The roentgenographic appearance of the "corrected clubfoot"

Surgical Management of the Undercorrected and Overcorrected Severe Club Foot Deformity

Managing complications of clubfoot deformities can be very challenging. Some patients present with recurrent clubfoot and residual symptoms, and some present with overcorrection leading to a severe complex flatfoot deformity. Both can lead to long-term degenerative changes of the foot and ankle joints owing to deformity caused by unbalanced loading. This article only focuses on severe complications caused by recurrence and overcorrection in both children and adult patients.

Magnetic resonance imaging of severe idiopathic club foot treated with one-week accelerated Ponseti (OWAP) technique

PURPOSE

This study aims to evaluate changes in tarsal bones relationship after the use of one week accelerated Ponseti method in the treatment of severe idiopathic clubfoot using MRI. We hypothesize that one-week accelerated Ponseti is at least as effective as standard techniques in achieving the desirable MRI parameters.

METHODS

This is a prospective study of 8 children with severe idiopathic clubfeet (Pirani 6) (4 unilateral and 4 bilateral) treated before the age of three months with one-week accelerated Ponseti technique, as described in a former study with minimum 2-year follow-up. The 8 corrected feet were compared with the 4 unilateral normal feet at clinical and radiological levels using a Pirani scoring system and an MRI, respectively.

RESULTS

Clinical results showed that Pirani score was 1.1 in the last follow up in comparison to Pirani 6 pretreatment (p < 0.05). MRI results indicated that the malleocalcaneal angle, axial malleocalcaneal index, coronal tibiocalcaneal angle, sagittal talocalcaneal angle, and talar head neck calcaneal rotation showed statistical difference between the two groups (p < 0.05). Sagittal malleocalcaneal index, sagittal tibiocalcaneal angle, talar head neck rotation related to talar body, and posterior calcaneal rotation showed no statistical difference between normal feet and clubfeet after correction (p value >0.05).

CONCLUSION

One-week accelerated Ponseti technique showed to be as effective and safe as other treatment methods through clinical and MRI follow up data. MRI role was to confirm the efficiency of this innovative accelerated technique, but not used as a routine follow up.

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

BACKGROUND

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

RESEARCH QUESTION

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

METHODS

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

RESULTS

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

SIGNIFICANCE

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

Reconstructive surgery for overcorrected clubfoot in adults

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hind-foot correction and stabilization by pins in plaster after surgical release of talipes equino varus feet in older children

Congenital talipes equino varus (CTEV) is a three dimensional deformity and is one of the most common congenital abnormalities affecting the lower limb and can be challenging to manage. Hind-foot deformity is considered the most difficult to treat. Unfortunately, the calcaneus is often small and thus difficult to control during casting after surgical release in severe or relapsed cases. We used three pins to control and maintain the hind foot correction, after surgical release, during casting in 47 cases (59 feet). We introduced a modified, coronal plane, transverse calcaneal pin. This pin is inserted from medial to lateral through the calcaneus to correct the varus mal-positioning of the calcaneus in the sagittal plane and to provide a better control on the small sized, hind-foot during casting. We paid special attention to the final hind-foot deformity after surgery, and the results were favorable after the application of this transverse pin.

Talonavicular fusion for dorsal subluxation of the navicular in resistant clubfoot

Dorsal rotatory subluxation of the navicular, a common sequela of resistant surgically treated clubfeet, presents a challenging treatment problem. This subluxation typically progresses after posteromedial release. Patients develop a cavovarus foot deformity and complain of pain, gait problems, and difficulty with shoe wear. Previous attempts at soft tissue release and reduction have been largely unsuccessful. We reviewed 13 patients with dorsal rotatory subluxation of the navicular treated with talonavicular arthrodesis. The minimum followup after surgery was 6 months (average, 36 months; range, 6 to 93 months). At last followup 12 of 13 patients were symptom-free. The mean preoperative subluxation of 42% was reduced to a mean of 6% at last followup. We noted improvement in the talo-first metatarsal angle from an average of 18 masculine preoperatively to 8 masculine postoperatively. One patient treated by another surgeon with attempted talonavicular arthrodesis developed a nonunion; we observed no other complications. We believe talonavicular arthrodesis a reasonable option to correct the deformity and symptoms associated with dorsal rotatory subluxation of the navicular in a single surgical setting with a low complication rate.

