The current management of idiopathic clubfoot revisited: results of a survey of the POSNA membership

Caregiver Impressions of Bracing and Its Association With Unsuccessful Outcomes Throughout the Ponseti Treatment

BACKGROUND

Clubfoot is a common congenital foot deformity, occurring in about 1 in 1000 live births. The Ponseti method consists of weeks of manipulation and serial casting, followed by years of orthotic wear. Recurrent or relapse deformity following the Ponseti method remains a challenging problem for many patients. Many studies have attributed relapse to noncompliance with the treatment plan, particularly during the maintenance phase. Many patient risk factors have been studied and attributed to recurrent deformity, but less emphasis has been placed on aspects of the treatment method from the caregiver's perspective.

METHODS

From 2010 to 2014, 127 patients between 1 and 354 days old who had been diagnosed with clubfoot were recruited for the parent study. At the initial visit, and each subsequent follow-up, the primary caregiver was given a questionnaire that included 21 binary belief questions exploring his or her experience with the Ponseti method. Univariate analyses were performed to find any relationship with caregiver responses and either clinical recurrence of the deformity or overall failure of treatment.

RESULTS

Of the recruited patients, 126 were enrolled in the parent study and 100 were able to complete the full 3-year follow-up. Patient demographics and characteristics (sex, race, family history of clubfoot, laterality, and severity of deformity) were similar. Statistical analysis of the questionnaire responses found that choosing "yes" for either "I don't feel the braces are necessary" or "I am not comfortable with applying and removing the braces" was associated with significantly increased risk of overall failure.

CONCLUSIONS

Gathering insight from the caregiver's perspective can help identify barriers to treatment not recognized by the provider. Lack of comfortability with the orthosis and lack of understanding are associated with increased risk of overall failure. A better understanding of the caregiver's perspective on barriers to treatment could help guide the Ponseti method provider's educational efforts.

LEVEL OF EVIDENCE

Level III.

Initial clubfoot treatment in Sweden from 2016 to 2019: A national register study

BACKGROUND

This study aimed to describe the initial treatment of clubfoot deformity in Sweden using a national cohort. Secondarily we aimed to analyse the results of the initial treatment in relation to foot severity and additional diseases.

METHODS

A national register, the Swedish Pediatric Orthopedic Quality Register, was used to extract data on children born with clubfoot in 2016-2019. Children with a registered evaluation after initial treatment were included. Data on deformity severity (Pirani score), casting treatment, and achillotenotomy were extracted. For children with bilateral clubfeet, one foot was included in the analysis.

RESULTS

A total of 565 children were included in the analysis. Of these, 73% were boys and 47% had bilateral clubfeet. Children with isolated clubfoot required a median of six casts to correct the deformity, while children with non-isolated clubfoot needed a median of eight casts. Seventy-seven percent underwent an achillotenotomy. Residual deformities of 0.5 or above (often soft-tissue issues) according to the Pirani score were noted in 23% (isolated clubfoot) and 61% (non-isolated clubfoot) after initial treatment.

CONCLUSIONS

We have described the initial clubfoot treatment of children born with isolated or non-isolated clubfoot in Sweden based on data from a national register. The initial treatment was performed to a large extent according to the Ponseti method and international recommendations. Moreover, we discuss the usefulness of the Pirani score in classifying clubfoot deformity after treatment.

Duration and outcome of orthotic treatment in children with clubfoot - a four-year follow-up national register study of Swedish children born between 2015 and 2017

BACKGROUND

The Ponseti method for treating clubfoot consists of initial treatment with serial casting accompanied by achillotenotomy if needed, followed by the maintenance phase including treatment with a foot abduction orthosis (FAO) for at least four years. This study aimed to examine the duration, course, and outcome of orthotic treatment in children with clubfoot.

METHODS

321 children with clubfoot, born between 2015 and 2017, registered in the Swedish Pediatric Orthopedic Quality Register (SPOQ), were included in this prospective cohort study. Data on deformity characteristics and orthotic treatment were extracted. For children with bilateral clubfoot, one foot was included in the analysis.

RESULTS

Of the 288 children with isolated clubfoot, 274 children (95.5%) were prescribed an FAO, and 100 children (35%) changed orthosis type before 4 years of age. Of the 33 children with non-isolated clubfoot, 25 children (76%) were prescribed an FAO, and 21 children (64%) changed orthosis type before 4 years of age. 220 children with isolated clubfoot (76%), and 28 children with non-isolated clubfoot (84%) continued orthotic treatment until 4 years of age or longer. Among children with isolated clubfoot, children ending orthotic treatment before 4 years of age (n = 63) had lower Pirani scores at birth compared to children ending orthotic treatment at/after 4 years of age (n = 219) (p = 0.01). It was more common to change orthosis type among children ending orthotic treatment before 4 years of age (p = 0.031).

CONCLUSIONS

The majority of children with clubfoot in Sweden are treated with an FAO during the maintenance phase. The proportion of children changing orthosis type was significantly greater and the Pirani score at diagnosis was lower significantly among children ending orthotic treatment before 4 years of age. Long-term follow-up studies are warranted to fully understand how to optimize, and individualize, orthotic treatment with respect to foot involvement and severity of deformity.

LEVEL OF EVIDENCE

II.

Prospective, Randomized Ponseti Treatment for Clubfoot: Orthopaedic Surgeons Versus Physical Therapists

BACKGROUND

Clubfoot is a common congenital foot deformity in children. The Ponseti method of serial casting has become the standard of care in clubfoot treatment. Clubfoot casting is performed in many centers by both orthopaedic surgeons and physical therapists (PTs); however, direct comparison of outcomes and complications of this treatment between these providers is limited. This study prospectively compared the outcomes of patients with clubfoot treated by these 2 groups of specialists.

METHODS

Between January 2010 and December 2014, all patients under the age of 12 months with a diagnosis of clubfoot were included. Patients were randomized to an orthopaedic surgeon (MD) group or a PT group for weekly serial casting. Main outcome measures included the number of casts required to achieve correction, clinical recurrence of the deformity, and the need for additional surgical intervention.

RESULTS

One hundred twenty-six infants were included in the study. Patient demographics and characteristics (sex, race, family history of clubfoot, laterality, and severity of deformity) were similar between treatment groups, with the only significant difference being the mean age of entry into the study (5.2 weeks in the MD group and 9.2 weeks in the PT group, P=0.01). Mean length of follow-up was 2.6 years. The number of casts required trended to a lower number in the MD group. There was no significant difference in the rates of clinical recurrence or additional surgical intervention between groups.

CONCLUSIONS

Ponseti casting for treatment of clubfoot performed by orthopaedic surgeons and PTs results in equivalent outcomes without any difference in complications. Although the number of casts required trended to a lower number in the MD group, this likely did not result in any clinical significance, as the difference in cast number equaled <1 week's difference in the overall duration of serial casting.

LEVEL OF EVIDENCE

Level I-therapeutic.

Three-dimensional gait analysis in children with recurrent idiopathic clubfoot undergoing complete tibialis anterior tendon transfer

This study was aimed to evaluate the kinetics and kinematics of the foot and ankle using three-dimensional gait analysis in children with recurrent clubfoot treated with tibialis anterior tendon transfer (TATT). Three-dimensional gait analysis of 17 children with dynamic supination (24 feet; 12 males; mean age: 6.34 years) was performed pre- and post-TATT. Spatial, temporal and kinematic parameters, as well as the gait deviation index (GDI), were recorded for all patients. Moreover, to evaluate the severity of dynamic supination during walking, we also measured the angle between the plane of the foot and the X-axis during the swing phase (V-angle-S). The postoperative step length (38.95 ± 8.36 cm) and stride length (76.73 ± 15.92 cm) were significantly smaller than their preoperative values (40.68 ± 9.35 cm and 80.57 ± 17.51 cm; P = 0.0316 and P = 0.0028, respectively). The postoperative peak internal ankle rotation angle in the frontal plane (20.45° ± 14.44) was significantly lower than the preoperative value (25.93° ± 9.84; P = 0.029). The postoperative peak internal foot progression angle in the transverse plane (0.96° ± 5.83) was significantly lower than the preoperative value (4.34° ± 8.88; P = 0.026). However, both the peak ankle varus moment and GDI were not significantly different between the pre- and postoperative data. Postoperative V-angle-S values (28.55° ± 7.56) were reduced compared to their preoperative values (32.52° ± 6.53; P = 0.0094). TATT to the lateral cuneiform can correct dynamic supination in patients with a recurrent clubfoot; however, it has limited or no effects on hindfoot varus deformity. Level of evidence: Level III.

