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The Evaluation of Deformity Correction in Idiopathic Clubfoot During Ponseti Casting Sessions: Two Scoring Methods Depicted Graphically

Volume 7 | Issue 2 | May-August 2021 | Page: 12-16 | Anil Agarwal, Prateek Rastogi

Authors: Anil Agarwal [1], Prateek Rastogi[2]

[1] Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, India.
[2] Department of Orthopedics, Sharda Medical College, Greater Noida, Uttar Pradesh, India.

Address of Correspondence
Dr. Anil Agarwal
4/103, East End Apartments, Mayur Vihar Ph-1 Ext., Delhi-110096, India.
E-mail: rachna_anila@yahoo.co.in


Abstract

Background
We graphically analyzed the correction of total Pirani and Dimeglio scores and their subcomponents at sequential casting sessions for children with idiopathic clubfeet.
Methods
Correction of scores at weekly sessions was represented graphically. The tenotomy effect was accounted for separately. We classified 1st to 3rd casts as early, 4th and 5th cast midlevel, and beyond 5 as final casts to describe casting treatment.
Results
A total of 88 clubfeet (34 bilateral) in 54 patients were studied. Both total Pirani and Dimeglio graphs were characterized by a steep fall in early casts; subsequent minimal improvement in midlevel and final casts; later marked correction with tenotomy. Equinus in both scores stood as the most resistant deformity, showed full correction only following tenotomy. Dimeglio graphs captured coupling of various foot motions better over early casts than Pirani graphs.
Conclusions
Both Pirani and Dimeglio scores can adequately guide caregivers to progressive deformity correction in clubfoot.
Keywords: Clubfoot, CTEV, Pirani, Dimeglio, Scores, Graphs


References

1. Staheli L. Clubfoot: Ponseti management. Seattle, WA: Global HELP; 2009.
2. Pirani S, Naddumba E, Staheli L. Ponseti Clubfoot management: Teaching manual for healthcare providers in Uganda. Seattle, WA: Global HELP; 2008.
3. Chaudhry S, Chu A, Labar AS, Sala DA, van Bosse HJ, Lehman WB. Progression of idiopathic clubfoot correction using the Ponseti method. J Pediatr Orthop B. 2012;21: 73-78.
4. Lampasi M, Trisolino G, Abati CN, Bosco A, Marchesini Reggiani L, Racano C, et al. Evolution of clubfoot deformity and muscle abnormality in the Ponseti method: evaluation with the Dimeglio score. Int Orthop. 2016;40:2199-2205.
5. Lampasi M, Abati CN, Stilli S, Trisolino G. Use of the Pirani score in monitoring progression of correction and in guiding indications for tenotomy in the Ponseti method: are we coming to the same decisions? J Orthop Surg (Hong Kong). 2017;25:2309499017713916
6. Agarwal A, Shanker M. Temporal variation of scores along the course of the Ponseti treatment in older children: A ready guide to progress of treatment. J Pediatr Orthop. 2020;40:246-250.
7. Pirani S, Outerbridge HK, Sawatzki B, et al. A reliable method of clinically evaluating a virgin clubfoot evaluation. In: Proceedings of the 21st SICOT World Congress, Sydney, Australia, 18-23 April 1999.
8. Diméglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop B. 1995;4:129-136.


How to Cite this Article:  Agarwal A, Rastogi P | The Evaluation of Deformity Correction in Idiopathic Clubfoot During Ponseti Casting Sessions: Two Scoring Methods Depicted Graphically |
International Journal of Paediatric Orthopaedics | May-August 2021; 7(2): 12-16.

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Should we Continue to Screen for Developmental Dysplasia of the Hip in Clubfoot? Our Experience and Review of the Literature

Volume 7 | Issue 2 | May-August 2021 | Page: 07-11 | Teixeira R, Ovídio J, Arcangelo J, Campagnolo J, Tavares D

Authors: Teixeira R [1], Ovídio J [2], Arcangelo J [2], Campagnolo J [2], Tavares D [2]

[1] Hospital São Francisco Xavier, Lisbon, Portugal.
[2] Hospital Dona Estefânia, Lisbon, Portugal

Address of Correspondence
Dr. Raquel Teixeira,
Rua dos Quartéis 80, r/c direito, 1300-483 Ajuda, Lisbon, Portugal.
E-mail: rt.corda@gmail.com


Abstract

Objective: The association between clubfoot and developmental dysplasia of the hip (DDH) remains uncertain, with only a few studies linking both. However, clubfoot is considered as a risk factor for DDH. The aim of this study was to determine the incidence of DDH and evaluate the need for routine hip imaging in our population of children with clubfoot.
Methods: Retrospective analysis of all patients treated for clubfoot in our center between 2010 and 2019. We included patients with hip imaging for DDH in the first 12 months of life.
Results: There were 108 children with clubfoot who underwent DDH screening. 92 had idiopathic clubfoot and 16 had syndromic clubfoot. Of the patients with idiopathic clubfoot, 2 (2.2%) had DDH; one had a clinically unstable hip and the other patient underwent hip screening on account of the clubfoot alone. Among patients with syndromic clubfoot, 3 (18.8%) had developmental dysplasia of the hip. Two of them had an abnormal hip examination while the other had normal hip clinical examination but other established risk factors for DDH.
Conclusion: A targeted ultrasound or radiological screening programme for DDH in idiopathic clubfoot diagnosed hip dysplasia in only 1 child that would have otherwise been missed by clinical examination alone. We conclude that hip imaging is not warranted in children with idiopathic clubfoot and regular clinical screening may suffice. In syndromic clubfoot, due to the higher incidence of DDH, we recommend specific ultrasound screening even in the presence of a normal hip examination.
Keywords: Clubfoot, Screening, Developmental dysplasia of the hip.


