POSNA REVIEW ARTICLE
What’s New in Idiopathic Clubfoot? Lewis E. Zionts, MD
Abstract: This update summarizes selected research highlights pertaining to idiopathic clubfoot deformity that were published in peer-reviewed journals between January 2010 and December 2013. Key Words: clubfoot, Ponseti method, treatment, review article (J Pediatr Orthop 2015;35:547–550)
RECENT TRENDS IN THE TREATMENT OF CLUBFOOT In the late 1990s, renewed interest emerged in less invasive treatment options, most notably the Ponseti method, to correct idiopathic clubfoot deformity. Using available national databases Zionts et al1 found that between 1996 and 2006, the number of surgical releases performed in patients below 12 months of age decreased substantially from 1641 releases in 1996 to 230 releases in 2006. The authors concluded that the trend was likely because of an increased use of less invasive treatment techniques. In a survey of the members of the Pediatric Society of North America (POSNA) taken in 2010, Zionts et al2 found nearly all (96.7%) of those surveyed stated that they use the Ponseti treatment method. Most importantly, the authors noted that the percentage of their patients requiring extensive surgical release had declined from 54%, as reported in a 2001 survey, to 7% in the more recent survey.
(a 19% false-positive rate). By eliminating those fetuses who had a “mild” diagnosis on ultrasound, the falsepositive rate was lowered to 7%.
CLASSIFICATION OF CLUBFOOT DEFORMITY The treatment and prognostic significance of the Dimeglio and Pirani classification systems have not been well established. Chu et al4 compared the initial Dimeglio and Pirani classification scores with the number of casts needed to correct clubfeet using the Ponseti technique and found that both of these scoring systems had a low correlation with the number of casts needed to obtain initial correction. They suggested an improved classification system was needed to predict the length of treatment and, ultimately, the outcome of clubfoot treatment. In contrast, Zhang et al,5 using the Dimeglio classification scheme, found a significant correlation between initial severity score and outcome. Feet that were classified as moderately severe had better outcomes than those that were classified severe or very severe. Feet that had initial severity score of 11 or less had an estimated 90% probability of a good outcome at 2 years. Chaudhry et al6 used the Dimeglio classification system to document the clinical change in each component of the clubfoot deformity after placement of successive Ponseti casts. They found the cavus and medial crease corrected first, followed by correction of the midfoot rotation, abduction, and heel varus. They also observed that the equinus component decreased from the very first cast onward, which they attributed to decreased tension in the gastrocnemius-soleus unit as the heel shifted from varus to valgus.
PRENATAL DIAGNOSIS Improvements in obstetrical ultrasound have led to increased prenatal detection of clubfoot. Glotzbecker et al 3 used a novel sonographic severity scale for clubfoot to attempt to correlate the prenatal sonographic score with the final postnatal diagnosis and clinical severity. They found 67 of 83 fetuses with a clubfoot noted on a prenatal ultrasound had a clubfoot documented at birth From the Orthopaedic Institute for Children and the Geffen School of Medicine at UCLA, Los Angeles, CA. This Pediatric Subspecialty Review Article has been reviewed and endorsed by the Publications Committee and Board of Directors of the Pediatric Orthopaedic Society of North America. The author declares no conflicts of interest. Reprints: Lewis E. Zionts, MD, Orthopaedic Institute for Children, 403 West Adams Boulevard, Los Angeles 90007, CA. E-mail: lzionts@ mednet.ucla.edu. Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 6, September 2015
TIMING OF CLUBFOOT TREATMENT It is generally believed that clubfoot correction should begin as soon as possible. Iltar et al7 prospectively studied the impact that the age of the patient at the onset of treatment had on outcome. They found that infants whose cast treatment began after the first post natal month achieved better clinical outcomes than those whose cast treatment began before the first month. They speculated that the less satisfactory results in newborns may have been related to difficulty with casting or bracing a very small foot.
CAST PHASE OF TREATMENT Although the Ponseti method specifically calls for the use of long leg casts to maintain abduction of the foot, Maripuri et al8 conducted a randomized clinical trial to www.pedorthopaedics.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
547
J Pediatr Orthop
Zionts
determine whether the time to achieve correction and the risk of cast slippage differs when a below-knee or aboveknee plaster cast is used. Unsurprisingly, they found an unacceptably high failure rate and significantly longer treatment times in the below-knee cast group.
TENDOACHILLES TENOTOMY (TAT) Ponseti chose to perform TAT percutaneously in the outpatient clinic using local anesthesia. Concerns about bleeding complications and incomplete sectioning of the tendon have led some surgeons to do this procedure in the operating room under general anesthesia. Lebel et al9 evaluated infants who had a TAT performed as an “office procedure” using local anesthesia. They retrospectively evaluated this approach on 56 infants (83 clubfeet) and reported no complications, although 7 infants (12.5%) later required a repeat tenotomy for relapsed deformity, which the authors attributed to poor brace compliance rather than incomplete sectioning of the tendon. The authors concluded that TAT can be safely performed using local anesthesia in the outpatient setting. Iravani et al10 retrospectively evaluated 114 patients who underwent 162 tenotomies under general anesthesia. Two methods of anesthesia were compared. The first used combined propofol and sevoflurane and various types of airway management. The second used only propofol with oxygen provided by facemask. There were no surgical or postanesthetic complications in either group. The authors concluded that TAT may be safely performed under general anesthesia. Propofol sedation obviated the need for airway instrumentation.
