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Cao L, Parenti S, Jo CH, Riccio AI. Is percutaneous heel cord tenotomy a necessary component in the Ponseti treatment of idiopathic clubfoot deformity? J Pediatr Orthop B 2025; 34:157-161. [PMID: 39783829 DOI: 10.1097/bpb.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2025]
Abstract
This study aimed to compare outcomes of idiopathic clubfeet (IC) treated with a percutaneous heel cord tenotomy (PHCT) at the conclusion of Ponseti casting with those that were not. A retrospective review of patients enrolled in a single institution prospective clubfoot registry over 19 years was performed. Patients under the age of 3 months with untreated IC managed via the Ponseti method that had a minimum of 2 years follow-up were included. Dimeglio score, number of casts to achieve correction, bracing compliance, need for subsequent procedures, and outcomes using the Richards classification were compared between patients who underwent a PHCT as part of their initial treatment and those that did not. A total of 1184 clubfeet in 791 patients met inclusion criteria; and 863 feet (73%) underwent a PHCT in clinic as part of initial Ponseti treatment. A total of 23% (75/321) of feet that did not undergo initial PHCT ultimately required a later PHCT or tendo-Achilles lengthening for recurrent equinus. Multivariate analysis demonstrated that an initial PHCT decreased the likelihood of requiring any additional surgical procedure by 30% (odds ratio: 0.70, P = 0.02). While an initial tenotomy was not predictive of clinical outcomes ( P = 0.09), the rate of fair and poor outcomes is more than double from 13.6 to 30% when an initial tenotomy was not performed in feet with Dimeglio scores of 13 or greater ( P = 0.02). Incorporation of a PHCT at the conclusion of Ponseti casting may reduce the need for subsequent and more invasive surgical interventions in IC patients, especially those with Dimeglio scores of 13 or greater. Level of evidence: therapeutic level III.
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Affiliation(s)
- Lisa Cao
- Department of Orthopaedic Surgery, Childrens Hospital Orange County, Orange, California
| | - Sarah Parenti
- Department of Orthopaedic Surgery, Scottish Rite for Children, Dallas, Texas, USA
| | - Chan-Hee Jo
- Department of Orthopaedic Surgery, Scottish Rite for Children, Dallas, Texas, USA
| | - Anthony I Riccio
- Department of Orthopaedic Surgery, Scottish Rite for Children, Dallas, Texas, USA
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Miller AH, Moisan A, Rhodes LN, Locke LL, Kelly DM. Caregiver Impressions of Bracing and Its Association With Unsuccessful Outcomes Throughout the Ponseti Treatment. J Pediatr Orthop 2025; 45:e148-e155. [PMID: 39385603 DOI: 10.1097/bpo.0000000000002842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Abstract
BACKGROUND Clubfoot is a common congenital foot deformity, occurring in about 1 in 1000 live births. The Ponseti method consists of weeks of manipulation and serial casting, followed by years of orthotic wear. Recurrent or relapse deformity following the Ponseti method remains a challenging problem for many patients. Many studies have attributed relapse to noncompliance with the treatment plan, particularly during the maintenance phase. Many patient risk factors have been studied and attributed to recurrent deformity, but less emphasis has been placed on aspects of the treatment method from the caregiver's perspective. METHODS From 2010 to 2014, 127 patients between 1 and 354 days old who had been diagnosed with clubfoot were recruited for the parent study. At the initial visit, and each subsequent follow-up, the primary caregiver was given a questionnaire that included 21 binary belief questions exploring his or her experience with the Ponseti method. Univariate analyses were performed to find any relationship with caregiver responses and either clinical recurrence of the deformity or overall failure of treatment. RESULTS Of the recruited patients, 126 were enrolled in the parent study and 100 were able to complete the full 3-year follow-up. Patient demographics and characteristics (sex, race, family history of clubfoot, laterality, and severity of deformity) were similar. Statistical analysis of the questionnaire responses found that choosing "yes" for either "I don't feel the braces are necessary" or "I am not comfortable with applying and removing the braces" was associated with significantly increased risk of overall failure. CONCLUSIONS Gathering insight from the caregiver's perspective can help identify barriers to treatment not recognized by the provider. Lack of comfortability with the orthosis and lack of understanding are associated with increased risk of overall failure. A better understanding of the caregiver's perspective on barriers to treatment could help guide the Ponseti method provider's educational efforts. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Andrew H Miller
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis
| | | | - Leslie N Rhodes
- Division of Orthopedic Surgery, ULPS Cerebral Palsy Clinic, Le Bonheur Children's Hospital, Memphis, TN
| | - Lindsey L Locke
- Division of Orthopedic Surgery, ULPS Cerebral Palsy Clinic, Le Bonheur Children's Hospital, Memphis, TN
| | - Derek M Kelly
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, Memphis
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Sassi FM, Nazario FAS, Bardelli G, Pauleto AC. Congenital Clubfoot: Difficulties in Maintaining the Use of the Dennis-Brown Orthosis by Caregivers. Rev Bras Ortop 2024; 59:e613-e616. [PMID: 39239580 PMCID: PMC11374405 DOI: 10.1055/s-0044-1788785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/14/2023] [Indexed: 09/07/2024] Open
Abstract
Objective This study aimed to identify the main difficulties faced by the family when a child with congenital clubfoot (CC) uses the Dennis-Brown orthosis. Method This study interviewed via Google Forms caregivers of children treated from 2015 to 2018 regarding their difficulties in orthosis use. Results The answers revealed that orthosis-related difficulties are independent of the child's gender, age, or affected side. We noted that 41.7% of the respondents reported some difficulty, especially the child's irritation when using the orthosis (93.3%). Conclusion The main factor in CC relapses is poor adherence to orthosis use. As a result, studying factors causing or increasing the probability of interrupting orthosis use is significant in creating strategies to facilitate their use, potentially reducing CC recurrence.
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Raslan EE, Bakhamees BH, Turjoman LA, Alalqam NN, Alalqam BN, Alhaddad BJ, Alim A, Alharbi AM, Alqahtani AH, Omaish OM, AlEdwani B, Dawas R. Kite Versus Ponseti Method in the Treatment of Idiopathic Congenital Clubfoot: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e63030. [PMID: 39050348 PMCID: PMC11268083 DOI: 10.7759/cureus.63030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Kite and Ponseti methods are two popular manipulating methods for correcting the deformity of idiopathic congenital clubfoot. We aimed to compare the efficacy of Kite and Ponseti methods in the treatment of children with idiopathic congenital clubfoot. A search was launched on Medline/PubMed, Cochrane Central Register of Controlled Trials, the Web of Science, ProQuest, and Scopus without limits, from inception to May 1, 2024. The outcomes included the rates of initial correction and relapse (primary) as well as the number of casts and duration of treatment (secondary). Mean difference (MD) and risk ratio (RR) were calculated for numerical and dichotomous outcomes, respectively, with 95% confidence intervals (CIs). Nine studies were included. Meta-analysis showed the Ponseti method is significantly associated with a higher probability of correction (n = 6, RR = 1.23 [95% CI = 1.14, 1.32], p < 0.001) and a lower risk of relapse (n = 5, RR = 0.50 [95% CI = 0.36, 0.71], p < 0.001) compared to the Kite method. The Ponseti method utilized a lower number of casts (MD = -3.0 [95% CI = -5.8, -0.2], p = 0.04) and took a shorter duration (MD = -39.76 [95% CI = -67.22, -12.30], p = 0.02) than the Kite method. Evidence suggests that the Ponseti method results in better outcomes than the Kite method in terms of successful initial correction and lower relapse rates. However, the available studies showed varying degrees of risk of bias, and the length of follow-up was inadequate in some studies.
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Affiliation(s)
| | | | | | | | | | | | - Abdallah Alim
- College of Medicine, King Khalid University, Abha, SAU
| | - Asma M Alharbi
- College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, SAU
| | | | - Olaa M Omaish
- College of Medicine, King Khalid University, Abha, SAU
| | - Batoul AlEdwani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Rawyah Dawas
- College of Medicine, King Khalid University, Abha, SAU
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Milanovic F, Ducic S, Jankovic M, Sindjic-Antunovic S, Dubljanin-Raspopović E, Aleksic M, Djuricic G, Nikolic D. Clinical Characteristics and Whole Exome Sequencing Analysis in Serbian Cases of Clubfoot Deformity-Single Center Study. CHILDREN (BASEL, SWITZERLAND) 2024; 11:647. [PMID: 38929227 PMCID: PMC11201961 DOI: 10.3390/children11060647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/09/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Recognized as one of the most serious musculoskeletal deformities, occurring in 1-2 per 1000 newborns, 80% of clubfeet are idiopathic while 20% present with associated malformations. The etiopathogenesis of clubfoot is described as multifactorial, including both genetic and environmental risk factors. The aim of this study was to analyze possible genetic causes of isolated and syndromic clubfoot in Serbian children, as well as to correlate clinical and genetic characteristics that would provide insight into clubfoot etiopathogenesis and possibly contribute to global knowledge about clinical features of different genetically defined disorders. METHODS We evaluated 50 randomly selected, eligible children with clubfoot aged 3 to 16 years that were initially hospitalized and treated at University Children's Hospital between November 2006 and November 2022. The tested parameters were gender, age, dominant foot, affected foot, degree of deformity, treatment, neuromuscular disorders, positive family history, and maternal smoking. According to the presence of defined genetic mutation/s by whole exome sequencing (WES), patients were separated into two groups: positive (with genetic mutation/s) and negative (without genetic mutation/s). RESULTS Seven patients were found to be positive, i.e., with genetic mutation/s. A statistically significant difference between categorical variables was found for families with a history of clubfoot, where more than half (57.14%) of patients with confirmed genetic mutation/s also had a family history of genetic mutation/s (p = 0.023). CONCLUSIONS The results from this study further expand the genetic epidemiology of clubfoot. This study contributes to the establishment of genetic diagnostic strategies in pediatric patients with this condition, which can lead to more efficient genetic diagnosis.
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Affiliation(s)
- Filip Milanovic
- Pediatric Surgery Department, University Children’s Hospital, 11000 Belgrade, Serbia; (S.D.); (S.S.-A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (E.D.-R.); (M.A.); (G.D.); (D.N.)
| | - Sinisa Ducic
- Pediatric Surgery Department, University Children’s Hospital, 11000 Belgrade, Serbia; (S.D.); (S.S.-A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (E.D.-R.); (M.A.); (G.D.); (D.N.)
| | - Milena Jankovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (E.D.-R.); (M.A.); (G.D.); (D.N.)
- Neurology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Sanja Sindjic-Antunovic
- Pediatric Surgery Department, University Children’s Hospital, 11000 Belgrade, Serbia; (S.D.); (S.S.-A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (E.D.-R.); (M.A.); (G.D.); (D.N.)
| | - Emilija Dubljanin-Raspopović
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (E.D.-R.); (M.A.); (G.D.); (D.N.)
- Center for Physical Medicine and Rehabilitation, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Milica Aleksic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (E.D.-R.); (M.A.); (G.D.); (D.N.)
- Center for Physical Medicine and Rehabilitation, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Goran Djuricic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (E.D.-R.); (M.A.); (G.D.); (D.N.)
- Radiology Department, University Children’s Hospital, 11000 Belgrade, Serbia
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.J.); (E.D.-R.); (M.A.); (G.D.); (D.N.)
- Department of Physical Medicine and Rehabilitation, University Children’s Hospital, 11000 Belgrade, Serbia
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Tabard-Fougère A, Bonnefoy-Mazure A, Dayer R, Vazquez O, De Coulon G. The Importance of Having a Single, Dedicated Medical Team to Treat Congenital Talipes Equinovarus Using the Ponseti Method: A Retrospective Analysis of Treatment Outcomes After 3 Years of Follow-up. J Pediatr Orthop 2024; 44:e361-e368. [PMID: 38189483 PMCID: PMC10913856 DOI: 10.1097/bpo.0000000000002613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Congenital talipes equinovarus (CTEV) is a relatively common pediatric orthopaedic disorder and a frequent cause of disability in adult populations. The Ponseti method has emerged as the generally preferred for treating children with CTEV. Strict adherence to this technique's basic principles is critical to achieving favorable outcomes. In 2013, our institution decided that every case of pediatric CTEV would be treated by a single dedicated medical team. The present study aimed to compare the treatment outcomes of children with CTEV treated using the Ponseti method in period I (multiple surgeons) versus those in period II (single dedicated team). PATIENTS AND METHODS We included respectively the children with CTEV treated using the Ponseti method in Geneva University Hospitals' pediatric units from 2007 to 2018. Data on patient demographics, clinical characteristics, and the treatment outcomes were collected. The primary outcome was the number of relapsed feet (treatment failure) after 3 years of follow-up. The 2 periods' outcomes were compared using χ 2 and independent Student t -tests. Run charts were used to report yearly rates of complications, minor and major recurrences, treatment failure, brace noncompliance, and feet that underwent tenotomy. RESULTS A total of 48 feet (32 patients) and 42 feet (29 patients) in periods I and II were included. The periods showed similar rates for participants' characteristics. The run charts illustrated the overall improvements in treatment outcomes in period II. A total of 8 relapsed feet (5 patients) were reported, all during period I. CONCLUSIONS Since all the pediatric CTEV patients at our institution began to be treated by a single dedicated medical team, we have observed a decrease in all recurrences and complications and an absence of treatment failure. These results highlight the importance of the continuity of care and strict adherence to the Ponseti method. LEVEL OF EVIDENCE Level-III Retrospective comparative study.