LEVEL OF EVIDENCE

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

Comparative results of the conservative treatment in clubfoot by two different protocols

The current study aims at presenting the results of the two methods of conservative treatment in clubfoot: the Romanian traditional method and the Ponseti method. The study population included 103 children (148 clubfeet) treated in our department between 1998 and 2005. Between 1998 and 2003, the conservative treatment protocol was based upon the Romanian method. The Ponseti method has been used since 2004. The main criterion for the assessment of the efficiency of the two conservative methods in clubfoot is the number of feet requiring surgical treatment - posteromedial release at 18 months. This criterion is clearly in favor of the Ponseti method: four feet (5%) needed posteromedial release in Ponseti group patients versus 13 feet (18%) in Romanian group patients (P=0.0193). The Ponseti method is safe, efficient in the conservative treatment of clubfoot and decreases the number of surgical interventions needed for the correction of the deformation compared with our traditional method.

Achilles tendon length in children evaluated sonographically

The purpose of this study was to improve our knowledge of the behavior of the Achilles tendon as a basis for decision-making in Achilles lengthening or tenotomy, we sonographically measured the normal and club feet of 101 babies, mean age 4 months, in standard parameters: tibio-talo-calcaneal angle, length of Achilles tendon, distance from tibia to calcaneus, and distance from a line parallel to the posterior cortex of the tibia to the calcaneus. All measurements were age-matched from birth to 1 year in maximal plantar and dorsal flexion. In conclusion, we describe the normal values for the four parameters in plantar and dorsal flexion. These can serve as a basis for decision-making in clubfoot management.

Treatment of idiopathic clubfoot utilizing botulinum A toxin: a new method and its short-term outcomes

A pivotal point in most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of botulinum A toxin (BTX-A) in attenuating the function of the triceps surae muscle complex as an alternative to tenotomy was investigated. Fifty-one patients with 73 idiopathic clubfeet were recruited. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: group 1 (<30 days old) and group 2 (>30 days and <8 months old). Ankle dorsiflexion in knee flexion and extension remained above 20 degrees and 15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. One of the 51 patients required limited posterior release and 9 patients required repeat manipulation and casting plus or minus BTX-A injection. The use of BTX-A as an adjunctive therapy in the noninvasive approach of manipulation and casting in idiopathic clubfoot is a safe and effective treatment.

Assessment of talar flattening in adult idiopathic clubfoot

BACKGROUND

The radius/length (R/L) ratio was developed to evaluate the convexity of the talar dome in idiopathic clubfoot. However, the index has not been tested for its reliability and reproducibility.

METHODS

The R/L ratio was determined by three independent observers on the radiographs of 21 adult patients with idiopathic clubfoot and 30 adult subjects with normal feet. The reproducibility and the reliability of the R/L ratio were calculated.

RESULTS

For the normal feet the reproducibility and the reliability of the R/L ratio was high (correlation coefficient > 0.87). For the patients with clubfoot, the reliability and reproducibility depended on the severity of talar flattening. For a radius of less than 45 mm the mean intraobserver correlation coefficient was 0.74 (range 0.54 to 0.83) and the mean interobserver correlation coefficient was 0.58 (range 0.49 to 0.75). For a radius of more than 45 mm no statistically significant intraobserver and interobserver correlations were found.

CONCLUSION

The current results indicate that the R/L ratio of talar flattening is reliable and reproducible for mild talar deformity but not for severe flattening (radius of more than 45 mm).

Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method

The initial treatment of congenital idiopathic talipes equinovarus (clubfoot) is most often nonsurgical. However, surgical treatment in the form of posteromedial release is often undertaken after failure of conservative measures. The prevalence of both immediate and long-term complications in surgically treated clubfeet has cultivated a renewed interest in nonsurgical treatment. The Ponseti method for treating clubfoot has seen a revived interest among those caring for infantile clubfeet. We report on our first 34 infants (57 clubfeet) treated by using the techniques and principles described by Ponseti. Using a standard scoring system, 54 of 57 clubfeet were successfully corrected without requiring posteromedial release. Only 2 patients (3 clubfeet) required extensive surgical correction. There were 6 relapses. In all recurrent cases, there was a lack of compliance with the straight-last shoe and foot abduction bar regimen. Based on this level of initial success, we believe that posteromedial release is no longer necessary for the majority of cases of congenital clubfeet.

