Neglected and Relapsed Clubfoot in Adults, the Functional Outcome of Acute Surgical Correction

Background: Neglected clubfoot in this series is defined as untreated equino-cavo-adducto-varus in older children or adults. Relapsed clubfoot is the residual deformity that remains after single or multiple surgical interventions. Severely neglected clubfoot rarely exists today in developed countries, except in some emigrants from low- and middle-income countries. Acute surgical management with corrective mid-foot osteotomy and elongation of the Achilles tendon has an excellent functional outcome. Objective: To assess the functional outcome of acute correction of neglected Talipes-quinoa-varus deformity in adults. Methods: This is a cross-sectional, hospital–based multi-centric study. Forty patients were included in this study. Midfoot osteotomy and elongation of the Achilles tendon were performed on all patients. Data was collected using a questionnaire and the functional outcome has been assessed using the American Orthopedic Foot and Ankle Society Score (AOFAS). This score was measured before surgery and one year after surgery. Results: the mean age was 19.9 ± 4.7 years. Males were 25 (62.5%) and females were 15 (37.5%). The mean preoperative AOFAS score was 37.7 ± 7.1 (poor). This score improved to 80.7 ± 13.7 (good to excellent), two years after surgery. However, this indicates a significant change in the functional outcome after the operation (p value Conclusion: acute correction of neglected and relapsed TEV with elongation of the Achilles tendon and single midfoot osteotomy has excellent functional outcome as assessed by AOFAS Score. The satisfaction with this procedure is impressive. The younger age population showed better outcomes with this procedure.

Ponseti Treatment of Bilateral Idiopathic Clubfoot: Does the Hand Dominance of the Provider Make a Difference?

Introduction: Congenital talipes equinovarus (CTEV) is the commonest musculoskeletal deformity worldwide. The Ponseti technique is the goal standard for clubfoot treatment. During the correction phase, the provider’s right hand manipulates the right foot and the left hand, left foot. Often, one foot is ready for Achilles tenotomy before the other in bilateral clubfoot. Objective: To determine the effect of the provider’s hand dominance would have on bilateral clubfoot treated with the Ponseti technique. Method: This was a prospective cross-sectional study that analyzed idiopathic bilateral clubfoot patients aged 0 - 5 years and treated using the Ponseti technique at FMC Umuahia from October 2019 to September 2020. Informed consent and ethical clearance were obtained. The Pirani scores were obtained and compared at presentation and at each clinic visit. All trained manipulators were right-handed. Two-tailed t-test was used and a p-value less than 0.05 was deemed significant. Results: Forty-seven patients participated in the study with an M:F of 2.6:1 and mean age of 13.79 ± 13.39 months. Thirty-six patients (76.6%) had the same Pirani score on both feet at presentation, while the right and left feet were more severely affected in 8 and 3 cases respectively. The mean number of casts before readiness for tenotomy was 4.95 on the right and 5.28 on the left with p-value of 0.042. Conclusion: Though the right foot had a worse mean Pirani score on presentation, however, it required fewer casts before readiness for tenotomy than the left.

Worldwide spread of the Ponseti method for clubfoot

The Ponseti method has become the gold standard for the treatment of idiopathic clubfoot. Its safety and efficacy has been demonstrated extensively in the literature, leading to increased use around the world over the last two decades. This has been demonstrated by the increase in Ponseti related Pub Med publications from many countries. We found evidence of Ponseti activity in 113 of 193 United Nations members. The contribution of many organizations which provide resources to healthcare practitioners in low and middle income countries, as well as Ponseti champions and modern communication technology, have helped to spread the Ponseti method around the world. Despite this, there are many countries where the Ponseti method is not being used, as well as many large countries in which the extent of activity is unknown. With its low rate of complication, low cost, and high effectiveness,this method has unlimited potential to treat clubfoot in both developed and undeveloped countries. Our listing of countries who have not yet shown presence of Ponseti activity will help non-governmental organizations to target those countries which still need the most help.

