Severe Clubfoot Research Articles

Walking age of infants with idiopathic clubfoot treated using the ponseti method.

The Ponseti method is an established approach to treating idiopathic clubfoot in infants. The method involves a period of cast immobilization and postcorrective bracing that potentially interferes with normal movements of the lower extremities. In the present study, we investigated the age at which infants who had idiopathic clubfoot treated using the Ponseti method achieved independent walking. We prospectively evaluated patients of a single surgeon. Included in the study were all patients with idiopathic clubfoot who were full term at birth, were no more than twelve weeks of age at the start of treatment, had received no prior outside treatment, and were followed for a minimum of twenty-four months. Ninety-four patients were included. The mean age at which patients began walking independently was 14.5 ± 2.6 months (range, ten to twenty-two months). By eighteen months, 90% of the patients were walking without assistance. Patients with moderate or severe clubfoot deformity began walking earlier than did patients with very severe deformity (a mean of 14.2 months compared with 15.8 months; p = 0.03). Patients who experienced a relapse before learning to walk began walking later than those who did not relapse (a mean of 15.9 months compared with 14.2 months; p = 0.04). Other patient and treatment-related variables had no significant influence on the onset of walking. On the basis of our findings, parents of infants with idiopathic clubfoot treated using the Ponseti method may expect their child to achieve independent walking approximately two months later than infants without clubfoot deformity. A greater delay may be expected for those patients who have a very severe deformity or those who experience a deformity relapse. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

CLUBFOOT RECCURENCES AFTER THE TREATMENT BY PONSETI

Congenital clubfoot is one of the most frequent pathologies of the musculoskeletal system. The treating of clubfoot by Ponseti gives promising results and complete correction of the deformity in 90-95% of patients sparing them from extensive surgery. In the Yaroslavl Regional Children's Hospital from May 2006 to December 2007 54 children (83 feet) with severe congenital clubfoot were treated. Treatment for all patients was initiated at the age of 1 year. With remote monitoring for 5 years recurrences were noted in 19.3% of cases. Despite its high efficacy in patients under the age of three years, non-compliance of brace wearing results in the number of recurrences and require re-gypsum. In older children (3 to 5 years) the treatment by Ponseti is supplemented by transfer of tibialis anterior muscle tendon. In cases of postoperative recurrence of the treatment program is complemented by local releases and arthrodesis.

ALGORITHM OF TREATMENT OF CONGENITAL CLUBFOOT IN CHILDREN OF YOUNGER AGE GROUP

Congenital clubfoot requires complete correction before the period of verticalization. Conservative methods are priority in treatment. The most effective method is Ponseti method that allows correcting all the deformations even in severe clubfoot. However, if clubfoot is accompanied with abnormal anatomy of foot or significant changes in functional ability of muscles, operative treatment is inevitable. The extent of surgical intervention depends on the severity of detected abnormalities and is determined individually. The use of ultasound, radiographic, and CT investigations, according to indications, contributes to the diagnostics. The indication for surgery is the lack of effect of conservative treatment after 10-12 cast correction in children over the age of 4 months. Diagnostic criteria for deciding in favor of surgery are: availability of fibrous coalition, the deformation of the talar or the sphenoid bone, the anomaly in the point of attachment of the tendon of the tibialis anterior muscle, lack of the repositioning of navicular bone on the talar head. Orthosis supply and rehabilitation treatment depend on the extent of surgical intervention.

Treatment of Resistant Clubfoot with Soft Tissue Release and Alkhooly External Fixator

After the first research with this technique done by the first author, ten operations on the foot and ankle were performed on five patients (two boys and three girls) suffering from severe club foot deformity all with bilateral foot affection. Their ages ranged from five to fourteen years. All of them were treated by soft tissue release, skin flap (rotational flap), supplemented with Alkhooly external fixator. The follow up period ranged from two to seven years. The results according to Mittal (1987) [1] were excellent in eight feet (80%) and good in two feet (20%).

