Classification of relapse pattern in clubfoot treated with Ponseti technique

Congenital Clubfoot: Difficulties in Maintaining the Use of the Dennis-Brown Orthosis by Caregivers

Objective This study aimed to identify the main difficulties faced by the family when a child with congenital clubfoot (CC) uses the Dennis-Brown orthosis. Method  This study interviewed via Google Forms caregivers of children treated from 2015 to 2018 regarding their difficulties in orthosis use. Results  The answers revealed that orthosis-related difficulties are independent of the child's gender, age, or affected side. We noted that 41.7% of the respondents reported some difficulty, especially the child's irritation when using the orthosis (93.3%). Conclusion  The main factor in CC relapses is poor adherence to orthosis use. As a result, studying factors causing or increasing the probability of interrupting orthosis use is significant in creating strategies to facilitate their use, potentially reducing CC recurrence.

Exploring Bracing Adherence in Ponseti Treatment of Clubfoot: A Comparative Study of Factors and Outcomes in Uganda

The Ponseti method of clubfoot treatment involves two phases: initial correction, usually including tenotomy; and bracing, to maintain correction and prevent relapse. Bracing should last up to four years, but in Uganda, approximately 21% of patients drop from clinical oversight within the first two years of using the brace. Our study compared 97 adherent and 66 non-adherent cases to assess the influential factors and effects on functional outcomes. We analyzed qualitative and quantitative data from clinical records, in-person caregiver interviews, and assessments of foot correction and functionality. Children who underwent tenotomy had 74% higher odds of adherence to bracing compared to those who did not undergo tenotomy. Conversely, children from rural households whose caregivers reported longer travel times to the clinic were more likely to be non-adherent to bracing (AOR 1.60 (95% CI: 1.11-2.30)) compared to those without these factors. Adhering to bracing for a minimum of two years was associated with improved outcomes, as non-adherent patients experienced 2.6 times the odds of deformity recurrence compared to adherent patients. Respondents reported transportation/cost issues, family disruptions, and lack of understanding about the treatment method or importance of bracing. These findings highlight the need to address barriers to adherence, including reducing travel/waiting time, providing ongoing education for caregivers on bracing protocol, and additional support targeting transportation barriers and household complexities.

Tibialis anterior tendon transfer using suture anchor provides excellent alternative treatment for relapse clubfoot: A case report

INTRODUCTION

Relapsed clubfoot is defined as the recurrence of any component of deformity after a complete correction. While the Ponseti method has been known to have excellent outcomes, several relapse cases have been reported. Thus, further surgical intervention is needed to achieve a good and reliable long-term outcome.

PRESENTATION OF THE CASE

We report a presentation of a 5-year-old boy who came to the clinic with a relapsed bilateral clubfoot after serial Ponseti casting. Plantar fascia release, Achilles tendon lengthening, and tibialis anterior tendon transfer (TATT) were performed respectively followed by an above-knee cast. The patient gained acceptable walking balance and ability to perform high impact sports at one year follow-up.

CLINICAL DISCUSSION

There are several factors contributing to the relapse clubfoot including adherence to post op foot abduction brace (FAB) protocol, muscle imbalance or inadequate correction of initial deformities. The current case report described a relapse clubfoot following serial Ponseti casting caused by non-compliance of the use of foot abduction brace. Further surgical interventions must be performed in the presence of relapse case of clubfoot.

CONCLUSION

Relapse clubfoot is the presence of any recurring deformity following correction. Surgical intervention, especially TATT procedure provides a favorable outcome in treating patients with relapse clubfoot.

Gait Analysis Characteristics in Relapsed Clubfoot

BACKGROUND

Relapse rates of clubfoot deformity after initial correction range between 19% and 68% regardless of treatment approach. Most studies focus on relapse before age 4. Little research has focused on late clubfoot relapse. The purpose of this study was to compare the gait characteristics of children with late clubfoot relapse (age ≥5 y) following treatment with the Ponseti method only compared with intra-articular and extra-articular surgeries.

METHODS

A retrospective review was conducted of all patients with idiopathic clubfoot ≥5 years old who underwent computerized gait analysis for clubfoot relapse between 2001 and 2021. Joint range of motion, muscle strength, gait kinematics, and kinetics were compared among 3 groups based on prior clubfoot treatment: (1) Ponseti casting, (2) Extra-articular (EA) surgery, and (3) Intra-articular (IA) surgery.