When does the flat-top talus lesion occur in idiopathic clubfoot: evaluation with magnetic resonance imaging at three months of age

Flat-top talus has been described as a pathologic change secondary to idiopathic clubfoot condition and/or as a direct result of nonoperative manipulation involving forced dorsiflexion and molding of the cartilaginous talus. No definitive study, however, on the etiology and the timing of the flat-top talus deformity has been performed to date. The authors evaluated the magnetic resonance images of eleven patients with idiopathic clubfoot deformities treated with 2 to 3 months of casting to assess if flattening of the talar dome occurred at this age with this amount of casting. All children were 3 months of age, were casted for a maximum of 2 to 3 months, and sedated before MRI examination. The images were evaluated for maximum talar head height, maximum talar body height, and deviation of the talar body from a perfect circle. Maximum talar head height ranged from 4 to 9 mm, maximum talar body height ranged from 6 to 10 mm. Eight of the eleven had maximum talar body measurements 3 to 5mm greater than maximum talar head height. Three of the eleven patients had head and body size of equal proportion. Two of the eleven had a talar body that was within 1 mm of a perfect circle. The remaining nine patients had perfectly round talar bodies. In the senior author's (RSD) experience with treating clubfeet, a substantial increase has been seen at operation in flat-top tali among children that were casted for more than 1 year before surgical correction, compared to children casted for 3 months before surgical correction. The current investigation indicated that although tali of children with clubfeet are abnormally shaped, the talar body remains larger than the talar head and maintains its roundness after two to three months of corrective casting. Maintenance of cast treatment for more than three months may lead to the flat-top talus deformity. The authors recommend surgical intervention following three months of failed manipulation and casting to prevent this deformity.

Magnetic resonance imaging in follow-up of treated clubfoot during childhood

In this study, we evaluated the short-term results of surgically treated clubfoot with magnetic resonance imaging (MRI). T1- and T2-weighted MRI images with 4-mm slices in the standard anatomic sagittal, transverse, and coronal planes were obtained in seven cases of clubfoot aged 4--11 years (mean 5.6 years old). The mean follow-up period was 3.6 years (ranged between 2 and 6 years). Sagittal talocalcaneal angle, talar head and neck axis internal rotation, calcaneal axis internal rotation, transverse talar neck and head/calcaneus angle and posterior calcaneus external rotation were measured. Three cases with dorsal talonavicular subluxation and a case of calcaneocuboid luxation were demonstrated by MRI. It was concluded that MRI may help to understand results of surgically-treated clubfoot by revealing hindfoot articular relationships and many complications.

Talo-navicular arthrodesis for residual midfoot deformities of a previously corrected clubfoot

Triangular navicular, dorsal-lateral subluxation of the talo-navicular (TN) joint with a secondary forefoot cavovarus deformity, and degenerative changes of the TN joint are frequent causes of residual clubfoot deformity and pain in the midfoot after surgical correction. This study investigates the usefulness of TN arthrodesis to correct these deformities and to resolve symptoms resulting from these deformities. During the period from 1991-1996, the senior author performed 19 TN fusions (16 patients) for the above residual clubfoot deformities involving a painful TN joint. Eight of the procedures (seven patients) also required a lateral column shortening with a calcaneal wedge osteotomy to allow for a complete correction of the TN joint. The procedure was only performed in cases involving a hindfoot that was adequately aligned during a previous clubfoot correction. The average age of the patients at the time of surgery was 11 years (range: 4-20). One patient (bilateral procedures) was lost to follow-up. Fifteen patients (17 procedures) were followed-up for an average of four years (range: 2-6). All patients reported symptomatic improvement after the TN arthrodesis. Fourteen of the patients (15 procedures) were completely satisfied. The remaining patient (bilateral procedures) was only partially satisfied due to the subsequent development of navicular-cuneiform osteoarthritis in both feet. Two cases (2 patients) developed complications requiring a second procedure for satisfactory results. In addition, the procedure resulted in an improvement of the talus-first metatarsal angle on both antero-posterior and lateral radiographs. TN arthrodesis produced a correction of the residual clubfoot deformities of the midfoot and resulted in satisfactory clinical improvement in all the patients.

Clinical and radiographic appearance of congenital talipes equinovarus after successful nonoperative treatment

Thirty-one children with 49 feet after successful nonoperative treatment for congenital talipes equinovarus (CTEV) by redressements, hypoallergic adhesive bands, and plaster casts underwent follow-up. At the follow-up, the patients ranged in age from 4.2 years to 12.3 years (average, 8.3 years). The initial type of the deformity was as follows: type I (mild), 18 feet; type II (intermediate), 29 feet; type III (severe), two feet. Mild supination of the forefoot in five feet, isolated excavation in three, and adduction greater than physiological in two feet were the only persistent elements of the deformity. The lack or restriction of the dorsal flexion in the ankle were noted in 22 feet. In only three feet was the Beatson-Pearson index was < 40 degrees. In 17 feet, the radiographs revealed full talonavicular reduction in sagittal and horizontal planes. The average value of the talometatarsal first and tibiocalcaneal angles as in accordance with the standard. The most characteristic osseous disturbances concerned the tarsal navicular (22 feet) and consisted of the decrease of the ossification center, its flattening, fragmentation, cystic-like changes, and wedging.