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Affiliation(s)
| | - Alice Bonnefoy-Mazure
- Kinesiology Laboratory, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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Williams ML, Dobbs MB. Clubfoot: Emphasis on the Complex and Atypical Subsets. Clin Podiatr Med Surg 2024; 41:17-25. [PMID: 37951674 DOI: 10.1016/j.cpm.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
The Ponseti method has proven to be successful in the treatment of both isolated and non-isolated clubfoot. The method should be executed prior to any pediatric invasive procedures and likewise should be attempted with any pediatric recurrence. A thorough neurologic examination and attention to clinical signs will help distinguish the atypical clubfoot. Despite this approach some children do require return to serial casting, physical therapy, and or surgery to achieve a plantigrade functional foot. Bracing strategies at a time of growth remain key.
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Affiliation(s)
- Mitzi L Williams
- Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics and Podiatric Surgery, Kaiser Permanente, 3600 Broadway, Oakland, CA 94611, USA.
| | - Matthew B Dobbs
- Palm Beach International Surgery Center, Paley Institute, 5325 Greenwood Avenue, Suite 203, West Palm Beach, FL 33407, USA; Clinical Orthopaedics and Related Research; United States Bone and Joint Initiative; Association of Bone and Joint Surgeons; International Federation of Pediatric Orthopaedic Societies
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Drury G, Nunn TR, Dandena F, Smythe T, Lavy CBD. Treating Older Children with Clubfoot: Results of a Cross-Sectional Survey of Expert Practitioners. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6846. [PMID: 37835115 PMCID: PMC10572625 DOI: 10.3390/ijerph20196846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023]
Abstract
Treating clubfoot in walking-age children is debated, despite studies showing that using the Ponseti casting principles can correct the midfoot effectively. We aimed to explore techniques and approaches for the management of older children with clubfoot and identify consensus areas. A mixed-methods cross-sectional electronic survey on delayed-presenting clubfoot (DPC) was sent to 88 clubfoot practitioners (response rate 56.8%). We collected data on decision-making, casting, imaging, orthotics, surgery, recurrence, rehabilitation, multidisciplinary care, and contextual factors. The quantitative data were analysed using descriptive statistics. The qualitative data were analysed using conventional content analysis. Many respondents reported using the Pirani score and some used the PAVER score to aid deformity severity assessment and correctability. Respondents consistently applied the Ponseti casting principles with a stepwise approach. Respondents reported economic, social, and other contextual factors that influenced the timing of the treatment, the decision to treat a bilateral deformity simultaneously, and casting intervals. Differences were seen around orthotic usage and surgical approaches, such as the use of tibialis anterior tendon transfer following full correction. In summary, the survey identified consensus areas in the overall principles of management for older children with clubfoot and the implementation of the Ponseti principles. The results indicate these principles are well recognised as a multidisciplinary approach for older children with clubfoot and can be adapted well for different geographical and healthcare contexts.
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Affiliation(s)
- Grace Drury
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7HE, UK
| | - Timothy R. Nunn
- CURE Children’s Hospital of Ethiopia, P.O. Box 21634, Addis Ababa 1000, Ethiopia
| | - Firaol Dandena
- CURE Children’s Hospital of Ethiopia, P.O. Box 21634, Addis Ababa 1000, Ethiopia
| | - Tracey Smythe
- International Centre for Evidence in Disability, Department of Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town 7602, South Africa
| | - Christopher B. D. Lavy
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7HE, UK
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Saini R, Sharma A, Ravalji D, Baisoya K, Sharma G. A Prospective Study on Functional Outcomes of Serial Cast Correction in Congenital Talipes Equinovarus (CTEV) by Ponseti Method. Cureus 2023; 15:e35987. [PMID: 37041913 PMCID: PMC10083060 DOI: 10.7759/cureus.35987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 03/12/2023] Open
Abstract
INTRODUCTION Congenital talipes equinovarus (CTEV), often known as clubfoot, is one of the most common congenital deformities of the foot and ankle, affecting one in every 1,000 live births. The deformity has four components: ankle equinus, hindfoot varus, forefoot adductus, and midfoot cavus. The Ponseti casting technique of CTEV management has proven to be more effective, generating higher positive outcomes and lesser complications than conventional surgical methods. METHODS This study was conducted in a tertiary care teaching hospital centre in southern Rajasthan, India. Twenty cases with 31 feet of untreated clubfoot were included. The deformity was scored according to Pirani's scoring system. Manipulation and serial corrective casts were applied at weekly intervals according to Ponseti's method. Percutaneous tendoachilles tenotomy was done whenever required (guided by Pirani score). Final results were calculated using the Pirani score, noted before putting the patient on foot abduction orthosis. RESULTS In our study, the average number of casts required for full correction was 6.5. Heel cord tenotomy was required in 27 feet (87%) to achieve full correction. Final Pirani score significantly improved from an average of 4.8 on presentation to 0.055 after completion of casting. CONCLUSION We conclude that the Ponseti technique of CTEV correction significantly reduces the need for invasive surgical procedures along with being exceedingly safe, effective, and affordable. The Ponseti technique of cast correction is crucial and provides a painless, plantigrade, cosmetically acceptable foot with higher functional outcomes and minimal complications.
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Affiliation(s)
- Ramavtar Saini
- Orthopaedics, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Anshu Sharma
- Orthopaedics, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Divyaraj Ravalji
- Orthopaedics, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Kuldeep Baisoya
- Orthopaedics, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Garima Sharma
- Obstetrics and Gynaecology, Geetanjali Medical College and Hospital, Udaipur, IND
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Yolaçan H, Güler S, Özmanevra R. Clubfoot from past to the present: A bibliometric analysis with global productivity and research trends. Medicine (Baltimore) 2023; 102:e32803. [PMID: 36820544 PMCID: PMC9907969 DOI: 10.1097/md.0000000000032803] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Clubfoot, a common congenital abnormality, affects the lower extremities; however, the literature search revealed no bibliometric research on this subject. Thus, we aimed to holistically analyze scientific articles and reveal global productivity and trend issues. This study statistically analyzed 1417 published articles on clubfoot (1980-2021) from the Web of Science database. Bibliometric network visualization maps were created to reveal trend topics, citation analysis, and cross-country collaborations. The analysis was conducted using Spearman correlation analysis. An exponential smoothing estimator was used to predict article productivity. The United States of America (433, 30.5%), the United Kingdom (166, 11.7%), and India (107, 7.5%) are the top 3 countries contributing to the literature. The Journal of Pediatric Orthopedics (220 articles), the Journal of Pediatric Orthopedics-Part B (147 articles), and Clinical Orthopedics and Related Research (69 articles) are the top 3 most productive journals. Dobbs MB (34 articles) is the most active author, and Shriners Hospital Children (44 articles) is the most active institution. Bibliometric analysis revealed that recently studied trend topics included Pirani score, Dimeglio score, Ponseti method, Ponseti casting, tenotomy, recurrence, neglected, tendon transfer, bracing, gait, risk factors, pedobarography, complex clubfoot, and polymorphism. The most studied subjects included Ponseti technique, treatment/casting, recurrent/relapsed clubfoot, Pirani score, pediatrics/children, foot deformities, surgery, ultrasound, Achilles tendon/tenotomy, gait analysis, casting, outcomes, neglected clubfoot, and tenotomy. Research leadership was determined in the western and European countries and Canada in studies and scientific collaborations on clubfoot; its impact was remarkable in India, China, and Turkey.
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Affiliation(s)
- Hakan Yolaçan
- Aksaray Training and Research Hospital, Orthopaedics and Traumatology, Aksaray, Turkey
- * Correspondence: Hakan Yolaçan, Aksaray Training and Research Hospital, Orthopaedics and Traumatology, Aksaray 68200, Turkey (e-mail: )
| | - Serkan Güler
- Aksaray Training and Research Hospital, Orthopaedics and Traumatology, Aksaray, Turkey
| | - Ramadan Özmanevra
- Cyprus International University, Orthopaedics and Traumatology, Nicosia, Cyprus
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The Ponseti Method for the Treatment of Clubfeet Associated With Down Syndrome: A Single-institution 18-year Experience. J Pediatr Orthop 2023; 43:e106-e110. [PMID: 36322976 DOI: 10.1097/bpo.0000000000002293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although the Ponseti method has been used with great success in a variety of nonidiopathic clubfoot deformities, the efficacy of this treatment in clubfeet associated with Down syndrome remains unreported. The purpose of this study is, therefore, to compare treatment characteristics and outcomes of clubfoot patients with Down syndrome to those with idiopathic clubfoot treated with the Ponseti method. METHODS An Institutional Review Board-approved, retrospective review of prospectively gathered data were performed at a single pediatric hospital over an 18-year period. Patients with either idiopathic clubfeet or clubfeet associated with Down syndrome who were less than 1 year of age at the outset of treatment were treated by the Ponseti method, and had a minimum of 2 year's follow-up were included. Initial Dimeglio score, number of casts, need for heel cord tenotomy, recurrence, and need for further surgery were recorded. Outcomes were classified using the Richards classification system: "good" (plantigrade foot +/- heel cord tenotomy), "fair" (need for a limited procedure), or "poor" (need for a full posteromedial release). RESULTS Twenty clubfeet in 13 patients with Down syndrome and 320 idiopathic clubfeet in 215 patients were identified. Average follow-up was 73 months for the Down syndrome cohort and 62 months for the idiopathic cohort. Down syndrome patients presented for treatment at a significantly older age (61 vs. 16 d, P =0.00) and with significantly lower average initial Dimeglio scores than the idiopathic cohort (11.3 vs. 13.4, P =0.02). Heel cord tenotomy was performed in 80% of the Down syndrome cohort and 79% of the idiopathic cohort ( P =1.00). Recurrence rates were higher in the Down syndrome cohort (60%) compared with the idiopathic group (37%), but this difference was not statistically significant ( P =0.06). Need for later surgical procedures was similar between the 2 cohorts, though recurrences in the Down syndrome group were significantly less likely to require intra-articular surgery (8.3% vs. 65.5%, P =0.00). Clinical outcomes were 95% "good," 0% "fair," and 5% "poor" in the Down syndrome cohort and 69% "good," 27% "fair," and 4% "poor" in the idiopathic cohort ( P =0.01). CONCLUSIONS Despite the milder deformity and an older age at presentation, clubfeet associated with Down syndrome have similar rates of recurrence and may have better clinical outcomes when compared with their idiopathic counterparts. When deformities do relapse in Down syndrome patients, significantly less intra-articular surgery is required than for idiopathic clubfeet. LEVEL OF EVIDENCE Level III.
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Prospective, Randomized Ponseti Treatment for Clubfoot: Orthopaedic Surgeons Versus Physical Therapists. J Pediatr Orthop 2023; 43:e93-e99. [PMID: 36607913 DOI: 10.1097/bpo.0000000000002291] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Clubfoot is a common congenital foot deformity in children. The Ponseti method of serial casting has become the standard of care in clubfoot treatment. Clubfoot casting is performed in many centers by both orthopaedic surgeons and physical therapists (PTs); however, direct comparison of outcomes and complications of this treatment between these providers is limited. This study prospectively compared the outcomes of patients with clubfoot treated by these 2 groups of specialists. METHODS Between January 2010 and December 2014, all patients under the age of 12 months with a diagnosis of clubfoot were included. Patients were randomized to an orthopaedic surgeon (MD) group or a PT group for weekly serial casting. Main outcome measures included the number of casts required to achieve correction, clinical recurrence of the deformity, and the need for additional surgical intervention. RESULTS One hundred twenty-six infants were included in the study. Patient demographics and characteristics (sex, race, family history of clubfoot, laterality, and severity of deformity) were similar between treatment groups, with the only significant difference being the mean age of entry into the study (5.2 weeks in the MD group and 9.2 weeks in the PT group, P=0.01). Mean length of follow-up was 2.6 years. The number of casts required trended to a lower number in the MD group. There was no significant difference in the rates of clinical recurrence or additional surgical intervention between groups. CONCLUSIONS Ponseti casting for treatment of clubfoot performed by orthopaedic surgeons and PTs results in equivalent outcomes without any difference in complications. Although the number of casts required trended to a lower number in the MD group, this likely did not result in any clinical significance, as the difference in cast number equaled <1 week's difference in the overall duration of serial casting. LEVEL OF EVIDENCE Level I-therapeutic.
