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Rucinski K, Njai A, Stucky R, Crecelius CR, Cook JL. Patient Adherence Following Knee Surgery: Evidence-Based Practices to Equip Patients for Success. J Knee Surg 2023; 36:1405-1412. [PMID: 37586412 DOI: 10.1055/a-2154-9065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Patient adherence with postoperative wound care, activity restrictions, rehabilitation, medication, and follow-up protocols is paramount to achieving optimal outcomes following knee surgery. However, the ability to adhere to prescribed postoperative protocols is dependent on multiple factors both in and out of the patient's control. The goals of this review article are (1) to outline key factors contributing to patient nonadherence with treatment protocols following knee surgery and (2) to synthesize current management strategies and tools for optimizing patient adherence in order to facilitate efficient and effective implementation by orthopaedic health care teams. Patient adherence is commonly impacted by both modifiable and nonmodifiable factors, including health literacy, social determinants of health, patient fear/stigma associated with nonadherence, surgical indication (elective vs. traumatic), and distrust of physicians or the health care system. In addition, health care team factors, such as poor communication strategies or failure to follow internal protocols, and health system factors, such as prior authorization delays, staffing shortages, or complex record management systems, impact patient's ability to be adherent. Because the majority of factors found to impact patient adherence are nonmodifiable, it is paramount that health care teams adjust to better equip patients for success. For health care teams to successfully optimize patient adherence, focus should be paid to education strategies, individualized protocols that consider patient enablers and barriers to adherence, and consistent communication methodologies for both team and patient-facing communication.
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Affiliation(s)
- Kylee Rucinski
- Department of Orthopedic Surgery, Missouri Orthopedic Institute, University of Missouri, Columbia, Missouri
- Thompson Laboratory for Regenerative Orthopedics, University of Missouri System, Columbia, Missouri
| | - Abdoulie Njai
- Department of Orthopedic Surgery, Missouri Orthopedic Institute, University of Missouri, Columbia, Missouri
| | - Renée Stucky
- Department of Orthopedic Surgery, Missouri Orthopedic Institute, University of Missouri, Columbia, Missouri
| | - Cory R Crecelius
- Department of Orthopedic Surgery, Missouri Orthopedic Institute, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopedic Surgery, Missouri Orthopedic Institute, University of Missouri, Columbia, Missouri
- Thompson Laboratory for Regenerative Orthopedics, University of Missouri System, Columbia, Missouri
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Rucinski K, Cook JL, Royse LA. The complexity of patient adherence in orthopaedics: A qualitative study to identify barriers and develop strategies for adherence partnerships. Musculoskeletal Care 2023; 21:1387-1400. [PMID: 37695247 DOI: 10.1002/msc.1817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 08/29/2023] [Accepted: 09/03/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION While the importance of patient adherence to treatment protocols is firmly accepted, a definition for adherence and mechanisms to address non-adherence are not well established. The goals of this study were to define adherence and identify barriers and enablers for adherence partnerships through the lens of the orthopaedic healthcare team. METHODS The qualitative study was designed using concepts from grounded theory. Eight focus groups, comprised of orthopaedic healthcare team members, were conducted to identify factors influencing orthopaedic patient adherence to treatment plans. RESULTS Healthcare team members identified a range of factors affecting patient adherence. Participants conveyed that patient non-adherence can be a deliberate decision but can also result from barriers faced by the patient. Synthesis of themes identified distinct phases of adherence and culminated in the creation of a preliminary model that encapsulates healthcare team and patient factors impacting adherence, which was entitled, The Barriers and Enablers to Treatment Adherence (BETA) Model. CONCLUSION The study findings alleviate the patient from the sole burden of adherence, recognising the influences that the healthcare team and system have on patients' ability to adhere. The BETA model of patient adherence represents the first step to mitigating non-adherence by providing a foundation for programmatic research aimed at developing and evaluating interventions and management strategies that empower healthcare teams to effectively equip patients for adherence, leading to optimised patient outcomes following orthopaedic interventions.
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Mohsenh WA, Alqarni MM, Alshehri AK, Asiri AM, Mohsenh OH, Mahmood SE, Alhifzi AI, Mohsenh RH, Al Zomia AS. Factors Related to Relapse of Congenital Talipes Equinovarus (CTEV) After the Ponseti Method. Cureus 2023; 15:e43701. [PMID: 37724225 PMCID: PMC10505498 DOI: 10.7759/cureus.43701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Congenital talipes equinovarus (CTEV) is one of the common congenital disorders in pediatric orthopedic practice that affects a large group of children.It is a combination of four parts of deformity that affect either a single foot or both feet. Our aim in this study is to estimate the prevalence and incidence of CTEV and to evaluate the risk factors that lead to relapse in some children to avoid relapse in future and complex surgical interventions, as well as to improve the final outcome. MATERIALS AND METHODS A retrospective cohort study for the cases of CTEV was conducted to estimate the prevalence of relapse in children with CTEV after management by the Ponseti method and to evaluate the risk factors that lead to recurrence. RESULT The study includes 103 patients with CTEV, and only 22 patients had relapse. The prevalence rate of relapsed cases was 20.4%, and the incidence was 42 per thousand. The average number of casts applied was 4.05 ± 1.37. The average severity of the deformity that was measured by the Pirani score was 4.97 ± 1.21. The most common atypical presentation of CTEV was associated with developmental dysplasia of the hip (DDH), followed by myelomeningocele (MMC). CONCLUSION The only significant factors in the study were the Pirani score and non-compliance of the brace with p < 0.05. There was not any significance in the correction of the deformity by Ponseti between idiopathic and non-idiopathic CTEV based on the number of casts and the Pirani score. The dynamic foot brace can be the solution for the high recurrence rate, yet more studies are needed in the future.
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Affiliation(s)
- Waleed A Mohsenh
- Department of Orthopedic Surgery, Aseer Central Hospital, Abha, SAU
| | - Mahdi M Alqarni
- Department of Pediatric Orthopedic, Abha Maternity and Children Hospital, Abha, SAU
| | | | - Abdullah M Asiri
- Department of Orthopedic Surgery, Aseer Central Hospital, Abha, SAU
| | | | - Syed E Mahmood
- Department of Family and Community Medicine, King Khalid University, Abha, SAU
| | - Ali I Alhifzi
- Department of Orthopedic Surgery, Aseer Central Hospital, King Khalid University, Abha, SAU
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Marcotte D, Ferri E, Xue X, Katsolis A, Rajotte E, Cardiff K, Preuss R. Barriers and facilitators to lower extremity orthotic compliance in the pediatric population: A scoping review of the literature. Prosthet Orthot Int 2023; 47:155-167. [PMID: 37040169 DOI: 10.1097/pxr.0000000000000145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/16/2022] [Indexed: 04/12/2023]
Abstract
Despite the purported benefits of lower extremity orthotics in the literature, pediatric compliance rates remain low. This scoping review synthesized the available literature regarding barriers and facilitators to lower extremity orthotic compliance in the pediatric population using the framework of the International Classification of Functioning, Disability and Health: Children and Youth (ICF). A comprehensive search of MEDLINE, EMBASE, and CINAHL was conducted on May 11, 2021, and of PsycInfo on May 12, 2021. Article reference lists and gray literature were also searched. A total of 81 articles were included. Factors described in at least four articles were labeled as universal barriers or facilitators. In the International Classification of Functioning, Disability and Health: Children and Youth domain of Body Functions/Body Structures, universal barriers were present in the global mental functions, experience of self and time, sensory functions, function of joints and bones, and structures related to the skin subcategories, with no universal facilitators identified. For the Activity Limitations/Participation Restrictions domain, one universal facilitator was identified in the mobility subcategory. In the Environmental Contextual Factors domain, universal barriers were found in the attitudes of immediate and extended family and societal attitude subcategories, with both universal barriers and facilitators found in support & relationships: immediate and extended family, support and relationships: health professionals, services, systems, and policies, and products and technology. The reviewed literature strongly emphasizes the importance of proper orthotic fit and comfort, and the child's experience of self, for lower extremity orthotic compliance, along with multiple environmental factors.
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Affiliation(s)
- David Marcotte
- School of Physical and Occupational Therapy, McGill University, Montréal, Canada
| | - Erica Ferri
- School of Physical and Occupational Therapy, McGill University, Montréal, Canada
| | - Xiaotong Xue
- School of Physical and Occupational Therapy, McGill University, Montréal, Canada
| | - Anastasia Katsolis
- School of Physical and Occupational Therapy, McGill University, Montréal, Canada
| | - Elise Rajotte
- Lethbridge-Layton-Mackay Rehabilitation Centre Site of the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Canada
| | - Katrina Cardiff
- Lethbridge-Layton-Mackay Rehabilitation Centre Site of the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Canada
| | - Richard Preuss
- School of Physical and Occupational Therapy, McGill University, Montréal, Canada
- Lethbridge-Layton-Mackay Rehabilitation Centre Site of the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Canada
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Rucinski K, Leary E, Crist BD, Cook JL. Orthopaedic trauma patient non-adherence to follow-up visits at a level 1 trauma center serving an urban and rural population. Injury 2023; 54:880-886. [PMID: 36725488 DOI: 10.1016/j.injury.2023.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To assess key demographic and psychosocial variables that may be associated with non-adherence to clinic visits following orthopaedic trauma injuries to patients in an urban and rural population. METHODS This retrospective review included all operative and non-operative patients presenting to a Level I academic trauma center serving an urban and rural population in the Midwest following an orthopaedic injury. The study tracked patient attendance to scheduled orthopaedic trauma follow-up clinic visits after a scheduled visit in the clinic following a trauma-related injury. RESULTS Data were obtained for 5816 unique orthopaedic trauma patients who had 21,066 post-treatment follow-up visits scheduled. 1627 "no-show" appointments were recorded. Factors associated with no-shows included male sex, age between 26 and 35 years, self-reported race other than white, employment listed as disabled, household income below $25,000, education less than a high school level, uninsured, Medicaid insured, and relationship status reported as single. CONCLUSIONS In the present study, key demographic and psychosocial factors were significantly associated with patient adherence to scheduled follow-up appointments after treatment for orthopaedic trauma. Identifying patients at higher risk for nonadherence will allow healthcare teams to educate patients, providers, and staff, link patients to resources to enhance adherence, and work with their institutions to develop and implement protocols for improving adherence to follow-up appointments.
