Investigating the association between vitamin D dietary intake during pregnancy and incidence of clubfoot in neonates

AIMS

Talipes equinovarus (clubfoot) is a congenital lower foot deformity that results from a neuromuscular deficiency, but the precise etiology remains elusive. Vitamin D is important for fetal neuromuscular development. In this study, we investigated the association between dietary vitamin D intake during pregnancy and incidence of clubfoot in neonates, since such a question has thus far been overlooked.

METHODS

We conducted a secondary analysis of data collected in the United States, between 2007 and 2011 for a case-control study of children born with clubfoot. Participating mothers were interviewed by telephone about dietary and other health and life-style indicators. Exposure to vitamin D was recorded as the average daily intake of dietary vitamin D over a period of 6 months before pregnancy began. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression.

RESULTS

The dataset included 2667 study participants, of which 663 were cases. Logistic regression showed no significant association between dietary vitamin D or log10 (Vitamin D) intake during pregnancy and incidence of clubfoot in neonates (OR = 1.00, CI = 1.00-1.00, OR = 1.51, CI = 0.83-2.82, respectively). No interaction in the regression model was found between vitamin D and other predictor variables. Results were not confounded by supplement intake of vitamin D during pregnancy.

CONCLUSIONS

Results show no evidence of an association between dietary vitamin D intake and incidence of clubfoot in neonates. The lack of association is not confounded by consumption of vitamin D supplements during pregnancy.

Selective Tibial Neurotomy for Spastic Equinovarus Foot: Operative Technique

BACKGROUND AND OBJECTIVES

Spastic equinovarus foot (SEF) is a common complication of stroke and other upper motor neuron injuries. It is characterized by a plantigrade and inverted foot, often with toe curling, causing significant disability from pain, gait, and balance difficulties. Management includes physical therapy, antispasticity drugs, orthoses, chemical neurolysis, or botulinum toxin, all of which may be insufficient, sedating, or transient. Selective tibial neurotomy (STN) provides a surgical option that is effective and long-lasting. Our goal is to provide a concise description of our technique for performing the STN for treatment of SEF. We discuss the standard posterior approach with surgical variations used by other groups and a medial approach, should the posterior approach be insufficient.

METHODS

A posterior leg approach allows access to the tibial nerve and its branches to the bilateral gastrocnemius muscles, soleus, posterior tibialis, and extrinsic toe flexors. A medial approach is used if the toe flexors cannot be accessed sufficiently from the posterior approach. Nerve branch targets identified by preoperative functional assessment are carefully exposed and fully neurolysed distally to identify all terminal branches to each muscle of interest before neurotomy.

RESULTS

The STN is a powerful tool for treating SEF, with an immediate and lasting effect. Approximately 80% of the target muscle should be denervated to ensure long-term efficacy while maintaining adequate function of the muscle through collateral innervation.

CONCLUSION

The STN is a safe and effective outpatient procedure that can be performed by an experienced nerve surgeon to improve balance and ambulation and reduce pain for patients with SEF. Large clinical trials are necessary to further establish this underutilized procedure in the United States.

Calcaneocuboid capsuloligamentous soft-tissue entrapment: a rare cause of acquired equinovarus deformity

Acquired equinovarus deformity is rare, with most cases related to congenital disorders such as clubfoot. We describe a unique case of traumatic capsuloligamentous soft-tissue entrapment within the calcaneocuboid joint in a 13-year-old girl, causing an acquired equinovarus deformity. This required surgical exploration and joint fixation. Assessing soft-tissue entrapment on magnetic resonance imaging can be beneficial as a potential cause of an acquired post-traumatic non-reducible foot deformity in children. We discuss the intricate capsuloligamentous structures that reinforce the calcaneocuboid joint and highlight the importance of interrogating such structures in the context of inversion injuries to the ankle.

The split transfer of tibialis anterior tendon to peroneus tertius tendon for equinovarus foot in children with cerebral palsy

OBJECTIVE

The aim of this study was to analyze the results of the split anterior tibialis tendon transfer (SPLATT) to peroneus tertius (PT) for equinovarus foot deformity in children with cerebral palsy (CP).

METHODS

The medical records of 25 ambulatory CP patients (mean age: 8.7±3.2 years, range: 4-16 years) with equinovarus foot (33 feet), who underwent SPLATT to PT surgery between 2014 and 2016, were retrospectively reviewed. A senior surgeon performed all the surgical procedures. SPLATT was performed as part of a single-event multilevel surgery for the lower limb, and the concomitant procedures on the same extremity were recorded. The patients who required any additional foot or ankle surgery that could affect the clinical outcome (except heel cord lengthening) were excluded from the study. The Kling's College Criteria were used to evaluate the procedural outcome of the foot position and gait, and the associated complications were recorded.

RESULTS

The mean follow-up time was 28.8±5 months (range: 24-42 months). The postoperative Kling scores were excellent for 27 feet of the patients who had a plantigrade foot, without fixed or postural deformity, in a regular shoe, having no calluses; good for 5 cases for those who walked with less than 5° varus, valgus, or equinus posture of the hind foot, wearing regular shoes, having no callosities; and fair for 1 case for those who had recurrence of the deformity. There was only one wound detachment, which was treated with wound care and dressing. None of the patients had overcorrection, infection, or bone fracture.

CONCLUSION

The dynamic SPLATT to PT surgery for the management of the equinovarus foot deformities in the CP patients is a safe and less complicated surgical alternative with a good functional outcome. It is a safe and effective treatment method for the management of equinovarus foot deformities in CP.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Fibula extension and correction of foot and ankle deformity to rectify post-osteomyelitis talipes equinovarus in a young adult: a case report and literature review

OBJECTIVE

Talipes equinovarus is traditionally viewed in the literature as a congenital disease.

CASE REPORT

We present here a case of the acquired talipes equinovarus (clubfoot) in a young adult patient that has developed the following osteomyelitis.

RESULTS

We have successfully corrected this condition by fibula extension and correction of foot and ankle deformity, using external fixation device. The treatment period has extended over three years and involved two operations.