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Dong W, Shi N, Wen C, Zhang Y. An investigation of maternal psychological status of children with congenital talipes equinovarus treated with the Ponseti method. J Child Orthop 2023; 17:184-190. [PMID: 37034198 PMCID: PMC10080240 DOI: 10.1177/18632521221145479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/23/2022] [Indexed: 01/07/2023] Open
Abstract
Objectives: To investigate maternal psychological status of children with congenital talipes equinovarus in different periods, and to clarify the influence on maternal psychological status of congenital talipes equinovarus treated with the Ponseti method. Methods: Sixty-seven mothers of children with congenital talipes equinovarus were investigated. Self-rating Depression Scale and Self-rating Anxiety Scale were used to evaluate the psychological stress of the mothers at different periods. Paired-samples t-test was used to analyze the results. Results: The mothers of 67 children with congenital talipes equinovarus ranged from 25 to 38 years old, with an average of 33.5 years old. Before prenatal diagnosis of congenital talipes equinovarus, the average score of Self-rating Anxiety Scale was 42.537 ± 10.476, and the average score of Self-rating Depression Scale was 47.254 ± 12.846; after prenatal diagnosis of congenital talipes equinovarus, the average score of Self-rating Anxiety Scale was 54.224 ± 13.050, and the average score of Self-rating Depression Scale was 57.403 ± 13.649 points. Before the postpartum treatment of congenital talipes equinovarus, the average score of Self-rating Anxiety Scale was 53.388 ± 12.716, the average score of Self-rating Depression Scale was 56.284 ± 13.617; after the treatment of congenital talipes equinovarus with the Ponseti method, the average score of Self-rating Anxiety Scale was 47.731 ± 12.259, and the average score of Self-rating Depression Scale was 51.910 ± 13.878 points. The above differences were statistically significant (P < 0.001). Conclusion: The prenatal diagnosis of congenital talipes equinovarus will increase the maternal psychological stress, and the maternal psychological status will be significantly improved after the deformity of congenital talipes equinovarus is corrected effectively by the Ponseti method. Level of evidence: level III, retrospective study.
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Affiliation(s)
- Wentao Dong
- Department of Orthopaedics, Shenzhen
University General Hospital, Shenzhen, P.R. China
| | - Ningning Shi
- Department of Operating Room and
Anesthesia, Shenzhen University General Hospital, Shenzhen, P.R. China
| | - Chunyu Wen
- Department of Orthopaedics, Shenzhen
University General Hospital, Shenzhen, P.R. China
| | - Yong Zhang
- Department of Orthopaedics, Shenzhen
University General Hospital, Shenzhen, P.R. China
- Yong Zhang, Department of Orthopaedics,
Shenzhen University General Hospital, Shenzhen 518055, P.R. China.
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Muacevic A, Adler JR, Edokpayi F, Chong HH, Shyamsundar S. A Systematic Review and Single Center Experience With Percutaneous Needle Tenotomy in Congenital Talipes Equinovarus (CTEV). Cureus 2022; 14:e32812. [PMID: 36694491 PMCID: PMC9860527 DOI: 10.7759/cureus.32812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
Percutaneous scalpel tenotomy is frequently performed as part of congenital talipes equinovarus (CTEV) to correct the equinus deformity. The use of a scalpel is associated with complications such as neurovascular bundle damage and pseudoaneurysms. In the literature, a percutaneous large-bore needle has been found to be a safer alternative to a scalpel for performing tenotomies. The goal of this study was to conduct a systematic review and report a single-center case series on the use of percutaneous needle tenotomy in the treatment of CTEV. A Preferred Reporting Items of Systematic Review and Meta-analysis (PRISMA)-compliant literature search was conducted to identify studies describing the use of a percutaneous needle tenotomy in the treatment of idiopathic CTEV. A retrospective case series of patients with idiopathic CTEV treated with percutaneous needle tenotomy over a seven-year period from a single center were also conducted. The patients' demographics, the location of the clubfoot, and the Pirani score were all recorded. An analysis of descriptive statistics was carried out. Continuous data were expressed as mean and SD, whereas categorical variables were expressed as absolute numbers and percentages (%). The systematic review included eight papers with a total of 1026 feet and a mean age of 10.4 weeks (SD 5.9). There were 47 (0.04%) complications across all studies, with a pooled success rate of 95%. Eleven patients (16 feet) were included in the single-center case study. The patients' initial Pirani score was 4.8 (SD 1.5), with a final score of 0. (SD 0). Four complications occurred in the patient's cohort - one minor bleeding and three recurrences as a result of poor compliance with the post-tenotomy foot abduction brace. In conclusion, the percutaneous Achilles tenotomy of a CTEV foot with a large bore needle is a safe and effective alternative.
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Rangasamy K, Baburaj V, Gopinathan NR, Sudesh P. Techniques, anaesthesia preferences, and outcomes of Achilles tenotomy during Ponseti method of idiopathic clubfoot correction: A systematic review. Foot (Edinb) 2022; 52:101922. [PMID: 36030649 DOI: 10.1016/j.foot.2022.101922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 03/13/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Achilles tenotomy (AT) forms an important aspect of Ponseti's casting method and is performed in 80-90% of idiopathic clubfoot cases to correct residual hindfoot equinus. Different techniques are described in the literature with no clarity on which method is superior. This review aims to analyse the various techniques described, anaesthesia preferences, and outcomes of AT. METHODS We searched PubMed, Embase, Scopus, and Ovid MEDLINE for articles describing idiopathic clubfoot cases undergoing primary AT during Ponseti's casting method. Data were extracted from eligible studies for qualitative and quantitative synthesis. The repeat tenotomy and complication rates were taken as outcome parameters. RESULTS Nineteen studies were included for systematic review. A percutaneous AT using a scalpel or needle is adequate in most cases and shows promising results. The out-patient department (OPD) tenotomies under local anaesthesia (LA) and operation room (OR) tenotomies under general anaesthesia (GA) were associated with a repeat tenotomy (RT) rate of 2.5% (95%CI, 0.4-5.4%) and 0.8% (95%CI, 0-1.6%), respectively. The difference between OPD and OR groups was not statistically significant (p = 0.875). The pooled analysis shows a failure/relapse rate of 4.2% (1.9-6.4%, p < 0.001) after AT. OPD and OR tenotomies were associated with a complication rate of 1.6% (95%CI, 0.2-3.0%) and 0.5% (95%CI, 0.1-0.8%), respectively, and the difference was not statistically significant (p = 0.807). Bleeding is the most common complication and is controlled in most cases by applying local pressure. CONCLUSION Performing Achilles tenotomy in OPD under LA is safe and cost-effective with similar success rates to those done under GA. With the lack of many comparative and higher-level evidence studies at present, we can't conclude if one technique is better than another.
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Affiliation(s)
- Karthick Rangasamy
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Vishnu Baburaj
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Nirmal Raj Gopinathan
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Pebam Sudesh
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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How to Cope with the Ponseti Method for Clubfoot: The Families’ Standpoint. CHILDREN 2022; 9:children9081134. [PMID: 36010025 PMCID: PMC9406557 DOI: 10.3390/children9081134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/17/2022] [Accepted: 07/26/2022] [Indexed: 11/17/2022]
Abstract
(1) Background: The Ponseti Method is the gold standard for the treatment of congenital clubfoot. It is a low-cost treatment consisting in a series of plaster casts, a percutaneous Achilles’ tenotomy and a Mitchell Ponseti brace to wear with a definite protocol. This treatment allows children to be with their families instead of being hospitalized. This advantage is also a challenge for the families that have to follow the protocol at home. This paper aims to analyze the perception, the difficulties and the overcomes of the families during the treatment. (2) Methods: We used a 41 questions questionnaire by Nogueira and Morquende. Questions were answered by families who had already finished the treatment or were still following it. (3) Results: We interviewed 92 families. The worst handling phase appeared to be the cast phase, while the brace seemed more bearable. In total, 57 families overrated tenotomy; (4) Conclusions: Families perceived the Ponseti Method as a quality treatment. The anxiety about the diagnosis played a strong role, but none of the difficulties encountered decreased the treatment outcomes or affected families’ adherence to the protocol. The open-ended answers highlighted that the positive relationship with doctors played a key role in the everyday compliance and the achievement of good results.
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Elbaum R, Noel B, Degueldre V, Hallez M, Filloque E, Guerin V, Duvivier A. 20 years of functional treatment for clubfoot: advantages and limitations compared with the Ponseti method. J Pediatr Orthop B 2022; 31:382-390. [PMID: 33741833 DOI: 10.1097/bpb.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Currently, the Ponseti method has become the most popular technique for the management of congenital clubfoot. Besides this treatment, the functional method or the 'French method' (FFM) represents another treatment option. Throughout our study, we will describe this method, based on the 'Saint Vincent de Paul' protocol with some modifications that we bring progressively. Carried out over the last 20 years at our institution. In total 145 children (210 clubfeet) were treated using FFM. Our technique is based on the 'Saint Vincent de Paul' protocol from Paris. This method consists of daily manipulations of the feet by specialised physiotherapists associated with thermoformable orthotics devices. An evaluation of the patient at 5 year of age is performed. Gait analysis was introduced in 2011 as a complementary assessment tool. Less than 15% of the feet underwent a surgical procedure at walking age. Compliance to treatment was significantly higher than with the Ponseti method. At the last follow-up, 80% of the children had good to excellent results without major residual deformity. Totally 7% of the children required a later intervention either for recurrence or for major residual deformity. FFM is an alternative approach in the management of clubfoot that has proven to be successful due to the precision and modularity of its splinting system. Good compliance and low recurrence rate are other elements to consider. However, it requires a well-trained physical therapist. The main disadvantages of this method are the high cost compared to the Ponseti method and the difficulty of applying this method in developing countries.
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Affiliation(s)
- Robert Elbaum
- Department of Orthopaedic surgery, CHIREC Hospital Group
| | - Brigitte Noel
- Department of Physiotherapy, IRIS South Hospital Center
| | | | - Marie Hallez
- Department of Physiotherapy, CHIREC Hospital Group, Belgium, Brussel
| | - Erelle Filloque
- Department of Physiotherapy, CHIREC Hospital Group, Belgium, Brussel
| | - Virginie Guerin
- Department of Physiotherapy, CHIREC Hospital Group, Hôpital de Braine L'Alleud, Rue Wayez, Braine L'Alleud, Belgium
| | - Amandine Duvivier
- Department of Physiotherapy, CHIREC Hospital Group, Hôpital de Braine L'Alleud, Rue Wayez, Braine L'Alleud, Belgium
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Pedrotti L, Bertani B, Tuvo G, Mora R, Marin L, De Rosa F. Achilles tendon surgery in clubfoot: Are long term sequelae predictable? LA PEDIATRIA MEDICA E CHIRURGICA 2022; 44. [PMID: 35506323 DOI: 10.4081/pmc.2022.280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 04/07/2022] [Indexed: 11/23/2022] Open
Abstract
Congenital Clubfoot (CCF) treatment involves a surgical procedure on the Achilles tendon most of the time, i.e. tenotomy or, in selected cases, Z-plasty lengthening. Many authors have studied the outcomes of Achilles tenotomy, describing complete clinical and ultrasound tendon fibers integrity restoration 3-6 weeks after surgery. Nevertheless, little is known about the mechanical properties of the operated tendon. Recently, cases of subcutaneous rupture of the Achilles tendon have been described in adolescents who practiced sports and who had undergone Achilles tenotomy for congenital clubfoot in childhood. Authors report two cases of atraumatic Achilles tendon injury (subcutaneous rupture and intratendinous ossification) in adult patients who had been treated for congenital clubfoot in childhood. In both cases, no causes determining the injury were identified; in the medical history there was a Z-plasty lengthening of the Achilles tendon, performed within the first year of life, which could be considered a predisposing factor. The usefulness of long-term monitoring of patients treated for CCF with surgical procedures on the Achilles tendon is therefore hypothesized, in order to promptly identify by symptoms, clinical pictures and ultrasound criteria, tendon suffering that may predispose subcutaneous rupture.