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Affiliation(s)
- Kylee Rucinski
- Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia MO, USA.
| | - Emily Leary
- Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia MO, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia MO, USA
| | - James L Cook
- Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia MO, USA
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Akinyoola LA, Gunderson Z, Sun S, Fitzgerald R, Caltoum CB, Christman TW, Bielski R, Loder RT. Association of Socioeconomic Status With Relapse After Ponseti Method Treatment of Idiopathic Clubfeet. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221119180. [PMID: 36046551 PMCID: PMC9421036 DOI: 10.1177/24730114221119180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: The Ponseti method is today’s standard treatment of idiopathic talipes equinovarus (ITEV). Compliance with foot abduction bracing (FABO) and socioeconomic factors have been shown to impact treatment outcome. We wished to further study socioeconomic factors using the Area Deprivation Index (ADI), a more comprehensive way to evaluate socioeconomic status, which has not been done before. Methods: All TEV patients from 2010 through 2019 treated with the Ponseti method were reviewed. Standard demographic variables, as well as the number of casts to complete initial correction, FABO compliance, and occurrence of relapse were tabulated. Socioeconomic level was quantified with the 2018 ADI. Results: There were 168 children; 151 had typical and 17 complex TEV. Average follow-up was 4.3 ± 1.8 years; relapse occurred in 46%. There were no significant differences in the percentage of relapse by sex, race, or ADI. FABO noncompliance was present in 46%. Relapse increased with increasing time of follow-up and FABO noncompliance (76% vs 21%, P < 10−6). Multivariate logistic regression analysis revealed that only FABO compliance and length of follow-up were associated with relapse. The OR of relapse for FABO noncompliance was 17.9 (7.6, 42.4, P < 10–6) and for follow-up >4 years the OR was 4.97 (2.1, 11.70, P = .0003). Conclusion: The outcome of the Ponseti method for TEV treatment is dependent on local circumstances. In our state, socioeconomic status, as determined by the ADI, was not associated with the occurrence of relapse. Thus, each center needs to assess its results, and analyze its own reasons for relapse. There were no other demographic variables associated with relapse except FABO compliance and length of follow-up. Parents should be strongly advised that FABO compliance and follow-up appears paramount to achieving the best results, and that complex TEV are at greater risk for relapse. Level of Evidence: Level IV, case series
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Affiliation(s)
| | | | - Seungyup Sun
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ryan Fitzgerald
- University of South Florida College of Medicine, Tampa, FL, USA
| | | | - Tyler W. Christman
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Robert Bielski
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Randall T. Loder
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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Elbaum R, Noel B, Degueldre V, Hallez M, Filloque E, Guerin V, Duvivier A. 20 years of functional treatment for clubfoot: advantages and limitations compared with the Ponseti method. J Pediatr Orthop B 2022; 31:382-390. [PMID: 33741833 DOI: 10.1097/bpb.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Currently, the Ponseti method has become the most popular technique for the management of congenital clubfoot. Besides this treatment, the functional method or the 'French method' (FFM) represents another treatment option. Throughout our study, we will describe this method, based on the 'Saint Vincent de Paul' protocol with some modifications that we bring progressively. Carried out over the last 20 years at our institution. In total 145 children (210 clubfeet) were treated using FFM. Our technique is based on the 'Saint Vincent de Paul' protocol from Paris. This method consists of daily manipulations of the feet by specialised physiotherapists associated with thermoformable orthotics devices. An evaluation of the patient at 5 year of age is performed. Gait analysis was introduced in 2011 as a complementary assessment tool. Less than 15% of the feet underwent a surgical procedure at walking age. Compliance to treatment was significantly higher than with the Ponseti method. At the last follow-up, 80% of the children had good to excellent results without major residual deformity. Totally 7% of the children required a later intervention either for recurrence or for major residual deformity. FFM is an alternative approach in the management of clubfoot that has proven to be successful due to the precision and modularity of its splinting system. Good compliance and low recurrence rate are other elements to consider. However, it requires a well-trained physical therapist. The main disadvantages of this method are the high cost compared to the Ponseti method and the difficulty of applying this method in developing countries.
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Affiliation(s)
- Robert Elbaum
- Department of Orthopaedic surgery, CHIREC Hospital Group
| | - Brigitte Noel
- Department of Physiotherapy, IRIS South Hospital Center
| | | | - Marie Hallez
- Department of Physiotherapy, CHIREC Hospital Group, Belgium, Brussel
| | - Erelle Filloque
- Department of Physiotherapy, CHIREC Hospital Group, Belgium, Brussel
| | - Virginie Guerin
- Department of Physiotherapy, CHIREC Hospital Group, Hôpital de Braine L'Alleud, Rue Wayez, Braine L'Alleud, Belgium
| | - Amandine Duvivier
- Department of Physiotherapy, CHIREC Hospital Group, Hôpital de Braine L'Alleud, Rue Wayez, Braine L'Alleud, Belgium
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Pigeolet M, Vital A, Daoud HA, Mita C, Corlew DS, Alkire BC. The impact of socio-economic factors on parental non-adherence to the Ponseti protocol for clubfoot treatment in low- and middle-income countries: A scoping review. EClinicalMedicine 2022; 48:101448. [PMID: 35706498 PMCID: PMC9112092 DOI: 10.1016/j.eclinm.2022.101448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Ponseti treatment is considered the gold standard for clubfoot globally, but requires strong engagement from parents. The aim of this review is to assess the impact of socio-economic factors on the presence of drop-out, relapse or non-compliance during Ponseti treatment in low and middle-income countries (LMICs). METHODS This scoping review includes all articles available from inception until 4.4.2022. All articles describing an association between one or more socio-economic factors and one or more adverse outcomes during the Ponseti treatment in an LMICs were considered for inclusion. Studies were identified by searching Medline/PubMed, Embase, Global Health and Global Index Medicus. Data extraction was done using Covidence extraction 2.0 by two independent reviewers. FINDINGS A total of 281 unique references were retrieved from the database searches, 59 abstracts were retained for full-text review, of which 19 studies were included in the final review. We grouped the identified socio-economic factors into 4 larger themes: poverty and physical accessibility of clubfoot clinics, presence of support systems, educational level of the parents, and household-level factors and cultural norms. Reduced access to care for girls was considered an important risk factor in South Asia and the Caribbean. Lack of family and community support was an issue raised more often in studies from Eastern Africa. The extreme heterogeneity among collected variables within a small sample of papers made it not possible to perform a meta-analysis. INTERPRETATION The identified factors are very similar to the socio-economic factors identified in studies looking at the barriers parents and children face when seeking care initially. Poverty was identified as a cross-cutting risk factor in all 4 domains and the most important socio-economic risk factor based on this review, reconfirming poverty eradication as the challenge for the 21st century. FUNDING None.
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Affiliation(s)
- Manon Pigeolet
- The Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, United States
- Université Libre de Bruxelles, Faculty of Medicine, Avenue de Lennik 808, 1070 Brussels, Belgium
- Corresponding author.
| | - Anchelo Vital
- The Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, United States
- State University of Haiti, Faculte de Medecine et de Pharmacie, 10 Imp. Ambroise, Port-au-Prince, Haïti
| | - Hassan Ali Daoud
- The Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, United States
- Amoud University, Somaliland Amoud University College of Health Sciences, Borama, Somalia
| | - Carol Mita
- Countway Library, Harvard Medical School, Harvard University Libraries, 10 Shattuck St, Boston, MA 02115, United States
| | - Daniel Scott Corlew
- The Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, United States
| | - Blake Christian Alkire
- The Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, United States
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Ottesen TD, Amick M, Kapadia A, Ziatyk EQ, Joe JR, Sequist TD, Agarwal-Harding KJ. The Unmet Need for Orthopaedic Services Among American Indian and Alaska Native Communities in the United States. J Bone Joint Surg Am 2022; 104:e47. [PMID: 35104253 DOI: 10.2106/jbjs.21.00512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
ABSTRACT Historic and present-day marginalization has resulted in a high burden of disease and worse health outcomes for American Indian and Alaska Native (AI/AN) communities in the United States. Musculoskeletal disease is the leading cause of disability for the general population in the U.S. today. However, few have examined musculoskeletal disease burden and access to orthopaedic surgical care in the AI/AN communities. A high prevalence of hip dysplasia, arthritis, back pain, and diabetes, and a high incidence of trauma and road traffic-related mortality, suggest a disproportionately high burden of musculoskeletal pathology among the AI/AN communities and a substantial need for orthopaedic surgical services. Unfortunately, AI/AN patients face many barriers to receiving specialty care, including long travel distances and limited transportation to health facilities, inadequate staff and resources at Indian Health Service (IHS)-funded facilities, insufficient funding for referral to specialists outside of the IHS network, and sociocultural barriers that complicate health-system navigation and erode trust between patients and providers. For those who manage to access orthopaedic surgery, AI/AN patients face worse outcomes and more complications than White patients. There is an urgent need for orthopaedic surgeons to participate in improving the availability of quality orthopaedic services for AI/AN patients through training and support of local providers, volunteerism, advocating for a greater investment in the IHS Purchased/Referred Care program, expanding telemedicine capabilities, and supporting community-based participatory research activities.
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Affiliation(s)
- Taylor D Ottesen
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Massachusetts General Hospital/Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Michael Amick
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Yale University School of Medicine, New Haven, Connecticut
| | - Ami Kapadia
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elizabeth Q Ziatyk
- Department of Family Medicine, Chinle Comprehensive Healthcare Facility, Chinle, Arizona
| | - Jennie R Joe
- Department of Family and Community Medicine, University of Arizona Health Sciences, Tucson, Arizona
- Native American Research and Training Center, University of Arizona Health Sciences, Tucson, Arizona
| | - Thomas D Sequist
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts
| | - Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Department of Orthopaedic Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
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Abstract
Idiopathic congenital clubfoot is the most common serious musculoskeletal birth defect in the United States and the world. The natural history of the deformity is to persist into adult life with a significant decrease in function and quality of life. The Ponseti method (serial casting, Achilles tenotomy, and bracing of the clubfoot) has become the most effective and accepted treatment of children born with clubfoot worldwide. The treatment is successful, particularly when the Ponseti-trained practitioner (often a pediatric orthopedic surgeon), the primary care clinician, and the family work together to facilitate success. An important factor in the ultimate success of the Ponseti method is parental understanding of the bracing phase. There is a very high rate of recurrent deformity when bracing is not done properly or is stopped prematurely. The importance of positive education and support for the parents to complete the entire treatment protocol cannot be overstated. The goal of treatment is a deformity-free, functional, comfortable foot. Ponseti clubfoot programs have been launched in most countries throughout the world, including many countries with limited resources. Ultimately, the goal is that every infant born with a clubfoot will have access to care with the Ponseti method. This clinical report is intended for medical practitioners who are involved in the care of pediatric patients with clubfoot. Understanding the standard of care will help these practitioners to care for patients and their families.
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Affiliation(s)
- Robert Cady
- Department of Orthopedic Surgery and Pediatrics, Upstate Medical University, Syracuse, New York,Address correspondence to Robert Cady, MD, FAAP. E-mail:
| | - Theresa A. Hennessey
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah,Shriners Hospitals for Children, Salt Lake City, Utah
| | - Richard M. Schwend
- Departments of Orthopedics and Pediatrics, Children’s Mercy Hospital, University of Missouri Kansas City, Kansas City, Kansas,Kansas University Medical Center, Kansas City, Kansas
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VAN SCHELVEN H, MOERMAN S, VAN DER STEEN M, BESSELAAR AT, GREVE C. Prognostic factors for recurrent idiopathic clubfoot deformity: a systematic literature review and meta-analysis. Acta Orthop 2022; 93:11-28. [PMID: 34607499 PMCID: PMC8815420 DOI: 10.1080/17453674.2021.1982576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - After initial clubfoot correction through Ponseti treatment, recurrence rates range from 26% to 48%. Even though various factors have been associated with increased recurrence risk, systematic assessments of the prognostic capacity of recurrence risk factors and their clinical relevance are lacking. Therefore we assessed clinically relevant prognostic factors for recurrent idiopathic clubfoot deformity after initial correction through Ponseti treatment. Methods - PubMed, Embase, Cinahl, and Web of Science were systematically searched for studies investigating the association between clinically relevant factors and recurrence rates. Prognostic factors were qualitatively assessed and included in the meta-analysis if ≥ 2 studies investigated the same factor and methods were comparable. Results - 34 articles were included in the qualitative synthesis, of which 22 were also included in the meta-analysis. Meta-analysis revealed that poor evertor muscle activity (OR = 255, 95% CI 30-2,190), brace non-compliance (OR = 10, CI 5-21), no additional stretching (OR = 31, CI 10-101), more casts (OR = 3.5, CI 1.6-7.8), lower education level of parents (OR = 1.8, CI 1.2-2.6), non-marital status of parents (OR = 1.8, CI 1.1-3.0), and higher Dimeglio scores (OR = 1.9, CI 1.2-3.3) were associated with higher recurrence rates. Interpretation - Brace non-compliance and poor evertor muscle activity have been identified as main recurrence risk factors and are therefore important to be closely monitored during clinical follow-up of clubfoot patients. Adding additional stretching during the bracing protocol might be promising in the quest to prevent relapse, but scientific evidence for clear clinical treatment recommendations is still limited.
