International Clubfoot Study Group Score Research Articles

The Ilizarov Fixator: A Treatment for Relapsed Clubfoot, an Observational Study

Purpose: The Clubfoot, or the Congenital Talipes Equinovarus, is the most common congenital orthopedic disease, with 1 or 2 cases reported per 1000 live births. The purpose of this study is to assess the efficacy of the treatment of the complex equinovarus deformity of the feet, using the Ilizarov technique. Materials and Methods: In a prospective case series study from January 2012 to April 2016, 32 patients (35 feet) with rigid and complicated club feet have been included. The Ilizarov technique was applied in order to treat the mentioned deformity. These patients had no other congenital anomalies or systemic diseases. Outcomes were evaluated using the International Clubfoot Study Group (ICFSG) scoring system. Results: All of the patients were between 8 and 14 years of age, with the mean age of 10.9 years old. The mean of preoperative ICFSG score, morphological score, functional score, and radiologic score were 21.25±7, 6.2±2.4, 13.6±3.2, and 6.8±3.6, respectively. The postoperative mentioned scores were 11.88±6.18, 3.4±1.8, 4.7±2.1, and 3.8±1.9, respectively. The difference in the ICFSG scores before and after treatment was statistically significant (P=0.001). Conclusion: The Ilizarov technique can be considered as an efficient and successful treatment for recurrent or neglected clubfoot deformities, since it has provided satisfactory results.

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.

Management of clubfoot in children above 5 years with differential distraction using joshi external stabilizing system

Introduction: Ponsetti's technique is the recommended procedure for treating idiopathic clubfoot in children below the age of 2 years, and the same is also followed in some severe clubfoot deformities including neglected, recurrent and resistant forms who eventually may need surgical intervention. In children >5 years of age (children belonging to 5–10 years), open surgical procedures make the foot rigid with soft-tissue surgery, and bony operations can make the foot even smaller. Simultaneous correction of all aspects of deformity by differential distraction using external fixator rescues the foot from such complications. Joshi's external stabilizing system (JESS) can be used to gradually correct the deformities by differential distraction. In comparison to Ilizarov ring fixators, these are lighter in weight, shorter, cheaper, and have an easier application. Purpose: The purpose of this study is to analyze the role of JESS fixator in correcting cases of clubfoot in children >5 years in terms of morphological, functional, and radiological outcomes which were assessed using the International Clubfoot Study Group (ICFSG) scores. Materials and Methods: Five consecutive children with eight clubfoot >5 years underwent differential fractional distraction in our hospital. Period of correction varied from 6 to 8 weeks, including the distraction phase and static phase. Follow-up was done by application of cast in plantigrade position for double the duration of corrective distraction. Patients were assessed preoperatively and postoperatively at 6 months for morphology, functionality, and radiological correction by the ICFSG score. Results: Excellent to good results were obtained in all cases, which were assessed using ICFSG score, with only minor complications in patients. Conclusion: JESS frame is simple, versatile, and best suited for correcting clubfoot deformities, which were neglected, resistant and recurrent, and also with residual deformity, even in the children above the age of 5 years with advanced osteoarticular development and higher rigidity.

Ilizarov method combined with reversed sural or saphenous neurocutaneous island flaps transfer for posttraumatic equinus with soft tissue defects on ankle and foot

Objective To evaluate the clinical effects of the Ilizarov method combined with two kinds of reversed neurocutaneous island flaps transfer for posttraumatic equinus with soft tissue defects on ankle and foot. Methods Data of 21 cases of posttraumatic equinus with soft tissue defects on ankle and foot who were treated with the Ilizarov external fixation combined with the two kinds of reversed neurocutaneous island flaps transfer from June 2006 to January 2018 were retrospectively analyzed. There were 17 males and 4 females, aged from 26 to 65 years, with an average age of 43.9 years. The soft tissue defect dimensions ranged from 6 cm×5 cm to 10 cm×9 cm, and the time from the initial trauma to the operation ranged from 2.5 to 240.0 months. The mean preoperative equinus contracture was -38.9° (range, -25° to -66°), and total ankle range of motion (ROM) was 7.1° (range, 0°-18°). All cases were treated with the Ilizarov external fixation combined with the two kinds of reversed neurocutaneous island flaps transfer. Two weeks after the flap transfer, distraction of the Ilizarov fixator was initiated to gradually correct the equinus foot. The flap survival was observed in the postoperative period, and the International Club Foot Study Group (ICFSG) score was collected at the latest follow-up. The criteria were used to assess the morphological and functional outcome. Results A total of 21 resversed flaps were transferred, including 15 sural neurocutaneous flaps and 6 saphenous neurocutaneous flaps. The sizes of flaps were from 7 cm×6 cm to 11 cm×10 cm. Among them, 17 patients underwent primary flap transfer, and 4 patients underwent a delayed second-stage procedure 2 weeks after primary surgery. The 4 delayed flaps contain 3 sural neurocutaneous flaps and 1 saphenous neurocutaneous flap. All 21 patients were followed up and the average periodof follow-up was 20.3 months (range, 8-96 months). Among the 21 flaps, 19 survived completely. Although marginal necrosis was observed in 2 cases, these wounds healed after subsequent debridement and dressing change treatment. No major complication was seen, but superficial pin tract infection was present in 4 cases who then received dressing change and oral antibiotic. Deformities were corrected, and ankle motion had increased significantly. The mean ankle activity at the latest follow up was 22° (range, 8°-38°), and postoperative ICFSG score at the latest follow-up was 5.67±3.09, which significantly reduced compared with preoperative one (30.81±3.63). The difference was statistically significant (t=32.815, P=0.035) . The results were excellent in 13 feet, good in 7, and fair in 1, with the excellent and good rate of 95.24% (20/21). The local infections were cured without recurrence at operative site. Equinus deformities were corrected, and the latest follow-up results showed that all patients walked normally without recurrence. Conclusion Ilizarov method combined with reversed sural and saphenous neurocutaneous island flap can improve the limb function and the flap can survival with good clinical effect. Key words: External fixators; Surgical flaps; Equinus deformity