References

1. Westberry DE, Davids JR, Pugh LI. Clubfoot and developmental dysplasia of the hip: Value of screening hip radiographs in children with clubfoot. J Pediatr Orthop. 2003;23(4):503-507.
2. Dobbs MB, Gurnett CA. Update on clubfoot: Etiology and treatment. Clin Orthop Relat Res. 2009;467(5):1146-1153.
3. Pavone V, Chisari E, Vescio A, Lucenti L, Sessa G, Testa G. The etiology of idiopathic congenital talipes equinovarus: A systematic review. J Orthop Surg Res. 2018;13(1):1-11.
4. Silva C, Costa G. Importância da ecografia no rastreio e diagnóstico precoce da displasia do desenvolvimento da anca. Rev Port Ortop e Traumatol. 2013;21(2):147-163.
5. Chou DTS, Ramachandran M. Prevalence of developmental dysplasia of the hip in children with clubfoot. J Child Orthop. 2013;7(4):263-267.
6. French, L; Dietz F. Screening for developmental dysplasia of the hip. Am Fam Physician. 1999;60(1):177-184.
7. Gurnett CA, Boehm S, Connolly A, Reimschisel T, Dobbs MB. Impact of congenital talipes equinovarus etiology on treatment outcomes. Dev Med Child Neurol. 2008;50(7):498-502.
8. Sadler B, Gurnett CA, Dobbs MB. The genetics of isolated and syndromic clubfoot. J Child Orthop. 2019;13(3):238-244.
9. Werler MM, Yazdy MM, Mitchell AA, et al. Descriptive epidemiology of idiopathic clubfoot. Am J Med Genet Part A. 2013;161(7):1569-1578.
10. Mahan, Susan; Yazdy, Mahsa; Kasser, James; Werler M. Is it worthwhile to routinely ultrasound screen children with idiopathic clubfoot for hip dysplasia? J Pediatr Orthop. 2013;33(8).
11. Ömeroğlu H, Akceylan A, Köse N. Associations between risk factors and developmental dysplasia of the hip and ultrasonographic hip type: A retrospective case control study. J Child Orthop. 2019;13(2):161-166.
12. D’Alessandro M, Dow K. Investigating the need for routine ultrasound screening to detect developmental dysplasia of the hip in infants born with breech presentation. Paediatr Child Heal. 2019;24(2):E88-E93. d
13. Perry DC, Tawfiq SM, Roche A, et al. The association between clubfoot and developmental dysplasia of the hip. J Bone Jt Surg – Ser B. 2010;92 B(11):1586-1588.
14. Gomes S, Antunes S, Diamantino C, et al. Displasia de desenvolvimento da anca: seis anos de rastreio ecográfico a crianças de risco. Nascer e Crescer – Rev do Hosp Crianças Maria Pia. 2012;21(4):226-229.
15. Calonge N, Allan JD, Berg AO, et al. Screening for developmental dysplasia of the hip: Recommendation statement – US Preventive Services Task Force. Pediatrics. 2006;117(3):898-902.
16. Vaquero-Picado A, González-Morán G, Garay EG, Moraleda L. Developmental dysplasia of the hip: Update of management. EFORT Open Rev. 2019;4(9):548-556.
17. The H. Screening for the detection of congenital dislocation of the hip. Arch Dis Child. 1987;62(3):315-316.
18. Santos, L; Fonseca M. Protocolo de rastreio de displasia de desenvolvimento da anca (DDA). 2012
19. Wynne-Davies R, Littlejohn A, Gormley J. Aetiology and interrelationship of some common skeletal deformities. (Talipes equinovarus and calcaneovalgus, metatarsus varus, congenital dislocation of the hip, and infantile idiopathic scoliosis). J Med Genet. 1982;19(5):321-328.
20. Lochmiller C, Johnston D, Scott A, Risman M, Hecht JT. Genetic epidemiology study of idiopathic talipes equinovarus. Am J Med Genet. 1998;79(2):90-96.


How to Cite this Article:  Teixeira R, Ovídio J, Arcangelo J, Campagnolo J, Tavares D | Should We Continue to Screen for Developmental Dysplasia of the Hip in Clubfoot? Our Experience and Review of the Literature | International Journal of Paediatric Orthopaedics | May-August 2021; 7(2): 07-11.

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Comparison of Standard and Accelerated Ponseti Technique in the Treatment of Idiopathic Clubfoot at a Regional Orthopaedic Hospital in Nigeria

Volume 7 | Issue 1 | January-April 2021 | Page: 10-15 | Anikwe I.A, Lasebikan O.A, Enweani U.N

Authors: I. A. Anikwe MBBS, FMC Ortho. [1], O. A. Lasebikan MBCHB, MPH, MBA, FWACS, FMC Ortho, FICS [2],
U. N. Enweani MBBS, FMCS, FMCOrtho, FWACS, FICS [3]

[1] Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria.
[2] Department of Orthopaedics, National Orthopedic Hospital, Enugu, Nigeria.
[3] Consultant Orthopedic Surgeon, City Hospital Enugu, Nigeria.