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Affiliation(s)
- Heleen VAN SCHELVEN
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen
| | - Sophie MOERMAN
- Department of Orthopedics, University Medical Center Groningen, University of Groningen, Groningen
| | - Marieke VAN DER STEEN
- Department of Orthopaedic Surgery & Trauma, Catharina Hospital, Eindhoven,Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Veldhoven
| | - Arnold T BESSELAAR
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Veldhoven
| | - Christian GREVE
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen,Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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12
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Cohen E, Katz T, Rozen U, Friesem T, Leibovitz E. The Influence of Achilles Tenotomy and Compliance with Foot Abduction Orthosis on the Relapse Rate of Ponseti Treatment for Idiopathic Clubfoot: A Regional Study. J Foot Ankle Surg 2021; 59:784-787. [PMID: 32307285 DOI: 10.1053/j.jfas.2019.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 11/02/2019] [Accepted: 12/18/2019] [Indexed: 02/03/2023]
Abstract
The Ponseti method for treating idiopathic clubfoot is based on gradual manipulations and corrective plaster castings followed by a years-long period of use of a foot orthosis. The role of surgery is limited. The factors that may affect outcome and their influence are subject of controversy. The aim of the study is to systematically and objectively evaluate the results of Ponseti treatment in our region of Southern Israel and focus on the role of the Achilles tenotomy and compliance to foot orthosis as factors that may influence outcome. The use of Ponseti method was retrospectively studied (level of evidence IV) by searching computerized medical files and clinical photos. The severity of deformity was evaluated by Dimeglio score (D-score) at baseline and at last examination. During 2006-2014, 57 children with idiopathic clubfoot (total 90 feet) were enrolled. An Achilles tenotomy was performed in 55/90 (61.1%) of the feet. If the D-score was 15 or higher there was a 20% increase in the incidence of Achilles tenotomy. The parental compliance had a weak protective effect against relapse. The treatment of idiopathic clubfoot by the Ponseti method was successful and reliable, proving efficiency and universality of the method. A dominant predictor for relapse was not seen. An incidental observation was that extended time in cast may buffer the adverse effects of low compliance rate. Although the initial severity, or compliance to braces are important, there may be other factors that affect the outcome such as, accuracy of the casting technique, time in the cast, access to a dedicated clubfoot clinic, cooperation with nurses and pediatricians, economic status that allows purchase of new generation of braces, cultural perception, and education level of the patient population are some examples.
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Affiliation(s)
- Eugen Cohen
- Lecturer, Orthopaedic Department, Soroka Medical Center, Ben Gurion University Beer-Sheva, Israel.
| | - Tiberiu Katz
- Lecturer, Orthopaedic Department, Soroka Medical Center, Ben Gurion University Beer-Sheva, Israel
| | - Uri Rozen
- Resident, Meuhedet Health Services, Tel Aviv, Israel
| | - Tai Friesem
- Senior Lecturer, Orthopaedic Department, Soroka Medical Center, Ben Gurion University Beer-Sheva, Israel
| | - Eugene Leibovitz
- Professor, Pediatric Division, Soroka Medical Center, Ben Gurion University Beer-Sheva, Israel
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Aroojis A, Pandey T, Dusa A, Krishnan AG, Ghyar R, Ravi B. Development of a functional prototype of a SMART (Sensor-integrated for Monitoring And Remote Tracking) foot abduction brace for clubfoot treatment: a pre-clinical evaluation. INTERNATIONAL ORTHOPAEDICS 2021; 45:2401-2410. [PMID: 33885922 PMCID: PMC8061451 DOI: 10.1007/s00264-021-05042-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/07/2021] [Indexed: 11/26/2022]
Abstract
Purpose Recurrences following clubfoot correction by the Ponseti method can be prevented by regular use of a foot abduction brace (FAB) until the child is four to five years old. However, there is a lack of an objective method to measure actual hours of brace usage. The aim was to develop a functional prototype of a SMART (Sensor-integrated for Monitoring And Remote Tracking) clubfoot brace to record accurate brace usage and transmit the data remotely to healthcare providers treating clubfoot. Methods A collaborative team of engineers and doctors was formed to investigate various types of sensors and wireless technologies to develop a functional prototype of a SMART brace. Results Infrared sensors were used to detect if the feet were placed inside the shoes and magnetic Hall effect sensors to detect that the shoes were latched on to the bar of the existing FAB. Brace usage data were captured by the sensors every 15 minutes and stored locally on a data card. A Bluetooth low energy (BLE)-based wireless transmission system was used to send the data daily from the brace to the remote cloud server via a smartphone application. Accurate brace usage data could be recorded by the sensors and visualized in real time on a web-based application in a pre-clinical setting, demonstrating feasibility in clinical practice. Conclusion The low-cost SMART brace prototype that we have developed can accurately measure and remotely transmit brace usage data and has the potential to transform caregivers’ behaviour towards brace adherence, which could result in a tangible reduction in recurrence rates.
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Affiliation(s)
- Alaric Aroojis
- Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Acharya Donde Marg, Parel, Mumbai, 400012 Maharashtra India
| | - Tapas Pandey
- Biomedical Engineering and Technology (Incubation) Center (BETiC), Indian Institute of Technology-Bombay (IIT-B), Mumbai, India
| | - Ajay Dusa
- Biomedical Engineering and Technology (Incubation) Center (BETiC), Indian Institute of Technology-Bombay (IIT-B), Mumbai, India
| | - Arun G. Krishnan
- Biomedical Engineering and Technology (Incubation) Center (BETiC), Indian Institute of Technology-Bombay (IIT-B), Mumbai, India
| | - Rupesh Ghyar
- Biomedical Engineering and Technology (Incubation) Center (BETiC), Indian Institute of Technology-Bombay (IIT-B), Mumbai, India
| | - Bhallamudi Ravi
- Department of Mechanical Engineering, Indian Institute of Technology-Bombay (IIT-B), Mumbai, India
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Richter DL, Held M, Campos T, Wascher DC, Schenck RC. The Management of Knee Dislocations in the Limited-Resource Setting. J Bone Joint Surg Am 2020; 102:e136. [PMID: 33060423 DOI: 10.2106/jbjs.20.00743] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Michael Held
- University of Cape Town, Cape Town, South Africa
| | - Túlio Campos
- Federal University of Minas Gerais, Belo Horizonte, Brazil
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Thomas HM, Sangiorgio SN, Ebramzadeh E, Zionts LE. Relapse Rates in Patients with Clubfoot Treated Using the Ponseti Method Increase with Time: A Systematic Review. JBJS Rev 2020; 7:e6. [PMID: 31116129 DOI: 10.2106/jbjs.rvw.18.00124] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Hannah M Thomas
- Orthopaedic Institute for Children, The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center, Los Angeles, California
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Schulz JF, Molho DA, Sylvia SM, Lo Y, Gomez JA, Moloney CM, Hanstein R, Fornari ED. Parental understanding of intoeing gait - A preliminary study. Foot (Edinb) 2019; 41:39-43. [PMID: 31683095 DOI: 10.1016/j.foot.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/11/2019] [Accepted: 06/25/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Evaluation of a child's intoeing gait is one of the most common referrals made to a pediatric orthopedist. Families may have difficulty understanding the often transient and usually benign nature of intoeing. The purpose of this study was to investigate parental perceptions of an intoeing gait both before and after consultation with an orthopedic practitioner. METHODS 48 parents of children referred to pediatric orthopedic surgeons for evaluation of intoeing gait completed a 22-item questionnaire that assessed demographics, anxiety, and parental perceptions of intoeing. Questionnaires were administered before and after visits. Statistical analysis was performed using Wilcoxon signed-rank tests and Fisher exact tests. RESULTS Before their visits, parents reported similar levels of anxiety and understanding regarding intoeing, independent of their age or education. After the visits, anxiety decreased (P < 0.001), and understanding increased (P < 0.001) although younger parents (18-25 years) reported higher post-visit anxiety compared to parents older than 25 (P = 0.014). Similarly, parents with a high school degree or less reported higher post-visit anxiety compared to parents who attended college (P = 0.009). Post-visit understanding was inversely correlated with post-visit anxiety (r = -0.717; P < 0.001). Additionally, parents who reported high anxiety post-visit stated they were more likely to seek additional care (P < 0.001). CONCLUSIONS Younger parents with lower education levels were more likely to leave visits with high anxiety and poor understanding. These parents were more likely to consider seeking further treatment for their child's intoeing, placing additional stress on their child, themselves and an overburdened healthcare system.
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Affiliation(s)
- Jacob F Schulz
- Division of Pediatric Orthopaedics, Children's Hospital at Montefiore Medical Center, 3400 Bainbridge Avenue, Bronx, NY 10467, USA.
| | - David A Molho
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA.
| | - Stephen M Sylvia
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA.
| | - Yungtai Lo
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA.
| | - Jaime A Gomez
- Division of Pediatric Orthopaedics, Children's Hospital at Montefiore Medical Center, 3400 Bainbridge Avenue, Bronx, NY 10467, USA.
| | - Christine M Moloney
- Division of Pediatric Orthopaedics, Children's Hospital at Montefiore Medical Center, 3400 Bainbridge Avenue, Bronx, NY 10467, USA.
| | - Regina Hanstein
- Division of Pediatric Orthopaedics, Children's Hospital at Montefiore Medical Center, 3400 Bainbridge Avenue, Bronx, NY 10467, USA.
| | - Eric D Fornari
- Division of Pediatric Orthopaedics, Children's Hospital at Montefiore Medical Center, 3400 Bainbridge Avenue, Bronx, NY 10467, USA.
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Incidence and risk factors for iatrogenic distal tibia/fibula fracture during Ponseti technique of clubfoot treatment. J Pediatr Orthop B 2019; 28:572-578. [PMID: 30741748 DOI: 10.1097/bpb.0000000000000595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
The incidence and risk factors of distal tibia/fibula fracture, an uncommon complication during Ponseti manipulation, are unknown. We evaluated 222 virgin clubfeet of patients aged less than 3 years for fractures of distal tibia/fibula. Incidence rate was found to be 1.3% per year. Associated risk factors were identified as neglected, syndromic clubfeet, feet requiring greater than 10 casts, post-tenotomy dorsiflexion less than 10° and casting by physician with less than 3 years of casting experience, with odds ratios of 14, 28, 4.9, 3.7 and 3.4, respectively. Most of these fractures healed without consequences; however, it is still advisable not to forcefully dorsiflex while casting, which may result in the fracture of distal tibia/fibula.