Predictive factors for residual equinovarus deformity following Ponseti treatment and percutaneous Achilles tenotomy for idiopathic clubfoot

Background and purpose There is no consensus on how to predict residual equinovarus deformities after application of the Ponseti method. We assessed the prognostic value of clinical scoring systems, and also radiographic parameters that can be measured just before percutaneous Achilles tenotomy (PAT).Method We reviewed 50 cases of clubfoot in 35 patients who were treated using the Ponseti method, including PAT, to analyze the factors that are predictive of residual equinovarus deformities. Mean age at the time of PAT was 2.4 (1.4–3.5) months, and the mean follow-up period was 23 (9–61) months. We divided these cases into 2 groups according to the need for further surgery to treat the residual deformities.Results 40 feet with satisfactory results were included in group 1, whereas the remaining 10 feet that required further surgery for unsatisfactory residual deformities were included in group 2. We compared the initial Dimeglio and Pirani scores obtained before the first Ponseti casting, follow-up Pirani scores, and radiographic parameters determined just before PAT between these 2 groups. There was no statistically significant difference between the groups in terms of the initial Dimeglio and Pirani scores, although the follow-up Pirani scores and lateral tibiocalcaneal angle were higher and the lateral talocalcaneal angle was lower in group 2 at the time of PAT.Interpretation We conclude that the Pirani score, lateral tibiocalcaneal angle, and talocalcaneal angle, when assessed immediately before PAT, might be predictive factors for residual equinovarus deformity following Ponseti treatment for severe idiopathic clubfoot.

Surgical management of congenital idiopathic clubfoot by twin incisions

Background: Idiopathic clubfoot surgery is known for a number of complications, that is, skin slough and wound dehiscence medially, infection and limitation of full correction at the time of surgery which leads to excessive scar hypertrophy, recurrence of deformity, and a poor functional outcome. Many procedures done in the past have reported complications ranging from 3 to 30%. We are doing surgical correction of congenital idiopathic clubfoot by two incisions avoiding dissection of the medial skin to overcome these problems and are reporting our results. Materials and Methods: We used two incisions (a medial and a posterior incision) in cases with moderate to severe congenital idiopathic clubfoot. These were those cases who did not want to continue with Ponseti's technique so as to avoid repeated follow-ups. Assessment of results was done by comparing preoperative and postoperative Pirani scores. Results: Our results were excellent in 7.9% (6 feet), good in 72.3% (55 feet), and fair in 15.8% (12 feet) cases. All of our cases had primary wound healing and no delayed scar related complication. Conclusions: Two incisions avoid stress on the medial skin. They permit release of all contracted structures posteromedially. We are describing this technique for its simplicity.

SURGICAL TREATMENT OF PARALYTIC SEVERE CLUBFOOT OF SEVERE DEGREE IN ADULTS (CLINICAL PRACTICE CASE)

The short-term result of treatment of the patient with an severe clubfoot who underwent a surgical treatment is represented. Besides the patient suffered from talipes varus and short cavovarus deformity which were eliminated during the surgery. To eliminate a multicomponent talipes a technique of two-stage surgical treatment of the given severe pathology devised in SarNIITO was used. It made it possible to achieve a complete elimination of the talipes, a high-grade restoration of anatomy and functions of the ankle, and in the future it will allow to improve life quality of the particular patient.

Surgical Management of Congenital TEV in Children at PMC Hospital Nawabshah

Introduction: Talipes equino varus TEV is one of the most common congenital anomaly. It is managed by some common ways i-e., conservative & surgical methods. Among surgical methods are Turco’s posterior medial release, posterior soft tissue release operation (Attenborough), four quadrant release (Mc Kay). Objective of this study was to determine the reliability of surgical option like postero medial release in children having congenital TEV. Material & Methods: This study was carried out during the period from October 2002 to March 2005 in the Deptt. of Orthopaedics of PMCH Nawab Shah. The inclusion criteria were children 2 months to 30 months of age having moderate to severe club foot. Clubfoot secondary to some other disorder such as cerebral palsy, arthrogryposis multiplex congenital, myeldysplasia or DDH were not included in this study. The deformity was treated surgically in all cases by postero medial release. Follow-up period was one & half year. Results: A total 57 patients were included in this study with the age range of 2 months-2.5 yrs with moderate to severe deformity. Forty two were male (73.7%) and 15 patients (26.3%) were female, seventeen patients (29.8%) had bilateral club foot while the rest the rest of 40 patients (67.1%) had unilateral deformity. Positive family history of club foot was in 10 patients (17.5%). Results were concluded on 57 patients who completed one & half year follow-up. Excellent results were observed in 41 patients (71.9%), good in 11 patients (19.2%), fair in 2 children (3.5%). No patients lost to follow up.Conclusion: Children up to 30 months (2 months - 2.5 years) age with congenital TEV can be treated with surgery successfully.

