Radiography and sonography of clubfoot: A comparative study

A prospective study on the role of foot evertor muscle activity in recurrence of clubfoot

BACKGROUND

Even after corrective casting and bracing, clubfoot recurrence is challenging throughout childhood, with around 14-40 % recurrence rates. Most of the literature on recurrence was attributed to various factors, and minimal research was conducted to know the role of foot evertor muscle activity and its stimulation benefits. This study aimed to assess the role of foot evertor muscle activity in idiopathic congenital clubfoot recurrence by using clinical, sonographic, and electromyographic parameters.

METHODS

A prospective cohort study was conducted at our tertiary care hospital from 2020 to 2022. The patient's demographic data, Pirani, Dimeglio, Clinical Evertor Muscle Activity scores, sonographic cross-sectional areas of leg muscle, and evertor motor activity using surface electromyography were recorded in adherence to the pre-defined intervals.

RESULTS

In total, 51 patients (51 feet) were included in the study, and the overall recurrence rate was 27.5 % (14/51). In this study, around 47 % (24/51) of children had mild or poor clinical evertor activity; among them, 58 % (14/24) children had a recurrence, and the insufficient clinical evertor activity and recurrence were strongly correlated (p = 0.01). Evertor muscle cross-sectional area ratio, motor unit potentials, and recruitment were comparatively less in the recurred group; however, only the cross-sectional area ratio was statistically significant (p = 0.02).

CONCLUSION

Early detection of evertor muscle weakness can help to individualize the treatment plans by predicting recurrence. Therefore, it should be included in routine clinical evaluations. Further research is required to determine the advantages of evertor muscle-strengthening activities in preventing idiopathic clubfoot deformity.

LEVEL OF CLINICAL EVIDENCE

A prospective cohort study, Level of evidence-II.

A four-year clinical and sonographic longitudinal follow-up of clubfeet treated according to Ponseti with normal references

Purpose

To follow children with a clubfoot by ultrasonography during the entire treatment period up to 4 years and compare with controls.

Method

Thirty clubfeet in 20 children treated using the Ponseti method and 29 controls were followed by repeated ultrasonography investigations from neonates to the age of 4 years. The previously established coronal medial and lateral, sagittal dorsal and posterior projections were used. Changes over time, correlations to the Diméglio score, and the course of treatment were studied.

Results

The medial malleolus-navicular distance was shorter, while the talar tangent-navicular distance and the talo-navicular angle were larger in clubfeet than in controls even after the initial correction. The healthy feet in unilateral cases did not differ significantly from the controls. The range of motion in the talo-navicular joint was approximately 20° less in clubfeet than in controls during the first four years of life. The medial malleolus-navicular distance (r = -0.58) and the talo-navicular angle (r = 0.66) at the first ultrasonography showed the highest correlation to the number of casts needed to correct the deformities.

Conclusion

Ultrasonography can be used to evaluate the initial degree of deformities in clubfeet and to follow the progress of the treatment and growth. Ultrasonography showed a clear difference between clubfeet and controls during the first four years of life. Although it was not possible to define specific limit values as benchmarks in the treatment, dynamic ultrasonography can provide valuable support in the decision-making process when complementary treatment may be needed.

Level of evidence

III.

The diagnostic dilemma of congenital foot deformity in pediatrics: could adding ultrasound be problem solving?

Background

Foot deformity is one of the most common congenital musculoskeletal anomalies in the pediatric age group. Accurate diagnosis can be sometimes impossible to be established clinically. In the assessment of foot abnormalities, radiology plays a crucial role. Lack of ossification of the tarsal bones renders plain radiographs of the foot as of little diagnostic value in this age group. MRI apart from its cost requires anesthesia and sedation. In contrast, ultrasonography allows for the imaging of cartilaginous structures. As a result, newborn foot abnormalities can be thoroughly assessed. The whole anatomy of the foot is evaluated using several scanning views. Additional planes may be needed to show the pathologic features of a specific deformity. The purpose of this study was to demonstrate the additive value of ultrasound to plain radiographs in the assessment of foot deformities in the pediatric age group.