Ponseti method compared with soft-tissue release for the management of clubfoot:A meta-analysis study

AIM: To compare the functional outcomes of patients who underwent open surgery vs Ponseti method for the management of idiopathic clubfoot and to determine whether correlations exist between functional outcome and radiographic measurements.METHODS: A meta-analysis of the literature was conducted for studies concerning primary treatment of patients with idiopathic clubfoot. We searched PubM ed Medline, EMBASE, and the Cochrane Library databases from January 1950 to October 2011. Meta-analyses were performed on outcomes from 12 studies. Pooled means, SDs, and sample sizes were either identified in the results or calculated based on the results of each study.RESULTS: Overall, 835 treated idiopathic clubfeet in 516 patients were reviewed. The average follow-up was 15.7 years. Patients managed with Ponseti method did have a higher rate of excellent or good outcome than patients treated with open surgery(0.76 and 0.62, respectively), but not quite to the point of statistical significance(Q = 3.73, P = 0.053). Age at surgery wasnot correlated with the functional outcome for the surgically treated patients(r =-0.32, P = 0.68). A larger anteroposterior talocalcaneal angle was correlated with a higher rate of excellent or good outcomes(r = 0.80, P = 0.006). There were no other significant correlations between the functional and radiographic outcomes.CONCLUSION: The Ponseti method should be considered the initial treatment of idiopathic clubfeet, and open surgery should be reserved for clubfeet that cannot be completely corrected.

TAZ and myostatin involved in muscle atrophy of congenital neurogenic clubfoot

BACKGROUND Muscular atrophy is the basic defect of neurogenic clubfoot.Muscle atrophy of clubfoot needs more scientific and reasonable imaging measurement parameters to evaluate.The Hippo pathway and myostatin pathway may be directly correlated in myogenesis.In this study,we will use congenital neurogenic clubfoot muscle atrophy model to verify in vivo.Further,the antagonistic mechanism of TAZ on myostatin was studied in the C2C12 cell differentiation model.AIM To identify muscle atrophy in fetal neurogenic clubfoot by ultrasound imaging and detect the expression of TAZ and myostatin in gastrocnemius muscle.To elucidate the possible mechanisms by which TAZ antagonizes myostatin-induced atrophy in an in vitro cell model.METHODS Muscle atrophy in eight cases of fetal unilateral clubfoot with nervous system abnormalities was identified by 2D and 3D ultrasound.Western blotting and immunostaining were performed to detect expression of myostatin and TAZ.TAZ overexpression in C2C12 myotubes and the expression of associated proteins were analyzed by western blotting.RESULTS The maximum cross-sectional area of the fetal clubfoot on the varus side was reduced compared to the contralateral side.Myostatin was elevated in the atrophied gastrocnemius muscle,while TAZ expression was decreased.They were negatively correlated.TAZ overexpression reversed the diameter reduction of the myotube,downregulated phosphorylated Akt,and increased the expression of forkhead box O4 induced by myostatin.CONCLUSION Ultrasound can detect muscle atrophy of fetal clubfoot.TAZ and myostatin are involved in the pathological process of neurogenic clubfoot muscle atrophy.TAZ antagonizes myostatin-induced myotube atrophy,potentially through regulation of the Akt/forkhead box O4 signaling pathway.

Factors associated with recurrence of clubfoot treated by the Ponseti method

AIM To assess several associated factors on the recurrence of clubfoot after successful correction by the Ponseti method. METHODS A total of 115 children with 196 clubfeet deformities, treated by the Ponseti method, were evaluated. Demographic data, family history of clubfoot in firstdegree relatives, maternal educational level and brace compliance were enquired. Based on their medical files, the characteristics of the patients at the time of presentation such as age, possible associated neuromuscular disease or especial syndrome, severity of the deformity according to the Dimeglio grade and Pirani score, residual deformity after previous Ponseti method and number of casts needed for the correction were recorded.RESULTS There were 83 boys(72.2%) and 32 girls(27.8%) with a male to female ratio of 2.6. The mean age at the initiation of treatment was 5.4 d(range: 1 to 60 d). The average number of casts applied to achieve complete correction of all clubfoot deformities was 4.2. Follow-up range was 11 to 60 mo. In total, 39 feet had recurrence with a minimum Dimeglio grade of 1 or Pirani score of 0.5 at the follow-up visit. More recurrence was observed in non-idiopathic clubfoot deformities(P = 0.001), noncompliance to wear braces(P < 0.001), low educational level of mother(P = 0.033), increased number of casts(P < 0.001), and more follow-up periods(P < 0.001). No increase in the possibility of recurrence was observed when the previous unsuccessful casting was further treated using the Ponseti method(P = 0.091). Also, no significant correlation was found for variables of age(P = 0.763), Dimeglio grade(P = 0.875), and Pirani score(P = 0.624) obtaining at the beginning of the serial casting. CONCLUSION Using the Ponseti method, non-idiopathic clubfoot, noncompliance to wear braces, low educational level of mother, increased number of casts and more followup periods had more association to possible increase in recurrence rate after correction of clubfoot deformity.

