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Current management of idiopathic clubfoot questionnaire: a multicentric study.
A survey was mailed to 541 members of the Pediatric Society of North America to define currently accepted treatment options in the management of talipes equinovarus. Four hundred sixteen (77%) responses were received, representing a total of 6125 years in practice (average of 17.4 years per physician) and 8595 clubfeet treated in the past year (average of 26 feet treated per physician). While specific trends were reported and great variability exists, certain principles are universal: initial nonoperative management followed by surgery for persisting deformities. A renewed interest in Ponseti's techniques of casting and surgery to address specific persisting deformities was reflected in this survey.
Bleeding complications following percutaneous tendoachilles tenotomy in the treatment of clubfoot deformity.
Ponseti demonstrated correction of most clubfeet in infants using proper manipulative techniques followed by application of well-molded long-leg plaster casts and a percutaneous tendoachilles tenotomy to correct residual equinus contracture. Medical complications occurring as a result of this technique have not to our knowledge been reported. The authors retrospectively reviewed 134 consecutive infants with 219 idiopathic clubfeet treated with the Ponseti method. A percutaneous tendoachilles tenotomy was performed on 200 clubfeet (91%) at a mean age of 16 weeks (range, 6-77 weeks) when less than 10 degress of ankle dorsiflexion was present after casting. A total of 4 patients had serious bleeding complications following the percutaneous tendoachillis tenotomy--3 due to presumed injury to the peroneal artery and 1 due to injury to the lesser saphenous vein. The authors detail the technique of performing a percutaneous tendoachilles tenotomy and offer guidelines that may help others avoid this same complication.
Current management of idiopathic clubfoot questionnaire: a multicenter study.
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Selective tendon transfers for recurrent clubfoot.
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The long undescribed inverted clubfoot.
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Regional anesthesia for clubfoot surgery in children.
In children, general anesthesia is usually chosen as the primary technique during lower extremity orthopedic procedures. Certain situations or underlying conditions may be present, however, that make the conduct of general anesthesia more difficult or even relatively contraindicated. We present 10 patients with underlying conditions or circumstances that may increase the risk of general anesthesia. Regional anesthesia (spinal or epidural) was used to provide surgical anesthesia, thereby eliminating the need for general anesthesia. The techniques used and the applications of regional anesthesia during orthopedic procedures in children are discussed.
Treatment of the complex idiopathic clubfoot.
Treatment with the Ponseti method corrects congenital idiopathic clubfeet in the majority of patients. However, some feet do not respond to the standard treatment protocol. We describe the characteristics and treatment results of these complex idiopathic clubfeet. We identified 50 patients (75 clubfeet) from 762 consecutive patients treated at five institutions. Clinically, complex clubfeet were defined as having rigid equinus, severe plantar flexion of all metatarsals, a deep crease above the heel, a transverse crease in the sole of the foot, and a short and hyperextended first toe. The Achilles' tendon was exceptionally tight and fibrotic up to the middle of the calf. Correction was achieved in all patients by modifying the Ponseti manipulation and casting technique. Correction required an average of five casts (range, 1-10 casts). Two patients (4%) not initially recognized as having complex clubfeet had a posterior release with tendo Achillis lengthening. There were seven relapses that responded to casting. Three patients had a second tenotomy. Modifying the treatment protocol for complex clubfeet successfully corrected the deformity without the need for extensive corrective surgery.
Results of an accelerated Ponseti protocol for clubfoot.
The Ponseti method has demonstrated excellent results when performed at weekly intervals, but it is not known whether correction can be accomplished in a shorter amount of time. This study evaluated the success in correction in relation to time between casts (5 or 7 days). The authors retrospectively reviewed 230 patients (319 clubfeet). One hundred sixty-five patients (72%) had undergone previous nonsurgical treatment elsewhere. Patients were assigned to 5 or 7 days based solely on geography. Ninety percent of patients required five or fewer casts for correction, and there was no difference between groups (P = 0.85). Average time from first cast to Achilles tenotomy was 16 days for the 5-day group and 24 days for the 7-day group (P = 0.001). Three patients (1.3%) required corrective surgery and there were 36 relapses (P = 0.4). In conclusion, the Ponseti method is very effective and the deformity can be corrected in a relatively short time.
Results of manipulation of idiopathic clubfoot deformity in Malawi by orthopaedic clinical officers using the Ponseti method: a realistic alternative for the developing world?
This study looks at whether orthopaedic clinical officers, a cadre of clinicians who are not doctors, can effectively manipulate idiopathic clubfeet using the Ponseti technique. One hundred consecutive cases of uncomplicated idiopathic clubfeet in newborn babies were manipulated by orthopaedic clinical officers. Fifty-seven of these were fully corrected to a plantigrade position by Ponseti manipulation alone, and a further 41 were corrected by manipulation followed by a simple percutaneous tenotomy. Orthopaedic clinical officers therefore corrected 98 out of 100 feet; the remaining 2 feet were referred for surgical correction. This shows that the Ponseti method is suitable for use by nonmedical personnel in the developing world to achieve a plantigrade foot.
Classification of clubfoot.