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Limpaphayom N, Sailohit P. Factors Related to Early Recurrence of Idiopathic Clubfoot Post the Ponseti Method. Malays Orthop J 2019; 13:28-33. [PMID: 31890107 PMCID: PMC6915309 DOI: 10.5704/moj.1911.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- N Limpaphayom
- Department of Orthopaedics, Chulalongkorn University, Bangkok, Thailand.,Department of Orthopaedics, Police General Hospital, Bangkok, Thailand
| | - P Sailohit
- Department of Orthopaedics, Police General Hospital, Bangkok, Thailand
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19
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Khorsheed MA, Hwaizi LJK. Early management of clubfoot by the Ponseti method with complete percutaneous tenotomy of tendoachillis. J Family Med Prim Care 2019; 8:2618-2622. [PMID: 31548943 PMCID: PMC6753817 DOI: 10.4103/jfmpc.jfmpc_291_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/27/2019] [Accepted: 06/09/2019] [Indexed: 11/15/2022] Open
Abstract
Background and Objective: As a highly common congenital deformity which can lead to serious walking problems, clubfoot has long been treated using the Ponseti method which is usually carried out without complete percutaneous tenotomy of tendoachillis. The present study was aimed at investigating the effects of early management of clubfoot by the Ponseti method with a complete percutaneous tenotomy of tendoachillis in Erbil Teaching Hospital located in Erbil, the Kurdistan Region of Iraq. Methods: Thirty neonates <3 months of age who had congenital idiopathic clubfoot were randomly selected. They were treated by the Ponseti method. For this purpose, successive casts were applied for them for 3 weeks, with changing the casts on a weekly basis. For those who did not respond to the first 3 weeks of casting, the classical Ponseti method was utilized along with complete percutaneous tenotomy of tendoachillis based on the theory of stem cell regeneration. Then, the casting was performed for 6 weeks, followed by foot abduction brace and maintained using a foot abduction brace (Dennis brown splint) until school age 5-6 years. The collected data were analyzed using the χ2 test through SPSS 22.0. Results: The results of the present study indicated that the most prevalent type of clubfoot was the unilateral type with 73.3% prevalence rate. Treating the newborns with clubfoot by the Ponseti method along with complete percutaneous tenotomy of tendoachillis led to good results in 86.7% of the cases, medium in 3 cases (10%), and poor only in 1 case (3.3%). Conclusion: Ponseti method along with complete percutaneous tenotomy of tendoachillis was proved to be an efficient method to treat clubfoot during the first few weeks of life.
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Affiliation(s)
| | - Las Jamal Khorsheed Hwaizi
- Head of Surgical Specialties Council, Kurdistan Board of Medical Specialties, Erbil, Kurdistan Region, Iraq
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Spaulding SE, Yamane A, McDonald CL, Spaulding SA. A conceptual framework for orthotic and prosthetic education. Prosthet Orthot Int 2019; 43:369-381. [PMID: 31199192 DOI: 10.1177/0309364619852455] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Variables that influence orthotic and prosthetic patient outcomes beyond direct care are poorly conceptualized for orthotic and prosthetic students. Restructuring educational curricula around important clinical reasoning variables (i.e. factors that may influence outcomes) could improve teaching, learning, and clinical practice. OBJECTIVES To propose an orthotic and prosthetic education framework to enhance the development of orthotic and prosthetic students' clinical reasoning skills. STUDY DESIGN Scoping review. METHODS We conducted a scoping review, identified variables of orthotic and prosthetic usability, and performed a qualitative thematic analysis through the lens of orthotic and prosthetic clinical educators to develop a conceptual framework for orthotic and prosthetic education. RESULTS Sorting of variables identified from the literature resulted in three thematic areas: (1) the state of functioning, disability, and health (International Classification of Functioning, Disability and Health); (2) orthotic and prosthetic technical properties, procedures, and appropriateness; and (3) professional service as part of orthotic and prosthetic interventions. The proposed orthotic and prosthetic education framework includes these three areas situated within the context of patient-centered care. CONCLUSIONS A conceptual framework was developed from variables identified in peer-reviewed literature. This orthotic and prosthetic education framework provides a structure to explore orthotic and prosthetic clinical reasoning and advance our teaching and assessment of students' clinical reasoning skills. CLINICAL RELEVANCE The proposed orthotic and prosthetic (O&P) education framework is intended to promote conversation about variables (e.g. health condition, procedures, services, and O&P principles) that influence O&P clinical practice outcomes and further advance our teaching and assessment of students' clinical reasoning skills.
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Affiliation(s)
- Susan E Spaulding
- 1 Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Ann Yamane
- 1 Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Cody L McDonald
- 1 Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
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Su Y, Xie Y, Kang X, Nan G. A polyaxial fixation brace for the treatment of idiopathic congenital talipes equinovarus in newborns. J Orthop Surg Res 2019; 14:211. [PMID: 31300013 PMCID: PMC6625020 DOI: 10.1186/s13018-019-1268-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/08/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Treatment of idiopathic congenital talipes equinovarus (CTEV) is challenging for pediatric orthopedic surgeons. The Ponseti method is an effective protocol for treatment due to its technique of manipulation, casting, and limited surgery. Plaster casting is an essential component of the Ponseti method. In this report, we describe a new brace that was developed for use in the treatment of clubfoot in newborns instead of a plaster cast. METHODS This retrospective study was performed in two orthopedic medical centers. Between January 2011 and October 2013, 89 newborns with CTEV (131 ft) underwent corrective treatment using fixation braces in the experiment group (E-group) in our hospital, and 107 newborns with CTEV (141 ft) underwent plaster casting in the control group (C-group) in another medical center. All patients were treated according to the Ponseti method after the application of the inclusion and exclusion criteria. Plaster casts were applied to patients in the C-group. The patients in the E-group received the custom-made polyaxial fixation braces instead of plaster casts. Prospective follow-up was performed for a mean duration of 36 months. The efficacy of the treatment was assessed using Pirani's scoring system. Chi-squared and independent t tests were used for statistical analyses. RESULTS In the E-group, 85 patients (125 ft) achieved good appearance within 3 months of treatment initiation (average, 1.7 months). Four patients (6 ft) required percutaneous Achilles tenotomy. Seven patients developed sores during treatment because of improper brace application, but all sores healed without scarring with timely treatment. In the C-group, 96 patients (123 ft) achieved good appearance within 3 months of treatment initiation (average, 1.6 months). Eleven patients (18 ft) required percutaneous Achilles tenotomy. Twenty-one feet developed sores during treatment because of plaster cast pressure on the dorsum of the feet. Sixteen sores healed without scarring with timely treatment, and 5 ft had obvious scars. The overall mean Pirani scores 1 year after treatment were 0.26 ± 0.06 in the E-group and 0.25 ± 0.03 in the C-group, and the Pirani scores 3 years after treatment were 0.23 ± 0.05 in the E-group and 0.22 ± 0.03 in the C-group. There were significant differences in the percutaneous Achilles tenotomy and skin sores but no significant difference in the Pirani scores between these two groups. CONCLUSIONS Our results showed that the new polyaxial fixation brace used in this study was an effective tool for the corrective treatment of CTEV in newborns. We propose the use of this brace as an alternative treatment for newborns.
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Affiliation(s)
- Yuxi Su
- Department II of Orthopaedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, 136# Zhongshan 2 road, Chongqing, 400014, Yuzhong District, China
| | - Yan Xie
- Clinical Laboratory Department, Maternal and Child Health Care Hospital of Chongqing Yubei District, No.71, Shuanghu branch road, Chongqing, Yubei District, China
| | - Xiaopeng Kang
- Orthopaedics Department, Kunming Children's Hospital, No. 288, Qianxing road, Xishan district, Kunming city, Yunnan Province, China
| | - Guoxin Nan
- Department II of Orthopaedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, 136# Zhongshan 2 road, Chongqing, 400014, Yuzhong District, China.
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Abstract
BACKGROUND Despite the high rate of initial success using the Ponseti method to manage idiopathic clubfoot deformity, relapse continues to be a problem. We surveyed the Pediatric Orthopedic Society of North America (POSNA) members about their experience with relapsed deformity following the initial correction of clubfeet. METHODS We created a survey to focus on the management of clubfeet after initial correction of deformity. The survey included questions on postcorrective bracing, clinical findings used to identify relapse, the observed frequency of relapsed deformity, and how relapses are managed. The questionnaire was approved by the POSNA Evidence Based Committee and was sent electronically to all POSNA members. RESULTS We received responses from 321 members (26%). Of those, 94% were fellowship trained in pediatric orthopaedics. The Ponseti method was used by 98% of respondents. The Mitchell-Ponseti orthosis was most commonly used (51%), followed by the Denis-Browne brace (25%). The duration of bracing used varied among members with 23% recommending only 2 years, 33% recommending 3 years, and 34% recommending 4 years. A tight heel cord was felt to be the first sign of relapse by 59% of respondents, and dynamic supination by 30%. The rate of relapse was observed to be <10% by 22% of the respondents, 10% to 20% by 52%, and 20% to 40% by 25%. Manipulation and cast treatment alone (55%) and cast treatment with tenotomy (23%) were reported as the 2 most common initial treatment approaches for a relapsed deformity. Cast treatment to correct relapsed deformity before tibialis anterior tendon transfer was reported by 62% of respondents. Heel cord tenotomy (75%) and posterior capsular release (43%) were the 2 most common procedures used in addition to tibialis anterior tendon transfer for the treatment of clubfoot relapse. CONCLUSION This study highlights the wide variation with which clubfoot relapses are evaluated and treated among the POSNA membership with differences in the recommended duration of bracing, identification of relapses, and their management. These wide differences highlight the need for future research and educational programs to inform and standardize the management of clubfoot using the Ponseti Method. LEVEL OF EVIDENCE Not applicable.
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Abstract
BACKGROUND It is challenging that some Ponseti method corrected clubfeet have a tendency to relapse. Controversies remain as to the implication of initial severity, representing the deformity degree, as well as number of casts needed, representing the treatment process, in predicting relapse. However, no study has been reported to take these 2 parameters into comprehensive consideration for outcome measurement. The purpose of this study is to investigate the correlation between the initial Pirani score and the number of casts required to correct the deformity in our series; to evaluate noncompliance as a risk factor of the deformity recurrence in Ponseti treatment; to test the validity and predictive value of a new proposed parameter, ratio of correction improvement (RCI) which is indicated by the initial Pirani scores divided by the number of casts. METHODS A total of 116 consecutive patients with 172 idiopathic clubfeet managed by Ponseti method were followed prospectively for a minimum of 2 years from the start of brace wearing. RCI value and the other clinical parameters were studied in relation to the risk of relapse by using multivariate logistic regression analysis modeling. RESULTS A positive correlation between the initial Pirani score and the number of casts required to correct the deformity was found in our series (r=0.67, P<0.01). There were 45 patients (39%) with brace noncompliance. The relapse rate was 49% (22/45). The odds ratio of relapse in noncompliant patients was 10 times more that in compliant patients (odds ratio=10.30 and 95% confidence interval, 2.69-39.42; P<0.01). The multivariate logistic regression analysis showed that there was significant association between relapse and RCI value. There were 42 patients (36%) with RCI value <1, among them, the relapse rate was 57% in 24 patients. The odds ratio of relapse in patients with RCI value <1 was 27 times more likely to relapse than those >1 (odds ratio=26.77 and 95% confidence interval, 5.70-125.72; P<0.01). CONCLUSIONS On the basis of the findings from our study, we propose the RCI to be a new parameter in predicting the risk of relapse in Ponseti method of clubfoot management. Early intervention is recommended to optimize the brace compliance particularly in case with lower RCI value. LEVEL OF EVIDENCE Level II-prognostic.
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Chand S, Mehtani A, Sud A, Prakash J, Sinha A, Agnihotri A. Relapse following use of Ponseti method in idiopathic clubfoot. J Child Orthop 2018; 12:566-574. [PMID: 30607203 PMCID: PMC6293330 DOI: 10.1302/1863-2548.12.180117] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/07/2018] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- S. Chand
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - A. Mehtani
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research & Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - A. Sud
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - J. Prakash
- Central Institute of Orthopaedics, VMMC & Safdarjung Hospital, New Delhi, India
| | - A. Sinha
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - A. Agnihotri
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
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25
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Zionts LE, Jew MH, Bauer KL, Ebramzadeh E, Sangiorgio SN. How Many Patients Who Have a Clubfoot Treated Using the Ponseti Method are Likely to Undergo a Tendon Transfer? J Pediatr Orthop 2018; 38:382-387. [PMID: 27379785 DOI: 10.1097/bpo.0000000000000828] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Ponseti method has become the standard of care for the treatment of idiopathic clubfoot. A commonly reported problem encountered with this technique is a relapsed deformity that is sometimes treated in patients older than 2.5 years by an anterior tibial tendon transfer (ATTT) to the third cuneiform. Presently, there is insufficient information to properly counsel families whose infants are beginning Ponseti treatment on the probability of needing later tendon transfer surgery. METHODS All idiopathic clubfoot patients seen at the authors' institution during the study period who met the inclusion criteria and who were followed for >2.5 years were included (N=137 patients). Kaplan-Meier Survival analysis was used to determine the probability of survival without the need for ATTT surgery. In addition, the influence of patient characteristics, socioeconomic variables, and treatment variables on need for surgery was calculated. RESULTS On the basis of the survivorship analysis, the probability of undergoing an ATTT remained below 5% for all patients at 3 years of age, but exceeded 15% by 4 years of age, increasing steadily afterwards such that by 6 years of age, the probability of undergoing an ATTT reached 29% of all patients. Overall, controlling for all other variables in the analysis, parent-reported adherence with bracing reduced the odds of undergoing surgery by 6.88 times, compared with parent-reported nonadherence (P<0.01). CONCLUSIONS This is the first study to report the probability of undergoing ATTT surgery as a function of age using survivorship analysis following Ponseti clubfoot treatment. Although the overall probability reached 29% at 6 years, this was significantly reduced by compliance with bracing. This information may be useful to the clinician when counseling families at the start of treatment. LEVEL OF EVIDENCE Level III-theraputic.
