Ponseti treated idiopathic clubfoot - outcome predictive factors in the test of time: analysis of 500 feet followed for five to 20 years

Purpose To investigate a set of risk factors on the outcome of Ponseti treated idiopathic clubfeet (ICF). Methods This study was approved by the institutional review board. A retrospective analysis of prospectively gathered data over a 20-year period, at a single dedicated clubfoot clinic. Records of 333 consecutive infants with 500 ICF were analyzed. Initial Pirani score, number of casts, need for tenotomy, foot abduction brace compliance and functional score had been documented. The need for surgery after initial correction was the outcome measure. All children were followed by the same team throughout the study period. Descriptive statistics, chi-squared and multivariate analysis were performed. Results In total, 82 children (24%) with 119 feet (23.8%) were operated on, with 95.1% of feet being operated up to the age of nine years. There was a significant correlation between the Pirani score at presentation and the number of surgical procedures (chi-squared = 79.32; p < 0.001). Achilles tenotomy was done in 94.8% of patients. Pirani score of > 4.5 before casting was strongly associated with increased surgical risk (odds ratio = 1.95). When six to eight cast changes were needed, surgical prospect was 2.9 more, increasing to 11.9 when nine or more casts were needed. Conclusion Foot severity and number of cast changes were the strongest predictors for future surgery. Estimation of the risk of deformity recurrence after initial correction may help in tailoring a cost-effective personal treatment and follow-up protocol. Personalized focused protocol will help patients and caregivers and will reduce expenses. Level of Evidence Level II - prognostic study.

Rational selection of treatment methods in recurrent clubfoot

Objective. Based on an analytical assessment of the results of surgical treatment of children with equinovarus foot deformity of various origins (idiopathic clubfoot, syndromic clubfoot), to determine a way of rational selection of surgical techniquesin each specifc case.Materials and methods. The results of the treatment of 78 children with congenital idiopathic clubfoot over the period 2010–2018 were assessed in comparison with the results of the treatment of 41 children with recurrent congenital clubfoot, whose primary treatment had been carried out before 2010. We have gained the experience in treating 30 children with severe clubfoot syndrome (meningomyelocele, CNS lesions, chromosomal diseases and others).Results. In the treatment of congenital clubfoot with the Ponseti method, recurrences occur in 21.79 % of the cases, and in the traditional treatment — in 57.74 %. The Ponseti surgical treatment of recurrences consists in performing release operations on the tendon-ligament apparatus from mini-accesses. Cases of rigid, long-standing deformities require extensive releases on soft tissues, as well as resection and arthrodesis interventions on the joints of the foot. The treatment of clubfoot syndrome requires “surgically aggressive” methods of correction in early childhood.Conclusion. In the idiopathic variants of clubfoot and its relapses, it is possible to correct the vicious position of the feet by minimally invasive operations with minimal damage to the tissues of the circumflex joints and without damage to the flexor tendons and their sheaths in the medial ankle area. Long-standing recurrent rigid variants, as well as syndromic clubfoot, presuppose the performance of extensive releases, osteotomies and arthrodetic resections of the joints of the foot at an early age. A promising direction for clubfoot correction in the process of child development is a surgery with the use of the bone growth potential of the lower leg and foot.

Concomitant Talocalcaneal Coalition as a Risk Factor for Early Relapse Following Ponseti Treatment of Idiopathic Clubfoot

