Occult subluxation of the subtalar joint in clubfoot (using computerized tomography)

Routine radiographic analysis does not visualize the posterior aspect of the hindfoot (posterior facet of the talocalcaneal joint). To help evaluate patients with persistent hindfoot abnormalities, computerized tomographic coronal sections in 22 clubfeet were studied. Seventeen feet (77.3%) had a lateral subluxation of the calcaneus. Of 14 feet with acceptable radiographic analysis, 12 (85.7%) had a lateral subluxation of the calcaneus. This study is evidence that a lateral subluxation of the calcaneus can exist, through a horizontal rotation, in the presence of acceptable radiographic analysis, reinforces the necessity for a posteromedial lateral release, and emphasizes that routine radiographic analysis should be supplemented with computerized tomography in evaluation of the resistant hindfoot deformity.     

Is it hazardous or mandatory to release the talocalcaneal interosseous ligament in clubfoot surgery?: a preliminary report

Extreme overcorrection and avascular necrosis are recognized complications in clubfoot surgery and are thought to be the result of division of the talocalcaneal interosseous ligament (TCIL).This is a preliminary report of a prospective study of the cases of 46 patients with 66 idiopathic clubfeet treated by means of soft tissue release using a posteromedial approach at a mean age of 9 months. The deformity was very severe in 51 feet and severe in 15. The feet were divided into 2 equal groups (33 feet each). In group A feet, the TCIL was released, whereas in group B, the ligament was left intact. At a mean follow-up period of 28 months, the result was satisfactory (excellent and good) in 96.9% of feet in group A and in 87.9% of feet in group B. When the mean overall clinical and radiological score was investigated, group A graded excellent whereas group B graded good. In feet with satisfactory outcome, group A showed statistically significant improvement of the anteroposterior and lateral talocalcaneal angles, talocalcaneal index, and lateral calcaneus-first metatarsal angles when compared with group B. This was reflected clinically on better hind foot correction with the release of the TCIL, with no evidence of significant overcorrection. Magnetic resonance imaging of the ankle and foot confirmed no evidence of talar avascular necrosis or extreme overcorrection in 40 feet (60.1%), 20 in each group. We conclude that it is advisable to release the TCIL in severe and very severe clubfeet.     

A comparison of resultant subtalar joint pathology with functional results in two groups of clubfoot patients treated with two different protocols

Two series of patients with congenital clubfoot treated by different manipulation techniques and by different complementary soft tissue release operations were evaluated at the end of skeletal growth. The severity of the deformity was graded at diagnosis, and the functional results were graded at follow-up with a functional rating system. Computed tomography scans of the subtalar joint were also obtained at follow-up for each patient in order to evaluate the joint morphology. A linear regression model was constructed to study the statistical correlation between the rating score of the treated clubfeet and the shape of the subtalar joint. A statistically significant correlation was found between the clubfeet rating score and the subtalar joint morphology. However, the rating score values of the second series were consistently higher than those of the first series when compared with the same morphological category of the subtalar joint.     

Significance of talar distortion for ankle mobility in idiopathic clubfoot

The abnormal bony feature found most consistently in clubfeet is talar distortion. The significance of the talar distortion for mobility of the tibiotalar joint was investigated. Twenty-seven congenital clubfeet in 19 patients were examined at a minimal followup of 20 years. In all patients Turco's posteromedial release was done because of idiopathic clubfoot. Radiographic assessment of the feet included measurement of the talocalcaneal angle and index, and the tibiocalcaneal angle. The degree of talar flattening was estimated by the ratio of the curvature of the talar dome to the length of the talar bone (radius to length ratio). Three-dimensional gait analysis was done to assess the dynamic range of ankle motion. The static range of motion was measured with a goniometer. The degree of talar flattening correlated significantly with the dynamic range of ankle motion but not with the static mobility. For assessment of idiopathic clubfoot, evaluation of talar flattening should be done because of its significance for dynamic ankle mobility.     

Role of talocalcaneal osteotomy in clubfoot surgery: results in 31 surgically treated feet

The most important deformities in clubfeet can be demonstrated by simultaneous arthrography of the talonavicular and talocrural joints. In patients with a severe talar deformity, wedge osteotomy through the talar neck and calcaneus has been performed as a prerequisite for correction. Our series consisted of 20 patients with 31 idiopathic clubfeet with pronounced talar deformity. The mean observation time after osteotomy was 11 years 3 months. The principles and aims are described, as are the indications for talocalcaneal osteotomy. Results were good in 19 feet (60%), fair in six (20%), and poor in six (20%).     