CONCLUSIONS

This case report will increase awareness of adult orthopedists on acquired talipes equinovarus and propose orthopedic reconstructive strategies to rectify this condition.

Botulinum Toxin Type A Injection for Spastic Equinovarus Foot in Children with Spastic Cerebral Palsy: Effects on Gait and Foot Pressure Distribution

PURPOSE

To investigate the effect of intramuscular Botulinum toxin type A (BoNT-A) injection on gait and dynamic foot pressure distribution in children with spastic cerebral palsy (CP) with dynamic equinovarus foot.

MATERIALS AND METHODS

Twenty-five legs of 25 children with CP were investigated in this study. BoNT-A was injected into the gastrocnemius (GCM) and tibialis posterior (TP) muscles under the guidance of ultrasonography. The effects of the toxin were clinically assessed using the modified Ashworth scale (MAS) and modified Tardieu scale (MTS), and a computerized gait analysis and dynamic foot pressure measurements using the F-scan system were also performed before injection and at 1 and 4 months after injection.

RESULTS

Spasticity of the ankle plantar-flexor in both the MAS and MTS was significantly reduced at both 1 and 4 months after injection. On dynamic foot pressure measurements, the center of pressure index and coronal index, which represent the asymmetrical weight-bearing of the medial and lateral columns of the foot, significantly improved at both 1 and 4 months after injection. The dynamic foot pressure index, total contact area, contact length and hind foot contact width all increased at 1 month after injection, suggesting better heel contact. Ankle kinematic data were significantly improved at both 1 and 4 months after injection, and ankle power generation was significantly increased at 4 months after injection compared to baseline data.

CONCLUSION

Using a computerized gait analysis and foot scan, this study revealed significant benefits of BoNT-A injection into the GCM and TP muscles for dynamic equinovarus foot in children with spastic CP.

Clubfoot associated with congenital constriction band: the Ponseti method perspective

BACKGROUND

The clubfoot and congenital constriction band is a known association in which the clubfoot is considered as being rigid, responding poorly to casting, and requiring surgical interventions.

OBJECTIVE AND METHODS

The series describes 3 cases of clubfoot with deep ipsilateral congenital constriction bands managed with Ponseti method and immediate outcomes achieved.

RESULTS AND CONCLUSIONS

The feet responded favorably to casting although equinus correction required more extensive surgical interventions. The preexisting edema in distal limb often precluded a snuggly fitting cast increasing the cast numbers. Careful monitoring of vascularity is essential. Simultaneous procedures of release of constriction bands, correction of hand anomalies and equinus can be combined to the advantage of the patient.

LEVELS OF EVIDENCE

Case report, Level IV.

[A paradigm shift in the Danish treatment of congenital clubfoot]

In the last decade the clubfoot treatment in Denmark has changed dramatically. The Ponseti treatment has now largely replaced the extensive surgical release which was a part of the Copenhagen method. An overview over aetiology, morphology and current and past treatment protocols is given. Even though there is no clinical evidence that the Ponseti method is superior to the Copenhagen method, the former method is the primary treatment as it has less extensive surgery and similar correction rates. Less extensive surgery leads to more flexible and functional feet.

Descriptive epidemiology of clubfoot in Peru: a clinic-based study

congenital clubfoot is the most common birth defect of the musculoskeletal system and affects 1 in every 1000 live births each year.(1) Although there have been numerous studies of investigation, the etiology and pathogenesis of clubfoot remains unknown. To date, no epidemiological studies have been conducted in Peru to assess possible genetic and environmental risk factors associated with this deformity. The purpose of this study was to evaluate specific environmental and socioeconomic factors that may increase the risk of clubfoot. A descriptive clinic-based study was conducted using structured questionnaires given to biological mothers of clinically confirmed clubfoot patients (n=72) and biological mothers of children between ages 0-18 with no first or second degree family history of clubfoot as controls (n=103). Phenotypic data from clubfoot subjects were also collected. We found that males were twice as likely to have clubfoot as females, and half of all clubfoot patients had bilateral clubfoot. There was no significant difference in the rate of left vs. right clubfoot. Infant birth in the winter months correlated with an increased risk of clubfoot (p=0.01476). Maternal characteristics found to be significantly associated with increased risk of clubfoot were young maternal age at conception (p=0.04369) and low maternal education (p=0.003245). Young paternal age also had a correlation with increased risk of clubfoot in the child (p=0.0371). Both paternal smoking (p=0.00001) and the presence of any household smoking (p=0.00003) were strongly associated with an increased risk of clubfoot.

Subjective outcome of reconstruction of the adult acquired neurological equinovarus foot

A retrospective study was done of the subjective outcome of surgical correction of a spastic equinovarus foot deformity in 27 adult patients with acquired spastic hemiplegia. The mean age of the patients was 49 years and the mean follow-up period was 29 months. The patients were submitted to individualized soft-tissue surgery intended to correct their deformities and rebalance the affected joints, and subsequently subjected to a standard rehabilitation protocol. The assessment was based on the clinical records and on a questionnaire sent to the patients about relevant aspects of their gait, lifestyle and untoward effects and complications. The results have shown that patients experience frank improvement in terms of gait, orthostatic posture, self-esteem and quality of life. Transient or permanent adverse effects occurred in 11 of the 27 patients. The changes induced by surgery to reduce the imbalance and deformity of the foot have a considerable impact on independence and quality of life of these patients despite the high rate of complications.

[Expression of COL9A1 gene and its polymorphism in children with idiopathic congenital talipes equinovarus]

OBJECTIVE

COL9A1 gene is located in the susceptibility region of idiopathic congenital talipes equinovarus (ICTEV) (6q12-13). This study aimed to investigate the expression of the COL9A1 gene and the distribution of single nucleotide polymorphism (SNP) of COL9A1 gene in patients with ICTEV and normal controls.

METHODS

Immunohistochemistry was used to detect the expression of COL9A1 in 25 children with ICTEV and 5 normal controls. The frequencies of genotypes and allele of two SNPs in COL9A1 gene rs35470562 and rs1135056 were investigated by PCR-restriction fragment length polymorphism (PCR-RFLP) and DNA sequencing in 118 patients with ICTEV and 100 normal controls.