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Affiliation(s)
- Luisella Pedrotti
- Clinical Surgical Department, Diagnostic and Pediatric Sciences, Locomotor System Diseases Unit, University of Pavia, Pavia; Orthopedic and Traumatology Unit, Città di Pavia Institute, Pavia.
| | - Barbara Bertani
- Orthopedic and Traumatology Unit, Città di Pavia Institute, Pavia.
| | - Gabriella Tuvo
- Orthopedic and Traumatology Unit, Città di Pavia Institute, Pavia.
| | - Redento Mora
- Orthopedic and Traumatology Unit, Città di Pavia Institute, Pavia.
| | - Luca Marin
- Laboratory of Adapted Motor Activity, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia.
| | - Federica De Rosa
- Pediatric Orthopedic and Traumatology Unit, Children's Hospital, AON SS Antonio e Biagio e Cesare Arrigo, Alessandria.
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Ahmad AA, Ghanem AF, Hamaida JM, Maree MS, Aker LJ, Abu Kamesh MI, Berawi SN, Abu Hamdeh MS. Magnetic resonance imaging of severe idiopathic club foot treated with one-week accelerated Ponseti (OWAP) technique. Foot Ankle Surg 2022; 28:338-346. [PMID: 34016540 DOI: 10.1016/j.fas.2021.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 03/05/2021] [Accepted: 04/09/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE This study aims to evaluate changes in tarsal bones relationship after the use of one week accelerated Ponseti method in the treatment of severe idiopathic clubfoot using MRI. We hypothesize that one-week accelerated Ponseti is at least as effective as standard techniques in achieving the desirable MRI parameters. METHODS This is a prospective study of 8 children with severe idiopathic clubfeet (Pirani 6) (4 unilateral and 4 bilateral) treated before the age of three months with one-week accelerated Ponseti technique, as described in a former study with minimum 2-year follow-up. The 8 corrected feet were compared with the 4 unilateral normal feet at clinical and radiological levels using a Pirani scoring system and an MRI, respectively. RESULTS Clinical results showed that Pirani score was 1.1 in the last follow up in comparison to Pirani 6 pretreatment (p < 0.05). MRI results indicated that the malleocalcaneal angle, axial malleocalcaneal index, coronal tibiocalcaneal angle, sagittal talocalcaneal angle, and talar head neck calcaneal rotation showed statistical difference between the two groups (p < 0.05). Sagittal malleocalcaneal index, sagittal tibiocalcaneal angle, talar head neck rotation related to talar body, and posterior calcaneal rotation showed no statistical difference between normal feet and clubfeet after correction (p value >0.05). CONCLUSION One-week accelerated Ponseti technique showed to be as effective and safe as other treatment methods through clinical and MRI follow up data. MRI role was to confirm the efficiency of this innovative accelerated technique, but not used as a routine follow up.
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Affiliation(s)
- Alaaeldin Azmi Ahmad
- Professor Pediatric Orthopedic Surgery, Palestine Polytechnic University, PO Box 3985, Ramallah, Palestine.
| | - Ahmed F Ghanem
- Radiology Department, Annajah Medical School, Palestine.
| | | | - Mosab S Maree
- Radiology Department, Annajah Medical School, Palestine.
| | - Loai J Aker
- Radiology Department, Hamad Hospital, Qatar.
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Abstract
Idiopathic congenital clubfoot is the most common serious musculoskeletal birth defect in the United States and the world. The natural history of the deformity is to persist into adult life with a significant decrease in function and quality of life. The Ponseti method (serial casting, Achilles tenotomy, and bracing of the clubfoot) has become the most effective and accepted treatment of children born with clubfoot worldwide. The treatment is successful, particularly when the Ponseti-trained practitioner (often a pediatric orthopedic surgeon), the primary care clinician, and the family work together to facilitate success. An important factor in the ultimate success of the Ponseti method is parental understanding of the bracing phase. There is a very high rate of recurrent deformity when bracing is not done properly or is stopped prematurely. The importance of positive education and support for the parents to complete the entire treatment protocol cannot be overstated. The goal of treatment is a deformity-free, functional, comfortable foot. Ponseti clubfoot programs have been launched in most countries throughout the world, including many countries with limited resources. Ultimately, the goal is that every infant born with a clubfoot will have access to care with the Ponseti method. This clinical report is intended for medical practitioners who are involved in the care of pediatric patients with clubfoot. Understanding the standard of care will help these practitioners to care for patients and their families.
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Affiliation(s)
- Robert Cady
- Department of Orthopedic Surgery and Pediatrics, Upstate Medical University, Syracuse, New York,Address correspondence to Robert Cady, MD, FAAP. E-mail:
| | - Theresa A. Hennessey
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah,Shriners Hospitals for Children, Salt Lake City, Utah
| | - Richard M. Schwend
- Departments of Orthopedics and Pediatrics, Children’s Mercy Hospital, University of Missouri Kansas City, Kansas City, Kansas,Kansas University Medical Center, Kansas City, Kansas
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Aggarwal H, Jain A, Kohli N, Bansal N, Sahni G, Mathur M. Evaluation of results of ponseti technique in idiopathic clubfoot using clinical evaluation and radiological assessment. Int J Appl Basic Med Res 2022; 12:43-46. [PMID: 35265480 PMCID: PMC8848566 DOI: 10.4103/ijabmr.ijabmr_281_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 11/12/2021] [Accepted: 12/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Congenital clubfoot (congenital talipes equinovarus) occurs in approximately one in 1000 live births and is one of the most common congenital birth defects. The Ponseti method is at present a well-established method of treatment for idiopathic clubfoot deformities. Aim: The aim of the present study was to evaluate the results of serial casting in clubfoot deformity with Ponseti method on the basis of Pirani's scoring and radiological findings before and after completion of treatment. Materials and Methods: A total of 30 patients were enrolled in the study and were treated with Ponseti's casting after grading the severity of deformity clinically by Pirani's scoring and radiological assessment by calculating the talo-first metatarsal angle in anteroposterior (AP) view and talocalcaneal angle in AP and lateral views. The same clinical and radiological assessment was done at the end of treatment before putting a patient on foot abduction orthosis (FAO). Results: The average number of casts applied before full correction was 5.56 (range: 5–8). The average duration of treatment was about 6.65 weeks before the patient was put on FAO. Pirani score significantly improved from an average of 5.50 (range: 4–6) on presentation to 0.24 (range: 0–2) after correction of deformity. Conclusion: The Ponseti method is an excellent method for the correction of all four deformities associated with congenital idiopathic clubfoot, and we found that the addition of radiographic to clinical evaluation helps in the better assessment of correction. It provides statistically significant results both clinically as measured by Pirani severity score and radiologically assessed by talocalcaneal and talo-first metatarsal angle.
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Farrar EJ, Lo M, Groothoff L, Cunningham J, Theuri J. Two-year retrospective cohort results on use of a dynamic unilateral brace for treatment of clubfoot: Can compliance and prevention of recurrence both be achieved? J Rehabil Assist Technol Eng 2022; 9:20556683221112084. [PMID: 35845117 PMCID: PMC9280036 DOI: 10.1177/20556683221112084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives The Ponseti method has led to vast improvements in outcomes for infants born with
clubfoot deformity, but challenges with compliance during the bracing phase of the
protocol remain. Unilateral braces promise higher compliance but often have led to
unacceptably high recurrence. Methods We have developed a novel unilateral brace for clubfoot deformity that strategically
applies patient-specific, anatomically-targeted forces to the lower limb to maintain
correction. We retrospectively reviewed the cases of 26 patients with minimum follow-up
of 24 months. The data were analyzed for recurrence rates, caregiver-reported
compliance, and differences in Pirani score, dorsiflexion, abduction, hindfoot eversion,
and resting rotation between initial and final follow-up. Results Most patients (N = 23, 88%) were compliant with the bracing protocol.
Two patients showed recurrence of deformity (8%). There were statistically significant
improvements in Pirani score, dorsiflexion, abduction, hindfoot eversion, and resting
external rotation. A subset of patients with sub-optimal correction at baseline showed
improvement in all parameters across the course of bracing. Conclusions This novel unilateral brace for maintenance of clubfoot correction after Ponseti
treatment demonstrates rates of recurrence rates and caregiver-reported compliance at
2 years of follow up that are comparable to outcomes with traditional bilateral foot
abduction orthoses.
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Affiliation(s)
- Emily J Farrar
- Department of Engineering, Messiah University, Mechanicsburg, PA, USA
| | - Michelle Lo
- Department of Engineering, Messiah University, Mechanicsburg, PA, USA
| | - Luke Groothoff
- Department of Art, Messiah University, Mechanicsburg, PA, USA
| | | | - Joseph Theuri
- African Inland Church CURE International Hospital, Kijabe, Kenya
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Abstract
Clubfoot or talipes equinovarus deformity is one of the most common anomalies affecting the lower extremities. This review provides an update on the outcomes of various treatment options used to correct clubfoot. The ultimate goal in the treatment of clubfoot is to obtain a fully functional and pain-free foot and maintain a long-term correction. The Ponseti method is now considered the gold standard of treatment for primary clubfoot. Relapse is common after primary treatment with the Ponseti method, and other interventions are discussed that are used to provide for long-term successful outcomes.
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Anipole OA, Oginni LM, Ayoola OO, Adegbehingbe OO, Esan O, Mejabi JO. Determination of the Effective Site for Percutaneous Achilles Tenotomy in Ponseti Management of African Idiopathic Clubfoot. J Am Podiatr Med Assoc 2021; 111. [PMID: 35294152 DOI: 10.7547/20-109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Gupta P, Patil B, Gupta P, Mehta R, Gupta R. Peroneal Nerve Dysfunction in Patients with Clubfoot Deformity: Evaluation of Clinical Presentation and Treatment. Clin Orthop Surg 2021; 13:558-563. [PMID: 34868506 PMCID: PMC8609218 DOI: 10.4055/cios20261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/23/2021] [Accepted: 01/25/2021] [Indexed: 11/26/2022] Open
Abstract
Backgroud Complete peroneal nerve dysfunction associated with congenital clubfoot is uncommonly reported. Our retrospective study highlights the recognition of clinical presentation and mid-term outcomes of treatment in these patients. Methods Eight out of 658 patients undergoing treatment for clubfoot were identified with unilateral complete peroneal nerve dysfunction associated with congenital clubfoot. Three patients presented primarily to our center; 5 were treated elsewhere initially. All patients were treated with Ponseti casts, Achilles tenotomy, and subsequent foot abduction bracing. Diagnosis of complete peroneal nerve dysfunction was confirmed using nerve conduction velocity studies in all patients. After full-time bracing, an insole polythene molded ankle foot orthosis was given. Three patients underwent tibialis posterior transfer to improve foot dorsiflexor power. Results The mean age at presentation was 1.3 years (range, 1 week–5 years). All patients had prominence of lateral 3 metatarsal heads and dimpling of intermetatarsal spaces. At a mean follow-up of 5.1 years, mean shortening of 1.2 cm in tibia (range, 1–2.5 cm) and mean calf wasting of 4.4 cm were observed. There was no relapse of any clubfoot deformity till the final follow-up. Conclusions Prominence of lateral metatarsal heads and dimpling of intermetatarsal spaces should raise early suspicion of peroneal nerve dysfunction. Standard Ponseti protocol is useful in treatment of these patients. Tibialis posterior transfer to dorsum partially restores the ankle dorsiflexion.