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Affiliation(s)
- Lewis E Zionts
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, Orthopaedic Institute for Children, Los Angeles, CA
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Berger N, Lewens D, Salzmann M, Hapfelmeier A, Döderlein L, Prodinger PM. Is unilateral lower leg orthosis with a circular foot unit in the treatment of idiopathic clubfeet a reasonable bracing alternative in the Ponseti method? Five-year results of a supraregional paediatric-orthopaedic centre. BMC Musculoskelet Disord 2018; 19:229. [PMID: 30021573 PMCID: PMC6052525 DOI: 10.1186/s12891-018-2160-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 06/27/2018] [Indexed: 01/03/2023] Open
Abstract
Background In the Ponseti treatment of idiopathic clubfoot, children are generally provided with a standard foot abduction orthosis (FAO). A significant proportion of these patients experience irresolvable problems with the FAO leading to therapeutic non-compliance and eventual relapse. Accordingly, these patients were equipped with a unilateral lower leg orthosis (LLO) developed in our institution. The goal of this retrospective study was to determine compliance with and the efficacy of the LLO as an alternative treatment measure. The minimum follow-up was 5 years. Results A total of 45 patients (75 ft) were retrospectively registered and included in the study. Compliance with the bracing protocol was 91% with the LLO and 46% with the FAO. The most common problems with the FAO were sleep disturbance (50%) and cutaneous problems (45%). Nine percent of patients experienced sleep disturbance, and no cutaneous problems occurred with the LLO. Thirteen percent of patients being treated with an FAO until the age of four (23 patients; 40 ft) underwent surgery because of relapse, defined by rigid recurrence of any of the components of a clubfoot. Fourteen percent of patients being treated with an LLO (22 patients; 35 ft), mostly following initial treatment with an FAO, experienced recurrence. Conclusion Changing from FAO to LLO at any point during treatment did not result in an increased rate of surgery and caused few problems. Electronic supplementary material The online version of this article (10.1186/s12891-018-2160-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- N Berger
- Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.
| | - D Lewens
- Behandlungszentrum Aschau im Chiemgau, Aschau, Germany
| | - M Salzmann
- Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - A Hapfelmeier
- Klinikum rechts der Isar der Technischen Universität München, Munich, Germany.,Institute of Medical Informatics, Statistics and Epidemiology, Technical University Munich, Munich, Germany
| | - L Döderlein
- Behandlungszentrum Aschau im Chiemgau, Aschau, Germany
| | - P M Prodinger
- Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
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Cosma DI, Corbu A, Nistor DV, Todor A, Valeanu M, Morcuende J, Man S. Joint hyperlaxity prevents relapses in clubfeet treated by Ponseti method-preliminary results. INTERNATIONAL ORTHOPAEDICS 2018; 42:2437-2442. [PMID: 29732492 DOI: 10.1007/s00264-018-3934-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/05/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE The aim of the study was to evaluate the role of joint hyperlaxity (by Beighton score) as a protective factor for clubfoot relapse. METHODS Patients with idiopathic clubfoot treated with the Ponseti method between January 2004 and December 2012, without other congenital foot deformity, and not previously treated by open surgery were included in either the Relapse group (n = 23) if it was a clubfoot relapse or the Control group (n = 19) if no relapse was noted. Joint laxity was evaluated using the Beighton score at the latest follow-up against the Normal group (n = 22, children matched by sex and age without clubfoot deformity). RESULTS We found a significantly higher joint laxity in the Control group (4.58, 95% confidence interval [CI]: 2.1-7.06) as compared to the Relapse (3.17, 95% CI: 1.53-4.81, p = 0.032) and Normal (3.14, 95% CI: 1.78-4.5, p = 0.03) groups. The univariate logistic regression showed a 5.28-times increase in the risk of relapse for a Beighton score lower than 4/9 points (odds ratio = 5.28; 95% CI = 1.29-21.5; p = 0.018). CONCLUSIONS Joint hyperlaxity could be a protective factor for clubfoot relapse.
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Affiliation(s)
- Dan Ionuţ Cosma
- Department of Orthopaedics, Traumatology and Paediatric Orthopaedics, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Andrei Corbu
- Department of Orthopaedics, Traumatology and Paediatric Orthopaedics, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Dan Viorel Nistor
- Department of Orthopaedics, Traumatology and Paediatric Orthopaedics, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Adrian Todor
- Department of Orthopaedics, Traumatology and Paediatric Orthopaedics, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Madalina Valeanu
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy "Iuliu Hatieganu", 6 Pasteur st, Cluj-Napoca, Romania.
| | - Jose Morcuende
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Sorin Man
- Department of Paediatrics, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
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Lang PJ, Avoian T, Sangiorgio SN, Nazif MA, Ebramzadeh E, Zionts LE. Quantification of the ossification of the lateral cuneiform in the feet of young children with unilateral congenital talipes equinovarus. Bone Joint J 2017; 99-B:1109-1114. [DOI: 10.1302/0301-620x.99b8.bjj-2016-0999.r2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 03/07/2017] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- P. J. Lang
- University of California, Los Angeles, 403
W. Adams Blvd, Los Angeles, CA
90007, USA
| | - T. Avoian
- University of California, Los Angeles, 403
W. Adams Blvd, Los Angeles, CA
90007, USA
| | - S. N. Sangiorgio
- University of California, Los Angeles, 403
W. Adams Blvd, Los Angeles, CA
90007, USA
| | - M. A. Nazif
- University of California, Los Angeles, 403
W. Adams Blvd, Los Angeles, CA
90007, USA
| | - E. Ebramzadeh
- University of California, Los Angeles, 403
W. Adams Blvd, Los Angeles, CA
90007, USA
| | - L. E. Zionts
- University of California, Los Angeles, 403
W. Adams Blvd, Los Angeles, CA
90007, USA
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Lara LCR, Gil BL, Torres LCDA, Dos Santos TPS. COMPARISON BETWEEN TWO TYPES OF ABDUCTION ORTHOTICS IN TREATING CONGENITAL CLUBFOOT. ACTA ORTOPEDICA BRASILEIRA 2017; 25:125-128. [PMID: 28955166 PMCID: PMC5608724 DOI: 10.1590/1413-785220172504155890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 08/31/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The objective of this study was to analyze and compare the effectiveness of two types of abduction orthotics used for the feet, the Denis-Browne type (traditional) and the Dobbs type (dynamic), with regard to maintenance of deformity correction and prevention of recurrence . METHOD In this comparative retrospective case study, information was collected from the medical records of children with idiopathic congenital clubfoot (CCF). We evaluated a total of 43 feet in 28 patients, which were divided into two groups. Group 1 was comprised of 16 patients with a total of 24 CCFs treated with the traditional orthotic device. Group 2 consisted of 12 patients with a total of 19 CCFs treated with the dynamic orthotic device. The statistical analysis used the ANOVA test to compare the categorical variables between the groups. A significance level of 5% was adopted (p-value≤0.05) . RESULTS In Group 1, recurrence was observed in 2 feet (8.33%), and in 1 foot in Group 2 (5.26%). No significant difference in effectiveness was seen between the two types of orthotic devices . CONCLUSION Both abduction devices were seen to be effective in maintaining correction of congenital clubfoot deformities. There was no statistical significance between type of orthotic device and recurrence. Level of Evidence III, Retrospective Comparative Study.
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Affiliation(s)
- Luiz Carlos Ribeiro Lara
- . Universidade de Taubaté (UNITAU), Department of Medicine, Hospital Universitário de Taubaté (HUT), Orthopedics and Traumatology Division, Foot and Ankle Group, Taubaté, SP, Brazil
| | - Bruno Leite Gil
- . Hospital Universitário de Taubaté (HUT), Orthopedics and Traumatology Division, Taubaté, SP, Brazil
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Abstract
BACKGROUND The timing and relevance of relapsed deformity after correction of idiopathic clubfoot have not been well documented. METHODS All patients with idiopathic clubfoot seen at the authors' institution during the study period who were followed for ≥2 years (range, 2.0 to 9.8 years) were included (N = 191). Survival analysis and multivariate regression analysis were used to analyze the data. RESULTS The median age at first relapse was 20 months. The probability of relapse remained approximately 30% at age 2 years and increased to 45% by 4 years and 52% by 6 years. Parent-reported adherence with bracing reduced the odds of a relapse by 15 times (P < 0.01). After an initial relapse, adherence with bracing was successful in avoiding a subsequent relapse in 68% of patients. Feet graded as very severe on the Diméglio scale were 5.75 times more likely to relapse than those graded severe and were 7.27 times more likely than those graded as moderate. DISCUSSION Patients whose parents reported nonadherence with bracing and patients with very severe deformities were most likely to relapse. After an initial relapse, regaining correction of the foot and resuming bracing were beneficial to avoid further relapses. These findings can be useful to clinicians in advising families regarding the prognosis of treatment. CONCLUSIONS The development of a relapse affects the subsequent management and outcome of clubfoot deformity. The importance of bracing should be reinforced to parents. Bracing until at least age 4 years may be beneficial. For patients whose families are especially resistant to brace use and for older patients who experience a second relapse, regaining correction of the deformity via cast treatment followed by an Achilles lengthening procedure and/or tendon transfer may be the best alternative.
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31
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Besselaar AT, Sakkers RJB, Schuppers HA, Witbreuk MMEH, Zeegers EVCM, Visser JD, Boekestijn RA, Margés SD, Van der Steen MC(M, Burger KNJ. Guideline on the diagnosis and treatment of primary idiopathic clubfoot. Acta Orthop 2017; 88:305-309. [PMID: 28266239 PMCID: PMC5434600 DOI: 10.1080/17453674.2017.1294416] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
- A delegation of 6 pediatric orthopedic surgeons from the Dutch Orthopedic Association (NOV) and 2 members of the board of the Dutch Parents' Association for children with clubfoot created the guideline "The diagnosis and treatment of primary idiopathic clubfeet" between April 2011 and February 2014. The development of the guideline was supported by a professional methodologist from the Dutch Knowledge Institute of Medical Specialists. This evidence-based guideline process was new and unique, in the sense that the process was initiated by a parents' association. This is the first official guideline in pediatric orthopedics in the Netherlands, and to our knowledge it is also the first evidence-based guideline on clubfoot worldwide. The guideline was developed in accordance with the criteria of the international AGREE instrument (AGREE II: Appraisal of Guidelines for Research and Evaluation II). The scientific literature was searched and systematically analyzed. In the second phase, conclusions and recommendations in the literature were formulated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Recommendations were developed considering the balance of benefits and harms, the type and quality of evidence, the values and preferences of the people involved, and the costs. The guideline is a solid foundation for standardization of clubfoot treatment in the Netherlands, with a clear recommendation of the Ponseti method as the optimal method of primary clubfoot treatment. We believe that the format used in the current guideline sets a unique example for guideline development in pediatric orthopedics that may be used worldwide. Our format ensured optimal collaboration between medical specialists and parents, and resulted in an important change in clubfoot care in the Netherlands, to the benefit of medical professionals as well as parents and patients. In this way, it is possible to improve professional collaboration between medical specialists and parents, resulting in an important change in clubfoot care in the Netherlands that will benefit medical professionals, parents, and patients. The guideline was published online, and is freely available from the Dutch Guideline Database ( www.richtlijnendatabase.nl ).
