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PubMed2006

Factors predicting the outcome of primary clubfoot surgery.

BACKGROUND: We aimed to determine the rate of further surgery, the functional outcome and the factors associated with outcome after primary clubfoot surgery. METHOD: We conducted a retrospective study of a cohort of all children who were less than 2 years of age at the time of surgery for idiopathic clubfoot deformity at the Hospital for Sick Children, Toronto, Ont., a tertiary care pediatric hospital. Of the 91 families who could be contacted, 63 agreed to return. The children's charts were reviewed, and their feet were given a Functional Rating System (FRS) score. RESULTS: Of the original operated population (n = 126), 75% were male and 41% had bilateral clubfoot. The average age at the time of surgery was 8 months, and the mean follow-up was 80.6 months. Further surgery was performed in 19% of cases. The mean FRS outcome score was 79. On average, the FRS score increased by 1.9 points as age at the time of surgery increased by 1 month. Only the presurgical talocalcaneal index was associated with the need for further surgery. CONCLUSION: The need for further surgery was 19% overall. Children who had surgery closer to 12 months of age had better functional results. Therefore, surgery should probably be performed in the second, rather than the first, 6 months of life.

Child↗
PubMed2006

"Different" approach in the operative treatment of congenital clubfoot and its results.

OBJECTIVES: This study compared long-term results of the treatment of idiopathic clubfoot at two different University orthopaedic departments. BACKGROUND: The treatment of clubfoot is still controversial due to different severity and different treatment philosophies. METHODS: Authors retrospectively analyzed a group of 273 feet (145 patients) operated on at the Unit of Pediatric orthopaedics, Children University Hospital, Bratislava (group A) and the cohort of 60 feet (33 patients) operated on at the Ist University Department of Orthopaedics, Bratislava (group B), between 1993 and 2002 with follow up period from 2 to 11 years (average 72 months). In the group A, McKay procedure was indicated in 3 feet, Carroll operation in 35 feet and 160 feet were operated by Brockmanns posteromedial release and its modifications (cuboid and metatarsal osteotomies). In the group B, McKay procedure was done in 8 feet and 50 feet were operated on by Turco/ Zacepin procedure. RESULTS: Recurrences in both groups due to the insufficient first step operative reduction and mistakes in after treatment were 12%. Satisfactory results (excellent and good) were achieved in 88% of cases in both groups. CONCLUSION: This study shows, that the results of operative treatment of congenital clubfoot from two different departments (using different operative techniques but "a la carte philosophy") were comparable in most of the cases (Tab. 4, Fig. 3, Ref: 9).

Child↗
PubMedDate not supplied

Practical applications in idiopathic clubfoot: a retrospective multicentric study in EPOS.

We report a European study of idiopathic clubfoot that was compiled with the aid of a detailed questionnaire. The retrospective study was presented at the seventh meeting of the European Paediatric Orthopaedic Society (EPOS). Most EPOS members treat idiopathic clubfoot at birth with plaster cast, but a few use physiotherapy and splints. The results of this conservative treatment vary. Operation is usually indicated at an age ranging from 4 to 15 months. Some physicians perform extensive procedures, and others limit operation to the medial and posterior parts of the foot. We propose a classification system for idiopathic clubfoot in an attempt to standardize procedures.

Casts, Surgical↗
PubMed1988

The role of major gene in clubfoot.

The roles of major gene and multifactorial inheritance in the etiology of clubfoot (talipes equinovarus) were studied using Caucasian clubfoot families ascertained in Indiana. The method of analysis used was complex segregation analysis under the mixed model, in which five genetic parameters were examined to test hypotheses on major gene by displacement (t), degree of dominance (d), gene frequency (q), transmission probability (tau2), and multifactorial inheritance by heritability (H). The analysis showed that the segregation pattern of clubfoot in these families is best explained by assuming the action of a major gene with additional contribution of multifactorial inheritance. The estimates of the parameters under the best-fitting model were d = .82, t = 4.69, q = .030, tau2 = .50, and H = .17.

Clubfoot↗
PubMed1984

Pathogenesis of idiopathic clubfoot.

