Functional results of surgical treatment in congenital talipes equinovarus (clubfoot): a comparison of outcome measurements

A total of 151 children with 234 grade 2 or grade 3 congenital talipes equinovarus were treated by lateral-posteromedial peritalar release utilizing the Cincinnati incision. The feet were reviewed independently after a mean follow-up period of 10 years (5-19 years), using a modified rating scale, and the results compared to the severity of the initial deformity. An excellent or good result was achieved in 196 feet (84%) and a modest correlation (r = 0.48) noted between the preoperative grading of the foot and the functional result at later review. Both gender and bilaterality were also influential since a boy with bilateral deformity has a 1 in 4 chance of only a fair result, compared to a girl with a unilateral clubfoot where the chance is 1 in 10. The total range of ankle movement and the talocalcaneal index correlated strongly with the eventual surgical outcome [r = 0.69 and 0.65 (P = 0.001 and 0.01) respectively].     

Distal calcaneal osteotomy in resistant talipes equinovarus

In resistant talipes equinovarus deformity, posterior medial release alone may be inadequate. Procedures involving the lateral column are sometimes necessary. Thirty-nine patients were treated by a distal calcaneal osteotomy and plantar fasciotomy. Good results were obtained in 30 of 39 patients; two had fair results and seven of 39 had poor results. Of the lateral column procedures, distal calcaneal osteotomy avoids the articular surfaces and provides for easier rotational positioning and correction of the forefoot. Older patients who have had multiple operations and, potentially, more severe pathology do not do well with this procedure. Preoperative evaluation of certain radiographic parameters is important in patient selection for these procedures.     

Contributory etiologic factor for talipes equinovarus in congenital myotonic dystrophy: comparative biopsy study of intrinsic foot musculature and vastus lateralis in two cases

Biopsy specimens from the feet and proximal thigh musculature of two patients with congenital myotonic dystrophy with talipes equinovarus were compared. The findings were also compared with those reported in muscle biopsy of idiopathic clubfoot. It was concluded that structural change in intrinsic foot muscle can contribute to the force imbalance that produces clubfoot in this disease.     

距跟周围松解旋转术治疗儿童先天性马蹄内翻足

目的：探讨距跟周围松解旋转术治疗儿童先天性马蹄内翻足（CCF）的临床应用及近期疗效。方法：2004年至2006年采用距跟周围松解旋转术治疗儿童先天性马蹄内翻足24例（共36足）,术中行广泛的软组织松解、距跟去旋转矫正,保留跟距骨间韧带,去旋转绞链,避免跟骨失稳,行胫前肌腱延长。术后管型石膏固定6-8周。去除内固定后穿矫形支具〉1年。结果：均痊愈,平均随访2．3年（1～3年）,根据术后足的外观形态、足印、踝部功能、有无疼痛及x线检查评价疗效,疗效优16例25足;良6例8足;可2例3足,优良率为93．33％。结论：距跟周围松解旋转术是矫正儿童先天性马蹄内翻足的有效手术方法,其优点是手术松解充分、畸形纠正彻底,矫形效果良好。     

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.     

软组织松解结合截骨治疗僵直性先天性马蹄内翻足

目的探讨软组织松解和（或）截骨治疗僵直性先天性马蹄内翻足畸形的手术方法及疗效。方法 2003年1月至2007年12月采用软组织松解和（或）截骨治疗僵直性先天性马蹄内翻足患者7例13足。男3例6足,女4例7足;年龄3～12岁,平均（5.3±3.1）岁;术前畸形程度按Dimeglio评分系统进行评分为13～20分,平均（15.1±2.2）分。按其评分进行分类,Ⅲ度畸形10足,Ⅳ度畸形3足。结果 7例13足的Cummings评分为31～88分,平均（75.5±14.3）分,其中优3足,良9足,差1足。结论充分而有序的软组织松解结合有限的截骨治疗僵直性先天性马蹄内翻足可获得良好疗效。     

Congenital talipes equinovarus: an epidemiological study in Sicily

Background and purpose Congenital talipes equinovarus (clubfoot) can present in 2 forms: “syndromic”, in which other malformations exist, and the more common “idiopathic” form, where there are no other associated malformations. We analyzed the epidemiology of congenital talipes equinovarus in the Sicilian population, looking for potential etiological factors.