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Affiliation(s)
- Parmanand Gupta
- Department of Orthopaedics, Government Medical College and Hospital, Chandigarh, India
| | - Bharath Patil
- Department of Orthopaedics, Government Medical College and Hospital, Chandigarh, India
| | - Prakash Gupta
- All India Institute of Medical Sciences, New Delhi, India
| | - Rohil Mehta
- Department of Orthopaedics, Government Medical College and Hospital, Chandigarh, India
| | - Ravi Gupta
- Department of Orthopaedics, Government Medical College and Hospital, Chandigarh, India
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Korth K, Bolam S, Leiferman E, Crenshaw T, Dray M, Crawford HA, Wallace M, Halanski MA. Histological and radiographic evaluation of three common tendon transfer techniques in an un-ossified bone porcine model: implications for early anterior tibialis tendon transfers in children with clubfeet. J Child Orthop 2021; 15:443-450. [PMID: 34858530 PMCID: PMC8582610 DOI: 10.1302/1863-2548.15.210076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/15/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To compare the histological healing and radiographic effects of tendons transferred to ossified or unossified bone using different tendon fixation techniques. METHODS Nine new-born piglets underwent bilateral tendon transfers to either the ossified boney calcaneal body or unossified apophysis. The tendons were fixed using metallic suture anchors, sutures alone or a bone tunnel. At six weeks of age, calcanei were harvested, radiologically imaged and then prepared for histology. A semi-quantitative aggregated scoring system with values ranging from 0 (poor) to 15 (excellent), was used to grade healing at the surgical enthesis and the apophyseal ossification was graded by five independent reviewers in triplicate using a modified (1 to 4) validated scoring system. RESULTS Histologically, the cartilaginous transfers utilizing the tunnel and suture techniques also demonstrated the best average aggregated scores of entheses healing rivalling that measured in transfers using the classic bone tunnel technique (clinical benchmark), whereas suture anchor fixation demonstrated the worst healing in both the ossified and unossified samples. All three transfer techniques caused at least minor alterations in apophyseal ossification, with the most significant changes observed in the metallic suture anchor cohort. The tunnel and suture techniques demonstrated similar and more mild abnormalities in ossification. CONCLUSION Tendon transfers to unossified bone heal histologically as well as transfers classically performed through tunnels in bone. Suture fixation or tunnel techniques appear radiographically and histologically superior to suture anchors in our newborn porcine model. LEVEL OF EVIDENCE
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Affiliation(s)
- Kyle Korth
- Department of Orthopaedic Surgery and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - Scott Bolam
- Department of Orthopaedic Surgery, Auckland Hospital, Auckland, New Zealand
| | - Ellen Leiferman
- Department of Orthopaedic Surgery and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - Thomas Crenshaw
- Department of Animal Sciences, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - Michael Dray
- Histology Department, Waikato Hospital, Hamilton, New Zealand
| | - Haemish A. Crawford
- Department of Paediatric Orthopaedic Surgery, Starship Children’s Health, Auckland, New Zealand
| | - Maegen Wallace
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha, Nebraska, United States
| | - Matthew A. Halanski
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha, Nebraska, United States
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Concomitant Talocalcaneal Coalition as a Risk Factor for Early Relapse Following Ponseti Treatment of Idiopathic Clubfoot. Diagnostics (Basel) 2021; 11:diagnostics11091682. [PMID: 34574023 PMCID: PMC8468355 DOI: 10.3390/diagnostics11091682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/12/2021] [Accepted: 09/12/2021] [Indexed: 11/25/2022] Open
Abstract
Concomitant talocalcaneal coalition (TCC) in idiopathic clubfeet is not well documented in the literature. The purpose of this study was to describe our experience with very early relapsing idiopathic clubfeet associated with TCC. Although cases have been successfully treated with the Ponseti casting method, all recurred within 2 months of removing the final cast. A single-centre cohort of twelve feet in eight patients treated by a single surgeon between 2006 and 2020 was investigated retrospectively. Recurred cavus with variable degrees of equinus was the earliest findings noted. TCC was incidentally detected during the open reduction of the earliest three feet in our series. Afterwards, ultrasonography was advised as a screening tool for detecting an associated anomaly; however, only the use of magnetic resonance imaging (MRI) was 100% accurate in diagnosing concurrent TCC. All coalitions were cartilaginous and the posterior facet was most commonly involved facet. The average age was 18 months for the coalition resection and open reduction of a dislocated talonavicular joint, and the average duration of follow-up was 52 months. None of the patients showed clinical signs of relapse at the latest follow-up. We recommend that an associated TCC should be considered in very early relapsing idiopathic clubfoot cases.
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The Ilizarov Fixator. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ranson JM, Nuttall G, Paton RW. Congenital Talipes Equinovarus: Results of Treatment and Are We Bracing Effectively? J Foot Ankle Surg 2021; 60:702-705. [PMID: 33573906 DOI: 10.1053/j.jfas.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 12/15/2020] [Accepted: 01/24/2021] [Indexed: 02/03/2023]
Abstract
The aim of this retrospective study was to assess our management of Congenial Talipes Equinovarus (CTEV) in relation to national standards published by the British Society for Children's Orthopaedic Surgery (BSCOS). A secondary aim was to evaluate if a more tailored bracing regime than advocated in the traditional Ponseti technique, would be appropriate for some cases of CTEV. One hundred and thirty-three feet in 96 patients were treated between June 2006 and January 2016. All patients were clinically assessed prospectively by the senior author at initial presentation using the Harrold & Walker classification system. A combination of the senior author's database, Elogbook and trust IT systems were used for data collection. The results of Ponseti surgical procedures such as tendoachilles release and tibialis transfer fell within the BSCOS guidelines. The rate of radical subtalar surgical release was higher than advocated (12.3%) which was partly due to the number of primary syndromal patients in the series. There was a significantly lower mean time spent in bracing of 14.3 months (95% confidence interval 14.8-19.3) compared to recommended national guidelines. There was a clinically significant difference in the lower relapse rate of female patients compared to male patients and also a higher propensity of surgical intervention in male patients. In addition, there was a statistically significant difference in both time spent in bracing, between H&W classifications and between patients who had bracing removed pre walking age or post walking age. This potentially demonstrates a more tailored bracing regime may be possible when applied to less severely affected feet and the condition may be more benign in female cases.
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Affiliation(s)
- John M Ranson
- Specialty Trainee, Orthopaedic Surgery Northwest Deanery, Blackburn, Lancashire, UK.
| | - Graham Nuttall
- Senior Orthotist, East Lancashire Hospitals NHS Trust, Blackburn, Lancashire, UK
| | - Robin W Paton
- Consultant Orthopaedic Surgeon & Honorary Professor, Medical School, University of Central Lancashire, Blackburn, Lancashire, UK
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Agarwal A, Rastogi A, Rastogi P. Relapses in clubfoot treated with Ponseti technique and standard bracing protocol- a systematic analysis. J Clin Orthop Trauma 2021; 18:199-204. [PMID: 34026487 PMCID: PMC8122108 DOI: 10.1016/j.jcot.2021.04.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/11/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The analysis determined the relapses in clubfoot children treated with Ponseti technique and standard bracing protocol and their correlation with overall follow up duration using pooled data from various series. It also tested the prescribed timelines of 5 and 7 years for slow-down/cessation of relapses in clubfoot children. METHODS A systematic literature search was performed for articles published in "Pubmed (includes Medline indexed journals)" electronic databases using key words: "Clubfoot or CTEV or congenital talipes equinovarus", "Ponseti" for years 1st January 2001 to 15th November 2020. Included were studies that addressed treatment of idiopathic clubfoot using the standard Ponseti technique, followed a well defined brace protocol (maintenance of corrected deformity using a central bar based brace and prescribed duration mentioned), reported a minimum mean follow up of 4 years and having relapse as one of their outcome measure. Studies reporting Ponseti technique for non-idiopathic clubfoot, child's age older than 1 year at the time of primary treatment, clubfoot with previous interventions before Ponseti treatment, where relapse and residual deformities were not identified distinctly in follow up, abstract only publications, letter to the editors, case reports, technique papers and review articles were excluded. The following characteristics of clubfoot patients in the selected articles were included for analysis: Patient numbers/feet treated with Ponseti technique; follow up years (<5; 5-7 and >7 years; overall) and corresponding relapse percentages for patients. RESULTS There were total 2206 patients in the included 24 studies. Average follow up was 6 years. The average relapse rates for clubfoot patients in the pooled data stood at 30%. The overall relapse rates increased with a longer follow up and the curve befitted a linear regression equation with weak positive correlation (Pearson correlation coefficient = 0.08). The relapse rates in follow up categories of <5 years (26.6 ± 15.6%), 5-7 years (30.8 ± 16.3%) and >7 years (28.4 ± 6.2%) were similar statistically (Analysis of variance, ANOVA). CONCLUSIONS Approximately 1 in 3 clubfoot patients suffer relapse post Ponseti technique and standard bracing protocol. A weak positive correlation was observed for relapses when correlated with increasing follow up years. The relapses however tend to slow down after initial growth years. There is a need to educate the care receivers regarding the possibility of late relapses despite proper Ponseti treatment and accordingly to keep them under supervised follow up for longer periods.
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Affiliation(s)
- Anil Agarwal
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India
| | - Anuj Rastogi
- Department of Orthopaedics, Integral Institute of Medical Sciences and Research, Integral University, Lucknow, Uttar Pradesh, India
| | - Prateek Rastogi
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 31, India
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Monforte S, Alberghina F, Paonessa M, Canavese F, Andreacchio A. Synthetic Cast Material Versus Plaster of Paris for the Treatment of Idiopathic Clubfoot by the Ponseti Protocol: A Comparative Analysis of 136 Feet. J Pediatr Orthop 2021; 41:296-300. [PMID: 33710129 DOI: 10.1097/bpo.0000000000001788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Synthetic casting materials have been used as alternatives to plaster of Paris (POP) in the treatment of clubfoot using the Ponseti method. The aim of this study was to evaluate the clinical outcome of children with idiopathic clubfoot managed by the Ponseti method using POP versus semirigid fiberglass (SRF). METHODS Medical records were retrospectively reviewed for all newborns with idiopathic clubfoot who underwent manipulation and casting by the Ponseti technique between January 2013 and December 2016 at 2 different institutions. In all, 136 consecutive clubfeet were included, of which 68 underwent casting with POP (Group A), and 68 were casted using SRF (Group B). Statistical analysis was performed using the Fisher exact test for categorical variables, and the unpaired t test for quantitative parameters. RESULTS Mean age at time of first cast was 10 days (range, 3 to 21 d). Mean Pirani score at start of treatment was 4.6 and 4.5 in Groups A and B, respectively. Mean number of casts for each patient in Group A was 5.2 against 4.2 in patients in Group B. Mean follow-up was 63.8 months (range, 42 to 88 mo). In each group, 4 cases of relapse were reported (2.9%). No complications related to cast phase or brace phase were recorded. Shorter duration of cast treatment was recorded in Group B. CONCLUSIONS Despite its higher cost and slightly lower moldability, the use of SRF in experienced hands showed comparable results in idiopathic clubfeet treated by the Ponseti technique. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sergio Monforte
- Pediatric Orthopedic Surgery Department, "Vittore Buzzi" Children's Hospital, Milano
| | - Flavia Alberghina
- Pediatric Orthopedic Surgery Department, "Regina Margherita" Children's Hospital, Torino, Italy
| | - Matteo Paonessa
- Pediatric Orthopedic Surgery Department, "Regina Margherita" Children's Hospital, Torino, Italy
| | - Federico Canavese
- Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre Hospital, Loos, France
| | - Antonio Andreacchio
- Pediatric Orthopedic Surgery Department, "Vittore Buzzi" Children's Hospital, Milano
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Ganesan B, Yip J, Luximon A, Gibbons PJ, Chivers A, Balasankar SK, Tong RKY, Chai R, Al-Jumaily A. Infrared Thermal Imaging for Evaluation of Clubfoot After the Ponseti Casting Method-An Exploratory Study. Front Pediatr 2021; 9:595506. [PMID: 33959569 PMCID: PMC8093797 DOI: 10.3389/fped.2021.595506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Conservative treatment, Ponseti method, has been considered as a standard method to correct the clubfoot deformity among Orthopedic society. Although the result of conservative methods have been reported with higher success rates than surgical methods, many more problems have been reported due to improper casting, casting pressure or bracing discomfort. Nowadays, infrared thermography (IRT) is widely used as a diagnostic tool to assess musculoskeletal disorders or injuries by detecting temperature abnormalities. Similarly, the foot skin temperature evaluation can be added along with the current subjective evaluation to predict if there is any casting pressure, excessive manipulation, or overcorrections of the foot, and other bracing pressure-related complications. Purpose: The main purpose of this study was to explore the foot skin temperature changes before and after using of manipulation and weekly castings. Methods: This is an explorative study design. Infrared Thermography (IRT), E33 FLIR thermal imaging camera model, was used to collect the thermal images of the clubfoot before and after casting intervention. A total of 120 thermal images (Medial region of the foot-24, Lateral side of the foot-24, Dorsal side of the foot-24, Plantar side of the foot-24, and Heel area of the foot-24) were collected from the selected regions of the clubfoot. Results: The results of univariate statistical analysis showed that significant temperature changes in some regions of the foot after casting, especially, at the 2nd (M = 32.05°C, SD = 0.77, p = 0.05), 3rd (M = 31.61, SD = 1.11; 95% CI: 31.27-31.96; p = 0.00), and 6th week of evaluation on the lateral side of the foot (M = 31.15°C, SD = 1.59; 95% CI: 30.75-31.54, p = 0.000). There was no significant temperature changes throughout the weekly casting in the medial side of the foot. In the heel side of the foot, significant temperature changes were noticed after the third and fourth weeks of casting. Conclusion: This study found that a decreased foot skin temperature on the dorsal and lateral side of the foot at the 6th week of thermography evaluation. The finding of this study suggest that the infrared thermography (IRT) might be useful as an adjunct assessment tool to evaluate the thermophysiological changes, which can be used to predict the complications caused by improper casting, over manipulative or stretching and casting-pressure related complications.