HEALING FOLLOWING TAT Three recent papers have evaluated healing following TAT using 2 different imaging modalities. Saini et al11 studied the regeneration potential of the tendoAchilles in 23 patients with 34 clubfeet using both clinical assessment and magnetic resonance imaging (MRI) performed at 6 weeks, and again at 6 months, following the tenotomy. At 6 weeks, MRI examination showed the tendon to be in continuity, but the outline was bulky with heterogenous signal, which the authors attributed to an ongoing healing process. By 6 months, the bulky outline had remodeled, and the intratendinous signal changes were no longer present. Mangat et al12 described the ultrasonic phases of healing of the tendon gap created by a TAT. The authors observed a bulbous continuity of the tendon on ultrasound 3 weeks after the tenotomy. However, complete healing, as defined by the observation of tendon homogeneity across the gap on ultrasound, was not present until at least 12 weeks posttenotomy. The authors cautioned against performing TAT for clubfeet in children over the age of 2 years; as such, patients appear to have slower healing, with added potential risk of adhesion formation.
548 | www.pedorthopaedics.com
Volume 35, Number 6, September 2015
More recently, Niki et al13 used serial ultrasound examinations to assess the healing of tenotomies performed in 23 infants (33 clubfeet) for up to 2 years. They noted that continuity and gliding of the tendon was present within 4 weeks. At 1 year, the thickness of the tendon in infants with a unilateral clubfoot did not differ from that of the uninvolved foot. These studies confirm the common clinical observation that continuity of the Achilles tendon is usually restored 3 weeks after a primary TAT; complete healing and remodeling of the tendon may take up to 12 weeks or more.
POSTCORRECTIVE BRACING Ramirez et al14 retrospectively reviewed the results in 53 patients with 73 idiopathic clubfeet followed for an average of 48 months. They found that for 25 of 53 infants (47%), the families were not compliant with the use of the Denis-Browne (D-B) bar. The authors found no association between brace noncompliance and the patient’s demographic data or the family’s educational or income level. They concluded that the postcasting orthotic protocol needs to be reevaluated to a less demanding option. Zionts et al15 described their experience using the Mitchell-Ponseti (MP) brace in a consecutive series of 57 infants with clubfeet treated using the Ponseti method. The authors reported the families of 34 infants (60%) were strictly adherent with the postcorrective brace protocol. Although it was their impression that the families found the MP brace easy to use, the authors were unable to document improved compliance compared to studies using other postcorrective braces. An ankle foot orthoses (AFO) has been suggested as an alternative to the traditional foot abduction orthoses (FAO) to improve brace adherence. Solanki et al16 studied the effectiveness of a modified, custom-designed, AFO made of low temperature thermoplastics, in combination with a regimen of stretching exercises, to maintain the correction of 43 clubfeet in 28 infants treated using the Ponseti method. After a short period of follow-up (6 mo) the authors suggested that the modified AFO maintained correction of the feet in their patients. One drawback cited by the authors was the need for oral sedation in some patients to remold the orthosis. In another study, George et al17 compared the use of a unilateral FAO to the more traditional D-B device in a study of 27 children with 35 idiopathic clubfeet. Although the authors found that most families reported that the unilateral FAO was easier for their child to use, and facilitated adherence, the recurrence rate with this device was higher than that found in patients using the D-B brace. Janicki et al18 compared the effectiveness of an AFO with that of the D-B orthoses, to prevent relapse following successful initial Ponseti clubfoot treatment in a retrospective cohort study of 45 children with 69 idiopathic clubfeet. One group (17 children, 30 feet) used an Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 6, September 2015
AFO, whereas the other group (28 children, 39 feet) used a traditional D-B device. After a minimum follow-up of 3 years, the authors found that relapsed deformity requiring additional treatment occurred in 83% of the patients using the AFO, compared with 31% in the group using the D-B brace. The authors concluded that foot abduction appears to be important to maintain correction of clubfeet treated using the Ponseti method and that this cannot be achieved using an AFO.
ACCELERATED TREATMENT OF CLUBFOOT DEFORMITY Traditionally, the Ponseti method employs weekly manipulations and cast applications. Three recent papers report the results of accelerated treatment protocols. In a prospective randomized control trial, Harnett et al19 compared a group of patients who underwent weekly application of casts (21 patients, 32 feet), with an accelerated group (19 patients, 29 feet) in whom the casts were changed 3 times a week. Three of the 19 patients in the accelerated group did not respond to the treatment and crossed over to the standard Ponseti protocol group. The authors reported no difference in the number of cast changes for each group. However, patients in the accelerated group achieved correction sooner. The median number of treatment days in plaster prior to tenotomy was 16 in the accelerated group compared with 42 in the control group. In another study, Xu20 compared a group of patients who underwent weekly manipulation and cast application (20 patients, 32 feet) with a group that underwent cast treatment 2 times a week (26 patients, 40 feet). The authors reported no difference in the number of casts needed to achieve correction. However, number of days needed to achieve correction was 20.6 days in the accelerated group compared to 35.4 in the traditional treatment group. Going a step further, Kumar and Gopalakrishna21 described a modification of the Ponseti method in which the TAT is performed at the first visit, followed by application of a single cast that is worn for 3 weeks. After the cast was removed, a postcorrective brace was applied. The authors used this method to treat 82 clubfeet in 50 infants less than 4 weeks of age. They reported a good outcome in 85% of cases at a minimum of 28 months of follow-up. Fifteen percent of feet did not show sufficient correction following tenotomy and single cast application, and they required 2 to 3 additional casts to obtain full correction.
