Management Of Clubfoot Research Articles

Can Below-Knee Casts be Effective for Clubfoot Management in Walking-Age Children? A Prospective Cohort Study.

Above-knee casts pose a major challenge in the day-to-day activities among walking age clubfoot patients due to complete restriction of knee movement. This current study investigates the effectiveness of below-knee casts compared to above-knee casts for managing walking age clubfoot deformity. After approval from the institutional ethical committee, we enrolled walking age clubfoot patients for deformity correction through corrective manipulation and casting through below-knee casts over 2years. The corrective manipulation was performed using the Ponseti technique. The patients were followed for a minimum of 2years period. To compare the effectiveness of below-knee casts over above-knee casts, we enrolled equal numbers of walking age clubfeet matched for age and gender. We compared the two groups in terms of initial and post-correction Dimeglio scores, individual deformities corrections (maximum ankle dorsiflexion, heel varus correction, foot abduction), failure rates, relapses, and complication rates. 56 patients with 80 clubfeet with a mean follow-up of 39.98monthswere considered for the final analysis. There were 29 patients in the below-knee cast group and 27 in the above-knee cast group, with 40 clubfeet each. The patients in the above-knee casting group had significantly better post-correction Dimeglio scores and individual deformity components corrections than the below-knee cast group. There were nil failures in the above-knee casting group and 7.5% in the below-knee cast group. The relapse rate was 15% in both groups, with none requiring any extensive soft tissue procedure. We did not encounter any major complications during the treatment and follow-up. The deformity correction and maintenance are suboptimal with the below-knee casts. Therefore, above-knee casts should be the preferred management modality for correction of walking age clubfoot deformities.

A 5-years results of the Ponseti method in the treatment of congenital clubfoot: a retrospective study

BackgroundClubfoot is a common congenital deformity affecting mobility of children. It leads to pain and disability. The Ponseti treatment method is non-surgical method for the correction of clubfoot. There is variation from country to country in how the result of clubfoot management is measured and reported. This study aimed to assess the 5-years results of the Ponseti method in the treatment of congenital clubfoot which was performed for children aged under 2 years in western Amhara, Ethiopia.ObjectivesThe objective of this study was to assess a 5-years results of the Ponseti method in the treatment of congenital clubfoot among under 2-years old children in Felege Hiwot Referral Hospital, Bahir-Dar, Ethiopia, from 2015 to 2019 G.C.MethodsA facility-based retrospective cross-sectional study was conducted. After receiving letter of ethical clearance from the University, IRB board, the data were collected from medical record/charts of patients’ who received Ponseti treatment, and the collected data were entered and analyzed with Statistical Package for Social Sciences version 21. The results were presented with texts and tables.ResultsA total of 200 children with 256 congenital clubfeet involved in the study. Among the total study subjects, 143 (71.5%) had unilateral clubfeet. The 5-years results of the Ponseti method in the treatment of congenital clubfoot conducted in 200 children with clubfeet were 187 (93.5%) with 95% (CI 90–99.5). Among the study participants, males were 66.5% (almost two times from females).Conclusions and recommendationsAccording to the results from a 5-years data showed that the Ponseti method in the treatment of congenital clubfoot was successful with a success rate of 93.5%. We recommend that children with congenital clubfeet should be managed with Ponseti treatment method timely.

Clinical management of clubfoot in the ambulatory setting- our 2- year experience with 20 patients

Clinical management of clubfoot in the ambulatory setting- our 2- year experience with 20 patients

Ponseti Method in the Management of Clubfoot under the 4 Years of Age

Background: The number of children born in the United States with a congenital clubfoot rises steadily each year. As per the Centers for Disease Control and Prevention, CTEV is spread once every 1,000 births. The vast majority of those infants are born in countries where they are mistreated or get insufficient care, resulting in a decrease in their overall life quality. CTEV has managed and been familiar to humanity since the dawn of time, and its surrounding disputes have existed similarly. Numerous studies have contributed to our understanding of patho-anatomy and therapy accountability for various illnesses. This study looked at how well a CTEV cast repair worked after a series of Ponseti cast repairs. Objective: Patients with a history of congenital talipesequinovarus who underwent serial cast repair using the Ponseti procedure were the focus of the study. Study Setting: Teaching Hospital Kech ;Turbat Pakistan Methods: The Ponseti method was used to treat 60 children between June 2017 and December 2019. A 1.5–2 year follow-up was undertaken in this study. Utilizing the goniometry and Pirani score, the researchers evaluated the deformity before and after therapy. Data was analysed with the SPSS programme. An average of five castings were necessary before the entire project could be completed. 85% of the feet were cast for a total of seven weeks of wear. Ninety-four patients (33%), requiring tenotomies, had a fully repaired achilles tendon. Pirani and goniometry scores differed significantly between the pre- and post-treatment periods. According to the optimistic prognosis, there were 66 cases of clubfoot, or 90.4%. For a moderate prognosis, the number was four, or 5.4%. In the event of a poor prognosis, the number of deformities was three, which corresponds to 4.1%. Conclusion: Regarding addressing clubfoot deformity, the Ponseti manipulation approach is effective, and plaster casting is also quite effective. It is fundamental in underdeveloped nations, and well-trained doctors and other healthcare professionals can successfully supervise cases through the use of casts and other control measures.