Address of Correspondence
Dr. Omolade. A. Lasebikan,
Department of Orthopaedics, National Orthopedic Hospital, Enugu, Nigeria.
Email: ladelash@yahoo.com


Abstract

Introduction: Congenital clubfoot is a developmental deformity of the foot. Management by the Ponseti method has been shown to be produce better results with fewer complications than traditional surgical methods. Some studies have shown that shorter intervals of serial manipulation/casting provide similar outcome to standard Ponseti technique. This study compared management outcome using an accelerated twice weekly technique, with standard weekly Ponseti casting.
Methodology: A prospective comparative study was conducted involving 62 patients with 90 clubfeet. From the study, 48 clubfeet in 34 patients were managed with standard Ponseti technique (weekly manipulation and casting), while 42 clubfeet in 28 patients were managed with accelerated Ponseti technique (twice weekly manipulation and casting). Pirani score was used for initial assessment and for follow-up.
Results: Children were 1 month to 36 months of age at the time of commencement of treatment. Majority of patients were male, (63%). The average number of casts did not differ significantly between the treatment groups (p = 0.13). The accelerated Ponseti technique patients were therefore able to complete their treatment within a significantly shorter period than those who went through the standard Ponseti protocol. The standard group had mean duration of correction of 29.65±11.69 days and 12.36±5.45 days for the accelerated group (p<0.001). The episodes of early relapses were 2.1% in the standard group and 2.4% in the accelerated group. The rates of complications were comparable between the groups.
Conclusion: Treatment of congenital clubfeet using the twice weekly casting appears to provide comparable outcomes to the weekly Ponseti casting with a significant reduction in the duration of the casting phase.
Keywords: Clubfoot; Pirani score; Ponseti technique; Accelerated.


References 

1. Morrissy RT, Weinstein SL. Clubfoot (Congenital Talipes Equinovarus) Lovell and Winter’s Paediatric Orthopaedics, 6th edition, Lippincott Williams and Wilkins, Philadelphia, 2006; 1262-1273.
2. Bridgens J, Kiely N. Current Management of Clubfoot (Congenital Talipes Equinovarus). British Medical Journal, 2010; 340: 308-311.
3. Dobbs MB, Gurnett CA. Update on Clubfoot: Etiology and Treatment. Clin Orthop Relat Res, 2009; 467(5) 1146-1153.
4. Solomon L, Warwick D. Congential Talipes Equinovarus (Idiopathic Clubfoot). Apley’s System of Orthopaedics and Fractures, 9th ed, Hodder Arnold, an Hachette UK company, London, 2010; 591-595.
5. Kampa R, Binks K, Dunkley M, Coates C. Multidisciplinary Management of Clubfeet Using the Ponseti method in a District General Hospital Setting. Journal of child Orthopaedics, 2008; 2:463-467.
6. Dobbs MB, Nunley R, Schoenecker PL. Long-Term Follow-up of Patients with Clubfeet Treated with Extensive Soft Tissue Release. J Bone Joint Surg (Am), 2006; 88:986-996.
7. Siapkara A, Duncan R. Congenital Talipes Equinovarus: A review of Current Management. J Bone Joint Surg (Br), 2007; 89-B: 995-1000.
8. Dyer PJ, Davis N. The Role of the Pirani Scoring System in the Management of Clubfoot by the Ponseti Method. J Bone joint Surg (Br), 2006; 88-B: 1082-1084.
9. Herzenberg JE, Radler C, Bor N. Ponseti versus Traditional Methods of Casting for Idiopathic Clubfoot. J Pediatr Orthop, 2002; 22:517-521.
10. Ponseti IV. Common Errors in the Treatment of Congential Clubfoot. International orthopaedic (SICOT), 1997; 21:137-141.
11. Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an Accelerated Ponseti Protocol for Cubfoot. J Pediatr Orthop, 2005;25:623-626.
12. Ponseti IV. Current concepts review: Treatment of Congenital Clubfoot. J Bone Surg, Inc, 1992; 74-A: 448-454.
13. Cosma D, Vasilescu D, Vasilescu D, Valeanu M. Comparative results of the conservation Treatment in Clubfoot by two different protocol. J Pediat. Orthop B, 2007; 16:317-321
14. Ukoha U, Egwu OA, Okafor IJ, Ogugua PC, Udemezue OO, Olisah R et al. Incidence of congenital talipes equinovarus among children in Southeast Nigeria. Int. J. Biol Med. Res. 2011; 2(3): 712-715.
15. Adewole OA, Williams OM, Kayode MO, Shoga MO, Giwa SO. Early Experience with Ponseti Clubfoot Management in Lagos, Nigeria. East Cent.Afri.J.surg. 2014; 19(2): 72-77.
16. Harnett P, Freeman R, Harrison WJ, Brown LC, Beckles. An Accelerated Ponseti versus standard Ponseti method: A Prospective Randomized Controlled Trial. J Bone Joint Surg B. 2011; 93(3): 404-408.
17. Sharma P, Yadav V, Verma R, Gohiya A, Gaur S. Comparative Analysis of Results Between Conventional and Accelerated Ponseti Technique for Idiopathic Congenital Clubfoot. OrthopJMPC 2016;22(1):3-7.
18. Elgohary HAS, Abulsaad M. Traditional and accelerated Ponseti technique: a comparative study. Eur J Orthop Surg Traumatol. 2015.
19. Ibraheem GH, Adegbehingbe OO, Babalola OM, Agaja SB, Ahmed BA, Olawepo A et al. Evaluation of an Accelerated Ponseti protocol for the treatment of Talipesequinovarus in Nigeria. East Cent.Afr.J.surg. 2016;22(1): 28-38.
20. Changulani M, Garg NK, Rajagopal TS, Bass A, Nayagam SN, Sampath J et al. Treatment of Idiopathic Clubfoot using Ponseti Method: Initial experience. J Bone Joint Surg Br. 2006;88-B: 1385-1387.
21. Xu RJ. A modified Ponseti method for the treatment of idiopathic clubfoot: A preliminary report. J PediatrOrthop. 2011; 31: 317-319.


How to Cite this Article: Anikwe I.A, Lasebikan O.A, Enweani U.N | Comparison of Standard and Accelerated Ponseti Technique in the Treatment of Idiopathic Clubfoot at a Regional Orthopaedic Hospital in Nigeria | International Journal of Paediatric Orthopaedics | January-April 2021; 7(1): 10-15.

