Can the Achilles tendon regenerate completely following percutaneous tenotomy in older children with clubfoot?

PURPOSE

The aims of the study were to document the outcomes of percutaneous Achilles tenotomy (pAT) performed in older children with clubfoot, by assessing the clinical, functional and ultrasonographic evidence of Achilles tendon regeneration.

METHODS

A retrospective case series of older children with clubfoot treated between August 2011 and July 2020 was studied. Clinical assessment of ankle range of motion and calf strength, functional assessment of triceps surae muscle endurance by single leg heel-rise test, and ultrasonographic assessment of Achilles tendon echotexture and dimensions to assess tendon regeneration were performed.

RESULTS

Percutaneous Achilles tenotomy was performed on 31 children (48 clubfeet) at a mean age of 5.24 ± 2.14 years (1-10.2 years). At a mean follow-up of 4.86 ± 1.97 years, all children demonstrated normal calf strength with mean dorsiflexion range of 13.64° (0-25°) and mean plantarflexion range of 37.95° (10-40°). The heel-rise endurance test was completed by 27 children with mean 25.85 heel rises/minute (range 17-30) and mean height of heel rise of 6.29 cm (range 4-10 cm). Normal fibrillar tendinous echotexture with homogenous echogenicity was seen on ultrasonography in 41 feet (85.4%) with mean tendon width of 9.7 mm (3.3-16 mm) and thickness of 5.1 mm (1.8-15 mm), comparable with unaffected feet.

CONCLUSIONS

Clinical, functional and ultrasonographic parameters unequivocally demonstrate complete regeneration of the Achilles tendon, when pAT is performed in older children with delayed-presenting idiopathic clubfoot treated using Ponseti principles.

The infant with a clubfoot and amniotic bands: a comprehensive understanding and the role of the Ponseti method

Amniotic band syndrome (ABS) and clubfoot are distinct congenital musculoskeletal conditions that can occasionally co-occur, creating unique challenges in their management. This paper summarizes the comprehensive discussion on the management of amniotic band syndrome (ABS) and clubfoot, emphasizing the critical role of the Ponseti method and the challenges faced in treatment, thereby providing a basis for further research and improved patient care.

Complex, atypical clubfoot: follow-up after up to 16 years reveals a high risk of relapse but good functional and radiological outcomes

INTRODUCTION

The treatment of complex atypical clubfoot poses many challenges. In this paper, we report on the course of complex clubfoot, primary correction using the modified Ponseti method and midterm outcomes. Special consideration is given to clinical and radiological changes in cases of relapse.

MATERIALS AND METHODS

Twenty-seven cases of complex, atypical, non-syndromic clubfoot were treated in 16 children between 2004 and 2012. Patient data, treatment data, functional outcomes and, in the relapse cohort, radiological findings were documented during the course of treatment. The radiological findings were correlated with the functional outcomes.

RESULTS

All atypical complex clubfeet could be corrected using a modified form of the Ponseti method. Over an average study period of 11.6 years, 66.6% (n = 18) of clubfeet relapsed. Correction after relapse showed an average dorsiflexion of 11.3° during a 5-years' follow-up period. Radiological results showed residual clubfoot pathologies such as a medialized navicular bone in four clubfeet. There were no instances of subluxation or dislocation of the talonavicular joint. Extensive release surgery was not necessary. Nevertheless, after 2.5 preoperative casts (1-5 casts), bone correction was performed in n = 3 feet in addition to Achilles tendon lengthening and tibialis anterior tendon transfer.

CONCLUSION

Good primary correction of complex clubfoot using the modified Ponseti technique results in a high recurrence rate in the medium term. Relapse treatment without peritalar arthrolysis procedures produces good functional results even though minor residual radiological pathologies did persist in a minor number of cases.

Indication for Achilles Tenotomy in Congenital Clubfoot: Effectiveness of Using the Tibio-Plantar Fascia Angle as a Radiographic Parameter

Congenital clubfoot is one of the most common deformities in children, and currently, the Ponseti method is used worldwide because of its favorable short-term results. With the Ponseti method, the indication for Achilles tenotomy is traditionally based on only physical examination findings; however, some surgeons have also utilized plain radiographs. Because using physical examinations to determine the degree of hindfoot dorsiflexion for the indication of tenotomy can lead to underestimation. We developed and utilized the effectiveness of the tibio-plantar fascia angle (Ti-P angle) in the lateral maximum dorsiflexion view in determining the need for Achilles tenotomy. A retrospective analysis of consecutive 26 patients with congenital idiopathic clubfeet (37 feet) was performed. Whether Achilles tenotomy was indicated was determined based on physical examination for a former period (Group P). For the latter period, whether tenotomy was indicated was determined by referencing radiographs (Group X). No significant differences were found in any of the background factors or severity between Group P and Group X. Cases with larger tibiocalcaneal and Ti-P angles were more likely to require Achilles tenotomy or additional soft tissue release. An angle of more than 72° of the Ti-P angle demonstrated adequate specificity for the indication of Achilles tenotomy. The radiographic lateral tibio-plantar fascia angle is useful for deciding whether a tenotomy needs to be performed.

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

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

Complex clubfoot: my 5 tips for appropriate evaluation and treatment with the Ponseti method

Complex clubfoot is a term used to describe a subset of patients that received previous treatment, and have distinctive anatomical features: severe equinus, with short first metatarsal, hyperextended big toe, severe plantar flexion of all metatarsals and deep folds through the sole of the foot and above the heel. Most complex clubfeet appear to be idiopathic and is usually associated with a poor casting technique. Complex clubfoot requires an early recognition and an adjustment of the casting protocol using the four finger Ponseti technique. This article gives the treating physician a general overview of the evaluation, treatment, and outcomes of complex clubfoot with the Ponseti method.

Time-dependent extracellular matrix alterations of young tendons in response to stress relaxation: a model for the Ponseti method

The Ponseti method corrects a clubfoot by manipulation and casting which causes stress relaxation on the tendons. Here, we examined the effect of long-term stress relaxation on tendon extracellular matrix (ECM) by (1) an ex vivo stress relaxation test, (2) an in vitro tenocyte culture with stress relaxation and (3) an in vivo rabbit study. Time-dependent tendon lengthening and ECM alterations including crimp angle reduction and cleaved elastin were observed, which illustrated the mechanism of tissue lengthening behind the treatment-a material-based crimp angle reduction resulted from elastin cleavage. Additionally, in vitro and in vivo results observed restoration of these ECM alterations along with increased elastin level after 7 days of treatment, and the existence of neovascularization and inflammation, indicating the recovery and adaptation from the tendon in reaction to the treatment. Overall, this study provides the scientific background and information that helps explain the Ponseti method.

Effectiveness of the Ponseti Method in the Treatment of Clubfoot: A Systematic Review

Clubfoot is a common congenital deformity of the lower limbs. It should be treated as soon as possible so that its correction is more easily achieved. The objective of this systematic review was to assess the effectiveness of the Ponseti method in the treatment of clubfoot. A bibliographic search was carried out in different databases, including PubMed and SciELO. Filters such as full text and randomized controlled trial were selected to find those articles that best matched our search. Among the results, we selected the ones that interested us, and the rest were discarded, either because they did not meet the requirements for our work or because they were repeated. In total, we collected 19 articles, but after using the critical evaluation instrument CASPe, 7 of them were eliminated, leaving us with a total of 12 articles for our systematic review. After analyzing the results obtained in the selected articles, we concluded that the Ponseti method is effective in the treatment of clubfoot, presenting a high success rate.

Common Errors in the Management of Idiopathic Clubfeet Using the Ponseti Method: A Review of the Literature

Congenital talipes equinovarus is one of the most prevalent birth defects, affecting approximately 0.6 to 1.5 children per 1000 live births. Currently, the Ponseti method is the gold-standard treatment for idiopathic clubfeet, with good results reported globally. This literature review focuses on common errors encountered during different stages of the management of idiopathic clubfeet, namely diagnosis, manipulation, serial casting, Achilles tenotomy, and bracing. The purpose is to update clinicians and provide broad guidelines that can be followed to avoid and manage these errors to optimize short- and long-term outcomes of treatment of idiopathic clubfeet using the Ponseti method. A literature search was performed using the following keywords: "Idiopathic Clubfoot" (All Fields) AND "Management" OR "Outcomes" (All Fields). Databases searched included PubMed, EMBASE, Cochrane Library, Google Scholar, and SCOPUS (age range: 0-12 months). A full-text review of these articles was then performed looking for "complications" or "errors" reported during the treatment process. A total of 61 articles were included in the final review: 28 from PubMed, 8 from EMBASE, 17 from Google Scholar, 2 from Cochrane Library, and 6 from SCOPUS. We then grouped the errors encountered during the treatment process under the different stages of the treatment protocol (diagnosis, manipulation and casting, tenotomy, and bracing) to facilitate discussion and highlight solutions. While the Ponseti method is currently the gold standard in clubfoot treatment, its precise and intensive nature can present clinicians, health care providers, and patients with potential problems if proper diligence and attention to detail is lacking. The purpose of this paper is to highlight common mistakes made throughout the Ponseti treatment protocol from diagnosis to bracing to optimize care for these patients.