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Affiliation(s)
- Balasankar Ganesan
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Kowloon, Hong Kong
- School of Biomedical Engineering, University of Technology Sydney, Sydney, NSW, Australia
| | - Joanne Yip
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | | | - Paul J. Gibbons
- Orthopaedic Department, The Children's Hospital at Westmead (Sydney Children's Hospitals Network), Sydney, NSW, Australia
| | - Alison Chivers
- Physiotherapy Department, Children's Hospital at Westmead, Sydney, NSW, Australia
| | | | - Raymond Kai-Yu Tong
- Department of Biomedical Engineering, The Chinese University of Hong Kong, Shatin, China
| | - Rifai Chai
- Department of Telecommunications, Electrical, Robotics and Biomedical Engineering, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Adel Al-Jumaily
- School of Biomedical Engineering, University of Technology Sydney, Sydney, NSW, Australia
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Anipole OA, Adegbehingbe OO, Ayoola O. Confirmation of Tenotomy Healing at 3 Weeks Using the Ponseti Protocol. J Foot Ankle Surg 2021; 59:529-534. [PMID: 31952922 DOI: 10.1053/j.jfas.2019.08.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/16/2019] [Accepted: 08/13/2019] [Indexed: 02/03/2023]
Abstract
Percutaneous Achilles tenotomy is an integral key element of the Ponseti method in clubfoot management. The duration of posttenotomy casting has been empirical. Evidence-based duration of healing in Achilles tendon is required to objectively determine the period of posttenotomy casting. This study aims to use clinical and ultrasonographic methods to evaluate the mean duration of Achilles tendon gap (ATG) closure and the weekly percentage of feet that achieved ATG closure after tenotomy. Prospectively, 37 feet of 25 patients <5 years old with idiopathic clubfoot were managed using Ponseti methods. The Achilles tendon was assessed clinically and ultrasonographically before and after tenotomy. The tendon stump gap was created at tenotomy, and posttenotomy assessments were done on a weekly basis until tendon stump gap closure was achieved, with a minimum follow-up of 2 years. The immediate posttenotomy ultrasonographic mean tendon gap area was 5 ± 2.8 mm. The mean duration of the tendon stump gap closure as determined clinically was 1.9 ± 0.8 weeks, whereas it was 2.6 ± 0.9 weeks as assessed ultrasonographically (p < .001). The significant difference between clinical and ultrasound methods of assessing the Achilles tendon gap closure appears to establish casting removal and ambulatory walking at 3 weeks after tenotomy for <5-year-old children with idiopathic clubfoot treated with the Ponseti method. We recommend that the duration of posttenotomy cast should be 3 weeks based on the ultrasonographic findings.
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Affiliation(s)
- Olalekan A Anipole
- Lecturer and Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery and Traumatology, Obafemi Awolowo University, Ile Ife, Nigeria
| | - Olayinka O Adegbehingbe
- Professor and Head of Department of Orthopaedic Surgery and Traumatology, Obafemi Awolowo University, Ile Ife, Nigeria.
| | - Oluwagbenga Ayoola
- Senior Lecturer and Consultant Radiologist, Department of Radiology, Obafemi Awolowo University, Ile Ife, Nigeria
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Abstract
BACKGROUND Clubfoot deformity (pes equinovarus) is one of the most common birth defects, and its etiology is still unknown. Initial clubfoot treatment is based on the Ponseti method throughout most of the world. Despite the effectiveness of this therapy, clubfoot may relapse. Recent studies confirm the theory of active fibrotic remodeling processes in the extracellular matrix of the affected tissue. The aim of this study was to clarify whether relapses in clubfoot therapy are associated with altered angiogenesis and to suggest possible regulatory pathways of this pathologic process. METHODS We compared microvessel density, arteriole density, and concentration of angioproliferative-related proteins found between tissues in the contracted, that is, the medial side (M-side), and noncontracted, that is, the lateral side (L-side) of the relapsed clubfeet. Tissue samples from 10 patients were analyzed. Histopathologic analysis consisted of immunohistochemistry and image analysis. Real-time polymerase chain reaction was used to study mRNA expression. RESULTS An increase in microvessel and arteriole density was noted in contracted, relapsed clubfoot tissue. This was accompanied by a significant increase in the levels of the vascular endothelial growth factor, vascular endothelial growth factor receptor 2, β catenin and active β catenin. Vascular endothelial growth factor, vascular endothelial growth factor receptor 2, and CD31 overexpression was also seen with mRNA analysis. CONCLUSIONS Increased microvessel and arteriole density in the contracted side of the relapsed clubfoot was noted. These processes are mediated by specific proangiogenic proteins that are overexpressed in the contracted tissue. These findings contribute to the etiology and the development of relapses in the treatment of clubfoot. LEVEL OF EVIDENCE Level II-analytical and prospective.
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Implementation of a Ponseti Clubfoot Program Decreases Major Surgery: A Quality Improvement Initiative. Pediatr Qual Saf 2020; 5:e362. [PMID: 33575522 PMCID: PMC7870159 DOI: 10.1097/pq9.0000000000000362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 08/12/2020] [Indexed: 11/30/2022] Open
Abstract
Supplemental Digital Content is available in the text. Clubfoot describes a congenital condition. If untreated, clubfoot can cause long-term functional issues. The Ponseti method is the gold-standard treatment; it emphasizes casting over surgery. We identified a high rate of major recurrence in patients with isolated clubfoot at our institution. We implemented a quality improvement intervention to address the recurrences.
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Abstract
BACKGROUND Complex clubfoot is a term used to describe those feet that present after treatment with a short first metatarsal, severe plantar flexion of all metatarsals, rigid equinus, and deep folds through the sole of the foot and above the heel. Ponseti has described a modification of his original technique for the treatment of the deformity. Few series have reported the treatment outcomes of this group of patients. The purpose of this study is to analyze mid-term results and complications of a large multicenter cohort. METHODS Patients with complex clubfoot treated at 6 tertiary-care institutions with a minimum of 1-year follow-up were retrospectively analyzed. Demographic data, previous treatment, number of casts, Achilles tenotomy, recurrences, complications, and additional procedures were documented. The patients were clinically evaluated at the time of presentation, after treatment, and at the last follow-up according to the Pirani score. All variables had a nonparametric distribution and are thus described as median (interquartile range (IQR), minimum-maximum). A comparison between the variables was performed using a Mann-Whitney U test, the change within each group was performed with a Wilcoxon-designated range test. A P-value <0.05 was used to indicate statistical significance. RESULTS One hundred twenty-four feet (79 patients) were evaluated. The median age at initial treatment was 7 months (IQR, 15; min-max, 1 to 53 mo). The mean follow-up was 49 months (IQR, 42; min-max, 12 to 132 mo). A median of 5 casts (IQR, 5; min-max, 3 to 13) was required for correction. Percutaneous tenotomy of the Achilles tendon was performed in 96% of the feet. One hundred twenty-two feet (98%) were initially corrected; 2 feet could not be corrected and required a posteromedial release. The Pirani score improved significantly from a pretreatment mean of 6 points (IQR, 1; min-max, 4.5 to 6) to 0.5 (IQR, 0.5; min-max, 0 to 2.5) at the last follow-up (P <0.001). Seven feet (6%) presented minor complications related to casting. Relapses occurred in 29.8% (37/124). In this subgroup, the number of casts required at initial treatment was higher (6; IQR, 5; min-max, 1 to 12 vs. 4 IQR, 4; min-max, 1 to 13; P<0.001), and follow-up was significantly longer (62 mo; IQR, 58; min-max, 28 to 132 vs. 37 mo; IQR, 48, min-max, 7 to 115; P<0.001). CONCLUSIONS Ponseti method is safe and effective for the correction of complex clubfeet. Early diagnosis and strict adherence to the Ponseti principles are key to achieve deformity correction. Patients with complex clubfoot require frequent follow-up because of a higher recurrence rate. LEVEL OF EVIDENCE Level III-therapeutic study.
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Bertinatto R, Forlin E, Wustro L, Tolotti JO, de Souza GAL. A presença do pé torto congênito atrasa o início da marcha? Rev Bras Ortop 2020; 55:637-641. [PMID: 33093730 PMCID: PMC7575361 DOI: 10.1055/s-0040-1709201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 01/20/2020] [Indexed: 10/24/2022] Open
Abstract
Resumo
Objetivo O pé torto congênito (PTC) é uma das alterações ortopédicas congênitas que mais frequentemente necessita tratamento intensivo, e pouco se sabe o impacto desse tratamento no desenvolvimento motor. O presente estudo buscou avaliar se pacientes portadores de PTC tratados pelo método de Ponseti desenvolvem a marcha mais tardiamente comparado a um grupo controle e analisar possíveis fatores relacionados.
Métodos Incluídos pacientes nascidos a termo, com < 6 meses de idade, sem tratamento prévio e com seguimento mínimo de 24 meses. O grupo controle foi de pacientes sem alterações musculoesqueléticas, atendidos no mesmo período da realização do presente estudo.
Resultados Um total de 97 pacientes formaram o grupo de estudo e 100 o grupo controle. A média de idade no início da marcha no grupo de estudo foi de 14,7 ± 3,2 meses, e 12,6 ± 1,5 meses (p < 0,05) no grupo controle. Fatores relacionados à marcha tardia foram: idade de início do tratamento > 3 semanas, número de trocas gessadas > 7, recidiva e não realização da tenotomia de Aquiles. Idade de início do tratamento > 3 semanas esteve relacionada a maior número de trocas de gessos. Gênero e lateralidade não tiveram relação com a marcha tardia.
Conclusão Pacientes com PTC tratados com o método de Ponseti apresentam marcha independente aproximadamente 2 meses mais tarde do que o grupo controle. Início mais tardio do tratamento, maior número de trocas de gessos, recidiva e não realização da tenotomia de Aquiles foram relacionados com atraso da marcha.
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Affiliation(s)
- Ronan Bertinatto
- Departamento de Ortopedia Pediátrica, Hospital Pequeno Príncipe, Curitiba, PR, Brasil
| | - Edilson Forlin
- Departamento de Ortopedia Pediátrica, Hospital Pequeno Príncipe, Curitiba, PR, Brasil
| | - Leonardo Wustro
- Departamento de Ortopedia Pediátrica, Hospital Pequeno Príncipe, Curitiba, PR, Brasil
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Rastogi P, Agarwal A, Singh S, Meena CP, Gupta N. Correlation of age and severity scores to the number of Ponseti casts in Indian infants with clubfeet. J Clin Orthop Trauma 2020; 11:S807-S811. [PMID: 32999560 PMCID: PMC7503784 DOI: 10.1016/j.jcot.2020.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE World over, age and various severity scores are among the foremost variables studied in relation to the number of casts in clubfoot. We studied the correlation between child's age at presentation, initial Pirani, Dimeglio scores to the number of Ponseti casts in Indian clubfoot children. Further, we matched Pirani versus Dimeglio scores at different severities of deformity to derive a correlation between them. METHODS We included 90 idiopathic clubfeet in 55 infants and scored them according to Pirani and Dimeglio grading systems. Syndromic, neurological, surgically intervened, atypical or complex clubfeet were excluded from the study. The number of casts before percutaneous tenotomy was counted. Correlations were calculated between corrective casts and age, Pirani, Dimeglio scores and their individual components. RESULTS Mean age of children was 63.7 days and average number of casts applied was 3.2. Age at presentation and number of casts had no correlation with r = 0.034 (p < 0.001). The correlation between initial Pirani score (average 5.39) and Dimeglio score (average 13.4) to number of casts was 0.35 (p < 0.001)and 0.56 (p < 0.0001) respectively. Among individual components of Pirani score, medial crease and rigid equinus had maximum correlation to the number of casts whereas empty heel sign had the lowest. For Dimeglio score, equinus and varus correlated the most and posterior crease the least. Pirani and Dimeglio scores were highly correlated (r = 0.87) to each other except for very supple or severe deformity. CONCLUSIONS In infancy, the age at presentation had no bearing on number of casts. Both scoring systems had positive correlation in terms of corrective casts for our population. The Dimeglio fared slightly better than Pirani scores.