The foot drawing method: reliability of measuring foot length and outward rotation in children with clubfoot

Background

The Ponseti method is the gold standard for clubfoot treatment. However, relapse and residual gait deviations are common, and follow-up until 7 years of age is recommended. We evaluated the reliability of the foot drawing method, a new instrument for the follow-up of clubfoot. The method uses drawings of the foot in the neutral position and external rotation to measure foot length and outward rotation.

Methods

Nineteen children aged 2.5–7 years who were treated with the Ponseti method for congenital clubfoot were included. Two raters made the drawings twice (D1 and D2). Each rater measured foot length, foot rotation, and foot–tibial rotation independently (D1). Later, the raters repeated the measurements (D2). Interrater reliability was assessed using the D1 from each rater. Intrarater reliability was assessed using the measurements from each rater’s D1 and D2. Bland–Altman plots were used to visualize the limits of agreement (LoA). The mean, 95% confidence interval, and one standard deviation of the differences in all measurements were calculated.

Results

The mean differences between and within raters were: foot length < 1 mm, foot rotation < 1°, and foot–tibia rotation < 2°, which indicated no systematic differences. The LoA for foot length were: 4.5 mm and 5.9 mm between raters for D1, − 4.8 mm and 5.9 mm for rater 1 (D1–D2), and − 5.1 mm and 5 mm for rater 2 (D1–D2). The LoA for foot rotation: were − 12° and 10.6° between raters (D1), − 8.4° and 6.6° for rater 1 (D1–D2), and − 14° and 14.1° for rater 2 (D1–D2). The LoA for foot–tibia rotation were: − 17.8° and 14.3° between raters (D1), − 12° and 12.2° for rater 1 (D1–D2), and − 12.7° and 13.6° for rater 2 (D1– D2).

Conclusions

The absence of systematic differences between and within raters, and LoA observed indicate that the foot drawing method is applicable in clinical practice and research. However, the results of the foot and foot–tibia rotation analyses imply that caution is needed when interpreting changes in foot rotation in feet with higher degrees of rotation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05465-9.

Romanian patients' access to clubfoot treatment services

The number of clubfoot new cases in Romania is on the rise. According to orthopedic research, the Ponseti method is the elective treatment for clubfeet. This paper aims to provide an overview of the current facilitators and barriers in accessing clubfoot treatment services in Romania and to assess the impact of care-related factors on patients’ well-being. Our research shows that nationally, few orthopedic surgeons are using the Ponseti method and most of them are concentrated only in Cluj-Napoca. Moreover, gynecologists, neonatologists, and family physicians were not informed about the initial diagnosis and the current treatment of clubfoot. Primary medical care was significantly postponed in some cases. Moreover, no clubfoot organizations were mentioned by the parents included in the study, and psychological support was provided neither for the parents nor for the children. Based on the results of our study, we conclude that more efforts need to be done for the diagnosis and treatment of children with clubfeet. These include actions which are focused on raising awareness around this abnormality and more well-developed treatment guidelines.

Long-term follow-up of children with a surgically treated clubfoot: Assessing the multi-segment-foot motions, dynamic plantar pressures, and functional outcomes

OBJECTIVE

The purpose of this study was to compare surgically treated clubfoot with typically developing (TD) children using plantar pressure, multi-segment-foot kinematic analysis, and multiple functional outcomes in comprehensive and long-term study. Methods: 26 patients with 45 clubfeet and 23 TD children with 45 normal feet were evaluated. Most clubfoot patients had a complete subtalar release and a few patients had a posterior medial-lateral release at the mean age of 5 years and 6 months. The mean age at follow-up for clubfoot was 12 years and 5 months. Subjects underwent physical and radiographic examination, plantar pressure analysis, multi-segment-foot motion analysis, AAOS Foot & Ankle Questionnaire (AAOS-FAQ), the Pediatric Outcomes Data Collection Instrument (PODCI), and the Child Behavior Checklist (CBCL).

RESULTS

Clubfoot patients scored significantly worse than TD on the AAOS-FAQ (90.9 vs.99.9 for pain and comfort), the CBCL Problems scale (23.1 vs.6.3), and several subscales of the PODCI (86.5 vs.96.7 for Sports and Physical Functioning) (P<0.05). Peak pressure at the lateral heel (25.6 vs.29.6 N/cm²), contact area at the 1 st metatarsal head (1 st MT) (6.0 vs. 7.2 cm²) and the pressure time integral at the 1 st MT (5.2 vs. 11.0 N/cm² ∗ s) were significantly lower for the clubfoot group compared to the TD foot group (P<0.05). Maximum dorsiflexion of the 1 st metatarsal-hallux (1 st MT-Hal) (17.5° vs. 34.8°) during stance phase (ST), supination of the 1 st MT-Hal during swing phase (SW) (4° vs. 7°), maximum plantarflexion of the ankle during ST (-6.8° vs.-11.2°), and maximum varus of the ankle during SW (4.4° vs. 6.9°) were also lower for clubfoot except for maximum dorsiflexion of the navicular-1 st MT (P<0.05).

CONCLUSION

This study supports evidence that surgically treated clubfoot continues to have residual deformity of forefoot, overcorrection of hindfoot, stiffness, and a decrease in physical functioning. This comprehensive study accurately portrays postsurgical clubfoot function with objective means through appropriate technologies. A plantar pressure redistributed and finite element analysis designed orthosis may be of importance in the improvement of the foot and ankle joint function for ambulatory children with a relapse of clubfoot deformity.

The Treatment of Recurrent Congenital Clubfoot

The Ponseti method for treatment of congenital clubfoot is well established and has been introduced in most pediatric orthopedic centers worldwide. However, reported rates of recurrence are largely variable and open joint surgery is still performed frequently, even in the age group younger than 6 years of age. Preventing recurrence and residual deformity can be achieved by strict adherence to the Ponseti method, ensuring and enforcing brace compliance, frequent follow-up, and early treatment of recurrence. This review discusses reasons for clubfoot recurrence, prevention of clubfoot recurrence, and the treatment of recurrent congenital clubfoot within the realm of the Ponseti method.

Ponseti treated idiopathic clubfoot - outcome predictive factors in the test of time: analysis of 500 feet followed for five to 20 years

PURPOSE

To investigate a set of risk factors on the outcome of Ponseti treated idiopathic clubfeet (ICF).

METHODS

This study was approved by the institutional review board. A retrospective analysis of prospectively gathered data over a 20-year period, at a single dedicated clubfoot clinic. Records of 333 consecutive infants with 500 ICF were analyzed. Initial Pirani score, number of casts, need for tenotomy, foot abduction brace compliance and functional score had been documented. The need for surgery after initial correction was the outcome measure. All children were followed by the same team throughout the study period. Descriptive statistics, chi-squared and multivariate analysis were performed.

RESULTS

In total, 82 children (24%) with 119 feet (23.8%) were operated on, with 95.1% of feet being operated up to the age of nine years. There was a significant correlation between the Pirani score at presentation and the number of surgical procedures (chi-squared = 79.32; p < 0.001). Achilles tenotomy was done in 94.8% of patients. Pirani score of > 4.5 before casting was strongly associated with increased surgical risk (odds ratio = 1.95). When six to eight cast changes were needed, surgical prospect was 2.9 more, increasing to 11.9 when nine or more casts were needed.

CONCLUSION

Foot severity and number of cast changes were the strongest predictors for future surgery. Estimation of the risk of deformity recurrence after initial correction may help in tailoring a cost-effective personal treatment and follow-up protocol. Personalized focused protocol will help patients and caregivers and will reduce expenses.

LEVEL OF EVIDENCE

Level II - prognostic study.