Factors Causing Dropout From Treatment During the Ponseti Method of Clubfoot Management: The Caregivers' Perspective

A retrospective comparative study was conducted, aiming to identify factors associated with dropout from clubfoot treatment by Ponseti method in low- and middle-income countries. A prospectively gathered database of patients who received treatment at a high-volume urban clubfoot clinic over 6 years was queried for dropouts. A "dropout" was identified as any child that had not had a visit within 3 weeks of casting, 4 weeks of tenotomy or 6 months of brace follow-up. The second part of the study was a telephonic interview with caregivers of the identified dropouts to ascertain their reasons for discontinuing treatment. Of the 965 patients treated during the study period, there were 155 (16.06%) dropouts-137 (88.38%) during bracing phase and 18 (11.62%) during casting phase. Age at presentation was significantly higher among the dropouts as compared to those who did not dropout (median 9.5 and 7 months for casting and bracing dropouts respectively versus 3.5 months for regular follow-ups, p < .001). No significant correlation was found between patient dropout and sex (p = .061), or laterality (p = .071). Thirty-seven caregivers (23.8%) could be contacted telephonically; including 6 casting and 31 bracing dropouts. The most commonly cited reason for dropout from treatment was lack of family support (75.7%), followed by distance to the clinic (59.5%) and unavailability of transport (54.1%). Sixteen caregivers (43.2%) dropped out on account of migration to another town/state. Maintenance of a meticulous registry with regular update of caregivers' contact details, and interventions to mitigate the identified hurdles can help in reducing treatment dropouts.

Clinico-Radiological and Functional Outcome of Difficult Talipes Equinovarus Deformity Corrected With an Ilizarov Fixator

Relapsed, resistant, and untreated congenital talipes equinovarus poses significant challenges in view of functional outcome following conventional serial casting and soft tissue release procedures. The Ilizarov ring fixator here offers significant possibilities as an extended conservative treatment modality. The aim of the present study was to critically evaluate effectiveness of the Ilizarov ring fixator with regard to radiological, clinical, and functional outcomes, in the difficult clubfeet. The study was carried out on patients presenting with relapsed, resistant, or untreated congenital talipes equinovarus deformity, who underwent deformity correction using the Ilizarov ring fixator application. All patients were reviewed at 6 monthly intervals for over 3 years following fixator removal with an objective clinical, radiological, and functional assessment. Twenty-three patients with 30 clubfeet were enrolled in our study. The mean age was 8.3 ± 3.6 (range 4-17) years. The postoperative clinical, radiological, and functional scores showed statistically significant improvement among all patients when compared with the preoperative data. All 30 feet developed varying complications during treatment with pin track infections being the most common. However, they were managed while continuing the distraction correction process. The Ilizarov ring fixator is an effective and reliable solution for difficult and challenging clubfeet. However, one must be aware of a strict adherence to a bracing protocol to avoid recurrence of deformities. A regular periodical functional and clinical follow up must be ensured among these children for a favorable outcome.

Attaining a British consensus on managing idiopathic congenital talipes equinovarus up to walking age

AIMS

The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV.

METHODS

The consensus process followed an established Delphi approach with a predetermined degree of agreement. The process included the following steps: establishing a steering group; steering group meetings, generating statements, and checking them against the literature; a two-round Delphi survey; and final consensus meeting. The steering group members and Delphi survey participants were all British Society of Children's Orthopaedic Surgery (BSCOS) members. Descriptive statistics were used for analysis of the Delphi survey results. The Appraisal of Guidelines for Research & Evaluation checklist was followed for reporting of the results.

RESULTS

The BSCOS-selected steering group, the steering group meetings, the Delphi survey, and the final consensus meeting all followed the pre-agreed protocol. A total of 153/243 members voted in round 1 Delphi (63%) and 132 voted in round 2 (86%). Out of 61 statements presented to round 1 Delphi, 43 reached 'consensus in', no statements reached 'consensus out', and 18 reached 'no consensus'. Four statements were deleted and one new statement added following suggestions from round 1. Out of 15 statements presented to round 2, 12 reached 'consensus in', no statements reached 'consensus out', and three reached 'no consensus' and were discussed and included following the final consensus meeting. Two statements were combined for simplicity. The final consensus document includes 57 statements allocated into six successive stages.

CONCLUSION

We have produced a consensus document for the treatment of idiopathic CTEV up to walking age. This will provide a benchmark for standard of care in the UK and will help to reduce geographical variability in treatment and outcomes. Appropriate dissemination and implementation will be key to its success. Cite this article: Bone Joint J 2022;104-B(6):758-764.

Anatomical Structures Responsible for CTEV Relapse after Ponseti Treatment

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

Romanian patients' access to clubfoot treatment services

The number of clubfoot new cases in Romania is on the rise. According to orthopedic research, the Ponseti method is the elective treatment for clubfeet. This paper aims to provide an overview of the current facilitators and barriers in accessing clubfoot treatment services in Romania and to assess the impact of care-related factors on patients’ well-being. Our research shows that nationally, few orthopedic surgeons are using the Ponseti method and most of them are concentrated only in Cluj-Napoca. Moreover, gynecologists, neonatologists, and family physicians were not informed about the initial diagnosis and the current treatment of clubfoot. Primary medical care was significantly postponed in some cases. Moreover, no clubfoot organizations were mentioned by the parents included in the study, and psychological support was provided neither for the parents nor for the children. Based on the results of our study, we conclude that more efforts need to be done for the diagnosis and treatment of children with clubfeet. These include actions which are focused on raising awareness around this abnormality and more well-developed treatment guidelines.

Factors associated with the relapse in Ponseti treated congenital clubfoot

Objectives

We retrospectively investigated the clinical materials to seek the factors that lead to relapse after using the Ponseti method.

Methods

We retrospectively reviewed all children with congenital clubfoot treated with the Ponseti method in our hospital from June 2008 to June 2013. The data included the following factors: age, gender, initial Pinari score, number of casts, number of feet (unilateral or bilateral), age at the first casting, age of mother, tenotomy, walking age, and compliance with using bracing. All investigations were conducted in conformity with ethical standards. This study was approved by Guilin Peoples’ Hospital Ethics Committee.

Results

In this study, there were 148 cases (164 ft) in total that underwent the Ponseti method, with the follow–up period at least 5 years. Of them, 64 children presented with left side, 58 with right side, and 26 with bilateral cases. This study included 75 males and 73 females; sex did not affect the outcomes. The mean age of the first casting was 2.50 ± 2.15 months. The average initial Pirani score was 4.98 ± 1.33, and the average number of casts was 5.71 ± 2.28 times. The mean age of mothers at birth was 25.81 ± 2.38 years old. The walking age of children was at a mean of 14.83 ± 1.18 months. Forty-nine cases could not tolerate using braces, namely the rate of noncompliance in this study was 33.1%. Tenotomy was performed on 113 ft (76.4%). The average follow–up period was 7.27 ± 1.29 years (from 5 to 10 years). The rate of relapse was 21.6% (32 cases) at the end of the follow-up. The rate of relapse in the noncompliance with using bracing group was significantly higher compared to the compliance group .

Conclusion

The initial Pirani score, compliance with the foot abduction brace and the age at the first casting are three independent factors for relapse in clubfoot.

Clubfoot Cast Simulation Using Pressure Sensors: A Novel Way to Teach the Ponseti Method

OBJECTIVE

The standard of care in treating congenital clubfoot is the Ponseti method. Resident education of this skill traditionally involves direct casting of patients with attending feedback. With increased clinical time demands, mastery of the skill may not be achievable using direct resident - patient interactions. We describe a novel Ponseti cast simulator using pressure sensors to teach this skill.