RESULTS

Sixty-eight subjects (107 feet) were included (39 bilateral). Thirty-one percent of feet had been treated with Ponseti casting alone; 57% had IA surgery, and 12% had EA surgery. The average age when presenting with late relapse was 8.2 years, 9.0 years and 10.7 years for the Ponseti, and IA and EA groups, respectively. The IA group had greater passive dorsiflexion than the other 2 groups (P<0.002), greater inversion weakness than the other 2 groups (P<0.0001), greater dorsiflexion during the stance phase of gait compared with the Ponseti group (P=0.001), and lower maximum power production at push-off compared with the other 2 groups (P=0.009).

CONCLUSION

Late relapse can occur after all types of clubfoot correction. Consistent with existing literature, patients who have undergone posteromedial release surgery have significantly greater plantarflexor weakness resulting in poorer plantarflexor moment and power production during gait.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Achilles tendon surgery in clubfoot: Are long term sequelae predictable?

Congenital Clubfoot (CCF) treatment involves a surgical procedure on the Achilles tendon most of the time, i.e. tenotomy or, in selected cases, Z-plasty lengthening. Many authors have studied the outcomes of Achilles tenotomy, describing complete clinical and ultrasound tendon fibers integrity restoration 3-6 weeks after surgery. Nevertheless, little is known about the mechanical properties of the operated tendon. Recently, cases of subcutaneous rupture of the Achilles tendon have been described in adolescents who practiced sports and who had undergone Achilles tenotomy for congenital clubfoot in childhood. Authors report two cases of atraumatic Achilles tendon injury (subcutaneous rupture and intratendinous ossification) in adult patients who had been treated for congenital clubfoot in childhood. In both cases, no causes determining the injury were identified; in the medical history there was a Z-plasty lengthening of the Achilles tendon, performed within the first year of life, which could be considered a predisposing factor. The usefulness of long-term monitoring of patients treated for CCF with surgical procedures on the Achilles tendon is therefore hypothesized, in order to promptly identify by symptoms, clinical pictures and ultrasound criteria, tendon suffering that may predispose subcutaneous rupture.

Anatomical Structures Responsible for CTEV Relapse after Ponseti Treatment

Relapse of deformity after a successful Ponseti treatment remains a problem for the management of clubfoot. An untreated varus heel position and restricted dorsal flexion of the ankle are the main features of recurrences. We analyze the anatomical structures responsible for these recurrences. Materials and methods: During 5 years, 52 children with CTEV (Congenital Talipes Equino Varus) were treated with casts according to the Ponseti method, with a mean number of 7 casts. Closed percutaneous tenotomy was performed in 28 infants. Children were followed monthly and treated with the continuous use of a molded cast. We had 9 children with relapsed clubfeet. During the standing and walking phase, they had a fixed deformity with a varus position of the heel and dorsal flexion of the ankle <10 d. They were surgically treated with the posterolateral approach. Results: In all patients, we found a severe thickening of the paratenon of the Achilles in the medial side, with adhesions with the subcutaneous tissue. The achilles after the previous tenotomy was completely regenerated. The achilles was medially displaced. Conclusions: A severe thickening of the paratenon of the achilles and adhesions with the subcutaneous tissue are anatomical structures in fixed relapsed cases of clubfoot. We treated our patients with an appropriate surgical release.

The outcomes of idiopathic congenital talipes equinovarus : a core outcome set for research and treatment

Aims

To identify the minimum set of outcomes that should be collected in clinical practice and reported in research related to the care of children with idiopathic congenital talipes equinovarus (CTEV).

Methods

A list of outcome measurement tools (OMTs) was obtained from the literature through a systematic review. Further outcomes were collected from patients and families through a questionnaire and interview process. The combined list, as well as the appropriate follow-up timepoint, was rated for importance in a two-round Delphi process that included an international group of orthopaedic surgeons, physiotherapists, nurse practitioners, patients, and families. Outcomes that reached no consensus during the Delphi process were further discussed and scored for inclusion/exclusion in a final consensus meeting involving international stakeholder representatives of practitioners, families, and patient charities.