RESULTS

The COL9A1 protein expression was significantly higher in 22 (88%) out of 25 children with ICTEV than normal controls. There were significant differences in the frequencies of genotypes and allele of rs1135056 in COL9A1 gene between the ICTEV and the control groups: the G allele frequency was higher, the frequency of AA genotype was lower, and the frequencies of AG and GG genotypes were higher in ICTEV patients than those in healthy controls (P<0.05).

CONCLUSIONS

COL9A1 protein is highly expressed in patients with ICTEV and rs1135056, which is located in the coding region of COL9A1 gene, may be associated with the pathogenesis of ICTEV.

Is there evidence for aetiologically distinct subgroups of idiopathic congenital talipes equinovarus? A case-only study and pedigree analysis

BACKGROUND

Idiopathic congenital talipes equinovarus (CTEV) is a common developmental foot disorder, the aetiology of which remains largely unknown. Some aspects of the epidemiology suggest the possibility of aetiologically distinct subgroups. Previous studies consider CTEV as a homogenous entity which may conceal risk factors in particular subgroups. We investigate evidence for aetiologically distinct subgroups of CTEV.

METHODS

Parents of 785 probands completed a postal questionnaire. Family pedigrees were compiled by telephone. Case-only analysis was used to investigate interactions between risk factors and sex of the proband, CTEV laterality and CTEV family history.

RESULTS

The male:female ratio was 2.3:1, 58% of probands were affected bilaterally and 11% had a first-second degree family history. There were modest interactions between family history and twin births (multivariate case - only odds ratio [ORca] = 3.87, 95%CI 1.19-12.62) and family history and maternal use of folic acid supplements in early pregnancy (ORca = 0.62, 95%CI 0.38-1.01); and between sex of the proband and maternal alcohol consumption during pregnancy (female, positive history and alcohol consumed: ORca = 0.33, 95%CI 0.12-0.89). Previous reports of an interaction between maternal smoking and family history were not confirmed. Relatives of female probands were affected more often than relatives of male probands.

CONCLUSIONS

These results provide tentative evidence for aetiologically distinct CTEV subgroups. They support the 'Carter effect', suggesting CTEV develops though a multifactorial threshold model with females requiring a higher risk factor 'load', and suggest areas where future aetiological investigation might focus. Large multi-centre studies are needed to further advance understanding of this common condition.

Smoking, the xenobiotic pathway, and clubfoot

BACKGROUND

Isolated clubfoot is a common orthopedic birth defect that affects approximately 135,000 newborns worldwide. It is characterized by ankle equinus, hindfoot varus, and forefoot adductus. Although numerous studies suggest a multifactorial etiology, the specific genetic and environmental components have yet to be delineated. Maternal smoking during pregnancy is the only common environmental factor consistently shown to increase the risk for clubfoot. Moreover, a positive family history of clubfoot, in conjunction with maternal smoking, increases the risk 20-fold. These findings suggest that genetic variation in smoking metabolism (xenobiotic) genes may increase susceptibility to clubfoot. Based on this reasoning, we interrogated eight candidate genes from the xenobiotic metabolism.

METHODS

Twenty-two single-nucleotide polymorphisms and two null alleles in these genes (CYP1A1, CYP1A2, CYP1B1, CYP2A6, EPHX1, NAT2, GSTM1, and GSTT1) were genotyped in a dataset composed of non-Hispanic white and Hispanic multiplex and simplex families.

RESULTS

Only rs1048943/CYP1A1 had significantly altered transmission in the aggregate and multiplex non-Hispanic white datasets (p = 0.003 and p = 0.009, respectively). Perturbation of CYP1A1 can cause an increase in harmful, adduct-forming metabolic intermediates. A significant interaction between EPHX1 and NAT2 was also found (p = 0.007). Importantly, for CYP1A2, significant maternal (p = 0.03; relative risk [RR] = 1.24; 95% confidence interval [CI], 1.04-1.44) and fetal (p = 0.01; RR = 1.33; 95% CI, 1.13-1.54) genotypic effects were identified, suggesting that both maternal and fetal genotypes can negatively impact limb development. No association was found between maternal smoking status and variation in xenobiotic metabolism genes.

CONCLUSION

Together, these results suggest that xenobiotic metabolism genes are unlikely to play a major role in clubfoot; however, perturbation of this pathway may still play a contributory role.

The accessory soleus muscle as a cause of persistent equinus in clubfeet treated by the Ponseti method : A report of 16 cases

Encountering an accessory soleus muscle in children undergoing surgical release for clubfeet is not a frequent occurrence and only a few reports could be traced in literature. The purpose of this study is to report a series of 20 observations in 16 patients with idiopathic clubfeet treated by the Ponseti technique where the accessory soleus muscle was responsible in preventing full ankle dorsiflexion after Achilles tendon tenotomy. Following its division, adequate dorsiflexion could be achieved. To our knowledge this is the largest series published to date on this topic. In addition, we discuss the frequency and epidemiology, as well as the anatomy of the accessory soleus muscle, its innervation and embryology. The mean age at presentation was 40.7 days (range : 6 to 210 days). The accessory soleus tendon was observed in 6 right and 6 left feet, 4 feet had bilateral involvement. The average ankle dorsiflexion after complete tendo Achilles tenotomy was 2.50 (SD: 638), and after sectioning of the accessory soleus tendon, it was 19.50 (SD: 559) (p < 0.001). Correction was obtained in all patients, after 3 to 10 casts. In conclusion, the recognition of an accessory soleus muscle, in patients with clubfeet, is important, and its release is necessary to fully correct the deformity. Failure to recognize this muscle may lead to persistent hindfoot deformity.

Incidence and aetiology of talipes equino-varus with recent population changes

This study looks at the changing incidence and aetiology of congenital talipes equinovarus due to the recent population changes within the area. Between 1st June 1992 and the 31st May 2006, 83 consecutive children (121 feet) born with fixed talipes equinovarus (TEV) were assessed and treated (an incidence of 1.6 per 1000 live births) in an observational longitudinal cohort study assessing associated factors. There were 17 syndromal cases in the fixed group (20.8%), 6 cases of non-syndromal distal arthrogryposis (7.2%), and a strong family history in 12 cases (14.5%). This study would suggest that genetic and primary causes of fixed TEV are more common than previously considered. Many of the primary aetiologies were diagnosed months or years after birth.