MOTOR DEVELOPMENT OF PATIENTS WITH CLUBFEET FOLLOWING PONSETI TREATMENT AS INFANTS When an infant is diagnosed with idiopathic clubfoot, parents are often concerned about how the diagnosis and treatment will affect the child’s attainment of normal gross motor milestones, especially age at walking. Copyright
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2014 Wolters Kluwer Health, Inc. All rights reserved.
What’s New in Idiopathic Clubfoot?
Garcia et al22 investigated the effect of clubfoot treatment, using the Ponseti and French techniques, on the acquisition of gross motor skills. They found the control group infants were more likely to be walking at 12 months compared to those infants undergoing clubfoot treatment. However, all but one of the infants in the clubfoot group was walking by age 18 months. The authors concluded that babies with idiopathic clubfoot will likely walk later than typically expected but that walking will likely occur by 15 to 18 months. More recently, Sala et al23 compared the age at achievement of gross motor milestones in 36 children with idiopathic clubfoot deformity treated using the Ponseti method with historical normative data. The authors found that independent ambulation was achieved up to 2.2 months later in the clubfoot patients. Ninety percent of children with clubfoot were walking by 17.7 months. The authors concluded that minimal gross motor delays may occur in children with idiopathic clubfoot treated using the Ponseti method and parents can be counseled accordingly.
THE PARENTS’ PERSPECTIVE The diagnosis of clubfoot may have a negative impact on the mother. Coppola et al24 compared the psychological well-being, coping strategies, and social support among mothers of infants born with a clubfoot with mothers of healthy full-term infants. They found that mothers of babies with a diagnosis of clubfoot reported more stress-related anxiety and depression; social support was negatively related with both stress and depression. A protocol of emotional and informational support in the hospital unit was well-received by the mothers of babies with clubfoot. Nogueira et al25 sought the impressions of the parents of infants with clubfoot treated using the Ponseti method. They followed 30 families at a private clinic through the completion of the brace period. The parents reported high levels of anxiety at the moment of diagnosis and in anticipation of the TAT. Eighty percent of the families considered the cast phase of treatment more difficult than the brace phase. More importantly, 26 families (86.9%) reported that their children had no physical limitations compared with other children, and all families reported that they would treat a second child with clubfoot using the same method. The authors concluded that physician awareness of how the parents perceive treatment can be useful to allay parental concerns. At the start of clubfoot treatment, parents may inquire as to how the diagnosis will affect their child’s ability to participate in regular sports activity. Kenmoku et al26 evaluated how 30 patients with treated clubfoot fared on the scoring of 5 elementary school physical activities and compared those scores with national averages. Thirteen of the patients had been treated with surgical releases; the remaining 17 patients were treated by either cast treatment alone, or cast treatment and TAT. The authors found that 96.6% of all scores for the clubfoot www.pedorthopaedics.com |
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patients fell within 2 SDs for all events, although they did note that the patients performed relatively poorly at running and the standing long jump compared with national averages.
RELAPSING DEFORMITY FOLLOWING CORRECTION USING THE PONSETI METHOD Relapse of a clubfoot following complete correction using the Ponseti method may occur at any age and will not spontaneously resolve without treatment. McKay et al27 described 60 clubfeet (39 patients) that relapsed after successful initial correction and had the relapsed foot treated after 4 years of age. Most of the feet had a late-onset relapse (after age 4 y) or a late-worsening relapse. Of 37 relapsed clubfeet treated by observation, bracing, or manipulation and cast application, 33 (89%) went on to having an anterior tibial tendon transfer (ATTT), with or without concurrent procedures. At latest follow-up, averaging 23.3 years, 55% of the feet had mild residual deformity and 17 of the patients (44%) reported some level of foot pain. A common belief among practioners of the Ponseti method is that a relapsed deformity that is managed with an ATTT will obviate the need for further bracing and will not be prone to subsequent relapse. Masrouha and Morcuende28 described 15 clubfeet in 10 patients that experienced a relapsed deformity following an ATTT. They noted that patients who experienced a relapsed deformity were younger at the time of the transfer procedure (mean age: 3.1 y) compared with those who did not (4.5 y). Two patients were found to have an underlying neurological condition that may have contributed to the relapse. The authors cautioned that the risk of relapse following an ATTT was 15.2%. A careful neurological evaluation is warranted in this group of children. REFERENCES 1. Zionts LE, Zhao G, Hitchcock K, et al. Has the rate of extensive surgery to treat idiopathic clubfoot declined in the United States? J Bone Joint Surg Am. 2010;92:882–889. 2. Zionts LE, Sangiorgio SN, Ebramzadeh E, et al. The current management of idiopathic clubfoot revisited: results of a survey of the POSNA membership. J Pediatr Orthop. 2012;32:515–520. 3. Glotzbecker MP, Estroff JA, Spencer SA, et al. Prenatally diagnosed clubfeet: comparing ultrasonographic severity with objective clinical outcomes. J Pediatr Orthop. 2010;30:606–611. 4. Chu A, Labar AS, Sala DA, et al. Clubfoot classification: correlation with Ponseti cast treatment. J Pediatr Orthop. 2010; 30:695–699. 5. Zhang W, Richards BS, Faulks ST, et al. Initial severity rating of idiopathic clubfeet is an outcome predictor at age two years. J Pediatr Orthop B. 2011;21:16–19. 6. Chaudhry S, Chu A, Labar AS, et al. Progression of idiopathic clubfoot correction using the Ponseti method. J Pediatr Orthop B. 2011;21:73–78. 7. Iltar S, Uysal M, Alemdaroglu KB, et al. Treatment of clubfoot with the Ponseti method: should we begin casting in the newborn period or later? J Foot Ankle Surg. 2010;49:426–431.
