Nonoperatively Corrected Clubfoot at Age 2 Years: Radiographs Are Not Helpful in Predicting Future Relapse

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.

Pediatric Foot: Development, Variants, and Related Pathology

Pediatric foot development throughout childhood and adolescence can present a diagnostic dilemma for radiologists because imaging appearances may be confused with pathology. Understanding pediatric foot development and anatomical variants, such as accessory ossification centers, is essential to interpret musculoskeletal imaging in children correctly, particularly because many of these variants are incidental but others can be symptomatic. We first briefly review foot embryology. After describing common accessory ossification centers of the foot, we explain the different patterns of foot maturation with attention to irregular ossification and bone marrow development. Common pediatric foot variants and pathology are described, such as tarsal coalitions and fifth metatarsal base fractures. We also discuss pediatric foot alignment and various childhood foot alignment deformities.

A study on the effect of radiographic angles on clubfoot's recurrence

Clubfoot is one of the common orthopaedic deformities. However, regardless of its' treatment high success rate, recurrence of the deformity is a serious issue. The aim of this study is to evaluate if radiographic angles can be used for clubfoot recurrence prediction. This is a prospective study on 91 patients (134 feet) with mean age of 9.5 ± 2.3 days and male/female ratio of 2/1 on patients with congenital clubfoot admitted to our hospital. Pre and one-year post-tenotomy tibiocalcaneal (TIC-L), talocalcaneal (TC-L) and calcaneal-first metatarsal angles (C1M-L) in the lateral view of the patients' radiographs, and their recurrence status until three years were measured. Ten feet experienced relapse. The mean pre and one-year follow-up measurements of TC-L, C1M-L, and TIC-L angles were significantly different between patients who experienced relapse and others (P < .05). The cut-off points of 1.75 and 6.5 for one-year follow-up Pirani and Dimeglio scores for recurrence prediction were suggested respectively. Also, cut-off points of 26.5 and 79.5 for one-year follow-up TC-L and TIC-L angles for recurrence prediction were calculated, respectively. We demonstrated that the pre-tenotomy and one-year follow-up TIC-L, TC-L, and C1M-L angles are helpful in clubfoot recurrence prediction after Ponseti treatment.

The Predictive Value of Radiographs and the Pirani Score for Later Additional Surgery in Ponseti-Treated Idiopathic Clubfeet, an Observational Cohort Study

There are few validated predictors of the need for additional surgery in idiopathic clubfeet treated according to the Ponseti method. Our aim was to examine if physical examination (Pirani score) and radiographs at the age of three months (after initial correction of the clubfeet) can predict the future need for additional surgery. In this retrospective cohort study, radiographs of idiopathic clubfeet were made at the age of three months. The Pirani score was determined at the first cast, before tenotomy, and at the age of three months. Follow-up was at least five years. The correlation between the radiograph, Pirani score, and the need for additional surgery was explored with logistic regression analysis. Parent satisfaction was measured with a disease-specific instrument. The study included 72 clubfeet (50 children) treated according to the Ponseti method. Additional surgery was needed on 27 feet (38%). A larger lateral tibiocalcaneal angle (i.e., equinus) and a smaller lateral talocalcaneal angle (i.e., hindfoot varus) at the age of three months were correlated with the need for additional surgery. Higher Pirani scores before tenotomy and at the age of three months also correlated with additional surgery. Parent satisfaction was lower in patients who needed additional surgery. Both the Pirani scores and the lateral radiographs are predictive for future additional surgery.

Lateral Cuneiform Ossification and Tibialis Anterior Tendon Width in Children Ages 3 to 6: Implications for Interference Screw Fixation of Tibialis Anterior Tendon Transfers in Children

BACKGROUND

While the transfer of the tibialis anterior tendon (TAT) to the lateral cuneiform (LC) following serial casting has been used for nearly 60 years to treat relapsed clubfoot deformity, modern methods of tendon fixation remain largely unstudied. Interference screw fixation represents an alternative strategy that obviates concerns of plantar foot skin pressure-induced necrosis and proper tendon tensioning associated with button suspensory fixation. A better understanding of LC morphology in young children is a necessary first step in assessing the viability of this fixation technique. Therefore, the purpose of this investigation is to define LC morphology and TAT width in children aged 3 to 6 years.