[Foot deformity in children with spastic forms of cerebral palsy: the treatment with botulinum toxin type A (dysport)]

The objective is to study the effect of dysport injections on the clinical and electromyographic changes in 35 patients (mean age 5,3+/-2,0 years) with spastic forms of cerebral palsy (26 with spastic diplegia, 9 with hemiparetic form) with equinus and equinovarus deformity. Depending on the clinical situation, dysport was injected in a total dose of 20-30 u per 1 kg of the body mass. Gastrocnemius muscles were injected more frequently than soleus and posterior tibial muscles. The treatment resulted in the significant reduction of spasticity on the Ashworth scale, decrease of equinus deformity, positive changes in the parameters of stepping on flat foot, independent standing and walking, the beginning of support period from the heel. During the arbitrary contraction, the amplitude of bioelectrical activity of target muscles of low extremities reduced, though not to the extent of the motor activity loss; the reciprocity coefficient decreased from 0,69+/-0,32 to 0,47+/-0,28 in patients with spastic diplegia and from 0,45+/-0,34 to 0,34+/-0,25 in patients with hemiparetic form. The effect of dysport was higher in hemiparetic form compared to spastic diplegia. The best results for spastic diplegia were revealed in patients with isolated spasticity without severe disturbances of reciprocal relations in shin muscles and pathological synkinesia.

[Split posterior tibial tendon transfer as a selected technique of treatment of spastic equino-varus deformity in children]

Equinovarus deformity is one of the most common deformities seen in patients with cerebral palsy. During years between 1993 and 2004 in 36 patients with cerebral palsy 46 operative procedures of split posterior tibial tendon transfer to peroneus brevis muscle were performed to correct varus deformity of the foot. Additionally equinus was corrected by lengthening lengtheninglengthening of the calcaneal tendon in 42 cases and in 4 cases by gastrocnemius recession according to Baker modification of Vulpius procedure. Children's age at the time of operation was between 3.5 and 16 years of age (average 7.5). In our cohort of 36 patients there were 10 cases of quadriplegia (28%), 12 cases of hemiplegia (33%), 12 cases of paraparesis inferior (33%) and 2 cases of monoplegia (6%). 25 patients with 34 operated feet (73.9%) reported for final examination. Follow-up period was from 18 months to 11 years (average 5.5 years). At final examination we evaluated clinical effectiveness of gait, passive and active range of movement, plantograms, and subjective evaluation of patient and patients' parents. Wearing of orthoses and orthopaedic footwear was noted. The results were divided into groups according to Green's classification. There were 67.6% of very good results, 23.6% of good results and 8.8% of poor results. Basing on our experience in treatment of spastic equinovarus deformity of the foot in children with cerebral palsy we stand, that split posterior tibial tendon transfer can bring good results and is a valuable surgical technique in treatment of equinovarus deformity.

The classic: observations on pathogenesis and treatment of congenital clubfoot. 1972

This Classic article is a reprint of the original work by Ignacio V. Ponseti and Jeronimo Campos, Observations on Pathogenesis and Treatment of Congenital Clubfoot. An accompanying biographical sketch on Ignacio V. Ponseti, MD, is available at DOI 10.1007/s11999-009-0719-8 and a second Classic article is available at 10.1007/s11999-009-0720-2. This article is ©1972 by Lippincott Williams and Wilkins and is reprinted with permission from Ponseti IV, Campos J. Observations on Pathogenesis and Treatment of Congenital Clubfoot. Clin Orthop Relat Res . 1972;84:50–60.

Correction of arthrogrypotic clubfoot with a modified Ponseti technique

Surgical releases for arthrogrypotic clubfeet have high recurrence rates, require further surgery, and result in short, painful feet. We asked whether a modified Ponseti technique could achieve plantigrade, braceable feet. Ten patients (mean age, 16.2 months; range, 3-40 months), with 19 arthrogrypotic clubfeet, underwent an initial percutaneous Achilles tenotomy to unlock the calcaneus from the posterior tibia followed by weekly Ponseti-style casts. A second percutaneous Achilles tenotomy was performed in 53%. Mean number of casts was 7.7 (range, 4-12). From pretreatment to completion of initial series of casts, mean scores of Dimeglio et al. improved from 16 to 5 (ranges, 12-18 and 2-9, respectively), Catterall scores (as modified by Pirani and colleagues) from 4.8 to 0.9 (ranges, 1.5-6.0 and 0.0-2.0), and maximum passive dorsiflexion from -45 degrees (range, -75 degrees to -20 degrees ) to 10 degrees (range, 0 degrees to 40 degrees ). Ankle-foot orthoses maintained correction. At the minimum followup of 13 months (mean, 38.5 months; range, 13-70 months), the mean maximum dorsiflexion was 5 degrees (range, -20 degrees to 20 degrees ), two patients had posterior releases and no patient's ambulatory ability was compromised by foot shape. Arthrogrypotic clubfeet can be corrected without extensive surgery during infancy or early childhood. Limited surgery may be required as the children age.

[Treatment of burn cicatricial foot drop with Ilizarov fixator]

OBJECTIVE

To investigate the efficacy of Ilizarov fixator on cicatricial foot drop after burn.

METHODS

Six patients with cicatricial foot drop after burn were treated with Ilizarov fixator during June 2004 approximately October 2007, the fixator was set on the leg and foot by fixed bone needles. Nuts on the threaded rod were turned from 3 post operation day, 2 approximately 4 rounds per time and 4 times per day in the first week, then 1 approximately 2 rounds per time and 4 times a day, which corrected the deformity of talipes equinus by shortening or lengthening the thread rod in the front and at the back. Ankle joint was maintained in neutral position for 2 approximately 3 months after effective correction. Weight carrying for patients was increased gradually after removal of fixator. Ankle joint was maintained in neutral position with fixator at least three months. Patients were followed up 5 approximately 10 months.