Results

This case–control study was performed on sixty children, 30 of which were patients admitted from the pediatric orthopedic clinic, presenting with foot deformity, after being examined clinically. Antero-posterior and lateral radiographs of foot, tibiocalcaneal, antero-posterior talocalcaneal, and lateral talocalcaneal angles were measured. Sonographic examination was done in different projections of both feet, while the patient is lying supine with dynamic sonography. The sonographic parameters measured were as follows: medial malleolar–navicular distance and medial soft tissue thickness on medial projection, calcaneocuboid distance on lateral projection, talonavicular relation on dorsal projection, and tibiocalcaneal distance on posterior projection. There was a statistically significant difference between patients and controls in the medial malleolar–navicular distance and medial soft tissue thickness measured on the medial view, the calcaneocuboid distance recorded on the lateral view, and the tibiocalcaneal distance measured on the posterior view.

Conclusions

Ultrasonography has a growing and useful role as a complementary imaging modality in the evaluation and follow-up of pediatric patients with foot deformity.

Evaluation of results of ponseti technique in idiopathic clubfoot using clinical evaluation and radiological assessment

Background:

Congenital clubfoot (congenital talipes equinovarus) occurs in approximately one in 1000 live births and is one of the most common congenital birth defects. The Ponseti method is at present a well-established method of treatment for idiopathic clubfoot deformities.

Aim:

The aim of the present study was to evaluate the results of serial casting in clubfoot deformity with Ponseti method on the basis of Pirani's scoring and radiological findings before and after completion of treatment.

Materials and Methods:

A total of 30 patients were enrolled in the study and were treated with Ponseti's casting after grading the severity of deformity clinically by Pirani's scoring and radiological assessment by calculating the talo-first metatarsal angle in anteroposterior (AP) view and talocalcaneal angle in AP and lateral views. The same clinical and radiological assessment was done at the end of treatment before putting a patient on foot abduction orthosis (FAO).

Results:

The average number of casts applied before full correction was 5.56 (range: 5–8). The average duration of treatment was about 6.65 weeks before the patient was put on FAO. Pirani score significantly improved from an average of 5.50 (range: 4–6) on presentation to 0.24 (range: 0–2) after correction of deformity.

Conclusion:

The Ponseti method is an excellent method for the correction of all four deformities associated with congenital idiopathic clubfoot, and we found that the addition of radiographic to clinical evaluation helps in the better assessment of correction. It provides statistically significant results both clinically as measured by Pirani severity score and radiologically assessed by talocalcaneal and talo-first metatarsal angle.

Do the clinical scores (Pirani and Dimeglio scores) correlate with the radiological parameters in idiopathic club foot in infants? A cross-sectional study

This study was done to identify how well clinical scores and their sub-scores correlate with the radiographic parameters in idiopathic clubfoot. We studied 76 patients of idiopathic clubfoot who are from 5 months to 12 months of age. Deformity was assessed clinically with Pirani and Dimeglio scores and radiologically using eight parameters. Correlation between clinical and radiological scores was studied. All the eight radiological parameters were showing statistically significant correlation with clinical scores - both Pirani and Dimeglio scores. The mean total Pirani score at the time of X-ray was 2.31 with a SD of 1.58 (N = 118 minimum score = 0 and maximum score = 5.5), whereas the mean radiographic score was 3.67 with a SD of 2.1 (N = 118, minimum score = 0, maximum score = 8). The mean total Dimeglio score at the time of X-ray was 9.03 with a SD of 3.54 (N = 118, minimum score = 4 and maximum score = 15), whereas the mean total radiographic score was 3.67 with a SD of 2.1 (N = 118, minimum score = 0, maximum score = 8). Clinical scores correlate well with radiological parameters in infants with idiopathic clubfoot and hence the routine use of radiographs can be avoided in evaluation and follow-up thereby avoiding exposure to radiation.

Correlation of radiographic parameters with clinical correction in idiopathic congenital talipes equinovarus undergoing Ponseti treatment

PURPOSE

Idiopathic congenital talipes equinovarus is the most commonly encountered congenital deformity of the foot. Ponseti technique of manipulation is the treatment of choice. The Pirani classification is a reliable scoring system for clinical evaluation of clubfeet. The role of radiographic parameters in the evaluation and treatment of clubfeet is still controversial. The aim of this study was to evaluate the correlation of radiological parameters with clinical correction in patients with idiopathic clubfeet undergoing correction using Ponseti method.