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8. Maripuri SN, Gallacher PD, Bridgens J, et al. Ponseti casting for club foot—above- or below-knee?: A prospective randomised clinical trial. Bone Joint J. 2013;95-B:1570–1574. 9. Lebel E, Karasik M, Bernstein-Weyel M, et al. Achilles tenotomy as an office procedure: safety and efficacy as part of the Ponseti serial casting protocol for clubfoot. J Pediatr Orthop. 2012;32:412–415. 10. Iravani M, Chalabi J, Kim R, et al. Propofol sedation for infants with idiopathic clubfoot undergoing percutaneous tendoachilles tenotomy. J Pediatr Orthop. 2012;33:59–62. 11. Saini R, Dhillon MS, Tripathy SK, et al. Regeneration of the Achilles tendon after percutaneous tenotomy in infants: a clinical and MRI study. J Pediatr Orthop B. 2010;19:344–347. 12. Mangat KS, Kanwar R, Johnson K, et al. Ultrasonographic phases in gap healing following Ponseti-type Achilles tenotomy. J Bone Joint Surg Am. 2010;92:1462–1467. 13. Niki H, Nakajima H, Hirano T, et al. Ultrasonographic observation of the healing process in the gap after a Ponseti-type Achilles tenotomy for idiopathic congenital clubfoot at two-year follow-up. J Orthop Sci. 2012;18:70–75. 14. Ramirez N, Flynn JM, Fernandez S, et al. Orthosis noncompliance after the Ponseti method for the treatment of idiopathic clubfeet: a relevant problem that needs reevaluation. J Pediatr Orthop. 2011;31:710–715. 15. Zionts LE, Frost N, Kim R, et al. Treatment of idiopathic clubfoot: experience with the Mitchell-Ponseti brace. J Pediatr Orthop. 2012;32:706–713. 16. Solanki PV, Sheth BA, Poduval M, et al. Effectiveness of modified ankle foot orthosis of low-temperature thermoplastics in idiopathic congenital talipes equino varus. J Pediatr Orthop B. 2010;19: 353–360. 17. George HL, Unnikrishnan PN, Garg NK, et al. Unilateral foot abduction orthosis: is it a substitute for Denis Browne boots following Ponseti technique? J Pediatr Orthop B. 2010;20:22–25. 18. Janicki JA, Wright JG, Weir S, et al. A comparison of ankle foot orthoses with foot abduction orthoses to prevent recurrence following correction of idiopathic clubfoot by the Ponseti method. J Bone Joint Surg Br. 2011;93:700–704. 19. Harnett P, Freeman R, Harrison WJ, et al. An accelerated Ponseti versus the standard Ponseti method: a prospective randomised controlled trial. J Bone Joint Surg Br. 2011;93:404–408. 20. Xu RJ. A modified Ponseti method for the treatment of idiopathic clubfoot: a preliminary report. J Pediatr Orthop. 2011;31:317–319. 21. Kumar MN, Gopalakrishna C. Modified Ponseti method of management of neonatal club feet. Acta Orthop Belg. 2012;78: 210–215. 22. Garcia NL, McMulkin ML, Tompkins BJ, et al. Gross motor development in babies with treated idiopathic clubfoot. Pediatr Phys Ther. 2011;23:347–352. 23. Sala DA, Chu A, Lehman WB, et al. Achievement of gross motor milestones in children with idiopathic clubfoot treated with the Ponseti method. J Pediatr Orthop. 2012;33:55–58. 24. Coppola G, Costantini A, Tedone R, et al. The impact of the baby’s congenital malformation on the mother’s psychological well-being: an empirical contribution on the clubfoot. J Pediatr Orthop. 2012;32:521–526. 25. Nogueira MP, Farcetta M, Fox MH, et al. Treatment of congenital clubfoot with the Ponseti method: the parents’ perspective. J Pediatr Orthop B. 2013;22:583–588. 26. Kenmoku T, Kamegaya M, Saisu T, et al. Athletic ability of schoolage children after satisfactory treatment of congenital clubfoot. J Pediatr Orthop. 2013;33:321–325. 27. McKay SD, Dolan LA, Morcuende JA. Treatment results of laterelapsing idiopathic clubfoot previously treated with the Ponseti method. J Pediatr Orthop. 2012;32:406–411. 28. Masrouha KZ, Morcuende JA. Relapse after tibialis anterior tendon transfer in idiopathic clubfoot treated by the Ponseti method. J Pediatr Orthop. 2011;32:81–84.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
What’s New in Idiopathic Clubfoot? Lewis E. Zionts, MD
Abstract: This update summarizes selected research highlights pertaining to idiopathic clubfoot deformity that were published in peer-reviewed journals between January 2010 and December 2013. Key Words: clubfoot, Ponseti method, treatment, review article (J Pediatr Orthop 2015;35:547–550)
RECENT TRENDS IN THE TREATMENT OF CLUBFOOT In the late 1990s, renewed interest emerged in less invasive treatment options, most notably the Ponseti method, to correct idiopathic clubfoot deformity. Using available national databases Zionts et al1 found that between 1996 and 2006, the number of surgical releases performed in patients below 12 months of age decreased substantially from 1641 releases in 1996 to 230 releases in 2006. The authors concluded that the trend was likely because of an increased use of less invasive treatment techniques. In a survey of the members of the Pediatric Society of North America (POSNA) taken in 2010, Zionts et al2 found nearly all (96.7%) of those surveyed stated that they use the Ponseti treatment method. Most importantly, the authors noted that the percentage of their patients requiring extensive surgical release had declined from 54%, as reported in a 2001 survey, to 7% in the more recent survey.