DESIGN

A novel Ponseti cast simulator was constructed using a standardized model and pressure sensors. A pre-training baseline (trial 1) and post education (trial 2) was made and scored using an objective structured assessment of technical skill (OSATS) checklist. Pressure sensors were placed at the first metatarsal and talar head to record cast forces.

SETTING

The study was performed in the Department of Orthopedic Surgery at an academic tertiary care hospital.

PARTICIPANTS

Study participants included 6 junior orthopedic residents defined as post-graduate year (PGY) 1 to 3, 6 senior orthopedic residents (PGY 4,5), and a board -certified pediatric orthopedic surgeon to serve as a control.

RESULTS

Trial 1 OSATS scores were significantly higher in senior residents (9.7 ± 1.5) than junior residents (5.2 ± 1.2) (p = 0.004). Trial 2 OSATS scores were also significantly higher in senior residents than junior residents: 13.7 ± 1.4 vs. 5.8 ± 1.6 (p = 0.003). Additionally, senior residents significantly improved scores between the first 2 trials 9.7 ± 1.5 vs. 13.7 ± 1.4 (p = 0.003), while junior residents did not 5.2 ± 1.2 vs. 5.8 ± 1.6 (p = 0.4566). In addition, there were no significant differences between junior, and senior resident Trial 1 talar head pressures or first metatarsal pressures, or Trial 2 first metatarsal pressures.

CONCLUSIONS

This is the first casting simulation model to use pressure sensors as a way to objectively measure cast application pressure. This simulator may be useful in an orthopedic training programs to teach Ponseti casting.

Magnetic Resonance Imaging of Clubfoot Treated With the Ponseti Method: A Short-Term Outcome Study

OBJECTIVE

To quantitatively evaluate the effectiveness of the Ponseti method for the correction of clubfoot, we decided to use magnetic resonance imaging (MRI) to evaluate changes in the tarsal bone relationship.

METHODS

This is a retrospective study of fifteen children with clubfeet who were treated with the Ponseti method. MRI studies were obtained using a 3.0T Machine (GE Healthcare, United States). T1-weighted and T2-weighted images were acquired in the standard anatomic sagittal, transverse, and coronal planes. For the measurement, the best slice that clearly demonstrated the anatomy was chosen. Sagittal talocalcaneal angle, sagittal tibiocalcaneal angle, coronal tibiocalcaneal angle, transverse talar neck angle, transverse talonavicular angle, and transverse talocalcaneal angle were measured. The eighteen corrected clubfeet were compared with the twelve unilateral normal feet at clinical and radiological levels using a Pirani scoring system and MRI, respectively.

RESULTS

In total, 15 cases (twelve boys and three girls) with clubfeet were examined by using MRI. Twelve cases had unilateral and three had bilateral involvement (eleven left clubfeet and seven right clubfeet), giving a total of eighteen clubfeet when compared with twelve normal feet. The mean age of patients at examination was 47.7 months (8-96 months). The recovery of the corrected clubfoot in these patients met the goals of Ponseti treatment (functional, normal looking, pain-free, and plantigrade foot). Before Ponseti treatment, the mean Pirani score of clubfoot was 5.5 (5-6). During this follow-up, the Pirani score was 0.07 (0-0.05). The results of the MRI indicated that only the transverse talonavicular angle showed a significant difference between the treated clubfeet and the normal feet (p < 0.001). One case had dorsal talonavicular subluxation in the sagittal plane and had the lateral subluxation of the navicular in the transverse plane, which has never been reported in previous studies.

CONCLUSION

Although the appearance and function of clubfoot were recovered well after the Ponseti method, the results of MRI indicated that the Ponseti method successfully corrected the varus, cavus, and equinus deformities and incompletely corrected the adduction deformity regarding transverse talonavicular angle. At the same time, the Ponseti method may cause dorsal talonavicular subluxation in the sagittal plane and lateral subluxation of the navicular in the transverse plane on MRI.

Comparative evaluation and analysis of outcomes in non-idiopathic and idiopathic clubfeet with Ponseti method at a tertiary care centre of a developing country

BACKGROUND

Idiopathic clubfoot (congenital talipes equinovarus, CTEV) is being managed worldwide by Ponseti method with high success rates, while for non-idiopathic clubfoot surgical interventions is being widely used with variable results. This study evaluated the effectiveness of Ponseti method in non-idiopathic clubfoot and compared the results with idiopathic clubfoot.

METHODS

The paper evaluated the epidemiological incidence and demographic profile of non-idiopathic clubfoot in a tertiary centre of developing country. A total of 108 subjects with 85 having idiopathic (group I;125 feet) and 23 having non-idiopathic variety (group II;34 feet) were managed with Ponseti method and were followed for a mean duration of 38.33 (12-62) and 36.27 months (12-58) in group I and II respectively. The most common associations were meningomyelocele (MMC/spina bifida,5), arthrogryposis multiplex congenita (AMC,4), developmental dysplasia of hip (DDH,3) and Down's syndrome and amniotic band syndrome (2 each).

RESULTS

Primary correction was achieved in both the groups in 98% and 87% in group I and II respectively, while recurrences of at least one deformity was observed in 11 (9%) and 12 (40%) feet in group I and II respectively. Favourable outcomes were noticed in 22 (65%) feet in non-idiopathic group and 12 feet (35%) underwent extensive soft tissue release as compared to 3 feet (2.4%) in idiopathic variety.

CONCLUSION

Deformities improved significantly in non-idiopathic clubfeet with Ponseti methods although complete correction was not possible. Extensive surgical interventions were reduced in up to 35% feet in non-idiopathic variety and hence, it is recommended as primary treatment for all variety of clubfeet, irrespective of their etiology.

The Treatment of Neglected Clubfoot

The adolescent neglected clubfoot is mostly treated in humanitarian programs by those with a great deal of surgical experience. This deformity needs a major correction, which can compromise the blood circulation and wound healing. A bony correction is preferable over an isolated soft tissue release. The extreme Lambrinudi arthrodesis with a double incision is therefore a preferred tool to correct a neglected clubfoot.

Objective analysis of intermediate-term outcome of the Ponseti technique: a review of the experience from Los Angeles

The Ponseti method of manipulative treatment for clubfoot deformity became widely adopted by pediatric orthopaedic surgeons beginning in the mid-1990s. The technique allows correction of most idiopathic clubfeet using gentle manipulation and cast application. The treatment represents a marked advance over past efforts to gain correction of the foot through extensive release surgery. In 2006, we began a Clubfoot Clinic at the Orthopaedic Institute for Children in Los Angeles, California dedicated to managing clubfoot patients using Ponseti’s method. An IRB-approved database of patient-related, treatment related, and demographic variables was assembled and used to ascertain the outcome of treatment as well as to address parental questions regarding certain aspects of treatment. Here, we present a review of our body of work, which has improved clinical decision making as well as our ability to better inform our patients’ parents regarding the treatment and prognosis of the Ponseti method. Studies from our institution showed that while relapses and the need for extra-articular tibialis anterior tendon transfer (TATT) surgery remain common to the Ponseti method, these events do not adversely affect overall patient function or satisfaction. These findings were not unlike those of classic studies reported from Ponseti’s institution. We conclude that the Ponseti method is not only a technique to achieve initial correction of an idiopathic clubfoot, but also how to manage relapses that will inevitably occur in many patients. While relapses and tendon transfer surgery are likely to remain common with this treatment method, these events do not adversely affect overall patient function or satisfaction. The parents of infants whose clubfeet are managed using the Ponseti method should be counselled accordingly.

Narrative review of the management of a relapsed clubfoot

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

Long-term outcomes of the Ponseti method for treatment of clubfoot: a systematic review

PURPOSE

The Ponseti method has revolutionized the clubfoot treatment and has been adopted globally in the past couple of decades. However, most reported results of the Ponseti method are either short or midterm. Studies reporting long-term outcomes of the Ponseti method are limited. The following systematic review aimed to provide a comprehensive overview of the published articles on long-term outcomes of the Ponseti method.

MATERIAL AND METHODS

A literature search was performed for articles published in electronic database PubMed (includes Medline) and Cochrane for broad keywords: "Clubfoot"; "Ponseti method/technique"; "long term outcomes/results." Studies selected included full-text articles in English language on children less than one year with primary idiopathic clubfoot treated by the Ponseti method with mean ten year follow-up. Non-idiopathic causes or syndromic clubfoot and case reports/review articles/meta-analyses were excluded. The following parameters were included for analysis: number of patients/clubfeet, male/female, mean age at treatment, mean/range of follow-up, relapses, additional surgery, range of motion, various outcome scores, and radiological variables.

