Diagnosis and Treatment of Idiopathic Congenital Clubfoot

The 10-Year Functional Outcome of Ponseti Treatment of Idiopathic and Arthrogrypotic Clubfeet With an Age-Matched Control

BACKGROUND

The Ponseti method is accepted as an effective primary conservative treatment for idiopathic clubfoot (IC) using serial casting, percutaneous Achilles tenotomy, and prolonged bracing. The outcomes of its use in treating rigid clubfoot in arthrogryposis are unclear. This study assesses the outcomes of the Ponseti method in children with IC and arthrogrypotic clubfoot at an average age of 10 years.

METHODS

Outcomes of the Ponseti method were retrospectively studied in ambulatory children ages 8.0 to 12.9 years in the gait lab between 2004 and 2024. Children were excluded due to the presence of nonidiopathic or nonarthrogryposis-related clubfoot and history of posteromedial release. The Ponseti treatment included serial casting and Achilles tenotomy in infancy, followed by night bracing until age 5 in both cohorts. Clubfoot groups were compared with typically developing children by analyses of foot pressure data, passive range of motion, Gross Motor Function Measure Dimension-D, and Pediatric Outcomes Data Collection Instrument. Surgical history was also recorded. A subsection of these children visited the gait lab at age 4.0 to 6.9 years (2003 to 2021) and data from their visits were abstracted for a longitudinal study.

RESULTS

One hundred seventy-seven children were reviewed (48 with clubfoot associated with arthrogryposis, 129 with IC) with an average age of 9.4±0.9 years. Repeat surgical intervention was used in 33% of IC feet and 44% of arthrogrypotic clubfeet. Residual equinovarus and limitations in range of motion were present in both clubfoot groups compared with typically developing feet (P<0.05). The foot deformity and passive range of motion restrictions were more severe in children with arthrogrypotic clubfeet (P<0.05). The arthrogrypotic clubfoot group additionally exhibited limited gross motor and global function (P<0.001). In 5-year to 10-year comparisons, both subgroups showed more limitations in ankle motion but improvements in dynamic equinovarus deformity and function at age 10 years (P<0.05).

CONCLUSIONS

Despite residual deformity, children with idiopathic clubfoot achieve typical functional outcomes through Ponseti treatment. Children with arthrogrypotic clubfeet exhibit functional limitations, but the Ponseti method is effective in improving foot position while minimizing the need for surgical intervention.

LEVEL OF EVIDENCE

Level III-therapeutic studies-investigating the results of treatment.

The Relationship Between Developmental Dysplasia of the Hip (DDH) and Congenital Talipes Equinovarus (CTEV)-A Retrospective Case Series

BACKGROUNDS

There is no consensus if a relationship exists between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip (DDH). Our research aim was to provide a contemporary Australian population statistical relationship between DDH and idiopathic CTEV, compared to published data.

METHODS

We conducted a retrospective data analysis of a continuous sample of infants with idiopathic CTEV, who attended a Ponseti Clinic at Sydney Children's Hospital, born between 2010 and 2019. The prevalence of DDH requiring treatment was diagnosed utilising screening ultrasonography and compared to the most valid population data from Australia. The relative risk compared to this data was also determined.

RESULTS

There were 250 subjects who met the inclusion criteria and had complete datasets for analysis. The prevalence of DDH in our idiopathic CTEV study population was 52.9 (95% CI 27.6-90.5) per 1000. This represents a higher prevalence rate than Western Australian and South Australian datasets, with 9.5 (95% CI 8.9-10.1) and 5.0 (95% CI 4.6-5.5) per 1000, respectively. The relative risk of DDH in our idiopathic CTEV study population was 5.59 (95% CI 3.21-9.73, p < 0.0001) and 10.50 (95% CI 6.01-18.34, p < 0.0001), compared to Western Australian and South Australian population datasets, respectively.

CONCLUSION

Our study findings support a positive correlation between idiopathic CTEV and DDH. The relative risk of DDH in the idiopathic CTEV population is 5-10 times higher than the general Australian population. When selective hip ultrasound screening is used, we believe idiopathic CTEV should be considered a risk factor for DDH.

Patient-Reported Outcomes in Children With Idiopathic Clubfoot Deformity Treated With Ponseti Casting: Does Recurrence of the Deformity Play a Role?

INTRODUCTION

Despite the high effectiveness of Ponseti casting in treating idiopathic clubfoot, patient-reported outcomes (PROs) are not studied well in the literature, necessitating further investigation into PROs to evaluate the effect on patients' lives. We used the Patient-Reported Outcomes Measurement Information System (PROMIS) to evaluate PROs in children with Ponseti-treated clubfoot and assess the effect of recurrence on these PROs.

METHODS

This study retrospectively reviewed medical records from patients ages 5 to 18 years treated for idiopathic clubfoot at a single institution from 2002 to 2023 with available PROMIS data for mobility, pain, and peer relationships. Exclusion criteria included initial treatment other than Ponseti casting, presentation to our institution after age 2 years, and PROMIS scores taken less than 6 months postsurgery. Recurrence was defined as patients who required further treatment with casting or surgery after initial correction.