Lateral Intra-Articular Transposition of the Anterior Tibialis Tendon for the Treatment of Relapsed Clubfoot in Toddlers: A Previously Unreported Surgical Technique

Dynamic supination of the foot is a common residual deformity in children with clubfeet treated with the Ponseti method. Transfer of the anterior tibialis tendon (ATT) to the lateral cuneiform is an effective method for correcting this deformity when the cuneiform is ossified in children who are 3 to 5 years of age. We describe two cases of a previously unreported method of ATT transposition for correction of bilateral residual dynamic supination in a 26-month-old and a 19-month-old patient. Both patients presented shortly after birth with bilateral congenital idiopathic clubfoot and were initially treated with the Ponseti method. Both had residual deformity following initial treatment that included posterior contracture and metatarsus adductus with dynamic forefoot supination. This was surgically corrected with a posterior release and medial release of the 1st metatarsal/1st cuneiform joint. To correct dynamic supination, the ATT was transplanted laterally into the released midfoot joint. These two patients were followed post-operatively for 7.5 years and have correction of their residual deformity in both feet based on subjective functioning, appearance, range of motion, strength, and gait. Both have excellent lateral pull of their ATT, which functions as a strong foot dorsiflexor. No residual supination is present. This is the first report of lateral transposition of the ATT as an interposition graft at the released 1st metatarsal/1st cuneiform joint in patients with relapsed clubfoot. We suggest that this method should provide a high level of functioning in children with relapsed supination deformity and whose 3rd cuneiform has not yet ossified.

Ponseti method treatment of neglected idiopathic clubfoot:Preliminary results of a multi-center study in Nigeria

AIM To evaluate the effectiveness of the Ponseti method for initial correction of neglected clubfoot cases in multiple centers throughout Nigeria.METHODS Patient charts were reviewed through the International Clubfoot Registry for 12 different Ponseti clubfoot treatment centers and 328 clubfeet(225 patients) met inclusion criteria. All patients were treated by the method described by Ponseti including manipulation and casting with percutaneous Achilles tenotomy as needed.RESULTS A painless plantigrade foot was obtained in 255 feet(78%) without the need for extensive soft tissue release and/or bony procedures.CONCLUSION We conclude that the Ponseti method is a safe, effective and low-cost treatment for initial correction of neglected idiopathic clubfoot presenting after walking age. Longterm follow-up will be required to assess outcomes.

Mutation screening of muscle development genes in patients with idiopathic clubfoot

Background: Congenital idiopathic clubfoot is a very common musculoskeletal birth defect, but with no known etiology. Dietz et al. have shown possible linkage in chromosome 3 and 13 in a large, multigenerational family with congenital idiopathic clubfoot. Current evidence suggests that muscle development is impaired in patients with congenital idiopathic club-foot, therefore we hypothesized that mutations in genes related to muscle development could be associated with this deformity. From the areas identified in the linkage study, candidate genes SPRY2, RAF1, IQSEC1, LMO7, and UCHL3 were selected based upon their presence in skeletal muscle as well as their involvement in muscle development. Methods: The exons and splice sites of the five genes were screened via sequence-based analysis in a group of 24 patients with congenital idiopathic clubfoot. All single nucleotide polymorphisms (SNPs) found were compared to public databases to determine allelic frequency and amino acid modification. Results: While many SNPs were found, none proved to be significantly associated with the phenotype of congenital idiopathic clubfoot. The SNPs found were shown to be common amongst a non-clubfoot population and to follow the allelic frequency of the general population. Conclusions: Based upon these results, SPRY2, RAF1, IQSEC1, LMO7, and UCHL3 are not likely to be the major causes of congenital idiopathic clubfoot. Given the complexity of myogenesis, many other candidate genes remain that could cause defects in the hypaxial musculature that is invariably observed in congenital idiopathic club-foot. Clinical Relevance: This study further identifies genes which are unlikely to be the direct cause of congenital idiopathic clubfoot. It also helps to eliminate suspected genes found within the given bounds of chromosome 3 and 13.