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The Role of Pirani Scoring in Predicting the Frequency of Casting and the Need for Percutaneous Achilles Tenotomy in the Treatment of Idiopathic Clubfoot Using the Ponseti Method

Volume 4 | Issue 2 | July-December 2018 | Page: 15-19 | Chukwuemeka O. Anisi, Joseph E. Asuquo, Innocent E. Abang, Michael E. Eyong, Onyebuchi G. Osakwe, Ngim E. Ngim

DOI- 10.13107/ijpo.2018.v04i02.013


Authors: Chukwuemeka O. Anisi, Joseph E. Asuquo, Innocent E. Abang, Michael E. Eyong [1], Onyebuchi G. Osakwe, Ngim E. Ngim

Departments of Orthopaedics and Traumatology, University of Calabar, Cross River State, Nigeria. [1] Departments of Paediatrics, University of Calabar, Cross River State, Nigeria.

Address of Correspondence
Dr. Chukwuemeka Okechukwu Anisi,
Department of Orthopaedics and Traumatology, University of Calabar Teaching Hospital, PMB 1278-Calabar, Cross River State, Nigeria.
E-mail: iall4him@yahoo.co.uk


Abstract

Background: The Pirani scoring system is a simple tool widely used for grading the severity of clubfoot. This study was designed to objectively assess its value in predicting the total number of casts required, and the need for percutaneous Achilles tenotomy to achieve correction of the idiopathic clubfoot treated by the Ponseti method. Patients and Methods: All patients with idiopathic clubfoot, who attended our clubfoot clinic between January, 2013 and December, 2015, were prospectively studied. Each clubfoot was scored at presentation and at each visit by the first and second authors, using the Pirani scoring system. All patients were treated by the first and second authors by weekly stretching and cast application following the Ponseti treatment protocol until correction was achieved (with or without percutaneous Achilles tenotomy). Chi-square tests were applied to establish any existing relationship between the Pirani scores and the need for percutaneous tenotomy as well as the number of casts required to achieve correction.
Results: A total of 69 patients with 108 idiopathic clubfeet wer recruited into the study. In that, 14 patients defaulted, leaving the study with 81 clubfeet belonging to 55 patients. The median total Pirani score (TPS), midfoot contracture score and hindfoot contracture score at presentation were 4.0, 2.0 and 2.0, respectively. A total of 57 (70.4%) feet required percutaneous Achilles tenotomy to achieve correction. The average number of casts (including casts after tenotomy) required to achieve correction was 4.9 (2–10). The average number of casts required to achieve correction was 4.1 (2–10) for the no tenotomy group and 5.4 (3–10) for the tenotomy group. Statistically significant relationship was established between the TPS and number of casts required to achieve correction for both the tenotomy group (P=0.039) and no tenotomy group (P=0.05).
Conclusion: High Pirani scores were associated with increased number of casts and percutaneous Achilles tenotomy for the correction of idiopathic clubfoot using the Ponseti method.
Keywords: Achilles tenotomy, clubfoot, idiopathic, Pirani scoring system, Ponseti method


References 

1. Solomon L,Warwick D, Selvadurai N.Appley’s Systemof Orthopaedics and Fractures. 9th ed. London: Hodder Arnold; 2010. p. 591-5.
2. Canale ST, Beaty JH. Congenital anomalies of the lower limb. Campbell’s Operative Orthopaedics. 11th ed. Philadelphia: Mosby Elsevier 2007. p. 937-55.
3. Ngim NE, Okokon E, Ikpeme IA, Udosen MA, Iya J. Profile of congenital limb anomalies in Calabar. Asian J Med Sci 2013;4:58-61.
4. Adewole AO, Giwa SO, Kayode MO, Shoga MO, Balogun RA. Congenital clubfoot in a teaching hospital in Lagos, Nigeria. Afr J Med Sci 2009;38:203-6.
5. Omololu B, Ogunlade SO, Alonge TO. Pattern of congenital orthopaedic malformations in an African Teaching Hospital. West Afr J Med 2005;24:92-5.
6. Adewole AO, Williams OM, Kayode MO, Shoga MO, Giwa SO. Early experience with Ponseti clubfoot management in Lagos, Nigeria. East Cent Afr J Surg 2014;19:72-7.
7. Ponseti IV. Current concept review. Treatment of congenital clubfoot. J Bone Joint Surg 1992; 74:448-54.
8. Sud A, Tiwari A, Sharma D, Kapoor S. Ponseti’s vs Kite’s methods in the treatment of clubfoot − A prospective randomized study. Int Orthop 2008;32:409-13.
9. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80.
10. Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J Pediatr Orthop 2005; 25:623-6.
11. Adegbehingbe OO, Oginni LM, Ogundele OJ, Ariyibi AL, Abiola PO, Ojo OD. Ponseti clubfoot management: Changing surgical trends in Nigeria. Iowa Orthop J 2010;30:7-14.
12. Ponseti IV. Current concept review. Treatment of congenital clubfoot. J Bone Joint Surg 1992;74:448-54.
13. Pirani S, Outerbridge H, Moran M. Method of evaluating the virgin clubfoot with substantial interobserver reliability. Presented at the annual meeting of the Pediatric Orthopaedic Society of North America, Miami, FL, 1995.
14. Dimeglio A, Bensahel H, Souschet P. Classification of clubfoot. J Pediatr Orthop 1995;3:129.
15. Adegbehingbe OO, Asuquo JE, Mejabi OJ, Alzahrani M, Morcuende JA. The heel pad in congenital idiopathic clubfoot: Implications for empty heel for clinical severity assessment. Iowa Orthop J 2015; 35:169-74.
16. Haft GF, Walter CG, Crawford HA. Early clubfoot recurrence after use of the Ponseti method in a New Zealand population. J Bone Joint Surg Am 2007;89:487-93.
17. Boehm S, Limpaphayom N, Alaee F, Sinclair MF, Dobbs MB. Early result of the Ponseti treatment of clubfoot in distal athrogryposis. J Bone Joint Surg Am 2008;90:1501-7.
18. Janicki JA, Narayanan UG, Harvey BJ, Roy A, Weir S, Wright JG. Comparison of surgeon and physiotherapist-directed Ponseti treatment of idiopathic clubfoot. J Bone Joint Surg Am 2009;91:1101-8.
19. Porecha MM, Parmar DS, Charda HR. Midterm results of Ponseti method for the treatment of congenital idiopathic clubfoot. J Ortho Surg Res 2011;6:3.
20. Rijal R, Shrestha BP, Singh GK, Singh M, Nepal P, Khanal GP, et al. Comparison of Ponseti’s and Kite’s methods of treatment of idiopathic clubfoot. Indian J Orthop 2010;44:202-7.
21. Morcuende JA, Dobbs MB, Frick SL. Results of the Ponseti method in patients with clubfoot associated with athrogryposis. Iowa Orthop J 2008;28:22-6.
22. Scher DM. The Ponseti method of treatment of clubfoot. Curr Opin Pediatr 2006;18:22-8.
23. Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfoot. J Bone Joint Surg Am 2004;86:22-7.
24. Flynn JM, Donohoe M, McKenzie WG. An independent assessment of two clubfoot classification systems. J Pediatr Orthop 1998;18:223.
25. Scher DM, Feldman DS, van Bosse HJ. Predicting the need for tenotomy in the Ponseti method for correction of clubfoot. J Pediatr Orthop 2004;24:349.
26. Dyer PJ, Davis N. The role of the Pirani scoring system in the management of club foot by the Ponseti method. J Bone J Surg Br 2006;88:1082-4.
27. BorN,Coplan JA,Herzenberg JE.Ponseti treatment for idiopathic clubfoot: Minimum 5-year follow up. Clin Orthop Relat Res 2009;467:1263-70.