Management of Idiopathic Clubfoot by Ponseti Method- Our Experience

Management of Idiopathic Clubfoot by Ponseti Method- Our Experience

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.

Clubfoot management during COVID-19 times: An Indian scenario

The coronavirus disease 2019 (COVID-19) pandemic has been universal and swift in its spread. As orthopaedic surgeons, for the most of us this timeframe has reduced our activity to emergency and trauma cases only, with virtual outpatient clinics and no elective surgeries. With some of the common deformity problems including clubfoot etc, which comprises a large number of children in the developing world, the management has been deferred, without any regional and national guidelines being framed. Updated guidelines relating to the management of clubfoot patients, in which parents can safely consult with the orthopaedic surgeon and physical rehabilitation specialists will allow them to cope with this unprecedented situation. We revisit the current scenario and the possible management protocol in the context of COVID-19 pandemic.

Comparison of Blade and Needle Tenotomy for Treatment of Residual Equinus in Idiopathic Clubfoot.

&#x0D; Background: Tenotomy for residual equinus is commonly required in the management idiopathic club. The need to reduce complication and cost has made the advancement from mini open to needle tenotomy. This is even more pertinent in low- and middle-income country where clubfoot is more common. The study compared the outcome of needle and blade tenotomy for management of idiopathic club foot.&#x0D; Patients and Methods: it is a prospective randomized study of patient requiring tenotomy for residual equinus from July 2015 to June 2020 at a tertiary Orthopediccenter.&#x0D; Results:A tenotomy rate of 60 percent was noted. It involves thirty-one patients with forty-three feet were include in the study. The mean follow up was 27,1 months. There was no significant difference in the outcome of equinus correction. Three patients had relapse of deformity, two in the blade group and one in the needle group. All were resolved by further manipulation.&#x0D; Conclusion: Needle tenotomy offers similar outcome to blade tenotomy. It is less expensive and more acceptable to those scared of the surgical blade.

Results of Ponseti Method in the Management of the Congenital Clubfoot

Background: Clubfoot is a debilitating pathology and a source of abnormal gait in children. Treatment with the Ponseti method is the treatment used in the management of congenital clubfoot in children under 9 years old. This study aims to identify the proportion of children with clubfoot supported by the Ponseti method and to evaluate their effectiveness. Materials and Method: A multicenter retrospective descriptive study for six (06) months from June 1st to November 30th, 2019 concerning the evaluation of the Ponseti method in the management of clubfoot in Madagascar was conducted. Results: One hundred ninety-one (191) children with club feet were screened during the study period. One hundred and fifty children, or 226 congenital equine varus clubfoot were treated with the Ponseti method during the study period. The male gender was the most affected compared to the female gender with a sex ratio of 1.75. The clubfoot was bilateral in 50.66% of cases and idiopathic in 92.66%. The initial Pirani score was on average (±SD) 5.04/4.98 (±1.22/1.20). A proportion of 23.33% of cases of recurrence was recorded at 3 months of use of brace abduction splint. Conclusion: In Madagascar, the incidence of congenital clubfoot remains relatively low but clubfoot is still the main limitation of walking and a lack of footwear in children. Ponseti method is the gold standard in the management of this pathology. However, it requires a long-term follow-up.