Early results of the Ponseti method for the treatment of idiopathic clubfoot

AIM: The Ponseti method for the treatment of congenital clubfeet has been propagated due to the sometimes disappointing functional results after surgical treatment. The aim of our study was to evaluate our early results and experiences with the Ponseti method. METHOD: Between December 2002 and December 2004 a total of 87 clubfeet in 59 patients were treated using the Ponseti method at our department. Only patients in whom treatment was initiated within the first three weeks of life were included in this study. Rate of successful correction without open release surgery, radiological findings, classification according to Pirani at the time of the last follow up, recurrence rate and duration of treatment were defined as outcome measures for this prospective study. RESULTS: Fifty-nine cases in 37 patients met the inclusion criteria. Ninety-three percent of all cases (55 feet) were corrected without open surgery. The mean duration of active treatment was 11.4 weeks (8-20 weeks). The mean tibiocalcaneal angle 3-4 weeks after the percutaneous tenotomy of the Achilles tendon was 69 degrees, the mean a.-p.-talocalcaneal angle measured 33 degrees and the lateral talocalcaneal angle 36 degrees. A recurrence was seen in one patient with bilateral clubfeet (3.6 %). CONCLUSION: Open release surgery can be averted in most cases of idiopathic clubfoot using the Ponseti method. Scarring of the soft tissue and especially of the joint capsule can thereby be avoided.     

One-stage posteromedial release of congenital clubfoot

Turco's one-stage posteromedial release with internal fixation has been performed in 51 children with a total of 73 congenital clubfeet since 1973. Thirty-one children (44 feet) followed for 4-12 years were evaluated using the McKay rating system. The occurrence of good and excellent results was 70%. The relationship between these results and angles measured from roentgenograms was analyzed using multiple regression. The results showed a closer relationship to the anteroposterior talocalcaneal angle, the tibiocalcaneal angle, and the MTR angle.     

Subtalar release in clubfeet: a retrospective study of 10-year outcomes

BACKGROUND: Optimal management of congenital talipes equinovarus continues to be controversial. There is a dramatically renewed emphasis on non-operative management partly because there has been a high recurrence rate among operated feet. Our hypothesis is that early, extensive subtalar ligament release as the cornerstone of aggressive hindfoot realignment prevents recurrence and retains mobility. MATERIALS AND METHODS: Twenty-two congenital clubfeet (14 patients) corrected by one surgeon were evaluated using two validated patient-based outcome instruments, dynamic pedobarographic analysis, hindfoot mobility, and weightbearing radiographs. Pedobarographic analysis consisted of quantifying peak plantar forces and pressures during the gait cycle in 22 corrected feet and 24 control feet using the FSCAN in-shoe device. RESULTS: The mean age at surgery was 8 months and mean followup was 10 years. No patients experienced recurrence of deformity. Reported foot function and satisfaction were very high for all patients and were comparable to reported normal population values. AP and lateral talocalcaneal angles for each foot were within normal limits for age. Hindfoot range of motion, including dorsiflexion, was preserved in all feet. Peak regional forces throughout the gait cycle and plantar pressures at foot flat were mildly, but statistically significantly, higher in the midfoot of corrected feet suggesting slight flattening of the arch. One patient had tendon transfers for bilateral calcaneal deformity and one patient had surgical correction of a bilateral valgus deformity. CONCLUSION: Aggressive hindfoot realignment provides definitive treatment of an equinovarus deformity, but care must be taken to avoid overcorrection.     

Posterior talocalcaneal coalition

Tarsal coalition is a rare congenital deformity. The most common coalitions involve the calcaneonavicular joint and the medial facet of the talocalcaneal joint. The posterior facet is rarely involved. We report a case of a patient with a posterior talocalcaneal bar who presented with painful limitation of subtalar motion without the classical appearance of spastic flat foot. Resection of the bar with interposition of fat graft resulted in an almost full range of pain-free subtalar motion.     

