Partial wound closure of the Cincinnati incision in clubfoot correction

We report the results of partial wound closure of the Cincinnati incision after surgical correction of 31 clubfeet in 21 children. The mean length of follow-up was 36.9 months. All feet were evaluated for the appearance of the scar and correction of the deformities. The initial appearance of the wound was a major concern to the parents. The final appearance of the scar was cosmetically acceptable to both the surgeon and the parents. Equinus deformity was corrected in all patients, with three of the feet attaining a dorsiflexion of more than 20°.     

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.     

Posteromedial release combined with peritalar release in the treatment of congenital clubfoot]

Basing on the authors' own experiences an attempt to assess the value of posteromedial release in treatment of congenital clubfoot was made. The procedure was performed in 70 feet in 52 children, age ranging from 6 months to 12 years, 90% of the procedures were performed before 4 years of age. Feet were classified as follows: a. non-coerrective--type III according to Marciniak, b. Partially corrective, c. in older children (> 4 years of age) in whom posteromedial release was combined with a lateral resection of the cuboid bone. Late results after 5-20 years (13 years on average) were assessed according to Magone's classification. Deformity free, fully functional feet were achieved in 60% cases. The authors stress the fact that posteromedial release is the method of choice in uncorrective cases of clubfeet, and in cases were conservative treatment was implemented after 10 months of age. In the procedure should be performed at the age of 2-3 months.     

Radiological score in the assessment of clubfoot

Summary The clinical appearance and the radiographs of 31 patients with 47 clubfeet taken before the start of treatment have been studied. In spite of making a careful clinical evaluation, 14 feet (29.8%) remained borderline and could not be definitely classified into the easy or resistant groups. The radiological score of the foot, which is an objective representation of the severity of the deformities at all important levels and in all planes, has been found to be an accurate and sensitive index which enables such a distinction to be made.

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Résumé On a étudié la symptomatologie clinique et radiologique de 31 sujets, porteurs de 47 pieds bots, avant le début du traitement. En dépit d'une évaluation clinique minutieuse, 14 pieds (29,8%) demeurent difficilement classables entre les deux groupes: pieds de traitement simple ou au contraire irréductibles. L'évaluation radiologique du pied, qui constitue une représentation objective de l'importance des déformations à tous les niveaux et dans tous les plans, s'est révélée être un indicateur fidèle et sensible qui permet un tel classement.

     

Relapsed clubfoot correction with soft-tissue release and selective application of Ilizarov technique

The Ilizarov technique is an alternative for the treatment of complex foot deformities in children. The authors retrospectively reviewed children with relapsed clubfoot deformity, treated with soft tissue procedures and additional correction with an Ilizarov frame. Twelve consecutive patients (13 feet) with relapsed clubfoot deformity after previous surgical correction were reviewed. Treatment included open releases. An Ilizarov frame was applied as an adjunct in seven patients (mean age of 7.8 years) with severe deformity where complete intraoperative correction was not achieved. Clinical and radiographic assessment was undertaken. The mean Laaveg–Ponseti score, for the 7 feet treated with the Ilizarov frame, was 85.1 after minimum 4 years follow-up. One recurrence of forefoot deformity required metatarsal osteotomies. Postoperative radiographic measurements revealed values that can be considered as normal. Complications included pin tract infections (12% of inserted wires). Flat-topped talus was observed in 3 feet. Deformity correction was possible when soft tissue procedures were combined with the use of Ilizarov technique, in order to support and gradually improve surgical correction.     

Heritability of clubfoot: a twin study

Introduction

The aetiology of congenital clubfoot is unclear. Although studies on populations, families, and twins suggest a genetic component to the aetiology, other studies have identified environmental factors. The purpose of this study was to calculate heritability in order to determine to what extent genetic and/or environmental factors contribute to the aetiology of congenital clubfoot and to asses whether there was a change in the prevalence over time.

Materials and Methods

The Odense based Danish Twin Registry is unique as it contains data on all the approximately 85,000 twin pairs born in Denmark over the last 140 years. All 46,418 twin individuals born from 1931 through 1982, who had earlier consented to contact, received a 17-page Omnibus questionnaire in the spring of 2002. Data were analysed with structural equation models to identify the best fitting aetiological model based on a balance of goodness-of-fit and parsimony and to estimate heritability.

Results

We found an overall self-reported prevalence of congenital clubfoot of 0.0027 (95 % confidence interval 0.0022–0.0034). Fifty-five complete (both twins answered the question) twin pairs were identified representing 12 monozygotic, 22 same-sex dizygotic, 18 opposite-sex dizygotic, and 3 with unclassified zygosity. The model with only environmental factors (CE) was best fitting based on AIC, and the model with an additive genetic factor (ACE) came in second. Due to the small statistical power, we hypothesise that the model with both genetic and environmental effects (ACE) was the better model. Choosing the ACE-model we found a heritability of clubfoot of 30 %. Regression coefficient for age was −0.002 (−0.011 to 0.005), indicating that there has been no change in prevalence of clubfoot over the 50-year age span we examined.