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.

Ponseti Casting vs. Soft Tissue Release for the Initial Treatment of Non-idiopathic Clubfoot

Purpose: Ponseti casting has universally been accepted as the gold standard for treatment of idiopathic clubfoot. Conversely, primary treatment for non-idiopathic clubfoot has not been established. The purpose of this study is to compare treatment outcomes following primary soft tissue release (STR) and Ponseti casting of non-idiopathic clubfoot.

Methods: An IRB-approved retrospective study of patients treated for non-idiopathic clubfoot between 2005 and 2020 was conducted. Patients were included if they began treatment before the age of 2 and had at least 1 year of follow up. Patients were placed into either the STR group or Ponseti group and variables of interest were documented including reoccurrence of deformity, number of surgeries performed, type of surgeries performed, anesthesia time, and surgery time. Data was analyzed using Mann-Whitney U test for continuous variables.

Results: A total of 33 children with 57 neuromuscular/syndromic clubfoot were identified of which 9 (15 feet) were treated with STR and 24 (42 feet) were treated with Ponseti casting. Average anesthesia and surgery time were found to be 291 and 179 min, respectively, for the STR group, and 113 and 67 min for the Ponseti group. The difference in operating time was determined to be significant (p = 0.02, p = 0.01). Patients treated with STR were found to have significantly more surgeries performed over the course of treatment than those treated with Ponseti casting (p = 0.001) with an average of 4.2 surgeries in the STR group and 1.5 surgeries in the Ponseti group. Extracapsular procedures were performed in 100% of the STR group and 97.6% of the Ponseti group (p = 0.55). Intracapsular procedures were performed in 100% of the STR group and 50% of the Ponseti group (p = 0.001).

Conclusion: The Ponseti method should serve as the primary approach in the initial treatment of non-idiopathic clubfoot as it can reduce the risk of future invasive intracapsular surgery and shorten anesthesia and surgery times when surgical treatment is necessary.

Level of Evidence: Level III retrospective case control study.

Idiopathic clubfoot treatment and heterogeneity of current therapeutic strategies: The Ponseti method versus the French functional method (a systematic review)

BACKGROUND

Since Hippocrates, the treatment of idiopathic clubfoot has undergone many changes, with surgical techniques and conservative approaches evolving over the centuries. Today, a wide variety of practices exist in France and throughout the world; consequently, the treatment of idiopathic clubfoot remains controversial, but the Ponseti method and the functional method seem to stand out. Nevertheless, has one of them demonstrated superiority?

METHODS

The purpose of this review is to compare these two methods. Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 recommendations, this research was conducted on Pubmed, Web of Science, and 1Findr. Only articles concerning patients with moderate or severe idiopathic clubfoot (10-17 on the Dimeglio scale) treated early using the Ponseti method or the functional method were eligible.

RESULTS

After reviewing 49 studies, seven published between 2008 and 2018 were selected: five prospective cohort studies, one retrospective cohort study, and one meta-analysis. Each method, according to morphological and kinetic criteria, seems to have advantages that the other does not have.

CONCLUSIONS

Although the Ponseti method is becoming the gold standard and appears more appropriate in poor countries, it is impossible to affirm its superiority over the functional method. Therefore, the combination of their advantages deserves attention: a hybrid method could be an appealing prospect for the future.

Radiological tarsal bone morphology in adolescent age of congenital clubfeet treated with the Ponseti method

BACKGROUND

Major abnormalities of tarsal bone shape after surgical clubfoot treatment are well known from the literature. The Ponseti method has gained widespread acceptance in primary treatment of congenital clubfeet. Despite the longtime experience, data regarding the development of tarsal bones after this treatment are still rare. The aim of the study was therefore to evaluate radiographic parameters describing tarsal bone shape of clubfeet after Ponseti treatment and compare them to age-matched healthy feet.

METHODS

Twenty two consecutive severe clubfeet in 14 patients were investigated by repeated diagnostic ultrasound during the corrective process. Extent and temporal course of correction were documented with standardized X-rays after a mean follow-up of 12 years (between the ages of 10-14 years) and compared to a group of age-matched normal feet.

RESULTS

Reliability testing for all X-ray parameters showed good to excellent results. In comparison to the control group, all parameters except the radius of the trochlea (RT) were significantly altered in clubfeet with highest differences shown for the anterior talar motion segment (ATM), talonavicular coverage (TNC) and the talometatarsal index (TMT-Index). Differentiation between minor and major deformities showed significant differences only for the front tarsal index (FTI).

CONCLUSIONS

Tarsal bone shape of clubfeet treated by the Ponseti method differs significantly from normal feet. One of the most pronounced and clinically relevant difference of the clubfoot talus compared to the normal talus is the markedly reduced anterior talar motion segment.

A retrospective study of idiopathic clubfoot managed by Ponseti method using Pirani and Dimeglio scoring, in Indian population: a minimum 3-year follow-up

Congenital talipo-equino-varus (CTEV) is one of the most common congenital deformities affecting children in India with an incidence of 1.19/1000 live births. Ponseti treatment regimen has been established as the gold standard of care for idiopathic clubfoot. We present quantitative and qualitative analysis of the results of Ponseti management in early presenting idiopathic clubfoot cases, with a minimum follow-up of three years after correction. We retrospectively analysed the data of 122 children (comprising a total of 191 feet) who were treated for clubfoot by the standard Ponseti method with a minimum 3-year follow-up post-correction at our clinic. All cases were treated under the supervision of a single senior Paediatric Orthopaedic Surgeon. The mean age at onset of treatment was 2.3 months. Mean follow-up period was 4.2 years. The mean number of casts applied was 6.7. The mean duration of treatment until the application of splint was 9.5 weeks. The mean Pirani score at the commencement of treatment was 4.5. At the completion of treatment (around 3.6 years of age), the Dimeglio score was 'Benign' (Good) in 106 cases, 'Moderate' (Fair) in 11 cases and 'Severe/Very Severe' (Poor) in 5 cases. The P-value was calculated to be 0.8 for the sex-wise comparison of the treatment outcome. Ponseti method of nonoperative treatment for idiopathic clubfeet remains a gold standard for all cases treated during infancy. Identifying atypical clubfeet is important as their prognosis ought to be guarded. Despite facing problems at various stages of management, adhering to the basic treatment principles laid down by Ponseti helps in achieving good outcomes in majority. Level of Evidence: IV.

A presença do pé torto congênito atrasa o início da marcha?

Objetivo O pé torto congênito (PTC) é uma das alterações ortopédicas congênitas que mais frequentemente necessita tratamento intensivo, e pouco se sabe o impacto desse tratamento no desenvolvimento motor. O presente estudo buscou avaliar se pacientes portadores de PTC tratados pelo método de Ponseti desenvolvem a marcha mais tardiamente comparado a um grupo controle e analisar possíveis fatores relacionados.

Métodos Incluídos pacientes nascidos a termo, com < 6 meses de idade, sem tratamento prévio e com seguimento mínimo de 24 meses. O grupo controle foi de pacientes sem alterações musculoesqueléticas, atendidos no mesmo período da realização do presente estudo.

Resultados Um total de 97 pacientes formaram o grupo de estudo e 100 o grupo controle. A média de idade no início da marcha no grupo de estudo foi de 14,7 ± 3,2 meses, e 12,6 ± 1,5 meses (p < 0,05) no grupo controle. Fatores relacionados à marcha tardia foram: idade de início do tratamento > 3 semanas, número de trocas gessadas > 7, recidiva e não realização da tenotomia de Aquiles. Idade de início do tratamento > 3 semanas esteve relacionada a maior número de trocas de gessos. Gênero e lateralidade não tiveram relação com a marcha tardia.

Conclusão Pacientes com PTC tratados com o método de Ponseti apresentam marcha independente aproximadamente 2 meses mais tarde do que o grupo controle. Início mais tardio do tratamento, maior número de trocas de gessos, recidiva e não realização da tenotomia de Aquiles foram relacionados com atraso da marcha.