Standard and accelerated ponseti technique in management of idiopathic congenital talipes equinovarus: A comparative study

Introduction: Congenital talipes equinovarus (CTEV) is one of the most common deformities of foot and ankle. Incidence of CTEV is around 1 in every 1000 live births. Males are affected twice as often as females. Bilateral deformities occur in 50% of cases and in unilateral cases, right foot has predominance. Components of Congenital talipes equinovarus are cavus, forefoot adduction, hindfoot varus, ankle equinus. Goal of clubfoot management is to produce and maintain a painless, functional, mobile and callosity free, normal shoeable foot. In an accelerated ponseti technique, cast is applied twice weekly on fixed days instead of one week. This study compares the results of Standard Ponseti technique with Accelerated Ponseti technique in management of idiopathic CTEV. Materials and Methods: A hospital based prospective randomized comparative study was conducted in the Dept. of Orthopaedics of Silchar Medical College,Silchar, Assam from 1stJune 2020 to 31st may 2021. Total of 50 cases were selected randomly, randomization was done, 25 were treated by Standard Ponseti and 25 were treated by Accelerated Ponseti technique. Results: Mean Pirani score at presentation in standard Ponseti group was 5.25±0.76, and in accelerated Ponseti group it was 5.37±0.65, with p-value indicating that two groups did not have significant difference. In standard Ponseti group, the treatment time in plaster ranged from 28-56 days, and in accelerated Ponseti group it ranged from 14-31 days. Discussion: Modification in frequency of casting has shown that the efficacy remains unchanged but correction of deformity occurs in a shorter span of time. Reduction in duration of treatment will help to improve compliance among parents. Conclusion: Ponseti method has shown good results in idiopathic as well as syndromic CTEV. This Study shows that Accelerated Ponseti method is equally effective as Standard Ponseti method in treatment of idiopathic CTEV with the benefit of reduction in treatment time.

Success of Ponseti Method in Idiopathic Club Feet of &lt;2 Years and 2-5 years of age – A Comparative Study

Background: The Ponseti technique is the gold standard for treatment of clubfoot. However, the data in walking children is still limited and results are ill defined. Aim: We prospectively compared Ponseti method in clubfoot patients aged &lt;2 and between 2 to 5 years in our local scenario. Methods: A total of 40 patients were included in the study through non-probability purposive sampling. The patients were examined, classified (Goldner and Fitch classification) and demographic information was recorded. They were explained about the risk and informed consent was taken. In group A, patients were below 2 years of age while in group B, patients were between 2-5 years of age. Ponseti casting was performed by a designated team. Follow-up was done for 6 months from the correction of feet. Results: We received 27(67.5%) male and 13(32.5%) female patients .The male to female ratio was 2:1. The mean age of patients in group A and B was 0.8±0.70 years and 4.3±2.1 years respectively. There was no statistical difference of severity of deformity of clubfoot in both study groups, p-value&gt;0.05. In group A, 17 (85%) patients had success of procedure while in group B the success was achieved in 11 (55%) patients. The success rate was statistically significantly higher in group-A as compared to group B, p-value&lt;0.001 Conclusion: Patient aged &lt;2 years have significantly higher success rate as compared to patients aged between 2-5 years. So we recommend the Ponseti method as standard therapy in clubfoot management for patients with age&lt;2 years and for correction of mild and moderate deformities in patients between 2 to 5 years. Keywords: Clubfoot, Congenital talipes equinovarus, Ponseti method

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.

Does the use of ultrasound guidance during percutaneous Achilles tendon tenotomy improve outcomes of clubfoot management? A randomized controlled trial.

Achilles tenotomy is a crucial aspect in the non-operative management of clubfoot as per Ponseti's casting protocol. Achilles tenotomy is routinely carried out percutaneously in a blind manner without any image guidance. This study aimed to determine the role of ultrasound-guided percutaneous Achilles tenotomy (PAT) in improving outcomes in clubfoot management. There are no previous studies that have explored the role of image guidance in PAT. This prospective, single-center randomized control trial included 50 clubfoot cases (74 feet) planned for PAT at a mean age of 30.2 months. A single experienced senior surgeon performed tenotomies. Patients were randomized to two groups, with the tenotomies performed under ultrasound guidance in one group (test group) and PAT carried out without image guidance in the other (control) group. Outcome measures assessed included rate of complications, immediate postoperative FLACC score for pain severity and Pirani score at a minimum follow-up of 12 months. There were no significant differences in the complication rates between the test and control groups regarding bleeding, nerve injury and incomplete tenotomies. The mean pain FLACC score was significantly higher in the control group (PAT without image guidance) (P = 0.03), suggesting that the child would better tolerate the ultrasound-guided procedure. All patients in both groups had a Pirani score of zero and plantigrade feet at final follow up, with no relapses. Ultrasound-guided PAT does not have any added advantage over PAT with clinical examination without image guidance in terms of long-term outcomes. Level of evidence: Therapeutic level II.

Evidence Favors Ponseti Management of Clubfoot: Commentary on an article by James A.F. Recordon, MBCHB, et al.: "A Prospective, Median 15-Year Comparison of Ponseti Casting and Surgical Treatment of Clubfoot".