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Affiliation(s)
- Arnold T Besselaar
- The Dutch Orthopaedic Association (Nederlandse Orthopaedische Vereniging, NOV);,Correspondence:
| | - Ralph J B Sakkers
- The Dutch Orthopaedic Association (Nederlandse Orthopaedische Vereniging, NOV)
| | - Hans A Schuppers
- The Dutch Orthopaedic Association (Nederlandse Orthopaedische Vereniging, NOV)
| | | | - Elgun V C M Zeegers
- The Dutch Orthopaedic Association (Nederlandse Orthopaedische Vereniging, NOV)
| | - Jan D Visser
- The Dutch Orthopaedic Association (Nederlandse Orthopaedische Vereniging, NOV)
| | - Robert A Boekestijn
- Dutch Parents’ Association for children with clubfoot (Nederlandse Vereniging Klompvoetjes, NVK)
| | - Sacha D. Margés
- Dutch Parents’ Association for children with clubfoot (Nederlandse Vereniging Klompvoetjes, NVK)
| | | | - Koert N J Burger
- Knowledge Institute of Medical Specialists (Kennisinstituut van Medisch Specialisten)
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Eamsobhana P, Kongwachirapaitoon P, Kaewpornsawan K. Evertor muscle activity as a predictor for recurrence in idiopathic clubfoot. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:1005-1009. [PMID: 28528482 DOI: 10.1007/s00590-017-1975-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/09/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clubfoot is a complex three-dimensional deformity. Although brace compliance after initial correction was previously found to be significantly associated with recurrence in clubfoot, few previous studies have specifically examined evertor muscle function as a factor that contributes to recurrence in children with idiopathic and non-idiopathic clubfoot. The aim of this study was to investigate the relationship among brace compliance, evertor muscle grading, and recurrence rate in pediatric clubfoot patients. METHODS Children with idiopathic clubfoot who were treated and followed for a minimum of 2 years were included. Patients who used their brace <20-23 h a day for the first 3 months and then <8-10 h per day during sleep and nap times thereafter were classified as group I. Patients who complied fully by using the brace 23 h a day for the first 3 months and then 8-10 h per day during sleep and nap times thereafter were classified as group II. Demographic and clinical data including age, gender, follow-up time, recurrence, evertor muscle grading, types of surgery, brace compliance, severity of initial deformity, age at onset, number of casts required for initial correction, and the need for Achilles tenotomy were collected and analyzed. RESULTS Seventy-nine children with clubfoot were included. There were 47 males and 32 females, mean age was 3.2 years (range 2.1-6.3), and the mean follow-up time was 31.4 months. All patients had follow-up of at least 2 years. Primary correction was obtained in all children. There was no significant difference in mean age, mean follow-up time, or recurrence rate between groups. There was, however, a statistically significant difference in mean brace time between groups (p = 0.002). The recurrence rate was 26.2% in group I and 22.2% in group II. The recurrence rate in group a (Pirani score 0) was 3.9%, group b (Pirani score 0.5) 43.8%, and group c (Pirani score 1) 75% (p < 0.001). No significant association was found between severity of the initial deformity, age at the onset of treatment, number of casts required for correction, or reported brace compliance and recurrence or rates of surgery. Only poor or absent evertor muscle activity was found to be statistically significantly associated with risk of recurrence. CONCLUSION Good evertor muscle grading was found to be a significant protective factor against recurrence of idiopathic clubfoot. Thus, improvement in muscle balance around the ankle, especially the evertor muscle, should be emphasized to parents after the casting regimen is completed and correction is achieved.
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Affiliation(s)
- Perajit Eamsobhana
- Department of Orthopedics Surgery, Siriraj Hospital, Mahidol University, 2 Wanglung Road, Bangkoknoi, Bangkok, Thailand.
| | - Pipat Kongwachirapaitoon
- Department of Orthopedics Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kamolporn Kaewpornsawan
- Department of Orthopedics Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Abstract
The Ponseti method to treat idiopathic clubfoot deformity has proven to be reliable, and several centers have reported excellent outcomes. Although the method has been dependable in obtaining initial correction of the foot, relapse rates ranging from 26% to 48% have been reported. When a relapsed deformity is detected early, treatment with a short series of manipulations and cast applications followed by resumption of postcorrective bracing may be all that is required to regain and maintain correction. In patients aged >2.5 years, especially those who may be refractory to further brace use, deformity correction by preoperative cast treatment, followed by anterior tibial tendon transfer to the third cuneiform, is a good treatment option. Other procedures, such as combined cuboid-cuneiform osteotomy, posterior ankle and subtalar release, and, rarely, comprehensive posteromedial release or correction by gradual distraction, may be useful in select patients.
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34
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Design and descriptive data of the randomized Clubfoot Foot Abduction Brace Length of Treatment Study (FAB24). J Pediatr Orthop B 2017; 26:101-107. [PMID: 27632641 DOI: 10.1097/bpb.0000000000000387] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The aim of this study was to describe the design and baseline characteristics of participants enrolled in the prospective randomized-controlled Clubfoot Foot Abduction Brace Length of Treatment Study (FAB24). Foot abduction bracing is currently the standard of care for preventing clubfoot relapse. Current recommendations include full-time bracing for the first 3 months and then 8-12 h a day for 4 years; however, the optimal length of bracing is not known. The FAB24 trial is a clinical randomized study to determine the effectiveness of 2- versus 4-year foot abduction bracing. Participant enrollment for FAB24 was conducted at eight sites in North America and included enrollment and randomization of 139 participants with isolated clubfoot. This clinical trial will generate evidence-based data that will inform and improve patient care.
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Liu Y, Zhao D, Zhao L, Li H, Yang X. Congenital Clubfoot: Early Recognition and Conservative Management for Preventing Late Disabilities. Indian J Pediatr 2016; 83:1266-1274. [PMID: 26341712 DOI: 10.1007/s12098-015-1860-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/22/2015] [Indexed: 12/11/2022]
Abstract
Congenital clubfoot is one of the most common musculoskeletal deformities presenting at birth. Many high risk factors have been associated with clubfoot such as male gender, primiparous mothers and maternal smoking. Accurate understanding of clubfoot pathoanatomy is supposed to be the basis for deformity correction. Prenatal ultrasonography is of reference value in recognizing clubfoot during pregnancy. Neglected clubfoot can eventually cause a noticeable disability and severely influence the quality life in adulthood. Early recognition and treatment are presumed to be the key for prevention of late disabilities. Nowadays, Ponseti method, as one of the conservative treatment regimen, has been widely accepted because of the reported good results of long-term follow-up. However, special attention should be paid to the details in clinical practice for achieving even better correction and a lower rate of relapse. After the complete correction, brace wearing is critical for preventing deformity relapse. Non-compliance or non-adherence with the brace protocol has been considered as the predominant risk factor predisposing to the relapse of clubfoot, which is still a challenging problem. This paper was prepared to give a general introduction about clubfoot, in terms of the importance of early recognition and conservative management, especially Ponseti method, for preventing late disabilities.
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Affiliation(s)
- Yubin Liu
- Department of Pediatric Orthopedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Yangpu District, Shanghai, 200092, China
| | - Dahang Zhao
- Department of Pediatric Orthopedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Yangpu District, Shanghai, 200092, China.,The Third Department of Orthopedics, The First Affiliated Hospital of Harbin Medical University, No. 23 Youzheng Street, Harbin, 150001, Heilongjiang Province, China
| | - Li Zhao
- Department of Pediatric Orthopedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Yangpu District, Shanghai, 200092, China.
| | - Hai Li
- Department of Pediatric Orthopedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Yangpu District, Shanghai, 200092, China
| | - Xuan Yang
- Department of Pediatric Orthopedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Yangpu District, Shanghai, 200092, China
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Azarpira MR, Emami MJ, Vosoughi AR, Rahbari K. Factors associated with recurrence of clubfoot treated by the Ponseti method. World J Clin Cases 2016; 4:318-322. [PMID: 27803913 PMCID: PMC5067494 DOI: 10.12998/wjcc.v4.i10.318] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 06/26/2016] [Accepted: 08/08/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To assess several associated factors on the recurrence of clubfoot after successful correction by the Ponseti method.
METHODS A total of 115 children with 196 clubfeet deformities, treated by the Ponseti method, were evaluated. Demographic data, family history of clubfoot in first-degree relatives, maternal educational level and brace compliance were enquired. Based on their medical files, the characteristics of the patients at the time of presentation such as age, possible associated neuromuscular disease or especial syndrome, severity of the deformity according to the Dimeglio grade and Pirani score, residual deformity after previous Ponseti method and number of casts needed for the correction were recorded.
RESULTS There were 83 boys (72.2%) and 32 girls (27.8%) with a male to female ratio of 2.6. The mean age at the initiation of treatment was 5.4 d (range: 1 to 60 d). The average number of casts applied to achieve complete correction of all clubfoot deformities was 4.2. Follow-up range was 11 to 60 mo. In total, 39 feet had recurrence with a minimum Dimeglio grade of 1 or Pirani score of 0.5 at the follow-up visit. More recurrence was observed in non-idiopathic clubfoot deformities (P = 0.001), non-compliance to wear braces (P < 0.001), low educational level of mother (P = 0.033), increased number of casts (P < 0.001), and more follow-up periods (P < 0.001). No increase in the possibility of recurrence was observed when the previous unsuccessful casting was further treated using the Ponseti method (P = 0.091). Also, no significant correlation was found for variables of age (P = 0.763), Dimeglio grade (P = 0.875), and Pirani score (P = 0.624) obtaining at the beginning of the serial casting.
CONCLUSION Using the Ponseti method, non-idiopathic clubfoot, non-compliance to wear braces, low educational level of mother, increased number of casts and more follow-up periods had more association to possible increase in recurrence rate after correction of clubfoot deformity.