Relapse Rates in Patients with Clubfoot Treated Using the Ponseti Method Increase with Time: A Systematic Review

BACKGROUND

The Ponseti method is the preferred technique to manage idiopathic clubfoot deformity; however, there is no consensus on the expected relapse rate or the percentage of patients who will ultimately require a corrective surgical procedure. The objective of the present systematic review was to determine how reported rates of relapsed deformity and rates of a secondary surgical procedure are influenced by each study's length of follow-up.

METHODS

A comprehensive literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed to identify relevant articles. The definition of relapse, the percentage of patients who relapsed, the percentage of feet that required a surgical procedure, and the mean duration of follow-up of each study were extracted. Pearson correlations were performed to determine associations among the following variables: mean follow-up duration, percentage of patients who relapsed, percentage of feet that required a joint-sparing surgical procedure, and percentage of feet that required a joint-invasive surgical procedure. Logarithmic curve fit regressions were used to model the relapse rate, the rate of joint-sparing surgical procedures, and the rate of joint-invasive surgical procedures as a function of follow-up time.

RESULTS

Forty-six studies met the inclusion criteria. Four distinct definitions of relapse were identified. The reported relapse rates varied from 3.7% to 67.3% of patients. The mean duration of follow-up was strongly correlated with the relapse rate (Pearson correlation coefficient = 0.44; p < 0.01) and the percentage of feet that required a joint-sparing surgical procedure (Pearson correlation coefficient = 0.59; p < 0.01). Studies with longer follow-up showed significantly larger percentages of relapse and joint-sparing surgical procedures than studies with shorter follow-up (p < 0.05).

CONCLUSIONS

Relapses have been reported to occur at as late as 10 years of age; however, very few studies follow patients for at least 8 years. Notwithstanding that, the results indicated that the rate of relapse and percentage of feet requiring a joint-sparing surgical procedure increased as the duration of follow-up increased. Longer-term follow-up studies are required to accurately predict the ultimate risk of relapsed deformity. Patients and their parents should be aware of the possibility of relapse during middle and late childhood, and, thus, follow-up of these patients until skeletal maturity may be warranted.

LEVEL OF EVIDENCE

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

Suture Button Technique for Tibialis Anterior Tendon Transfer for the Treatment of Residual Clubfoot

BACKGROUND

The Ponseti method has revolutionized the treatment of idiopathic clubfoot, but recurrence remains problematic. Dynamic supination is a common cause of recurrence, and the standard treatment is tibialis anterior tendon transfer using an external button. Although safe and effective, the placement of the button on the sole creates a pressure point, which can lead to skin ulceration. In our institution, a suture button has been used for the tibialis anterior tendon transfer and we report our results here.

METHODS

Two senior authors' case logs were retrospectively reviewed to identify 23 patients (34 feet) for tibialis anterior tendon transfer using a suture button. Complications and additional operative procedures were assessed by reviewing operative notes, follow-up visit clinic notes, and radiographs. The mean age of the patients was 6 years 2 months (SD 40 months) and the average follow-up duration was 67.1 weeks (SD 72 weeks).

RESULTS

There were 5 complications (14.7%). Recurrence occurred bilaterally in 1 patient (5.9%) but did not require reoperation. Other complications included a cast-related pressure sore (2.9%) and an infection (2.9%) requiring irrigation with debridement along with hardware removal.

CONCLUSIONS

Tibialis anterior tendon transfer using a suture button was a safe procedure with theoretical advantage of providing stronger fixation and reducing the risk of skin pressure necrosis compared to the standard external button technique. We believe a suture button could allow earlier rehabilitation and may afford stronger ankle eversion. Prospective studies are required to compare the differences in functional outcomes between the procedures.

LEVEL OF EVIDENCE

Level IV, case series, therapeutic study.

Brace Yourselves: Outcomes of Ponseti Casting and Foot Abduction Orthosis Bracing in Idiopathic Congenital Talipes Equinovarus

BACKGROUND

Foot abduction orthoses (FAO) are believed to decrease recurrence following treatment of congenital talipes equinovarus (CTEV) as described by Ponseti. The purpose of this project is to examine the outcomes of FAO bracing following treatment by the Ponseti method in a cohort of idiopathic CTEV patients.

METHODS

After IRB approval, a cohort of patients aged 3 to 46 days with idiopathic CTEV was identified in a previous prospective study of brace compliance by family report and sensor. Dimeglio score and family demographic information were collected. Initial treatment was by the Ponseti method, with or without Achilles tenotomy. Following correction, patients had three months of full-time FAO bracing during which parents kept a log of compliance. Patients were followed until recurrence (need for further treatment) or age 5.

RESULTS

In total, 42 patients with 64 affected feet met the above criteria and were included in the final analysis. Twenty-six feet (40%) went on to develop recurrence requiring further treatment, including casting, bracing, or surgery. Because of poor tolerance of the original FAO, 20 feet were transitioned to an alternative FAO, and 14 of these (70%) went on to recur (P<0.01). The casting duration (P=0.02) had a statistically significant relationship to recurrence. Patients who were casted for 9 weeks or more had a higher rate of recurrence (57.1% vs. 27.8%; P=0.02). Age at treatment start, Dimeglio score, demographic factors, and compliance during full-time bracing, whether by report or sensor, did not show a significant relationship with recurrence.

CONCLUSIONS

The study showed a statistically significant relationship between the difficulty of CTEV correction and the risk of recurrent deformity requiring treatment. This relationship could be used to provide prognostic information for patients' families. Caregiver-reported compliance was not significantly related to recurrence.

LEVEL OF EVIDENCE

Level III-Prognostic Retrospective Cohort Study.

Ten year challenge with Ponseti method for clubfoot: our experience

Equino-varus-adducted-supinated, also known as clubfoot, is the most frequent congenital malformation of the foot. Scientific evidences of the last decades has definitively confirmed the efficacy of the non-invasive Ponseti Technique, which is based on manipulation, plaster casts, percutaneous achillean tenotomy and stabilization of the foot using a brace. The aim of the article is to describe the experience of our third level hospital in treating clubfoot with Ponseti Method. Our data are similar to the ones in literature, confirming the effectiveness and good reproducibility of the Method. (www.actabiomedica.it)

Clubfoot and Tethered Cord Syndrome: Results of Treatment With the Ponseti Method

BACKGROUND

The Ponseti technique has demonstrated high success rates worldwide for the treatment of idiopathic clubfoot. The purpose of this study was to determine whether clubfoot associated with tethered cord syndrome (TCS) was more resistant to Ponseti treatment than isolated clubfoot.

METHODS

An IRB-approved retrospective cohort study of subjects undergoing Ponseti treatment of clubfoot between 2002 and 2013 was conducted. Subjects with TCS were matched to subjects with isolated clubfoot (1:2) on the basis of laterality, date of birth, sex, and age at presentation. Subject demographics, number of casts placed (pretenotomy and posttenotomy), and recurrence data were collected. Generalized logistic regression and linear mixed model regression analyses were used to compare recurrence within 2 years of the initiation of casting and the log number of casts needed to achieve an acceptable correction, respectively.

RESULTS

Data from 24 subjects (16 isolated clubfeet, 8 with TCS) with clubfoot (12 bilateral, 12 unilateral) were analyzed. The isolated clubfoot group was the same age at presentation on average (21.9±4.7 d) as the TCS group (28.3±9.6 d) (P=0.55). The number of casts required to achieve an acceptable correction was 54% higher (95% CI, 7.8%-120.3%; P=0.0217) in the TCS group compared with the isolated clubfoot group. The cumulative crude incidence of deformity recurrence within the first 2 years after casting initiation was 8% in the isolated clubfoot group compared with 42% in the TCS group. The odds of deformity recurrence in the TCS group were 5.6 (95% CI, 0.7-45.2; P=0.1054) times the odds of deformity recurrence in the isolated clubfoot group. Furthermore, the incidence of deformity recurrence was higher among subjects who had a tethered cord release posttenotomy (56%, 5/9) as compared with pretenotomy (0%, 0/3).

CONCLUSION

Clubfoot associated with TCS required more casts to achieve an acceptable correction. Subjects with tethered cord were also at an increased risk of deformity recurrence compared with subjects with isolated clubfoot.

