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PubMedDate not supplied

The Ilizarov method for the treatment of resistant clubfoot: is it an effective solution?

The resistant clubfoot deformity presents a significant challenge. Several corrective procedures have been described, with the goal to provide a pain-free, plantigrade foot. The Ilizarov method of external fixation and gradual distraction has been reported as an alternative to conventional techniques. Previous reviews have concluded that this method can provide satisfactory correction and outcome. This study presents a review of 21 resistant clubfeet in 17 patients, who had undergone previous surgery, treated with Ilizarov external fixation and gradual distraction by 1 of 2 surgeons. Outcome measures were graded based on function and presence of residual deformity: (a) excellent (painless, plantigrade foot, with no functional limitations); (b) good (plantigrade foot in a patient able to ambulate long distances with mild pain; (c) fair (mild residual deformity, required bracing, and/or had some functional limitations but an active life); and (d) poor (significant residual deformity, pain, and activity limitations). Radiographic measures of the talocalcaneal and talo-first metatarsal angles were compared preoperatively and postoperatively. At an average follow-up of 6.64 years (range, 2.25-10.50 years), 9.5% (2) achieved an excellent result; 4.8% (1), good; 33.3% (7), fair; and 52.4% (11), poor. All 11 of the feet graded poor required revision surgery at an average of 5.63 years postoperatively (range, 2.67-10.2 years). Only the talo-first metatarsal angle displayed a clinically and statistically significant correction. We conclude that the Ilizarov method for treatment of resistant clubfoot deformities results in poor outcome associated with residual or recurrent deformity, often requiring revision surgery.

Child↗
PubMed1995

Acetabulum pedis. Part II: Talocalcaneonavicular joint socket in clubfoot.

Many pathoanatomic studies of clubfeet have been made. Bone changes and ligament and tendon alterations are among the different deformities reported in the literature. The socket of the talocalcaneonavicular joint is termed the acetabulum pedis (AP), and alterations of the joint have been reported previously as malformations associated with clubfoot. We report pathoanatomic observations of AP in three human clubfoot specimens. Anomalies in AP were observed and compared with those in normal feet. In such cases, AP volume is restricted. Surface area is reduced on the acetabular floor and medial wall. Changes occur in the osseous components as well as in the ligaments of the AP.

Cadaver↗
PubMed1995

Three-dimensional analysis of clubfoot deformity by computed tomography.

The bony pathoanatomy of clubfoot has been assessed by a three dimensional reconstruction of transverse CT images obtained from 27 feet in children aged 3-10 years. Principal axes of the bones were determined to quantitate interosseous deformity, while visual inspection of the reconstructed images demonstrated intraosseous deformity. "Medial spin" and midfoot adduction were analyzed on the AP view of the foot ("top" view), while hindfoot pronosupination was analyzed on the AP view of the ankle (posterior view). This technique allows visualization of deformities which normally cannot be analyzed on plain radiographs, and also shows that a variety of interosseous relationships make up the clinical entity known as clubfoot. Abnormal talar pronation ("intorsion") was an unexpected finding of this three dimensional analysis.

Child↗
PubMed1995

Evaluation of residual clubfoot deformities using gait analysis.

Gait analysis was used to evaluate 15 patients who had previously undergone clubfoot surgery. Because six patients had had bilateral surgery, 21 feet had undergone previous clubfoot surgery. Three of the operated feet had no residual deformity. In the remaining 18 feet, the reason for referral was intoeing in 13, calcaneovalgus in three, hindfoot varus in one, and supination/adduction in one. Clinical assessment and information from the gait analysis were used to establish a treatment plan. Satisfactory treatment outcome was achieved in 13 patients, one result was unsatisfactory, and one result was undetermined.

Child↗
PubMed2004

Ischemic necrosis following clubfoot surgery: the purple hallux sign.