(a 19% false-positive rate). By eliminating those fetuses who had a “mild” diagnosis on ultrasound, the falsepositive rate was lowered to 7%.
CLASSIFICATION OF CLUBFOOT DEFORMITY The treatment and prognostic significance of the Dimeglio and Pirani classification systems have not been well established. Chu et al4 compared the initial Dimeglio and Pirani classification scores with the number of casts needed to correct clubfeet using the Ponseti technique and found that both of these scoring systems had a low correlation with the number of casts needed to obtain initial correction. They suggested an improved classification system was needed to predict the length of treatment and, ultimately, the outcome of clubfoot treatment. In contrast, Zhang et al,5 using the Dimeglio classification scheme, found a significant correlation between initial severity score and outcome. Feet that were classified as moderately severe had better outcomes than those that were classified severe or very severe. Feet that had initial severity score of 11 or less had an estimated 90% probability of a good outcome at 2 years. Chaudhry et al6 used the Dimeglio classification system to document the clinical change in each component of the clubfoot deformity after placement of successive Ponseti casts. They found the cavus and medial crease corrected first, followed by correction of the midfoot rotation, abduction, and heel varus. They also observed that the equinus component decreased from the very first cast onward, which they attributed to decreased tension in the gastrocnemius-soleus unit as the heel shifted from varus to valgus.
PRENATAL DIAGNOSIS Improvements in obstetrical ultrasound have led to increased prenatal detection of clubfoot. Glotzbecker et al 3 used a novel sonographic severity scale for clubfoot to attempt to correlate the prenatal sonographic score with the final postnatal diagnosis and clinical severity. They found 67 of 83 fetuses with a clubfoot noted on a prenatal ultrasound had a clubfoot documented at birth From the Orthopaedic Institute for Children and the Geffen School of Medicine at UCLA, Los Angeles, CA. This Pediatric Subspecialty Review Article has been reviewed and endorsed by the Publications Committee and Board of Directors of the Pediatric Orthopaedic Society of North America. The author declares no conflicts of interest. Reprints: Lewis E. Zionts, MD, Orthopaedic Institute for Children, 403 West Adams Boulevard, Los Angeles 90007, CA. E-mail: lzionts@ mednet.ucla.edu. Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 6, September 2015
TIMING OF CLUBFOOT TREATMENT It is generally believed that clubfoot correction should begin as soon as possible. Iltar et al7 prospectively studied the impact that the age of the patient at the onset of treatment had on outcome. They found that infants whose cast treatment began after the first post natal month achieved better clinical outcomes than those whose cast treatment began before the first month. They speculated that the less satisfactory results in newborns may have been related to difficulty with casting or bracing a very small foot.
CAST PHASE OF TREATMENT Although the Ponseti method specifically calls for the use of long leg casts to maintain abduction of the foot, Maripuri et al8 conducted a randomized clinical trial to www.pedorthopaedics.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
547
J Pediatr Orthop
Zionts
determine whether the time to achieve correction and the risk of cast slippage differs when a below-knee or aboveknee plaster cast is used. Unsurprisingly, they found an unacceptably high failure rate and significantly longer treatment times in the below-knee cast group.
TENDOACHILLES TENOTOMY (TAT) Ponseti chose to perform TAT percutaneously in the outpatient clinic using local anesthesia. Concerns about bleeding complications and incomplete sectioning of the tendon have led some surgeons to do this procedure in the operating room under general anesthesia. Lebel et al9 evaluated infants who had a TAT performed as an “office procedure” using local anesthesia. They retrospectively evaluated this approach on 56 infants (83 clubfeet) and reported no complications, although 7 infants (12.5%) later required a repeat tenotomy for relapsed deformity, which the authors attributed to poor brace compliance rather than incomplete sectioning of the tendon. The authors concluded that TAT can be safely performed using local anesthesia in the outpatient setting. Iravani et al10 retrospectively evaluated 114 patients who underwent 162 tenotomies under general anesthesia. Two methods of anesthesia were compared. The first used combined propofol and sevoflurane and various types of airway management. The second used only propofol with oxygen provided by facemask. There were no surgical or postanesthetic complications in either group. The authors concluded that TAT may be safely performed under general anesthesia. Propofol sedation obviated the need for airway instrumentation.