LEVEL OF EVIDENCE

Level II-retrospective prognostic study.

Clinical outcomes and risk-factor analysis of the Ponseti Method in a low-resource setting: Clubfoot care in Haiti

Purpose

The Ponseti Method has dramatically altered the management of clubfoot, with particular implications for limited-resource settings. We sought to describe outcomes of care and risk factors for sub-optimal results using the Ponseti Method in Haiti.

Methods

We conducted a records review of patients presenting from 2011–2015 to a CURE Clubfoot clinic in Port-au-Prince, Haiti. We report patient characteristics (demographics and clinical), treatment patterns (cast number/duration and tenotomy rates), and outcomes (relapse and complications). We compared treatment with benchmarks in high-income nations and used generalized linear models to identify risk factors for delayed presentation, increased number of casts, and relapse.

Results

Amongst 168 children, age at presentation ranged from 0 days (birth) to 4.4 years, 62% were male, 35% were born at home, 63% had bilateral disease, and 46% had idiopathic clubfeet. Prior treatment (RR 6.33, 95% CI 3.18–12.62) was associated with a higher risk of delayed presentation. Risk factors for requiring ≥ 10 casts included having a non-idiopathic diagnosis (RR 2.28, 95% CI 1.08–4.83) and higher Pirani score (RR 2.78 per 0.5 increase, 95% CI 1.17–6.64). Female sex (RR 1.54, 95% CI 1.01–2.34) and higher Pirani score (RR 1.09 per 0.5 increase, 95% CI 1.00–1.17) were risk factors for relapse. Compared to North American benchmarks, children presented later (median 4.1 wks [IQR 1.6–18.1] vs. 1 wk), with longer casting (12.5 wks [SD 9.8] vs. 7.1 wks), and higher relapse (43% vs. 22%).

Conclusions

Higher Pirani score, prior treatment, non-idiopathic diagnosis, and female sex were associated with a higher risk of sub-optimal outcomes in this low-resource setting. Compared to high-income nations, serial casting began later, with longer duration and higher relapse. Identifying patients at risk for poor outcomes in a low-resource setting can guide counseling, program development, and resource allocation.

Management of Clubfoot Relapses With the Ponseti Method: Results of a Survey of the POSNA Members

BACKGROUND

Despite the high rate of initial success using the Ponseti method to manage idiopathic clubfoot deformity, relapse continues to be a problem. We surveyed the Pediatric Orthopedic Society of North America (POSNA) members about their experience with relapsed deformity following the initial correction of clubfeet.

METHODS

We created a survey to focus on the management of clubfeet after initial correction of deformity. The survey included questions on postcorrective bracing, clinical findings used to identify relapse, the observed frequency of relapsed deformity, and how relapses are managed. The questionnaire was approved by the POSNA Evidence Based Committee and was sent electronically to all POSNA members.

RESULTS

We received responses from 321 members (26%). Of those, 94% were fellowship trained in pediatric orthopaedics. The Ponseti method was used by 98% of respondents. The Mitchell-Ponseti orthosis was most commonly used (51%), followed by the Denis-Browne brace (25%). The duration of bracing used varied among members with 23% recommending only 2 years, 33% recommending 3 years, and 34% recommending 4 years. A tight heel cord was felt to be the first sign of relapse by 59% of respondents, and dynamic supination by 30%. The rate of relapse was observed to be <10% by 22% of the respondents, 10% to 20% by 52%, and 20% to 40% by 25%. Manipulation and cast treatment alone (55%) and cast treatment with tenotomy (23%) were reported as the 2 most common initial treatment approaches for a relapsed deformity. Cast treatment to correct relapsed deformity before tibialis anterior tendon transfer was reported by 62% of respondents. Heel cord tenotomy (75%) and posterior capsular release (43%) were the 2 most common procedures used in addition to tibialis anterior tendon transfer for the treatment of clubfoot relapse.

CONCLUSION

This study highlights the wide variation with which clubfoot relapses are evaluated and treated among the POSNA membership with differences in the recommended duration of bracing, identification of relapses, and their management. These wide differences highlight the need for future research and educational programs to inform and standardize the management of clubfoot using the Ponseti Method.

LEVEL OF EVIDENCE

Not applicable.

Early radiographic risk factors for rigid relapse in idiopathic clubfoot treated with the Ponseti method

BACKGROUND

This study aimed at identifying early risk factors for rigid relapse in idiopathic clubfoot using foot radiographs.

METHODS

Thirty-four patients with 43 idiopathic clubfeet treated with the Ponseti method were retrospectively reviewed.

RESULTS

There were seven rigid relapse recalcitrant to manipulation and requiring extensive soft-tissue release. Three radiograabphic measurements on the maximum dorsiflexion lateral (MD-Lat) radiograph, talocalcaneal (TaloCalc-Lat), tibiocalcaneal (TibCalc-Lat), and calcaneus-first metatarsal (CalcMT1-Lat) angles, showed significant differences between patients with and without rigid relapse. The TaloCalc-Lat and CalcMT1-Lat angles showed significant hazard ratio for rigid relapse by multivariate survival analysis. Clubfeet demonstrating TibCalc-Lat>90° and CalcMT1-Lat<5° have a 24.9-fold odds ratio to develop rigid relapse compared to those demonstrating TibCalc-Lat≤90° or CalcMT1-Lat≥5°.

CONCLUSIONS

The TaloCalc-Lat, TibCalc-Lat, and CalcMT1-Lat angles on the MD-Lat radiograph immediately before the tenotomy, probably representing intrinsic tightness of the midfoot and/or hindfoot, are significant risk factors for rigid relapse in patients treated with the Ponseti method.

Sixty Years On: Ponseti Method for Clubfoot Treatment Produces High Satisfaction Despite Inherent Tendency to Relapse

BACKGROUND

Developed at the University of Iowa in 1950, the Ponseti method to manage idiopathic clubfoot deformity was slow to gain wide acceptance until the mid-1990s. There is a paucity of intermediate and long-term outcome studies involving this technique, with nearly all such studies coming from a single institution. The purpose of this study is to report the contemporary outcome of patients with clubfoot deformity whose feet were managed with the Ponseti method and who were followed to ≥5 years old, to provide outcome expectations for parents and for clinicians managing patients with idiopathic clubfoot.

METHODS

Families of infants seen in our clinic diagnosed with idiopathic clubfoot since July 2006 were prospectively invited to participate in our institutional review board-approved study. Patients who received no prior outside treatment and had a minimum follow-up to the age of 5 years were included. Demographic, treatment, and outcome data were collected. To provide an array of outcome measures, both the Dallas outcome criteria and the Roye disease-specific instrument (DSI) were used.

RESULTS

One hundred and one patients met the inclusion criteria. The mean length of follow-up (and standard deviation) was 81.1 ± 17.1 months. Initial correction was achieved in all feet. Thirty-seven percent of families reported that they were adherent with the bracing protocol; 68% of patients had ≥1 relapse, and 38% underwent a tendon transfer. With the Dallas criteria, 62% had outcomes rated as good, 38% had outcomes rated as fair, and no patient had an outcome rated as poor. With the Roye DSI, most families were generally very satisfied with the function and appearance of the feet.

CONCLUSIONS

Satisfactory results at intermediate follow-up were achieved using the Ponseti method. However, despite a better understanding of the Ponseti method and the importance of longer post-corrective brace use, the need for anterior tibial tendon transfer remains an important adjunct to the Ponseti method. Brace adherence also continues to be a critical clinical issue.

LEVEL OF EVIDENCE

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

What factors impact on the implementation of clubfoot treatment services in low and middle-income countries?: a narrative synthesis of existing qualitative studies

Background

Around 100,000 children are born annually with clubfoot worldwide and 80% live in low and middle-income counties (LMICs). Clubfoot is a condition in which children are born with one or both feet twisted inwards and if untreated it can limit participation in everyday life. Clubfoot can be corrected through staged manipulation of the limbs using the Ponseti method. Despite its efficacy and apparent availability, previous research has identified a number of challenges to service implementation. The aim of this study was to synthesise these findings to explore factors that impact on the implementation of clubfoot services in LMICs and strategies to address them. Understanding these may help practitioners in other settings develop more effective services.

