Background
Clubfoot can be treated nonoperatively, most commonly using a Ponseti approach, or surgically, most often with a comprehensive clubfoot release. Little is known about how these approaches compare with one another at longer term, or how patients treated with these approaches differ in terms of foot function, foot biomechanics, or quality-of-life from individuals who did not have clubfoot as a child.Questions/purposes
We compared (1) focused physical and radiographic examinations, (2) gait analysis, and (3) quality-of-life measures at long-term followup between groups of adult patients with clubfoot treated either with the Ponseti method of nonsurgical management or a comprehensive surgical release through a Cincinnati incision, and compared these two groups with a control group without clubfoot.Methods
This was a case control study of individuals treated for clubfoot at two separate institutions with different methods of treatment between 1983 to 1987. One hospital used only the Ponseti method and the other mainly used a comprehensive clubfoot release. There were 42 adults (24 treated surgically, 18 treated with Ponseti method) with isolated clubfoot along with 48 healthy control subjects who agreed to participate in a detailed analysis of physical function, foot biomechanics, and quality-of-life metrics.Results
Both treatment groups had diminished strength and motion compared with the control subjects on physical examination measures; however, the Ponseti group had significantly greater ankle plantar flexion ROM (p < 0.001), greater ankle plantar flexor (p = 0.031) and evertor (p = 0.012) strength, and a decreased incidence of osteoarthritis in the ankle and foot compared with the surgical group. During gait the surgical group had reduced peak ankle plantar flexion (p = 0.002), and reduced sagittal plane hindfoot (p = 0.009) and forefoot (p = 0.008) ROM during the preswing phase compared with the Ponseti group. The surgical group had the lowest overall ankle power generation during push off compared with the control subjects (p = 0.002). Outcome tools revealed elevated pain levels in the surgical group compared with the Ponseti group (p = 0.008) and lower scores for physical function and quality-of-life for both clubfoot groups compared with age-range matched control subjects (p = 0.01).Conclusions
Although individuals in each treatment group experienced pain, weakness, and reduced ROM, they were highly functional into early adulthood. As adults the Ponseti group fared better than the surgically treated group because of advantages including increased ROM observed at the physical examination and during gait, greater strength, and less arthritis. This study supports efforts to correct clubfoot with Ponseti casting and minimizing surgery to the joints, and highlights the need to improve methods that promote ROM and strength which are important for adult function.Level of Evidence
Level III, prognostic study. 相似文献Background and purpose
In 2002–2003, several hospitals in Norway introduced the Ponseti method for treating clubfoot. The present multicenter study was conducted to evaluate the initial results of this method, and to compare them to the good results reported in the literature.Patients and methods
116 children with 162 congenital idiopathic clubfeet who were born between 2004 and 2006 were treated with the Ponseti method at 8 hospitals in Norway. All children were prospectively registered at birth, and 116 feet were assessed according to Pirani before treatment was started. 63% used a standard bilateral foot abduction brace, and 32% used a unilateral above-the-knee brace. One of the authors examined all feet at a mean age of 4 years. At follow-up, all feet were assessed by Pirani’s scoring system, and range of motion of the foot and ankle was measured.Results
At follow-up, 77% of the feet had a Pirani score of 0.5 or better, good dorsiflexion and external rotation, and no forefoot adduction. An Achilles tenotomy had been performed in 79% of the feet. Compliance to any brace was good; only 7% were defined as non-compliant. Extensive soft tissue release had been performed in 3% of the feet.We found no statistically significant differences between the two braces, except a tendency of better Pirani score in the group using the bilateral foot abduction brace, and a tendency of better compliance in patients using the unilateral brace. Better Pirani scores were found in children who were treated at the largest hospitals.Interpretation
After introducing the Ponseti method in Norway, the clinical outcome was good and in accordance with the reports from single centers. Only 5 feet needed extensive surgery during the first 4 years of life.The methods of treating clubfoot have varied over the years and between the different hospitals in Norway. The results reported have not been satisfactory, as 75% of the feet needed posterior or postero-medial release (Nesse et al. 1996). Thus, orthopedic surgeons treating clubfoot in Norway decided to start with the Ponseti method, which has shown promising short-term and long-term results (Laaveg and Ponseti 1980, Cooper and Dietz 1995, Herzenberg et al. 2002). The Ponseti method of treating clubfoot was introduced at several hospitals in Norway in 2002 and 2003.A foot abduction brace is a crucial part of the Ponseti treatment, and it is well documented that the brace prevents a clubfoot from relapsing (Dobbs et al. 2004, Morcuende et al. 2004). The brace recommended by Ponseti is a bilateral foot abduction brace. Many hospitals in Norway have traditionally used a custom-made unilateral above-the-knee dynamic brace to prevent relapse. Some of these hospitals continued to offer this brace to children with clubfoot, even after the introduction of the Ponseti casting method.Norway is a small country regarding population (4.9 million inhabitants), but it has a relatively large area and none of the hospitals were responsible for treating more than 10 newborns with clubfoot every year in this study.We evaluated our results and compared them to the good short-term and long-term results reported in the literature. We also compared the unilateral above-the-knee brace with the standard bilateral foot abduction brace regarding both clinical outcome and compliance to brace use. Finally, we determined whether the results were influenced by the number of clubfeet treated at each hospital. 相似文献Introduction
