Therapie des Rezidivklumpfußes und residueller Deformitäten nach kongenitalem Klumpfuß

Relapse and residual deformity after treatment of congenital clubfoot are common problems. Recurrences occur in up to 48?% of cases after successful initial treatment using Ponseti’s technique. By casting and anterior tibial tendon transfer as recommended by Ponseti a flexible and well functioning foot can be achieved in most cases. Neglected clubfoot remains a demanding challenge. Depending on the severity of the deformity, the impairment of function and patient age, conservative and/or different operative treatment options can be considered. Manipulation and casting according to Ponseti is also recommended in toddlers with relapses even after peritalar joint release. Thus the need and extent of operative treatment can be reduced. Additional osteotomy may be indicated in more rigid feet and older children. An accurate evaluation of the existing deformity and functional impairment is mandatory for the individual choice of treatment. The number of previous operative procedures reduces the amount of improvement and mobility of the foot. Therefore, the best and most efficient treatment for recurrent clubfoot is prevention in the form of consistent primary treatment, consistently wearing braces and regular follow-up examinations.     

A new approach to the treatment of congenital vertical talus

Congenital vertical talus is an uncommon foot deformity that is present at birth and results in a rigid flatfoot deformity. Left untreated the deformity can result in pain and disability. Though the exact etiology of vertical talus is unknown, an increasing number of cases have been shown to have a genetic cause. Approximately 50% of all cases of vertical talus are associated with other neuromuscular abnormalities or known genetic syndromes. The remaining 50% of cases were once thought to be idiopathic in nature. However, there is increasing evidence that many of these cases are related to single gene defects. Most patients with vertical talus have been treated with major reconstructive surgeries that are fraught with complications such as wound necrosis, talar necrosis, undercorrection of the deformity, stiffness of the ankle and subtalar joint, and the eventual need for multiple operative procedures. Recently, a new approach to vertical talus that consists of serial casting and minimal surgery has resulted in excellent correction in the short-term. Longer follow-up will be necessary to ensure maintenance of correction with this new technique. A less invasive approach to the correction of vertical talus may provide more favorable long-term outcomes than more extensive surgery as has been shown to be true for clubfoot outcomes.     

Accelerated Ponseti method: First experiences in a more convenient technique for patients with severe idiopathic club feet

BackgroundCongenital 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.MethodsThis 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.ResultsFive patients had bilateral club foot deformity. Average age at treatment was 54.8 days (range 8–150 days). 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.ConclusionsThe 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.     

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.     

Minimal-invasive Therapieverfahren angeborener Fußdeformitäten im Säuglingsalter

In the last decade treatment of foot deformities has changed from extensive surgery to casting and minimally invasive surgery. The Ponseti method has become the most preferred treatment for clubfoot deformities and early evaluations showed promising results. Mid-term results for idiopathic clubfoot revealed the need for additional surgery by anterior tibial tendon transfer in 11–32?% of cases depending on the duration of bracing. Anterior tibial tendon transfer is the most important surgical procedure for relapses in the Ponseti concept. Casting, recasting in cases of relapses, bracing and anterior tibial tendon transfer altogether represent the Ponseti method and cannot be considered as single entities. The Dobbs method is a new concept for the treatment of vertical talus. Treatment of vertical talus should start with the Dobbs method but in comparison to clubfoot treatment there has not been a complete change to minimally invasive treatment. Especially in non-idiopathic vertical talus cases open reduction of the talonavicular and calcaneocuboid joint are often necessary.     

An Unusual Aberrant Muscle in Congenital Clubfoot: An Intraoperative Finding

Congenital clubfoot is a common congenital deformity, characterized by equinus of the hindfoot and adduction of the midfoot and forefoot, with varus through the subtalar joint complex. A cavus deformity will also be present. The etiology of this congenital deformity remains elusive. Muscle anomalies are not commonly found in patients with idiopathic clubfoot, and, when present, their significance is not clear. The presence of a flexor digitorum accessorius longus muscle and an accessory soleus muscle found at surgical correction of clubfoot deformity has been previously reported. Our case was a female child, aged 2 years, 3 months, who developed bilateral relapsed congenital clubfoot. She was found to have an unusual aberrant muscle in both legs. This was discovered accidentally during surgical correction of her deformity through posteromedial soft tissue release. This muscle might have contributed to the hindfoot varus and equinus in the clubfoot deformity, because the latter were completely corrected after release of the muscle from its insertion. Awareness of such a new anatomic variant, with the other anatomic variants found in clubfoot deformity, will not only improve our understanding of normal lower limb development, but could also lead to improved genetic counseling and diagnostic and treatment methods of such a common congenital deformity.     