Patients and methods Among the 801,324 live births recorded between January 1991 and December 2004, 827 cases were registered (560 males; M/F sex ratio: 2.1). Control infants were randomly selected from a historical cohort of live births without any major congenital malformations.

Results A positive family history of clubfoot, gender, and maternal smoking were found to be risk factors for clubfoot. Patients with clubfoot were born most frequently during the period January–March. No association was found between clubfoot and reproductive history, peri-conceptional maternal drug exposure, maternal education, or ethnicity.

Interpretation Our findings emphasize the importance of birth defects surveillance programs and their usefulness in investigating potential risk factors.     

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.     

Management issues of congenital talipes equinovarus in the neonatal intensive care unit: A systematic review

BackgroundThe Ponseti method is the standard of care for managing idiopathic congenital talipes equinovarus (clubfoot) in the outpatient setting, but there are no clinical guidelines for inpatient treatment. Children in the neonatal intensive care unit (NICU) with clubfoot often delay treatment initiation due to medical reasons.MethodsWe systematically reviewed literature related to the treatment of clubfoot in the NICU, non-idiopathic clubfoot, and older infants, as well as barriers to care.ResultsIn a mixed NICU population of syndromic and idiopathic clubfoot, the Ponseti method has good functional outcomes with minimal interference with medical management. The Ponseti method has good functional outcomes with reduced need for extensive surgical procedures in non-idiopathic clubfoot and idiopathic clubfoot with delayed presentation (under one year of age).ConclusionsIt is possible to begin Ponseti treatment in the NICU without compromising medical management. It is not clear if this confers an advantage over waiting for outpatient casting.     

Subjective and objective outcome in congenital clubfoot; a comparative study of 204 children

Background  

Outcome following management of congenital talipes equinovarus (clubfoot) can be assessed in a number of ways. Bjonness stated simply that "the patient is the final judge of whether he has a good foot"; a purely subjective assessment. Others have employed objective measures. Combining subjective evaluation with a more objective assessment of movement and position of the foot, is likely to give a more comprehensive picture of the final result of clubfoot. The purpose of this study was to compare subjective and objective outcome following management of clubfoot, and evaluate sex differences in outcome.     

Congenital talipes equinovarus: II. A staged method of surgical management

A staged method of surgical management for congenital talipes equinovarus is described. The hindfoot was corrected and rebalanced early in 125 feet, and in 66 feet a second-stage medial forefoot correction was performed in the second, third or fourth year. The hindfoot relapsed in 19% and the forefoot in 9%; these feet were treated by further soft-tissue surgery. No bony operation was necessary. Assessment before and after operation allows comparison with other series.     

Ilizarov external fixator in treatment of severe recurrent congenital talipes equinovarus

Aim  

Severe recurrent congenital talipes equinovarus deformity remains a significant problem in orthopedic surgery particularly in the developing countries with limited facilities. Surgical treatment of patients with severe recurrent congenital talipes equinovarus is difficult and has many complications. This study discusses the results of using Ilizarov external fixator in treatment of severe recurrent congenital talipes equinovarus deformity.     

The association between clubfoot and developmental dysplasia of the hip

The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia. This study supports selective ultrasound screening of hips in infants with CTEV.     

The role of bilateral talectomy in the management of bilateral rigid clubfeet

Severe clubfoot is a common sequela of arthrogryposis multiplex congenita and myelomeningocele. Talectomy is a practical surgical procedure to assist in the correction of severe, rigid equinovarus foot deformity. However, the results of talectomy may be less predictable in rigid bilateral equinovarus foot deformity than in the treatment of unilateral clubfoot. To determine the outcome of talectomy in the treatment of bilateral rigid clubfoot, we reviewed the cases of all patients at our center who underwent bilateral talectomy. Seven children were treated for bilateral talipes equinovarus with talectomy. The patient group consisted of 3 children with arthrogryposis, 3 with myelomeningocele, and 1 with Duchenne muscular dystrophy. The age at surgery averaged 6 years and ranged from 1 year and 10 months to 15 years and 7 months. The length of follow-up averaged 5 years and 6 months and ranged from 3 years to 12 years and 6 months. Three feet had a good and 7 feet a satisfactory correction of the deformity. Four feet had poor results. Bilateral talectomy was found overall to be a successful and predictable procedure, with low morbidity for the attainment of functional feet.     