RESULTS

Fourteen studies with 774 patients/1122 feet were included. The male:female ratio was 2.4:1. Mean follow-up recorded in studies was 14.5 years. Relapses occurred in 47% patients with additional surgery being required in 79% patients with relapses. Of these, 86% of surgery were extra-articular while 14% were intra-articular. Plantigrade foot was achieved in majority patients with mean ankle dorsiflexion of 11 degrees. The outcome scores were in general good in contrast to radiological angles which were mostly outside normal range with talar flattening/navicular wedging/degenerative osteoarthritis changes occurring in 60%, 76%, and 30%, respectively.

CONCLUSIONS

Long-term follow-up of infants with primary idiopathic clubfeet treated by the Ponseti method revealed relatively high relapse and additional surgery rates. Radiologically, the various angles were inconsistent compared to normal ranges and anatomical deformations/degenerative changes were present in treated feet. Moreover, the relapse rates and requirement of additional surgery increased on long-term follow-up. Despite this, majority feet were plantigrade and demonstrated good clinical results as measured by various outcome tools. There should be emphasis on long-term follow-up of children with clubfeet in view of late relapses and secondary late changes.

Prenatal diagnosis of isolated clubfoot: Diagnostic accuracy and long-term postnatal outcomes

OBJECTIVE

To evaluate concordance between prenatal and postnatal diagnosis of congenital talipes equinovarus (cTEV), rates of surgery and postnatal outcomes in relation to the prenatal classification of severity.

STUDY DESIGN

This is a retrospective observational cohort study on fetuses with a prenatal diagnosis of cTEV between 2004 and 2018. All cases of isolated cTEV in singleton pregnancies were included. Postnatally, the Ponseti method was applied. Children were followed-up postnatally for at least two years, with a specific focus on neurodevelopmental outcome.

RESULTS

The cohort included 81 fetuses with a prenatal diagnosis of cTEV confirmed postnatally in 86.4% of cases. Concordance between prenatal and postnatal assessment was good for both laterality and degree of severity (k = 0.61 and 0.66, respectively). The average Pirani score, number of casts and rates of Achilles tendon tenotomy were higher for III degree cTEV (p < 0.001). Within this group only, the rate of relapse was 11% and the rates of major surgery was 6%. The postnatal outcome was normal in 68.6% newborns, while 14% of cases had a diagnosis of minor additional findings and 17% had an impairment of neurological development. None of the outcome was statistically correlated to the prenatal assessment of laterality or degree.

CONCLUSIONS

The accuracy of prenatal ultrasound for isolated cTEV is 86% with a false positive diagnosis of 14%. The grade of cTEV assigned prenatally correlates to postnatal severity and longer orthopedic rehabilitation in terms of number of casts and need of surgery. The assessment of the correlation between cTEV and neurological impairment requires further prospective studies on larger cohorts.

Ponseti Idiopathic and Nonidiopathic Clubfoot Correction With Secondary Surgeries

The Ponseti method has revolutionized clubfoot treatment for not only idiopathic clubfoot but also non-idiopathic clubfoot. This study aimed to validate the existing literature with respect to the Ponseti method serving as first line treatment for clubfoot. The purpose of this study was to compare clubfoot type and recurrence with secondary surgical procedures following Ponseti method. Kaiser Permanente Northern California database was queried to identify clubfoot children under 3 years old with a consecutive 3-year membership. Associated comorbidities and operative procedure codes were identified. Chart review was performed on all surgical clubfoot patients who completed Ponseti method. Patients' average age at time of surgery, frequency of surgeries, and types of procedures performed were recorded. A logistic regression analysis assessed the adjusted association between surgery status and clubfoot type. Clubfoot incidence was about 1 in 1000 live births. Of the 375 clubfoot children, 334 (89%) were idiopathic and 41 (11%) were non-idiopathic. In the total study population, 82% (n = 309) patients maintained Ponseti correction without a secondary surgery; 66 patients (18%) underwent subsequent secondary surgeries. The non-idiopathic clubfoot underwent surgery more frequently compared to idiopathic clubfoot patients (41.5% vs 14.7%, respectively, p = .0001). Non-idiopathic clubfoot children underwent surgery at a younger age. This study validates the Ponseti method is the first line treatment for clubfoot correction despite etiology. However, patients with recurrent clubfoot may require secondary surgery following Ponseti method. Clubfoot recurrence surveillance is key for identifying early symptomatic recurrence in order to minimize foot rigidity and the need for osseous procedures.

Management issues of congenital talipes equinovarus in the neonatal intensive care unit: A systematic review

BACKGROUND

The Ponseti method is the standard of care for managing idiopathic congenital talipes equinovarus (clubfoot) in the outpatient setting, but there are no clinical guidelines for inpatient treatment. Children in the neonatal intensive care unit (NICU) with clubfoot often delay treatment initiation due to medical reasons.

METHODS

We systematically reviewed literature related to the treatment of clubfoot in the NICU, non-idiopathic clubfoot, and older infants, as well as barriers to care.

RESULTS

In a mixed NICU population of syndromic and idiopathic clubfoot, the Ponseti method has good functional outcomes with minimal interference with medical management. The Ponseti method has good functional outcomes with reduced need for extensive surgical procedures in non-idiopathic clubfoot and idiopathic clubfoot with delayed presentation (under one year of age).

CONCLUSIONS

It is possible to begin Ponseti treatment in the NICU without compromising medical management. It is not clear if this confers an advantage over waiting for outpatient casting.

Idiopathic clubfoot treatment and heterogeneity of current therapeutic strategies: The Ponseti method versus the French functional method (a systematic review)

BACKGROUND

Since Hippocrates, the treatment of idiopathic clubfoot has undergone many changes, with surgical techniques and conservative approaches evolving over the centuries. Today, a wide variety of practices exist in France and throughout the world; consequently, the treatment of idiopathic clubfoot remains controversial, but the Ponseti method and the functional method seem to stand out. Nevertheless, has one of them demonstrated superiority?

METHODS

The purpose of this review is to compare these two methods. Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 recommendations, this research was conducted on Pubmed, Web of Science, and 1Findr. Only articles concerning patients with moderate or severe idiopathic clubfoot (10-17 on the Dimeglio scale) treated early using the Ponseti method or the functional method were eligible.

RESULTS

After reviewing 49 studies, seven published between 2008 and 2018 were selected: five prospective cohort studies, one retrospective cohort study, and one meta-analysis. Each method, according to morphological and kinetic criteria, seems to have advantages that the other does not have.

CONCLUSIONS

Although the Ponseti method is becoming the gold standard and appears more appropriate in poor countries, it is impossible to affirm its superiority over the functional method. Therefore, the combination of their advantages deserves attention: a hybrid method could be an appealing prospect for the future.

A survey on idiopathic congenital talipes equinovarus (ICTEV) managed by the Ponseti technique at Mulago Hospital - Uganda

Introduction

Ponseti technique is the treatment of choice for idiopathic congential talipes equino varus (ICTEV) since 1950s with excellent treatment outcomes reported worldwide. However, despite the popularity of this technique, Uganda adapted it as a treatment modality for ICTEV in May 2005. Since then, the effectiveness of delivered Ponseti care to children with this very common orthopaedic deformity under the supervision of an orthopaedic surgeon was unknown. The implication of this undertaking was that, satisfactory outcomes would then support the Ministry of Health (MOH)-Uganda´s decision to embrace this mode of treatment and if the outcomes were unsatisfactory, MOH would then consider a policy revision in this regard. To assess the midterm treatment outcomes of children with ICTEV who had been enrolled for treatment at Mulago National Referral Hospital in the period of 2006-2009.

Methods

in November/December 2013, a cross-sectional study was conducted to assess the treatment outcomes of 68 feet of 45 children using the designed questionnaire and the PBS score; a pilot study of 10 neonates was performed prior to research. A good treatment outcome meant having a foot or feet that did not require any major or minor surgery.

Results

forty-five (45) children with 68 ICTEV feet were evaluated; males 29 (64.4%) and 16 (35.6%) females with a mean age of 73.22 months (SD 11.364, range 48-96 months). Among the feet assessed, 46 (68%) had good to excellent outcomes while 22 (32%) had a relapse of moderate and severe deformity. Good functionality was seen in 61.8% out of which, 69% and 55.9% had no limitation in walking or running respectively.

