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Congenital talipes equinovarus (CTEV), which is also known as clubfoot, is a common congenital orthopaedic condition. It is characterised by an excessively turned in foot (equinovarus) and high medial longitudinal arch (cavus). If left untreated it can result in long-term disability, deformity and pain. Interventions can be conservative (such as splinting or stretching) or surgical.
To evaluate the effectiveness of interventions for CTEV.
We searched CENTRAL (2011, Issue 2), NHSEED (2011, Issue 2), MEDLINE (January 1966 to April 2011), EMBASE (January 1980 to April 2011), CINAHL Plus (January 1937 to April 2011), AMED (1985 to April 2011) and the Physiotherapy Evidence Database (PEDro to April 2011). We checked the references of included studies.
Randomised and quasi-randomised controlled trials evaluating interventions for CTEV. Participants were people of all ages with CTEV of either one or both feet.
DATA COLLECTION AND ANALYSIS:
Two authors independently assessed risk of bias in included trials and extracted the data. We contacted authors of included trials for missing information. We collected adverse event information from trials when it was available.
We identified 13 trials in which there were 507 participants. The use of different outcome measures prevented pooling of data for meta-analysis even when interventions and participants were comparable. All trials displayed bias in four or more areas. One trial reported on the primary outcome of function, though raw data were not available to be analysed. We were able to analyse data on foot alignment (Pirani score), a secondary outcome, from three trials. The Pirani score is scored from zero to six, in which higher is worse. Two of the trials involved participants at initial presentation. One of them reported that the Ponseti technique significantly improved foot alignment compared to the Kite technique. After 10 weeks of serial casting, the average total Pirani score of the Ponseti group was 1.15 (95% confidence interval 0.98 to 1.32) lower than that of the Kite group. The second trial found the Ponseti technique to be superior to a traditional technique, with average total Pirani scores of the Ponseti participants 1.50 lower (95% confidence interval 0.72 to 2.28) after serial casting and Achilles tenotomy. A trial in which the type of presentation was not reported found no difference between an accelerated Ponseti or standard Ponseti treatment. At the end of serial casting, the average total Pirani scores in the standard group were 0.31 lower (95% confidence interval -0.40 to 1.02) than the accelerated group. Adverse events were not compared in the trial. There is a lack of evidence for different plaster casting products or the addition of botulinum toxin A during the Ponseti technique. There is also a lack of evidence for different types of major foot surgery for CTEV, continuous passive motion treatment following major foot surgery, or treatment of relapsed or neglected cases of CTEV. Most trials did not report on adverse events. In trials evaluating serial casting techniques, adverse events included cast slippage (needing replacement), plaster sores (pressure areas) and skin irritation. Adverse events following surgical procedures included infection and the need for skin grafting.
From the limited evidence available, the Ponseti technique may produce better short-term outcomes compared to the Kite technique. An accelerated Ponseti technique may be as effective as a standard technique. We could draw no conclusions from other included trials because of the limited use of validated outcome measures and lack of available raw data. Future randomised controlled trials should address these issues.
To evaluate the efficacy of a modified Copenhagen physical therapy method in reducing surgery rates for congenital idiopathic clubfoot.
This research is a retrospective descriptive study of 82 patients (123 clubfeet). All patients were younger than 2 months at the beginning of the treatment and were initially evaluated to classify clubfoot severity using the Harrold and Walker scale. The study period included the years from 1980 to 2003, with an average monitoring of 14.5 years (range, 3-26 years).
After 3 years of treatment, 55% of the involved feet did not need surgery, 2% needed percutaneous tenotomy of the Achilles tendon, and 43% had posterior release. At the end of monitoring, 34% feet did not need surgery, 2% had percutaneous tenotomy of the Achilles tendon, and 64% required posterior releases.
The Copenhagen method may reduce the necessity of surgical intervention for idiopathic clubfoot.
Re: Interventions for congenital talipes equinovarus (clubfoot).