Value of the Fetal Plantar Shape in Prenatal Diagnosis of Talipes Equinovarus

The purpose of this study was to evaluate the value of the fetal plantar shape in prenatal diagnosis of talipes equinovarus. A case-control study was conducted between September 2009 and February 2011. We measured the width and length of 249 feet (156 fetuses) included in this study and then calculated the width to length ratio. All of the fetuses were followed to obtain the pregnancy outcomes and confirm whether the deformity existed; then the bimalleolar angle of each foot with talipes equinovarus was measured. Independent samples t tests were performed to compare the foot width, length, and width to length ratio between normal and talipes equinovarus groups. We also assessed the correlation between the width to length ratio and bimalleolar angle in the talipes equinovarus cases with the Pearson correlation coefficient. Statistically significant differences were shown between the two groups (P< .001) for the three foot measurements, and a significant negative correlation was found between the width to length ratio and bimalleolar angle of the affected foot (r = -0.857). The fetal plantar shape can provide valuable information for prenatal diagnosis of clubfoot. Compared with a normal foot, a clubfoot tends to be wider and shorter. A higher width to length ratio is associated with a smaller bimalleolar angle and indicates a more severe talipes equinovarus deformity.

Idiopathic club foot treated with the Ponseti method. Clinical and sonographic evaluation of Achilles tendon tenotomy. A review of 221 club feet

The Ponseti method applied to treating idiopathic club foot consists in placing successive corrective casts, possibly an Achilles tendon tenotomy, then derotation braces, a method that has proven its efficacy. This study compared 221 cases of club foot treated with this method between 2002 and 2007 divided into two groups, based on whether or not Achilles tendon tenotomy was performed. Assessment was both clinical and sonographic. We observed clear improvement of the results in the group that underwent Achilles tendon tenotomy and a significant difference in the rate of secondary surgery. The sonographic evaluation also showed improvement of the morphological results. We now systematically propose Achilles tendon tenotomy however severe club foot may be.

SURGICAL TREATMENT OF ADULT PATIENTS WITH CONGENITAL CLUBFOOT IN SEVERITY DEGREE

There were treated 48 patients (adolescents and adults) with severe congenital clubfoot in Saratov Research Institute of Traumatology and Orthopedics. 43 patients had the age ranged from 16 to 30, 5 patients had the age over 30. 19 patients had bilateral clubfoot, 29 patients had unilateral clubfoot including 19 on right side and 10 left side. To improve treatment results and to prevent deformity recurrence we developed two-staged surgery for congenital clubfoot treatment in adults. Cartilages of talo-navicular, talo-calcanean, cuneo-talar joints are deleted and deformity is corrected with external fixator on I stage. Surgeon performs external fixator resetting, autobone grafting of these joints with compressive arthrodesis on second stage. This method results in full foot reconstruction, good functional outcome, full weight-bearing and improves patient life’s quality.

Ponseti method of treatment of severe and neurogenic clubfoot

Primary results of treatment for neurogenic clubfoot of various genesis using Ponseti technique are presented. During the course of treatment and follow up period clinical and roentgenologic changes were assessed in 34 children. Mean age of patients at treatment initiation was from 4 months to 8 years. Treatment efficacy was in direct dependence upon the patient's age. The best results were achieved in children under 12 months. Use of Ponseti method in neurogenic forms of clubfoot is characterized by a number of technical features. In severe forms of disease it is reasonable to use this technique as a first step of correction which enables to reduce the volume of following surgical intervention.

Long-Term Result of Complex Treatment for Recurrent Congenital Club Foot (Case Report)

An example of successful complex treatment of 8 years old patient with severe recurrent club foot is presented. Treatment included surgical restoration of osteoarticular interrelations in the foot and elimination of muscle imbalance. For the restoration of shin muscles' reciprocal interrelations and formation of proper motor skill, training of muscles according to the method of functional biocontrol was applied. Treatment result was assessed after 3 years: no deformity relapse was observed, function of the extremity was completely compensated.

