Results of surgical correction of congenital talipes equinovarus]

Different surgical procedures in the treatment of clubfoot were analyzed, especially in correlation to over-correction and inadequate correction. Indications for surgery, surgical errors and their influence on outcome were assessed. 82 children (28 females and 54 males) with 130 congenital equinovarus underwent surgery between 1988 and 1994. Age at the time of operation ranged from 6 to 13 months (average: 9 months). Posterior release (i.e. partial subtalar release) was conducted in 68 cases of clubfeet and complete subtalar release in 62 cases. During follow-up 44 children with 64 clubfeet were reviewed. Magone's criteria were used to assess final results. 15 (23%) feet showed very good results, 26 (41%)--good results, 14 (22%)--satisfactory and 9 (14%)--poor or no correction.     

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

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

Level of evidence

Level IV.     

Recurrent clubfoot

About 25% of operated clubfeet will develop a recurrency or show a marked residual deformity. As main factor the failure of concentric reduction at the time of initial surgery has to be considered. Residual forefoot adduction and supination are the most common persistent deformities. Based on the experience with 94 recurrent/residual clubfeet (patients < 10 years) the surgical treatment at different age-groups is presented. As a general rule soft tissue release is applicable as a repeated procedure until the age of about eight to ten years. For revision in patients between two and eight years we recommend a closing wedge osteotomy of the cuboid and a tibialis transfer additional to repeated release-procedures. In patients older than eight to ten years mid-tarsal osteotomies, correction according to llizarov with the external fixator or triple arthrodesis are to be considered as single or combined procedures.     

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.     

Ponseti method in the treatment of post-operative relapsed idiopathic clubfoot after posteromedial release. A short term functional study

BackgroundRelapsed clubfeet deformity after surgical treatment by posteromedial release are frequently encountered in pediatric orthopedic practice and further revision surgery may be needed. As surgery adds more fibrosis and scaring, complication may be devastating and treatment is challenging. Ponseti method, the gold standard technique for treatment of clubfoot may be of a value in the management of postoperative relapses.Aim of the studyDetermine the effectiveness of Ponseti casting Method in treatment of relapsed idiopathic clubfoot in children after being treated with surgical posteromedial release.Materials and methodsProspective interventional study of 17 patients (25 feet) presented with a relapsed idiopathic clubfoot deformity after previous surgical posteromedial release. The patients were reviewed using Pirani and Dimeglio score. Ponseti method was done to obtain supple, flexible foot rather than a fully corrected foot, the residual deformity were treated by, heel cord lengthening or tenotomy, tibialis anterior transfer, follow up was for a minimum of 12 months.Result17 Patients (25 feet) their age ranging from 1 to 10 years were evaluated and treated. Casts were applied until the only deformities remaining were either hindfoot equinus and/or dynamic supination.22 feet required a heel cord procedure for equinus and 13 required tibialis anterior transfer for dynamic supination. The follow up (average 56.1 months) was for a minimum of one year. 4 feet had persistent heel varus deformity which required Calcaneal osteotomy later. Three feet didn’t need more casting and 2 feet were resistant cases that required further Ilizarov procedure, 4 needed lateral arch shortening and other 4 needed posterior capsulotomy. Improvement in the Pirani and Dimeglio scores was highly statistically significant.ConclusionPonseti method for treatment of relapsed clubfeet after a previous posteromedial soft tissue surgical release is an effective, non invasive, with excellent results.     

The functional outcome of staged surgery for the correction of talipes equinovarus

Between 1988 and 1995, 110 idiopathic clubfeet from a cohort of 120 recalcitrant feet in 86 patients requiring surgical treatment were studied. There were 61 male and 25 female patients. The mean age at surgery was 9.5 months. In 91 feet, the surgery consisted of an initial plantarmedial release, followed 2 weeks later by a posterolateral release. Nineteen feet required only a posterolateral release. Feet were categorised preoperatively and prospectively according to a system suggested by Dimeglio into four groups, and the rates of relapse and wound healing data were previously reported. This paper reports the functional outcome of this cohort of idiopathic clubfeet and the results are related to the preoperative grade, the patient's gender, the age at which the child first walked, and whether the deformity is unilateral or bilateral. The interim functional outcome is good in the majority of cases despite a high rate of relapse in the more severe deformities.     