Correction of residual clubfoot deformities in older children using the taylor spatial butt frame and midfoot gigli saw osteotomy.
Eidelman M, Keren Y, Katzman A. J Pediatr Orthop. 2012 Jul;32(5):527-33.
: Residual clubfoot deformities in older children are a difficult surgical problem. The foot is stiff and almost always has already undergone some surgical intervention. The traditional approach includes soft-tissue release or osteotomy and external fixation (usually with an Ilizarov frame).
: In this study, we summarized our experience with the treatment of residual clubfoot deformities in older children using a percutaneous midfoot Gigli saw osteotomy and the Taylor spatial frame. There were 11 children in the study, with a mean age of 14.7 years, and mean frame fixation time was 15.1 weeks. Because the primary problems in these children were midfoot and forefoot deformities (forefoot adduction, supination, and cavus), a Butt frame was applied after the midfoot osteotomy.
: At the time of frame removal, the goal of deformity correction was achieved in all the children. Two patients had partial recurrence of the deformities and were reoperated. One patient with residual supination is planned to be operated close to maturity. Complications included superficial pin-tract infection in 5 patients and premature consolidation of the osteotomy that needed reosteotomy.
: On the basis of our experience, we believe that midfoot osteotomy and correction by Taylor spatial frame is an effective and reliable surgical option for this challenging problem.
The Mitchell-Ponseti (MP) foot abduction orthosis was introduced to provide a more user-friendly alternative to the traditional Denis-Browne (DB) brace in the treatment of idiopathic clubfoot. We describe our experience with the effectiveness of the MP brace to maintain correction of clubfeet corrected using the Ponseti method.
We evaluated 57 consecutive infants with 84 idiopathic clubfeet who were treated using the Ponseti method. After initial correction of the deformity was obtained, all infants were placed in the MP brace.
The patients were followed for a minimum of 2 years (mean, 37.9 mo; range, 24 to 56 mo). Seventy-nine feet (94%) had heel-cord tenotomy or lengthening. The families of 34 (60%) patients were adherent with the postcorrective brace protocol. Skin problems were observed in 8 patients (14%), 6 of which were superficial dorsal skin abrasion, and none of the sandals required customization by an orthotist. A recurrence occurred in 40 feet (48%). Correction was regained with manipulation and cast application in all cases. Nineteen feet (23%) in 14 patients have had, or are scheduled for, an anterior tibial tendon transfer. At latest follow-up, all feet were plantigrade and had at least 10 degrees of dorsiflexion. None of the patients required surgical releases. Of 31 patients followed for at least 3 years, 26 (84%) used the brace for a minimum of 3 years.
Using the MP foot abduction orthosis, we were able to achieve compliance rates that were at least comparable with those of earlier reports using the DB brace. Families found the brace easy to use. The MP brace may be considered a useful alternative to the DB brace.
Background: Two main options for treatment of congenital idiopathic clubfoot are the “French” functional method and the Ponseti method. The goal of this article was to evaluate the results of the functional treatment method, which, if necessary, is completed by a surgical release.
Patients and Methods: A series of 187 feet (129 patients) underwent functional conservative treatment. At first evaluation, the feet were classified according to the classification of Dimeglio. All patients then underwent daily physiotherapy and splintage, which was progressively stopped during childhood. Among these 187 feet, 85 feet (45.5%) required soft-tissue release to correct the remaining deformity. Surgery, when required, consisted of a complete posterolateral and medial release procedure, combined with a lengthening of the tibialis anterior tendon in most cases and a bony lateral procedure in case of forefoot adduction.