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Affiliation(s)
- Prateek Rastogi
- Corresponding author. 46-C, Pocket A, Sukhdev Vihar, New Delhi, 110025, India.
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The diagnosis and management of common childhood orthopedic disorders: An update. Curr Probl Pediatr Adolesc Health Care 2020; 50:100884. [PMID: 33069588 DOI: 10.1016/j.cppeds.2020.100884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Musculoskeletal illness represents a significant portion of office visits to primary and urgent care clinicians. Despite this, little emphasis is placed on learning pediatric orthopaedics during medical school or residency. The focus of this paper is to provide a systematic approach to this general musculoskeletal physical exam and to assist in the recognition of what conditions are normal development and what conditions require observation, workup and referral to an experienced pediatric orthopaedist.
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Karaman I, Ozturk RI, Cirdi YU, Oner M. Treatment of Relapsed and Neglected Pes Equinovarus with Binary Arthrodesis and Hexapodal Spider Frame. Indian J Orthop 2020; 55:128-134. [PMID: 34122765 PMCID: PMC8149537 DOI: 10.1007/s43465-020-00232-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/08/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to assess the clinical and radiological outcomes of patients with recurrent or neglected pes equinovarus (PEV), who underwent talonavicular or calcaneocuboid arthrodesis with a hexapod spider frame. METHODS The study included 18 patients; a total of 25 feet were treated with dual arthrodesis and a hexapod spider frame. The International Club Foot Study Group (ICFSG) scoring system and visual analog scale (VAS) were used to assess preoperative status and postoperative outcomes. All functional, morphological and radiologic evaluations during the follow-up were done as described by Kling et al. RESULTS Patients were followed up for an average of 24.1 ± 11.8 months. The mean age of our cohort was 8.84 ± 2.83 years. The mean duration of correction was 3 weeks and the mean duration treatment length was 15.3 ± 1.9 weeks. Postoperative assessment revealed eight excellent, 13 good, and four poor outcomes, according to the ICFSG scoring system. There was a significant difference between preoperative and postoperative ICFSG scores, 12 feet showed an excellent outcome, 12 feet had good outcomes, and one foot was rated as a failure in the final assessment, based on the Kling criteria. There was also a significant difference between preoperative and postoperative VAS scores. CONCLUSION Dual arthrodesis plus a hexapod spider frame is a valuable option for patients with recurrent or neglected PEV. It can be offered safely to avoid secondary recurrences and potential complications in cases of rigid feet as well as challenging cases that are resistant to soft tissue manipulation.
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Affiliation(s)
- Ibrahim Karaman
- grid.411739.90000 0001 2331 2603Department of Orthopaedics and Traumatology, Erciyes University Medical Faculty, 38039 Kayseri, Turkey
| | | | - Yigit Umur Cirdi
- Clinic of Orthopaedics and Traumatology, State Hospital, Yüksekova, Hakkari Turkey
| | - Mithat Oner
- Clinic of Orthopaedics and Traumatology, Private Memorial Hospital, Kayseri, Turkey
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In-toeing gait in children with clubfoot and the effect of tibial rotation osteotomy. J Pediatr Orthop B 2020; 29:348-354. [PMID: 31651746 DOI: 10.1097/bpb.0000000000000688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In-toeing gait is common after treatment for clubfoot deformity and is often secondary to residual internal tibial torsion. The purpose of the current study was to characterize the gait pattern in children with an intoeing gait pattern associated with talipes equinovarus (TEV) deformity, identify secondary changes at the hip that occur with intoeing, and determine if these secondary effects resolve after correction of tibial torsion. Patients with a diagnosis of TEV deformity, in-toeing gait secondary to residual internal tibial torsion corrected with tibial rotation osteotomy (TRO) and complete preoperative and postoperative motion analysis studies obtained approximately 1 year apart, were included in the study. Nineteen children (19 left extremities) with a TRO at a mean age of 8.2 years met inclusion criteria. Clinical examination showed improvement in tibial torsion assessment by measure of the thigh foot axis and transmalleolar axis. Kinematically, an abnormal internal FPA was present in all cases preoperatively, was corrected to normal in 12 (63%), remained internal in 5 (26%), and was abnormally external in 2 (11%). External hip rotation was identified in 13 (68%) cases preoperatively. Hip rotation was normalized postoperatively in 7 (54%), and was unchanged in the remaining 6 (46%). TRO provides effective correction of excessive internal tibial torsion, resolution of kinematic internal knee rotation, and normalization of the internal foot progression angle in the majority of patients with TEV deformity. External hip rotation resolved in approximately 50% of cases. Overcorrection of the internal FPA is possible when secondary changes at the hip do not resolve.
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Duman S, Camurcu Y, Cobden A, Ucpunar H, Karahan N, Bursali A. Clinical outcomes of iatrogenic complex clubfoot treated with modified Ponseti method. INTERNATIONAL ORTHOPAEDICS 2020; 44:1833-1840. [PMID: 32377781 DOI: 10.1007/s00264-020-04529-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/04/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There are not enough studies demonstrating the results of the modified Ponseti method on iatrogenic complex clubfoot that occurs due to errors during the application of the method for treating idiopathic clubfoot. The present study aimed to present the treatment results of the modified method reported by Ponseti for treating feet that became complex solely due to errors during casting. METHODS Patients with the confirmed diagnosis of iatrogenic complex clubfoot were according to initial physicians' report and photographs were included in this retrospective case series study. Patients with congenital atypical feet, incomplete medical records, and accompanying pathologies were excluded from the study. Patients' clinical data and clinical scores were recorded at the initial visit and at the latest follow-up. RESULTS There were 21 children (15 boys and 8 girls) with 32 complex clubfeet. Initial correction was achieved in all children, with an average of five serial casts (range 3 to 6 casts). At the last follow-up, ISGCF score of 25 feet (78.1%) was excellent and seven feet (21.9) was good. CONCLUSION According to the results acquired from this study, an iatrogenic complex clubfoot can be successfully treated using the modified Ponseti method.
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Affiliation(s)
- Serda Duman
- Department of Orthopaedics and Traumatology, Selahaddin Eyyubi State Hospital, Yenisehir Mahallesi, 21100, Diyarbakir, Turkey.
| | - Yalkin Camurcu
- Department of Orthopaedics and Traumatology, Erzincan University Faculty of Medicine, Basbaglar Mahallesi, 24030, Erzincan, Turkey
| | - Adem Cobden
- Department of Orthopaedics and Traumatology, Kayseri City Hospital, Şeker Mahallesi, Kocasinan, 38080, Kayseri, Turkey
| | - Hanifi Ucpunar
- Department of Orthopaedics and Traumatology, Erzincan University Faculty of Medicine, Basbaglar Mahallesi, 24030, Erzincan, Turkey
| | - Nazim Karahan
- Department of Orthopaedics and Traumatology, Selahaddin Eyyubi State Hospital, Yenisehir Mahallesi, 21100, Diyarbakir, Turkey
| | - Aysegul Bursali
- Private Office Pediatric Orthopaedics, Yıldızposta Cad. Emekli Subayevleri, 34. Blok, Daire: 1, İstanbul, Turkey
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Ahmad AA, Aker L. Accelerated Ponseti method: First experiences in a more convenient technique for patients with severe idiopathic club feet. Foot Ankle Surg 2020; 26:254-257. [PMID: 30930070 DOI: 10.1016/j.fas.2019.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/22/2019] [Accepted: 03/10/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Congenital Idiopathic Talipes Equinovarus (CTEV), or clubfoot, is a complex deformity that involves pathological anatomy in the foot with ankle equinus, hindfoot varus, midfoot cavus and forefoot adductus [1]. Universal agreement is established about Ponseti technique as the initial management for this deformity. This preliminary study aims to investigate the possibility of having a braceable foot through a proposed accelerated Ponseti method by which, manipulations, 5 castings and Achilles tendon tenotomy are implemented in a week. METHODS This study included 11 patients with 16severe congenital idiopathic clubfeet treated by an accelerated Ponseti method. The method involves manipulation of the deformed foot, and 1st casting in one day, with the 2nd, 3rd, 4th, 5th castings in the 4th, 5th, 6th, 7th day post-manipulation. After the 4th cast removal, Achilles tenotomy was performed with subsequent three-week casting for all patients. Nonparametric tests were used for comparing the Pirani scores before starting the treatment and after removal of final cast. RESULTS Five patients had bilateral club foot deformity. Average age at treatment was 54.8 days (range 8-150days). All patients, who had severe congenital idiopathic club feet with a Pirani score of 6, underwent the accelerated Ponseti technique. After removal of the three-week cast, the scores median was 0.59, (range 0-1.5), indicating a correction of the deformity and having braceable feet in all patients without experiencing any short-term complication. CONCLUSIONS The first step accelerated Pnoseti technique was found to be safe and effective for initial correction of severe idiopathic clubfoot deformity in children below three months of age , though it is an initial study that needs more studies with more follow up data.
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Affiliation(s)
- Alaaeldin A Ahmad
- Faculty of Medicine and Health Sciences, An-Najah National University , P.O. box 3985, Ramallah, Palestine.
| | - Loai Aker
- Faculty of Medicine and Health Sciences, An-Najah National University, Palestine.
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Chandirasegaran S, Gunalan R, Aik S, Kaur S. A comparison study on hindfoot correction, Achilles tendon length and thickness between clubfoot patients treated with percutaneous Achilles tendon tenotomy versus casting alone using Ponseti method. J Orthop Surg (Hong Kong) 2020; 27:2309499019839126. [PMID: 30947613 DOI: 10.1177/2309499019839126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To compare the hindfoot correction using clinical and ultrasonography assessment in clubfoot patients undergoing Achilles tendon tenotomy with patients corrected with casting alone. METHOD A prospective observational study on idiopathic clubfoot patients less than 3 months old. Clinical assessment was done using hindfoot Pirani score and measurement of ankle dorsiflexion. Serial ultrasonography was done to measure the length and thickness of the Achilles tendon pre-hindfoot correction, 3 and 6 weeks post-hindfoot correction. Independent t-test was used to analyse the increase in ankle dorsiflexion, improvement in length and thickness of Achilles tendon between the two groups. Mann-Whitney U test was used to analyse the improvement in hindfoot Pirani score. Pearson correlation test was used for correlation in between clinical severity and ultrasonography assessment. RESULTS Twenty-three patients with bilateral clubfoot and four with unilateral clubfoot were recruited with a total of 50 clubfeet. Each group consists of 25 feet with a mean age of 2 months. Marked improvement in hindfoot correction was noted in tenotomy group compared to non-tenotomy group as evidenced by significant increase in Achilles tendon length, ankle dorsiflexion and improvement of hindfoot Pirani score. No significant difference in Achilles tendon thickness was noted between the two groups. Positive correlation was demonstrated between increase in Achilles tendon length and increase in ankle dorsiflexion as well as improvement in hindfoot Pirani score. CONCLUSION We would like to propose Achilles tendon tenotomy in all clubfoot patients as it is concretely evident that superior hindfoot correction was achieved in tenotomy group.
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Affiliation(s)
- Saturveithan Chandirasegaran
- 1 Department of Orthopaedics Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Roshan Gunalan
- 1 Department of Orthopaedics Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Saw Aik
- 1 Department of Orthopaedics Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Shaleen Kaur
- 2 Department of Biomedical Imaging, University Malaya Medical Centre, Kuala Lumpur, Malaysia
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Abstract
PURPOSE OF REVIEW This review aims to provide primary care physicians with updates on recent literature regarding clubfoot and answer questions asked by parents and caregivers of children with clubfoot. The topics discussed include prenatal counseling, relapse after Ponseti treatment, long-term outcomes following successful treatment of clubfoot, and the effect of diagnosis and treatment on the parent or caregiver. RECENT FINDINGS Clubfoot is one of the most commonly searched orthopaedic conditions on the internet by parents. There is a lack of evidence-based guidelines on clubfoot worldwide. Recent systematic reviews have identified emerging evidence of genetic and modifiable risk factors that lead to clubfoot. Patients treated by the Ponseti method show better ankle power and strength compared with those treated with surgery for residual deformity or recurrence. SUMMARY The treatment of clubfoot is a long and involved process. Exposure to and familiarity with the Ponseti method will aid primary care physicians and parents in the optimization of children's clubfoot deformity correction using largely nonoperative management.