Ischemic necrosis, which develops rarely after clubfoot surgery, may have a vascular etiology, since many idiopathic and neurogenic clubfeet have congenital deficiency of the anterior tibial and dorsalis pedis arteries. Dorsalis pedis deficiency is demonstrated more frequently in those clubfeet showing greater deformity. Substantial hypoplasia of the profunda femoris and posterior and anterior tibial arteries was evident in the affected limb of a patient in this series who underwent postoperative arteriography. Herein, we report massive necrosis in seven limbs of six patients after clubfoot surgery and have combined this series with seven previously published cases. Additional cases support our hypothesis that arterial deficiencies put some postoperative clubfeet at risk of perioperative ischemic necrosis. Necrosis occurs in those regions supplied by the congenitally diminished anterior tibial and dorsalis pedis arteries. Knowing that children with congenital vascular deficiency are at risk for ischemic necrosis, surgeons should be alert to the subtle, early signs of ischemia and be prepared to prevent or ameliorate the consequences of this condition. Since hypoperfusion in these postoperative feet is a surgical emergency, we propose clinical guidelines for treatment for this phenomenon, which we have named the purple hallux sign.

Abnormalities, Multiple↗
PubMed1982

Congenital clubfoot: an electromyographic study.

Twenty-five patients with congenital idiopathic clubfoot, aged 1 day to 22 months, were studied electromyographically. No myopathic or neurogenic changes were found in tibialis anterior, peroneus, gastrocnemius, extensor digitorum brevis, and abductor hallucis brevis muscles of the leg and foot. Maximum motor nerve conduction velocities for the peroneal and tibial nerves were normal. It is concluded that conventional electromyographic techniques were unable to demonstrate abnormalities suggesting neuropathic or myopathic changes in idiopathic clubfoot.

Clubfoot↗
PubMed1983

The functional anatomy of clubfoot.

The authors have studied anatomical specimens and findings at time of surgery to determine the functional anatomy of clubfoot. The importance of the midtarsal joints (especially of the talonavicular joint) is emphasized as well as the importance of the tibialis posterior. The findings of the authors concerning the function of these elements have allowed them to develop a new approach to the treatment of clubfoot.

Child↗
PubMedDate not supplied

An electron microscopic study of the fascia from the medial and lateral sides of clubfoot.

Two cell types were observed in fascia from the lateral side of the clubfoot: a cell resembling the fibroblast of hypertrophic scar and a fibroblast-like cell with dilated rough endoplasmic reticulum. Three cell types were observed in fascia from the medial side of the clubfoot: typical fibroblasts, cells resembling myofibroblasts, and mast cells. The contracture of the medial side may be due to the myofibroblast-like cells, and this contracture may be enhanced by histamine released from the mast cells. The stretching of the lateral side is probably due to a compensatory fibrosis that maintains the tissue density.

Child↗
PubMedDate not supplied

Tibiofibular torsion in normal and treated clubfoot populations.

Tibiofibular torsion was measured in normal and clubfoot populations. A gradual increase, up to skeletal maturity, was demonstrated in normal legs. Lateral tibiofibular torsion was reduced in patients at the completion of clubfoot treatment, and it was concluded that derotation braces did not influence this result.

Adolescent↗
PubMedDate not supplied

The contralateral foot in children with unilateral clubfoot: a study of pressures and forces involved in gait.

The unaffected contralateral side of patients with unilateral clubfeet has sometimes been taken as control in foot pressure measurement studies. However, it has never been shown that the pressure pattern under the contralateral foot is similar to a normal foot. Sixteen patients with unilateral clubfoot and 110 normal subjects took part in this study. All participants were aged from 4 to 8 years. Studies comprised clinical examination and foot pressure measurements in barefoot walking. Evaluations of the measurements were completed by the calculation of forces acting under 10 anatomical foot areas normalized to ground reaction force at foot-flat and push-off. Significant differences in peak pressure were observed between the control group and the contralateral foot of patients under the heel and the metatarsals 1 to 4. Significant differences in the forces at foot-flat and push-off are seen especially in the midfoot. Both sides of the patients with unilateral clubfeet exert significantly less ground reaction force than normal subjects. Different pressure and force distributions of clubfoot children on their contralateral side compared with the normal feet of the control group may indicate differences in the general control pattern generated by the central nervous system. Differences can still be observed after normalization of the forces. We therefore conclude that when foot pressure measurements are made with clubfeet, it might be advisable to use a collective of normal feet, instead of the contralateral foot, for comparison.