Discussion

We conclude that non-genetic factors must play a role, and a genetic factor might contribute, in the aetiology of congenital clubfoot.     

Mid-term results of a physiotherapist-led Ponseti service for the management of non-idiopathic and idiopathic clubfoot

BackgroundThe Ponseti method is the preferred treatment for idiopathic clubfoot. Although popularised by orthopaedic surgeons it has expanded to physiotherapists and other health practitioners. This study reviews the results of a physiotherapist-led Ponseti service for idiopathic and non-idiopathic clubfeet and compares these results with those reported by other groups.MethodA prospective cohort of clubfeet (2005–2012) with a minimum 2-year follow-up after correction was reviewed. Physiotherapists treated 91 children—41 patients (69 feet) had non-idiopathic deformities and 50 children (77 feet) were idiopathic. Objective outcomes were evaluated and compared to results from other groups managing similar patient cohorts.ResultsThe mean follow-up was 4.6 years (range 2–8.3 years) for both groups. The non-idiopathic group required a median of 7 casts to correct the clubfoot deformity with an 83 % tenotomy rate compared to a median of 5 casts for the idiopathic group with a 63 % tenotomy rate. Initial correction was achieved in 96 % of non-idiopathic feet and in 100 % of idiopathic feet. Recurrence requiring additional treatment was higher in the non-idiopathic group with 40 % of patients (36 % of feet) sustaining a relapse as opposed to 8 % (6 % feet) in the idiopathic group. Surgery was required in 26 % of relapsed non-idiopathic feet and 6 % of idiopathic.ConclusionsAlthough Ponseti treatment was not as successful in non-idiopathic feet as in idiopathic feet, deformity correction was achieved and maintained in the mid-term for the majority of feet. These results compare favourably to other specialist orthopaedic-based services for Ponseti management of non-idiopathic clubfeet.

Level of evidence

Prognostic Level III.     

Worldwide spread of the Ponseti method for clubfoot

The Ponseti method has become the gold standard for the treatment of idiopathic clubfoot. Its safety and efficacy has been demonstrated extensively in the literature, leading to increased use around the world over the last two decades. This has been demonstrated by the increase in Ponseti related PubMed publications from many countries. We found evidence of Ponseti activity in 113 of 193 United Nations members. The contribution of many organizations which provide resources to healthcare practitioners in low and middle income countries, as well as Ponseti champions and modern communication technology, have helped to spread the Ponseti method around the world. Despite this, there are many countries where the Ponseti method is not being used, as well as many large countries in which the extent of activity is unknown. With its low rate of complication, low cost, and high effectiveness, this method has unlimited potential to treat clubfoot in both developed and undeveloped countries. Our listing of countries who have not yet shown presence of Ponseti activity will help non-governmental organizations to target those countries which still need the most help.     

掌部小切口治疗腕管综合征

目的介绍应用新型掌部小切口行腕管松解术。方法对确诊为腕管综合征的68例(89侧)患者采用新型掌部小切口行腕管松解术,该切口为纵行、位于鱼际纹尺侧2～3mm、长约2.0～2.5cm,近端不超过远侧腕横纹。结果经术后6个月随访,所有患者症状均消失,拇短展肌肌力、握力、捏力、皮肤感觉功能均明显改善,术前术后差异在统计学极具显著意义(P<0.001)。本组无任何神经血管并发症,无1例出现腕掌部瘢痕疼痛。结论本切口具有安全、损伤小、直视下松解腕管并同时可行正中神经内松解和尺管松解、手术瘢痕小等诸多优点,是腕管松解术的一种新型、可靠的手术入路。     

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.     

Surgical treatment of congenital vertical talus using the cincinnati approach

Objectives  

Complete correction of a congenital vertical talus at the subtalar joint complex in 1 sitting. The goal is a restoration of normal shape and function of the foot.     

Report of the 1st European consensus meeting on Ponseti clubfoot treatment

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.     

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.     

Preliminary evaluation of implementing the Ponseti method for correction of clubfoot in Vietnam

Purpose  

To evaluate the short-term results of the non-surgical Ponseti method training programs run in Ho Chinh Minh City, Vietnam.     