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.     

Posteroplantar release for congenital clubfoot in children younger than 1 year

One hundred thirty-three resistant congenital clubfeet in 93 patients between 3 and 10 months of age were operated on using a standardized posteroplantar release. Clinical and radiographic assessments were done with a mean followup of 7 years 4 months (range, 3-12 years). Using the McKay score, 79.7% of the surgically treated clubfeet were classified as having a good or excellent result. Three patients had relapse of their clubfoot that required additional surgery. Seventeen feet in 15 patients had residual forefoot adduction at the time of followup. The radiographs showed that the early posteroplantar release led to sufficient hindfoot correction in all but the three patients who had relapse of the clubfoot. With this standardized surgical treatment, satisfactory results can be achieved in most patients younger than 1 year with congenital clubfoot. However, in patients with persistent talonavicular subluxation after conservative treatment, an additional talonavicular release combined with the posteroplantar release is recommended.     

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.     

Treatment of congenital clubfoot with the Ponseti method

AIM: The primary therapy for congenital clubfoot is non-surgical involving manipulation and serial casting. With traditional casting, relatively large numbers of feet require extensive surgery to achieve full correction. The purpose of this study was to evaluate the efficacy of the Ponseti method. METHODS: Between 1.1.2004 und 31.12.2005, 29 patients with 41 clubfeet were treated with the Ponseti method. Only patients without any prior treatment were included. Classification followed Pirani's score. The number of casts to full correction, tenotomies, number of posteromedial releases, dorsi-, plantarflexion and hindfoot position were documented. The follow-up time was 1-9 months, the average follow-up time was 9.1 months. RESULTS: 39 clubfeet were successfully treated with the Ponseti method. The average Pirani score was 4.9. Percutaneous tenotomies were necessary in 34 of the clubfeet. Average dorsiflexion was 19 degrees and plantarflexion 42 degrees . After failed Ponseti treatment 2 feet were treated with a posteromedial release. CONCLUSION: With the Ponseti method the need for extensive corrective surgery is greatly reduced. We recommend the Ponseti method as standard therapy in clubfoot management.     

Patient-based outcomes after Ilizarov surgery in resistant clubfeet

We present the results of clinical evaluation and patient-based outcomes after Ilizarov surgery in resistant clubfeet (grade D clubfeet, Dimeglio-Bensahel system). This is a retrospective study of 26 resistant clubfeet in 23 children who were managed by the Ilizarov technique. The average age of the patients at the time of the operation was 9 years and the average follow-up period was 47 months. A calcaneal or mid-foot osteotomy followed by bony distraction was undertaken in nine feet and a soft-tissue distraction, with or without soft-tissue release, was undertaken in 17 feet. Clinical evaluation of the degree of correction of the deformity and functional evaluation, using patient-based questionnaires, were used in assessing the outcome in these patients. Patient-based outcomes give useful information about the functional status following surgery, complementing the objective assessment by the surgeon. Clinical evaluation revealed stiff, plantigrade feet in nine patients and a recurrent deformity after initial correction in the remaining 14 patients. The patient-based outcomes were good to excellent in 52% for satisfaction, 57% for cosmesis, 48% for walking and 73% for teasing (made fun of because of the shape of foot), showing that the functional results were better in these patients in spite of a poor surgical outcome.     

Long term results of the treatment of clubfoot with postero-medial fibular graft]

The authors present long term results of treatment of congenital clubfoot by postero-medial release. Our material consisted of 82 patients, with 103 clubfeet, 5 months to 9 years old (mean age 22 months) at the time of surgery. The age at the time of the final follow-up ranged from 6.3 to 27 years. Final results were evaluated according to the Magone classification. Basing on this classification we achieved very good results in 9 feet, good results in 20, sufficient results in 28 and poor results in 46 feet. In the analyzed group most of the results were either sufficient or poor--71.84% of the cases. These feet required further surgical procedures. The authors stress that incorrect classification for this type of surgery and inadequate surgical technique caused a high percentage of poor and sufficient results.     