RESULTS

Among 50 patients eligible for this study, 78% (39) were male and 34% (17) had bilateral clubfoot. Average age when the most recent PROMIS data were collected was 6.1 years. Average PROMIS scores were 51.1 mobility, 44.2 pain interference, and 51.9 peer relationships. Notably, patients with recurrence showed similar PROMIS scores across all domains when compared with nonrecurrent patients: 50.7 ± 8.1 vs. 51.5 ± 9.8 ( P = 0.753) mobility, 45.5 ± 8.9 vs. 43.1 ± 8.7 ( P = 0.334) pain interference, and 52.5 ± 9.7 vs. 51.3 ± 9.1 ( P = 0.634) peer relationships.

CONCLUSION

To our knowledge, this is the first study to use PROMIS scores to evaluate the effect of recurrence on PROs in children with Ponseti-treated clubfoot. The findings of this study suggest that children who sustained recurrence did not have markedly different PROMIS outcomes compared with nonrecurrent children, regardless of treatment modality for recurrence, indicating limited effect of recurrence on PROs at an average 5-year follow-up.

Tibialis Anterior Tendon Transfer for Clubfoot Deformity: Cuboid Versus Lateral Cuneiform

BACKGROUND

Tibialis anterior tendon transfer in relapsing clubfoot deformity is a well-known treatment option for dynamic forefoot supination and adduction deformities. The tibialis anterior tendon can be anchored to the lateral cuneiform or the cuboid. A complication of this surgery is overcorrection to a flatfoot deformity or undercorrection that maintains the clubfoot deformity. We compared reoperation rates and clinical outcomes between these 2 groups.

METHODS

This is a retrospective study performed from 2005 to 2020. The primary outcome was repeat operation. The secondary outcome included clinical appearance scores described by Garceau and Palmer.

RESULTS

There were 114 clubfeet (111 patients) treated in our study. Of them, 67 (58.8%) had a transfer to the lateral cuneiform, whereas 47 (41.2%) had a transfer to the cuboid. Nine patients had reoperations which included 4 (44.4%) in the lateral cuneiform group and 5 (55.6%) in the cuboid group which was not statistically significant ( P =0.485). Clinical appearance scores revealed significantly better clinical appearance in the lateral cuneiform group after surgery compared with the cuboid group ( P =0.0172).

CONCLUSIONS

There were no clinically significant differences in reoperation rates between transfers to the lateral cuneiform versus the cuboid. We did find better clinical appearance in the lateral cuneiform group after surgery compared with the cuboid group.

LEVEL OF EVIDENCE

Level III retrospective comparative study.

Comparison between unilateral and bilateral clubfoot treated with Ponseti method at walking age: static and dynamic assessment

This study evaluated the static, postural, dynamic, and clinical outcomes among five groups of patients: a bilateral CTEV (congenital talipes equinovarus) group treated with tenotomy ( n = 14), bilateral CTEV group treated conservatively ( n = 6), unilateral CTEV group treated with tenotomy ( n = 7), unilateral CTEV group treated conservatively ( n = 3), and control group ( n = 20). Data were collected through baropodometric examinations and clinical evaluations using Pirani, clubfoot assessment protocol, foot and ankle disability index (FADI), and American Orthopedic Foot and Ankle Society scores. Bilateral CTEV patients treated with tenotomy showed no statistically significant differences compared to healthy controls. Significant differences were found in lateral-lateral variation in the bilateral postural group ( P  = 0.002) and in static peak pressure in unilateral tenotomy patients ( P  = 0.046). Dynamic comparisons revealed significant differences in mean pressure between unilateral groups ( P  = 0.002) and lateral-lateral variation in bilateral groups ( P  = 0.004). The Pirani score showed significant differences between tenotomy-treated and postural patients ( P  = 0.000). Statistically significant differences in FADI scores were found between bilateral groups ( P  = 0.0037), between tenotomy-treated groups ( P  = 0.0020), and between the bilateral tenotomy-treated group and the unilateral postural group ( P  = 0.021). Bilateral CTEV patients treated with tenotomy develop static and dynamic values comparable to healthy controls. Bilateral patients develop better dynamic values compared to patients with a unilateral variant. Level of evidence: III.

Factors influencing recurrence in clubfoot treatment with the Ponseti method in children under 5 years of age: a scoping review

Clubfoot (CF) is one of the most common musculoskeletal congenital abnormalities. Despite having optimal methods for its treatment, factors associated with the recurrence of CF treatment continue to be a topic of interest. The aim of this study was to perform a scoping review of the existing literature on factors associated with the recurrence of CF following treatment with the Ponseti method in children under 5 years of age. A scoping literature review was conducted in March 2024 using PubMed and Embase databases, and a structured research strategy. Screening of articles was performed by independent reviewers to ensure the inclusion of all pertinent studies. Considering inclusion and exclusion criteria, a final of 18 articles were included which encompassed factors associated with the recurrence of CF after treatment with the Ponseti method. The Ponseti method has demonstrated a high success rate in achieving CF correction. Various factors come into play regarding favorable outcomes and recurrence cases. The identified factors were initial severity scores for CF, age at the beginning of treatment, correct identification of idiopathic CF and complex CF, neuromuscular imbalance, poor nutritional status, noncompliance for the brace use, and the availability of a specialized attention center that ensured proper Ponseti method application and treatment adherence. Our findings highlight the importance of identifying different factors associated with the recurrence of CF following treatment with the Ponseti method, where timely intervention could minimize the risk of recurrence and achieve favorable outcomes.