How to Cite this Article:  Anisi CO, Asuquo JE, Abang IE, Eyong EM, Osakwe OG, Ngim E | The Role of Pirani Scoring in Predicting the Frequency of Casting and the Need for Percutaneous Achilles Tenotomy in the Treatment of Idiopathic Clubfoot Using the Ponseti Method | July-December 2018; 4(2): 15-19.

 


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Predicting the Need for Tenotomy in the Management of Idiopathic Clubfoot by the Ponseti Method

Volume 4 | Issue 2 | July-December 2018 | Page: 11-14 | Ranjit V. Deshmukh, Aditi A. Kulkarni

DOI- 10.13107/ijpo.2018.v04i02.012


Authors: Ranjit V. Deshmukh, Aditi A. Kulkarni [1]

 

Departments of Orthopedics, [1] Research, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India.

Address of Correspondence
Dr. Ranjit V. Deshmukh,
Department of Orthopedics, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune − 411 004, Maharashtra, India.
E-mail: drranjitdeshmukh@gmail.com


Abstract

Purpose: The aim of this study was to determine the role of Pirani scoring system for predicting the treatment of idiopathic clubfoot with the Ponseti technique.
Materials and Methods: A retrospective study was conducted. The records of 132 idiopathic clubfeet of patients treated by the Ponseti method and scored by the Pirani system between May 2007 and September 2015 were analyzed.
Result: Of the 132 feet, 101 (76.5%) feet of the patients required tenotomy. The mean number of casts required was significantly higher (P=0.033) for the group that required tenotomy (5.53 ± 1.6 casts) than the group that did not require tenotomy (4.87 ± 0.9 casts).
Conclusion: The initial Pirani score is predictive of the number of casts that may be required and the need for a tenotomy of the Achilles tendon.
Keywords: Casting, Clubfoot, Congenital talipes equinovarus, Pirani scoring, Ponseti, Tenotomy


References 

1. Chotel F, Parot R, Durand JM, Garnier E, Hodgkinson I, Berard J. Initial management of congenital varus equinus clubfoot by Ponseti’s method. Rev Chir Orthop Reparatrice Appar Mot 2002;88:710-7.
2. Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg Am 2004;86:22-7.
3. ColburnM,Williams M. Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method. J Foot Ankle Surg 2003;42:259-67.
4. Herzenberg JE, Radler C, Bor N. Ponseti versus traditional methods of casting for idiopathic clubfoot. J Pediatr Orthop 2002;22:517-21.
5. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80.
6. Ponseti IV, Smoley EN. The classic: Congenital club foot: The results of treatment. 1963. Clin Orthop Relat Res 2009;467:1133-45.
7. Ponseti IV. Treatment of congenital club foot. J Bone Joint Surg Am 1992;74:448-54.
8. Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up note. J Bone Joint Surg Am 1995;77:1477-89.
9. Pirani S, Outbridge HK, Sawatzky B, Stothers K. A reliable & valid method of assessing the amount of deformity in the virgin congenital clubfoot deformity. 21st SICOT Congress, 1999.
10. Wainwright AM, Auld T, Benson MK, Theologis TN. The classification of congenital talipes equinovarus. J Bone Joint Surg Br 2002;84:1020-4.
11. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am 1980;62:23-31.
12. Radler C. The Ponseti method for the treatment of congenital club foot: Review of the current literature and treatment recommendations. Int Orthop 2013;37:1747-53.
13. Dyer PJ, Davis N. The role of the Pirani scoring system in the management of club foot by the Ponseti method. J Bone Joint Surg Br 2006;88:1082-4.
14. Scher DM, Feldman DS, van Bosse HJ, Sala DA, Lehman WB. Predicting the need for tenotomy in the Ponseti method for correction of clubfeet. J Pediatr Orthop 2004;24:349-52.
15. Porecha M, Parmar D. The predictive value of Pirani scoring system in the management of idiopathic club foot by Ponseti method. Int J Orthop Surg 2008;11:1-4.
16. Goriainov V, Judd J, Uglow M. Does the Pirani score predict relapse in clubfoot? J Child Orthop 2010;4:439-44.
17. Bhaskar A, Patni P. Classification of relapse pattern in clubfoot treated with Ponseti technique. Indian J Orthop 2013;47:370-6.
18. Chandrakanth U, Sudesh P, Gopinathan N, Prakash M, Goni VG. Tarsal bone dysplasia in clubfoot as measured by ultrasonography: Can it be used as a prognostic indicator in congenital idiopathic clubfoot? A prospective observational study. J Pediatr Orthop 2016;36: 725-9.
19. Chu A, Labar AS, Sala DA, van Bosse HJ, Lehman WB. Clubfoot classification: Correlation with Ponseti cast treatment. J Pediatr Orthop 2010;30:695-9.
20. Agarwal A, Gupta N. Does initial Pirani score and age influence number of Ponseti casts in children? Int Orthop 2014;38:569-72.