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Sangiorgio SN, Ho NC, Morgan RD, Ebramzadeh E, Zionts LE. The Objective Measurement of Brace-Use Adherence in the Treatment of Idiopathic Clubfoot. J Bone Joint Surg Am 2016; 98:1598-1605. [PMID: 27707845 DOI: 10.2106/jbjs.16.00170] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A successful outcome for the treatment of idiopathic clubfoot is believed to require adequate adherence to brace use. Previous studies have relied on parental reporting of brace application. We used temperature sensors to determine the adherence to the bracing protocol, the accuracy of parent-reported use, and differences in adherence between patients who experienced relapse of deformity and those who did not. METHODS Using wireless sensors attached to brace sandals, we monitored brace wear over a 3-month period in this cross-sectional study involving 48 patients in 4 age-based groups: 6 to 12 months (Group 1), >1 to 2 years (Group 2), >2 to 3 years (Group 3), and >3 to 4 years (Group 4). Parents were blinded to the purpose of the sensors. The mean number of hours of daily brace use as measured by the sensors was compared with the physician-recommended hours and parent-reported hours of brace use. RESULTS Sensors were retrieved from 44 of 48 patients. Overall, the median brace use recorded by the sensors was 62% (range, 5% to 125%) of that recommended by the physician, and 77% (range, 6% to 213%) of that reported by the parents. For Groups 1 to 3, the difference between the physician-recommended and measured number of hours of daily brace use was significant (p ≤ 0.002), and the difference between the parent-reported and measured number of hours of daily brace use was also significant (p ≤ 0.013). Eight (18%) of the 44 patients who completed the study experienced relapse during the period of monitoring; most importantly, the mean number of hours of brace wear for these patients, 5 hours per day (median, 4; and standard deviation [SD], 3 hours per day) was significantly lower than the 8 hours per day for those who did not experience relapse (median, 9; and SD, 5 hours per day) (p = 0.045). CONCLUSIONS The present study objectively quantified the number of daily hours of post-corrective brace wear for patients with clubfoot in varying age groups and provides an estimate of the number of hours required to avoid relapse. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sophia N Sangiorgio
- The J. Vernon Luck, Sr., MD, Orthopaedic Research Center, Orthopaedic Institute for Children, Los Angeles, California Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Nathan C Ho
- The J. Vernon Luck, Sr., MD, Orthopaedic Research Center, Orthopaedic Institute for Children, Los Angeles, California Department of Biomedical Engineering, University of Southern California, Los Angeles, California
| | - Rebecca D Morgan
- The J. Vernon Luck, Sr., MD, Orthopaedic Research Center, Orthopaedic Institute for Children, Los Angeles, California
| | - Edward Ebramzadeh
- The J. Vernon Luck, Sr., MD, Orthopaedic Research Center, Orthopaedic Institute for Children, Los Angeles, California Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Lewis E Zionts
- The J. Vernon Luck, Sr., MD, Orthopaedic Research Center, Orthopaedic Institute for Children, Los Angeles, California Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
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Manousaki E, Czuba T, Hägglund G, Mattsson L, Andriesse H. Evaluation of gait, relapse and compliance in clubfoot treatment with custom-made orthoses. Gait Posture 2016; 50:8-13. [PMID: 27544063 DOI: 10.1016/j.gaitpost.2016.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 07/11/2016] [Accepted: 08/04/2016] [Indexed: 02/02/2023]
Abstract
Relapse after successful initial correction of idiopathic clubfoot with the Ponseti method is often related to poor compliance with the foot abduction orthosis (FAO). The aim of this study was to evaluate treatment with custom-made dynamic orthoses. Twenty children with idiopathic clubfoot (30feet) who had been treated with dynamic orthoses after the correction phase according to the Ponseti casting technique were evaluated. Relapse rates during orthotic treatment were registered. A Vicon gait analysis system was used to measure gait parameters at the age of seven years. The overall gait quality was estimated with the Gait Deviation Index (GDI). Data were analyzed with a nested mixed model and compared with a control group of 16 healthy children. No relapse occurred during the orthotic treatment. High compliance with the orthoses was observed based on parents' self report and physiotherapist observations. Gait analysis showed decreased ankle power and moment, increased internal foot progression, decreased dorsiflexion during stance, and increased plantar flexion at initial contact compared with the control group. Hip and shank rotations were normal. No calcaneus or equinus gait was observed. The mean GDI was 89.7 (range 71.6-104). The gait analysis outcomes and frequency of relapse were comparable to those of previous studies. Internal foot progression originated primarily from the foot level and was not, as frequently found after FAO treatment, compensated by external rotation at knee or hip level. In children exhibiting poor compliance with an FAO, this dynamic model is considered an effective alternative.
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Affiliation(s)
- Evgenia Manousaki
- Lund University, Department of Clinical Sciences, Lund, Orthopedics, SE 221 85 Lund, Sweden.
| | - Tomasz Czuba
- Lund University, Department of Research and Education, Klinikgatan 22, Wigerthuset University Hospital, 221 85 Lund, Sweden.
| | - Gunnar Hägglund
- Lund University, Department of Clinical Sciences, Lund, Orthopedics, SE 221 85 Lund, Sweden.
| | | | - Hanneke Andriesse
- Lund University, Department of Clinical Sciences, Lund, Orthopedics, SE 221 85 Lund, Sweden.
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Abstract
INTRODUCTION Parents of an infant with an idiopathic clubfoot deformity are often urged by their primary care physician to seek treatment as soon as possible. This advice frequently appears in many general pediatric and pediatric orthopaedic textbooks and monographs on the subject. This recommendation has not changed since the wide acceptance of the minimally invasive Ponseti method to treat clubfoot. We determined the correlations among patient-related variables, early treatment variables, and the age at which the patient was first seen to begin treatment. METHODS Infants with moderate to very severe idiopathic clubfoot deformity were invited to participate. Age at which the patient presented to begin treatment was correlated against early treatment-related variables, including number of casts required, cast slippage, cast-related skin problems, brace-related skin problems, early noncompliance with brace wearing, and relapse before 1 year. Patient-related variables were also correlated against age at first visit. RESULTS Over 7 years, 176 infants met the inclusion criteria. There were no significant differences in the aspects of the early management as a function of age at first visit, with the exception of cast slippage (P=0.05). CONCLUSIONS The age at first visit influenced the incidence of cast slippage, but otherwise did not affect the early treatment of clubfoot. CLINICAL RELEVANCE The treatment of idiopathic clubfoot deformity should not be considered an orthopaedic emergency, and parents whose infants are born with this deformity should be counseled accordingly.
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Abstract
BACKGROUND Ponseti serial casting is the most commonly used method in North America to treat children with clubfeet. Despite initial correction, recurrence is common. tibialis anterior tendon transfer (TATT) is commonly used to treat recurrent clubfeet. Recurrence can occur after TATT, and patients at risk of recurrence may benefit from closer monitoring. We studied the rate of second recurrence (recurrence after TATT) and studied the predictive factors for this recurrence. METHODS Retrospective chart review of patients who have undergone TATT for recurrent clubfeet between 2002 and 2010 at our institution was performed. Recurrence was defined as recurrence of any elements of the clubfoot deformity that requires operative or nonoperative treatment. Effect of age at the time of TATT, initial severity of the deformity, and family history of clubfoot on rate of recurrence was studied. RESULTS Sixty patients with 85 clubfeet were included in the study. Sixteen feet in 12 patients (20%) developed recurrence after TATT. Eight feet were treated nonoperatively and the rest (8 feet) required surgical procedure. Young age at time of TATT and brace noncompliance significantly increased the rate of second recurrence. Effect of severity of initial deformity and family history did not reach statistical significance. CONCLUSIONS Second recurrence can happen in around one fifth of patients with clubfeet after TATT. Patients with young age at TATT and patients with brace noncompliance are at an increased risk of recurrence and should be monitored closely. LEVEL OF EVIDENCE Level II-prognostic.
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Abstract
BACKGROUND The purpose of this study was to determine the early factors associated with the need for surgical interventions in patients with idiopathic clubfoot treated with the Ponseti method. METHODS All patients with idiopathic clubfoot treated with Ponseti method at our institution with >3 years of follow-up were evaluated. Age at presentation, history of previous treatment, number of casts used, need for percutaneous Achilles tenotomy (PAT), age of initiation of foot abduction orthosis (FAO), compliance with FAO, and need for additional casts were recorded. Dimeglio/Bensahel and Catterall/Piriani scores were recorded at initial presentation, at initiation of FAO, at 1, 2, 3 years of follow-up, and at the most recent follow-up. RESULTS Since 2000, 86 patients (134 feet) had >3 years of follow-up from time of initial presentation, and 43 of these feet (32%) had undergone surgery beyond a PAT. Patients who were noncompliant with the FAO were 7.9 times more likely to need surgery than those who were compliant [confidence interval (CI), 2.8-22.0; P<0.001]. Female patients were 5.4 times more likely to need surgery than male patients (CI, 1.8-16.6; P=0.003). For every 1 point increase in Dimeglio/Bensahel score at presentation, patients were 1.3 times more likely to need surgery (CI, 1.0-1.5; P=0.033). For every 1 point increase in Dimeglio/Bensahel score at initiation of the FAO, patients were 1.5 times more likely to need surgery (1.1-2.0, P=0.005). Moreover, for each additional cast required before the initiation of the FAO, patients were 1.5 times less likely to need surgery (CI, 1.1-2.7; P=0.030). No other variable significantly contributed to predicting the need for surgery. CONCLUSIONS There are early factors that can be used to predict increased risk for surgical intervention in patients undergoing treatment for idiopathic clubfoot. Female patients and those patients with higher Dimeglio/Bensahel scores at presentation and at initiation of the FAO are at increased risk for needing surgical intervention. Noncompliance with the FAO is associated with the highest risk for surgical intervention. LEVEL OF EVIDENCE Level III.
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van Wijck SFM, Oomen AM, van der Heide HJL. Feasibility and barriers of treating clubfeet in four countries. INTERNATIONAL ORTHOPAEDICS 2015; 39:2415-22. [PMID: 25940604 DOI: 10.1007/s00264-015-2783-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 03/29/2015] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to elucidate why neglected clubfeet still exists despite the availability of a highly (cost)-effective treatment-the Ponseti treatment. METHODS A qualitative and partly quantitative study with semi-structured interviews was conducted in four countries: the Netherlands, South Africa, Argentina and Indonesia with both caregivers, mostly parents, of children with clubfoot and practitioners treating clubfoot. The topics discussed with the caregivers (n = 51) were the conceptions of the cause of clubfeet, received information, accessibility, financial aspects, and social stigma. With the practitioners (n = 11) the focus of the interviews was the treatment protocol and finance. RESULTS Several barriers towards the start of the treatment were highlighted. At all places treatment was financed by the government, insurance or charity. Nevertheless, the cost of transport and missed working days formed a barrier, although there is a large difference between and within countries. Poverty, long travel duration, and beliefs of supernatural causes for the clubfoot result in delay in the start of treatment. CONCLUSION These are problems we need to address when making effective treatment available for every child to diminish the burden of neglected clubfoot; especially accessible clinics in rural areas can be a good alternative to highly specialized hospitals in large cities. We as a community should try to find and overcome the barriers to treat these patients, because we have a relatively easy and highly cost-effective treatment option which can be given by trained non-physicians supervised by an interested medical doctor.
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Affiliation(s)
- Suzanne F M van Wijck
- Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - A Marjanne Oomen
- Yayasan Stepping Stones Bali, Jalan Pura Wingin, Kalibukbuk, Singaraja, Indonesia.
| | - Huub J L van der Heide
- Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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Ikeda AJ, Grabowski AM, Lindsley A, Sadeghi-Demneh E, Reisinger KD. A scoping literature review of the provision of orthoses and prostheses in resource-limited environments 2000-2010. Part two: research and outcomes. Prosthet Orthot Int 2014; 38:343-62. [PMID: 23942758 DOI: 10.1177/0309364613490443] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Despite the activities of many orthotic and prosthetic provision organizations in resource-limited environments, there is still a great need and there are several areas for improvement, as identified in Part One of this series. OBJECTIVES Our goal was to examine outcomes and conclusions of research studies to produce an evidence base for determining factors that may lead to successful provision of orthoses and prostheses in resource-limited environments. STUDY DESIGN Literature review. METHODS We conducted a scoping literature review of all information related to orthotic and prosthetic provision in resource-limited environments published from 2000 to 2010. We extracted measured outcomes reported in all types of articles and analyzed conclusions from research studies. RESULTS Reported outcomes included durability, cost, satisfaction, use/nonuse of device, amount of utilization, walking speed, discomfort, pain, fit, misalignment, capacity for service provision, number of devices produced or delivered, and number of graduates from training programs. CONCLUSIONS There are many gaps in the evidence base, notably in measuring inclusion, participation, and quality of life for orthosis and prosthesis users in resource-limited environments. There is a paucity of reported outcomes for orthotics. Valid, reliable, and standard methods of data collection and reporting are needed to advance the field and enhance the evidence base.