Results

In total, 39 OMTs were included from the systematic review. Two additional OMTs were identified from the interviews and questionnaires, and four were added after round one Delphi. Overall, 22 OMTs reached ‘consensus in’ during the Delphi and two reached ‘consensus out’; 21 OMTs reached ‘no consensus’ and were included in the final consensus meeting. In all, 21 participants attended the consensus meeting, including a wide diversity of clubfoot practitioners, parent/patient representative, and an independent chair. A total of 21 outcomes were discussed and voted upon; six were voted ‘in’ and 15 were voted ‘out’. The final COS document includes nine OMTs and two existing outcome scores with a total of 31 outcome parameters to be collected after a minimum follow-up of five years. It incorporates static and dynamic clinical findings, patient-reported outcome measures, and a definition of CTEV relapse.

Conclusion

We have defined a minimum set of outcomes to draw comparisons between centres and studies in the treatment of CTEV. With the use of these outcomes, we hope to allow more meaningful research and a better clinical management of CTEV.

Cite this article: Bone Jt Open 2022;3(1):98–106.

Concomitant Talocalcaneal Coalition as a Risk Factor for Early Relapse Following Ponseti Treatment of Idiopathic Clubfoot

Concomitant talocalcaneal coalition (TCC) in idiopathic clubfeet is not well documented in the literature. The purpose of this study was to describe our experience with very early relapsing idiopathic clubfeet associated with TCC. Although cases have been successfully treated with the Ponseti casting method, all recurred within 2 months of removing the final cast. A single-centre cohort of twelve feet in eight patients treated by a single surgeon between 2006 and 2020 was investigated retrospectively. Recurred cavus with variable degrees of equinus was the earliest findings noted. TCC was incidentally detected during the open reduction of the earliest three feet in our series. Afterwards, ultrasonography was advised as a screening tool for detecting an associated anomaly; however, only the use of magnetic resonance imaging (MRI) was 100% accurate in diagnosing concurrent TCC. All coalitions were cartilaginous and the posterior facet was most commonly involved facet. The average age was 18 months for the coalition resection and open reduction of a dislocated talonavicular joint, and the average duration of follow-up was 52 months. None of the patients showed clinical signs of relapse at the latest follow-up. We recommend that an associated TCC should be considered in very early relapsing idiopathic clubfoot cases.

Results of ala carte Posteromedial Soft Tissue Release in Idiopathic Clubfoot

Introduction

The aim of this study is to assess the outcomes of ala carte posteromedial release in children over two years of age who were not responding to the Ponseti method of treatment of idiopathic clubfoot.

Material and Methods

A retrospective observational study from September 2013 to August 2015 was conducted at a tertiary level medical teaching institution. The clubfeet were classified according to the Harold and Walker classification. Radiographic parameters assessed were the talocalcaneal angle (AP, lateral), talus-first metatarsal angle (AP, lateral) and calcaneal-fifth metatarsal angle. The scar and the functional score, according to Laaveg and Ponseti, were evaluated as outcome measures at the final follow-up.

Results

Twenty-four children with a mean age of 43.7 ± 24.7 months were enrolled in the study. There was a total of 36 clubfeet: 21 (65.6%) with a poor functional outcome; 12 (37.4%) with excellent to good scar in both horizontal and vertical components. There was a statistical significance between the pre-operative and post-operative radiological parameters (p<0.05). None of the patients presented with any limitation of activities of daily living despite the poor functional outcome in many of the children. There was no significant association between the qualities of scar (horizontal, vertical) and the functional outcome with age at presentation, pre-operative Harold and Walker classification and pre-operative radiographic angles.

Conclusion

Surgical intervention in terms of ala carte posteromedial soft tissue release could not produce a good outcome over four years in CTEV. The threshold for surgery in CTEV should be high, given the poor results.

Narrative review of the management of a relapsed clubfoot

The management of idiopathic clubfoot has transformed over the past several decades as the Ponseti method for the correction of this deformity became the standard of care, and surgical release has almost all but been abandoned. The Ponseti method has shown very high initial success rate and excellent long-term functional results. Relapse of the deformity, however, continues to be a major problem, occurring in up to 40% of patient, and there is no consensus on the definition and management of the relapsed clubfoot. This review discusses the available management options for the treatment of a relapsed clubfoot deformity following initial treatment with the Ponseti method [including repeat casting, tendo-Achilles lengthening, plantar fascia release, and tibialis anterior tendon transfer (TATT)] as well as following initial surgical treatment with posteromedial release (including casting, hemiepiphysiodesis, revised posteromedial release, osteotomies, fusion, and the use of gradual distraction with external fixators). These are discussed from the least to the most invasive. Available evidence, and limitations of the literature, for the management of relapses following both the Ponseti method and initial surgical release is reviewed along with along with the reported outcomes. Future efforts should be geared towards standardizing the definition of a relapse with objective criteria for its management.