Early results of clubfoot management by Joshi's external stabilizing system

Introduction: With the use of Ponseti's technique, majority of children with clubfoot do not need operative treatment; however, some severe clubfoot including neglected, recurrent, and resistant forms cannot be managed by conservative methods and needs surgical intervention. The foot becomes rigid with soft tissue surgery, and bony operations can make the foot even more smaller. To avoid it, a simple alternative is to use joshi's external stabilising system (JESS) and distractor components which are used on the principle of controlled differential fractional distraction histogenesis. JESS distractors allow gradual distraction of contracted soft tissues and align all the joints of the foot so as to bring corrections of all aspects of deformity of the foot simultaneously. Purpose: To analyze the role of JESS fixator in correcting case of clubfoot in terms of cosmetic, functional, and anatomical outcome which were assessed by International Clubfoot Study Group (ICFSG) scores. Materials and Methods: Total of 6 Clubfoot underwent differential fractional distraction in AIIMS, Raipur. Patients were assessed preoperatively for morphology and functionality and radiologically by ICFSG score. Period of correction varied from 5 to 8 weeks. Once correction is obtained, then apparatus is locked in that position for the same period and later converted to cast in plantigrade for maintenance and followed up regularly. The results were analyzed with ICFSG score. Results: Excellent to good results were obtained in all the cases which were assessed by ICFSG score. There were only minor complications in patients. Conclusion: JESS frame is simple, versatile, and best suited for correcting clubfoot deformities which were neglected, resistant, and recurrent.

Timing for Ponseti clubfoot management: does the age matter? 90 children (131 feet) with a mean follow-up of 5 years

Background and purpose — There are still controversies as to the age for beginning treatment with the Ponseti method. We evaluated the clinical outcome with different age at onset of Ponseti management for clubfoot.Patients and methods — 90 included children were divided into 3 groups in terms of age at start of treatment. The difference in treatment-related and prognosis-related variables including presentation age, initial Pirani and Dimeglio score, casts required, relapse rates, final Dimeglio score, and international clubfoot study group score (ICFSG) was analyzed.Results — Age between 28 days and 3 months at start of treatment method was associated with fewer casts required, lower relapse rate, and lower final ICFSG score (p < 0.05). Early treatment before 28 days of age required more casts and had a higher relapse rate (p < 0.05). The highest ICFSG scores were found in the ages between 3 and 6 months (p < 0.05). After propensity score matching, age between 28 days and 3 months was demonstrated to have a lower finial ICFSG score. Linear regression models showed that presentation age was positively correlated with final ICFSG score, and was identified as the only independent prognostic risk factor.Interpretation — There was lower rate of relapse and better clinical outcome when treatment was initiated at age between 28 days and 3 months. With the Ponseti method, clubfeet may not need urgent treatment.