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Affiliation(s)
- Andrea J Ikeda
- Whirlwind Wheelchair International, San Francisco State University, San Francisco, CA, USA
| | - Alena M Grabowski
- Department of Integrative Physiology University of Colorado Boulder, Boulder, CO, USA Eastern Colorado Healthcare System, U.S. Department of Veterans Affairs, Denver, CO, USA
| | - Alida Lindsley
- Whirlwind Wheelchair International, San Francisco State University, San Francisco, CA, USA
| | - Ebrahim Sadeghi-Demneh
- Musculoskeletal Research Center, Orthotics and Prosthetics Department, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran
| | - Kim D Reisinger
- Whirlwind Wheelchair International, San Francisco State University, San Francisco, CA, USA
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Zhao D, Liu J, Zhao L, Wu Z. Relapse of clubfoot after treatment with the Ponseti method and the function of the foot abduction orthosis. Clin Orthop Surg 2014; 6:245-52. [PMID: 25177447 PMCID: PMC4143509 DOI: 10.4055/cios.2014.6.3.245] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 12/23/2013] [Indexed: 12/17/2022] Open
Abstract
Ponseti clubfoot treatment has become more popular during the last decade because of its high initial correction rate. But the most common problem affecting the long-term successful outcome is relapse of the deformity. Non-compliance with Ponseti brace protocol is a major problem associated with relapse. Although more comfortable braces have been reported to improve the compliance, they all have the same design and no significant changes have been made to the protocols. After refinement in the Ponseti method and emphasizing the importance of brace to parents, the relapse rate has been markedly decreased. Nevertheless, there are patients who do not have any recurrence although they are not completely compliant with the brace treatment, whereas other patients have a recurrence even though they are strictly compliant with the brace treatment. The aim of this article is to review the relapse of clubfoot and the function of the brace and to develop an individualized brace protocol for each patient by analyzing the mechanism of the brace and the biomechanical properties of muscles, tendons, and ligaments.
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Affiliation(s)
- Dahang Zhao
- Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianlin Liu
- Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Zhao
- Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhenkai Wu
- Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Ikeda AJ, Grabowski AM, Lindsley A, Sadeghi-Demneh E, Reisinger KD. A scoping literature review of the provision of orthoses and prostheses in resource-limited environments 2000-2010. Part one: considerations for success. Prosthet Orthot Int 2014; 38:269-86. [PMID: 24026045 DOI: 10.1177/0309364613500690] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 07/16/2013] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Literature Review BACKGROUND We estimate that over 29 million people worldwide in resource-limited environments (RLEs) are in need of orthotic and prosthetic (O&P) devices and services. OBJECTIVES Our goal was to ascertain the current state of O&P provision in RLEs and identify factors that may lead to more successful O&P provision. METHODS We conducted a comprehensive scoping literature review of all information related to O&P provision in RLEs published from 2000 to 2010. We targeted Vietnam, Cambodia, Tanzania, Malawi, Colombia, and the Navajo Nation, but also included information about developing countries in general. We searched academic databases and grey literature. We extracted information from each article in the areas of design, manufacturing, distribution, service provision, and technology transfer. RESULTS We identified commonly reported considerations and strategies for O&P provision from 431 articles. Analysis of expert consensus documents revealed recurring themes for improving O&P provision. We found that some suggestions from the consensus documents are being followed, but many are overlooked or have not yet been implemented. CONCLUSIONS Areas for improvement include conducting field testing during the design process, providing services to rural environments, offering follow-up services, considering government collaboration, and encouraging an active role of the orthosis/prosthesis user. Outcomes and research studies will be further discussed in Part Two.
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Affiliation(s)
- Andrea J Ikeda
- Whirlwind Wheelchair International, San Francisco State University, San Francisco, CA, USA
| | - Alena M Grabowski
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - Alida Lindsley
- Whirlwind Wheelchair International, San Francisco State University, San Francisco, CA, USA
| | - Ebrahim Sadeghi-Demneh
- Musculoskeletal Research Center, Orthotics and Prosthetics Department, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran
| | - Kim D Reisinger
- Whirlwind Wheelchair International, San Francisco State University, San Francisco, CA, USA
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Zhao D, Li H, Zhao L, Liu J, Wu Z, Jin F. Results of clubfoot management using the Ponseti method: do the details matter? A systematic review. Clin Orthop Relat Res 2014; 472:1329-36. [PMID: 24435715 PMCID: PMC3940729 DOI: 10.1007/s11999-014-3463-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 01/07/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although the Ponseti method is accepted as the best choice for treatment of clubfoot, the treatment protocol is labor intensive and requires strict attention to details. Deviations in strict use of this method are likely responsible for the variations among centers in reported success rates. QUESTIONS/PURPOSES We wished to determine (1) to what degree the Ponseti method was followed in terms of manipulation, casting, and percutaneous Achilles tenotomy, (2) whether there was variation in the bracing type and protocol used for relapse prevention, and (3) if the same criteria were used to diagnose and manage clubfoot relapse. METHODS We conducted a systematic review of MEDLINE, EMBASE(TM), and the Cochrane Library. Studies were summarized according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement. Five hundred ninety-one records were identified with 409 remaining after deduplication, in which 278 irrelevant studies and 22 review articles were excluded. Of the remaining 109 papers, 19 met our inclusion criteria. All 19 articles were therapeutic studies of the Ponseti method. RESULTS The details of manipulation, casting, or percutaneous Achilles tenotomy of the Ponseti method were poorly described in 11 studies, whereas the main principles were not followed in three studies. In three studies, the brace type deviated significantly from that recommended, whereas in another three studies the bracing protocol in terms of hours of recommended use was not followed. Furthermore no unified criteria were used for judgment of compliance with brace use. The indication for recognition and management of relapse varied among studies and was different from the original description of the Ponseti method. CONCLUSIONS We found that the observed clinically important variation may have been the result of deviations from the details regarding manipulation, casting, percutaneous Achilles tenotomy, use of the bar-connected brace, and indication for relapse recognition and management recommended for the classic Ponseti approach to clubfoot management. We strongly recommend that clinicians follow the Ponseti method as it initially was described without deviation to optimize treatment outcomes.
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Affiliation(s)
- Dahang Zhao
- Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Hai Li
- Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Li Zhao
- Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Jianlin Liu
- Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Zhenkai Wu
- Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092 China
| | - Fangchun Jin
- Department of Pediatric Orthopaedics, Xin-Hua Hospital, Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092 China
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Abstract
This study aimed to analyze the perceptions of parents of children with clubfoot regarding the Ponseti method of treatment, and identify aspects of treatment that families found most difficult. Thirty families of children with clubfoot were treated with the Ponseti method over a 4-year period, and questionnaires were distributed at the conclusion of treatment. The most difficult components of treatment were identified. However, these challenges did not impact treatment outcome negatively. We hypothesize that a strong physician-patient relationship and high levels of parental education may decrease perceived difficulties of treatment with the Ponseti method.
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Lykissas MG, Crawford AH, Eismann EA, Tamai J. Ponseti method compared with soft-tissue release for the management of clubfoot: A meta-analysis study. World J Orthop 2013; 4:144-53. [PMID: 23878784 PMCID: PMC3717249 DOI: 10.5312/wjo.v4.i3.144] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 03/27/2013] [Accepted: 04/27/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the functional outcomes of patients who underwent open surgery vs Ponseti method for the management of idiopathic clubfoot and to determine whether correlations exist between functional outcome and radiographic measurements. METHODS A meta-analysis of the literature was conducted for studies concerning primary treatment of patients with idiopathic clubfoot. We searched PubMed Medline, EMBASE, and the Cochrane Library databases from January 1950 to October 2011. Meta-analyses were performed on outcomes from 12 studies. Pooled means, SDs, and sample sizes were either identified in the results or calculated based on the results of each study. RESULTS Overall, 835 treated idiopathic clubfeet in 516 patients were reviewed. The average follow-up was 15.7 years. Patients managed with Ponseti method did have a higher rate of excellent or good outcome than patients treated with open surgery (0.76 and 0.62, respectively), but not quite to the point of statistical significance (Q = 3.73, P = 0.053). Age at surgery was not correlated with the functional outcome for the surgically treated patients (r = -0.32, P = 0.68). A larger anteroposterior talocalcaneal angle was correlated with a higher rate of excellent or good outcomes (r = 0.80, P = 0.006). There were no other significant correlations between the functional and radiographic outcomes. CONCLUSION The Ponseti method should be considered the initial treatment of idiopathic clubfeet, and open surgery should be reserved for clubfeet that cannot be completely corrected.
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Iravani M, Chalabi J, Kim R, Ebramzadeh E, Zionts LE. Propofol sedation for infants with idiopathic clubfoot undergoing percutaneous tendoachilles tenotomy. J Pediatr Orthop 2013; 33:59-62. [PMID: 23232381 DOI: 10.1097/bpo.0b013e318267037a] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To determine whether percutaneous tenotomy of the Achilles tendon in infants with idiopathic clubfeet can be safely performed under propofol sedation. BACKGROUND Many orthopaedic surgeons prefer to do a tenotomy under general anesthesia. At our institution, we have been using 2 different methods of induction and maintenance of anesthesia: one method using combined propofol and sevoflurane and various types of airway management, and the other using only propofol with facemask. METHODS We reviewed the medical records of all patients less than 1 year of age with idiopathic clubfoot who underwent a percutaneous tendoachilles tenotomy under anesthesia. Collected data included: chronological age, earlier apneic events, medical risk factors, time from operating room entry to surgery, and surgical-related and anesthesia-related complications. RESULTS The study group comprised 114 patients who underwent 162 tenotomies. Sixty-five patients were in group 1 (sevoflurane/propofol) and 49 patients were in group 2 (propofol). The 2 groups did not differ with respect to sex, bilaterality, chronological age, number of preterm infants, ASA class, or associated risk factors. The average time from operating room entry to surgery was approximately 5 minutes longer with group 1, which included 14 cases taking longer than 20 minutes. However, there were no differences between the 2 groups with respect to postoperative complications. CONCLUSIONS Percutaneous tendoachilles tenotomy in infants with idiopathic clubfeet may be safely performed under anesthesia. Propofol sedation was safe and effective without the need for airway instrumentation for this short procedure. LEVEL OF EVIDENCE Level IV (retrospective).
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Affiliation(s)
- Mohamad Iravani
- UCLA Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Abstract
BACKGROUND In 2001, the members of the Pediatric Orthopaedic Society of North America (POSNA) were surveyed regarding their approach to treating idiopathic clubfoot deformity. Since that time, several studies have advocated a change in the approach to treating this deformity, moving away from surgical release and toward less invasive methods. The purpose of this study was to assess the recent approach to treating clubfoot among the POSNA membership. METHODS A survey was emailed to all POSNA members to define their current treatment of idiopathic clubfoot deformity. RESULTS We received 323 responses. Ninety-three percent of participants were fellowship trained and were in practice for an average of 17.2 years. On an average, physicians reported each treating 23.5 new clubfoot patients during the year of survey. Nearly all (96.7%) of those surveyed stated that they use the Ponseti treatment method. The average time to initial correction was estimated at 7.1 weeks. Eighty-one percent of patients were estimated to require a tenotomy; 52.7% were performed under general anesthesia or conscious sedation, whereas 39.4% were done under local. Those surveyed estimated that 22% of clubfeet relapsed and 7% required a comprehensive release. Seventy-five percent of the respondents stated that their current treatment approach differed from how they were trained, and 82.7% were trained in the Ponseti method in the last few years. CONCLUSIONS Our study provides convincing evidence that a large majority of pediatric orthopaedic surgeons now prefer the Ponseti method to treat idiopathic clubfoot and indicates that the move away from extensive release surgery occurred during the past decade. LEVEL OF EVIDENCE Not applicable.
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