METHODS

A retrospective radiographic review of 40 healthy pediatric feet aged 3 to 6 years who had either magnetic resonance imaging or computed tomography scans was performed at a single pediatric hospital. The length, width, and height of only the ossified portion of the LC were measured digitally using sagittal, coronal, and axial imaging. In addition, the maximal cross-sectional diameter of the TAT was measured at the level of the tibiotalar joint.

RESULTS

The average ossified LC width ranged from 8.5 mm in the 3-year-old cohort to 10.3 mm in 6-year-old children. Analysis of variance testing revealed no statistically significant difference in width between age groups. Average ossified LC length ranged from 13.5 mm in the 3-year-old cohort to 18.3 mm in 6-year-old children with statistically significant increases in age groups separated by 2 or more years. Significant differences in LC height, volume, and TAT diameter were demonstrated after analysis of variance testing. The TAT to ossified LC width ratio ranged from 44% to 53% across age groups.

CONCLUSIONS

The dimensions of the LC ossification center are large enough to allow interference screw fixation in children 3 to 6 years of age. Further studies are needed to investigate interference screw fixation performance in the pediatric clubfoot population.

LEVEL OF EVIDENCE

Level IV.

Ultrasound measurements in clubfoot treated with the Ponseti method and risk factors for recurrence: A retrospective study

Background

Recurrence remains the main challenge in the treatment of clubfoot. The primary goal of this study is to determine if ultrasound measurements are associated with recurrence after successful management with the Ponseti method. Furthermore, other factors are identified which can be associated with recurrence of the deformity.

Methods

Seventy-six infants (114 idiopathic clubfeet), all treated with the Ponseti technique were reviewed. All patients had an ultrasound evaluation by the same radiologist at the beginning of the treatment. Recurrence, defined as the need to return to Ponseti casting, was recorded at a mean follow-up of 5 years. Measurements of association with recurrence were obtained for the following ultrasound measures: the medial talonavicular displacement (MTa-N), the medial malleolus to navicular distance (MM-N), the talocalcaneal angle (Ta-C), and the distal tibial physis to proximal calcaneal apophysis distance (Ti-C). Subsequently, a multivariate logistic regression analysis modeling recurrence examined patients' characteristics, compliance, Achilles tenotomy, and ultrasound measurements.

Results

Recurrence rate was 22% noted in 17 patients. On univariate analysis, relapse was associated with increased MTa-N (p = 0.038), decreased MM-N (p = 0.008), and decreased Ti-C (p = 0.023). On multivariate analysis, we identified the Ti-C as the only ultrasound measurement significantly associated with recurrence (p = 0.026). Other significant predictors for relapse in this study were noncompliance with orthosis (OR = 139.0 (95% CI: 8.7-2224.0), p < 10-3), and omitting percutaneous Achilles tenotomy in clubfoot treatment (OR = 23.9 (95% CI: 1.2-493.6), p = 0.041).

Conclusion

The Ti-C sonographic measurement at the start of treatment can be a useful adjunct to help identify high-risk patients for recurrence of deformity. Non-compliance with bracing and omitting percutaneous Achilles tenotomy are also predictive factors.

Level of evidence

Prognostic study, Level III.

Are early antero-posterior and lateral radiographs predictive of clubfoot relapse requiring surgical intervention in children treated by Ponseti method?

Purpose

To investigate the value of antero-posterior and lateral radiographs in predicting clubfoot relapse after treatment with the Ponseti method.