Population-based assessment of major congenital malformations in the United States: smoking risk association

The incidence of congenital malformations (CM) among non-Hispanic White American (NHWA) mothers was reviewed to identify and evaluate the geographic differences in the most frequent CM subtypes associated with smoking and other risk factors. Data on CM were obtained from 150,775 children (2000-2004) from the Centers for Disease Control and Prevention. Risk factors associated with CM development were the mother's age < 21 and > 35 years, body weight gain during pregnancy, anemia, diabetes mellitus, eclampsia (cases of preeclampsia were omitted), smoking, and alcohol use during pregnancy. Among smoking mothers, the most common CM was omphalocele, club foot, cleft lip, and polydactyly. The highest incidences (CM/10,000 births/year) of observed CM in children of smoking mothers were clubfoot, 25.51 cases (Utah), cleft lip, 22.47 (South Dakota), polydactyly, 21.23 (North Dakota), and omphalocele, 13.14 (Montana). The presence of maternal comorbidities, tobacco and alcohol consumption, and their association with other environmental factors can affect the incidence of CM in NHWA mothers. Further comparisons among the American states regarding the overall changes in CM over the last two decades should uncover crucial outcomes in terms of CM and smoking.

Outcome of the Ponseti Method for Treatment of Idiopathic Congenital Clubfoot

Introduction Idiopathic congenital clubfoot is a complex deformity that requires treatment to reduce the deformity to a flexible, plantigrade, and painless foot. The Ponseti method has gained international prominence due to its effectiveness and reduction in the need for surgical procedures. The aim of this study is to determine the outcome of the Ponseti method in patients with idiopathic congenital clubfoot, which will generate local evidence. Methods A descriptive cross-sectional study was conducted in the Department of Orthopaedics at Jinnah Postgraduate Medical Centre (JPMC) Karachi over a six-month period, from September 6, 2022, to March 7, 2023. Participants were included if they were children under three years of age, presented with idiopathic congenital clubfoot, and had a Pirani score of 2 or higher. The outcome was assessed immediately after the completion of treatment and after four months by using the Pirani score. Results were graded as excellent (Pirani score <1), good (score 1-2), and poor (score >2). Baseline demographic characteristics and Pirani score were recorded immediately after completion of treatment and after four months. Effect modifiers such as age, gender, weight, residence, and baseline Pirani score were controlled through stratification. Post-stratification Chi-square test was applied taking p-value ≤0.05 as significant. Results Of 91 neonates, the mean age of the neonates was 1.44 ±0.66 years. There were 51 (56%) males and 40 (44%) females. The Pirani score immediately after the treatment was 1.61 ± 1.38. Excellent outcome immediately after the treatment was observed in 43 (47.3%), good in 26 (28.6%), and fair in 22 (24.2%). At four months follow-up, the Pirani score was 0.91 ± 0.81. Excellent outcome immediately after the treatment was observed in 63 (69.2%), good in 23 (25.3%), and fair in five (5.5%). Conclusion The Ponseti method is an effective and reliable treatment for idiopathic congenital clubfoot at a tertiary care hospital. The intervention achieves marked improvement in deformity correction and also sustains clinical benefits over the short-term follow-up period. Future research with extended follow-up periods and broader sample sizes is needed to further evaluate long-term functional outcomes.

Prenatal Counseling for Congenital Clubfoot

Congenital clubfoot is a common deformity that affects 1 in 1000 newborns and is frequently detected prenatally during routine prenatal care. A wide variety of detection methods and testing are used to identify clubfoot and other congenital anomalies in the fetus, including complete ultrasonography, amniocentesis, chorionic villus sampling, or cell-free DNA. Newer studies have associated certain genome sequences to clubfoot specifically. It is important for orthopaedic surgeons to understand the implications of the various tests to provide the appropriate prenatal counseling. Early prenatal detection of clubfoot can help parents prepare for the demands of caring for a child with clubfoot and build trust between families and clinicians, ultimately leading to better, patient-centered care for their children.

Key Concepts

(1)Prompt recognition and treatment of congenital clubfoot is imperative to facilitate optimal treatment.(2)Prenatal diagnosis usually consists of sonography of the plantar surface of both feet at 13-16 weeks' gestation.(3)Additional post-natal testing may be indicated in patients with neurological impairment or syndromic features.(4)Genetic markers such as PITX1, RBM10, HOX, and CASP (among others) have been identified as involved in clubfoot development and have implications on prenatal testing and counseling.

