.

For convergent/divergent construct validity the Spearman's correlation coefficients were calculated. Discriminate validity was evaluated by studying the scores in bilateral clubfeet. The floor-ceiling effects at baseline (untreated clubfeet) and at two years of age (treated clubfeet) were evaluated. Responsiveness was evaluated by using effect sizes (ES) and by calculating if significant changes (Wilcoxons signed test) had occurred between the different measurement occasions.

Results

High to moderate significant correlation were found between CAP mobility I and morphology and the Dimeglio scores (r_s = 0.77 and 0.44 respectively). Low correlation was found between CAP muscle function, mobility II and motion quality and the Dimeglio scoring system (r_s = 0.20, 0.09 and 0.06 respectively). Of 13 children with bilateral clubfeet, 11 showed different CAP mobility I scores between right and left foot at baseline (untreated) compared with 5 with the Dimeglio score. At the other assessment occasions the CAP mobility I continued to show higher discrimination ability than the Dimeglio. No floor effects and low ceiling effects were found in the untreated clubfeet for both instruments. High ceiling effects were found in the CAP for the treated children and low for the Dimeglio.

Responsiveness was good. ES from untreated to treated ranged from 0.80 to 4.35 for the CAP subgroups and was 4.68 for the Dimeglio. The first four treatment months, the CAP mobility I had generally higher ES compared with the Dimeglio.

Conclusion

The Clubfoot Assessment Protocol shows in this study good validity and responsiveness. The CAP is more responsive when severity ranges between mild – moderate to severe, while the Dimeglio focuses more on the extremes. The ability to discriminate between different mobility status of the right and left foot in bilaterally affected children in this population was higher compared with the Dimeglio score implicating a better sensitivity for the CAP.

The clubfoot assessment protocol (CAP); description and reliability of a structured multi-level instrument for follow-up

BACKGROUND

In most clubfoot studies, the outcome instruments used are designed to evaluate classification or long-term cross-sectional results. Variables deal mainly with factors on body function/structure level. Wide scorings intervals and total sum scores increase the risk that important changes and information are not detected. Studies of the reliability, validity and responsiveness of these instruments are sparse. The lack of an instrument for longitudinal follow-up led the investigators to develop the Clubfoot Assessment Protocol (CAP). The aim of this article is to introduce and describe the CAP and evaluate the items inter- and intra reliability in relation to patient age.

METHODS

The CAP was created from 22 items divided between body function/structure (three subgroups) and activity (one subgroup) levels according to the International Classification of Function, Disability and Health (ICF). The focus is on item and subgroup development. Two experienced examiners assessed 69 clubfeet in 48 children who had a median age of 2.1 years (range, 0 to 6.7 years). Both treated and untreated feet with different grades of severity were included. Three age groups were constructed for studying the influence of age on reliability. The intra- rater study included 32 feet in 20 children who had a median age of 2.5 years (range, 4 months to 6.8 years). The Unweighted Kappa statistics, percentage observer agreement, and amount of categories defined how reliability was to be interpreted.

RESULTS

The inter-rater reliability was assessed as moderate to good for all but one item. Eighteen items had kappa values > 0.40. Three items varied from 0.35 to 0.38. The mean percentage observed agreement was 82% (range, 62 to 95%). Different age groups showed sufficient agreement. Intra- rater; all items had kappa values > 0.40 [range, 0.54 to 1.00] and a mean percentage agreement of 89.5%. Categories varied from 3 to 5.

CONCLUSION

The CAP contains more detailed information than previous protocols. It is a multi-dimensional observer administered standardized measurement instrument with the focus on item and subgroup level. It can be used with sufficient reliability, independent of age, during the first seven years of childhood by examiners with good clinical experience.A few items showed low reliability, partly dependent on the child's age and /or varying professional backgrounds between the examiners. These items should be interpreted with caution, until further studies have confirmed the validity and sensitivity of the instrument.