Methods

Five databases were searched and articles screened using six criteria. Articles were appraised using the Critical Appraisal Skills Programme (CASP) checklist. 11 studies were identified for inclusion. A thematic analysis was conducted.

Results

Thematic analysis of the included studies showed that a lack of access to resources was a challenge including a lack of casting materials and abduction braces. Difficulties within the working environment included limited space and a need to share treatment space with other clinics. A shortage of healthcare professionals was a concern and participants thought that there was a lack of time to deliver treatment. This was exacerbated by the competing demands on clinicians. Lack of training was seen to impact on standards, including the nurses and midwives attending to the child at birth that were failing to diagnose the condition. Financial constraints were seen to underlie many of these problems. Some participants identified failures in communication and cooperation within the healthcare system such as a lack of awareness of clinics. Strategies to address these issues included means of increasing resource availability and the delivery of targeted training. The use of non-governmental organisations to provide financial support and methods to disseminate best practice were discussed.

Conclusions

This study identified factors that impact on the implementation of clubfoot services in LMIC settings.Findings may be used to improve service delivery.

Ilizarov technique combined with limited adjunctive surgical procedures for correction of relapsed talipes equinovarus in children

Objective To evaluate the efficacy and safety of using the Ilizarov invasive distraction technique combined with limited surgical operations in the treatment of relapsed talipes equinovarus in children. Methods This retrospective study analysed the outcomes of paediatric patients with relapsed talipes equinovarus who were treated with the Ilizarov technique with moderate open limited soft tissue or bony operations. The International Clubfoot Study Group (ICFSG) classification system score was used to evaluate the deformities before and after surgery. Results The study evaluated 16 feet in 14 patients (nine boys). The correction time ranged from 6 to 12 weeks. The mean duration of frame application was 5.9 months. The gait was improved significantly in all patients. At final follow-up, the mean ankle dorsiflexion and plantarflexion ranges were 8.3° and 34.6°, respectively. The talocalcaneal angle improved from 10.0° preoperatively to 28.3° postoperatively in the anteroposterior plane; and from 4.1° preoperatively to 42.1° postoperatively in the lateral plane. The differences in the angle of plantarflexion, dorsiflexion, range of motion of the ankle joint and talocalcaneal angles pre- and postoperation were significant. Conclusions These current findings suggest that the Ilizarov technique combined with limited surgery effectively corrects relapsed talipes equinovarus in children.

Ilizarov technique and limited surgical methods for correction of post-traumatic talipes equinovarus in children

BACKGROUND

The objective of this study was to evaluate the efficacy and safety of using Ilizarov invasive distraction technique combined with limited surgical operations in the treatment of post-traumatic talipes equinovarus in children.

METHODS

Eighteen cases of post-traumatic deformed feet in 15 patients who received the treatment of Ilizarov frame application, limited soft-tissue release or osteotomy were selected in this study. After removal of the frame, an ankle-foot orthosis was used continuously for another 6-12 months. Pre- and post-operatively, the International Clubfoot Study Group (ICFSG) score was employed to evaluate the gait and range of motion of the ankle joint. Radiographical assessment was also conducted.

RESULTS

Patients were followed up for 22 (17-32) months. Ilizarov frame was applied for a mean duration of 5.5 (4-9) months. When it was removed, the gait was improved significantly in all the patients. The correction time was 6-8 weeks for patients who underwent soft-tissue release and 8-12 weeks for those with bone osteotomy. At the last follow-up assessment, the differences between pre- and post-operative plantar-flexion angle, dorsiflexion, motion of ankle joint and talocalcaneal angle were significant (all P < 0.05). The observed complications included wire-hole infection in one foot, toe contracture in one, residual deformity in three, recurrence of deformity in two and spastic ischaemia in one foot.

CONCLUSION

Our findings suggest that Ilizarov technique combined with limited surgical operation can be considered as an efficient and successful method for correction of post-traumatic talipes equinovarus in children.

Clubfoot relapse: does presentation differ based on age at initial relapse?

PURPOSE

Treatment of idiopathic clubfoot with the Ponseti method is now standard, but predicting relapse can be difficult. Most experts recommend bracing to the age of four years, but this can be challenging for families, and may not be necessary in all patients. The purpose of this study is to compare patterns of bracing and age of relapse to help determine if predictable patterns exist.

METHODS

The 70 patients with idiopathic clubfoot treated initially with the Ponseti technique who had relapse of their clubfoot were identified. Relapse was defined as a return to casting or surgery due to recurrent deformity. Data collected included demographics, treatment and brace adherence. Patients who sustained initial relapse before the age of two years were compared with those who sustained initial relapse after the age of two years.

RESULTS

In total 56% (39/70) had their initial relapse prior to age two years while 44% (31/70) were after age two years. Of the patients who relapsed prior to the age of two years, 28% (11/39) were adherent with bracing while 72% were non--adherent. For patients who initially relapsed after age two, 74% (23/31) were adherent with bracing while 26% were non-adherent (p < 0.001). Of those who had initial -relapse -prior to age two, a subsequent relapse was seen in 69% (27/39).

CONCLUSION

Patients with idiopathic clubfoot who experienced recurrence prior to age two years are significantly more likely to be non-adherent with bracing than those who sustain recurrence after age two. After initial relapse prior to age two, bracing adherence does not affect likelihood of subsequent recurrence.

The Timing and Relevance of Relapsed Deformity in Patients With Idiopathic Clubfoot

BACKGROUND

The timing and relevance of relapsed deformity after correction of idiopathic clubfoot have not been well documented.

METHODS

All patients with idiopathic clubfoot seen at the authors' institution during the study period who were followed for ≥2 years (range, 2.0 to 9.8 years) were included (N = 191). Survival analysis and multivariate regression analysis were used to analyze the data.

RESULTS

The median age at first relapse was 20 months. The probability of relapse remained approximately 30% at age 2 years and increased to 45% by 4 years and 52% by 6 years. Parent-reported adherence with bracing reduced the odds of a relapse by 15 times (P < 0.01). After an initial relapse, adherence with bracing was successful in avoiding a subsequent relapse in 68% of patients. Feet graded as very severe on the Diméglio scale were 5.75 times more likely to relapse than those graded severe and were 7.27 times more likely than those graded as moderate.

DISCUSSION

Patients whose parents reported nonadherence with bracing and patients with very severe deformities were most likely to relapse. After an initial relapse, regaining correction of the foot and resuming bracing were beneficial to avoid further relapses. These findings can be useful to clinicians in advising families regarding the prognosis of treatment.

CONCLUSIONS

The development of a relapse affects the subsequent management and outcome of clubfoot deformity. The importance of bracing should be reinforced to parents. Bracing until at least age 4 years may be beneficial. For patients whose families are especially resistant to brace use and for older patients who experience a second relapse, regaining correction of the deformity via cast treatment followed by an Achilles lengthening procedure and/or tendon transfer may be the best alternative.

Results of Ponseti Brasil Program: Multicentric Study in 1621 Feet: Preliminary Results

BACKGROUND

The Ponseti method has been shown to be the most effective treatment for congenital clubfoot. The current challenge is to establish sustainable national clubfoot treatment programs that utilize the Ponseti method and integrate it within a nation's governmental health system. The Brazilian Ponseti Program (Programa Ponseti Brasil) has increased awareness of the utility of the Ponseti method and has trained >500 Brazilian orthopaedic surgeons in it.

METHODS

A group of 18 of those surgeons had been able to reproduce the Ponseti clubfoot treatment, and compiled their initial results through structured spreadsheet.

RESULTS

The study compiled 1040 patients for a total of 1621 feet. The average follow-up time was 2.3 years with an average correction time of approximately 3 months. Patients required an average of 6.40 casts to achieve correction.

CONCLUSIONS

This study demonstrates that good initial correction rates are reproducible after training; from 1040 patients only 1.4% required a posteromedial release.

LEVEL OF EVIDENCE

Level IV.

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.