METHODS

Between March 2018 and March 2019, 42 feet in 27 patients with idiopathic clubfeet were treated in our hospital. We used the Pirani scoring system for clinical evaluation. Anteroposterior and lateral views of the feet were taken before and after correction and at the last follow-up. The anteroposterior view was evaluated for the talocalcaneal angle and talo-first metatarsal angle, while the lateral view was only evaluated for the talocalcaneal angle.

RESULTS

Twelve were boys (44.4%), and 15 were girls (55.6%). The deformity was bilateral in 15 patients (55.6%) and unilateral in 12 patients (44.4%). The average age was three months. According to the Pirani score, the mean Pirani Total score was 4.4 before correction and reduced to 0.4 after correction. The mean talocalcaneal angle in anteroposterior and lateral views was 15.1° and 7.8° before correction, increased to 32.7° and 31.8° after correction, respectively. The mean talocalcaneal index increased from 23.2 before correction to 64.5 after correction. The mean talo-first metatarsal angle in anteroposterior view improved from 25.7° before correction to - 1.6° after correction. The relation between the differences in Pirani scores before and after correction and the differences in measured radiographic parameters before and after correction revealed a statistically significant correlation.

CONCLUSION

Radiographic parameters showed a statistically significant correlation with the clinical outcome. Thus, evaluation of clubfeet correction treated by Ponseti technique can rely mainly on clinical scores with limited utilization of radiological assessment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of severity of clubfoot in walking children by combined multiple tools: A new classification system

INTRODUCTION

Clubfoot is one of the most common congenital deformities that cause mobility impairment. In developing countries, however, due to lack of appropriate medical care, treatment is either not initiated or incompletely performed. Due to lack of consensus for evaluation of deformities in such patients, there is no standardized treatment protocol yet developed. So, a new evaluation system is devised to assess the deformity in untreated or previously managed conservatively clubfoot of walking children.

METHODS

It was a prospective, observational study, conducted from December 2017 to July 2019. Patients from age 1-5 years, with unilateral deformity and previously managed conservatively were included. Patients having atypical clubfoot, syndromic clubfoot, or previously surgically intervened were excluded. Pre-treatment severity was graded with Diméglio score. Anthropometric, Foot Imprinting, Radiographic angles, and Ultrasonographic measurements were taken. Parameters taken were assessed and correlated with gradings of Diméglio score.

RESULTS

37 patients with mean age of 2.14 ± 0.87 years were included. Diméglio score was 11.57 ± 2.15 with 28 patients in 'severe' category. Talocalcaneal index and Tibiocalcaneal angle were correlating with the equinus whereas Bean shape ratio and Talocalcaneal index were correlating with varus deformity. Derotation of calcaneoforefoot block gradings correlating with Foot bimalleolar angle, Talo-first metatarsal angle, and MMN (medial malleolus to navicular distance) Ratio. FBM (Foot Bimalleolar) Angle, Talo-first metatarsal angle, MMN Ratio, and Medial soft tissue thickness were correlating with forefoot adduction. Following the correlation, a new classification system was devised to assess the severity of deformity at presentation.

CONCLUSION

It is essential to develop an objective methodology to evaluate the severity of the clubfoot; whether the foot is responding to manipulation and casting; to detect the early signs of recurrences and predict the outcomes. The evaluation system should take into consideration the complex characteristics of the deformity and its three-dimensional aspects.