Can immediate postoperative radiographs predict outcomes in pediatric clubfoot?

BACKGROUND The goal of treatment for pediatric idiopathic clubfoot is to enable the patient to comfortably walk on his or her soles without pain.However,currently accepted treatment protocols are not always successful.Based on the abnormal bone alignment reported in this disease,some studies have noted a correlation between radiographic characteristics and outcome,but this correlation remains debated.AIM To assess the correlation between immediately postoperative radiographic parameters and functional outcomes and to identify which best predicts functional outcome.METHODS To predict the outcome and prevent early failure of the Ponseti’s method,we used a simple radiographic method to predict outcome.Our study included newborns with idiopathic clubfoot treated with Ponseti’s protocol from November 2018 to August 2022.After Achilles tenotomy and a long leg cast were applied,the surgeon obtained a single lateral radiograph.Radiographic parameters included the tibiocalcaneal angle(TiCal),talocalcaneal angle(TaCal),talofirst metatarsal angle(Ta1st)and tibiotalar angle(TiTa).During the follow-up period,the Dimeglio score and functional score were examined 1 year after surgery.Additionally,recurring events were reported.The correlation between functional score and radiographic characteristics was analyzed using sample and multiple logistic regression,and the optimal predictor was also identified.RESULTS In total,54 feet received approximately 8 manipulations of casting and Achilles tenotomy at a mean age of 149 days.The average TiCal,TaCal,Ta1st,and TiTa angles were 75.24,28.96,7.61,and 107.31 degrees,respectively.After 12 mo of follow up,we found 66%excellent-to-good and 33.3%fair-to-poor functional outcomes.The Dimeglio score significantly worsened in the poor outcome group(P value<0.001).Tical and TaCal showed significant differences between each functional outcome(P value<0.05),and the TiCal strongly correlated with outcome,with a smaller angle indicating a better outcome,each 1 degree decrease improved the functional outcome by 10 percent.The diagnostic test revealed that a TiCal angle of 70 degrees predicts an inferior functional outcome.CONCLUSION The TiCal,derived from lateral radiographs immediately after Achilles tenotomy,can predict functional outcome at 1 year postoperatively,justifying its use for screening patients who need very close follow-up.

Functional physiotherapy method results for the treatment of idiopathic clubfoot

BACKGROUND Idiopathic clubfoot is a congenital deformity of multifactorial etiology.The initial treatment is eminently conservative;one of the methods applied is the Functional physiotherapy method(FPM),which includes different approaches:Robert Debré(RD)and Saint-Vincent-de-Paul(SVP)among them.This method is based on manipulations of the foot,bandages,splints and exercises adapted to the motor development of the child aimed to achieve a plantigrade and functional foot.Our hypothesis was that the SVP method could be more efficient than the RD method in correcting deformities,and would decrease the rate of surgeries.AIM To compare the RD and SVP methods,specifically regarding the improvement accomplished and the frequency of surgery needed to achieve a plantigrade foot.METHODS Retrospective study of 71 idiopathic clubfeet of 46 children born between February 2004 and January 2012,who were evaluated and classified in our hospital according to severity by the Dimeglio-Bensahel scale.We included moderate,severe and very severe feet.Thirty-four feet were treated with the RD method and 37 feet with the SVP method.The outcomes at a minimum of two years were considered as very good(by physiotherapy),good(by percutaneous heel-cord tenotomy),fair(by limited surgery),and poor(by complete surgery).RESULTS Complete release was not required in any case;limited posterior release was done in 23 cases(74%)with the RD method and 9(25%)with the SVP method(P<0.001).The percutaneous heel-cord tenotomy was done in 2 feet treated with the RD method(7%)and 6 feet(17%)treated with the SVP method(P<0.001).Six feet in the RD group(19%)and twenty-one feet(58%)in the SVP group did not require any surgery(P<0.001).CONCLUSION Our study provides evidence of the superiority of the SVP method over the RD method,as a variation of the FPM,for the treatment of idiopathic clubfoot.