Early Radiographic Characteristics of the Lateral Talocalcaneal Angle and its Predictive Significance for Relapse in Patients With Idiopathic Clubfoot Treated With the Ponseti Method

In order to evaluate the early radiographic characteristics of the lateral talocalcaneal (L-TC) angle in patients with idiopathic clubfoot (ICF) and to investigate its prognostic significance for relapse after initial treatment with the Ponseti method. We retrospectively included 151 patients (96 males and 55 females; 227 feet) with ICF treated at our Institution between January 2005 and December 2014. The age at initial treatment was less than 6 months, and radiographs were obtained within 3 months of the Achilles tenotomy (mean age: 2.3 months; range: 0.77-6.8). All patients were followed up for at least 7 years (range, 7-18). The participants' feet were classified into 3 groups: relapsed (Group A), not relapsed (Group B), and normal foot groups which consisted of healthy feet in patients with unilateral ICF (Group C). All angle measurements were expressed in degrees. Forty-seven ICF feet in 33 patients relapsed, while 180 feet in 118 patients did not, and the age at relapse was 5.92 ± 1.91 years. Seventy-five normal feet were included in Group C. The average L-TC angle in Group A and B patients was 33.57° ± 12.05° and 39.37° ± 12.55°, respectively, while Group C was 49.61° ± 9.11°. A significant difference was found among the 3 groups of patients (F = 31.48, p < .001). The L-TC angle cut-off value below which a recurrence could be predicted was 36.1° (sensitivity, 74.47%). The L-TC angle of ICF patients treated using the Ponseti method were reduced compared to normal feet. An L-TC angle of <36.1° has relative value in predicting ICF relapse.

Peroneal Nerve Dysfunction in Patients With Clubfoot Deformity: Evaluation of Clinical Presentation and Treatment

The congenital foot drop associated with congenital talipes equinovarus (CTEV) deformity secondary to common peroneal nerve injury is rare. Moreover, the foot drop may even be completely overlooked when associated with clubfoot due to its similar appearance. We report a case of peroneal nerve dysfunction in a child with a late presentation of congenital clubfoot who underwent tibialis posterior transfer to improve mobility and function.

Midterm clinical and radiological outcomes of arthrogryposis-associated clubfoot treated with the Ponseti method: a retrospective observational study and comprehensive literature review

BACKGROUND

The treatment results of the Ponseti method for arthrogrypotic clubfoot have been described in only a few case series. Further evaluations are necessary.

METHODS

Children from two German paediatric orthopaedic hospitals with arthrogryposis-associated clubfoot treated with the Ponseti method between 2004 and 2011 and who were at least five years of age at their last follow-up were retrospectively evaluated. The endpoints were the clinical foot position, necessary surgeries during the follow-up period and radiological constellations. A comprehensive literature review was conducted after a systematic literature search.

RESULTS

Seventeen patients (47% with amyoplasia [AP] and 53% with distal arthrogryposis [DA]) met the inclusion criteria. Thirty-one feet were evaluated. The period between the treatment start and the last follow-up examination covered 8.9 ± 2.5 years. After the last cast removal within the initial Ponseti cast series, 74% of the clinical results were good to excellent. However, the clinical outcomes in the patients with AP were significantly worse. Overall, in 23 feet (74%), at least one major surgery at the age of 2.9 ± 2.2 years was necessary during the clinical course. Major surgeries were much more frequent on the feet of the patients with AP than with DA. Lateral X-rays showed normal age-appropriate radiological angles in 4% of the feet, hindfoot equinus in 19%, under-corrected hindfoot in 44%, under-corrected clubfoot in 26% and rocker bottom deformity in 7%. The radiological residual deformities in AP were much more severe than in DA (p = 0.042). Most of the studies reviewed (11 case series, 144 patients) reported high initial clinical correction rates, followed by high recurrence rates and the need for further surgeries.

CONCLUSION

About a quarter of the arthrogrypotic patients benefited from the Ponseti therapy without further major surgery. However, the clinically observed high initial correction rate after Ponseti therapy of arthrogrypotic clubfoot was not accompanied by a correction of the bony foot position in the X-rays. The feet of the patients with DA had better outcomes than those of the patients with AP. Therefore, in outcome studies, a clear distinction between patients with AP and those with DA is necessary.

Missed Visits Predict Recurrence in Idiopathic Clubfoot

BACKGROUND

Congenital talipes equinovarus, also known as "clubfoot," is a common congenital deformity. While reported relapse rates vary widely, relapse continues to be a common problem faced in the treatment of this condition. The objective of this study is to assess relationships between demographic/socioeconomic factors, follow-up, and rates of relapse in our population of clubfoot patients.

METHODS

Retrospective chart review was conducted for patients undergoing treatment for idiopathic clubfoot from February 2012 to December 2022 at a tertiary children's hospital. Records were analyzed for follow-up adherence and recurrence in the Ponseti method, in addition to patient demographic and socioeconomic factors. Statistical analysis was performed to evaluate associations between recurrence, missed clinical visits, and demographic/socioeconomic factors of interest.