Efficacy of Ponseti Technique in Virgin and Relapsed Clubfeet: A Comparative Study

Doubts still loom over the effectiveness of Ponseti casting in treating children with recurrent clubfeet. We have undertaken this study to confirm whether excellent results obtained in treating virgin clubfeet by Ponseti casting can be reproduced with equal success in relapsed clubfeet. The patients were divided into 2 groups; Group I was untreated children with congenital clubfeet younger than 1 year of age (21 feet) and Group II was children with relapsed congenital clubfeet younger than 2 years of age (21 feet). The Ponseti method was applied with equal success in both groups. Groups I (virgin) and II (recurrent) were similar in terms of number of casts, period of immobilization, and successful initial correction. We did not find statistically significant differences (p value?=?.75) when comparing the number of casts required for correcting deformity in virgin (mean 6.3) and relapsed group (mean 5.5). The Pirani score improved significantly after treatment from 4.3 to a post-treatment value of 0.4 (p < .001) in recurrent clubfeet and from 5.4 to 0.31 (p < .001) in virgin clubfeet. The results of our study suggest that excellent initial correction of deformity can be achieved without the need for an extensive soft tissue release in more than 95% of children with recurrent clubfeet.     

Calcaneocuboid malalignment in clubfoot.

In a series of 179 clubfeet treated surgically with a follow-up of 3 to 14 years, the clinical significance of calcaneocuboid malalignment was assessed on the basis of a standardized anteroposterior radiograph. The revision rate was 15% and the clinical requirement for a further soft tissue release was related to the talocalcaneal and calcaneocuboid angles. Calcaneocuboid malalignment does not have an adverse effect on the good prognosis of an otherwise well-corrected foot and does not alter the surgery needed to improve a clearly uncorrected foot. When talocalcaneal correction is doubtful, calcaneocuboid malalignment should tilt the balance toward a revision and is of value when the navicular has yet to ossify. Surgical release of the calcaneocuboid joint is unnecessary, particularly the lateral dissection, provided that the medial and subtalar dissection is complete.     

The role of posterior release in the treatment program for congenital clubfoot]

The aim of this paper was to assess the utility of this procedure and to define it's role in treatment of congenital clubfeet. The material comprises 123 children, among whom 154 feet were treated by posterior release. The age of the patients ranged from 5 to 36 months (average age: 16 months). The procedure involved the lengthening of the Achilles tendon in the sagittal plane, partial resection or transverse dissection of the articular capsule of the ankle joint. In selected cases lengthening of the tendon of the extensor hallucis muscle was performed and sometimes of the posticus muscle. The described procedure was performed in all cases where all forefoot components of the deformity were found, as well as an equines position of the foot. A group of 87 patients (70.7%), among whom posterior release was performed in 101 feet (65.6%). The follow-up time ranged from 5 to 15 years (average: 12.3 years). Results were assessed according to the classification by Magone et al. Very good results (95-100 points) were achieved in 27 feet (26.8%), good results (80-89 points) were found in 40 feet (39.6%), satisfactory (70-79 points) in 25 feet (24.7%), and bad results (less than 70 points) in 9 feet (8.9%). Basing on their own experience the authors' believe this procedure is very useful in treatment of congenital clubfeet. It's therapeutic usefulness is at it's best when deformities of the forefoot have been conservatively corrected. The extent of posterior release depends on the severity of the deformity.     

Surgery in residual clubfoot: one-stage medioposterior release "à la carte"

A series of 142 clubfeet in 113 children were treated by a one-stage medioposterior release for deformity persisting after vigorous physical therapy. The talonavicular joint and hindfoot are released to achieve correct alignment. Long-term good results were seen in 73% of the entire series and in 87% of the idiopathic subgroup.     

Vergleich der Behandlungsergebnisse bei kongenitalen idiopathischen und nichtidiopathischen Klumpfü?en

Background

Clubfoot deformity is one of the most common congenital musculoskeletal deformities and occurs in newborns with different neuromuscular diseases. To date the Ponseti method is the gold standard for the treatment of idiopathic clubfeet but not for non-idiopathic clubfeet which are associated with neuromuscular diseases. The results of the treatment for congenital idiopathic and non-idiopathic clubfeet according to Ponseti performed in our department since 2004 were compared concerning results and relapse surgery with particular reference to the compliance of the parents concerning the use of an abduction splint.