During embryonic development the foot passes consecutively into three different positions: (1) when the embryo is in the 15-mm stage the foot is in a straight line with the leg (initial position); (2) by 30 mm the foot passes to a marked equinovarus-adductus position (embryonic position); and (3) finally, by 50 mm, the foot changes to a slightly equinovarus adductus position (fetal position). The morphologic and structural changes of the foot from the initial to the embryonic position result from the growth of the distal ends of the fibula and of the skeletal elements of the lateral foot during the "fibular phase" of rapid growth (from 21 to 30 mm). The changes from the embryonic to the fetal position are due to the growth of the distal ends of the tibia and of the skeletal rays of the medial foot during the "tibial phase" of rapid growth. Many known noxious industrial chemicals (and probably many more yet to be recognized) have antimitotic and antimetabolic action. Depending on the characteristics of the chemical, some produce permanent arrest and therefore congenital malformation, while others cause temporary growth arrest, e.g., Harris transverse lines, which is frequently unnoticed. Finally, some substances, e.g., glucocorticoids, cause a growth delay. Depending on the developmental stage of the embryo and the duration of the action of the noxious substance, growth arrest of the foot occurs in an attitude close to the embryonic position. If it occurs at the end of the fibular phase and during the first half of the tibial phase, the foot will remain in a permanent and marked equinovarus-adductus position, and a severe clubfoot will result. When a noxious chemical acts only during the last half of the tibial phase, a mild, flexible clubfoot will result because by this stage most parts of the embryonic components have been corrected. If it occurs at the end of the tibial phase, a simple metatarsus adductus deformity will persist. As soon as the growth arrest phase ends, all of the skeletal elements begin to grow again, but only from a later point in development. If the growth disturbance occupies the entire tibial phase, neither the tibia nor the skeletal elements of the foot would be able to complete a rapid growth spurt, since by that stage the moment genetically programmed for such growth has already passed. The morphology of the deformities existing in the clubfoot corresponds to the morphologic program of the embryonic foot.(ABSTRACT TRUNCATED AT 400 WORDS)

Clubfoot↗
PubMed1983

Congenital clubfoot: results and therapeutic guidelines.

The authors report the results observed between 5 and 11 years after surgery in 100 cases of congenital clubfoot treated by posterior release and another 100 cases treated by combined posterior and medial release. On the basis of their experience, they believe that: 1. Grade 1 clubfoot can be successfully treated conservatively; 2. Grade 2 and grade 3 clubfoot must always be treated by complete posterior and medial release; 3. The best age for surgical intervention is around the age of 3 months; 4. In the first three months of life, manipulation and plaster casts should be used to try to correct the deformity.

Age Factors↗
PubMed1993

Complete soft-tissue clubfoot release with and without internal fixation.

Two groups of patients who underwent soft-tissue release of clubfoot are compared. In group I, internal fixation (two Kirschner wires) was used for 6 weeks to retain correction of clubfoot. In group II, no internal fixation was used. Patients from the two groups were operated on by one surgeon using the same procedure. Because there was no statistically significant difference in functional result between the two treatment groups (P = .08; Mann-Whitney Test), the authors recommend avoiding internal fixation (with all the associated problems) in cases of uncomplicated clubfoot, and encourage early removal of the cast and frequent manipulations to prevent stiffness of the joints and reduce the recurrence rate.

Bone Wires↗
PubMed1997

Surgical treatment of clubfoot deformity in arthrogryposis multiplex congenita.

Clubfoot deformity in arthrogrypotic patients is difficult to correct, and its recurrence rate is high. We retrospectively reviewed 37 clubfeet in 20 patients with arthrogryposis multiplex congenita who were treated from 1984 to 1993. There were 11 males and nine females. Bilateral involvement was seen in 17 patients and unilateral involvement in three. The mean age at the initial surgery was 2.5 years (range 4 mo to 25 yr). Soft tissue release alone was performed on 33 feet. Primary talectomy was done on both feet of one other patient. The remaining patient (two feet) underwent triple arthrodesis. Recurrence or residual deformities were seen in 18 feet with soft tissue release, among which 12 feet underwent secondary surgeries including soft tissue release, osteotomy, talectomy and connection with Ilizarov apparatus. After the secondary surgery, four of the 12 feet still had deformities. One foot had a third surgery. Achilles tendon lengthening and osteotomy. Twenty-six feet were rated as having good results (plantigrade, painless and without obvious deformity), seven were rated fair (residual deformity requiring secondary procedures) and four had poor results (persistance or recurrence of clubfoot). Despite a high recurrence rate, clubfoot deformity in arthrogrypotic patients can be treated first with radical soft tissue release when the patient is less than 1 year of age. If the foot deformity is persistant or recurs, talectomy can achieve a plantigrade foot. Triple arthrodesis should be reserved for patients with a mature bony structure.