Treatment of rigid congenital clubfoot with Ilizarov technique in older children

To investigate the effectiveness of Ilizarov technique in treatment of rigid congenital clubfoot in older children. A clinical data of 55 patients (69 feet) with rigid congenital clubfoot (Diméglio grade Ⅳ) between September 2005 and September 2015 were retrospectively analyzed. There were 33 boys and 22 girls with an average age of 11 years (range, 6-14 years). There were 41 cases of unilateral clubfoot and 14 cases of bilateral clubfeet. The degree of foot deformity was rated as fair in 24 feet and as poor in 45 feet according to International Clubfoot Study Group (ICFSG) score before operation. Sixty-nine feet were treated by Ilizarov external fixator combined with limited soft tissue release, and 21 feet were combined with individualized V-shaped osteotomies. All patients were followed up 2-10 years ( mean, 4.2 years). The incisions healed well after operation. Five cases of needle tract infection occurred and were cured by local dressing change. The effectiveness was excellent in 39 feet, good in 21 feet, and fair in 9 feet according to ICFSG score, with the excellent and good rate of 87.0%. During the follow-up, X-ray films showed that no blood supply disorder or necrosis of talus, scaphoid, cuneiform, metatarsal, calcaneus, and cuboid occurred. No osteomyelitis occurred. Ilizarov technique combined with limited soft tissue release or V-shaped osteotomy for the older children with rigid congenital clubfeet is safe and can obtain significant orthopedic effectiveness.

Complex iatrogenic clubfoot: is it a real entity?

In our study, we aimed to demonstrate whether a complex iatrogenic clubfoot really exists; identify the causative mechanisms; and determine the outcome if properly treated. We observed 54 clubfeet previously treated unsuccessfully by manipulation and casting elsewhere. All the feet had been classified at diagnosis as typical clubfeet. In 26 cases, the cast had slipped down, entrapping the foot in a plantar-flexed position. Nine clubfeet out of those 26 cases presented the clinical features of a complex iatrogenic deformity. These were treated with the modified Ponseti protocol and evaluated at follow-up according to the International Clubfoot Study Group Score. The length of follow-up averaged 7.2 years. Two feet showed an excellent result, five feet showed a good result, and two feet showed a fair result. The relapse rate was 55% in complex clubfeet. Relapsed clubfeet were treated by Achilles tenotomy or lengthening and anterior tibial tendon transfer. We believe that faulty manipulation and a poor casting technique may convert a typical clubfoot into a complex iatrogenic deformity. Risk factors include severe clubfoot, short and stubby foot, and unmolded casts slipping down.

Ponseti method is superior to surgical treatment in clubfoot – Long-term, randomized, prospective trial

Treatment of idiopathic clubfoot has shifted from extensive surgical release to conservative Ponseti method; however, randomized prospective trials to compare both methods are lacking. The goal of this study was to compare the long-term results of Ponseti method with those of surgery in terms of morphology, function, X-rays, overall health and gait.In 2001, a single center, prospective, randomized, and controlled trial with a parallel design was started. Twenty-four feet of 15 patients were randomly assigned to two groups: 12 feet each to a Ponseti and surgical group. Mean follow-up was 10 years. International Clubfoot Study Group score (ICFSG), the Pediatric Outcomes Data Collection Instrument (PODCI) and the Functional Rating System (FRS) were used to compare morphology, functional, radiological and subjective outcomes, and the Oxford Foot Model (OFM) was used to evaluate foot kinematics.No significant difference was seen between groups in the initial Pirani scores (p=0.618). Ponseti group had more favorable long-term outcomes according to the FRS (p=0.005), higher ICFSG, scores for morphology (p=0.021), function (p=0.005) and X-rays (p=0.02), and better parent reported functional status according to the PODCI (p=0.018). Surgically treated clubfeet were stiffer – ankle dynamic range of motion (p=0.015) and the maximal hindfoot dorsiflexion during gait were limited as measured by OFM (p=0.039). This was compensated by an increase in motion between the hindfoot and forefoot. Furthermore, these children had more difficulty playing sports and experienced more pain, which might have led to inferior results in the happiness domain of the PODCI.These results suggest that the Ponseti method provides superior long-term outcomes for idiopathic clubfoot deformity.

Ponseti Treatment of Rigid Residual Deformity in Congenital Clubfoot After Walking Age.

There is no established treatment for rigid residual deformity of congenital clubfoot (CCF) after walking age. Soft-tissue procedures, osseous procedures, and external fixation have been performed with unpredictable results. We applied the Ponseti method to patients with this condition in order to improve the outcomes of treatment. We retrospectively reviewed the cases of 44 patients (68 feet) with congenital clubfoot whose mean age (and standard deviation) at treatment was 4.8 ± 1.6 years. All patients had been previously treated in other institutions by various conservative and surgical protocols. Residual deformity was evaluated using the International Clubfoot Study Group Score (ICFSGS), and stiffness was rated by the number of casts needed for deformity correction. Ponseti manipulation and cast application was performed. Equinus was usually treated with percutaneous heel-cord surgery, while the cavus deformity was treated with percutaneous fasciotomy when needed. Tibialis anterior tendon transfer (TATT) was performed in patients over 3 years old. At the time of follow-up, the results were evaluated using the ICFSGS. Before treatment, 12 feet were graded as fair and 56, as poor. Two to 4 casts were applied, with each cast worn for 4 weeks. Stiffness was moderate (2 casts) in 23 feet, severe (3 casts) in 30 feet, and very severe (4 casts) in 15 feet. Percutaneous heel-cord surgery was performed in 28 feet; open posterior release, in 5 feet; plantar fasciotomy, in 30 feet; and TATT, in 60 feet. The mean length of follow-up was 4.9 ± 1.8 years. Eight feet had an excellent result; 49 feet, a good result; and 11 feet, a fair result. No patient had pain. All of the feet showed significant improvement. Ponseti treatment with TATT, which was performed in 88% of the feet, was effective, and satisfactory results were achieved in 84% of the feet. At the time of follow-up, no patient showed an abnormal gait, all feet were plantigrade and flexible, but 2 feet (2.9%) had relapsed. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medial to posterior release procedure after failure of functional treatment in clubfoot: a prospective study.