Conclusion

Ponseti treatment technique in children with ICTEV under the care of predominantly orthopaedic officers with some supervision from orthopaedic surgeons had fair to good midterm outcomes even in low resource settings like Uganda. Public health approach should be embraced in the management of clubfoot in Uganda by enhancing adequate comprehensive support supervision and establishment of reliable institutionalized systems for patient follow up which will lead to early detection and treatment of relapsed ICTEV cases or neglected clubfeet in the communities.

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

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.

Infrared Thermal Imaging for Evaluation of Clubfoot After the Ponseti Casting Method-An Exploratory Study

Background: Conservative treatment, Ponseti method, has been considered as a standard method to correct the clubfoot deformity among Orthopedic society. Although the result of conservative methods have been reported with higher success rates than surgical methods, many more problems have been reported due to improper casting, casting pressure or bracing discomfort. Nowadays, infrared thermography (IRT) is widely used as a diagnostic tool to assess musculoskeletal disorders or injuries by detecting temperature abnormalities. Similarly, the foot skin temperature evaluation can be added along with the current subjective evaluation to predict if there is any casting pressure, excessive manipulation, or overcorrections of the foot, and other bracing pressure-related complications. Purpose: The main purpose of this study was to explore the foot skin temperature changes before and after using of manipulation and weekly castings. Methods: This is an explorative study design. Infrared Thermography (IRT), E33 FLIR thermal imaging camera model, was used to collect the thermal images of the clubfoot before and after casting intervention. A total of 120 thermal images (Medial region of the foot-24, Lateral side of the foot-24, Dorsal side of the foot-24, Plantar side of the foot-24, and Heel area of the foot-24) were collected from the selected regions of the clubfoot. Results: The results of univariate statistical analysis showed that significant temperature changes in some regions of the foot after casting, especially, at the 2nd (M = 32.05°C, SD = 0.77, p = 0.05), 3rd (M = 31.61, SD = 1.11; 95% CI: 31.27-31.96; p = 0.00), and 6th week of evaluation on the lateral side of the foot (M = 31.15°C, SD = 1.59; 95% CI: 30.75-31.54, p = 0.000). There was no significant temperature changes throughout the weekly casting in the medial side of the foot. In the heel side of the foot, significant temperature changes were noticed after the third and fourth weeks of casting. Conclusion: This study found that a decreased foot skin temperature on the dorsal and lateral side of the foot at the 6th week of thermography evaluation. The finding of this study suggest that the infrared thermography (IRT) might be useful as an adjunct assessment tool to evaluate the thermophysiological changes, which can be used to predict the complications caused by improper casting, over manipulative or stretching and casting-pressure related complications.

Can clubfoot scoring systems predict the number of casts and future recurrences in patients undergoing Ponseti method?

Background

Congenital clubfoot is one of the common congenital orthopaedic deformities. Pirani and Dimeglio scoring systems are two classification systems for measuring the severity of the clubfoot. However, the relation between the initial amount of each of these scores and the treatment parameters is controversial.

Methods

Patients with severe and very severe idiopathic clubfoot undergoing Ponseti treatment were entered. Their initial Pirani and Dimeglio scores, the number of castings as a short-term treatment parameter, and the recurrences as a long-term parameter until the age of three were prospectively documented.

Results

One hundred patients (143 feet) with mean age of 9.51 ± 2.3 days including 68 males and 32 females and the mean initial Pirani score of 5.5 ± 0.5 and the mean initial Dimeglio score of 17.1 ± 1.6 were studied. The incidence of relapse was 8.4 %( n = 12). The mean initial Pirani score (P < 0.001) and the mean initial Dimeglio score (P < 0.003) of the feet with recurrence were significantly more than the non-recurrence feet. The mean number of casts in the recurrence group (7 ± 0.9) was significantly more than the feet without recurrences (6.01 ± 1.04) (P = 0.002). The ROC curve suggested the Pirani score of 5.75 and the Dimeglio score of 17.5 as the cut-off points of these scores for recurrence prediction.

Conclusion

In our study, Pirani and Dimeglio scores are markedly related with more number of casts and recurrence in patients with severe and very severe clubfoot. Also, we have introduced new cut-off points for both classification systems for prediction of recurrence. To the best of our knowledge, this finding has not been introduced into the English literature.

Confirmation of Tenotomy Healing at 3 Weeks Using the Ponseti Protocol

Percutaneous Achilles tenotomy is an integral key element of the Ponseti method in clubfoot management. The duration of posttenotomy casting has been empirical. Evidence-based duration of healing in Achilles tendon is required to objectively determine the period of posttenotomy casting. This study aims to use clinical and ultrasonographic methods to evaluate the mean duration of Achilles tendon gap (ATG) closure and the weekly percentage of feet that achieved ATG closure after tenotomy. Prospectively, 37 feet of 25 patients <5 years old with idiopathic clubfoot were managed using Ponseti methods. The Achilles tendon was assessed clinically and ultrasonographically before and after tenotomy. The tendon stump gap was created at tenotomy, and posttenotomy assessments were done on a weekly basis until tendon stump gap closure was achieved, with a minimum follow-up of 2 years. The immediate posttenotomy ultrasonographic mean tendon gap area was 5 ± 2.8 mm. The mean duration of the tendon stump gap closure as determined clinically was 1.9 ± 0.8 weeks, whereas it was 2.6 ± 0.9 weeks as assessed ultrasonographically (p < .001). The significant difference between clinical and ultrasound methods of assessing the Achilles tendon gap closure appears to establish casting removal and ambulatory walking at 3 weeks after tenotomy for <5-year-old children with idiopathic clubfoot treated with the Ponseti method. We recommend that the duration of posttenotomy cast should be 3 weeks based on the ultrasonographic findings.

Neglected Idiopathic Clubfoot Successfully Treated by the Ponseti Method: A Case Report of an Adult Patient who Started Treatment at 26 Years of Age

Introduction:

The Ponseti method has been universally adopted for the treatment of children’s neglected clubfoot, but not for adult patients. In low- and middle-income countries, there are adult patients with neglected CTEV that remains untreated because the patients have limited access to specialized treatment.

Case Report:

The Ponseti method was applied in a 26-year-old adult female patient with neglected clubfoot with no previous treatment. The feet had functional mobility and no residual deformities at the end of follow-upperiod. An abduction foot orthosis was prescribed for 1 year after casting period. The patient returned to normal activities after an8-month follow-up period.

Conclusion:

This unique therapeutic success in an adult patient with neglected idiopathic bilateral clubfoot showed that the Ponseti method was a good treatment option.

[Analysis of the efficacy of the Ponseti method for treatment of secondary clubfoot in young children with tethered cord syndrome]

Objective: To explore the feasibility of Ponseti method in treatment of secondary clubfoot in young children with Tethered Cord Syndrome(TCS). Methods: The clinical data of 53 young children with clubfeet treated with Ponseti method from March 2014 to March 2017 at Department of Pediatric Orthopedics, the Third Affiliated Hospital of Zhengzhou University were analyzed retrospectively. These patients were divided into TCS group and Idiopathic group according to the etiology. There were 19 patients (33 feet) in TCS group,with an mean age of 2.8 months(range:0.2 to 24.0 months), including 13 males and 6 females, 5 patients with unilateral clubfeet and 14 patients with bilateral clubfeet. There were 34 patients (45 feet) in idiopathic group, with an mean age of 3.1 months(range: 0.1 to 21.0 months), including 18 males and 16 females, 23 patients with unilateral clubfeet and 11 patients with bilateral clubfeet. All the children received casts correction according to Ponseti method, and were followed up at 3 weeks, 3 months, 6 months and every 6 months after the Achilles tendon tenotomy or the last cast correction. Complications were recorded and therapeutic effect was evaluated of these children by Dimeglio Scoring System and the International Clubfoot Study Group (ICFSG) at the last follow-up. Independent t test, Mann-Witney U test or χ(2) test were used to compare the indicators of the two groups. Results: The number of plaster fixation in TCS group was (6.1±2.0) times, and that of idiopathic group was (4.8±1.0) times(t=3.482, P<0.01).In TCS group, 22 feet treated with Achilles tendon transection and that of idiopathic group was 40 feet(χ(2)=0.279, P=0.598). There were 18 cases recurrence in TCS group and 8 cases in Idiopathic group (t=11.149, P<0.01). In TCS group, 16 cases (27 feet) completed the initial correction, the success rate was 60.6% (27/33), 3 cases (6 feet) could not correct the deformity after 9 to 10 times of plaster fixation, and then underwent soft tissue release.In idiopathic group, 34 cases (45 feet) achieved initial correction after Ponseti treatment(χ(2)=6.488, P=0.011).At the last follow up, there were 5 cases (9 feet) in TCS group and 2 cases (2 feet) in idiopathic group underwent soft tissue release(χ(2)=6.110, P=0.013). The classification grade of ICFSG score of the two groups without soft tissue release were (2.1±0.6) and (1.8±0.7), the difference was not statistically significant (t=1.765, P=0.082). All the children had no skin ulceration, bedsores, skin allergy and other complications. Conclusion: Ponseti method is effective in the treatment of clubfoot secondary to TCS, and the functional recovery is similar to that of children with idiopathic clubfoot.