Patients and methods

A total of 101?children (28 female and 73 male) with 159 clubfeet were treated with the Ponseti method and included in this prospective non-randomized cohort study. Of these children 27 with 48 affected feet suffered from neuromuscular diseases which are associated with clubfoot deformity, such as myelomeningocele (n=4), arthrogryposis (n=9) and various other syndromes (n=14). The degree of the deformity was evaluated with the Pirani score initially, after casting and at follow-up. Parents were asked at follow-up to state subjectively how compliant they were with the abduction splint treatment. The necessity of surgical treatment of relapses was recorded. Statistical analysis was performed applying ??² and Kruskal-Wallis tests for the comparison of idiopathic and non-idiopathic clubfeet.

Results

The average period of follow-up was 36?month (range 6?C75?months) and non-idiopathic clubfeet were initially significantly more severely deformed according to the Pirani-score (p=0.013). Treatment of non-idiopathic clubfeet was started significantly later than that of idiopathic clubfeet (p=0.003) and took significantly longer (p <0.001). A correlation between the initiation of casting and the duration of casting was not found (p=0.399). At the end of the casting period no significant differences were found between correction of idiopathic and non-idiopathic clubfeet with respect to the Pirani score (p=0.8). The mean score after casting was 0.1 in both groups. At mid-term follow-up the score increased in both groups but stayed below 0.5 with non-idiopathic clubfeet showing a significantly higher score than idiopathic clubfeet (p=0.014). Relapse surgery was necessary in 11% of the patients. No significant difference in the revision rate was found between the two groups (p=0.331) and peritalar release was not necessary in either group. The rate of revisions correlated with the compliance concerning the use of the abduction splint (p <0.001). Only 61% of the parents stated that they adhered strictly to the abduction splint treatment recommendations with no significant difference between the groups (p=0.398).

Conclusion

This study shows good initial results after Ponseti treatment for idiopathic as well as non-idiopathic clubfeet. Based on the good functional results all clubfeet should initially be treated with the Ponseti method regardless of the etiology.     

Deformity of talus and calcaneous in congenital clubfoot: an anatomical study

Clubfoot is a complex congenital deformity. Midtarsal joint is a key point to understand the deformity in clubfoot as a consequence of the malalignment of the osseous columns. Talar and calcaneal deformities affecting the normal alignment of the medial and lateral osseous columns in the foot can be the factors that determine the difficulty in the management of clubfoot. We report observations of two clubfeet of one stillborn. Our observations in the head of the talus report two different articular areas: the histological section of medial area facing the navicular shows active articular cartilage and the lateral area shows an atrophic articular cartilage suggesting a difference between the anatomical declination angles of the talus from a functional declination angle. Observing the calcaneous, we report a twisting rotational deformity along the longitudinal axis of the calcaneous. These observations may contribute to a better understanding of the clubfoot relapse, and also the treatment of complicated cases of clubfeet.     

Clinico-Radiological and Functional Outcome of Difficult Talipes Equinovarus Deformity Corrected With an Ilizarov Fixator

Relapsed, resistant, and untreated congenital talipes equinovarus poses significant challenges in view of functional outcome following conventional serial casting and soft tissue release procedures. The Ilizarov ring fixator here offers significant possibilities as an extended conservative treatment modality. The aim of the present study was to critically evaluate effectiveness of the Ilizarov ring fixator with regard to radiological, clinical, and functional outcomes, in the difficult clubfeet. The study was carried out on patients presenting with relapsed, resistant, or untreated congenital talipes equinovarus deformity, who underwent deformity correction using the Ilizarov ring fixator application. All patients were reviewed at 6 monthly intervals for over 3 years following fixator removal with an objective clinical, radiological, and functional assessment. Twenty-three patients with 30 clubfeet were enrolled in our study. The mean age was 8.3 ± 3.6 (range 4-17) years. The postoperative clinical, radiological, and functional scores showed statistically significant improvement among all patients when compared with the preoperative data. All 30 feet developed varying complications during treatment with pin track infections being the most common. However, they were managed while continuing the distraction correction process. The Ilizarov ring fixator is an effective and reliable solution for difficult and challenging clubfeet. However, one must be aware of a strict adherence to a bracing protocol to avoid recurrence of deformities. A regular periodical functional and clinical follow up must be ensured among these children for a favorable outcome.     