A novel mutation in TNNT3 associated with Sheldon–Hall syndrome in a Chinese family with vertical talus

Distal arthrogryposis (DA) is a group of rare, clinically and genetically heterogeneous disorders primarily characterized by congenital contractures of the limb joints. Recently, mutations in genes encoding the fast-twitch skeletal muscle contractile myofibers complex, including troponin I2 (TNNI2), troponin T3 (TNNT3), tropomyosine 2 (TPM2), and embryonic myosin heavy chain 3 (MYH3), and the slow-twitch skeletal muscle myosin binding protein C1 (MYBPC1) were confirmed to cause DA1, DA2A, and DA2B. DA2B, or Sheldon–Hall syndrome (SHS; MIM 601680), is intermediate to DA1 and DA2A, or Freeman-Sheldon syndrome (FSS; MIM193700), and shows prominent facial traits. This report describes a Chinese family with SHS over three generations in which all affected individuals showed vertical talus and one demonstrated preauricular tags on the face. Linkage analysis and PCR sequencing revealed a novel substitute mutation at a hot-spot site in TNNT3 (c.187C > T; p.R63C). This mutation was confirmed to cosegregate with the DA phenotype in affected individuals. SIFT and PolyPhen analyses suggest that the mutation is pathogenic. We report this mutation in TNNT3 and speculate that bilateral vertical talus, or severe clubfoot, might be a special characteristic for cases with the TNNT3 R63C mutation.

MANAGEMENT OF ATYPICAL CLUBFOOT BY PONSETI METHOD

From May 2006 to August 2009 analyzed 28 clinical observations (34 feet) for children aged from 7 days to 1.5 years with severe atypical congenital clubfoot (Pirani 5,6 points), treated by the method of I. Ponseti. The average number of gypsum one foot to the full correction was - 6.3. It was written 38 achillotomy. Dates from the beginning of gypsum to achillotomy averaged - 34 days. All of the children undergoing treatment with us after the removal of plaster, dressed brace, fixing the foot fixed in position 45° abduction and 15° of flexion of the back and encouraged them to carry up to 3-4 years. All the children in this group achieved a complete correction of foot deformities without performing tenoligamentocapsulotomy. Results of treatment were evaluated according to the classification C. Pirani. Average score was 1.1 points. Follow-up was an average of 1 year 35 days.

Treatment of severe clubfoot with manipulation using synthetic cast material and a foam-casting platform: a preliminary report

Conservative clubfoot treatment requires weekly cast changes. We questioned whether a method using synthetic fiberglass instead of the traditional plaster material and with the infant lying comfortably on a special foam-casting platform could be satisfactorily used. A retrospective cohort review on idiopathic clubfoot treated with this particular method was carried out. The severity of clubfoot at presentation was assessed with the classification of Dimeglio et al. The outcome of treatment was assessed with the same scoring system at the latest follow-up. The need of secondary open surgical releases was noted. The parent's acceptability of this method was evaluated with a self-designed questionnaire. The existence of a learning curve was explored by comparing the outcomes of 22 feet during two time periods: those treated before 31 December 2003 (group 1) and those treated after 1 January 2004 (group 2). The mean Dimeglio Scores improved from 17.5 to 4.1 for group 1 and from 15.0 to 3.2 for group 2. Nine of 10 feet in group 2 had tenotomy of the tendo Achilles and none needed open surgical release whereas 10 out of 12 feet in group 1 required open releases. A learning curve did exist for this method. No major complication was noted with the technique. Parent acceptability was high for this method, which was effective in the management of severe idiopathic clubfoot.

Freeman-Sheldon syndrome-prenatal and postnatal diagnosis

A six-day-old girl, born to normal non-consanguineous parents presented with mask like facies with a small mouth giving a 'whistling' appearance. Other dysmorphic features include deep set eyes, broad nasal bridge, long philtrum and 'H' shaped cutaneous dimple on the chin. There was congenital windmill vane hand position and severe talipes equinovarus deformity. The above features are characteristic of Freeman-Sheldon syndrome also known as Whistling Face syndrome. Ultrasound scanning during 8(th) month of the pregnancy showed the fetus to have facial abnormality and bilateral clenched hand and talipes with extension contractures of knees. Provisional diagnosis of FSS was made which was confirmed after the birth. Thus all cases of Arthrogryposis during prenatal scan should be carefully looked for the facial abnormality in the fetus.