Arthrogryposis↗
PubMed1998

[Increasing incidence of clubfoot in the county of Frederiksborg].

The incidence of congenital clubfoot in Frederiksborg County, Denmark, was studied over a period of 16 years (1979-1994). Altogether 60, 186 live infants were born, and of these 72 had a congenital clubfoot. Twenty-five children (35%) had bilateral clubfoot and 54 (75%) were boys. The overall incidence was 1.20 per thousand children. The incidence increased significantly during the observation period and was 2.41 per thousand in 1994. We cannot explain the rise in incidence.

Clubfoot↗
PubMedDate not supplied

Prenatal ultrasound diagnosis of clubfoot.

Prenatal ultrasound diagnosis of clubfoot is increasing. Of 103 patients with clubfoot diagnosed at birth, 26 (25.2%) positive prenatal scans were identified with the earliest diagnosis being made at 15 weeks. A questionnaire assessment indicated that 17 (65.4%) deemed that the explanation of the baby's condition was clear. With an increasing incidence of antenatal detection, it is suggested that parents require adequate antenatal counseling by a specialist in the area of clubfoot to improve the understanding of the natural history and treatment of this condition.

Clubfoot↗
PubMed1987

A genetic analysis of clubfoot in Hawaii.

The roles of major genes and multifactorial inheritance in the etiology of clubfoot (talipes equinovarus) were investigated based on 365 nuclear families consisting of three major racial groups of Hawaiians, Caucasians, and Orientals in Hawaii. Complex segregation analysis was employed using the mixed model with four parameters: major gene displacement (t), degree of dominance (d), gene frequency (q), and heritability (H). Heterogeneity was evident among the racial groups in the pattern of segregation of clubfoot. The most plausible genetic model is the presence of major gene effects with the multifactorial component for the Hawaiian and Caucasian groups, whereas no major gene action is evident for the Oriental group.

Asian People↗
PubMed1980

Follow-up examinations: 30 years of Imhäuser clubfoot treatment.

The author describes his own methods of clubfoot treatment used over 30 years on more than 2,000 children. Correction of form and restoration of function are the two goals of the orthopaedic surgeon. Early treatment consists of closed reduction of forefoot deformity and of varus of the heel, and of operative correction of equinus deformity. Function is restored by a training program developed and introduced by the author for evertors and dorsiflexor muscles. Treatment starting at a later age must take into consideration that in the course of time increasing deformity of all bones and joints as well as marked alterations of soft tissues occur. In these cases closed measures are ineffective and operative measures necessary. After straightening the foot operatively, it is necessary to maintain the normalized position by means of an exterior removable plastic cast until the translocated tibialis anterior muscle can fulfil this task. The later the clubfoot is treated, the longer the period for which these casts are required. The author reexamined nearly 400 feet of adults whom he had treated during their baby or childhood years. The late results of three groups are demonstrated: (a) cases treated before the age of 2; (b) cases treated between 2 and 7 years; (c) cases treated at the age of 7 years or later. Good late results were observed in a surprisingly high percentage of the cases. The author's method--based on a pathophysiological approach--seems to represent real progress in the treatment of idiopathic clubfeet.

Adolescent↗
PubMed1996

Ultrasound contribution in the analysis of the newborn and infant normal and clubfoot: a preliminary study.

The aim of this study was to evaluate the potential use of ultrasound in the preoperative assessment of clubfoot and follow-up growth. We first studied 50 normal newborns and infants (aged 1 day to 1 year). The normal values established were reliable, dynamic and reproducible measurements allowing the assessment of osteo-articular relationships and cartilage morphology. Ultrasound appears to be more useful than radiography because it allows delineation of cartilaginous structures (which are not visible on conventional radiographs) and dynamic study of foot positions, and has no danger from radiation. A future paper will contain preliminary results of cases of clubfoot studied by ultrasound.