Standards for treating idiopathic clubfoot are still under discussion. Over the last 10–15 years the Ponseti method has been widely accepted as the treatment of choice, but the method has been modified very often, and the original protocol is not always properly performed. A consensus group was set up in the UK in 2011 to define standards for Ponseti clubfoot treatment, and the purpose of our meeting is to extend these standards to the European level. Clubfoot experts from 12 countries met at Karolinska University in Stockholm to discuss goals, standards, challenges and treatment outcome, based on literature review and personal experience.Items discussed
The ambitious agenda included most aspects of clubfoot treatment. Discussion following an intensive literature review was constructive, and the group was able to carry out discussions on defining the goal of clubfoot treatment and the preferred standard of treatment.Conclusion
In order to establish the Ponseti method as the most effective treatment in the European context a methodological approach and analysis of existing literature remain crucial. Focus should hereby remain on defining outcome measures, the evaluation and comparison of all available methods over the long term and ease of implementation in the different healthcare environments across Europe. 相似文献Purpose
Despite few studies comparing Ponseti treatment and traditional treatment of clubfoot (talipes equinovarus), the Ponseti method is now accepted as standard treatment for this deformity. The Ponseti method was introduced in Norway in 2003 and the purpose of this multicenter-study was to compare the results of Ponseti treatment with the results of the previous treatment for clubfoot in Norway.Methods
90 children (134 clubfeet) treated with previous treatment (pre-Ponseti group), were compared to 115 Ponseti treated children (160 clubfeet) (Ponseti group). The previous treatment consisted of casting and surgery if needed. At 8–11 years of age, all children were examined by the same orthopaedic surgeon, the parents answered a questionnaire, all feet were X-rayed and information about surgical procedures was obtained from the patient records.Results
The number of surgeries was higher in the pre-Ponseti group, and the number of extensive surgeries was 119 in the pre-Ponseti group compared to 19 in the Ponseti group. The range of motion in the ankle joint was better in the Ponseti group. Children in this group had better function, higher satisfaction and less pain according to patient and parent reported outcome measures. The incidence of moderate or severe talar flattening was higher in the pre-Ponseti group.Conclusion
Ponseti treatment seems to be superior to the previous treatment in Norway, with regards to number and severity of operations, flexibility of the foot and ankle, parent/patient reported outcome and the presence of talar flattening on X-ray.Background and purpose —
Neglected clubfoot deformity is a major cause of disability in low-income countries. Most children with clubfoot have little access to treatment in these countries, and they are often inadequately treated. We evaluated the effectiveness of Ponseti’s technique in neglected clubfoot in children in a rural setting in Ethiopia.Patients and methods —
A prospective study was conducted from June 2007 through July 2010. 22 consecutive children aged 2–10 years (32 feet) with neglected clubfoot were treated by the Ponseti method. The deformity was assessed using the Pirani scoring system. The average follow-up time was 3 years.Results —
A plantigrade functional foot was obtained in all patients by Ponseti casting and limited surgical intervention. 2 patients (4 feet) had recurrent deformity. They required re-manipulation and re-tenotomy of the Achilles tendon and 1 other patient required tibialis anterior transfer for dynamic supination deformity of the foot.Interpretation —
This study shows that the Ponseti method with some additional surgery can be used successfully as the primary treatment in neglected clubfoot, and that it minimizes the need for extensive corrective surgery.Many children with congenital talipes equino varus (CTEV) in low-income countries end up with neglected clubfoot deformity (untreated children > 2 years) because of the lack of treatment capacity. In Ethiopia, it is estimated that there are 3,000–5,000 new CTEV cases per year, but there are no reliable data available.Neglected clubfoot is a common, disabling problem in Ethiopia. For many years, the treatment for clubfoot in Ethiopia has been nonoperative treatment with Kite’s technique, followed by a posteromedial release, with significant surgical complications and poor results (personal observations by the authors). A dramatic reduction in radical clubfoot operation has been reported in parts of the world where Ponseti treatment has been