Relapses in clubfoot treated with Ponseti technique and standard bracing protocol- a systematic analysis

PURPOSE

The analysis determined the relapses in clubfoot children treated with Ponseti technique and standard bracing protocol and their correlation with overall follow up duration using pooled data from various series. It also tested the prescribed timelines of 5 and 7 years for slow-down/cessation of relapses in clubfoot children.

METHODS

A systematic literature search was performed for articles published in "Pubmed (includes Medline indexed journals)" electronic databases using key words: "Clubfoot or CTEV or congenital talipes equinovarus", "Ponseti" for years 1^st January 2001 to 15^th November 2020. Included were studies that addressed treatment of idiopathic clubfoot using the standard Ponseti technique, followed a well defined brace protocol (maintenance of corrected deformity using a central bar based brace and prescribed duration mentioned), reported a minimum mean follow up of 4 years and having relapse as one of their outcome measure. Studies reporting Ponseti technique for non-idiopathic clubfoot, child's age older than 1 year at the time of primary treatment, clubfoot with previous interventions before Ponseti treatment, where relapse and residual deformities were not identified distinctly in follow up, abstract only publications, letter to the editors, case reports, technique papers and review articles were excluded. The following characteristics of clubfoot patients in the selected articles were included for analysis: Patient numbers/feet treated with Ponseti technique; follow up years (<5; 5-7 and >7 years; overall) and corresponding relapse percentages for patients.

RESULTS

There were total 2206 patients in the included 24 studies. Average follow up was 6 years. The average relapse rates for clubfoot patients in the pooled data stood at 30%. The overall relapse rates increased with a longer follow up and the curve befitted a linear regression equation with weak positive correlation (Pearson correlation coefficient = 0.08). The relapse rates in follow up categories of <5 years (26.6 ± 15.6%), 5-7 years (30.8 ± 16.3%) and >7 years (28.4 ± 6.2%) were similar statistically (Analysis of variance, ANOVA).

CONCLUSIONS

Approximately 1 in 3 clubfoot patients suffer relapse post Ponseti technique and standard bracing protocol. A weak positive correlation was observed for relapses when correlated with increasing follow up years. The relapses however tend to slow down after initial growth years. There is a need to educate the care receivers regarding the possibility of late relapses despite proper Ponseti treatment and accordingly to keep them under supervised follow up for longer periods.

Pediatric Health Outcome Evaluation in Low-and Middle-Income Countries: A Scoping Review of NGO Practice

Objective. The purpose of this study was to explore the research on the delivery and evaluation of pediatric health services by non-governmental organizations in low-and middle-income countries to better understand how they contribute to positive and sustainable health outcomes. Methods. A scoping review was completed using a 2-step study selection procedure. Results. Of the 5742 studies, 17 met criteria, including quantitative and mixed method designs, representing 10 different non-governmental organizations with programs in 33 low-and middle-income countries. Health outcomes were reported 89 times across the studies. A total of 56 different outcomes were identified in total, of which 24 were positive, 27 were negative, and 5 were unchanged. Conclusions. Widespread variation between non-governmental organizations exist, however, comprehensive pediatric health outcome evaluation is growing. Further emphasis should be given to adolescent specific research and robust measurement of quality of life.

A Community Audit of 300 "Drop-Out" Instances in Children Undergoing Ponseti Clubfoot Care in Bangladesh-What Do the Parents Say?