Biomechanical Phenomena↗
PubMed2001

When does the flat-top talus lesion occur in idiopathic clubfoot: evaluation with magnetic resonance imaging at three months of age.

Flat-top talus has been described as a pathologic change secondary to idiopathic clubfoot condition and/or as a direct result of nonoperative manipulation involving forced dorsiflexion and molding of the cartilaginous talus. No definitive study, however, on the etiology and the timing of the flat-top talus deformity has been performed to date. The authors evaluated the magnetic resonance images of eleven patients with idiopathic clubfoot deformities treated with 2 to 3 months of casting to assess if flattening of the talar dome occurred at this age with this amount of casting. All children were 3 months of age, were casted for a maximum of 2 to 3 months, and sedated before MRI examination. The images were evaluated for maximum talar head height, maximum talar body height, and deviation of the talar body from a perfect circle. Maximum talar head height ranged from 4 to 9 mm, maximum talar body height ranged from 6 to 10 mm. Eight of the eleven had maximum talar body measurements 3 to 5mm greater than maximum talar head height. Three of the eleven patients had head and body size of equal proportion. Two of the eleven had a talar body that was within 1 mm of a perfect circle. The remaining nine patients had perfectly round talar bodies. In the senior author's (RSD) experience with treating clubfeet, a substantial increase has been seen at operation in flat-top tali among children that were casted for more than 1 year before surgical correction, compared to children casted for 3 months before surgical correction. The current investigation indicated that although tali of children with clubfeet are abnormally shaped, the talar body remains larger than the talar head and maintains its roundness after two to three months of corrective casting. Maintenance of cast treatment for more than three months may lead to the flat-top talus deformity. The authors recommend surgical intervention following three months of failed manipulation and casting to prevent this deformity.

Casts, Surgical↗
PubMed1986

The roentgenographic appearance of the "corrected clubfoot".

Roentgenographic changes associated with a corrected clubfoot may not be readily apparent. In some individuals with minimal residual deformity, these roentgenographic changes are quite subtle. The roentgenographic abnormalities of the corrected clubfoot are described.

Clubfoot↗
PubMed1992

Histochemistry of the triceps surae muscle in idiopathic congenital clubfoot.

The histochemical composition of the triceps surae muscle was investigated in 13 previously unoperated children (age 9-24 months) with unilateral idiopathic clubfoot. On both the normal and the affected side, the percentage of type I fibers was significantly higher than that of the other fiber types. The muscle biopsies from the clubfoot side showed an increase in their connective tissue content. The affected side showed a nonsignificant higher percentage of type I fibers, whereas the average capillary density and capillary to fiber ratio were significantly lower.

Clubfoot↗
PubMedDate not supplied

Use of tissue expansion in clubfoot surgery.

Tissue expansion was used successfully to prepare adequate soft tissue for closure following a difficult clubfoot correction. The gradual expansion was done weekly at the outpatient clinics (average 3-4 months). The procedure proved to be useful in severe cases of clubfoot.

Arthrogryposis↗
PubMed2005

The clubfoot assessment protocol (CAP); description and reliability of a structured multi-level instrument for follow-up.

BACKGROUND: In most clubfoot studies, the outcome instruments used are designed to evaluate classification or long-term cross-sectional results. Variables deal mainly with factors on body function/structure level. Wide scorings intervals and total sum scores increase the risk that important changes and information are not detected. Studies of the reliability, validity and responsiveness of these instruments are sparse. The lack of an instrument for longitudinal follow-up led the investigators to develop the Clubfoot Assessment Protocol (CAP). The aim of this article is to introduce and describe the CAP and evaluate the items inter- and intra reliability in relation to patient age. METHODS: The CAP was created from 22 items divided between body function/structure (three subgroups) and activity (one subgroup) levels according to the International Classification of Function, Disability and Health (ICF). The focus is on item and subgroup development. Two experienced examiners assessed 69 clubfeet in 48 children who had a median age of 2.1 years (range, 0 to 6.7 years). Both treated and untreated feet with different grades of severity were included. Three age groups were constructed for studying the influence of age on reliability. The intra- rater study included 32 feet in 20 children who had a median age of 2.5 years (range, 4 months to 6.8 years). The Unweighted Kappa statistics, percentage observer agreement, and amount of categories defined how reliability was to be interpreted. RESULTS: The inter-rater reliability was assessed as moderate to good for all but one item. Eighteen items had kappa values > 0.40. Three items varied from 0.35 to 0.38. The mean percentage observed agreement was 82% (range, 62 to 95%). Different age groups showed sufficient agreement. Intra- rater; all items had kappa values > 0.40 [range, 0.54 to 1.00] and a mean percentage agreement of 89.5%. Categories varied from 3 to 5. CONCLUSION: The CAP contains more detailed information than previous protocols. It is a multi-dimensional observer administered standardized measurement instrument with the focus on item and subgroup level. It can be used with sufficient reliability, independent of age, during the first seven years of childhood by examiners with good clinical experience.A few items showed low reliability, partly dependent on the child's age and /or varying professional backgrounds between the examiners. These items should be interpreted with caution, until further studies have confirmed the validity and sensitivity of the instrument.