RESULTS

Ninety-five patients were included in the study [74.7% male (N=71) and 25.2% female (N=24)]. A total of 64.2% (N=61) of patients developed recurrence during their treatment. Recurrence rates differed significantly by reported bracing noncompliance >1 month (35/46 vs. 26/49, P =0.019), having missed 1 or more clinical visits (38/61 vs. 8/34, P < 0.001), Medicaid or equivalent insurance type (41/56 vs. 20/39, P =0.028), non-white race (47/66 vs. 14/29, P =0.032, higher Social Deprivation Index score (56.13 vs. 41.06, P =0.019). Significant variables were analyzed using a multivariate logistic regression analysis (MVLR). After MVLR, having 1 or more missed clinical visits (OR 4.462, 95% CI: 1.549-12.856) remained significantly associated with increased rates of recurrence. Primary language preference and distance to the hospital were not associated with recurrence.

CONCLUSIONS

Higher SDI scores, non-white race, Medicaid insurance, and missed clinical follow-up visits were all associated with increased rates of recurrence for clubfoot patients. Using an MVLR model, missed clinical follow-up visits remained independently associated with increased recurrence rates.

LEVEL OF EVIDENCE

Level 2-retrospective, prognostic study.

Prevalence and associated factors of clubfoot in the eastern province of Saudi Arabia: A hospital-based study

BACKGROUND

Clubfoot, or congenital talipes equinovarus, is a widely recognized cause of disability and congenital deformity worldwide, which significantly impacts the quality of life. Effective management of clubfoot requires long-term, multidisciplinary intervention. It is important to understand how common this condition is in order to assess its impact on the population. Unfortunately, few studies have investigated the prevalence of clubfoot in Saudi Arabia.

AIM

To determine the prevalence of clubfoot in Saudi Arabia via the patient population at King Fahad University Hospital (KFUH).

METHODS

This was a retrospective study conducted at one of the largest hospitals in the country and located in one of the most densely populated of the administrative regions.

RESULTS

Of the 7792 births between 2015 to 2023 that were included in the analysis, 42 patients were diagnosed with clubfoot, resulting in a prevalence of 5.3 per 1000 live births at KFUH.

CONCLUSION

The observed prevalence of clubfoot was significantly higher than both global and local estimates, indicating a substantial burden in the study population.

Reproducibility of pop sensation, Thompson sign in achillotomy, and final Pirani score to predict clubfoot relapse: Achillotomy clinical signs and Pirani predictive ability

Ultrasound (US) can guide and confirm percutaneous release of the achilles tendon in the clubfoot. However, this technique may not always be available; therefore, surgeons' reported feelings of tendon release ("click" or "pop") and the Thompson sign could demonstrate that they are sensitive and reliable for confirming complete tendon release. The purpose of this study was to compare the reproducibility of clinical maneuvers that aim to detect the reported "click" or "pop" sensation by the surgeon and the Thompson sign after surgical release in percutaneous achilles tenotomy compare with US in patients with clubfoot. A cross-sectional reproducibility study of consecutive patients with idiopathic clubfoot was conducted. All the patients were scheduled to undergo tenotomy in the operating room using the standard percutaneous achilles tenotomy technique under sedation. The surgeon's reported surgical sensation ("click" or "pop") and Thompson signs were compared to the US assessment of the cut. The final Pirani score was used to predict recurrence risk and was correlated with the number of plaster casts and age. Forty-five feet were affected in 30 patients. Eighteen (60%) men. Age range: 1 to 60 months. The sensation of "click" or "pop" was recorded in 38 patients, and complete release was confirmed by US in 37 patients, for a sensitivity (Se) of 0.95 and specificity (Sp) of 0.63. Thompson signs were positive in 33 and 36 patients at 2 evaluations, with Se values of 0.87 and 0.92 and Sp values of 0.88 and 0.75, respectively. The Pirani final score, a predictor of recurrence risk, had an area under the curve of 0.80 (95% CI = 0.63-0.97; P = .005), Se = 0.78, and Sp = 0.56, with a cutoff point of 2.75. The feeling of achilles tendon release and Thompson sign had high sensitivity, prevalence, accuracy, and posttest probability. The confirmation of tendon release based on clinical signs could prevent the use of US.

A thorough analysis of data on the correlation between COL9A1 polymorphisms and the susceptibility to congenital talipes equinovarus: a meta-analysis

BACKGROUND

Congenital talipes equinovarus (CTEV) is a prevalent pediatric deformity with a multifactorial etiology. The objective of this meta-analysis was to explore the association between genetic variations in COL9A1 and the susceptibility to CTEV.

METHODS

A comprehensive analysis of pertinent literature released before November 15, 2023, in electronic bibliographic databases was carried out. The importance of the connection was clarified through odds ratios (ORs) with 95% confidence intervals (CIs), utilizing random or fixed-effects models depending on study heterogeneity. Statistical analysis was executed using Comprehensive Meta-Analysis software (Version 4.0).