The Objective Measurement of Brace-Use Adherence in the Treatment of Idiopathic Clubfoot

BACKGROUND

A successful outcome for the treatment of idiopathic clubfoot is believed to require adequate adherence to brace use. Previous studies have relied on parental reporting of brace application. We used temperature sensors to determine the adherence to the bracing protocol, the accuracy of parent-reported use, and differences in adherence between patients who experienced relapse of deformity and those who did not.

METHODS

Using wireless sensors attached to brace sandals, we monitored brace wear over a 3-month period in this cross-sectional study involving 48 patients in 4 age-based groups: 6 to 12 months (Group 1), >1 to 2 years (Group 2), >2 to 3 years (Group 3), and >3 to 4 years (Group 4). Parents were blinded to the purpose of the sensors. The mean number of hours of daily brace use as measured by the sensors was compared with the physician-recommended hours and parent-reported hours of brace use.

RESULTS

Sensors were retrieved from 44 of 48 patients. Overall, the median brace use recorded by the sensors was 62% (range, 5% to 125%) of that recommended by the physician, and 77% (range, 6% to 213%) of that reported by the parents. For Groups 1 to 3, the difference between the physician-recommended and measured number of hours of daily brace use was significant (p ≤ 0.002), and the difference between the parent-reported and measured number of hours of daily brace use was also significant (p ≤ 0.013). Eight (18%) of the 44 patients who completed the study experienced relapse during the period of monitoring; most importantly, the mean number of hours of brace wear for these patients, 5 hours per day (median, 4; and standard deviation [SD], 3 hours per day) was significantly lower than the 8 hours per day for those who did not experience relapse (median, 9; and SD, 5 hours per day) (p = 0.045).

CONCLUSIONS

The present study objectively quantified the number of daily hours of post-corrective brace wear for patients with clubfoot in varying age groups and provides an estimate of the number of hours required to avoid relapse.

LEVEL OF EVIDENCE

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

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.

Evaluation of gait, relapse and compliance in clubfoot treatment with custom-made orthoses

Relapse after successful initial correction of idiopathic clubfoot with the Ponseti method is often related to poor compliance with the foot abduction orthosis (FAO). The aim of this study was to evaluate treatment with custom-made dynamic orthoses. Twenty children with idiopathic clubfoot (30feet) who had been treated with dynamic orthoses after the correction phase according to the Ponseti casting technique were evaluated. Relapse rates during orthotic treatment were registered. A Vicon gait analysis system was used to measure gait parameters at the age of seven years. The overall gait quality was estimated with the Gait Deviation Index (GDI). Data were analyzed with a nested mixed model and compared with a control group of 16 healthy children. No relapse occurred during the orthotic treatment. High compliance with the orthoses was observed based on parents' self report and physiotherapist observations. Gait analysis showed decreased ankle power and moment, increased internal foot progression, decreased dorsiflexion during stance, and increased plantar flexion at initial contact compared with the control group. Hip and shank rotations were normal. No calcaneus or equinus gait was observed. The mean GDI was 89.7 (range 71.6-104). The gait analysis outcomes and frequency of relapse were comparable to those of previous studies. Internal foot progression originated primarily from the foot level and was not, as frequently found after FAO treatment, compensated by external rotation at knee or hip level. In children exhibiting poor compliance with an FAO, this dynamic model is considered an effective alternative.

Does Clubfoot Treatment Need to Begin As Soon As Possible?

INTRODUCTION

Parents of an infant with an idiopathic clubfoot deformity are often urged by their primary care physician to seek treatment as soon as possible. This advice frequently appears in many general pediatric and pediatric orthopaedic textbooks and monographs on the subject. This recommendation has not changed since the wide acceptance of the minimally invasive Ponseti method to treat clubfoot. We determined the correlations among patient-related variables, early treatment variables, and the age at which the patient was first seen to begin treatment.

METHODS

Infants with moderate to very severe idiopathic clubfoot deformity were invited to participate. Age at which the patient presented to begin treatment was correlated against early treatment-related variables, including number of casts required, cast slippage, cast-related skin problems, brace-related skin problems, early noncompliance with brace wearing, and relapse before 1 year. Patient-related variables were also correlated against age at first visit.

RESULTS

Over 7 years, 176 infants met the inclusion criteria. There were no significant differences in the aspects of the early management as a function of age at first visit, with the exception of cast slippage (P=0.05).

CONCLUSIONS

The age at first visit influenced the incidence of cast slippage, but otherwise did not affect the early treatment of clubfoot.

CLINICAL RELEVANCE

The treatment of idiopathic clubfoot deformity should not be considered an orthopaedic emergency, and parents whose infants are born with this deformity should be counseled accordingly.

Residual forefoot deformity predicts the need for future surgery in clubfeet treated by Ponseti casting

Tibialis anterior tendon transfer (TATT) is performed for treatment of recurrent clubfeet. We investigated the predictability of residual adductus on the future need for TATT. A retrospective review of 143 patients with clubfoot was performed. The patients were divided into two groups: group 1 with a history of TATT and group 2 with no TATT. Heel-forefoot angle (HFA) was measured. HFA was compared between the groups. HFA was significantly different between groups 1 and 2. Residual adductus deformity in clubfeet treated by Ponseti casting is a risk factor for future need for surgical treatment.

Initial Correction Predicts the Need for Secondary Achilles Tendon Procedures in Patients With Idiopathic Clubfoot Treated With Ponseti Casting

BACKGROUND

The Ponseti method is the most common method to treat idiopathic clubfoot in North America. Despite initial correction, recurrence is common with this method. The factors predictive of recurrence are not well defined in the literature.

METHODS

A retrospective chart review was done of procedures performed at our institution from 2005 to 2010 in children undergoing general anesthesia for primary percutaneous Achilles tenotomy for the treatment of idiopathic clubfoot using the Ponseti casting method (101 patients, 148 feet). All patients were followed up for at least 2 years postoperatively (2 to 7.5 y, average 3.5 y). The patients were divided into 2 groups: group N with no repeat procedures on Achilles tendon and group R with a secondary procedure to address the residual equinus deformity. We looked at postoperative equinus correction through the use of postoperative measurements on digital images using a goniometer. The amount of postoperative dorsiflexion at the initial procedure was compared between the 2 groups using the paired t test. The feet were then divided into 3 groups on the basis of the amount of initial correction, and the rates of future surgical procedures were compared among these groups.

RESULTS

A total of 101 patients (148 feet) were evaluated. Seventy-two patients (106 feet) did not have any future procedures to address equinus deformity (group N). Twenty-nine patients (42 feet) underwent future procedure (group R) to correct the residual equinus. The N and R groups differed in amount of postoperative dorsiflexion (14.0 vs. 5.1; P<0.01). Patients in whom at least 10 degrees of dorsiflexion was achieved after the initial tenotomy had only a 12% rate of future procedures. Patients with neutral or less than neutral dorsiflexion had 64% chance of future procedures to address the residual equinus.

CONCLUSIONS

Residual equinus deformity after Achilles tenotomy in clubfeet treated by the Ponseti method is associated with a high rate of future surgical procedures. Correction of this deformity before bracing could potentially decrease the rate of future surgery.

LEVEL OF EVIDENCE

Level III—Retrospective.

What's New in Idiopathic Clubfoot?

This update summarizes selected research highlights pertaining to idiopathic clubfoot deformity that were published in peer-reviewed journals between January 2010 and December 2013.

How do different anterior tibial tendon transfer techniques influence forefoot and hindfoot motion?

BACKGROUND

Idiopathic clubfoot correction is commonly performed using the Ponseti method and is widely reported to provide reliable results. However, a relapsed deformity may occur and often is treated in children older than 2.5 years with repeat casting, followed by an anterior tibial tendon transfer. Several techniques have been described, including a whole tendon transfer using a two-incision technique or a three-incision technique, and a split transfer, but little is known regarding the biomechanical effects of these transfers on forefoot and hindfoot motion.

QUESTIONS/PURPOSE

We used a cadaveric foot model to test the effects of three tibialis anterior tendon transfer techniques on forefoot positioning and production of hindfoot valgus.