introduced (Morquende et al. 2004, Zionts et al. 2010). We have the same subjective impression in Ethiopia, but there are no published data.Ponseti treatment was introduced in Ethiopia in June 2005 at the Orthopaedic Department, Black Lion Hospital (BLH), University of Addis Ababa. It has gradually been adopted in several places in a cooperation between BLH and Cure International, Ethiopia. Several thousand children have been involved.In the past decade, the Ponseti method has become recognized globally as the gold standard for clubfoot treatment in younger children (< 2 years old) (Cooper et al. 1995, Bor et al. 2009, Pirani et al. 2009, Sætersdal et al. 2012).There have been some reports of Ponseti treatment being given successfully to children with neglected clubfoot (Verma et al. 2012, Laurenco et al. 2007, Alves et al. 2009), but there has been no general acceptance of treating children older than 2 years with this method. Today, these children are probably treated with radical operations or left untreated (De Rosa and Norrish 2012).Inspired by the results of A. F. Laurenco, which were communicated personally before his article was published in 2007, we treated some neglected children over the age of 2 years when the Ponseti treatment was started in Addis Ababa (at BLH), and the initial results were encouraging.The objective of this study was to prospectively evaluate the short-term results of using the Ponseti technique for treatment of children with neglected clubfoot deformity in a rural hospital in Ethiopia. 相似文献Background
Clubfoot is disabling, with an incidence of 0.9/1,000 live births to 7/1,000 live births. It affects mobility, productivity, and quality of life. Patients are treated surgically or non-surgically using the Ponseti method. We estimated the cost per patient treated with both methods and the cost-effectiveness of these methods in Pakistan.Methods
Parents of patients treated, either surgically or with the Ponseti method, at the Indus Hospital’s free program for clubfoot were interviewed between February and May 2012. We measured the direct and indirect household expenditures for pre-diagnosis, incomplete treatment, and current treatment until the first brace for Ponseti method and the first corrective surgery for surgically treated patients. Hospital expenditure was measured by existing accounts.Results
Average per-patient cost was $349 for the Ponseti method and $810 for patients treated surgically. Of these, the Indus hospital costs were $170 the for Ponseti method and $452 for surgically treated patients. The direct household expenditure was $154 and $314 for the Ponseti and surgical methods, respectively. The majority of the costs were incurred pre-diagnosis and after inadequate treatment, with the largest proportion spent on transportation, material, and fee for service. The Ponseti method is shown to be the dominant method of treatment, with an incremental cost-effectiveness ratio of $1,225.Conclusions
The Ponseti method is clearly the treatment of choice in resource-constrained settings like Pakistan. Household costs for clubfoot treatment are substantial, even in programs offering free diagnostics and treatments and may be a barrier to service utilization for the poorest patients. 相似文献Purpose
To evaluate the effectiveness of the Ponseti method in treating clubfoot associated with arthrogryposis.Methods
Retrospective consecutive review over a 10-year period in a tertiary centre of all patients with arthrogrypotic clubfoot treated with the Ponseti method. The primary outcome measure at final follow-up was the functional correction of the deformity.Results
There were ten children with 17 arthrogrypotic clubfeet, with an average follow-up of 5.8 years (range 3–8 years). The average age at presentation was 5 weeks (range 2–20 weeks). Deformities were severe, with an average Pirani score of 5.5 (range 3–6). Initial correction was achieved in all children with an average of 8 (range 4–10) Ponseti casts and a tendo-Achilles tenotomy (TAT) was performed in 94.1 %. Two-thirds of patients had a satisfactory outcome at final follow-up, with functional plantigrade, pain-free feet.Conclusions
The Ponseti method is an effective first-line treatment for arthrogrypotic clubfeet to achieve functional plantigrade feet. Children will often require more casts and have a higher risk of relapse.Background
Patients with diabetes and peripheral neuropathy are at higher risk for falls. People with diabetes sometimes adopt a more conservative gait pattern with decreased walking speed, widened base, and increased double support time. The purpose of this study was to use a multivariate approach to describe this conservative gait pattern.Methods
Male veterans (mean age = 67 years; SD = 9.8; range 37–86) with diabetes (n = 152) participated in this study from July 2000 to May 2001 at the Veterans Affairs Medical Center, White River Junction, VT. Various demographic, clinical, static mobility, and plantar pressure measures were collected. Conservative gait pattern was defined by visual gait analysis as failure to demonstrate a heel-to-toe gait during the propulsive phase of gait.Results
Patients with the conservative gait pattern had lower walking speed and decreased stride length compared to normal gait. (0.68 m/s v. 0.91 m/s, p < 0.001; 1.04 m v. 1.24 m, p < 0.001) Age, monofilament insensitivity, and Romberg's sign were significantly higher; and ankle dorsiflexion was significantly lower in the conservative gait pattern group. In the multivariate analysis, walking speed, age, ankle dorsiflexion, and callus were retained in the final model describing 36% of the variance. With the inclusion of ankle dorsiflexion in the model, monofilament insensitivity was no longer an independent predictor.Conclusion