RESULTS

Ankle joints from all patients were restored to neutral position after application with fixator for 4 approximately 6 weeks. All patients achieved 0 degrees dorsiflexion in weight carrying for whole planta pedis after use of fixator for 12 approximately 15 weeks with good locomotion function.

CONCLUSION

Ilizarov fixator is safe and mini-injury, which is an effective method for treatment of cicatricial foot drop.

Combined effects of botulinum toxin and casting treatments on lower limb spasticity after stroke

Optimal treatment of spasticity requires a combination of pharmacotherapy and muscle lengthening. We evaluated 13 stroke patients with equinovarus foot randomized to treatment with either botulinum toxin A (BTA) injection plus ankle-foot casting (n=6) or BTA alone (n=7). The tibialis posterior and calf muscles (range of BTA injection: 190 to 320 U) were treated in each patient. Castings were worn at night for four months. Each patient was examined before, and at two and four months after BTA injection using the static and dynamic baropodometric tests, the Modified Ashworth Scale and the 10-meter walking test. At two months, therapeutic effects were observed in both groups. At four months, the study group showed further clinical improvement, while the control group returned to baseline performance. Thus, prolonged stretching of spastic muscles after BTA injection affords long-lasting therapeutic benefit, enhancing the effects of the toxin alone.

Results of the Ponseti method in patients with clubfoot associated with arthrogryposis

Clubfoot associated with arthrogryposis has been traditionally considered very resistant to manipulation and casting, and therefore has required surgical correction. The purpose of this study was to evaluate the results of the Ponseti method of clubfoot casting in this patient population. We reviewed the records of patients with clubfoot associated with arthrogryposis consecutively treated at our respective institutions from January 1992 to December 2004. All patients were treated by serial manipulations and casting following the principles of the Ponseti method. Main outcome measures included initial correction of the deformity, relapses and the need for surgical releases or any other surgeries. Average age at last follow up was 4.6 years. There were 16 patients, all with bilateral deformities (32 clubfeet). there were 11 males and 5 females. Nine patients had both upper and lower extremity involvement. Seven patients had previous treatment elsewhere and one patient had an Achilles tenotomy. Initial correction was obtained in all but 1 patient. Average number of casts required for correction was 7 (range: 5 to 12). Average post-tenotomy dorsiflexion was 5 degrees. One patient required a posterior-medial release (PMR) for insufficient initial correction. Four cases required subsequent surgery for relapses (1 bilateral PMR with a repeat left PMR; 2 posterior releases (PR), 1 PR and anterior tibialis transfer (ATT), and 1 ATT). No talectomies were required. This study demonstrates that the Ponseti method is very effective for the correction of patients with clubfoot associated to arthrogryposis. Although this deformity is more rigid than in idiopathic clubfoot, many cases can be corrected when started in the first few weeks after birth.

Review of current methods used in the treatment of clubfoot at initial presentation and at recurrence

Idiopathic clubfoot is a common condition seen by orthopaedic surgeons and is characterized by complex three-dimensional deformity of the foot. It is recognized that clubfoot treatment is a challenging issue in orthopaedics because it is an ongoing process, beginning in early infancy and continuing until the patient has reached skeletal maturity. This review article summarizes two important stages of clubfoot treatment. First, methods of initial correction-including nonoperative, semi-operative, and operative techniques-that have been used in the last 20 years are described. Second, the management of the recurrent clubfoot is discussed in terms of methods used to address specific deformities.

A population-based case-control study on the effect of bronchial asthma during pregnancy for congenital abnormalities of the offspring

Bronchial asthma is one of the most common maternal diseases complicating pregnancy. We assessed the risks of congenital abnormalities in a case-control population-based analysis using the dataset of the Hungarian Case-Control Surveillance of Congenital Abnormalities between 1980 and 1996. Of the 22,843 cases with congenital abnormalities, 511 (2.2%) had mothers with bronchial asthma, while of the 38,151 matched control subjects without congenital abnormalities 757 (2.0%) had mothers with bronchial asthma (unadjusted prevalence odds ratios [POR] 1.2; 95% CI: 1.0-1.3). In all mothers with bronchial asthma, a higher incidence of respiratory tract infections and higher drug intake could be observed. In the case group of medically recorded bronchial asthma, a slightly increased risk for club foot has been revealed. However, this weak association could be explained by the higher proportion of preterm births in this group. The main limitation of the analysis was that at the time of data collection only a small proportion of pregnant mothers were using anti-asthma medications recommended by the actual guidelines.

Congenital constriction band with pseudoarthrosis of the tibia: a case report and literature review

A passive constriction phenomenon has been proposed to explain the development of congenital pseudoarthrosis of the tibia. We report a case of congenital pseudoarthrosis of the tibia in a child with congenital constriction band syndrome, successfully treated with soft tissue release (cutaneous and deep) only, restoring normal periosteal blood supply and enabling gradual correction of the angular osseous deformity and reformation of the intramedullary canal.

Cloacal exstrophy: a case study

Cloacal exstrophy is a complex congenital anomaly that affects both the gastrointestinal and genitourinary systems. It is characterized by an omphalocele, an exstrophied bladder, abnormal genitalia, and imperforate anus. Prior to 1960, there were no reported cases of survival, but because of advancements in neonatology, surgery, and anesthesiology, the survival rate has improved drastically. This case presentation of an infant born with cloacal exstrophy includes discussion of etiology, diagnosis, treatment, ethical issues, and nursing care.