RESULTS

A total of eight case-control studies involving 833 CTEV patients and 1280 healthy individuals were included in the analysis. Among these, four studies investigated the rs1135056 variant, encompassing 432 CTEV cases and 603 controls; two studies examined the rs35470562 variant, with 189 CTEV cases and 378 controls; and two studies explored the rs592121 variant, including 212 CTEV cases and 299 controls. The results revealed a significant association between the rs1135056 and rs35470562 polymorphisms in the COL9A1 gene, suggesting an increased risk of CTEV in the overall population. Conversely, no such association was found for the rs592121 variant.

CONCLUSION

Our findings reveal a substantial association between the genetic variants COL9A1 rs1135056 and rs35470562 and susceptibility to CTEV. Conversely, the variant rs592121 did not exhibit any corresponding link. However, the limitations imposed by the small study population have compromised the statistical reliability and generalizability of the results.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Determining the Optimal Treatment for Idiopathic Clubfoot: A Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Clubfoot, or congenital talipes equinovarus deformity, is a common anomaly affecting the foot in infants. However, clinical equipoise remains between different interventions, especially those based on the Ponseti method. The aim of this study was to examine the clinical outcomes of the various interventions for treating idiopathic clubfoot.

METHODS

Searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Scopus, and CINAHL were conducted. Randomized controlled trials comparing different interventions, including the Ponseti method, accelerated Ponseti method, Ponseti method with botulinum toxin type A (Botox) injection, Ponseti method with early tibialis anterior tendon transfer (TATT), Kite method, and surgical treatment, were included. Network meta-analyses (NMAs) were conducted according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) reporting guidelines. The primary outcomes were the change in total Pirani score and maximal ankle dorsiflexion. Secondary outcomes were the number of casts, time in casts, and rates of tenotomy, total complications, relapse, adverse events, and additional required major surgery.

RESULTS

Eleven randomized controlled trials involving 740 feet were included. According to the SUCRA (surface under the cumulative ranking curve)-based relative ranking, the Ponseti method was associated with the best outcomes in terms of Pirani score changes, maximal ankle dorsiflexion, number of casts, adverse events, and total complications, whereas the accelerated Ponseti method was associated with the best outcomes in terms of time in casts and tenotomy rate. Early TATT ranked best in terms of relapse rate. The Ponseti method with Botox injection was associated with the best outcomes in terms of the need for additional major surgery.

CONCLUSIONS

The NMAs suggest that the Ponseti method is the optimal treatment overall, despite potential drawbacks such as longer time in casts and higher rates of tenotomy, relapse, and the need for additional surgery compared with other modified approaches. Therefore, clinicians should consider how treatments can be tailored individually.

LEVEL OF EVIDENCE

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

Neonatal Assessment: Put Your Best Foot Forward

BACKGROUND

Assessment of the foot is an essential part of the newborn examination. Foot abnormalities range from an isolated deformity due to intrauterine positioning to a functional impairment due to a structural malformation. The purpose of this article is to review assessment, abnormal findings, and current treatment options of common foot deformities.

EVIDENCE ACQUISITION

A review of literature was conducted using keywords in PubMed, Google Scholar, and CINAHL databases from 2018 to 2023.

RESULTS

Although assessment techniques for the neonatal foot remain the same, recent nonsurgical treatment options are available for a variety of neonatal foot deformities. Early recognition allows for proper evaluation of foot deformities and corrective measures.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Neonatal providers equipped with knowledge of common foot problems can provide support and anticipatory guidance to families.

Treating Older Children with Clubfoot: Results of a Cross-Sectional Survey of Expert Practitioners

Treating clubfoot in walking-age children is debated, despite studies showing that using the Ponseti casting principles can correct the midfoot effectively. We aimed to explore techniques and approaches for the management of older children with clubfoot and identify consensus areas. A mixed-methods cross-sectional electronic survey on delayed-presenting clubfoot (DPC) was sent to 88 clubfoot practitioners (response rate 56.8%). We collected data on decision-making, casting, imaging, orthotics, surgery, recurrence, rehabilitation, multidisciplinary care, and contextual factors. The quantitative data were analysed using descriptive statistics. The qualitative data were analysed using conventional content analysis. Many respondents reported using the Pirani score and some used the PAVER score to aid deformity severity assessment and correctability. Respondents consistently applied the Ponseti casting principles with a stepwise approach. Respondents reported economic, social, and other contextual factors that influenced the timing of the treatment, the decision to treat a bilateral deformity simultaneously, and casting intervals. Differences were seen around orthotic usage and surgical approaches, such as the use of tibialis anterior tendon transfer following full correction. In summary, the survey identified consensus areas in the overall principles of management for older children with clubfoot and the implementation of the Ponseti principles. The results indicate these principles are well recognised as a multidisciplinary approach for older children with clubfoot and can be adapted well for different geographical and healthcare contexts.