HEALING FOLLOWING TAT Three recent papers have evaluated healing following TAT using 2 different imaging modalities. Saini et al11 studied the regeneration potential of the tendoAchilles in 23 patients with 34 clubfeet using both clinical assessment and magnetic resonance imaging (MRI) performed at 6 weeks, and again at 6 months, following the tenotomy. At 6 weeks, MRI examination showed the tendon to be in continuity, but the outline was bulky with heterogenous signal, which the authors attributed to an ongoing healing process. By 6 months, the bulky outline had remodeled, and the intratendinous signal changes were no longer present. Mangat et al12 described the ultrasonic phases of healing of the tendon gap created by a TAT. The authors observed a bulbous continuity of the tendon on ultrasound 3 weeks after the tenotomy. However, complete healing, as defined by the observation of tendon homogeneity across the gap on ultrasound, was not present until at least 12 weeks posttenotomy. The authors cautioned against performing TAT for clubfeet in children over the age of 2 years; as such, patients appear to have slower healing, with added potential risk of adhesion formation.
548 | www.pedorthopaedics.com
Volume 35, Number 6, September 2015
More recently, Niki et al13 used serial ultrasound examinations to assess the healing of tenotomies performed in 23 infants (33 clubfeet) for up to 2 years. They noted that continuity and gliding of the tendon was present within 4 weeks. At 1 year, the thickness of the tendon in infants with a unilateral clubfoot did not differ from that of the uninvolved foot. These studies confirm the common clinical observation that continuity of the Achilles tendon is usually restored 3 weeks after a primary TAT; complete healing and remodeling of the tendon may take up to 12 weeks or more.
POSTCORRECTIVE BRACING Ramirez et al14 retrospectively reviewed the results in 53 patients with 73 idiopathic clubfeet followed for an average of 48 months. They found that for 25 of 53 infants (47%), the families were not compliant with the use of the Denis-Browne (D-B) bar. The authors found no association between brace noncompliance and the patient’s demographic data or the family’s educational or income level. They concluded that the postcasting orthotic protocol needs to be reevaluated to a less demanding option. Zionts et al15 described their experience using the Mitchell-Ponseti (MP) brace in a consecutive series of 57 infants with clubfeet treated using the Ponseti method. The authors reported the families of 34 infants (60%) were strictly adherent with the postcorrective brace protocol. Although it was their impression that the families found the MP brace easy to use, the authors were unable to document improved compliance compared to studies using other postcorrective braces. An ankle foot orthoses (AFO) has been suggested as an alternative to the traditional foot abduction orthoses (FAO) to improve brace adherence. Solanki et al16 studied the effectiveness of a modified, custom-designed, AFO made of low temperature thermoplastics, in combination with a regimen of stretching exercises, to maintain the correction of 43 clubfeet in 28 infants treated using the Ponseti method. After a short period of follow-up (6 mo) the authors suggested that the modified AFO maintained correction of the feet in their patients. One drawback cited by the authors was the need for oral sedation in some patients to remold the orthosis. In another study, George et al17 compared the use of a unilateral FAO to the more traditional D-B device in a study of 27 children with 35 idiopathic clubfeet. Although the authors found that most families reported that the unilateral FAO was easier for their child to use, and facilitated adherence, the recurrence rate with this device was higher than that found in patients using the D-B brace. Janicki et al18 compared the effectiveness of an AFO with that of the D-B orthoses, to prevent relapse following successful initial Ponseti clubfoot treatment in a retrospective cohort study of 45 children with 69 idiopathic clubfeet. One group (17 children, 30 feet) used an Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 6, September 2015
AFO, whereas the other group (28 children, 39 feet) used a traditional D-B device. After a minimum follow-up of 3 years, the authors found that relapsed deformity requiring additional treatment occurred in 83% of the patients using the AFO, compared with 31% in the group using the D-B brace. The authors concluded that foot abduction appears to be important to maintain correction of clubfeet treated using the Ponseti method and that this cannot be achieved using an AFO.
ACCELERATED TREATMENT OF CLUBFOOT DEFORMITY Traditionally, the Ponseti method employs weekly manipulations and cast applications. Three recent papers report the results of accelerated treatment protocols. In a prospective randomized control trial, Harnett et al19 compared a group of patients who underwent weekly application of casts (21 patients, 32 feet), with an accelerated group (19 patients, 29 feet) in whom the casts were changed 3 times a week. Three of the 19 patients in the accelerated group did not respond to the treatment and crossed over to the standard Ponseti protocol group. The authors reported no difference in the number of cast changes for each group. However, patients in the accelerated group achieved correction sooner. The median number of treatment days in plaster prior to tenotomy was 16 in the accelerated group compared with 42 in the control group. In another study, Xu20 compared a group of patients who underwent weekly manipulation and cast application (20 patients, 32 feet) with a group that underwent cast treatment 2 times a week (26 patients, 40 feet). The authors reported no difference in the number of casts needed to achieve correction. However, number of days needed to achieve correction was 20.6 days in the accelerated group compared to 35.4 in the traditional treatment group. Going a step further, Kumar and Gopalakrishna21 described a modification of the Ponseti method in which the TAT is performed at the first visit, followed by application of a single cast that is worn for 3 weeks. After the cast was removed, a postcorrective brace was applied. The authors used this method to treat 82 clubfeet in 50 infants less than 4 weeks of age. They reported a good outcome in 85% of cases at a minimum of 28 months of follow-up. Fifteen percent of feet did not show sufficient correction following tenotomy and single cast application, and they required 2 to 3 additional casts to obtain full correction.