Accessory soleus muscle as a cause of resistance to correction in congenital club foot: a case report

A 14-month-old female with bilateral clubfeet was initially treated by serial casting and percutaneous tenotomy of the Achilles tendon, bilaterally. Both clubfeet subsequently underwent surgical treatment with a posteromedial release through a Cincinnati incision. At surgery on one clubfoot, an accessory Soleus muscle was found anterior to the Achilles tendon with a distinct insertion on the upper surface of calcaneus, anterior and medial to the insertion of Achilles tendon. This accessory Soleus muscle may have been the cause of resistance to correction in this congenital clubfoot.     

Corrective surgical procedures as repeated treatment of residual clubfoot]

The authors present an analysis of failed surgery in 139 patients with congenital clubfeet. There were 72 feet, which required repeated surgical procedures after primary treatment. Twelve feet were treated by posterior release, and 65 by postero-medial release. The repeated reconstruction was performed at a mean age of 3.6 years. No very good results were found in either group at final follow-up, done according to the Magone et al. classification. In the first group treated by posterior release god results were noted in 53.3% of the cases, sufficient in 43.1% and poor in 38.5%. The authors underline that the final results depend on early consequent conservative treatment, use of adequate operating techniques and cooperation between child, parents, physician and orthotic specialist.     

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.     

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.     

Functional midterm outcome in 131 consecutive cases of surgical clubfoot treatment

Introduction  

Since introduction and widespread use of the Ponseti method in the last decade, the need for surgical treatment of clubfeet is nowadays limited to resistant cases. In the time before, surgery via dorsomedial release was a very common treatment option.     

Management of foot deformity in children

This study describes the management of foot deformity in children. Severe congenital clubfeet treated using posteromedial release without talocalcaneal joint release were flexible and functional. Talectomy may be necessary for congenital clubfeet with arthrogryposis multiplex congenita. The diagnosis and severity of vertical talus were defined based on stress radiographs. For the deformity with spina bifida, a combination of talocalcaneal joint fusion and precise correction by soft tissue release and tendon transfer was performed. This combined surgery is effective, particularly in patients with equino-varus feet.     

The history of treatment of congenital clubfoot at the Royal Liverpool Children's Hospital: improvement of results by early extensive posteromedial release

The results of treatment in 77 clubfeet were assessed after an average follow-up of 8 years. In those patients with surgical treatment it was found that the Turco posteromedial release within the first 3 months of life resulted in 13 of 16 satisfactory feet. In comparison, only five of 21 feet had satisfactory results when the average age of operation was delayed to 3.7 years and a less extensive release performed. At follow-up, abnormal radiological findings were not found in the early operated cases. The average talocalcaneal index was 47 degrees. The late operated feet showed major abnormal X-ray film findings, and their average index was 38 degrees. Good functional results, however, often coexisted with abnormal radiological findings in the midfoot. Abnormal findings of the hindfoot were always associated with unsatisfactory results. We conclude that the use of early (3 months) Turco posteromedial release can offer excellent results in treating severe resistant clubfeet.     

Nonsurgical management of idiopathic clubfoot

Because nonsurgical management was thought not to yield adequate correction and a durable result, most children with idiopathic clubfoot have undergone surgery with extensive posteromedial and lateral release. However, surgical management caused residual deformity, stiffness, and pain in some children; thus, the favorable long-term results with the Ponseti and French methods of nonsurgical management have garnered interest. The Ponseti method consists of manipulation and casting of idiopathic clubfeet; the French method consists of physiotherapy, taping, and continuous passive motion. Careful evaluation of the techniques and results of these two approaches may increase their use and decrease or minimize the use of surgical management and thus the associated morbidity resulting from extensile releases.