Parental Concerns Regarding Bracing Compliance for Children With Clubfoot: Seeking Support on Facebook

Background Clubfoot treatment requires a period of bracing until early childhood to maintain the initial correction achieved by Ponseti casting and serial manipulations. During this period, bracing compliance is the most important factor in preventing the relapse of clubfoot deformity. This period can be challenging for parents, given several factors that affect treatment adherence. In recent years, social media has opened up new ways to seek guidance from an online community, including health-focused areas such as congenital clubfoot. This study examines bracing-related concerns that arise during clubfoot treatment that lead caregivers to seek support from online forums like Facebook. Methodology Six Facebook clubfoot support groups with the highest number of clubfoot posts were evaluated to identify the relative proportion and content of posts related to bracing compliance during December 2021. Bracing-related concerns across all identified posts were then organized into the following six domains that may affect the child's bracing adherence: physical, psychological, commercial, social, bracing device-related, and parental. Results In December 2021, there were 442 total posts across the six clubfoot-focused Facebook groups analyzed. Of these, 23.1% of posts were directly related to bracing compliance. Approximately 22% of these posts had responses where at least one fellow parent suggested seeking advice from a healthcare professional. When these root concerns were organized into six domains that can affect the child's bracing compliance, we found 49 physical, 26 psychological, 5 commercial, 0 social, 14 bracing device-related, and 8 parental factors. Conclusions In this study, 23.1% of all analyzed Facebook posts involved discussion about brace-related concerns, making this a significant topic of discussion on online parental forums. Facebook groups create a community and provide emotional support to parents that support bracing compliance. Clubfoot physicians should be aware of key parental concerns related to bracing compliance, and physicians can provide education on bracing that provides accurate information and anticipatory counseling during regular check-ups with patients and their families.

Congenital Talipes Equinovarus Management and Outcomes: The Experiences of Pediatric Tertiary Centers in Abha, Saudi Arabia

BACKGROUND

Congenital talipes equinovarus (CTEV), also known as clubfoot, describes a range of foot abnormalities usually present at birth (congenital) in which a baby's foot is twisted out of shape or position. In clubfoot, tendons are shorter than usual. Clubfoot is a fairly common birth defect and is usually an isolated problem for an otherwise healthy newborn.

AIM

This study aimed to investigate the experiences of pediatric tertiary centers in Abha, Saudi Arabia, regarding the management, frequency, treatment options, and outcomes of CTEV.

METHODS

A retrospective chart review of pediatric patients with clubfoot was conducted to evaluate the number of cases, treatment options, and outcomes at Abha Maternity and Children Hospital and Khamis Mushait Maternity and Children Hospital. Data were extracted independently using prestructured data extraction forms. The collected data included demographic and medical information, family history, clinico-epidemiological information, risk factors, management options, and complications of clubfoot.

RESULTS

The study included 89 children with CTEV from the target hospitals. Their ages ranged from 20 days to six years, with a mean age of 10.5 ± 14.5 months. Of these, 57 (64%) were male. CTEV was unilateral in 53 (59.5%) cases and bilateral in 36 (40.5%) cases. The majority of the cases had isolated CTEV. Nearly all cases had Ponseti casting with a tendo-Achilles tenotomy (TAT) surgical procedure. Patient follow-up ranged from one week to three years, with an average follow-up of 3.1 months. Only three (3.4%) cases experienced recurrence of deformity after management.

CONCLUSION

Ponseti casting with the tendo-Achilles tenotomy approach emerged as the most commonly employed management option, demonstrating a low rate of recurrence.

Ankle and Foot Deformities in Children

Ankle and foot deformity is one of the most common musculoskeletal disorders in children and a leading cause of functional impairment and diminished quality of life when not treated. A spectrum of conditions may produce foot and ankle deformities, with congenital disorders the most frequent cause, followed by acquired conditions. Congenital disorders include congenital talipes equinovarus or congenital clubfoot, metatarsus adductus, skewfoot, congenital vertical talus, and tarsal coalition.Some of these deformities are frequent and easily diagnosed based on clinical features, but clinical overlap between pathologies can be challenging. Thus imaging plays a paramount role in evaluating these patients. Radiographs are the first imaging modality of choice, but they may not be sufficient in infants due to the lack of ossification of the tarsal bones. Ultrasonography allows not only a detailed visualization of the cartilaginous structures but also permits a dynamic study of the foot and ankle. Computed tomography may be necessary in certain conditions such as tarsal coalitions.

Biomechanical Implications of Congenital Conditions of the Foot/Ankle

Segmental foot and ankle models are often used as part of instrumented gait analysis when planning interventions for complex congenital foot conditions. More than 40 models have been used for clinical analysis, and it is important to understand the technical differences among models. These models have been used to improve clinical planning of pediatric foot conditions including clubfoot, planovalgus, and equinovarus. They have also been used to identify clinically relevant subgroups among pediatric populations, quantify postoperative outcomes, and explain variability in healthy populations.