Methods

This was a retrospective review of 104 children (157 feet) younger than 3 months of age with idiopathic clubfoot treated using the Ponseti method at our institution between January 2007 and December 2014. All patients underwent Achilles tenotomy and were divided into two groups according to the need for further surgery to correct the deformity: relapsed group (24 patients; 36 feet) and non-relapsed group (80 patients; 121 feet). All antero-posterior and lateral foot radiographs were performed less than 3 months after Achilles tenotomy. The talo-calcaneal (TC-AP) and talus-first metatarsal (TM-AP) angles were measured in the antero-posterior view, while the tibio-calcaneal (TIC-L), talus-first metatarsal (TM-L), and talo-calcaneal (TC-L) angles were measured in the lateral view. The multi-factor logistic regression model of the stepwise selection method was used to predict the relapse of clubfoot deformity from the potential predictive values.

Results

The mean age at initial plain radiography examination was 99.45 ± 21.54 days. Differences in TC-AP, TM-AP, TC-L, and TIC-L between the two groups were statistically significant. However, only TM-AP and TIC-L were included in the "risk of relapse" formula using the multi-factor logistic stepwise selection method.

Conclusion

Early antero-posterior and lateral radiographs in children younger than 3 months of age at initial Ponseti treatment have positive predictive value for relapse. Reduced TM-AP angle and increased TIC-L were associated with an increased risk of relapse.

Level of evidence

level III.

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.

Narrative Review of the objective analysis of long-term outcome of the Ponseti technique: experience from Dallas

In 2001, Texas Scottish Rite Hospital for Children (TSRH) prospectively began a clubfoot database that included all of our patients with clubfeet who were willing to enroll. Nonoperative treatment, primarily the Ponseti method, was utilized. This article summarizes the experience from Dallas treating idiopathic clubfeet using the Ponseti technique, and is based on previously published studies utilizing information from the database. Patient clinical outcomes were defined as “good” (plantigrade foot achieved either with or without a percutaneous heel-cord tenotomy), “fair” (a plantigrade foot that required a limited procedure, such as tibialis anterior tendon transfer or posterior release), or “poor” (a plantigrade foot that required posteromedial release). Nearly 95% of idiopathic clubfeet obtained initial correction using the Ponseti technique, but relapses occurred and by age two years 24% needed some surgical intervention, usually limited procedures. Use of Dimeglio’s rating system before treatment strongly correlated with the probability of a “good” outcome at two years. Objective measurements of brace wear compliance (iButton) in those who reached age two years with “good” outcomes demonstrated an unexpected pattern of diminishing use of the foot abduction orthoses over the first two years of brace wear. By the 18-month period of brace wear, 1/3 patients wore the orthoses less than 6 hours per day, and nearly half of the patients wore the orthoses less than 8 hours per day. Between ages 2–5 years, nearly 21% of the corrected clubfeet at age two years needed limited procedures to maintain/regain plantigrade positioning. Lateral weight-bearing radiographs between 18–24 months were not helpful in predicting future relapse in these patients, and are no longer routinely obtained. Following these patients for normal development is important, as nearly 9% of infants initially presenting as idiopathic clubfeet were eventually found to have another disorder including neurological, syndromic, chromosomal, or spinal abnormalities. We continue to emphasize the need to devote great attention to detail when using the Ponseti method in an effort to optimize the clinical outcomes.

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

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

Well though-out introduction of percutaneous Achilles tenotomy during functional treatment of congenital talipes equinovarus: Which indications produce the best results?

INTRODUCTION

Percutaneous Achilles tenotomy (PAT) was recently added to functional treatment of congenital talipes equinovarus (aka clubfoot). The aim of this study was to determine the relevance of a carefully chosen radiological criterion for the PAT indication and to evaluate its results.

HYPOTHESIS

When the tibiocalcaneal angle (aTiCa) is larger than 75° at 4 months, doing PAT will improve the results of the functional method in the medium term and will reduce the surgery rate.