How to Cite this Article:  Deshmukh RV, Kulkarni AA | Predicting the Need for Tenotomy in the Management of Idiopathic Clubfoot by the Ponseti Method | July-December 2018; 4(2): 11-14.

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Treatment of Neglected and Relapsed Clubfoot with Midfoot Osteotomy: A Retrospective Study

Vol 1 | Issue 1 | July-Sep 2015 | page: 38-43 | Ruta M Kulkarni, Anurag Rathore, Rajeev Negandhi,  Milind G Kulkarni, Sunil G Kulkarni, Arpit Sekhri.


Authors : Ruta M Kulkarni[1], Anurag Rathore[1], Rajeev Negandhi[1],  Milind G Kulkarni[1], Sunil G Kulkarni[1], Arpit Sekhri[1].

[1] Dept. of Orthopaedics, Post Graduate Institute of Swasthiyog Pratishthan, Miraj, Maharashtra.

Address of Correspondence
Dr Anurag Rathore
Dept. of Orthopaedics, Post Graduate Institute of Swasthiyog Pratishthan, Miraj, Maharashtra, India.
Email:rathore.anurag18@gmail.com


Abstract

Background: Neglected and residual clubfoot deformities in older children is a difficult surgical problem as the foot in these patients is stiff with some amount of pain and almost always had already undergone some surgical intervention. Basic aim of foot surgeries in such cases is to achieve painless functional plantigrade foot. In this study, a percutaneous dorsolateral closing wedge midfoot osteotomy with correction of angulation and translation deformity was done fixed with k-wires or ilizarov frame. Additional procedures like plantar fascia release and Achilles lengthening procedures were done for associated deformities as required. The aim of this study is to evaluate outcome of the proposed surgical procedure in correction of complex clubfoot deformities.
Methods: Our centre is a tertiary care orthopaedic hospital. A total of 25 patients [32 feet] were included in this retrospective study done from august 2009 to august 2014. Patient aged 5-12 years were selected for the surgical procedure. All the patients were followed up at least up to 18 months after surgery. Both preoperative and postoperative evaluation of patients done clinically, with help of dimeglio score, and radiologically.
Results: Follow up period ranged from 18-30 months. Clinical and radiographic improvement was achieved in all the patients. Dimeglio score improved from 10.63 to 2.93 which denotes good result. All radiographic angles showed correction to near normal values. All the patient showed pain relief and optimal function at 18 month follow-up.
Complications in form of pin tract infection, under correction and skin problems were noted in three, three and five patients respectively.
Conclusion: A percutaneous dorsolateral closing wedge osteotomy in combination with plantar fascia release and Achilles tenotomy is a good alternative procedure for neglected and recurrent clubfoot deformities with minimal complications. This is a joint sparing surgical technique which preserves ankle and foot flexibility.
Keywords: Relapsed, neglected, clubfoot, midfoot osteotomy, dimeglio score.


Introduction
The four basic components of clubfoot are cavus, adduction, varus, and equinus.  Successful correction of clubfoot deformity generally is reported in more than 90% of children two years and younger treated with Ponseti casting even after previous unsuccessful non-operative treatment [1]. Neglected clubfoot include feet that had not been treated in the past and relapsed clubfoot included feet that had undergone one or more surgical procedures but still had deformity [2].  Neglected or relapsed clubfoot deformity remains a major congenital disability in children and adults in developing nations [3]. Approximately 25% of operated clubfeet recur or have marked residual deformity, mainly owing to insufficient primary treatment [4]. The less is sufficient the intervention, the more severe is the relapse or residual deformity [5]. Multiple soft-tissue or bony operations often result in a stiff and painful foot in relapsed clubfoot patients.. These children face difficulties in walking long distances, playing games and carrying out routine daily activities. They are also prone to get repeated wounds at callosities formed over dorsum and lateral border of foot due to inability to wear normal footwear (figure 1 & 2).