MOTOR DEVELOPMENT OF PATIENTS WITH CLUBFEET FOLLOWING PONSETI TREATMENT AS INFANTS When an infant is diagnosed with idiopathic clubfoot, parents are often concerned about how the diagnosis and treatment will affect the child’s attainment of normal gross motor milestones, especially age at walking. Copyright
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What’s New in Idiopathic Clubfoot?
Garcia et al22 investigated the effect of clubfoot treatment, using the Ponseti and French techniques, on the acquisition of gross motor skills. They found the control group infants were more likely to be walking at 12 months compared to those infants undergoing clubfoot treatment. However, all but one of the infants in the clubfoot group was walking by age 18 months. The authors concluded that babies with idiopathic clubfoot will likely walk later than typically expected but that walking will likely occur by 15 to 18 months. More recently, Sala et al23 compared the age at achievement of gross motor milestones in 36 children with idiopathic clubfoot deformity treated using the Ponseti method with historical normative data. The authors found that independent ambulation was achieved up to 2.2 months later in the clubfoot patients. Ninety percent of children with clubfoot were walking by 17.7 months. The authors concluded that minimal gross motor delays may occur in children with idiopathic clubfoot treated using the Ponseti method and parents can be counseled accordingly.
THE PARENTS’ PERSPECTIVE The diagnosis of clubfoot may have a negative impact on the mother. Coppola et al24 compared the psychological well-being, coping strategies, and social support among mothers of infants born with a clubfoot with mothers of healthy full-term infants. They found that mothers of babies with a diagnosis of clubfoot reported more stress-related anxiety and depression; social support was negatively related with both stress and depression. A protocol of emotional and informational support in the hospital unit was well-received by the mothers of babies with clubfoot. Nogueira et al25 sought the impressions of the parents of infants with clubfoot treated using the Ponseti method. They followed 30 families at a private clinic through the completion of the brace period. The parents reported high levels of anxiety at the moment of diagnosis and in anticipation of the TAT. Eighty percent of the families considered the cast phase of treatment more difficult than the brace phase. More importantly, 26 families (86.9%) reported that their children had no physical limitations compared with other children, and all families reported that they would treat a second child with clubfoot using the same method. The authors concluded that physician awareness of how the parents perceive treatment can be useful to allay parental concerns. At the start of clubfoot treatment, parents may inquire as to how the diagnosis will affect their child’s ability to participate in regular sports activity. Kenmoku et al26 evaluated how 30 patients with treated clubfoot fared on the scoring of 5 elementary school physical activities and compared those scores with national averages. Thirteen of the patients had been treated with surgical releases; the remaining 17 patients were treated by either cast treatment alone, or cast treatment and TAT. The authors found that 96.6% of all scores for the clubfoot www.pedorthopaedics.com |
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patients fell within 2 SDs for all events, although they did note that the patients performed relatively poorly at running and the standing long jump compared with national averages.
RELAPSING DEFORMITY FOLLOWING CORRECTION USING THE PONSETI METHOD Relapse of a clubfoot following complete correction using the Ponseti method may occur at any age and will not spontaneously resolve without treatment. McKay et al27 described 60 clubfeet (39 patients) that relapsed after successful initial correction and had the relapsed foot treated after 4 years of age. Most of the feet had a late-onset relapse (after age 4 y) or a late-worsening relapse. Of 37 relapsed clubfeet treated by observation, bracing, or manipulation and cast application, 33 (89%) went on to having an anterior tibial tendon transfer (ATTT), with or without concurrent procedures. At latest follow-up, averaging 23.3 years, 55% of the feet had mild residual deformity and 17 of the patients (44%) reported some level of foot pain. A common belief among practioners of the Ponseti method is that a relapsed deformity that is managed with an ATTT will obviate the need for further bracing and will not be prone to subsequent relapse. Masrouha and Morcuende28 described 15 clubfeet in 10 patients that experienced a relapsed deformity following an ATTT. They noted that patients who experienced a relapsed deformity were younger at the time of the transfer procedure (mean age: 3.1 y) compared with those who did not (4.5 y). Two patients were found to have an underlying neurological condition that may have contributed to the relapse. The authors cautioned that the risk of relapse following an ATTT was 15.2%. A careful neurological evaluation is warranted in this group of children. REFERENCES 1. Zionts LE, Zhao G, Hitchcock K, et al. Has the rate of extensive surgery to treat idiopathic clubfoot declined in the United States? J Bone Joint Surg Am. 2010;92:882–889. 2. Zionts LE, Sangiorgio SN, Ebramzadeh E, et al. The current management of idiopathic clubfoot revisited: results of a survey of the POSNA membership. J Pediatr Orthop. 2012;32:515–520. 3. Glotzbecker MP, Estroff JA, Spencer SA, et al. Prenatally diagnosed clubfeet: comparing ultrasonographic severity with objective clinical outcomes. J Pediatr Orthop. 2010;30:606–611. 4. Chu A, Labar AS, Sala DA, et al. Clubfoot classification: correlation with Ponseti cast treatment. J Pediatr Orthop. 2010; 30:695–699. 5. Zhang W, Richards BS, Faulks ST, et al. Initial severity rating of idiopathic clubfeet is an outcome predictor at age two years. J Pediatr Orthop B. 2011;21:16–19. 6. Chaudhry S, Chu A, Labar AS, et al. Progression of idiopathic clubfoot correction using the Ponseti method. J Pediatr Orthop B. 2011;21:73–78. 7. Iltar S, Uysal M, Alemdaroglu KB, et al. Treatment of clubfoot with the Ponseti method: should we begin casting in the newborn period or later? J Foot Ankle Surg. 2010;49:426–431.