Results: At the latest follow-up (14.7 y; range, 7.4 to 23 y), results were “good” or “very good” in almost 98% of feet, according to the Ghanem and Seringe score. Severe feet at first consultation showed a worse result and required surgery more often than did the less severe ones. Among nonoperated feet, very good results were found in 99% of feet, and none had a fair or bad result. The average age at surgery was 2.5 years. Feet operated upon had lower results compared with the others. At last follow-up, among the operated feet, the results were excellent or good in 95% of the feet. The results were fair or bad in 4 cases; all 4 feet had been operated upon more than once. The results were not statistically dependent on age at the time of surgery, but feet operated upon before the age of 2 years had statistically more flattening of the talar dome and subtalar stiffness.
Conclusions: The functional treatment of clubfoot leads to a very good result without the need for surgery in more than half of the patients. The initial severity of the feet is the main factor that influences the final result. The rate of feet not requiring surgery should be increased by recent modifications to the method, including percutaneous Achilles tenotomy.
Clubfoot (talipes equinovarus) is a three-dimensional deformity of unknown etiology. Treatment aims at correction to obtain a functional, plantigrade pain-free foot. The "French" functional method involves specialized physiotherapists. Daily manipulation is associated to immobilization by adhesive bandages and pads. There are basically three approaches: the Saint-Vincent-de-Paul, the Robert-Debré and the Montpellier method. In the Ponseti method, on the other hand, the reduction phase using weekly casts usually ends with percutaneous tenotomy of the Achilles tendon to correct the equinus. Twenty-four hour then nighttime splinting in abduction is then maintained for a period of 3 to 4 years. Recurrence, mainly due to non-compliance with splinting, is usually managed by cast and/or anterior tibialis transfer. The good long-term results, with tolerance of some anatomical imperfections, in contrast with the poor results of extensive surgical release, have led to a change in clubfoot management, in favor of such minimally invasive attitudes. The functional and the Ponseti methods reported similar medium term results, but on scores that were not strictly comparable. A comparative clinical and 3D gait analysis with short follow-up found no real benefit with the increasingly frequent association of Achilles lengthening to the functional method (95% to 100% initial correction). Some authors actually suggest combining the functional and Ponseti techniques. The Ponseti method seems to have a slight advantage in severe clubfoot; if it is not properly performed, however, the risk of failure or recurrence may be greater. "Health economics" may prove decisive in the choice of therapy after cost-benefit study of each of these treatments.
The Ponseti and French taping methods have reduced the incidence of major surgery in congenital idiopathic clubfoot but incur a significant burden of care, including heel-cord tenotomy. We developed a non-operative regime to reduce treatment intensity without affecting outcome. We treated 402 primary idiopathic clubfeet in patients aged < three months who presented between September 1991 and August 2008. Their Harrold and Walker grades were 6.0% mild, 25.6% moderate and 68.4% severe. All underwent a dynamic outpatient taping regime over five weeks based on Ponseti manipulation, modified Jones strapping and home exercises. Feet with residual equinus (six feet, 1.5%) or relapse within six months (83 feet, 20.9%) underwent one to three additional tapings. Correction was maintained with below-knee splints, exercises and shoes. The clinical outcome at three years of age (385 feet, 95.8% follow-up) showed that taping alone corrected 357 feet (92.7%, ‘good’). Late relapses or failure of taping required limited posterior release in 20 feet (5.2%, ‘fair’) or posteromedial release in eight feet (2.1%, ‘poor’). The long-term (> 10 years) outcomes in 44 feet (23.8% follow-up) were assessed by the Laaveg–Ponseti method as excellent (23 feet, 52.3%), good (17 feet, 38.6%), fair (three feet, 6.8%) or poor (one foot, 2.3%). These compare favourably with published long-term results of the Ponseti or French methods. This dynamic taping regime is a simple non-operative method that delivers improved medium-term and promising long-term results.
Idiopathic congenital talipes equinovarus (CTEV) is the commonest form of clubfoot. Its exact cause is unknown, although it is related to limb development. The aim of this study was to quantify the anatomy of the muscle, subcutaneous fat, tibia, fibula and arteries in the lower legs of teenagers and young adults with CTEV using 3D magnetic resonance imaging (MRI), and thus to investigate the anatomical differences between CTEV participants and controls.