Evidence Favors Ponseti Management of Clubfoot: Commentary on an article by James A.F. Recordon, MBCHB, et al.: "A Prospective, Median 15-Year Comparison of Ponseti Casting and Surgical Treatment of Clubfoot".

Determination of the Effective Site for Percutaneous Achilles Tenotomy in Ponseti Management of African Idiopathic Clubfoot.

Percutaneous Achilles tenotomy is an essential step in the Ponseti treatment of idiopathic clubfoot, with reported complications such as injury to the surrounding neurovascular structures and incomplete division of the Achilles tendon (AT). Knowledge of AT thickness would guide tenotomy blade insertion depth, obviating these related complications. We embarked on this study to ultrasonographically determine AT thickness at its different levels from the calcaneal insertion in children with idiopathic clubfoot. This prospective comparative study consisted of two groups of children 4 years and younger: a study group of patients with clubfoot requiring tenotomy and a control group. Both groups underwent ultrasonographic evaluation of their AT. The ultrasonographic data collected include AT thickness 1 and 2 cm from the calcaneal insertion of the AT, thickness of the thinnest portion of the tendon, and the distance of this thinnest portion from the calcaneal insertion. Twenty-seven children with idiopathic clubfoot constituted the study group, and 23 children with no musculoskeletal deformity were enrolled in the control group. Mean ± SD AT thicknesses 1 and 2 cm from the calcaneal insertion in the study group were 2.4 ± 0.7 mm and 2.1 ± 0.7 mm, respectively, and in the control group were 2.5 ± 0.7 mm and 2.3 ± 0.7 mm, respectively. The average thickness of the thinnest portion of the AT along its length was 2 mm at 1.8 cm from the calcaneal insertion in both groups. Safe and complete percutaneous tenotomy would most likely be achieved when performed 1.8 cm from the calcaneal insertion, where the corresponding average AT thickness of 2 mm would be a guide to determine the insertion depth of the tenotomy blade.

Orthopaedic Management of Loeys-Dietz Syndrome: A Systematic Review.

Introduction:Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder associated with aortic aneurysm/dissection in children. However, LDS may also present with a host of orthopaedic conditions. This study aimed to elucidate the management of orthopaedic conditions and associated outcomes in patients with LDS.Methods:PubMed, Ovid MEDLINE, and Cochrane Library were systematically searched for primary articles regarding the management of orthopaedic conditions in patients with LDS. The goals and findings of each included study were described. Data regarding demographics, conditions studied, treatment modalities, and outcomes were extracted and analyzed.Results:Three hundred sixty-two unique articles were retrieved, 13 of which were included, with 4 retrospective cohort studies and 9 case reports representing 435 patients. In total, 19.8% of patients presenting with orthopaedic conditions received surgical treatment;54.3% of them experienced adverse outcomes, and 44.4% required revision surgery. The mean age at surgery was 9.0 ± 2.1 years.Conclusion:Patients with LDS may require early surgical intervention for a variety of orthopaedic conditions and may be at an increased risk for surgical complications. The current LDS literature is primarily focused on spinal conditions with a relative paucity of data on the management of hip deformity, joint subluxation, clubfoot, and trauma. Additional research is required regarding orthopaedic management for this unique population.

A modification of the Ponseti method for clubfoot management: a prospective comparative study.

PurposeWe aimed to compare our parent-based exercise programem’s efficacy with the foot abduction brace (FAB) Ponseti manipulation as a retention programme.MethodsWe conducted this prospective multicentre cohort study between August 2009 and November 2019. The included children were allocated into one of two groups according to the retention protocol. The Pirani and Laaveg-Ponseti scores were used to assess the feet clinically and functionally. Radiological assessment was performed using standing anteroposterior and lateral radiographs of the feet. We assessed the parents’ satisfaction and adherence to the retention method. SPSS version 25 was used for the statistical analysis.ResultsA total of 1265 feet in 973 children were included. Group A included 637 feet managed with FAB, while group B included 628 feet managed with our retention programme. All patients were followed up to the age of four years. At the final follow-up, Pirani scores in group A participants were excellent, good and poor in 515, 90, and 32 feet, respectivel, while in group B the scores were excellent, good and poor in 471, 110 and 44 feet, respectively. The mean total score of Laaveg-Ponseti was 87.81 (sd 19.82) in group A and 90.55 (sd 20.71) in group B (p = 0.02). Group B participants showed higher satisfaction with the treatment method (p = 0.011) and more adherence to the treatment (p = 0.013).ConclusionThe deformity’s recurrence related to the brace’s non-compliance in the Ponseti method might be reduced by substituting the brace with our home-based daily stretching exercises.Level of EvidenceII