[Split tibialis posterior tendon transfer on peroneus brevis for equinovarus foot in CP children]

Equinovarus deformity of the foot is a result of the muscles imbalance in which inventors of the foot, mostly posterior and anterior tibialis muscle, overpower evertors. In children with cerebral palsy untreated spastic equinovarus deformity may cause severe fixed foot deformity and painful callosities under metatarsal heads and on the lateral side of the foot. The gait pattern becomes less effective and needs more energy. The study group consisted of 154 children with cerebral palsy treated in our Clinic by the multilevel soft tissue surgery. For foot problems 136 children needed surgical intervention. In 19 ambulatory patients, with hemiplegia or diplegia, split tibialis posterior tendon transfer together with tendo Achilles lengthening and plantar aponeurectomy were performed. The study was based on clinical examination, parents' questionnaire, radiology and gait analysis at least one year after surgery. The mean follow up was 4.6 years. The functional improvement was observed in 17 (89%) children with tendon transfer. At the last follow up those patients were brace free, with plantigrade foot while walking (without DAFO orthesis) and normal shoes were used. All painful callosities disappeared. On a standing AP X-ray adequate correction of the hindfoot-forefoot relation was achieved in 14 (74%) cases. Persistent equinovarus deformity over 10 degrees was observed in 2 cases. Those patients underwent additional bone surgery. With a properly planned approach the split tibialis posterior tendon transfer can bring good clinical and functional results in CP children with equinovarus deformation. We recommend this procedure in early stage of the deformity what can eliminate more harmful triple arthrodesis in severe deformities.

Accessory soleus muscle as a cause of congenital talipes equino varus. A case report

The authors report a case of congenital clubfoot in a one-year-old male child, in which an accessory soleus muscle was noted intraoperatively, running anteromedially to the Achilles tendon and with a distinct insertion on the postero-medial aspect of the calcaneus. Correction of the varus and equinus of the hindfoot could only be achieved after cutting the tendon of the accessory soleus muscle at its insertion on the calcaneus.

Effects of Botulinum Toxin-A on Gait Velocity, Step Length, and Base of Support of Patients with Dynamic Equinovarus Foot

OBJECTIVE

The aim of this study was to identify if botulinum toxin type A is a drug able to modify walking velocity, step length, and width of the base of support of adult patients with dynamic equinovarus foot deformity resulting from upper motor neuron syndrome.

DESIGN

This retrospective study analyzed data from 20 patients' files selected from 448 consecutive charts. The main inclusion criteria were the presence of dynamic equinovarus foot deformity due to upper motor neuron syndrome, age between 20 and 80 yrs, evaluation of temporospatial parameters of gait by the Gait Mat II before and 4 wks after botulinum toxin type A injection to the calf muscles, and the ability to walk barefoot, unassisted, and without braces. For data analysis, based on walking velocity, we divided the patients into two groups, slow walking velocity (0.18-0.49 m/sec) and medium walking velocity (0.50-0.99 m/sec).

RESULTS

Width of the base of support was significantly reduced after botulinum toxin type A treatment, both for the affected (P < 0.005) and the unaffected limbs (P < 0.002), in the group of subjects walking at medium velocity. Walking velocity or step length of either group of patients was not significantly modified by botulinum toxin type A treatment.

CONCLUSIONS

Based on this study, a significant effect of botulinum toxin type A on width of the base of support is evident and seems to be the result of a better position of the affected foot during the stance phase of locomotion leading to increased body stability and consequent reduction of width of the base of support of the unaffected limb. No change was evident in step length or walking velocity for this patient population.

[Results of operative therapy of idiopathic clubfoot using a dorsomedial approach with soft tissue preparation "à la carte"]

INTRODUCTION

Several concepts have been published for therapy of idiopathic clubfoot. Actually the Cincinnati approach is the "gold-standard" in operative treatment of idiopathic clubfoot. Using this approach delayed wound healing and overcorrection are wellknown complications. During the last 30 years a dorsomedial approach is used in operative treatment of idiopathic clubfoot in our clinic. Using this approach a dorsal, medial and/or lateral release can be performed. Postoperatively a plaster cast is used. The following years a rigid therapy with orthosis and support is requested.

PATIENTS AND METHOD

Between June 1986 and December 2000 130 clubfoot operations with soft tissue release were performed. 119/130 (91 %) patients could be clinically and radiologically followed-up after a mean of 4.5 years (min: 2, max: 17) including 65.5 % male and 34.5 % female patients. Average age at time of operation was 7.6 months. The findings were classified according to Dimeglio. To evaluate the clinical results the score according to Laaveg and Ponseti was used. X-rays with load (a. p. and lateral view) were evaluated preoperatively and at follow-up for a. p. and lateral talocalcaneal angle, talometatarsal-I-angle, calcaneometatarsal-V-angle and the angle of the first ray. Additionally complications and recurrences were documented.

RESULTS

21.8 % of the feet were classified IV degrees , 39.5 % III degrees and 38.7 % II degrees according to Dimeglio. Recurrent clubfoot was found in 7.6 % of all cases. All angles showed a significant improve. At latest follow-up 95.6 +/- 9.2 points according to the score of Laaveg and Ponseti were achieved. Flat top talus was found in 37 cases.

CONCLUSION

The dorsomedial approach allows an excellent correction of clubfeet with a low rate of complications and recurrences in comparison to other studies.

Clinical and radiographic features of operatively treated stiff clubfeet after skeletal maturity: etiology of the deformities and how to prevent them

BACKGROUND

Residual deformities of operatively treated severe clubfeet evaluated radiographically have been rarely studied in detail in adults.

METHODS

Twenty-five operatively treated stiff clubfeet were analyzed at a mean age of 21 years and 6 months. The clinical evaluation used the Laaveg and Ponseti scale for clubfeet. Radiographic assessment was done with weightbearing and dynamic views.

RESULTS

Clinical evaluation was globally good except for motion (poor). Radiographic assessment showed residual abnormalities in all feet. The distal tibial epiphysis showed slanting of its posterior part in seven feet (28%) and notching of its anterior lip in 13 (52%). Talar length, calcaneal length, and talar trochlear height were significantly smaller in clubfeet compared to normal feet. Undercorrection of hindfoot varus, was found in 19 feet (76%) but was well tolerated. Navicular wedging was present in seven (28%), and cavus deformity was found in seven (28%). Dorsal bunion, hallux varus, and skewfoot were found in four (16%), two (8%), and three (12%), respectively. The dynamic views demonstrated a significant decrease in the foot and ankle mobility with compensation mechanisms such as anterior talar incongruence or midfoot hypermobility.