Clubfoot from past to the present: A bibliometric analysis with global productivity and research trends

Clubfoot, a common congenital abnormality, affects the lower extremities; however, the literature search revealed no bibliometric research on this subject. Thus, we aimed to holistically analyze scientific articles and reveal global productivity and trend issues. This study statistically analyzed 1417 published articles on clubfoot (1980-2021) from the Web of Science database. Bibliometric network visualization maps were created to reveal trend topics, citation analysis, and cross-country collaborations. The analysis was conducted using Spearman correlation analysis. An exponential smoothing estimator was used to predict article productivity. The United States of America (433, 30.5%), the United Kingdom (166, 11.7%), and India (107, 7.5%) are the top 3 countries contributing to the literature. The Journal of Pediatric Orthopedics (220 articles), the Journal of Pediatric Orthopedics-Part B (147 articles), and Clinical Orthopedics and Related Research (69 articles) are the top 3 most productive journals. Dobbs MB (34 articles) is the most active author, and Shriners Hospital Children (44 articles) is the most active institution. Bibliometric analysis revealed that recently studied trend topics included Pirani score, Dimeglio score, Ponseti method, Ponseti casting, tenotomy, recurrence, neglected, tendon transfer, bracing, gait, risk factors, pedobarography, complex clubfoot, and polymorphism. The most studied subjects included Ponseti technique, treatment/casting, recurrent/relapsed clubfoot, Pirani score, pediatrics/children, foot deformities, surgery, ultrasound, Achilles tendon/tenotomy, gait analysis, casting, outcomes, neglected clubfoot, and tenotomy. Research leadership was determined in the western and European countries and Canada in studies and scientific collaborations on clubfoot; its impact was remarkable in India, China, and Turkey.

Postsurgical Evaluation of the Pediatric Foot and Ankle

This article reviews situations in which surgical treatment is required in the context of different types of pathology in the foot and ankle of children, focusing on the role of imaging in surgical planning and postsurgical assessment. The types of pathology analyzed from this perspective are congenital pathology, neuromuscular disorders, osteochondral lesions, fractures and infection, ligament injuries, and tumors.We address the most common pitfalls of postsurgical imaging of the ankle and foot in children. With some exceptions, postsurgical follow-up focuses on clinical assessment, with imaging follow-up only needed in patients where complications are suspected or symptoms recur. Postoperative assessment of the foot and ankle in children and adolescents requires knowing the indications for surgery and the most common types of interventions, along with their imaging characteristics. The radiologist needs to be aware of the normal sequence of development of structures and how to select adequate imaging techniques to assess anatomy at various stages or in different postsurgical scenarios.

Provision of rehabilitation for congenital conditions

Considerable progress has been made in saving the lives of children younger than 5 years. Nevertheless, these advances have failed to help all children thrive, particularly children with disabilities. We describe the increasing prevalence of disability among children and adolescents. We evaluate the current situation regarding children with disabilities and rehabilitation in the context of health systems, particularly those in low- and middle-income countries. Within the newborn health agenda, congenital anomalies often require early intervention and rehabilitation. We provide Argentina as an example of a country where rehabilitation for congenital anomalies is integrated into the health system. We argue that congenital anomalies that require rehabilitation have the potential to strengthen rehabilitation systems and policies by: strengthening coordination between primary care and rehabilitation; identifying and understanding pathways that allow families to engage with services; providing human resources for rehabilitation; and building systems and resources that support assistive technology and rehabilitation. We propose ways for countries to prioritize and integrate early identification, referral and care for children with congenital anomalies to strengthen health systems for all. We identify opportunities to expand policy and planning and to design service delivery and workforce strategies through World Health Organization guidelines and frameworks for rehabilitation. We argue that the global health community must act to ensure that rehabilitation services to support functioning from birth are well established, accepted and integrated within health systems, and that disability is prioritized within child health. These steps would strengthen health systems, ensure functioning from birth and make rehabilitation accessible to all.

Comparative study of the outcome of McKay surgery with and without pin in clubfoot patients

BACKGROUND

Clubfoot is one of the most common foot deformities in children. Surgical treatment is the only choice for patients who have failed conservative treatment. To the best of our knowledge, no studies have been done to compare the McKay surgery with a pin versus without a pin. Our study aimed to compare the outcomes of McKay surgery with and without pins in clubfoot patients.

METHOD

This study is an analytical study. The sample size included patients referred to Imam Reza Hospital from 2016 to 2018. Children who did not respond to plaster therapy were under McKay surgery. In this study, patients were divided into two groups of 50 patients. In the first group, after ligament release and tendon extension, a pin was used to maintain the direction of the talonavicular joint. In the second group, no pin was used. Every six months, radiographs were taken of the patients to monitor their progress. After collecting the study data, they were entered into SPSS software (version 25, IBM Corporation, Armonk, NY) and analyzed.

RESULT

The mean age of patients was 5.36±2.07 months. Of these, 79 were boys and 21 girls, most of the subjects were aged 4-6 months, and 24% had unilateral one-way clubs. The severity of the disease was 7 feet in grade 2 (moderate) and 93 feet in grade 3 (severe). There was a significant relationship between age, outcome and type of complications with surgical type.

CONCLUSION

Finally, it can be concluded that McKay surgery (both with and without a pin) is exceptionally effective at treating clubfoot.