Ehlers-Danlos syndrome with concomitant joint contractures]

We present 6 children with Ehlers-Danlos syndrome (EDS) with concomitant joint contractures. In 3 of them bilateral clubfeet together with hip, and (or) knee, or wrist flexion contractures were observed. In all of them, after initial soft tissue surgery for clubfeet, reccurences were noted requiring another surgery. Clubfeet were the only manifestation of joint contractures in another 2 children. In one of them soft tissue surgery was succesful, in the second a hypercorrection was noted. One child with EDS had a recurvatum knee deformity which was succesfully treated conservatively. We speculate on two different forms of EDS with joint contractures: a mild one, in which clubfeet are the only joint contractures, and in which a soft tissue surgery may lead to overcorrection, and a severe one, with multiple joint contractures like in arthrogryposis multpiplex congenita, in which soft tissue surgery for clubfeet and joint contractures may lead to reccurences.     

Magnetic resonance imaging of the congenital clubfoot treated with the French functional (physical therapy) method

The purpose of this study was to assess magnetic resonance imaging (MRI) changes that occur in clubfeet after nonoperative treatment with the French functional method, specifically pertaining to the chondro-osseous anatomy and the joint relationships. The magnetic resonance images were obtained in 6 infants before treatment and 3 months later. The MRI protocol described previously for clubfeet which were treated by the Ponseti method (J Pediatr Orthop. 2001;21:719) was closely adhered to, except that no sedation was allowed by our institutional review board. The severity of the clubfoot deformities before treatment made assessment of the tibiotalar, talonavicular, and talocalcaneal joint relationships difficult in some feet. Despite this, improvements were noted after treatment in tibiotalar plantarflexion, the talonavicular relationship, the calcaneocuboid relationship, and the varus position of the calcaneus. The wedge shape of both the navicular and distal end of the calcaneus that occasionally was noted on the MRI before treatment improved after therapy. Although improved clinically, persistent equinus of the calcaneus on MRI was significant in 2 feet and was associated with slight dorsal displacement of the cuboid on the calcaneus (MRI evidence of rocker bottom). As noted with use of the Ponseti nonoperative treatment method, the chondro-osseous abnormalities seen on MRI studies in congenital clubfoot improve after treatment with the French functional (physical therapy) method, with the exception of equinus.     

Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method

The initial treatment of congenital idiopathic talipes equinovarus (clubfoot) is most often nonsurgical. However, surgical treatment in the form of posteromedial release is often undertaken after failure of conservative measures. The prevalence of both immediate and long-term complications in surgically treated clubfeet has cultivated a renewed interest in nonsurgical treatment. The Ponseti method for treating clubfoot has seen a revived interest among those caring for infantile clubfeet. We report on our first 34 infants (57 clubfeet) treated by using the techniques and principles described by Ponseti. Using a standard scoring system, 54 of 57 clubfeet were successfully corrected without requiring posteromedial release. Only 2 patients (3 clubfeet) required extensive surgical correction. There were 6 relapses. In all recurrent cases, there was a lack of compliance with the straight-last shoe and foot abduction bar regimen. Based on this level of initial success, we believe that posteromedial release is no longer necessary for the majority of cases of congenital clubfeet.     

Anterior tibial tendon transfer in relapsing congenital clubfoot: long-term follow-up study of two series treated with a different protocol

Two series of patients with relapsing congenital clubfoot were treated by transfer of the anterior tibial tendon to the third cuneiform under the extensor retinaculum. The two series were reviewed at the end of skeletal growth to evaluate the effectiveness of the surgical procedure. The first series included 19 clubfeet and the second 16. The two series of clubfeet were initially treated by two different manipulative techniques and two different complementary soft tissue release operations. In relapsing clubfeet, the foot dorsiflexion/eversion activity of the tibialis anterior was suppressed and the muscle functioned as an invertor. At follow-up the functional results of the second series of patients, in whom the relapsing deformity was passively correctable at the time of surgery, were better than those of the first series of patients, in whom the relapsing deformity was sometimes less passively correctable. None of the operated patients had a further relapse. In both series, the angles formed by the longitudinal axis of the navicular and the first cuneiform, the calcaneus and the fifth metatarsal, and the calcaneus and the cuboid, evaluated both by plain radiographs and by CT scan, were smaller than in normal feet and in the clubfeet that did not relapse. Transfer of the anterior tibial tendon to the third cuneiform underneath the extensor retinaculum corrects and stabilizes relapsing clubfeet by restoring their normal function of foot dorsiflexion/eversion. As a consequence, the cuneiforms and the cuboid were shifted more laterally than normal, as shown by both x-rays and CT scan.