CONCLUSION

Severe clubfeet never become normal at adult age either clinically or radiographically. Multiple radiographic deformities exist. Their etiology and possible prevention are discussed. Despite the numerous abnormalities, clinical results were good at skeletal maturity.

The management of congenital talipes equinovarus

Congenital talipes equinovarus is a common deformity that is present at birth. It can be treated conservatively. Of the techniques available, the Ponseti method is effective in correcting most of these foot deformities and is best started early. Some of the stiffer "teratological" foot deformities may require surgical releases. Other conservative methods may be applied to correct deformity, but they have not been demonstrated to be as effective as the Ponseti method, although they may reduce the extent of subsequent surgical releases. Surgery can be undertaken to correct deformity, but some loss of motion is inevitable with extensive open procedures. Complications of treatment can be divided into: failure to correct, recurrence and overcorrection. Outcome can be assessed clinically and radiologically. Radiological outcome does not necessarily correspond to clinical results. The best long-term clinical outcome has been reported using the Ponseti method, for which there is great and increasing demand, largely driven by parents and facilitated by the Internet.

Joint laxity and the risk of clubfoot

BACKGROUND

Clubfoot is a relatively common and potentially disabling birth defect. The etiology of clubfoot (talipes equinovarus [TEV]) is not known. Joint laxity, or hypermobility, is a suspected risk factor for congenital hip dislocation and clubfoot.

METHODS

We conducted a case-control study of TEV in five western Washington counties. A total of 239 cases of TEV were identified from hospital and outpatient sources from 1986 to 1994. Controls (n = 356) were identified by random-digit dialing (RDD). Parents were interviewed over the telephone, and medical records were abstracted. In-person measurements of four joint laxity indices in parents and the index child were obtained.

RESULTS

Moderately elevated adjusted odds ratios (ORs) were found for extension > 90 degrees of the entire little finger, and extension of all four fingers to a position parallel to the forearm (OR = 1.6; 95% CI = 0.9-2.9; and OR = 1.7; CI = 1.1-2.5; respectively). No elevation in the OR was found for the wrist and elbow laxity measures. No consistent pattern of association between joint laxity measures in parents and an elevated OR of clubfoot among their children was found.

CONCLUSIONS

The results of this study suggest a role for joint laxity in the etiology of TEV.

Needle acupuncture in chronic poststroke leg spasticity

OBJECTIVE

To determine whether needle acupuncture may be useful in the reduction of leg spasticity in a chronic state.

DESIGN

Single-blind, randomized, placebo-controlled trial.

SETTING

Neurologic outpatient department of a medical school in Germany.

PARTICIPANTS

Twenty-five patients (14 women) suffering from chronic poststroke leg spasticity with pes equinovarus deformity (Modified Ashworth Scale [MAS] score, >/=1), aged 38 to 77 years (mean +/- standard deviation, 58.5+/-10.4 y), were enrolled in the study. The mean time from stroke to inclusion in the study was approximately 5 years (mean, 65.4+/-48.3 mo; range, 7-180 mo).

INTERVENTIONS

Participants were randomly assigned to placebo treatment (n=12) by using a specially designed placebo needling procedure, or verum treatment (n=13).

MAIN OUTCOME MEASURES

MAS score of the affected ankle, pain (visual analog scale), and walking speed.

RESULTS

There was no demonstrated beneficial clinical effects from verum acupuncture. After 4 weeks of treatment, mean MAS score was 3.3+/-0.9 in the placebo group versus 3.3+/-1.1 in the verum group. The neurophysiologic measure of H-reflex indicated a significant increase of spinal motoneuron excitability after verum acupuncture (H-response/M-response ratio: placebo,.39+/-.19; verum,.68+/-.41; P<.05).

CONCLUSIONS

This effect might be explained by afferent input of A delta and C fibers to the spinal motoneuron. The results from our study indicate that needle acupuncture may not be helpful to patients with chronic poststroke spasticity. However, there was neurophysiologic evidence for specific acupuncture effects on a spinal (segmental) level involving nociceptive reflex mechanisms.

Tibial Nerve Block with Anesthetics Resulting in Achilles Tendon Avulsion

Diagnostic tibial nerve block with anesthetics is a common and safe procedure for the management of the spastic equinovarus foot. Side effects have been rarely reported. We present the case of a hemiplegic patient with a spastic equinovarus foot who presented with an avulsion fracture of the calcaneum at the insertion of the Achilles tendon consecutive to a diagnostic tibial nerve block with anesthetic agents. Although rare, such a complication should be considered when the Achilles tendon is shortened and when the patient is suspected of bone osteoporosis or dystrophy.

Embryonic blastemic changes in retinoic acid-induced hindlimb deformity

In this study we analyzed, on an experimental model, blastemic changes occurring during the embryonic period that may later cause fetal hindlimb deformity. Experimental induction of clubfoot-like deformity in rat fetuses was performed by maternal administration of retinoic acid (RA) (120 mg/kg body weight) as a single intragastric dose on day 10 of pregnancy (previous phase of this assay). The caudal and hindlimb blastemic changes were studied by mitosis count and stereological, immunohistochemistry and AgNOR techniques in the hindlimbs of 15-day embryos and in the caudal somites of 11-day embryos. In 15-day embryos from the assay group, hypoplasia and misorientation of hindlimbs were present in 90% of the cases. The histological study showed a blastemal defect as follows: (a) reduction in mesenchymal cell activity (mitotic and AgNOR activities); (b) increase of volume of vascular lumen; (c) reduction in volume of nerve structures, and (d) reduction in the percentage of pre-rhabdomyoblastic cells. In 11-day embryos from the assay group, caudal somites showed disruption, including loss of usual morphology. Moreover, somitic AgNOR activity decreased compared to the control group. The greatest reduction in the number of black-dots per cell was in the myotome. These findings suggest that a certain pathology of the somites, very little studied to date, might be involved in clubfoot pathogenesis.