What Proportion of Patients Need Extensive Surgery After Failure of the Ponseti Technique for Clubfoot?

In 1948, Professor Ignacio Ponseti began a nonoperative management form of treatment for severe talipes equinovarus. This method of manipulative treatment became attractive because long-term outcomes demonstrated the majority of feet were pain-free, plantigrade, and functioning at a high level of activity without evidence of degenerative arthrosis. We retrospectively reviewed the charts of 51 children (31 boys and 20 girls; 72 feet) with idiopathic clubfeet deformity treated with the Ponseti method from January 5, 2002, to January 5, 2007. The median age at treatment was 2 weeks (95% confidence limit, 1-2 weeks); there was no difference in age at presentation between boys and girls. The minimum followup was 4 months (mean, 19.8 months; range, 4-48 months). A total of 288 casts were applied (mean, 5.5; standard deviation, 0.92). Successful treatment was defined as a plantigrade foot with a normal hindfoot, midfoot, and forefoot on clinical examination. Correction was achieved and maintained in 90% (65 of 72) of the feet; 10% (seven of 72) of the treated feet did not improve and needed subsequent surgery. There was no difference in the proportion of children who had tenotomy or previous treatment among those who presented with residual deformity or recurrence or had surgery. However, patients who tolerated bracing had lower recurrence rates and underwent less surgery. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Zur chirurgischen Behandlung des Pes equinovarus als Folge eines Kompartment- und/oder Postischämiesyndroms der tiefen Flexorenloge des Unterschenkels

Cases of posttraumatic pes equinovarus after compartment syndrome have become more frequent in the last 3 decades because limb-saving procedures like compartment splitting, vascular repair, and microvascular free flaps have become well established in trauma surgery, thus reducing early below knee amputations. But if the deep flexor compartment is not split completely or if the muscles are crushed by direct trauma severe necrosis and subsequent muscle contractures result in a very severe clubfoot deformity. Metatarsalgia of fifth, fourth, and third metatarsal head even in well-fitted orthopaedic shoes occurs as well as painful bunions and fatigue fractures of the fifth metatarsal. Infected ulcers below the fifth/fourth metatarsal bone in a numb plantar sole often require head resection because of osteomyelitis.From 1994 to 2007 a total of 24 patients with severe pes equinovarus after compartment and/or postischemic syndrome were treated operatively. Only in 5 cases was a triple, Chopart, or Lisfranc arthrodesis necessary; 19 cases however could be treated only by soft tissue procedures like tenolysis, tendon lengthening, medial release of the scarred flexor retinacula and contracted capsules of the posterior ankle, subtalar and talonavicular joint to reorientate all axes of the foot. By temporary K-wire transfixation (6 weeks), initial external tibiotarsal transfixation of the foot (10 days), and additional tendon transfer for active foot elevation excellent and good long-term (5 years) results are achievable.The results according to the McKay Score are not significantly different regarding the triple arthrodesis group versus the pure soft tissue release group. Nevertheless, saving joints in the latter group seems to be very important.

Is there a role for lengthening flexor hallucis and flexor digitorum longus tendons in surgery for club foot?

Most cases of club foot (congenital talipes equinovarus) respond to non-operative treatment but resistant cases may need surgery. It is broadly accepted that lengthening of tendo Achillis, the tendon of tibialis posterior and capsulotomy of the ankle and subtalar joints are necessary during surgical release, but there is no consensus as to whether lengthening of the tendons of flexor hallucis longus and flexor digitorum longus is required. We randomised 13 children with severe bilateral club foot deformities to undergo lengthening of the flexor hallucis longus and flexor digitorum longus tendons on one side and simple decompression on the other. We found no difference in the deformities of the toes between the lengthened and non-lengthened sides at a mean follow-up of four years (2 to 6). We conclude that routine lengthening of the tendons of flexor hallucis longus and flexor digitorum longus during soft-tissue surgery for resistant club foot is not necessary.