Correlation of Foot Bimalleolar Angle and Ultrasonography in Assessing the Severity of Club Foot in Neonates Treated by the Ponseti Method

Introduction: Correlation of Pirani score and foot bimalleolar (FBM) angle has been used in few studies but correlation of FBM angle with ultrasonography has never been evaluated so they are being correlated in assessing the severity of clubfoot in neonates treated by Ponseti method. Material and Methods: Thirty-two feet with congenital talipes equinovarus (CTEV) deformity in neonates were prospectively treated by the Ponseti method. FBM angle and ultrasound parameters were measured three times i.e. at the time of initial presentation, at four weeks of treatment and at completion of treatment. The feet were divided according to the Pirani score in groups: one (0-2.0), two (2.5-4) and three (4.5-6). Correlation between FBM angle and ultrasound parameters were evaluated using Pearson correlation/regression. Results: Correlation between FBM angle and ultrasound parameters were statistically significant (p-value < 0.05). Conclusion: Ultrasound has the potential to accurately depict the pathoanatomy in clubfoot. FBM angle and ultrasound are objective methods to assess the severity of clubfoot. FBM angle and ultrasonography correlated in severity of deformity and correction achieved along the course of treatment.

Range of motion in the talo-navicular and the calcaneo-cuboid joints evaluated by ultrasound during clubfoot treatment with normal references up to the age of four years

PURPOSE

Previous ultrasound studies of clubfeet have mainly focused on the first year of life. The purpose of this study was to improve the evaluation of the talo-navicular and calcaneo-cuboid joints by adding new variables, evaluating the repeatability of ultrasound measurements for normal feet and clubfeet and establishing values for normal feet up to four years of age.

METHODS

A control group of 105 children divided into ten age groups, and 71 clubfeet in 46 children were examined. Four new variables were introduced: medial malleolus-Talar head-Navicular distance, medial tangent of the talus to the medial border of the navicular distance, the angle between the longitudinal axis of the talus and a line from the centre of the talar head to the medial corner of the navicular, the angle between the lateral borders of the calcaneus and the cuboid. The mobility in the talo-navicular and the calcaneo-cuboid joints was assessed by comparing measurements with the foot in adduction and abduction.

RESULTS

The variables could be assessed with fair to very good intra- and inter-observer repeatability (intraclass correlation coefficient > 0.8 and ≥ 0.6, respectively), with a few exceptions. There was less movement in talo-navicular and calcaneo-cuboid joints in clubfeet than in controls.

CONCLUSION

Morphology of normal feet and clubfeet, as well as mobility in the talo-navicular and calcaneo-cuboid joints, can be assessed by ultrasound with a fair to very good reliability from birth to the age of four years.

LEVEL OF EVIDENCE

III.

Assessment of the ankle joint in clubfeet and normal feet to the age of four years by ultrasonography

PURPOSE

To establish reproducible posterior ultrasonographic projections for evaluation of the movement in the talocrural joint in clubfeet and normal feet from the perinatal period up to the age of four years.

METHODS

The feet in 105 healthy children and 46 patients (71 clubfeet and 21 normal feet) were examined. In all, 14 feet in seven patients were examined twice by two examiners independently to evaluate the repeatability of the ultrasonography scans. A posterior sagittal projection was used. The distance from the posterior aspect of the tibial physis to the posterior border of the talocalcaneal joint (Tib. phys - TCJ) was measured with the foot in neutral position and dorsiflexion. In plantar flexion the shortest distance between the tibial physis and the calcaneus was measured. The distance from the skin to the tibial epiphyses and the talus was measured in neutral position. The intraclass correlation coefficient (ICC) was calculated to evaluate the repeatability of the measurements.

RESULTS

The interexaminer reliability was 0.71 to 0.89 ICC. The intra- and interobserver reliability measured as ICC was 0.68 to 0.99 for all measurements. The correlation between Tib. phys. - TCJ and clinical dorsiflexion varied much between the age groups.

CONCLUSION

Ultrasonography of the posterior aspect of the ankle joint can be done with high interexaminer reliability. The repeatability of image evaluation was high. Correlation to clinical measurements varied, therefore dynamic ultrasound in real time is clinically more useful than single measurements on frozen ultrasound images.

Clinico-sonographical evaluation of idiopathic clubfoot and its correction by Ponseti method - A prospective study

BACKGROUND

Objective evaluation of infant with clubfoot is required as conventional imaging modality is of limited usefulness. Ultrasound shows to be a promising technique for assessing deformity and monitoring of clubfoot correction.