Results of Ponseti Method in the Management of the Congenital Clubfoot

Background: Clubfoot is a debilitating pathology and a source of abnormal gait in children. Treatment with the Ponseti method is the treatment used in the management of congenital clubfoot in children under 9 years old. This study aims to identify the proportion of children with clubfoot supported by the Ponseti method and to evaluate their effectiveness. Materials and Method: A multicenter retrospective descriptive study for six (06) months from June 1st to November 30th, 2019 concerning the evaluation of the Ponseti method in the management of clubfoot in Madagascar was conducted. Results: One hundred ninety-one (191) children with club feet were screened during the study period. One hundred and fifty children, or 226 congenital equine varus clubfoot were treated with the Ponseti method during the study period. The male gender was the most affected compared to the female gender with a sex ratio of 1.75. The clubfoot was bilateral in 50.66% of cases and idiopathic in 92.66%. The initial Pirani score was on average (±SD) 5.04/4.98 (±1.22/1.20). A proportion of 23.33% of cases of recurrence was recorded at 3 months of use of brace abduction splint. Conclusion: In Madagascar, the incidence of congenital clubfoot remains relatively low but clubfoot is still the main limitation of walking and a lack of footwear in children. Ponseti method is the gold standard in the management of this pathology. However, it requires a long-term follow-up.

Treatment of Resistant Clubfoot with Soft Tissue Release and Alkhooly External Fixator

After the first research with this technique done by the first author, ten operations on the foot and ankle were performed on five patients (two boys and three girls) suffering from severe club foot deformity all with bilateral foot affection. Their ages ranged from five to fourteen years. All of them were treated by soft tissue release, skin flap (rotational flap), supplemented with Alkhooly external fixator. The follow up period ranged from two to seven years. The results according to Mittal (1987) [1] were excellent in eight feet (80%) and good in two feet (20%).

Prevalence and associated factors of clubfoot in the eastern province of Saudi Arabia: A hospital-based study

BACKGROUND Clubfoot,or congenital talipes equinovarus,is a widely recognized cause of disability and congenital deformity worldwide,which significantly impacts the quality of life.Effective management of clubfoot requires long-term,multidiscip-linary intervention.It is important to understand how common this condition is in order to assess its impact on the population.Unfortunately,few studies have investigated the prevalence of clubfoot in Saudi Arabia.AIM To determine the prevalence of clubfoot in Saudi Arabia via the patient population at King Fahad University Hospital(KFUH).METHODS This was a retrospective study conducted at one of the largest hospitals in the country and located in one of the most densely populated of the administrative regions.RESULTS Of the 7792 births between 2015 to 2023 that were included in the analysis,42 patients were diagnosed with clubfoot,resulting in a prevalence of 5.3 per 1000 live births at KFUH.CONCLUSION The observed prevalence of clubfoot was significantly higher than both global and local estimates,indicating a substantial burden in the study population.

Investigating clubfoot in Saudi Arabia: Prevalence, factors, and future directions

This editorial discusses the significant findings and implications of the study conducted by Alomran et al.This retrospective study,soon to be published,provides valuable insights into the epidemiology of and risk factors associated with clubfoot in a specific Saudi population.By highlighting the study’s key outcomes and discussing its broader implications for public health and clinical practices,this editorial aims to underscore the importance of continued research and targeted interventions in addressing congenital deformities such as clubfoot.