PATIENTS AND METHODS

This prospective study involved 101 patients (151 feet) born between 2011 and 2014 with clubfoot who were treated with the French functional method and had at least 4 years' follow-up. The initial severity of the deformity was evaluated using the Diméglio scoring system. In our sample, 30 feet had a Diméglio rating of II (20%), 61 had a Diméglio rating of III (40%) and 60 feet had a Diméglio rating of IV (40%). The indication for PAT was made at 4 months of age when the aTiCa on a lateral radiograph of the foot in maximum correction was greater than 75°. The mean follow-up was 5 years. The final assessment was done using the modified Ghanem and Seringe classification.

RESULTS

In the entire cohort, PAT was done in 113 feet (75%). None of the feet required a repeat PAT. Surgical release of the soft tissues was done in 20 feet (13%). None of the feet developed a rocker bottom deformity. Two feet were operated in the absence PAT (out of 38 in this subgroup) and 18 feet after PAT (out of 113 in this subgroup). The aTiCa angle did not vary in the PAT group based on whether surgical release was indicated afterwards or not. At the final assessment, 140 feet (93%) were classified as very good and 11 feet (7%) as good.

DISCUSSION

The tibiocalcaneal angle is a relevant radiological criterion for the PAT indication in children with clubfoot. PAT has a positive impact on the outcomes.

LEVEL OF EVIDENCE

II; prospective study.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Functional physiotherapy method results for the treatment of idiopathic clubfoot

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

The PBS Score - a clinical assessment tool for the ambulatory and recurrent clubfoot

PURPOSE

The signs for clubfoot relapse are poorly defined in the literature and there is a lack of a scoring system that allows assessment of clubfeet in ambulatory children. The aim of this study is to develop an easy to use, reliable and validated evaluation tool for ambulatory children with a history of clubfoot.

METHODS

A total of 52 feet (26 children, 41 clubfeet, 11 unaffected feet) were assessed. Three surgeons used the seven-item PBS Score to rate hindfoot varus, standing and walking supination, early heel rise, active/passive ankle dorsiflexion and subtalar abduction blinded to the other examiners. All parents answered the modified Roye score questionnaire prior to the clinical assessment. Correlation between the mean PBS Score and the Roye score was evaluated using Spearman's rank correlation coefficient. Interobserver reliability was tested using weighted and unweighted Cohen's Kappa coefficients.

RESULTS

The Spearman's rank correlation coefficient for correlation between mean PBS Score and Roye score was 0.73 (moderate to good correlation).The interobserver agreement for the total PBS Score resulted in an intraclass correlation coefficient of 0.93 (almost perfect agreement).

CONCLUSION

The PBS score is an easy to use, clinical assessment tool for walking age children with clubfoot deformity. It includes passive and active criteria with a very good interobserver reliability and moderate to good validity.

LEVEL OF EVIDENCE

Level I - Diagnostic study.

Quantification of the ossification of the lateral cuneiform in the feet of young children with unilateral congenital talipes equinovarus

Aims

After the initial correction of congenital talipes equinovarus (CTEV) using the Ponseti method, a subsequent dynamic deformity is often managed by transfer of the tendon of tibialis anterior (TATT) to the lateral cuneiform. Many surgeons believe the lateral cuneiform should be ossified before surgery is undertaken. This study quantifies the ossification process of the lateral cuneiform in children with CTEV between one and three years of age.

Patients and Methods

The length, width and height of the lateral cuneiform were measured in 43 consecutive patients with unilateral CTEV who had been treated using the Ponseti method. Measurements were taken by two independent observers on standardised anteroposterior and lateral radiographs of both feet taken at one, two and three years of age.

Results

All dimensions of the lateral cuneiform on the affected side increased annually but remained smaller than the corresponding dimensions of the unaffected foot (p < 0.01). The lateral cuneiform resembled a 9 mm cube at two years and an 11 mm cube at three years.

Conclusion

At one and two years, the ossification centre of the lateral cuneiform may not be large enough to accommodate a drill hole for tendon transfer. However, by three years, it has undergone sufficient ossification to do so. Cite this article: Bone Joint J 2017;99-B:1109–14.