Introduction: Drop-out before treatment completion is a vexing problem for all clubfoot clinics. We and others have previously identified better engagement with parents as a crucial method of ameliorating incomplete clubfoot treatment, which increases deformity relapse. Materials and methods: The novel use of community facilitators enabled an audit of over 300 families who had dropped-out from a child’s clubfoot treatment. A questionnaire standardized the parent interviews. Parents were encouraged to present for clinical review of their child’s clubfeet. Results: When treatment was discontinued for six months, 309 families were audited. A social profile of families was developed, showing that most lived in tin houses with one working family member, indicating low affluence. Family issues, brace difficulty, travel distances, and insufficient understanding of ongoing bracing and follow-up were the main reasons for discontinuing treatment. Overt deformity relapse was found in 9% of children, while half of the children recommenced brace use after review. Conclusions: Identifying families at risk of dropping out from clubfoot care enables support to be instigated. Our findings encourage clinicians to empathize with parents of children with clubfoot deformity. The parent load indicator, in parallel with the initial clubfoot severity assessment, may help clinicians to better appreciate the demand that treatment will place on parents, the associated risk of drop-out, and the opportunity to enlist support.

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

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

A 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.

Factors affecting compliance to hospital visit among clubfoot patients: A cross-sectional study from a tertiary referral clubfoot clinic in the developing country

PURPOSE

Ensuring compliance to treatment protocol, especially regular visit to treating facility, is an important aspect of clubfoot management. However, the factors affecting compliance to follow-up schedule are myriad.

METHODS

A cross-sectional study was undertaken among caregivers of clubfoot patients from a tertiary referral clubfoot clinic in a developing country. Hospital records were reviewed to collect demographic data and subjects were classified as either "regular" or "irregular" if they missed ≤3 and >3 scheduled hospital visits, respectively. Various factors that could affect compliance such as family size, number of children, literacy of caregiver, occupation of breadwinner, and time taken to travel to hospital were studied. Caregivers were probed regarding the reason for their irregularity.

RESULTS

A total of 238 patients were included, of which 138 formed the "regular" group and the rest 100 formed the "irregular" group. Patients in the regular group were significantly younger (mean age 43.8 months) compared to the irregular group (59.8 months; p = 0.001). The mean follow-up period in the regular group was 28.1 months and in the irregular group was 33.8 months. On univariate analysis, age, duration of follow-up, and transport duration were found to be significant between the two groups. However, multivariate analysis revealed that female children with clubfoot are more likely to be irregular as compared to males ( p = 0.038).

CONCLUSION

In a developing country setting, higher age and being a female child are associated with irregularity to hospital visit protocol. At clubfoot clinics, identifying these children and counseling their caregivers might improve compliance.

A Modified Ponseti Method for the Treatment of Rigid Idiopathic Congenital Clubfoot

This study reviewed the efficacy of a modified Ponseti method (MP) for treating rigid clubfeet insufficiently corrected by the classic Ponseti method. Briefly, the MP consisted of 3 procedures. First, Achilles tenotomy, abductor hallucis tenotomy, and plantar fasciotomy were conducted through 3 small incisions. Second, the talocalcaneal and talonavicular joints were manually reduced. Third, plaster immobilization was introduced to maintain the initial correction. Dimeglio scores, radiographs, and pain evaluations were used to analyze outcomes. All 38 patients with 56 clubfeet enrolled in the present study achieved initial correction after the MP, followed by a mean of 3.68 ± 0.77 (range 3 to 5) cast immobilizations, which were changed each week. The average duration of treatment was 30.63 ± 6.45 days (range 23 to 47), and 6 (10.71%) clubfeet exhibited cast-related pressure injury. After a mean follow-up period of 19.71 ± 4.83 months (range 12.47 to 31.33), no child presented foot pain, and except for 1 patient with relapse, all patients received correction, with Dimeglio scores of 0.55 ± 1.06 points (range 0 to 7). The recurrence rate was 1.79% (1 of 56) at the first year. The anteroposterior talocalcaneal angle was 34.83° ± 10.65°, and the lateral talocalcaneal angle was 31.38° ± 9.86° at the last follow-up period, and both were significantly improved compared with the corresponding preoperative angles (p < .001). The anteroposterior talus-first metatarsal angle was 12.33° ± 10.04°, and the lateral calcaneal tibial angle was 74.15° ± 14.12°, which were significantly decreased compared with the preoperative values (p < .001). In conclusion, the present short-term evaluation of this minimally invasive soft-tissue release method showed promising results for treating rigid clubfoot that was not responsive to the traditional Ponseti method.