Plasma total homocysteine level in mothers of children with clubfoot

The pathogenesis of clubfoot is unknown despite numerous hypotheses. To clarify the relationship between the plasma total homocysteine level and congenital idiopathic clubfoot, blood samples from mothers of children with congenital idiopathic clubfoot (group 1) and mothers of children without congenital anomaly (group 2) were studied. Groups were the same for factors affecting the plasma total homocysteine level. Mean plasma total homocysteine level was 16.34+/-4.78 micromol/L in group 1 and 11.02+/-1.85 micromol/L in group 2, and there was significant statistical difference between the groups (P<0.05). Congenital idiopathic clubfoot showed a significant association with high plasma total homocysteine level. This study may be a step toward clarification of clubfoot pathogenesis.

Evaluation of serial casting to correct equinovarus deformity of the ankle after acquired brain injury in adults

OBJECTIVE

To determine the potential short-term benefit of serial plaster casting in the management of equinovarus deformity associated with acquired brain injury.

DESIGN

Prospective uncontrolled interventional trial.

SETTING

Inpatient rehabilitation facility in Australia.

PARTICIPANTS

Sixteen patients (19 limbs) with equinovarus deformity or deteriorating ankle range of motion associated with severe plantarflexor and invertor muscle overactivity underwent serial plaster casting over an 18-month period.

INTERVENTIONS

Below-knee plaster casts were reapplied weekly to increase joint range and muscle extensibility.

MAIN OUTCOME MEASURES

Precasting goniometric measures of maximal ankle dorsiflexion range (in knee extension and flexion) were compared with 4 subsequent test occasions (after initial cast, midpoint of casting, after final cast, 1 wk after removal). The amount and type of assistance required to perform a standardized wheelchair-to-bed transfer before and 3 months from commencement of casting were also compared.

RESULTS

Subjects who underwent the serial casting regimen had significantly improved ankle range (knee flexed mean, 18 degrees; knee extended mean, 16 degrees; P<.0001); 13 subjects reduced their need for transfer assistance (P<.0015).

CONCLUSION

Serial casting appears to be effective, at least in the short term, in reducing the equinovarus deformity that occurs after acquired brain injury. Greater ankle mobility was associated with improved transfer independence in the majority of subjects.

Clinical and molecular study in congenital muscular dystrophy with partial laminin alpha 2 (LAMA2) deficiency

Complete laminin alpha2 (LAMA2) deficiency causes approximately half of congenital muscular dystrophy (CMD) cases. Many loss-of-function mutations have been reported in these severe, neonatal-onset patients, but only single missense mutations have been found in milder CMD with partial laminin alpha2 deficiency. Here, we studied nine patients diagnosed with CMD who showed abnormal white-matter signal at brain MRI and partial deficiency of laminin alpha2 on immunofluorescence of muscle biopsy. We screened the entire 9.5 kb laminin alpha2 mRNA from patient muscle biopsy by direct capillary automated sequencing, single strand conformational polymorphism (SSCP), or denaturing high performance liquid chromatography (DHPLC) of overlapping RT-PCR products followed by direct sequencing of heteroduplexes. We identified laminin alpha2 sequence changes in six of nine CMD patients. Each of the gene changes identified, except one, was novel, including three missense changes and two splice-site mutations. The finding of partial laminin alpha2 deficiency by immunostaining is not specific for laminin alpha2 gene mutation carriers, with only two patients (22%) showing clear causative mutations, and an additional three patients (33%) showing possible mutations. The clinical presentation and disease progression was homogeneous in the laminin alpha2-mutation positive and negative CMD patients.

Congenital clubfoot

Although the etiology of congenital clubfoot remains unknown, reproducible pretreatment grading now seems possible. However, the lack of an agreed-on and reproducible posttreatment evaluation system still hinders outcome studies of the treatment of clubfoot. The literature from about 1970 to 1990 contains enthusiastic reports on the correction of congenital clubfoot through extensive surgical release procedures. Over time, we have come to recognize the complications of such surgery, including recurrence, overcorrection, stiffness, and pain (WJ Shaughnessy, MD, P Dechet, MD, HB Kitaoka, MD, Vancouver, BC, Canada, unpublished data, 2000). Perhaps because of these findings, there is a renewed interest in nonsurgical techniques for the correction of congenital clubfoot. Recent studies have documented the effectiveness of the two leading techniques involving serial manipulation and cast treatment. The Ponseti technique appears to be effective and requires only a reasonable amount of time out of the lives of the patient and his or her parents. The technique frequently includes some minimally invasive surgery. The Kite and Lovell technique requires minimally invasive surgery less often but is more time consuming. French investigators and others have introduced new ideas that may reduce the need to immobilize the foot. The French approach requires fairly extensive physical therapy and demands substantial parental time and attention. It is not yet clear that the French technique is more successful in obviating the need for surgery than is expertly applied serial manipulation and cast immobilization. It also has not been proved that the long-term results of the French technique are better than those of serial manipulation and cast immobilization. It is probably that unless the French technique is found to substantially decrease the need for surgery, it will prove to be less cost effective than serial manipulation and cast immobilization. It is likely that a small number of clubfeet will require surgery even after expertly applied nonsurgical treatment. However, it is hoped that such surgery will be less extensive than procedures commonly performed in the recent past.

Dynamic pedobarograph in evaluation of varus and valgus foot deformities

Objective documentation of dynamic varus and valgus deformities of the hindfoot is still a clinical dilemma. In a review of spastic foot deformities, clinical, radiographic, and foot pressure data were collected in 108 children with cerebral palsy. According to the clinical assessment, five categories of foot deformities were defined: severe varus, varus, neutral, valgus, and severe valgus. A coronal index of the pedobarograph was determined by comparing the pressure/time integral under the medial column to that under the lateral column of the foot. Coronal index is highly correlated with clinical assessment and offers better information than radiographic measurements in differentiating the clinical categories. The authors recommend the pedobarograph as the primary evaluation tool to measure the severity of deformity for patients with varus and valgus foot dysfunction. The severity of the deformity can be monitored with a single measurement, which has the best correlation with the clinical assessment. The clinical assessment is still the primary tool to determine general patterns, but it is difficult to apply an objective measurement. Radiographic study is most useful for the preoperative assessment when surgery is indicated.