Clubfeet must be classified according to severity to obtain reference points, assess the efficacy of orthopaedic treatment, and analyze the operative results objectively. A scale of 0-20 was established on the basis of four essential parameters: equinus in the sagittal plane, varus deviation in the frontal plane and derotation around the talus of the calcaneo-forefoot (CFF) block and adduction of forefoot on hindfoot in the horizontal plane. Four grades of clubfeet can be individualized: (a) Benign feet so-called "soft-soft feet," grade I, similar to postural feet, with a score of 5 to 1 (these mild feet must be excluded from any statistics as they tend to increase good results); (b) moderate feet, so-called "soft > stiff feet," grade II (reducible but partly resistant, with a score of 5-10); (c) severe feet, so-called "stiff > soft feet," grade III (resistant but partly reducible, with a score of 10-15); and (d) very severe, pseudoarthrogryposic feet, so-called "stiff-stiff feet," grade IV (score of 15-20 points). To avoid risks of errors, our method is based on a very complete checklist and on diagrams. Our training material inculdes an audiovisual package.
Final evaluation of clubfoot.
After analyzing the multiple evaluations described in the literature, we propose an evaluation that can be used during growth. The global score is based on 50 points. The normal foot is scored 0. The functional evaluation (passive motion, muscle function, and gait analysis) is based on 28 points. The morphology is based on 12 points. The radiographic analysis is scored on 10 points. The final evaluation score is linked to the initial classification at birth. The gain during the treatment is the difference between the score at birth and the score of the final evaluation. It is noted as a percentage.
Ultrasound assessment of early clubfoot treatment: a comparison of the Ponseti method and a modified Copenhagen method.
The purpose of this study was to sonographically compare the early anatomical outcome of a group of clubfeet treated with the Ponseti method (group A, nine clubfeet) with a group treated with an adjustable plexidur splint, the Copenhagen method (group B, 19 feet). The clinical severity was assessed using the Diméglio-Bensahel classification. The need for complementary surgery was clinically assessed at the age of about 2 months. Ultrasound investigation was made in the neonatal period, after 2-3 months of non-surgical treatment and 1-2 months post-surgically. After 2 months of non-surgical treatment the correction obtained at the talo-navicular joint, expressed as the distance between the medial malleolus and the navicular (MM-N distance), was significantly greater in group A. After surgery, tenotomy of the Achilles tendon for all group A feet, and posterior or posteriomedial release for 13 feet in group B, the correction at the talo-navicular and calcaneo-cuboid joints was similar for the two groups. Anatomical correction of the displacement in these joints can be achieved without extensive interventional procedures. Ultrasound may be a valuable tool to assess the effects of different treatment protocols quantitatively.
New concept of and approach to clubfoot treatment: section I-principles and morbid anatomy.
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The history of treatment of congenital clubfoot at the Royal Liverpool Children's Hospital: improvement of results by early extensive posteromedial release.
The results of treatment in 77 clubfeet were assessed after an average follow-up of 8 years. In those patients with surgical treatment it was found that the Turco posteromedial release within the first 3 months of life resulted in 13 of 16 satisfactory feet. In comparison, only five of 21 feet had satisfactory results when the average age of operation was delayed to 3.7 years and a less extensive release performed. At follow-up, abnormal radiological findings were not found in the early operated cases. The average talocalcaneal index was 47 degrees. The late operated feet showed major abnormal X-ray film findings, and their average index was 38 degrees. Good functional results, however, often coexisted with abnormal radiological findings in the midfoot. Abnormal findings of the hindfoot were always associated with unsatisfactory results. We conclude that the use of early (3 months) Turco posteromedial release can offer excellent results in treating severe resistant clubfeet.
Management of the resistant myelodysplastic or arthrogrypotic clubfoot with the Verebelyi-Ogston procedure.
The Verebelyi-Ogston (V-O) procedure, consisting of subchrondral excision of the talus and cuboid, was used for the treatment of 13 resistant clubfeet secondary to myelomeningocele or arthrogryposis. Nine feet were initially satisfactory, but the condition recurred in both feet of one patient after bracing was discontinued 3 years postoperatively. Three feet were graded as satisfactory after a second V-O procedure, and one after a third. The procedure must be monitored by intraoperative fluoroscopy or radiography, and followed by orthotic support. Despite the theoretical long-term disadvantage of incongruent joint surfaces, we consider the V-O procedure to be a good method for the treatment of this subset of rigid neuropathic clubfeet.
Occult subluxation of the subtalar joint in clubfoot (using computerized tomography).
Routine radiographic analysis does not visualize the posterior aspect of the hindfoot (posterior facet of the talocalcaneal joint). To help evaluate patients with persistent hindfoot abnormalities, computerized tomographic coronal sections in 22 clubfeet were studied. Seventeen feet (77.3%) had a lateral subluxation of the calcaneus. Of 14 feet with acceptable radiographic analysis, 12 (85.7%) had a lateral subluxation of the calcaneus. This study is evidence that a lateral subluxation of the calcaneus can exist, through a horizontal rotation, in the presence of acceptable radiographic analysis, reinforces the necessity for a posteromedial lateral release, and emphasizes that routine radiographic analysis should be supplemented with computerized tomography in evaluation of the resistant hindfoot deformity.
Results of posteromedial release for the resistant clubfoot.
Sixty-nine children with 99 resistant clubfeet were operated on between 1973 and 1979 at the James Whitcomb Riley Hospital for Children (Indianapolis, IN). Three groups of children according to age at the time of surgery were identified: Group I, less than 12 months of age; Group II, between 12 and 36 months of age; and Group III, greater than 36 months of age. Minimum follow-up was 30 months, with an average follow-up for the entire series of 58 months. The radiographic results based on the talocalcaneal index revealed 95 of the 99 feet to have good or acceptable results. The clinical assessment of pain and function mirrored these good results, although, on occasion, the appearance was somewhat less than optimal.