Factors Related to Early Recurrence of Idiopathic Clubfoot Post the Ponseti Method

Introduction: Idiopathic clubfoot or congenital talipes equinovarus (CTEV) is managed by the Ponseti method worldwide; however, the recurrence of the deformity is a challenging problem. The purpose was to review the factors associated with early recurrence of CTEV post the Ponseti method. Materials and Methods: During 2011-2016, 34 infants with 52 CTEV, who underwent the Ponseti method and a minimum follow-up period of six months, were reviewed. Twenty-two infants (65%) were male, and 18 infants (53%) had bilateral CTEV. Recurrence of CTEV was defined as a reappearance of at least one of the four components of the deformity. The association between recurrence and factors, including age, gender, bilaterality, family geography, type of principal caregiver, severity at presentation, centre where the Ponseti method was initiated, compliance to foot abduction brace (FAB), practice of stretching exercise, type of FAB, and complications of casting, were evaluated using univariate logistic regression analysis. Results: The median age at initiation of the treatment was 3.4 (IQR; 2.1-12.6) weeks. A median of six (range; 3-12) casts were required. Tenotomy was performed in 32/34 (94%) of cases. Recurrence occurred in 14/52 feet (27%) at an average follow-up period of 2.3±1.1 years. Non-compliance to FAB protocol began at an average age of 11.2±6.5 months, and significantly increased the risk of recurrence during the weaning phase [OR (95%CI)=8.4 (1.2-92.4), p=0.03]. Other factors were not associated with the recurrence. Conclusion: Non-compliance to FAB occurred early during the treatment and related to a risk of recurrence of CTEV. Physicians should encourage the parents and/or guardians to follow the protocol to decrease the risk of recurrence.

Congenital talipes equinovarus

Aims

The Ponseti method is the benchmark treatment for the correction of clubfoot. The primary rate of correction is very high, but outcome further down the treatment pathway is less predictable. Several methods of assessing severity at presentation have been reported. Classification later in the course of treatment is more challenging. This systematic review considers the outcome of the Ponseti method in terms of relapse and determines how clubfoot is assessed at presentation, correction, and relapse.

Patients and Methods

A prospectively registered systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that reported idiopathic clubfoot treated by the Ponseti method between 1 January 2012 and 31 May 2017 were included. The data extracted included demographics, Ponseti methodology, assessment methods, and rates of relapse and surgery.

Results

A total of 84 studies were included (7335 patients, 10 535 clubfeet). The relapse rate varied between 1.9% and 45%. The rates of relapse and major surgery (1.4% to 53.3%) and minor surgery (0.6% to 48.8%) both increased with follow-up time. There was high variability in the assessment methods used across timepoints; only 57% of the studies defined relapse. Pirani scoring was the method most often used.

Conclusion

Recurrence and further surgical intervention in idiopathic clubfoot increases with the duration of follow-up. The corrected and the relapsed foot are poorly defined, which contributes to variability in outcome. The results suggest that a consensus for a definition of relapse is needed. Cite this article: Bone Joint J 2019;101-B:639–645.

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

Background

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Relapse following use of Ponseti method in idiopathic clubfoot

PURPOSE

We assessed the pattern of relapse as well as the correlation between the number of casts required for correction and Pirani and Dimeglio scores at presentation, and age at presentation. We hypothesized that the Ponseti method would be effective in treatment of relapsed clubfoot as well.

METHODS

We evaluated 115 idiopathic clubfeet in 79 children presenting with relapse following treatment by the Ponseti method. The mean age was 33.8 months with mean follow-up of 24 months. All patients were assessed for various patterns of relapsed deformities. Quantification of deformities was done using the Pirani and Dimeglio scores. All relapsed feet were treated by a repeat Ponseti protocol.

RESULTS

Non-compliance to a foot abduction brace was observed to be the main contributing factor in relapse, in 99 clubfeet (86%). Combination of three static deformities (equinus, varus and adduction) together was observed most commonly (38.3% feet). Overall, relapse of equinus deformity was noted most commonly followed by adduction. A painless plantigrade foot was obtained in all 115 feet with a mean of five casts. In all, 71 feet (61.7%) underwent percutaneous tenotomy. A total of 15 feet (13%) required tibialis anterior tendon transfer. Re-relapse rate in group 1 was 21% compared with 12.6% in group 2 and overall 16.5%.

CONCLUSION

We conclude that the Ponseti method is effective and the preferred initial treatment modality for relapsed clubfeet. Surgical intervention should be reserved for residual deformity only after a fair trial of Ponseti cast treatment. Regular follow-up and strict adherence to brace protocol may reduce future relapse rates. Further research is required to identify high-risk feet and develop individualized bracing protocol.