Hallux flexus: Review of current opinion on aetiology and management

Hallux flexus is a deformity of the foot characterised by elevation of the first metatarsal head and fixed flexion at the first metatarsophalangeal joint. The deformity is predominantly seen in children following clubfoot surgery or with cerebral palsy. In this article, current opinion on the aetiology and treatment of hallux flexus is reviewed. We argue that a conservative approach to management is appropriate initially, with subsequent soft tissue or skeletal surgery if appropriate.     

Review of current methods used in the treatment of clubfoot at initial presentation and at recurrence

Idiopathic clubfoot is a common condition seen by orthopaedic surgeons and is characterized by complex three-dimensional deformity of the foot. It is recognized that clubfoot treatment is a challenging issue in orthopaedics because it is an ongoing process, beginning in early infancy and continuing until the patient has reached skeletal maturity. This review article summarizes two important stages of clubfoot treatment. First, methods of initial correction-including nonoperative, semi-operative, and operative techniques-that have been used in the last 20 years are described. Second, the management of the recurrent clubfoot is discussed in terms of methods used to address specific deformities.     

Correction of neglected clubfoot using the Ilizarov external fixator

BACKGROUND: This study was conducted to evaluate the corrective capability of the Ilizarov external fixator in the treatment of neglected clubfoot. METHODS: Thirty patients (38 feet) with a mean age of 19 (5 to 39) years with severe deformities and stiff feet associated with neglected clubfoot were studied. A limited soft-tissue dissection, Achilles tenotomy, and plantar fasciotomy were done. Progressive correction of the deformities was achieved through a standard setting of the Ilizarov external fixator. The device was used for 16 weeks, on average, and after removal a short-leg walking cast was used for an additional 6 weeks, followed by an ankle-foot orthosis (AFO) for 6 months. RESULTS: The final outcome was scored as good (complete correction and no pain); fair (partial correction with plantigrade foot and occasional pain); or poor (nonplantigrade foot and continuous pain during walking). After a mean followup of 58 (range 12 to 107) months, the results were good in 30 feet (78.9%); fair in three feet (7.9%); and poor in five feet (13.2%). Early complications were a distal tibial fracture in one foot, dislocation of the first metatarsophalangeal joint in one foot, and arterial damage that resulted in amputation of the toes in one foot. Recurrence of the deformity was found in 19 feet (50%): 11 minor, three mild, and five severe. Spontaneous ankylosis developed in 28 feet (73.7%). Nine feet (23.7%) required arthrodesis for symptomatic arthritis of the ankle or midfoot and deformity that could not be treated with orthoses. CONCLUSION: The Ilizarov external fixator allows simultaneous correction of all the severe foot deformities associated with neglected clubfoot with minimal surgery, reducing risks of cutaneous or neurovascular complications and avoiding excessive shortening of the foot. Even in those patients in whom final corrective arthrodesis is necessary, this may be carried out with minimal bone resection, since the severe deformities of the foot and ankle have been corrected.     