Child↗
PubMed2003

Long-term comparative results in patients with congenital clubfoot treated with two different protocols.

BACKGROUND: Long-term follow-up studies of adults who had been treated for congenital clubfoot as infants are rare. The purpose of this study was to review and compare the long-term results in two groups of patients with congenital clubfoot treated with two different techniques. In both groups, treatment was started within the first three weeks of life by manipulation and application of toe-to-groin plaster casts, with a different technique in each group. At the end of the manipulative treatment, a posteromedial release was performed when the patient was between eight and twelve months of age in the first group and a limited posterior release was performed when the patient was between two and four months of age in the second group. METHODS: At the follow-up evaluations, all patients were interviewed and examined, and standing anteroposterior and lateral radiographs and computed tomography scans of the foot were made. The results of treatment were graded according to the system of Laaveg and Ponseti. Numerous angular measurements were made on the radiographs, and the measurements in the two groups were compared. RESULTS: The first group, which included thirty-two patients (forty-seven clubfeet), was followed until an average age of twenty-five years. The second group, with thirty-two patients (forty-nine clubfeet), was followed until an average age of nineteen years. In the first group, there were two excellent, eighteen good, eleven fair, and sixteen poor results. In the second group, there were eighteen excellent, twenty good, six fair, and five poor results. According to the system of Laaveg and Ponseti, the mean rating in the first group was 74.7 points and that in the second group was 85.4 points. CONCLUSIONS: In the second group, use of Ponseti's manipulation technique and cast immobilization followed by an open heel-cord lengthening and a limited posterior ankle release gave much better long-term results than those obtained in the first group, treated with our manipulation technique and cast immobilization followed by an extensive posteromedial release of the foot. In our hands, this operation did not prevent relapse, and neither cavovarus nor forefoot adduction was completely corrected.

Achilles Tendon↗
PubMed1990

Clubfoot with supernumerary soleus muscle. Report of 2 cases.

In 2 cases of clubfoot with severe and rigid varus deformity, an accessory soleus muscle with attachment on the medial side of the calcaneus was found. After cutting the distal attachment of this muscle, the deformity diminished. The accessory soleus muscle is not interpreted as the primary cause of the clubfoot, but as a highly contributing cause to the rigid varus deformity.

Abnormalities, Multiple↗
PubMed1998

Long-term results of the operative treatment of clubfoot: a representative study.

This study reports the long-term results of operative treatment of clubfoot. Of the patients who underwent posteromedial release for congenital clubfoot between 1972 and 1975 at the Medical University in Pécs, Hungary, 41 feet of 30 patients have been under control examination. Control consisted of the distribution of questionnaires, physical examination, and in some cases, radiologic analysis. At an average of 20 years postsurgery, good clinical results were observed in 31 (75%) feet. In these patients, satisfying foot form and good function were achieved, yet the characteristic atrophy of the calf and shortening of the foot were visible. Abnormal conditions were found in 10 feet, consisting of overcorrection in 6 and undercorrection in 4 cases. Subjective judgment of the patients was considerably better; only 5 (12%) feet had no satisfying results. Data of feet in an incorrect position were analyzed and compared with other cases. In cases of feet operated on in patients aged > or = 1 year and in patients who underwent multiple operations, abnormalities were found in a significantly higher percentage.

Adult↗