METHODS

Ten fresh-frozen cadaveric lower legs were used. We applied 150 N tension to the anterior tibial tendon, causing the ankle to dorsiflex. Three-dimensional motions of the first metatarsal, calcaneus, and talus relative to the tibia were measured in intact specimens, and then repeated after each of the three surgical techniques.

RESULTS

Under maximum dorsiflexion, the intact specimens showed 6° (95% CI, 2.2°-9.4°) forefoot supination and less than 3° (95% CI, 0.4°-5.3°) hindfoot valgus motion. All three transfers provided increased forefoot pronation and hindfoot valgus motion compared with intact specimens: the three-incision whole transfer provided 38° (95% CI, 33°-43°; p < 0.01) forefoot pronation and 10° (95% CI, 8.5°-12°; p < 0.01) hindfoot valgus; the split transfer, 28° (95% CI, 24°-32°; p < 0.01) pronation, 9° (95% CI, 7.5°-11°; p < 0.01) valgus; and the two-incision transfer, 25° (95% CI, 20°-31°; p < 0.01) pronation, 6° (95% CI, 4.2°-7.8°; p < 0.01) valgus.

CONCLUSION

All three techniques may be useful and deliver varying degrees of increased forefoot pronation, with the three-incision whole transfer providing the most forefoot pronation. Changes in hindfoot motion were small.

CLINICAL RELEVANCE

Our study results show that the amount of forefoot pronation varied for different transfer methods. Supple dynamic forefoot supination may be treated with a whole transfer using a two-incision technique to avoid overcorrection, while a three-incision technique or a split transfer may be useful for more resistant feet. Confirmation of these findings awaits further clinical trials.

The effect of a dedicated Ponseti service on the outcome of idiopathic clubfoot treatment

We report the effect of introducing a dedicated Ponseti service on the five-year treatment outcomes of children with idiopathic clubfoot. Between 2002 and 2004, 100 feet (66 children; 50 boys and 16 girls) were treated in a general paediatric orthopaedic clinic. Of these, 96 feet (96%) responded to initial casting, 85 requiring a tenotomy of the tendo-Achillis. Recurrent deformity occurred in 38 feet and was successfully treated in 22 by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, The remaining 16 required an extensive surgical release. Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls) were treated in a dedicated multidisciplinary Ponseti clinic. All responded to initial casting: 60 feet (83.3%) required a tenotomy of the tendo-Achillis. Recurrent deformity developed in 14, 11 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The other three required an extensive surgical release. Statistical analysis showed that children treated in the dedicated Ponseti clinic had a lower rate of recurrence (p = 0.068) and a lower rate of surgical release (p = 0.01) than those treated in the general clinic. This study shows that a dedicated Ponseti clinic, run by a well-trained multidisciplinary team, can improve the outcome of idiopathic clubfoot deformity.

Results of gait analysis including the Oxford foot model in children with clubfoot treated with the Ponseti method

BACKGROUND

The aim of the study was to evaluate how clubfeet treated with the Ponseti method compare with control feet in gait analysis and whether additional information can be provided by the Oxford foot model.

METHODS

All patients with a minimum age of three years in our prospective database of clubfeet treated with the Ponseti method were considered for inclusion. Exclusion criteria were an associated syndrome or neurological disease, positional (slight) clubfoot, and presentation at an age of more than three months. Of the 125 patients with 199 clubfeet who satisfied the criteria, thirty-six (29%) agreed to participate in the study. Four of these were excluded because of insufficient gait analysis data, leaving thirty-two patients with fifty clubfeet for evaluation. Clinical examination and three-dimensional gait analysis including the Oxford foot model were performed, and a disease-specific questionnaire was administered. Kinetic and kinematic results were compared with those of an age-matched control group (n = 15).

RESULTS

The mean score on the disease-specific questionnaire was 83.5. Gait analysis showed significantly decreased range of motion, plantar flexion, and power of the ankle compared with controls. The mean external foot progression angle of 5.7° in the Ponseti group was slightly less than that in the controls. Slight intoeing occurred in 24%, and 12% did not achieve a neutral position during swing phase. Slight compensation was observed, including external rotation of the hip in 28%. The Oxford foot model revealed differences in foot motion between the groups.

CONCLUSIONS

Clubfoot treatment with the Ponseti method yielded good clinical results with high functional scores. Three-dimensional gait analysis demonstrated distinctive but slight deviations. Intoeing was less frequent and less severe compared with groups in the literature. We recommend the use of three-dimensional gait analysis, including a foot model, as an objective tool for evaluation of the results of clubfoot treatment.

LEVEL OF EVIDENCE

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

Walking age of infants with idiopathic clubfoot treated using the ponseti method

BACKGROUND

The Ponseti method is an established approach to treating idiopathic clubfoot in infants. The method involves a period of cast immobilization and postcorrective bracing that potentially interferes with normal movements of the lower extremities. In the present study, we investigated the age at which infants who had idiopathic clubfoot treated using the Ponseti method achieved independent walking.

METHODS

We prospectively evaluated patients of a single surgeon. Included in the study were all patients with idiopathic clubfoot who were full term at birth, were no more than twelve weeks of age at the start of treatment, had received no prior outside treatment, and were followed for a minimum of twenty-four months.

RESULTS

Ninety-four patients were included. The mean age at which patients began walking independently was 14.5 ± 2.6 months (range, ten to twenty-two months). By eighteen months, 90% of the patients were walking without assistance. Patients with moderate or severe clubfoot deformity began walking earlier than did patients with very severe deformity (a mean of 14.2 months compared with 15.8 months; p = 0.03). Patients who experienced a relapse before learning to walk began walking later than those who did not relapse (a mean of 15.9 months compared with 14.2 months; p = 0.04). Other patient and treatment-related variables had no significant influence on the onset of walking.

CONCLUSIONS

On the basis of our findings, parents of infants with idiopathic clubfoot treated using the Ponseti method may expect their child to achieve independent walking approximately two months later than infants without clubfoot deformity. A greater delay may be expected for those patients who have a very severe deformity or those who experience a deformity relapse.

LEVEL OF EVIDENCE

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

Ilizarov external fixation for management of severe relapsed clubfeet in older children

BACKGROUND

Although the standard treatment of clubfoot deformity is conservative by serial casting techniques, relapses are not uncommon. Management of relapsed clubfoot deformity in older children is an orthopedic challenge. There is a growing interest in management of such complex deformities using the Ilizarov technique.

METHODS

In this study, the Ilizarov frame was used to correct severe relapsed clubfoot deformities in older children, whom underwent previous surgical interventions. 42 relapsed clubfeet were included. The Dimeglio classification was used for clinical assessment of the relapsed feet pre-operatively as well as post-operatively.

RESULTS

After an average follow-up period of 4.6 years, and according to the Beatson and Pearson numerical assessment, favorable results (excellent or good) were found in 37 feet, while poor results took place in only five feet.

CONCLUSION

Based on the final clinical and radiographic results, the Ilizarov technique could be considered as a good management alternative for such severe deformities.

The Ponseti method for the treatment of congenital club foot: review of the current literature and treatment recommendations

The Ponseti method has become the gold standard of care for the treatment of congenital club foot. Despite numerous articles in MEDLINE reporting results from around the globe there are still crucial details of the Ponseti method which seem to be less commonly known or considered. The Ponseti method is not only a detailed method of manipulation and casting but also of preventing and treating relapse. Recommendations on how to correct complex club foot have resulted in an almost 100 % initial correction rate. The foot abduction brace is crucial for preventing relapse and is still a challenge for families and sometimes doctors alike. Experience and knowledge on how to support the parents, how to set and apply the brace in the best possible way and how to solve problems that can be encountered during the bracing period are essential to ensure compliance. Regular follow-up visits are necessary to be able to detect early signs of recurrence and prevent full relapse by enforcing abduction bracing, recasting or performing tibialis anterior tendon transfer. Recent midterm outcome studies have shown that by following the Ponseti treatment regime in all aspects it is possible to prevent open joint surgery in almost all cases. The body of literature of the last decade has evaluated many steps and aspects of the Ponseti method and gives valuable answers to questions encountered in daily practice. This review of the current literature and recommendations on the different aspects of the Ponseti method aims to promote understanding of the treatment regime and its' details.