The lower legs of six CTEV (2 bilateral, 4 unilateral) and five control young adults (age 12–28) were imaged using a 3T MRI Philips scanner. 5 of the CTEV participants had undergone soft-tissue and capsular release surgery. 3D T1-weighted and 3D magnetic resonance angiography (MRA) images were acquired. Segmentation software was used for volumetric, anatomical and image analysis. Kolmogorov-Smirnov tests were performed. The volumes of the lower affected leg, muscle, tibia and fibula in unilateral CTEV participants were consistently smaller compared to their contralateral unaffected leg, this was most pronounced in muscle. The proportion of muscle in affected CTEV legs was significantly reduced compared with control and unaffected CTEV legs, whilst proportion of muscular fat increased. No spatial abnormalities in the location or branching of arteries were detected, but hypoplastic anomalies were observed.
Combining 3D MRI and MRA is effective for quantitatively characterizing CTEV anatomy. Reduction in leg muscle volume appears to be a sensitive marker. Since 5/6 CTEV cases had soft-tissue surgery, further work is required to confirm that the treatment did not affect the MRI features observed. We propose that the proportion of muscle and intra-muscular fat within the lower leg could provide a valuable addition to current clinical CTEV classification. These measures could be useful for clinical care and guiding treatment pathways, as well as treatment research and clinical audit.
Congenital talipes equinovarus (clubfoot) is a complex deformity of the lower extremity and foot occurring in 1/1000 live births. Regardless of treatment, whether conservative or surgical, clubfoot has a stubborn tendency to relapse, thus requiring postcorrection bracing. However, to date, there are no investigations specifically focused on clubfoot bracing from a bioengineering perspective. This study applied engineering principles to clubfoot bracing through construction of a surrogate biomodel. The surrogate was developed to represent an average 5-year-old human subject capable of biomechanical characteristics including joint articulation and kinematics. The components include skeleton, articulating joints, muscle-tendon systems, and ligaments. A protocol was developed to measure muscle-tendon tension in resting and braced positions of the surrogate. Measurement error ranged from 1% to 6% and was considered variance due to brace and investigator. In conclusion, this study shows that surrogate biomodeling is an accurate and repeatable method to investigate clubfoot bracing. The methodology is an effective means to evaluate wide ranging brace options and can be used to assist in future brace development and the tuning of brace parameters. Such patient-specific brace tuning may also lead to advanced braces that increase compliance.
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.
Neglected clubfoot in older children is characterized by a stiff, nonreducible deformity with relative elongation of the lateral column of the foot with respect to the medial column. Surgical correction often has involved a double osteotomy with elongation of the medial column and shortening of the lateral column, or the use of an external fixator to achieve more gradual correction. Both approaches have shortcomings.
We therefore (1) used objective physical examination measurements and a functional assessment to evaluate the effectiveness of cuboid osteotomy combined with a selective soft tissue release to achieve correction of neglected clubfoot in older children, (2) determined the rate of complications, and (3) ascertained whether the initial correction achieved was maintained.
We reviewed 31 patients (56 feet) older than 5 years with severe, neglected nonreducible clubfoot deformity who underwent the index procedure. Minimum followup was 2 years (average, 6 years; range, 2-9 years). Postoperatively, the Laaveg and Ponseti classification and Dimeglio score were used to grade correction. Complication rates were tallied.
According to the Laaveg and Ponseti classification, 24 feet showed excellent correction, 20 good, nine fair, and three poor at 1-year followup. These results were maintained up to the latest followup. Patients showed significant improvement of Dimeglio score after surgery (p < 0.0001). Two patients had postoperative skin-related complications that healed without additional surgery.
Cuboid subtraction osteotomy combined with posteromedial release is an effective approach to manage a stiff nonreducible neglected clubfoot deformity in older children.