fIGURE 1, 2

The goal of management in such patients is to obtain a plantigrade, painless, and functional foot. The patient should be able to use normal footwear at the end of treatment [6]. Numerous soft tissue procedures [releases, tendon lengthening, tendon transfer and redressment by means of an external fixator] and osseous interventions [osteotomies, arthrodesis] have been discussed in the literature which can be used according to “ala cart” approach. Yet, there are no clear guidelines for the surgical management of relapsed clubfoot [7-10]. Extensive soft tissue releases in such relapsed and neglected cases often lead to wound healing problems and persistent deformities whereas procedures like triple arthrodesis is associated with stiffness and ankle arthritis as early as three years postoperatively [11]. Talectomy is associated with a high incidence of Hind foot recurrence, pain, and spontaneous bony ankyloses in the tibio-tarsal joint [12]. We have performed a percutaneous dorsolateral closing wedge midfoot osteotomy along with additional procedures like steindler release, posterior soft tissue release and tendoachilles lenthening as required to correct various clubfoot deformities in neglected and relapsed cases. The osteotomies were either fixed internally with help of k-wires or fixed externally with ilizarov. Ilizarov used mostly in patients having rigid hind foot varus deformity. The aim of this study is to evaluate the clinical and radiological outcome of the proposed surgical technique in correcting the various deformities in neglected and relapsed cases of clubfoot.

Materials and methods
This is a retrospective study conducted at tertiary level orthopaedic hospital. A total of 25 patients with 32 affected foot were included in this study done between august 2009 to august 2014. The patients selected with age more than five years having neglected and relapsed clubfoot deformities including both idiopathic and syndromic varieties. Patients excluded were above 12 years of age or those who were medically unfit for surgery. Approval for the study was given by ethical committee of the institute and informed consent was obtained from all the patients. Data were collected in a predesigned proforma which included detailed history obtained from the informants of the patient including the birth history, developmental history, family history and history of any previous surgery. On clinical examination, the foot was examined to note all the deformities that were present and the rigidity of foot was also examined based on the maximum possible correction achieved by manipulation. It was also determined that whether the rigidity is due to soft tissue tightness or defect in skeletal architecture of foot. The cavus was examined to establish the apex of the deformity. Using the Coleman Block Test, the flexibility of the heel varus was checked. Based on patients clinical examination, a preoperative dimeglio scoring [13] of all the affected foot was done.
Dimeglio classification includes scoring of varus , equinus , derotation of calcaneopedal block and adduction on the scale of 0 to 4 according to severity of deformity. Additional 1 point assigned each for posterior crease , medial crease , Cavus and poor muscle condition. Score of <5 denotes benign, 5-9 is moderate, 10-14 is severe and 15-20 is very severe deformity. AP and weight bearing lateral x-rays of the foot with ankle were taken, also lateral x-ray of foot with ankle is taken in maximum possible dorsiflexion. Talus-1st metatarsal angle and talo-calcaneal angle for adduction, meary’s and hibb’s angle for cavus, tibio-calcaneal angle for equinus were measured preoperatively in all the affected foot.  The patients were evaluated postoperatively for dimeglio score and various radiographic angles. The follow up visits were scheduled at 1st month, 2nd month, 3rd month, 6th month and thereafter at six monthly intervals. Patients were also evaluated clinically for wound condition, position of foot, ankle ROM, neurovascular status of foot and radiologically for union, position of implant and alignment.
Surgical technique: The patient is placed in supine position on a radiolucent table after administering anaesthesia. Tourniquet is inflated after exsanguinating the limb. Local parts are cleaned, painted and draped. Steindler’s release is performed in a percutaneous fashion. Posterior soft tissue release and tendoachilles z-plasty done in few cases with severe equinus. Transverse incision is taken over the cuboid (Fig 3A) and subcutaneous dissection is done. Abductor digiti minimi muscle is encountered at the lower part of cuboid which is retracted away. Two K-wires are inserted, one through distal end of cuboid and second through proximal end of cuboid under IITV guidance (Fig 3B & 3C). The wires are within the cuboid without compromising the distal or proximal articulation of the cuboid. Both the wires are advanced from the dorsolateral aspect of the foot till the medial border of medial cuneiform where they meet. Using an osteotome and mallet, the osteotomy is performed between the k wires (figure 3D & 3E). The wedge is removed with a rongeur. The osteotomy is closed dorsolaterally along with some translation and confirmed with IITV (figure 3F). The osteotomy is fixed with two K-wires through the cuboid (figure 3G) and confirmed under IITV (figure 3H & 3I). In cases where osteotomy could not be completed through lateral incision, it is done through small incision medially over medially cuneiform. In complicated deformities or severe contracture external fixation with Ilizarov foot and ankle frame is done and gradual correction is obtained. The skin incision is closed with ethilon. Tourniquet deflated and sterile dressing is done and below-knee splint in corrected position is given. Postoperative management: Three days of intravenous antibiotics are given along with an epidural for pain relief. A well-padded below knee non weight bearing cast is applied as soon as oedema subsides and the wound is healthy. If associated procedure requires, then above knee cast is applied. Patients are discharged on the fourth or fifth postoperative day and nonweight bearing is advised for six weeks. After six weeks, the Kirschner-wires and cast are removed, and a below knee weight bearing cast applied which is removed after one month and plastic molded ankle-foot orthosis is applied to be worn for six months.

Figure 3, 4
Statistical methods:
Statistical analysis was done by using Microsoft Excel and SPSS-22.
Means and standard deviation score were obtained. Paired t-test was used to compare the mean of preoperative and postoperative values.