BMP/Smad信号通路与先天性马蹄内翻足模型大鼠足踝部的软骨发育

背景:先天性马蹄内翻足主要表现为骨本身异常及软骨发育异常,BMP/Smad信号通路可以指导胚胎期骨和软骨的发育,但其在马蹄内翻足病因领域发挥的作用尚无动物实验证实。目的:探讨BMP/Smad信号通路参与调控先天性马蹄内翻足模型大鼠足踝部软骨发育异常的机制。方法:将生长状况相同的孕10 d的SD大鼠随机分为实验组和对照组。实验组采用135 mg/kg维甲酸灌胃制作马蹄内翻足模型,对照组采用等量植物油灌胃;孕21 d后剖腹取出胎鼠,实验组孕鼠产下胎鼠41只中出现马蹄足畸形27只,畸型率65.9%;对照组获得胎鼠36只,均未出现畸形。分离胎鼠足踝部组织进行苏木精-伊红染色,并采用Western blot、RT-qPCR、免疫组化检测BMP/Smad信号通路核心蛋白Smad5、P-Smad5、通路下游蛋白SP7以及Sox9的表达水平。结果与结论:①与对照组相比,苏木精-伊红染色可见实验组大鼠足踝部组织中软骨基质增多,骨间缝隙增大;②免疫组化显示实验组Smad5与SP7表达水平下降,而Sox9基因表达增高;③RT-qPCR结果显示实验组大鼠足踝部组织中Smad5、SP7的mRNA表达水平下降,Sox9 mRNA表达水平升高;④Western blot结果显示实验组大鼠足踝部软骨组织中P-Smad5/Smad5及SP7表达降低,Sox9表达升高;⑤结果说明,先天性马蹄内翻足模型大鼠足踝部软骨异常的发生与BMP/Smad信号通路传导障碍有关。

先天性马蹄内翻足的遗传相关基因研究进展

先天性马蹄内翻足是一种影响双下肢肌肉、骨骼、结缔组织和血管或神经结构的先天性足畸形,其发病机制尚未明确。目前研究表明其主要与基因突变(HOXA和D、PITX1、TBX4、肌肉收缩基因)、环境因素等有关。该文综述先天性马蹄内翻足遗传相关基因的研究进展,以期为其的预防及治疗思路提供理论依据。

Are incidence and severity of clubfoot related to the season of birth?

Background:This study was designed to determine whether the occurrence of clubfoot follows a seasonal pattern in neonates from eastern and south-eastern China and to speculate the potential etiology of clubfoot.Methods:We reviewed 239 neonates with clubfeet during a period of 4 years as well as the monthly neonatal population of the Sixth National Population Census.Seasonal variations in terms of month of birth and severity were analyzed.Results:The incidence of clubfoot in neonates from eastern and south-eastern China showed seasonal variations,and the incidence was higher in autumn with a reference to the average birth rate in this corresponding area.No signifi cant difference was found in severity of clubfoot.Conclusion:This seasonal pattern is of signifi cant value to further understanding the etiology and pathogenesis of clubfoot in the corresponding area of China.

Subtalar dislocations:Mechanisms,clinical presentation and methods of reduction

Subtalar joint is a complex joint in hindfoot formed by the talus superiorly and the calcaneus and navicular inferiorly.Subtalar dislocations are high-mechanism injuries,which are caused by simultaneous dislocation of both talonavicular and talocalcaneal joints,without major fracture of the talus.They are usually classified as medial(most common),lateral,anterior and posterior dislocations,based on the position of foot in relation to talus and the indirect forces that have been applied to cause this significant injury.They are usually diagnosed by X rays,but computed tomography and magnetic resonance imaging can be used to identify associated intra-articular fractures and peri-talar soft tissue injuries respectively.Majority being closed injuries,can be managed in ED by closed reduction and cast immobilisation,but if they are open,have poor outcomes.Complications that ensue open dislocations are post-traumatic arthritis,instability and avascular necrosis.

胎儿不同程度足内翻的产前超声表现及妊娠结局分析

目的:观察胎儿不同程度足内翻的产前超声表现,探讨并分析其不同的妊娠结局。方法:对45例在江门市中心医院产前超声诊断为足内翻的胎儿足部进行二维超声扫查及三维超声成像,根据胎儿足部内翻程度进行评分,并对合并的结构异常进行归纳总结。追踪至产后或引产后,对不同妊娠结局进行分析。结果:45例超声诊断为足内翻病例中,0.5~1.0分有3例,产后均证实为假阳性病例;1.5~2.0分有13例,产后均证实为单纯足内翻;2.5~3.0分有15例,其中10例产后证实为单纯足内翻,5例合并不同程度的其他结构异常;3.5~4.0分有14例,均合并不同程度的其他结构异常。较常见的合并畸形类型有心血管畸形、肢体畸形、腹部结构异常及神经系统畸形,其中心血管畸形发生率最高。结论:产前对胎儿足内翻的超声评分与妊娠结局高度相关。通过对足内翻程度的量化评估及合并畸形的超声诊断,为产前诊断提供依据,并评估胎儿预后。