Clubfoot↗
PubMed2003

[Aplasia of the posterior tibial artery in a child with idiopathic clubfoot].

A case of a completely absent posterior tibial artery discovered during a procedure for congenital clubfoot correction in a 6 month old male infant is reported. Anomalies of the anterior tibial artery associated with the clubfoot-deformity are common, the absence of the posterior tibial artery is, however, very rare.

Clubfoot↗
PubMed2006

[Early functional treatment of congenital clubfoot].

The concept of conservative clubfoot treatment beginning in the neonatal period has changed considerably in the last 2 decades. The rate of clubfeet requiring surgery (20%) and the extent of surgical interventions have dropped significantly. The early functional Montpellier method has proved to be highly effective for all degrees of deformity. It is used for patients from birth until the age of 1 year. The treatment during the first 3 months of life is decisive and consists of daily physical therapy, use of a continuous passive motion machine, and taping. This method represents an efficient alternative to the popular treatment of serial casting. Nevertheless, conservative clubfoot treatment reaches its limits as the degree of deformity increases and it should be complemented by a selective minimally invasive surgical concept. The technique is described systematically and its current value is discussed.

Clubfoot↗
PubMed2002

Ultrasound anatomy in the neonatal clubfoot.

Our objective was to assess clubfoot anatomy by US in newborn babies before and in the early phase of treatment. Reproducible US projections and measurements were carried out on 30 untreated clubfeet in 22 children, consecutively included in the study. The position of the navicular in relation to the head of the talus was visualised in all feet. The mean distance between the medial malleolus and the navicular was significantly shorter in the clubfeet than in normal feet. There was a tendency to medial displacement of the cuboid. Soft tissue thickness at the medial side of the foot was increased in all deformed feet. The measurements showed an acceptable intra- and inter-observer reliability for the different variables assessed ( r=0.71-0.96, Pearson's correlation coefficient). With US it is possible to obtain well-defined planes of investigation that give important information about the clubfoot deformity concerning the talo-crural, the talo-navicular and the calcaneo-cuboid joints. The method is simple enough to be used in everyday clinical practice and we recommend it as a guide during the non-operative treatment and for preoperative planning.

Clubfoot↗
PubMed1998

Significance of radiographic angle measurements in evaluation of congenital clubfoot.

Numerous formal, positional and angular foot skeleton deviations have been described in radiographic evaluation of congenital clubfoot. To clear up the correlation between clinical and radiological findings, a retrospective study involving 62 cases of congenital clubfoot in 38 patients was carried out, including follow-up observation for 7 years after soft-tissue surgery. Only clubfeet with grade II Harrold and Walker classifications according to the initial findings were included. Clinical follow-up examinations followed the Functional Rating System (FRS) of Laaveg and Ponseti. The postoperative talocalcaneal (TC) angle, measured on a lateral image, averaged 23 degrees as opposed to 32 degrees in healthy feet, i.e. much smaller, although this very significant angle dimension showed only minimum differences between the evaluation groups "very good" to "poor". The TC angle anteroposterior (AP), talonavicular angle (AP and lateral) as well as the calcaneometatarsal V angle revealed considerable deviations, although a correlation of clinical severity grading with the measured angular dimensions was not possible due to measurement imprecision and the range of values occurring within the different severity groups.

Ankle Joint↗
PubMedDate not supplied

Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method.

The initial treatment of congenital idiopathic talipes equinovarus (clubfoot) is most often nonsurgical. However, surgical treatment in the form of posteromedial release is often undertaken after failure of conservative measures. The prevalence of both immediate and long-term complications in surgically treated clubfeet has cultivated a renewed interest in nonsurgical treatment. The Ponseti method for treating clubfoot has seen a revived interest among those caring for infantile clubfeet. We report on our first 34 infants (57 clubfeet) treated by using the techniques and principles described by Ponseti. Using a standard scoring system, 54 of 57 clubfeet were successfully corrected without requiring posteromedial release. Only 2 patients (3 clubfeet) required extensive surgical correction. There were 6 relapses. In all recurrent cases, there was a lack of compliance with the straight-last shoe and foot abduction bar regimen. Based on this level of initial success, we believe that posteromedial release is no longer necessary for the majority of cases of congenital clubfeet.

Casts, Surgical↗