PurposeTwo conservative techniques for clubfoot treatment are still being debated and depend upon the institution’s expertise. For >40 years, the current institution has been a pioneer in the development of the physiotherapy method; however, some severe deformities remain resistant to this method which causes pain, sprains, and difficulties wearing shoes. Therefore, a surgical approach was developed simultaneously for the treatment of these residual or recurring clubfeet. The procedure reproduces the same chronological steps by performing forefoot derotation before correcting hindfoot equinus. The aim of the current study was to assess the results of this surgical technique.MethodsAll clubfeet undergoing surgery between October 1995 and February 2009 were prospectively included. Initial severity was based on Dimeglio’s classification and final outcomes on the International Clubfoot Study Group (ICFSG) outcome evaluation system. Last follow-up results were assessed by physical examination and radiographs.ResultsA total of 137 patients with severe clubfeet (mean Dimeglio score 12.0) underwent surgery. At the mean follow-up of 10.8 years, mean ICFSG score was 4.3 (range 0–23), and 12 % required revision surgery. The rate of undercorrection and overcorrection was low (17 pes-plano-valgus ft and 11 ft with undercorrection). Eight feet had a fixed deformity.ConclusionsSevere deformities are more resistant to conservative techniques even for institutions with large experience. These deformities require further treatment, including surgery if necessary. The medial to posterior soft-tissue release is a valuable technique with stable results.Level of evidenceLevel IV.

Flexibility of idiopathic congenital clubfeet treated by posteromedial release without talocalcaneal joint release

We retrospectively reviewed 57 patients with 84 idiopathic clubfeet and followed them up for at least 15 years. All feet were rated as good or excellent according to the International Clubfoot Study Group score. Stress radiographs showed that the arc of forefoot motion of conservatively treated feet was 81%, in operated feet of patients aged more than 1 year it was 74%, and in feet of patients aged less than 1 year during surgery it was 65%, compared with those in contralateral normal feet. Despite the severity of the deformity, feet treated by our posteromedial release without talocalcaneal joint release were flexible and functional.

Ilizarov in relapsed clubfoot

This study aims to retrospectively evaluate the results of soft tissue distraction using Ilizarov in relapsed clubfeet following a previous posteromedial soft tissue release. This study, as compared with previous studies, has a cohort of patients with relapsed clubfeet only following posteromedial soft tissue release. Fifteen patients (16 feet) were assessed using the International Clubfoot Study Group score and plantigrade foot was achieved in all except one patient who had equinus deformity. Fourteen feet were graded as showing excellent or good result on the basis of the International Clubfoot Study Group (ICFSG) score. Although no patient had an ICFSG score of 0, parental satisfaction was good. This report supports the use of Ilizarov as the benefits offered outweigh the risk of associated complications, making this potentially cumbersome apparatus a useful tool in the armamentarium to treat relapsed clubfeet following soft tissue release.

Soft Tissue Ilizarov Correction of Congenital Talipes Equinovarus-5 to 10 Years Postsurgery

The aim of this study was to address concerns regarding maintenance of correction of foot deformity after soft tissue Ilizarov distraction in relapsed clubfeet. We retrospectively reviewed the results of Ilizarov surgery of 19 rigid clubfeet in 14 children. The postoperative follow-up was at least 5 years (range, 5-10 years). All patients were assessed using the International Clubfoot Study Group score. This is a comprehensive scoring system published in 2003, incorporating morphological, functional, and radiological assessments. Patient and parent satisfaction was also assessed. Using the International Clubfoot Study Group score, 14 of the 19 feet managed by the Ilizarov soft tissue distraction technique were graded good or excellent. Only 1 patient experienced recurrence of the deformity. Subjectively, 13 of the 14 children in the study were satisfied with the result of the treatment. The study confirms that the short-term good results reported previously are maintained at least 5 years after the operation. There are no other similar studies with a minimum 5-year follow-up.