Ponseti method in the treatment of post-operative relapsed idiopathic clubfoot after posteromedial release. A short term functional study

BACKGROUND

Relapsed clubfeet deformity after surgical treatment by posteromedial release are frequently encountered in pediatric orthopedic practice and further revision surgery may be needed. As surgery adds more fibrosis and scaring, complication may be devastating and treatment is challenging. Ponseti method, the gold standard technique for treatment of clubfoot may be of a value in the management of postoperative relapses.

AIM OF THE STUDY

Determine the effectiveness of Ponseti casting Method in treatment of relapsed idiopathic clubfoot in children after being treated with surgical posteromedial release.

MATERIALS AND METHODS

Prospective interventional study of 17 patients (25 feet) presented with a relapsed idiopathic clubfoot deformity after previous surgical posteromedial release. The patients were reviewed using Pirani and Dimeglio score. Ponseti method was done to obtain supple, flexible foot rather than a fully corrected foot, the residual deformity were treated by, heel cord lengthening or tenotomy, tibialis anterior transfer, follow up was for a minimum of 12 months.

RESULT

17 Patients (25 feet) their age ranging from 1 to 10 years were evaluated and treated. Casts were applied until the only deformities remaining were either hindfoot equinus and/or dynamic supination. 22 feet required a heel cord procedure for equinus and 13 required tibialis anterior transfer for dynamic supination. The follow up (average 56.1 months) was for a minimum of one year. 4 feet had persistent heel varus deformity which required Calcaneal osteotomy later. Three feet didn't need more casting and 2 feet were resistant cases that required further Ilizarov procedure, 4 needed lateral arch shortening and other 4 needed posterior capsulotomy. Improvement in the Pirani and Dimeglio scores was highly statistically significant.

CONCLUSION

Ponseti method for treatment of relapsed clubfeet after a previous posteromedial soft tissue surgical release is an effective, non invasive, with excellent results.

Talipes equinovarus or Clubfoot: A review of study approaches, management and trends in Pakistan

This paper aims to assess the status of scientific literature on talipes equinovarus (TEV) published from Pakistan, to get an insight into the trend in knowledge over the years, and to highlight study gaps in this area. A detailed review of published literature was conducted from November 2019 to January 2020. ‘Talipes/congenital talipes’, ‘clubfoot/congenital clubfoot’, ‘talipes equinovarus /congenital talipes equinovarus’ AND ‘Pakistan’ were used as key terms. Different search engines, PubMed, PakMediNet, ScienceDirect, Embase and Google Scholar were utilized to retrieve articles. A total of 63 articles were retrieved. The hotspot of TEV research in Pakistan has been its treatment and management. Over the years, treatment trend has shifted from operative to conservative; Ponseti method is predominantly employed. Hospital-based studies focusing on pediatric patients are common while population-based studies are devoid. In majority of cohorts, there is preponderance of male patients, idiopathic and unilateral cases. There is, however, scarcity of basic research on the prevalence, etiology, risk factors, clinical heterogeneity, associated anomalies, genetics, and molecular diagnostics of TEV. In conclusion, prudent scientific evidence is required for any policy-making and relevant public health action. Hence, large scale population-based studies are required for a broader overview and understanding the clinical spectrum of TEV.

Prospective Study of Gross Motor Milestones in Children with Severe Idiopathic Clubfoot Treated by Ponseti Method

BACKGROUND

A prospective study of motor milestones achieved in severe clubfeet treated by Ponseti method and comparison between unilateral and bilateral clubfoot will help us gain further insight of motor milestones in these children.

METHODS

Prospective study of 150 consecutive children with idiopathic clubfoot who were treated by Ponseti method and in whom percutaneous tendoachilles tenotomy was performed. The gross motor milestones recorded were: rolls from back to stomach, sitting without support, standing with assistance, walks with assistance, standing alone, walking alone. This was compared with published regional and World Health Organization (WHO) normal data.

RESULT

15 patients were excluded due to non-compliance and recurrence. Children with unilateral clubfoot (80 children) and bilateral clubfoot (55 children) showed a delay of 0.2-2.1 months in various milestones, and this was statistically significant when compared with both normal data. 95% children with unilateral clubfoot had independent ambulation by 17 months and in bilateral ambulation by 17.8 months. There was also a statistically significant difference in unilateral and bilateral clubfeet in all variables except sitting without support and walking with support.

CONCLUSION

There is a delay in achievement in all children with clubfoot, with more delay in bilateral clubfoot as compared to unilateral clubfoot. The probable reasons could be plaster treatment, possible weakness due to tendoachilles tenotomy, use of orthosis or the inherent pathology associated with clubfeet. Parents hence need to be explained about this delay.

Difficulties During Ponseti Casting for the Treatment of Idiopathic Clubfoot

The Ponseti method has resulted in excellent outcomes in the treatment of idiopathic clubfoot. To evaluate the process of serial casting, most studies previously used the number of casts required to achieve correction. In contrast, difficulties that occurred during serial casting were rarely studied. We reviewed 47 patients with severe idiopathic clubfoot (Dimeglio score ≥10) and a follow-up period of ≥4 years by focusing on difficulties during the Ponseti casting and their related factors. All events requiring temporary discontinuation and/or delay of scheduled casting were considered difficulties. Among the 47 patients, difficulties occurred in 18 patients (38.3%). Initial Dimeglio score (14.9 ± 2.5 [vs 13.5 ± 2.3, p = .042]), its subcomponent of equinus (3.8 ± 0.4 [vs 3.3 ± 0.6, p = .005]), and the number of casts (6.3 ± 2.0 [vs 4.9 ± 1.2, p = .009]) in the 18 patients with difficulties were greater than those of the remaining 29 patients. In addition, the foot length was shorter (7.2 ± 0.6 cm [vs 7.7 ± 0.8 cm, p = .030]) in patients with difficulties. In the regression analysis, both subcomponents of equinus and foot length showed the significance for the occurrence of difficulties. During 8.7 ± 3.8 years, further surgery was needed in 35 patients (74.5%) because of residual or recurrent deformity. The ratio was higher in patients with difficulties (94.4% [vs 62.1%, p = .017]). In our experience, difficulties frequently occurred in feet with rigid equinus and small length, and further surgery was required after the initial correction in almost all of the feet with difficulties.

Clubfoot treatment with Ponseti method-parental distress during plaster casting

Background

Clubfoot is one of the most prevalent musculoskeletal congenital defects. Gold standard treatment of idiopathic clubfoot is the conservative Ponseti method, including the reduction of deformity with weekly serial plaster casting and percutaneous Achilles tenotomy. It is well known that parents of children with severe and chronic illnesses are mentally stressed, but in recent studies regarding clubfoot treatment, parents were only asked about their satisfaction with the treatment. Largely unknown is parental distress before and during plaster casting in clubfoot.

Therefore, we want to determinate first, how pronounced the parents’ worries are before treatment and if they decrease during the therapy. Second, we hypothesized that parents faced with an extreme deformity (high Pirani score), reveal more distress, than parents whose children have a less pronounced deformity (low Pirani score). Therefore, we wanted to investigate whether the Pirani score correlates with the parents’ mental resilience in relation to the therapy of the child as a global distress parameter.

Methods

To answer this question, we developed a questionnaire with the following emphases: Physical capacity, mental resilience, motion score, parents score, and child score with point scores 1 (not affected) to 6 (high affected). Subsequently, we interviewed 20 parents whose children were treated with clubfeet and determined the Pirani score of the infants at the beginning (T₀) and at the end (T_E) of the treatment with plaster casting.