The complete subtalar release in clubfeet

CSTR is a release of the subtalar joint and the talonavicular joint that corrects calcaneal rotation, a major deformity of the clubfoot, as well as the other major deformities of the midfoot and hindfoot. Indications for the CSTR are presented. These include failure of conservative treatment or unsatisfactory surgical results with residual varus deformity, and a foot longer than 8 cm. Contraindications to CSTR include radiographic evidence of a flat-top talus and uncorrected anterior ankle contractures. The Cincinnati incision, which permits excellent visualization of all the relevant structures and good cosmesis, is described and compared with other approaches. The technique of the CSTR is described in detail. Key steps include marking the knee for later alignment with the foot (a major advantage of this procedure), superficial medial dissection, posterior dissection, lateral dissection, and deep medial dissection. Technical details and criteria for evaluation are provided. Four supplemental procedures and their indications are described. These include metatarsal osteotomy, calcaneocuboid capsulotomy, calcaneal wedge osteotomy, and plantar release. Procedures for pinning and casting are described, with special attention to accuracy of realigning the foot and measures for avoiding avascular necrosis and other complications. The importance of intraoperative radiographs is presented, together with methods for obtaining and assessing these films to assure that surgical correction is complete. It is imperative that these films be taken before tendon repair or wound closure so that pinning procedures can be repeated, if necessary.     

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.     

Wound complications from idiopathic clubfoot surgery: a comparison of the modified Turco and the Cincinnati treatment methods

PURPOSE: Treatment protocols using the Turco and the Cincinnati incisions are widely used for the surgical correction of clubfoot deformity. However, it is unclear which surgical approach leads to fewer wound problems. We therefore sought to determine which treatment method led to a lower incidence of wound complications. STUDY DESIGN: A retrospective chart review of 217 consecutive patients (308 feet) who underwent a primary posteromedial release for the treatment of idiopathic clubfoot under the age of 24 months via either the modified Turco or Cincinnati treatment methods was used to document the incidence of postoperative wound complications. The modified Turco protocol involved immediate postoperative casting in neutral, whereas the Cincinnati method involved staged casting with the foot initially in equinus, then to neutral with a cast change 7 days later. RESULTS: A significantly lower incidence of wound complications was seen in the Cincinnati treatment group when compared with the modified Turco treatment method (6.9% vs 19.6%, respectively, P < 0.003). When patients were stratified based on immediate versus staged postoperative casting methods, there was a significantly lower incidence of wound complications (P < 0.05) in feet in the Cincinnati treatment group versus the modified Turco treatment method; however, the statistical populations were markedly unequal. Among all feet treated with the Cincinnati method, patients who underwent a staged cast change had significantly fewer wound problems when compared with those who underwent immediate casting with the foot in neutral (5.1% vs 16.7%, respectively, P < 0.04). CONCLUSIONS: In the surgical correction of idiopathic clubfoot, the incidence of wound complications is significantly decreased with the use of the Cincinnati treatment method rather than the modified Turco treatment protocol. Whether this effect is a result of the incision or the postoperative casting protocol is unclear.     

Analytical radiography and the progressive approach in talipes equinovarus

1. A radiographic method is described for making the diagnosis of talonavicular subluxation before ossification of the navicular occurs. 2. Seven basic deformity combinations are thought to occur in clubfoot. 3. Preoperative analytical radiography enables the surgeon to determine which of these combinations exists in a particular foot. 4. The progressive approach, a comprehensive sequential plan of corrective surgery, indicates the appropriate treatment for each of the seven deformity combinations that may exist in a clubfoot following initial conservative treatment. 5. At the time of surgery the surgeon uses analytical radiography during the operation to determine whether the surgery has been successful or whether the next stage of the progressive approach will be required to correct the deformity combination.     

Complications of midfoot and hindfoot arthrodesis

Midfoot and hindfoot arthrodeses traditionally have been done to treat deformities resulting from paralytic disorders, residual clubfoot deformity, and posttraumatic arthritis. The surgical indications for midfoot and hindfoot arthrodeses more recently have been expanded to include painful arthritic deformities associated with neuroarthropathy, seropositive or seronegative arthropathies, and neurologic disorders. Regardless of the joint fused or the technique used, the goal of each remains similar: the creation of a painless, plantigrade foot capable of being fitted into, at the very least, a custom shoe. The aim of the current study is to describe the major complications associated with midfoot and hindfoot fusions in adults, and the prevention and the treatment of these complications.     