LEVEL OF EVIDENCE

IV.

Identification and treatment of residual and relapsed idiopathic clubfoot in 88 children

Background and purpose - The Ponseti treatment is successful in idiopathic clubfoot. However, approximately 11-48% of all clubfeet maintain residual deformities or relapse. Early treatment, which possibly reduces the necessity for additional surgery, requires early identification of these problematic clubfeet. We identify deformities of residual/relapsed clubfeet and the treatments applied to tackle these deformities in a large tertiary clubfoot treatment center. Patients and methods - Retrospective chart review of patients who visited our clinic between 2012 and 2015 focused on demographics, deformities of the residual/relapsed clubfoot, and applied treatment. Residual deformities were defined as deformities that were never fully corrected and needed additional treatment. We defined relapse as any deformity of the clubfoot reoccurring, after initial successful treatment, with necessity for additional treatment. Results - We identified 33 patients with residual and 55 patients with relapsed clubfeet. In both groups decreased dorsal flexion and adduction were the most often registered deformities. Furthermore, often equinus/decreased dorsiflexion, active supination, and varus occurred. In more than half, typical profiles of combined deformities were found. Relapses occurred at all stages of treatment and follow-up; half of the residual or relapsed clubfeet were identified before the end of the bracing period. In half of the patients, additional treatment consisted of the Ponseti treatment, one-quarter also required adaptation of the brace protocol, and one-quarter needed additional surgery. The Ponseti treatment was mainly reapplied if feet presented with relapses or residues until the age of 5. Interpretation - Practitioners should especially be aware of equinus/decreased dorsiflexion, adduction, and active supination as a sign of a residual or relapsed clubfoot. Due to the heterogeneous profiles of these clubfeet, treatment strategy should be based on a step-by step approach including recasting, bracing, and if necessary surgical intervention.

Developing a Three-Dimensional (3D) Assessment Method for Clubfoot-A Study Protocol

Background: Congenital talipes equinovarus (CTEV) or clubfoot is a common pediatric congenital foot deformity that occurs 1 in 1,000 live births. Clubfoot is characterized by four types of foot deformities: hindfoot equinus; midfoot cavus; forefoot adductus; and hindfoot varus. A structured assessment method for clubfoot is essential for quantifying the initial severity of clubfoot deformity and recording the progress of clubfoot intervention.

Aim: This study aims to develop a three-dimensional (3D) assessment method to evaluate the initial severity of the clubfoot and monitor the structural changes of the clubfoot after each casting intervention. In addition, this study explores the relationship between the thermophysiological changes in the clubfoot at each stage of the casting intervention and in the normal foot.

Methods: In this study, a total of 10 clubfoot children who are <2 years old will be recruited. Also, the data of the unaffected feet of a total of 10 children with unilateral clubfoot will be obtained as a reference for normal feet. A Kinect 3D scanner will be used to collect the 3D images of the clubfoot and normal foot, and an Infrared thermography camera (IRT camera) will be used to collect the thermal images of the clubfoot. Three-dimensional scanning and IR imaging will be performed on the foot once a week before casting. In total, 6–8 scanning sessions will be performed for each child participant. The following parameters will be calculated as outcome measures to predict, monitor, and quantify the severity of the clubfoot: Angles cross section parameters, such as length, width, and the radial distance; distance between selected anatomical landmarks, and skin temperature of the clubfoot and normal foot. The skin temperature will be collected on selected areas (forefoot, mid foot, and hindfoot) to find out the relationship between the thermophysiological changes in the clubfoot at each stage of the casting treatment and in the normal foot.

Ethics: The study has been reviewed and approved on 17 August 2016 by the Sydney Children's Hospitals Network Human Research Ethics Committee (SCHN HREC), Sydney, Australia. The Human Research Ethics Committee (HREC) registration number for this study is: HREC/16/SCHN/163.

Walk for life - the National Clubfoot Project of Bangladesh: the four-year outcomes of 150 congenital clubfoot cases following Ponseti method

Background

Congenital clubfoot deformity can cause significant disability, and if left untreated, may further impoverish those in developing countries, like Bangladesh. The Ponseti method has been strategically introduced in Bangladesh by a non-government organisation, Walk For Life (WFL). WFL has provided free treatment for over 17,500 Bangladeshi children with clubfeet since 2009, sustained by local ownership, and international support. This study assesses the 4-year results in children for whom treatment began before the age of 3 years.