Concomitant talocalcaneal coalition (TCC) in idiopathic clubfeet is not well documented in the literature. The purpose of this study was to describe our experience with very early relapsing idiopathic clubfeet associated with TCC. Although cases have been successfully treated with the Ponseti casting method, all recurred within 2 months of removing the final cast. A single-centre cohort of twelve feet in eight patients treated by a single surgeon between 2006 and 2020 was investigated retrospectively. Recurred cavus with variable degrees of equinus was the earliest findings noted. TCC was incidentally detected during the open reduction of the earliest three feet in our series. Afterwards, ultrasonography was advised as a screening tool for detecting an associated anomaly; however, only the use of magnetic resonance imaging (MRI) was 100% accurate in diagnosing concurrent TCC. All coalitions were cartilaginous and the posterior facet was most commonly involved facet. The average age was 18 months for the coalition resection and open reduction of a dislocated talonavicular joint, and the average duration of follow-up was 52 months. None of the patients showed clinical signs of relapse at the latest follow-up. We recommend that an associated TCC should be considered in very early relapsing idiopathic clubfoot cases.

Bilateral idiopathic club foot in baby of a rheumatoid mother: A rare case report and its management

Congenital clubfoot has a multifaceted etiology, with several hypotheses offered in its etiopathogenesis. The clubfoot has rarely been reported in babies born to women who have rheumatoid arthritis (RA). We present a rare case of a 31-year-old lady with RA on disease-modifying anti-rheumatoid drugs who delivered a child with bilateral congenital clubfoot. She had previously been using Methotrexate, Hydroxychloroquine, and Sulfasalazine regularly, but Methotrexate was stopped seven months before pregnancy. A full-term female baby was born through the cesarean section with bilateral clubfoot deformity and a modified Pirani score of eight out of 10. The deformity correction was done with the Ponseti serial casting method. The final modified Pirani score was two out of ten. In newborns born to rheumatoid arthritis mothers, the club foot deformity was effectively treated with serial Ponseti corrective casts, as was idiopathic clubfoot in babies born to non-rheumatoid mothers. Our findings validate the Ponseti serial casting method for these kinds of patients.

Reconstructive surgery in recurrent deformity (clubfoot relapse)

Introduction Recurrent clubfoot deformity may be due to either an imperfect initial correction, or a natural history of a severe disease. In the later, idiopathic clubfoot is uncommon. In the review we describe reconstructive surgery in recurrent deformity of idiopathic clubfoot. Material and methods Surgery may be justified at different age and according to the type of deformity. Different surgical approaches and their indications are exposed in the article. Results After Ponseti’s method application additional surgeries may be considered in recurrent clubfoot deformity which may represent 10 to 20 % of cases: second Achilles tenotomy, postero-lateral relapse, complete antero-medial and postero-lateral relapse, transfer of the anterior tibial tendon, correction of sequelae: metatarsus varus, residual equinus, residual rotation of the calcaneopedal unit. Conclusion Idiopathic equine varus clubfoot is a frequent condition. Well-codified management should lead to extremely favorable functional results. Unfortunately, some cases lead to a recurrence of the deformity. Surgical procedures are sometimes required. The goal is to avoid as much as possible arthrodesis and secondary degenerative arthritis.

Clubfoot: current concept of treatment

Introduction Idiopathic clubfoot (IC), also referred to as congenital talipes equinovarus, is one of the most common lower limb deformities observed in newborns, leading to significant functional impairment when left untreated. Early minimally invasive treatment has been praised as one of the most successful practice of modern pediatric orthopedics. This review aims to report current knowledge and controversies about clubfoot treatment. Material and methods We describe the main trends in clubfoot managing, identifying peculiarities, difficulties and prognostic factors related to the treatment. Results Many treatment techniques either conservative, surgical or hybrid have been used over the past decades. Based on good and excellent results during long-term follow-up, Ponseti method has been globally accepted by paediatric orthopaedic surgeons as standard method of treatment. However, some other conservative methods are still widely applied in the clinical setting, such as the French Physical Therapy method. Adherence to the bracing protocol is critical for the long-term success of the treatment, being a better predictor for relapse than severity of the deformity at birth. Conclusions Taking care of the manipulation and casting details by trained professionals, together with enhancing the child and patents’ adherence to the brace, are essential for the success of conservative treatment. Surgery should be performed only when strictly needed, preferably on a “a la carte” approach.