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Affiliation(s)
| | - Shevaun M Doyle
- Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Vaishy AK, Arif M, Acharya D, Choudhary R, Seervi PM, Kumar R. Influence of Beginning Time of Casting for Clubfoot Treatment by Ponseti Method in Different Age Group Infants: A Retrospective Study. Indian J Orthop 2020; 54:55-59. [PMID: 32257017 PMCID: PMC7093653 DOI: 10.1007/s43465-019-00004-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 09/16/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The clubfoot is one of the commonly found congenital deformities in newborn. The Ponseti method is the most effective nonoperative clubfoot management method. It is based on understanding of pathoanatomy of clubfoot. For classifying severity of clubfoot, Pirani score is used. The number of cast required for clubfoot correction is dependent on its initial Pirani score. This study aimed on how the number of cast for correction of clubfoot deformity depends on starting time of casting and pretreatment Pirani score. MATERIALS AND METHODS This study comprises of 200 patients with 297 affected foot nonoperatively managed with Ponseti technique of casting. We measured initial and final Pirani scores of patients with different age groups. RESULTS We found that initial severity was less in 0-1 month age group children but mean casting number was more while initial severity was more in 1-2 month age group, the mean number of casting was less. Tenotomy requirement was also less in 1-2 month age group. CONCLUSION We concluded that casting according to the Ponseti method should be started in 1-2 months age group which shows better results than the other age groups in clubfoot.
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Affiliation(s)
- Arun K. Vaishy
- Department of Orthopaedics, S N Medical College, Jodhpur, India
| | - Mohd Arif
- Department of Orthopaedics, S N Medical College, Jodhpur, India ,Present Address: Jodhpur, India ,Bikaner, India
| | | | | | - Prem M. Seervi
- Department of Orthopaedics, S N Medical College, Jodhpur, India
| | - Ravi Kumar
- Department of Orthopaedics, S N Medical College, Jodhpur, India
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Alsiddiky A, Alrwibaah S, Alqahtani A, Alnujidi A, Alhomaidhi A, Almasoud A, Alatassi R. Assessing public awareness of clubfoot and knowledge about the importance of early childhood treatment: a cross-sectional survey. BMC Pediatr 2019; 19:358. [PMID: 31623581 PMCID: PMC6796333 DOI: 10.1186/s12887-019-1740-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 09/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clubfoot is a treatable abnormality that can be managed with early intervention. However, there is a lack of public knowledge regarding clubfoot, which can delay treatment. This study aimed to assess the public awareness of clubfoot and knowledge regarding the importance of treatment in early childhood. METHODS This cross-sectional survey spanned 6 months, from June through November 2018, and involved persons living in Saudi Arabia. To collect data on public awareness of clubfoot risk factors, treatment, and prognosis, a questionnaire was developed by orthopedic experts and disseminated online. The target population included people of both genders and all age groups from the general population, regardless of their knowledge of someone with clubfoot. RESULTS By the end of the study period, 746 participants completed the online survey. In total, 520 of the respondents (69.7%) had never heard about clubfoot syndrome. Among the participants, 5.4% had a child with clubfoot syndrome and 4.6% were aware of clubfoot because they had an affected child. The top resource accessed by respondents for obtaining knowledge about clubfoot was social media channels (38.4%), followed by obtaining knowledge from relatives and friends (19.9%). The most reported perceived cause of clubfoot was hereditary and genetic disorders (58.4%), followed by neurological disorders (39.9%). CONCLUSIONS Results show that there is low public knowledge of clubfoot which may be attributed to a lack of awareness campaigns. We recommend increasing awareness regarding clubfoot through social media platforms and public campaigns in key locations, such as malls, as this may encourage people to seek early treatment. This is important because early management of clubfoot is less invasive and with regular follow-up, leads to better patient outcomes.
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Affiliation(s)
- Abdulmonem Alsiddiky
- Department of Orthopedics, College of Medicine, Research Chair of Spinal Deformities, King Saud University, Riyadh, Saudi Arabia
| | - Salman Alrwibaah
- Department of Orthopedics, College of Medicine, Research Chair of Spinal Deformities, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman Alqahtani
- Department of Orthopedics, College of Medicine, Research Chair of Spinal Deformities, King Saud University, Riyadh, Saudi Arabia
| | - Abdulmalek Alnujidi
- Department of Orthopedics, College of Medicine, Research Chair of Spinal Deformities, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah Alhomaidhi
- Department of Orthopedics, College of Medicine, Research Chair of Spinal Deformities, King Saud University, Riyadh, Saudi Arabia
| | - Abdulla Almasoud
- Department of Orthopedics, College of Medicine, Research Chair of Spinal Deformities, King Saud University, Riyadh, Saudi Arabia
| | - Raheef Alatassi
- Security Forces Hospital, Department of Orthopedic Surgery, P.O. Box: 3643, Riyadh, 11481, Saudi Arabia.
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Lööf E, Andriesse H, Broström EW, André M, Böhm S, Bölte S. Neurodevelopmental difficulties negatively affect health-related quality of life in children with idiopathic clubfoot. Acta Paediatr 2019; 108:1492-1498. [PMID: 30588661 DOI: 10.1111/apa.14709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/29/2018] [Accepted: 12/21/2018] [Indexed: 12/16/2022]
Abstract
AIM To study health-related quality of life (HRQoL) in children with idiopathic clubfoot (IC) and the influence of sex, clubfoot laterality and neurodevelopmental difficulties (NDD) on HRQoL. METHODS A cross-sectional questionnaire-based study in Stockholm and Skåne Counties, Sweden, of 106 children with IC born 2004-2007 (mean 9.4 ± 0.6 years) and a general population sample of 109 schoolchildren (mean 9.5 ± 0.6 years). The children and their caregivers answered the EQ-5D-Y (Youth) and Five to Fifteen questionnaires to operationalise HRQoL and NDD, respectively. RESULTS No reduced HRQoL on the EQ-5D-Y dimensions were reported by 51% of the children with IC, and 71% in the general population sample, with significant more problems in the IC sample regarding 'mobility', 'doing usual activities' and 'having pain or discomfort', despite similar overall health status. Neither sex nor clubfoot laterality affected HRQoL. Children with IC and NDD combined reported more problems in three out of five dimensions and lower overall health status compared with children with IC alone. CONCLUSION Despite similar overall health status, children with IC had more HRQoL problems compared with the general population, being associated with coexisting NDD but not sex or clubfoot laterality.
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Affiliation(s)
- Elin Lööf
- Paediatric Neurology; Department of Women's and Children's Health; Karolinska Institutet; Karolinska University Hospital; Stockholm Sweden
- Functional Area Occupational Therapy and Physiotherapy; Allied Health Professionals Function; Karolinska University Hospital; Stockholm Sweden
| | | | - Eva W. Broström
- Paediatric Neurology; Department of Women's and Children's Health; Karolinska Institutet; Karolinska University Hospital; Stockholm Sweden
- Highly Specialised Paediatric Orthopaedics and Paediatric Medicine; Astrid Lindgren Children's Hospital; Karolinska University Hospital; Stockholm Sweden
| | - Marie André
- Functional Area Occupational Therapy and Physiotherapy; Allied Health Professionals Function; Karolinska University Hospital; Stockholm Sweden
| | - Stephanie Böhm
- Paediatric Neurology; Department of Women's and Children's Health; Karolinska Institutet; Karolinska University Hospital; Stockholm Sweden
- Highly Specialised Paediatric Orthopaedics and Paediatric Medicine; Astrid Lindgren Children's Hospital; Karolinska University Hospital; Stockholm Sweden
| | - Sven Bölte
- Center of Neurodevelopmental Disorders (KIND); Centre for Psychiatry Research; Department of Women's and Children's Health; Karolinska Institutet and Child and Adolescent Psychiatry; Stockholm Health Care Services; Stockholm County Council; Stockholm Sweden
- Curtin Autism Research Group; Essential Partner Autism CRC; School of Occupational Therapy, Social Work and Speech Pathology; Curtin University; Perth WA Australia
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McCartney S, Turner S, Davies K, Morris J, Sproston C, Kiely N. A new unilateral abduction orthosis for Ponseti-treated clubfoot: A cohort study to assess compliance. Prosthet Orthot Int 2019; 43:325-330. [PMID: 30557091 DOI: 10.1177/0309364618814866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Ponseti method for treating congenital talipes equinovarus requires an orthosis to maintain correction after manipulation and casting, typically the 'boots and bar'. Non-compliance with the orthosis increases the risk of recurrent deformity. This study investigates a new orthosis, the abduction dorsiflexion mechanism. OBJECTIVES The aim of this study is to assess compliance of the abduction dorsiflexion mechanism when used at night and maintenance of foot morphology. STUDY DESIGN This study is a cohort study. METHODS A total of 10 children with unilateral congenital talipes equinovarus previously treated with Ponseti casting were recruited to trial the abduction dorsiflexion mechanism at night for 12 weeks. Foot morphology and compliance were assessed every 4 weeks. RESULTS Participant families were pleased with the orthosis, opting to continue to use the device following conclusion of the trial. Compliance was good and no deterioration in Pirani score or dorsiflexion seen. Abduction improved during the trial. The incidence of skin problems was equivalent to that experienced with the traditional boots and bar that the children had been wearing. CONCLUSION Good compliance and parental satisfaction, coupled with no deterioration in foot morphology, abduction or dorsiflexion present the abduction dorsiflexion mechanism boot as a feasible alternative to the traditional boots and bar, particularly in children with unilateral congenital talipes equinovarus. CLINICAL RELEVANCE The abduction dorsiflexion mechanism is currently the subject of considerable interest as clinicians look to increase compliance and reduce the recurrence rate in Ponseti-treated congenital talipes equinovarus. The abduction dorsiflexion mechanism boot is a feasible alternative to the traditional boots and bar, particularly in children with unilateral congenital talipes equinovarus.
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Affiliation(s)
| | - Sarah Turner
- 2 Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
| | - Kirsty Davies
- 2 Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
| | - Jan Morris
- 2 Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
| | - Claire Sproston
- 2 Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
| | - Nigel Kiely
- 2 Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
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Abstract
UNLABELLED Over the past two decades, the Ponseti 'conservative' (non-surgical) method of clubfoot treatment has been almost universally adopted worldwide. As a result, the need for operative treatment for clubfoot has decreased dramatically. However, even Ponseti himself routinely used surgery for certain patients: at least 90% of feet need percutaneous tenotomy, and 15% to 40% may require tibialis anterior tendon transfer. Additionally, relapses are common, sometimes necessitating further surgical intervention. Relapses are recurrent deformities in previously well corrected feet. Residual deformities may be defined as persistent deformities in incompletely corrected feet. In addition, in many parts of the developing world, neglected clubfoot is still a major challenge. Many neglected feet can be treated with Ponseti principles, particularly in younger children. However, in older children and adults, surgical approaches are more likely to be needed. Major reasons for relapsed/residual clubfoot include incomplete application of the Ponseti principles, inability to adhere to the foot abduction brace protocol, failure to recommend a complete course of bracing and inadequate follow-up. Sometimes, despite excellent treatment, and perfect adherence to the bracing protocols, there are still relapses, related to intrinsic muscle imbalance. We describe several solutions that include reinstitution of Ponseti casting and 'á la carte' operative treatment. As an alternative for particularly stubborn cases, application of a hexapod external fixator can be a powerful tool. In order to be a full-service clubfoot specialist, and not only a Ponseti practitioner, one must have in their toolbox the full gamut of adjunctive surgical options. LEVEL OF EVIDENCE V.
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Affiliation(s)
- M. Eidelman
- Ruth Children’s Hospital, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel,Correspondence should be sent to Mark Eidelman, MD, Pediatric Orthopedic Unit, Ruth Rappoport Children’s Hospital, Rambam Healthcare Campus, 8 Haaliya Hashniya Street, Haifa, 3525408, Israel. E-mail:
| | - P. Kotlarsky
- Ruth Children’s Hospital, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
| | - J. E. Herzenberg
- Rubin Institute for Advanced Orthopedics, International Center for Limb Lengthening, Sinai Hospital, Baltimore, Maryland, USA
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