Methods

A centrally located WFL clinic at Mymensingh Medical College Hospital (MMCH), representative of the larger WFL clinics, which treats >100 cases annually, was reviewed. In 2015, 99 of the 147 eligible subjects who had begun treatment in 2011 were available for follow up. Specific assessment tools enabled evaluation of parent satisfaction, gait function, and relapse cases.

Results

Results for 99/147 cases were returned after four years: 72 males, 27 females. Typical clubfeet comprised 98/99 of cases, and 55/99 were bilateral. The tenotomy rate was 80 %. Brace use after 3 months was 90 %, at 12 months was 65 %, and at 4 years post treatment was 40 %. Functionally, 98/99 of children could walk and run (99 %). Relapsing deformity was found in 13 %. Relapse severity varied: eight were flexible and partial, five were rigid. Half of the children lost to follow were due to changed phone numbers. While parents were very happy with their child’s feet (97 %), a materials cost of 3000 Taka ($US40) was deemed unaffordable by 60 %.

Conclusions

The 4-year outcomes after Ponseti treatment for clubfoot deformity, showed that 99 % of children available for follow up, were walking independently. The relapse rate was low. Parent satisfaction was high, but those whose children required further treatment were less satisfied.

Treatment of Severe Recurrent Clubfoot

Understanding the pathoanatomy of severe recurrent clubfoot and its implication on treatment options is important for the successful treatment. A comprehensive clinical evaluation of the different components helps in selecting procedures. Individual needs and social and psychological factors influencing treatment and the impact of treatment on the child have to be considered. With increasing dissemination and improved understanding of the Ponseti method, a further decrease in the frequency of severe recurrent clubfoot can be hoped for and expected.

Lateral Tibiocalcaneal Angle As a Determinant for Percutaneous Achilles Tenotomy for Idiopathic Clubfeet

BACKGROUND

The aim of the present study was to evaluate the clinical value of using the lateral tibiocalcaneal (LTiC) angle, measured on a lateral radiograph made with the foot and ankle in maximal dorsiflexion, instead of the ankle dorsiflexion (ADF) angle, measured on physical examination, as a determining indicator of the need for percutaneous Achilles tenotomy after Ponseti serial cast treatment of idiopathic clubfoot.

METHODS

We identified patients with idiopathic clubfoot who had been treated at our institution between March 2006 and June 2012. After exclusion of patients with Diméglio grade-I clubfoot and those followed for less than two years, 125 idiopathic clubfeet were evaluated. The clubfeet were grouped according to their LTiC and ADF angles, after which we evaluated the clinical outcomes of each group and investigated the prognostic effects of each angle-based decision regarding whether to perform percutaneous Achilles tenotomy.

RESULTS

Patients with a favorable LTiC angle (≤80°) showed no sagittal relapse even though none underwent percutaneous Achilles tenotomy. In contrast, patients with an unfavorable LTiC angle (>80°) had a high chance of sagittal relapse if percutaneous Achilles tenotomy had not been performed, even when they had a favorable ADF angle (≥15°). The LTiC-angle-based decision showed the most significant prognostic value in multivariate analyses of relapse-free and surgery-free survival rates.

CONCLUSIONS

The LTiC angle measured on simple radiographs is a more objective and prognostic indicator of the need for percutaneous Achilles tenotomy, as compared with the ADF angle measured on physical examination, in patients with idiopathic clubfoot.

LEVEL OF EVIDENCE

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

Treatment of persistent forefoot adduction during ponseti method in treatment of idiopathic talipes equinovarus by minimal soft release

INTRODUCTION

Abductor hallucies tenotomy sometimes necessary in treatment of clubfoot.

MATERIAL AND METHODS

Thirty children (45 feet) of one day old up to six months presented with idiopathic clubfoot. Patients were treated using the technique of Ponseti combined by abductor hallucies tenotomy after serial casting.

RESULTS

At a mean follow up period of 16.7 months, 43/45 feet were good (95%), 2/45 feet were bad (5%). The mean Pirani score at the final follow up was 1.05.

CONCLUSION

Abductor hallucies tenotomy shortens the duration of casts, decrease the cost and risk of leg atrophy.