Results

High values were obtained in child score (Mean (M) = 3.11), motion score (M = 2.63), and mental resilience (M = 2.25). During treatment, mental resilience improved (p = 0.015) significantly. Spearman correlation coefficient between Pirani score (T₀) and mental resilience (T₀) is 0.21, so the initial hypothesis had to be rejected.

Conclusion

The issues of the children are in the focus of parental worries concerning clubfoot treatment, especially the assumed future motion and the assumed ability to play with other children. Particular emphasis should be placed on educating parents about the excellent long-term results in the function of the treated feet especially as this topic shows the greatest parental distress.

The influence of laterality, sex and family history on clubfoot severity

PURPOSE

Epidemiological studies on idiopathic clubfeet have shown a typical distribution consistent across ethnic groups: bilaterality in about 50% of cases and a male to female ratio of 2:1. Whether this corresponds also to differences in severity according to laterality and sex has been poorly evaluated. As well, the correlation between family history and severity has not been previously investigated. The aim of this study was to investigate how laterality, sex and family history influence severity and treatment.

METHODS

In all, 97 infants with idiopathic clubfoot (81 male, 16 female; 55 unilateral, 42 bilateral; 19 with a first or second-degree relative affected) consecutively treated with Ponseti method were prospectively enrolled. Initial severity (according to Dimeglio and Pirani scores) and treatment (number of casts and need for tenotomy) were analyzed in the different subgroups.

RESULTS

Initial severity according to Pirani (p = 0.020) and Dimeglio score (p = 0.006), number of casts (p = 0.000) and tenotomy (p = 0.045) were significantly higher in bilateral than in unilateral cases. In bilateral cases, a significant correlation was found between the right and left foot of each patient in terms of initial severity, number of casts and tenotomy performed. No statistically significant difference was found according to sex and family history.

CONCLUSIONS

This study has confirmed the different behaviour of bilateral cases reported by previous studies; bilateral cases are more severe and show similar features in their right and left foot. This could be the result of different pathogenic mechanisms, likely on a genetic basis. Sex and family history did not seem to influence severity.

LEVEL OF EVIDENCE

Level of evidence II.

Early Radiographic Changes in the Lateral Talocalcaneal Angle Following Achilles Tenotomy in Children With Idiopathic Clubfoot

BACKGROUND

Percutaneous Achilles tenotomy (PAT) is an important component of the Ponseti method and is performed in 85% to 90% of patients. However, there is a lack of objective data assessing early radiographic changes in children undergoing PAT.

METHODS

Forty-nine patients with idiopathic clubfoot treated by Ponseti casting were prospectively enrolled between October 2017 and October 2018. Preoperative and postoperative ankle dorsiflexion (pre-ADF^max, post-ADF^max) and lateral talocalcaneal angle (pre-LTCA^max, post-LTCA^max) values with the ankle in maximal dorsiflexion as well as postoperative LTCA values with the ankle in the neutral position (post-LTCA^neutral) were measured. The relationship between the preoperative and postoperative ADF and LTCA values was studied using Pearson or Spearman correlation coefficients. Forty-nine patients (72 feet) were included; the mean age at initial treatment was 32.2 ± 24.1 days.

RESULTS

Post-LTCA^max improved significantly from 18.6 ± 9.2 degrees to 25.1 ± 10.5 degrees (P < .0001). Pre-ADF and pre-LTCA^max showed a positive correlation in both the less than 28-day group (r = 0.42; P = .015) and the Dimeglio III group (r = 0.29; P = .035). However, post-ADF and post-LTCA^max showed a positive correlation in the Dimeglio III group (r = 0.30; P = .028). The degree of improvement in post-LCTA^max in the Dimeglio III group was similar to that in the Dimeglio IV group (P = .28).

CONCLUSION

The LTCA increased immediately after PAT in clubfoot, although the improvement seemed to be unrelated to the severity of the disease. PAT led to an increase in both ADF and the LTCA, and it contributed to the improvements in subtalar joint motion and alignment.

LEVEL OF EVIDENCE

Level III, comparative study.

Influence of Beginning Time of Casting for Clubfoot Treatment by Ponseti Method in Different Age Group Infants: A Retrospective Study

BACKGROUND

The clubfoot is one of the commonly found congenital deformities in newborn. The Ponseti method is the most effective nonoperative clubfoot management method. It is based on understanding of pathoanatomy of clubfoot. For classifying severity of clubfoot, Pirani score is used. The number of cast required for clubfoot correction is dependent on its initial Pirani score. This study aimed on how the number of cast for correction of clubfoot deformity depends on starting time of casting and pretreatment Pirani score.

MATERIALS AND METHODS

This study comprises of 200 patients with 297 affected foot nonoperatively managed with Ponseti technique of casting. We measured initial and final Pirani scores of patients with different age groups.

RESULTS

We found that initial severity was less in 0-1 month age group children but mean casting number was more while initial severity was more in 1-2 month age group, the mean number of casting was less. Tenotomy requirement was also less in 1-2 month age group.

CONCLUSION

We concluded that casting according to the Ponseti method should be started in 1-2 months age group which shows better results than the other age groups in clubfoot.

Hallux length and deep medial crease in complex clubfeet: Do they recover?

OBJECTIVE

The shortened hallux and deep medial crease are a significant cosmetic deformity in complex clubfeet. We quantitatively determined the correction of hallux length and deep medial crease following treatment of complex clubfeet.

METHODS

A chart review of 11 patients (17 feet) with complex clubfeet treated with modified Ponseti method was undertaken. Pretreatment clinical photographs and Pirani scores were compared with those obtained at a recent follow-up to analyze outcomes. Hallux length was matched with 2nd toe and graded similar to Pirani score.

RESULTS

Mean patient age at enrollment was 26.8 weeks. Average follow up was 22.6 months. Pre treatment and follow up Pirani score averaged 5.8 and 0.2 respectively. The average number of cast utilized was 7. Incomplete/non correction of hallux was observed in 6 feet (35%), of which 4 suffered an equinus relapse. Deep medial crease corrected in all.

CONCLUSIONS

The study describes a clinical method of hallux length quantification in complex clubfeet. Medial crease recovered in all feet. The recovery of hallux length was delayed in some patients and might indicate persistent posteromedial soft tissue contracture/fibrosis in these feet.

Correlation of scores with number of Ponseti casts required for clubfoot correction in the older child

BACKGROUND

We examined the correlation between initial Pirani and Dimeglio scores and their individual components to the number of casts for older clubfoot children.

METHODS

Twenty seven patients (39 feet) aged 2-11 years with idiopathic clubfeet were treated using the Ponseti technique and correlation with number of corrective casts calculated. The number of cast required was counted from application of primary cast to the time of initiation of the foot abduction orthosis.

RESULTS

Average 8.45 ± 2.31 (range, 4-13) casts were used for treatment. A low correlation (r = 0.203) was identified when total Dimeglio score was compared with the number of casts. No correlation was identified for Pirani score (r = 0.023). Among individual components, only cavus deformity had a significant positive correlation to cast numbers.

CONCLUSIONS

The Pirani and Dimeglio classifications still remain the most widely practiced clubfoot severity grading systems for the older clubfoot child. However, their prognostic value to predict the total cast duration from initial severity remains questionable.

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

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

Motor and cognitive functioning in children treated for idiopathic clubfoot at the age of 3 years

Background

Several studies have investigated motor and cognitive skills in infants as well as gross motor abilities in schoolchildren treated for congenital idiopathic clubfoot, mostly indicating specific impairments in those children. However, until now, little is known about the motor and cognitive abilities of preschool children treated for idiopathic clubfoot. Thus, it was the aim of this study to examine gross motor, fine motor and cognitive skills of 3-year-old-children treated for idiopathic clubfoot.

Method

We tested gross motor, fine motor and cognitive functioning of 10 children treated for idiopathic clubfoot and 10 typically developing children at the age of 40 months (SD = 1) with the Bayley Scales of Infant and Toddler Development.

Results

The children treated for idiopathic clubfoot showed a slight delay in gross motor development. In particular, they demonstrated difficulties in tiptoeing, walking upstairs and walking downstairs. Moreover, we found some slight deficits in cognitive development, particularly in visual-spatial memory.