Our multivariate investigation of conservative gait in diabetes patients suggests that walking speed, advanced age, limited ankle dorsiflexion, and callus describe this condition more so than clinical measures of neuropathy. 相似文献Background
Clubfoot occurs in nearly 1 in every 1,000 live births worldwide, representing a significant burden of disease. In high-income countries, an evidence-based treatment protocol utilizing sequential casting was pioneered by Ponseti and has resulted in excellent outcomes among children treated for this condition. However, treatment methods and results of treatment vary greatly across low- and middle-income countries (LMICs). Our goal was to create a framework for understanding how effective programs that treat clubfoot in LMICs choose and organize their activities.Methods
A systematic literature review was conducted using the keywords “developing countries” and “clubfoot.” A public health analysis model known as the Care Delivery Value Chain (CDVC) was applied to discover public health practices that would optimize value over the entire course of a patient’s life.Results
The literature review yielded 32 unique results, seven of which met our inclusion and exclusion criteria. Review of the bibliographies yielded two additional papers for a total of nine papers. We identified seven vital steps in the clubfoot cycle of care and constructed a CDVC.Conclusions
The analysis of this CDVC model suggests six best practices that are essential to successfully scaling up clubfoot treatment programs and ensuring excellent clinical outcomes: (1) diagnosing clubfoot early; (2) organizing high-volume Ponseti casting centers; (3) using nonphysician health workers; (4) engaging families in care; (5) addressing barriers to access; (6) providing follow-up in the patient’s community. These practices must be adapted to each context. Applying them will optimize outcomes when designing public health programs that deliver clubfoot care in LMICs. 相似文献Purpose
Calcaneocuboid arthrodesis was used during revision clubfoot surgery in order to maintain midfoot correction. The purposes of this study were to determine: (1) functional level at 17-year follow-up compared to 5-year follow-up; (2) patients’ current functional level, satisfaction, and pain; and (3) current arthropometric measurements.Methods
Twenty patients (27 clubfeet) with clubfoot relapse underwent revision soft tissue release and calcaneocuboid fusion between 1991 and 1994. They were previously evaluated at a mean follow-up of 5.5 years. Ten out of 20 patients (13 clubfeet), mean age of 24 years, were reevaluated at mean follow-up of 17.5 years. The Hospital for Joint Diseases Functional Rating System (HJD FRS) for clubfoot surgery, Outcome Evaluation in Clubfoot developed by the International Clubfoot Study Group, the Clubfoot Disease-Specific Instrument, American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire, Laaveg and Ponseti’s functional rating system for clubfoot and pain scale were completed by patient and/or surgeon to assess function, patient satisfaction and pain. Foot and ankle radiographs and anthropometric measurements were reviewed. For HJD FRS, scores from original follow-up were compared to current ones.Results
The HJD FRS score of all feet was 65.9, demonstrating a significant decline from the original mean score of 77.8 (p = 0.03). Excellent/good HJD FRS scores went from 85 to 38 %. Mean AAOS Foot Ankle Outcomes Questionnaire standardized core and shoe comfort scores were 84.6 and 84.5, respectively. Average foot pain was 1.8 on a scale of 1–10. Patients were very/somewhat satisfied with status of foot in 76 % of feet and appearance of foot in 46 % of feet, based on Clubfoot Disease-Specific Instrument questions.Conclusions
Revision clubfoot surgery with calcaneocuboid fusion in patients 5–8 years of age showed an expected decline in functional outcome measures over a 17-year follow-up period. It still produced comparable results to other studies for a similar population of difficult, revision cases, and should have a place in current surgical treatment techniques. 相似文献Patients and methods — Three-dimensional gait analyses of 59 children, mean age 5.4 years, with bilateral (n = 30) or unilateral (n = 29) idiopathic clubfoot were stratified into groups of bilateral, unilateral, or contralateral feet. Age-matched controls (n = 28) were evaluated for comparison. Gait assessment included: (1) discrete kinematic and kinetic parameters, and (2) gait deviation index for kinematics (GDI) and kinetics (GDI-k).
Results — No differences in gait were found between bilateral and unilateral idiopathic clubfoot, but both groups deviated when compared to controls. Compared to control feet, contralateral feet showed no deviations in discrete gait parameters, but discrepancies were evident in relation to unilateral clubfoot, causing gait asymmetries in children with unilateral involvement. However, all groups deviated significantly from control feet according to GDI and GDI-k.
Interpretation — Bilateral and unilateral idiopathic clubfoot cases show the same persistent deviations in gait, mainly regarding reduced plantarflexion. Nevertheless, knowledge of foot involvement is important as children with unilateral clubfoot show gait asymmetries, which might give an impression of poorer deviations. The results of GDI/GDI-k indicate global gait adaptations of the contralateral foot, so the foot should preferably not be used as a reference for gait. 相似文献