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8. Maripuri SN, Gallacher PD, Bridgens J, et al. Ponseti casting for club foot—above- or below-knee?: A prospective randomised clinical trial. Bone Joint J. 2013;95-B:1570–1574. 9. Lebel E, Karasik M, Bernstein-Weyel M, et al. Achilles tenotomy as an office procedure: safety and efficacy as part of the Ponseti serial casting protocol for clubfoot. J Pediatr Orthop. 2012;32:412–415. 10. Iravani M, Chalabi J, Kim R, et al. Propofol sedation for infants with idiopathic clubfoot undergoing percutaneous tendoachilles tenotomy. J Pediatr Orthop. 2012;33:59–62. 11. Saini R, Dhillon MS, Tripathy SK, et al. Regeneration of the Achilles tendon after percutaneous tenotomy in infants: a clinical and MRI study. J Pediatr Orthop B. 2010;19:344–347. 12. Mangat KS, Kanwar R, Johnson K, et al. Ultrasonographic phases in gap healing following Ponseti-type Achilles tenotomy. J Bone Joint Surg Am. 2010;92:1462–1467. 13. Niki H, Nakajima H, Hirano T, et al. Ultrasonographic observation of the healing process in the gap after a Ponseti-type Achilles tenotomy for idiopathic congenital clubfoot at two-year follow-up. J Orthop Sci. 2012;18:70–75. 14. Ramirez N, Flynn JM, Fernandez S, et al. Orthosis noncompliance after the Ponseti method for the treatment of idiopathic clubfeet: a relevant problem that needs reevaluation. J Pediatr Orthop. 2011;31:710–715. 15. Zionts LE, Frost N, Kim R, et al. Treatment of idiopathic clubfoot: experience with the Mitchell-Ponseti brace. J Pediatr Orthop. 2012;32:706–713. 16. Solanki PV, Sheth BA, Poduval M, et al. Effectiveness of modified ankle foot orthosis of low-temperature thermoplastics in idiopathic congenital talipes equino varus. J Pediatr Orthop B. 2010;19: 353–360. 17. George HL, Unnikrishnan PN, Garg NK, et al. Unilateral foot abduction orthosis: is it a substitute for Denis Browne boots following Ponseti technique? J Pediatr Orthop B. 2010;20:22–25. 18. Janicki JA, Wright JG, Weir S, et al. A comparison of ankle foot orthoses with foot abduction orthoses to prevent recurrence following correction of idiopathic clubfoot by the Ponseti method. J Bone Joint Surg Br. 2011;93:700–704. 19. Harnett P, Freeman R, Harrison WJ, et al. An accelerated Ponseti versus the standard Ponseti method: a prospective randomised controlled trial. J Bone Joint Surg Br. 2011;93:404–408. 20. Xu RJ. A modified Ponseti method for the treatment of idiopathic clubfoot: a preliminary report. J Pediatr Orthop. 2011;31:317–319. 21. Kumar MN, Gopalakrishna C. Modified Ponseti method of management of neonatal club feet. Acta Orthop Belg. 2012;78: 210–215. 22. Garcia NL, McMulkin ML, Tompkins BJ, et al. Gross motor development in babies with treated idiopathic clubfoot. Pediatr Phys Ther. 2011;23:347–352. 23. Sala DA, Chu A, Lehman WB, et al. Achievement of gross motor milestones in children with idiopathic clubfoot treated with the Ponseti method. J Pediatr Orthop. 2012;33:55–58. 24. Coppola G, Costantini A, Tedone R, et al. The impact of the baby’s congenital malformation on the mother’s psychological well-being: an empirical contribution on the clubfoot. J Pediatr Orthop. 2012;32:521–526. 25. Nogueira MP, Farcetta M, Fox MH, et al. Treatment of congenital clubfoot with the Ponseti method: the parents’ perspective. J Pediatr Orthop B. 2013;22:583–588. 26. Kenmoku T, Kamegaya M, Saisu T, et al. Athletic ability of schoolage children after satisfactory treatment of congenital clubfoot. J Pediatr Orthop. 2013;33:321–325. 27. McKay SD, Dolan LA, Morcuende JA. Treatment results of laterelapsing idiopathic clubfoot previously treated with the Ponseti method. J Pediatr Orthop. 2012;32:406–411. 28. Masrouha KZ, Morcuende JA. Relapse after tibialis anterior tendon transfer in idiopathic clubfoot treated by the Ponseti method. J Pediatr Orthop. 2011;32:81–84.
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Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