AIM

Study was done to evaluate the deformity sonographically; to assess the changes in these parameters after treatment by Ponseti method and to correlate these ultrasonographic variables with clinical Pirani score.

MATERIALS AND METHODS

82 feet in 54 children were observed. Clinical assessment was done using Pirani six point system and ultrasound machine with 7.5-12MHz linear transducer was used to measure several parameters and data obtained was assessed to derive correlation between sonographic parameters and clinical system.

RESULTS

Medial malleolus navicular distance (MMN) measured on medial view, calcaneo-cuboid distance (CCD) and calcaneo-cuboid angle (CCA) measured on lateral view, talar length (TAL) measured on dorsal view and tibio-calcaneal distance (TCL) measured on posterior view showed statistical significance. Sonographic parameters correlated statistically with Pirani scoring system on measuring Pearson correlation coefficient.

CONCLUSION

Ultrasound is a relatively simple, non invasive and widely available procedure that can improve pathomorphological documentation of nonossified clubfoot and its correction.

LEVEL OF EVIDENCE

Level II prospective study, as per guidelines for authors.

Design and development of a device to measure the deformities of clubfoot

Clubfoot describes a range of foot abnormalities usually present at birth, in which the foot of a baby is twisted out of shape or position. In order to develop an effective treatment plan for clubfoot and/or assess the extent to which existing interventions are successful, medical practitioners need to be able to accurately measure the nature and extent of the deformity. This is typically performed using a goniometer. However, this device is only able to measure one dimension at a time. As such, a complete assessment of the condition of a foot can be extremely burdensome and time-consuming. This article describes a new device that can quickly and efficiently take several measurements on feet of various sizes and shapes. The use of this device was verified by measuring the deformities of real clubfeet. A silicone rubber clubfoot model was also used in this study to clearly illustrate the effectiveness with which the proposed device can measure the various deformities of clubfoot. It is envisaged that the use of this device will significantly reduce the time and effort orthopedists require to measure clubfoot deformities and develop and assess treatment plans.

Early ultrasonographic evaluation of idiopathic clubfeet treated with manipulations, casts, and Botox(®): a double-blind randomized control trial

BACKGROUND

The manipulations, casts, and Botox(®) method for treating idiopathic clubfoot is an alternative non-surgical treatment method. Botox(®)-induced reversible muscle paralysis of the gastrocsoleus enables a physician to manipulate and cast the clubfoot in greater dorsiflexion. Ultrasound is incorporated during the early treatment stages to monitor the underlying physiology of the muscle-tendon unit following Botox(®).

METHODS

Ultrasonographic evaluation was performed parallel to a double-blind randomized control trial administering Botox(®) or placebo to correct clubfoot. Patients underwent two-dimensional ultrasound to monitor the length changes to the gastrocsoleus and Achilles tendon unit at two time points: pre-injection (baseline) and 6 weeks post-blinded injection. Gastrocsoleus and Achilles tendon length measurements were analyzed among placebo, Botox(®) and contralateral controls using repeated measures ANOVA.

RESULTS

The baseline gastrocsoleus length of the clubfoot (322.4 pixels) before blinded injection appears shorter than controls (337.5 pixels), but fails to reach significance (p = 0.05). The complex length within each of the three treatment groups displayed no significant change between baseline and 6 weeks. The complex-tendon ratio and muscle-tendon ratio of the Botox(®) treatment group was significantly decreased compared to controls (p = 0.049 and 0.042, respectively). Briefly, when expressed as a proportion, an increase in Achilles tendon length and decrease in gastrocsoleus is observed when clubfeet are treated with Botox(®).

CONCLUSIONS

Only in the Botox(®) treatment cohort did the muscle shrink to uncover tendon (seen as a decreased complex-tendon ratio and muscle-tendon ratio) over the 6-week interval to effectively increase tendon length with respect to the unit as a whole.

Sonography as an objective tool for monitoring serial corrections and detecting spurious corrections in clubfoot: a review

Ultrasonography is an emerging tool for monitoring clubfoot correction and for early diagnosis of spurious correction and of deformity recurrence. Sonography is widely available, inexpensive and has dynamic capability and can visualize tarsals in infants accurately.