Correction of clubfoot deformity associated with Weber type I tibial hemimelia using the Ponseti method

The clubfoot deformity associated with Weber type I tibial hemimelia, a rare congenital disorder, is rigid and difficult to correct. Surgeons have utilized a variety of treatment methods. Since the 1960s, some adopted the Syme amputation to produce a weightbearing lower limb. Others began to explore alternatives such as the Ilizarov technique, ankle reconstruction, and casting, which salvage the foot but have produced mixed results. The current investigators suggest that the Ponseti method, a minimally invasive technique, can produce a functional weightbearing foot. Two cases were treated with the Ponseti method, including a percutaneous Achilles tenotomy and post-cast bracing. After a minimum of 2-years follow-up, both are ambulatory.     

Onset of developmental dysplasia of the hip during clubfoot treatment: report of two cases and review of patients with both deformities followed at a single institution

Developmental dysplasia of the hip and idiopathic clubfoot are common musculoskeletal conditions in the pediatric orthopedic population. Although ultrasound or radiographic screening is generally recommended to rule out occult hip dysplasia, it has been suggested that children with clubfoot should no longer be screened. We report two cases of newborns with unilateral clubfoot and bilaterally stable hips that developed unilateral hip dysplasia on the same side as the foot deformity during clubfoot treatment. All cases previously reported in the literature are reviewed. We recommend systematic hip ultrasound screening in patients with idiopathic clubfoot. A second hip ultrasound or a pelvis radiograph, if the ossific nucleus has appeared, should be performed after completion of the clubfoot treatment if clinical examination is abnormal.     

Tendo-achilles lengthening and total contact casting for plantar forefoot ulceration in diabetic patients with equinus deformity of the ankle

Total contact casting has been successful in treating neuropathic foot ulcers, but little information is available abouttreating patients with diabetes mellitus for whom total contact casting treatment for forefoot ulceration fails. Equinus deformity of the ankle and limited joint motion in a neuropathic foot can lead to abnormal foot pressures, resulting in failure of total contact casting. This report describes the technique of tendo-Achilles lengthening in conjunction with total contact casting and reports the results achieved in a randomly selected group of diabetic patients with unhealed forefoot ulcerations. Surgical correction with percutaneous tendo-Achilles lengthening and total contact casting can result in rapid healing of the forefoot ulcer and helps prevent ulcer recurrence.     

Management of idiopathic clubfoot in toddlers by Ponseti's method

The Ponseti method has been reported to have successful results in clubfoot patients less than 6 months of age but the literature on its efficacy in older clubfoot patients still remains sparse. In our study, we prospectively evaluated 55 clubfeet (37 patients) to determine clinically whether the Ponseti method is effective in the management of clubfoot in older children between the age of 12 and 36 months (mean: 24.8 months). All the patients belonged to moderate or severe grades of deformity as per the Pirani scoring. Painless, supple, plantigrade and cosmetically acceptable feet were achieved in 49 clubfeet. Seven patients (seven feet) developed recurrence of adduction, varus and equinus deformity whereas three patients (five feet) developed isolated recurrence of equinus deformity. These seven patients responded to repeat treatment and obtained satisfactory outcome. Four of these seven patients underwent tibialis anterior transfer to third cuneiform for dynamic supination. Three patients, those developed isolated recurrence of equinus deformity, underwent repeat tenotomy. One foot achieved satisfactory amount of dorsiflexion, three feet underwent tendoachilles lengthening whereas another foot underwent posterior release to obtain satisfactory dorsiflexion. Six to 12 numbers of casts (mean: 10) were required to obtain correction of clubfoot deformities. Mean period of immobilization in a cast was 13.9 weeks (10-15 weeks). We found that the Ponseti method is effective in children between the age of 12 and 36 months.     

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.     

The influence of brace type on the success rate of the Ponseti treatment protocol for idiopathic clubfoot

Purpose  

The success of the Ponseti method for treating idiopathic clubfoot deformity is dependent on the casting techniques and the adherence of the patient to the foot abduction brace protocol. Newly developed brace designs claim to be more comfortable, to be easier to use and to prevent dislodgement of the foot from the brace, making them more efficient and improving patient compliance. They are, however, more costly, and, therefore, accessible to fewer patients. We compared the compliance and treatment outcome using two brace designs, the traditional simple brace of pre-walking shoes attached to a Dennis Browne (DB) bar and the new sophisticated Mitchell brace.