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.     

Muscular strength after extensive operative treatment of congenital talipes equinovarus

Maximum isometric voluntary contraction (MIVC) strength of muscles (extensors, plantar flexors, pronators and supinators of the foot) in children with congenital talipes equinovarus who underwent extensive operative treatment was evaluated. The first group consisted of 28 children (50 clubfeet) operated on with posteromedial-lateral release aged 7 months to 76 months (mean, 22 months), with mean follow-up period of 85 months. The second group consisted of 32 children (39 clubfeet) operated on with complete subtalar release from Cincinnati incision aged from 3 months to 50 months (mean, 11 months), with mean follow-up period of 51 months. In both groups, the muscles moving the foot in the sagittal and coronal plane showed a decreased MIVC. The greatest deficit was observed in the supinators and extensors, less in the pronators and plantar flexors. Better results were accompanied by greater MIVC, but significant relations existed in the first group between the strength of the extensors and the quality of results (better results correlated with better MIVC of the extensors). No significant differences between both patient groups were noted. For the plantar flexors, the difference of the MIVC strength between the normal and affected feet is stable; instead, for the extensors, supinators and pronators, it increases in the analyzed age interval.     

应用Ilizarov技术治疗青少年重度马蹄内翻足

目的 :探索青少年重度马蹄内翻足的治疗方法。方法 :应用足踝部有限软组织松解 ,结合术后外固定器缓慢牵伸松解关节挛缩 ,以及二期关节融合与肌力平衡手术治疗青少年重度马蹄内翻足 10例 (16足 )。结果 :16足均获得满意的畸形矫正及足底持重 ,3例遗有轻度前足内收。结论 :应用Ilizarov技术结合有限的手术治疗 ,可获得青少年重度马蹄内翻足的良好畸形矫正和功能恢复。     

Congenital talipes equinovarus: an epidemiological study in Sicily

Background and purpose

Congenital talipes equinovarus (clubfoot) can present in 2 forms: “syndromic”, in which other malformations exist, and the more common “idiopathic” form, where there are no other associated malformations. We analyzed the epidemiology of congenital talipes equinovarus in the Sicilian population, looking for potential etiological factors.

Patients and methods

Among the 801,324 live births recorded between January 1991 and December 2004, 827 cases were registered (560 males; M/F sex ratio: 2.1). Control infants were randomly selected from a historical cohort of live births without any major congenital malformations.

Results

A positive family history of clubfoot, gender, and maternal smoking were found to be risk factors for clubfoot. Patients with clubfoot were born most frequently during the period January–March. No association was found between clubfoot and reproductive history, peri-conceptional maternal drug exposure, maternal education, or ethnicity.

Interpretation

Our findings emphasize the importance of birth defects surveillance programs and their usefulness in investigating potential risk factors.Congenital talipes equinovarus (CTEV), usually known as ‘clubfoot’, is the most common congenital orthopedic disease. Its etiology is unknown but appears to be complex (De Andrade et al. 1998, Chesney et al. 1999). The incidence is estimated to be 0.64–6.8 per 1,000 live births (Cartlidge 1984, Lochmiller et al. 1998, Wallander et al. 2006). However, in all epidemiological studies there are uncertainties created by variations in registration methods.CTEV can present in 2 forms. In severe syndromic CTEV, other malformations are present such as spina bifida, spinal muscular atrophy, sacral agenesis, or arthrogryposis. Associated features may also include joint laxity, congenital dislocation of the hip, tibial torsion, ray anomalies of the foot, and the absence of some tarsal bones. In idiopathic CTEV—the more common form—the anomaly is isolated or may be associated with minor malformations. There may be a family history of foot anomalies.The diagnosis of CTEV is based on clinical examination (irreducible equinus, varus of the hindfoot, adduction of the forefoot, cavus, and an “empty” heel pad) (Lochmiller et al. 1998, Wallander et al. 2006) and is straightforward. It can also be also diagnosed in utero by ultrasound (Danielson 1992, Sharma et al. 2011).Studies on the epidemiology of CTEV could provide a basis for identifying potential risk factors. Thus, the aim of the present study was to determine the epidemiology of congenital talipes equinovarus in the Sicilian population and to describe the characteristics associated with the disease.