Discussion

Children treated for idiopathic clubfoot appear to have an increased risk of gross motor and spatial cognitive deficits. Orthopedic pediatrics should incorporate measures of gross motor functioning, for example tiptoeing, in their orthopedic setting. Moreover, future studies are needed to clarify whether the observed deficits persist through childhood. If so, some kind of a motor training for children with idiopathic clubfoot might be required.

Interobserver reliability of Diméglio and Pirani score and their subcomponents in the evaluation of idiopathic clubfoot in a clinical setting: a need for improved scoring systems

PURPOSE

Diméglio (DimS) and Pirani (PirS) scores are the most commonly used scoring systems for evaluation of clubfoot, with many centres performing both. Interobserver reliability of their global score has been rated high in a few studies, but agreement of their subcomponents has been poorly investigated. The aim of the study was to assess interrater reliability of global scores and of items in a clinical setting and to analyse overlapping features of the two scores.

METHODS

Fifty-six consecutive idiopathic clubfeet undergoing correction using the Ponseti method were independently evaluated at each casting session by two trained paediatric orthopaedic surgeons using both scores. Interobserver reliability of collected data was analysed; a kappa coefficient > 0.60 was considered adequate.

RESULTS

For DimS and PirS, the Pearson correlation coefficients were 0.87 and 0.91 (p < .0001) respectively, and kappa coefficients were 0.23 and 0.31. Among subcomponents, kappa values were rated > 0.60 only for equinus and curvature of lateral border in PirS; muscular abnormality in DimS was rated 0.74 but a high prevalence index (0.94) indicated influence of scarce prevalence of this feature. All other items showed k < 0.60 and were considered to be improved.For overlapping features: posterior and medial crease showed similar agreement in the two systems, items describing equinus and midfoot adduction were much more reliable in PirS than in DimS.

CONCLUSIONS

In a clinical setting, despite a high correlation of evaluations for total scores, the interobserver agreement of DimS and PirS was not adequate and only a few items were substantially reliable. Simultaneous use of two scores seemed redundant and some overlapping features showed different reliability according to criterion or scale used. Future scoring systems should improve these limitations.

LEVEL OF EVIDENCE

Level I - Diagnostic studies.

Standing and walking age in children with idiopathic clubfoot: French physiotherapy versus Ponseti method

PURPOSE

A mild delay in gross motor milestones and walking age has been reported in infants with clubfoot. The influence of different treatments on motor development has been poorly investigated. Some parents and physical therapists express concern that the Ponseti method (PM) and its constraints (abduction brace, casts) would affect development more than the French physical therapy method (FM) due to greater immobilization and lesser stimulation.The purpose of this study was to evaluate achievement of three motor milestones (pull-to-standing, cruising and independent walking) in two groups of clubfoot patients treated at two experienced institutes respectively with the PM and FM.

METHODS

In all, 52 consecutive infants (full-term at birth, mean age at beginning of treatment 24.3 days (sd 10), mean Dimeglio score 12 (sd 3.4)) were prospectively enrolled (26 patients per centre) and followed up to walking age recording milestones.

RESULTS

The two groups were not different in terms of age at the beginning of treatment (p = 0.067) and rate of tenotomy. Age at tenotomy was significantly lower in the PM group (p = 0.000). Severity (p = 0.004) and number of bilateral cases (p = 0.012) were higher in the PM group. A non-significant difference was found for age of achievement of pull-to-standing (p = 0.109), cruising (p = 0.253) and independent ambulation (p = 0.349) between the two groups. Overall, milestones were achieved approximately two months later than normal population. Sex, severity, laterality and need of tenotomy were not found to significantly influence milestones.

CONCLUSION

Our results confirmed that infants with clubfoot are expected to have a minimum delay in motor development. Infants treated with the PM and those treated with the FM did not show significant differences in gross motor milestones achievement at walking age.

LEVEL OF EVIDENCE

Level II - Prospective comparative therapeutic studies.

Ponseti clubfoot management method: Initial experience with 273 clubfeet treated in a clubfoot clinic of a Nigerian regional orthopedic hospital

Objective

The aim of this study was to evaluate the initial experience and outcome of clubfoot treated using the Ponseti technique in a regional orthopedic hospital setting of a developing country.

Methods

This was a retrospective review of all the clubfoot patients who were treated at the clubfoot clinic of National Orthopaedic Hospital Enugu from 1^st of August 2013 to 31^st January 2015.

Result

There were 175 patients with 273 clubfeet. The male to female ratio was 1.2:1, and the age range was 1 week to 27 years with a median age of 11 months. One hundred and fifty-one patients (86.5%) had congenital clubfoot, whereas 24 (13.5%) had acquired clubfoot. The mean Pirani score of the patients at presentation was 4. The mean number of cast sessions needed for correction was 6.3. The majority of the feet (96.6%) were treated and correction achieved with Ponseti method alone, whereas 3.4% had other additional surgical procedures. Seventy-two (41.1%) patients afforded and used foot abduction brace as prescribed. Plaster sores in 12.5% of patients were the most common complication. At a mean follow-up period of 6 months, a relapse rate of 3.4% was observed.

Conclusion

Ponseti clubfoot management technique alone is very effective in most cases of clubfoot in our setting. Late presentation of patients and foot abduction brace related challenges observed call for a policy response aimed at educating the public on the importance of early presentation and improving the use of foot abduction brace.

Bracing in clubfoot: do we know enough?

PURPOSE

The Ponseti method is widely used in clubfoot treatment. Long-term follow-up shows high patient satisfaction and excellent functional outcomes. Clubfoot tendency to relapse is a problem yet to solve. Given the importance of bracing in relapse prevention, we ought to discuss current knowledge and controversies about bracing.

METHODS

We describe types of braces used, with its advantages and disadvantages, suggesting bracing schedules and duration. We identify bracing problems and pinpoint strategies to promote adherence to bracing.

RESULTS

When treating a clubfoot by the Ponseti method, the corrected foot should be held in an abducted and dorsiflexed position, in a foot abduction brace (FAB), with two shoes connected by a bar. The brace is applied after the clubfoot has been completely corrected by manipulation, serial casting and possibly Achilles tenotomy. Bracing is recommended until four to five years of age and needs to be fitted to the individual patient, based on age, associated relapse rate and timing when correction was finished. Parental non-adherence to FAB use can affect 34% to 61% of children and results in five- to 17-fold higher odds of relapse. In patients who have recurrent adherence problems, a unilateral lower leg custom-made orthosis can be considered as a salvage option. Healthcare providers must communicate with patients regarding brace wearing, set proper expectations and ensure accurate use.

CONCLUSION

Bracing is essential for preventing clubfoot relapse. Daily duration and length of bracing required to prevent recurrence is still unknown. Prospective randomized clinical trials may bring important data that will influence clinicians' and families' choices regarding bracing.

LEVEL OF EVIDENCE

V.

Treatment of non-idiopathic clubfeet with the Ponseti method: a systematic review

PURPOSE

Although non-idiopathic clubfeet were long thought to be resistant to non-surgical treatment methods, more studies documenting results on treatment of these feet with the Ponseti method are being published. The goal of this systematic review is to summarize current evidence on treatment of non-idiopathic clubfeet using the Ponseti method.

METHODS

PubMed and Limo were searched, reference lists of eligible studies were screened and studies that met the inclusion criteria were included. Data on average number of casts, Achilles tendon tenotomy (ATT), initial correction, recurrence, successful treatment at final follow-up and complications were pooled. The Methodological Index for Non-Randomized Studies was used to assess the methodological quality of the selected studies.

RESULTS

In all, 11 studies were included, yielding a total of 374 non-idiopathic and 801 idiopathic clubfeet. Non-idiopathic clubfeet required more casts (7.2 versus 5.4) and had a higher rate of ATT (89.4% versus 75.7%). Furthermore, these feet had a higher recurrence rate (43.3% versus 11.5%) and a lower rate of successful treatment at final follow-up (69.3% versus 95.0%). Complications were found in 20.3% of the non--idiopathic cohort. When comparing results between clubfeet associated with myelomeningocele and arthrogryposis, the first group presented with a lower number of casts (5.4 -versus 7.2) and a higher rate of successful treatment at final follow-up (81.8% versus 58.2%).

CONCLUSION

The Ponseti method is a valuable and non-invasive option in the primary treatment of non-idiopathic clubfeet in young children. Studies with longer follow-up are necessary to evaluate its long-term effect.

LEVEL OF EVIDENCE

Level III - systematic review of Level-III studies.This work meets the requirements of the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and -Meta-Analyses).