English

BACKGROUND Pirani scoring system is one of the classification systems in management of club foot which is simple and easy to use. However, there is paucity of studies using Pirani system to determine the severity and monitor progress in the treatment of club foot. We therefore set out with the aim of assessing severity and monitoring the progress of treatment using the Pirani scoring system. The Pirani scoring system, together with the Ponseti method of club foot management, was assessed for its predictive value. METHODS It was a hospital-based prospective study of 57 club foot in 41 patients designed to evaluate the role of Pirani score in deformity assessment and management of club foot by Ponseti method. Consecutive patients presenting at the outpatient department at SVRRGGH, Tirupati with idiopathic club foot, and in-patients department with idiopathic club foot were recruited into the study. Informed consent was obtained from parents/guardians of the patients that were recruited in the study. This was a prerequisite for obtaining the ethical approval. Data collected from the study groups was entered into a worksheet, and analysis was performed using the statistical package for social sciences (SPSS) software for windows version 21. Significant statistical inferences were drawn at p &amp; lt ; 0.05. RESULTS The correlation between the midfoot score, hindfoot score, Pirani score and the number of casts to achieve correction was significant (P = 0.001). Also, there was correlation between the Pirani score and the need for tenotomy (P = 0.001); between the number of casts to achieve correction and the need for tenotomy (P = 0.001). Moreover, the progress of treatment can be monitored with the Pirani score (P = 0.001). CONCLUSIONS Pirani scoring system is a simple, easy, quick and reliable system to determine severity and monitor progress in the treatment of club foot with excellent interobserver variability. KEYWORDS Pirani Score, Club Foot, Ponseti Method

Clubfoot Correction in Walking-age Children: A Review

Children with clubfoot often present after the walking age, especially in low- and middle-income countries where approximately 80% of children with clubfoot are born. With advancing age, there is increased stiffness of the soft tissue structures and decreased remodeling potential of the bones of the foot. Not all clubfeet in older children are rigid—some are flexible and amenable to stretching and conservative treatment. Hence, the initial evaluation of the deformity must include an assessment of correctability. The treatment of clubfoot in the older child is challenging and was traditionally performed using complex soft tissue and bony surgeries, often with poor outcomes in the long term. Recent literature has focused on the role of conservative treatment utilizing Ponseti principles of serial manipulation and casting, combined with limited surgery. The purpose of this review is to report the changing trends in the management of clubfoot in the walking child, to review the current literature regarding various treatment modalities, and to recommend a practical approach to treatment based upon age, inherent flexibility of the foot, available resources, and contextual factors. <!-- named anchor --> How to cite this article Penny N, Aroojis A, Mehtani A, et al. Clubfoot Correction in Walking-age Children: A Review. J Foot Ankle Surg (Asia Pacific) 2021;8(3):102–109.

Management of resistant congenital clubfeet by the new operative procedure (Hussain's procedure): An experience of a fellowship program

Background and Objectives: Pakistan Society for Rehabilitation of the Disabled Orthopedic Hospital is renowned for the correction of orthopedic deformities including foot and ankle deformities. Consultant orthopedic surgeon Afzal Hussain, pioneers the treatment of orthopedic deformities and has developed a new operative technique for congenital clubfoot. This research was planned to report the success of Hussain's Procedure in detecting and managing the anomalous structures.&#x0D; Material and Methods: This research was mixed retrospective and prospective research carried out during fellowship of first author in which, operative procedure of the resistant congenital clubfoot associated with anomalous structures viz. anomalous muscles and tarsal coalitions, were performed with the new operative procedure by Dr. Hussain, were assisted by the first author and a minimum of 5 years of follow up of the cases was done by the senior author (Afzal Hussain). Cumming’s modification of Laavag and Ponseti score was applied for the calculation of the results at the follow-ups.&#x0D; Results: During the fellowship, 10 cases of clubfeet with muscle anomalies were managed. Similarly 7 clubfeet with tarsal coalitions were managed. There was full correction of the clubfoot deformity. The cases were followed up by the senior author (Afzal Hussain) for at least 5 years. During the minimum of 5 years followup post completion of treatment, Cumming’s modification of Laavag and Ponseti scores of the operated clubfeet were found to be excellent.&#x0D; Conclusion: The resistance to management of congenital clubfoot by casting may be because of anomalous structures. New operative procedure by Consultant Afzal Hussain names as Hussain's Procedure was helpful in detecting and managing the anomalous structures.