开放式手术矫正陈旧性外伤性歪鼻畸形

目的总结治疗外伤性歪鼻畸形的经验，掌握正确的歪鼻矫正技术，提高临床治疗效果。方法1996年12月至2004年2月，采用开放式手术，完全显露歪曲的结构，松解外在及内在牵拉力量，复位鼻骨、矫直鼻中隔使其解剖复位，重塑鼻支架。结果本组患者36例，术后随访4个月至5年，优31例，良5例。鼻畸形获得满意的矫正，鼻外形恢复良好。结论外伤性歪鼻畸形多因伤后早期未获得及时有效地处理所致，经开放式手术复位鼻骨、矫直鼻中隔及鼻部整形术，消除引起畸形的原因，可取得较满意的效果。     

Early radiographic risk factors for rigid relapse in idiopathic clubfoot treated with the Ponseti method

Background

This study aimed at identifying early risk factors for rigid relapse in idiopathic clubfoot using foot radiographs.

Use of the Ponseti method for recurrent clubfoot following posteromedial release

Background:

A child with recurrent or incompletely corrected clubfoot after previous extensive soft tissue release is treated frequently with revision surgery. This leads to further scarring, pain and limitations in range of motion. We have utilized the Ponseti method of manipulation and casting and when indicated, tibialis anterior tendon transfer, instead of revision surgery for these cases.

Materials and Methods:

A retrospective review of all children treated since 2002 (n = 11) at our institution for recurrent or incompletely corrected clubfoot after previous extensive soft tissue release was done. Clinical and operative records were reviewed to determine procedure performed. Ponseti manipulation and casting were done until the clubfoot deformity was passively corrected. Based on the residual equinus and dynamic deformity, heel cord lengthening or tenotomy and tibialis anterior transfer were then done. Clinical outcomes regarding pain, function and activity were reviewed.

Results:

Eleven children (17 feet) with ages ranging from 1.1 to 8.4 years were treated with this protocol. All were correctable with the Ponseti method with one to eight casts. Casts were applied until the only deformities remaining were either or both hindfoot equinus and dynamic supination. Nine feet required a heel cord procedure for equinus and 15 required tibialis anterior transfer for dynamic supination. Seven children have follow-up greater than one year (average 27.1 months) and have had excellent results. Two patients had persistent hindfoot valgus which required hemiepiphyseodesis of the distal medial tibia.

Conclusion:

The Ponseti method, followed by tibialis anterior transfer and/or heel cord procedure when indicated, can be successfully used to correct recurrent clubfoot deformity in children treated with previous extensive soft tissue release. Early follow-up has shown correction without revision surgery. This treatment protocol prevents complications of stiffness, pain and difficulty in ambulating associated with multiple soft tissue releases for clubfeet.     

Correction of relapsed or neglected clubfoot using a simple Ilizarov frame

We present the results of using a simple Ilizarov fixator frame in treatment of 66 feet in 52 patients (mean age 8.5 years) of 58 relapsed and eight neglected clubfeet with grade III or IV severity with a mean follow-up of 40 (26–58) months. Our frame, in spite of being simple and easy for surgeons and patients to handle, achieved satisfactory correction comparable to the literature.

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Résumé Nous présentons les résultats de lutilisation dun cadre simple de fixateur Ilizarov dans le traitement de 66 pieds bots chez 52 malades (âge moyen 8,5 années) avec un suivi moyen de 40 mois (26–58). Il sagissait de pieds bots de niveau de sévérité III ou IV, 8 négligés et 58 récidives. Notre cadre, bien que simple et de maniement facile pour les chirurgiens et les malades, a conduit à une correction comparable aux résultats de la littérature.

     

Nwdps protocol - A simple functional outcome assessment tool for clubfoot correction and a review of literature

IntroductionVarious clubfoot severity scoring systems are known to us. Dimeglio and Pirani Scoring systems are most widely used. Also, various treatment outcome measures have been proposed by researchers to assess patient satisfaction and results of treatment. None of the available methods are widely popular and amenable for routine use. A “nwdps protocol” was proposed for functional assessment of patients with clubfoot correction, where “n” was no pain during walking or running; “w” was ability to wear normal shoes; “d” was no significant difference in foot/shoe size of both sides; “p” was plantigrade foot and “s” was ability of the child to squat without heel lift-off. The aim of this study was to test this functional outcome assessment tool for easy day to day use post clubfoot correction.MethodsThe nwdps protocol was applied to all the children at followup on a yearly basis who underwent clubfoot deformity correction in Department of Orthopaedics of our Institute between March 2016 and January 2018.ResultsEighty children were enrolled for the study, 45 had bilateral affection while 35 had unilateral affection. In all 125 feet were treated for clubfoot correction and evaluated using nwdps protocol. Each child was assessed by 2 researchers independently. There was no difference in functional assessment of 2 observers. Fifty-nine children were nwdp positive, one was nwps positive, while 2 were dwps positive at the end of 1 year. 79 children became nwdps positive at the end of 2nd year of followup.ConclusionNwdps protocol is a very easy to remember and easy to use functional outcome assessment tool post clubfoot correction with high degree of objectivity and interobserver reliability.Level of evidenceLevel IV.