Figure 5

Results
A total of 25 children [32 feet] were available for final evaluation. Seven children had bilateral deformity and 18 had unilateral deformity. Among 25 children, 4 [7 feet] were of the neglected type and 21 [25 feet] were of the relapsed type. The age at surgery ranged from 5-12 years with a mean age of 8.16 years [S.D. = 2.05]. The follow-up period ranged from 18-30 months. There were 11 boys and 14 girls. Osteotomy site was fixed with k-wires in 22 patients [28 feet] and with ilizarov in 3 patients [4 feet].
Preoperative Evaluations- of the 32 feet, 6 feet were classified as grade IV, 8 feet were grade III, 15 were grade II and 3 were grade I Dimeglio deformity. The mean preoperative Dimeglio score was 10.63 [S.D. =4.086] which comes under grade III deformity.
Mean preoperative talus-1st metatarsal angle, tibiocalcaneal angle, meary’s angle, hibb’s angle and talocalcaneal angle were -7.59˚, 69.94˚, 5.94˚, 137.53˚ and 10.16˚ respectively.
Follow up Evaluations at one year- Of the 32 feet, 27 feet improved to grade I, 2 feet were grade II and 3 feet were grade III. The mean postoperative Dimeglio score was 2.97 [S.D. =2.868].
Mean postoperative talus-1st metatarsal angle, tibiocalcaneal angle, meary’s angle, hibb’s angle and talocalcaneal angle were 8.53˚, 43.63˚, 1.66˚, 153.78˚ and 34.34˚ respectively.
All the patient showed improvement in clinical and radiological scores (Fig 4) at one year follow up, quantitated with preoperative and postoperative evaluations which proved highly significant statistically (table 2 & 3). All patients noted significant improvement in appearance of feet (Fig 5) and ease in fitting into shoes and were pain free. Union at osteotomy site occurred at an average of 5 weeks.
Complications: Out of 32 feet, 3 developed pin tract infection which resolved with antibiotic treatment, 5 feet had wound healing problem due to previous callosities in neglected cases which healed with regular dressing and 3 feet found with under correction which required revision surgery.
There was no reduction noted in ankle range of motion in any of the case treated With k wires.

table 1

Table 1: Comparison of preoperative and postoperative clinical scores


 

Table 2: Comparison of preoperative and postoperative radiological scores

Table 2: Comparison of preoperative and postoperative radiological scores

Discussion
Residual and recurrent clubfeet deformities are a difficult problem. Feet are stiff and have usually been operated at least once. Traditionally, treatment of stiff clubfoot deformities included extensive soft-tissue release in younger children and osteotomies in older patients. Nearly all patients with severe residual clubfoot [most of our patients] already underwent at least 1 soft-tissue release. Therefore, there is little hope that another release will dramatically improve the situation. Tendon transfer can improve only dynamic deformity and is contraindicated for correcting stiff deformities [14]. Acute osteotomy correction can be a powerful method of correction [15]. The closing wedge osteotomies of Cole basically provided uniplanar correction with very minimal biplanar correction [16]. Jahss created an osteotomy distal to the usual apex of deformity [17]. Japas developed a V-shaped osteotomy that was located near the apex of the deformity but was limited in the degree of multiplanar correction by the ‘V’ limbs of the osteotomy [18]. Akron dome midfoot osteotomy addresses the center of the deformity and provides multidirectional correction [19]. Wicart and Seringe proposed a Plantar Opening-Wedge Osteotomy of Cuneiform Bones combined with selective plantar release and Dwyer osteotomy which the authors hypothesize provides real detwisting of the helicoidal deformity [20]. Shingade et al proposed a single stage procedure including Percutaneous Achilles tenotomy with plantar fasciotomy and dorsal closing wedge osteotomy for the management of neglected or relapsed clubfeet [21]. Our procedure of a dorsolateral closing wedge osteotomy with slight translation and Steindler’s procedure provides correction at the apex of the deformity and allows proper positioning of the foot. Cole et al, recommended the use of plantar release in the form of Steindler or modified Steindler’s release along with the midfoot osteotomy [16, 18, 20, 22]. Jahss et al on the other hand suggested leaving the plantar structures undisturbed so as to support the osteotomy and obviate the need of any internal fixation [17]. We routinely performed the Steindler’s procedure in a percutaneous fashion in all our patients.
We kept the children for a while longer in the cast to ensure solidity of the union which allows weight bearing and full return to activity. We had no case of non-union of the osteotomy.  Wicart-Seringe had a mean post operative Meary’s angle of 6 degrees and 75% of the patients had lower than preoperative Meary’s angle at final follow up [20]. The dorsolateral closing wedge osteotomy used in our study is successful in correcting the cavus and maintaining it, as the post-operative values of Hibb’s and Meary’s angles are near normal values. Most studies have performed additional procedures [steindler’s release for cavus and posterior release for equinus] after the midfoot surgery. One of the goals of our study is to document the associated abnormalities and correct them along with the midfoot surgery in order to give the child a functional limb. All these procedures were done to give the child a functional limb after one surgery only and appropriate postoperative protocols were followed. Also, the absence of loss of range of motion of ankle joint after the midfoot osteotomy shows the efficacy of the post-operative rehabilitation protocol followed by us. The patients were evaluated by the Dimeglio score. The mean score in our study improved from 10.63 to 2.97 with 90% patient showing good result… Giannini et al, reported that 72% of their patients had a good to excellent result while the other 28% had poor to fair result [22]. This shows that our technique and rehabilitation provides a good result in appropriately selected patients. Average follow up duration in our study was 25 months which is less compared to the Akron group where mean follow up was for 17.3 years and the Wicart-Seringe paper where it was 6.9 years. Giannini et al had a mean follow up duration of 7 years [19, 20, 22]. Probably due to the shorter duration of follow up in our study we have not been able to identify those feet which may require triple arthrodesis in the future. Wicart and Seringe reported 33% of patients at final follow up requiring triple arthrodesis [20].

With the proposed surgical procedure, angular and translational deformity correction in 3 planes can be achieved simultaneously in cases of severe neglected and residual clubfoot deformities without need of extensive soft tissue release. This technique is especially effective with low rates of arthritic degeneration and stiffness in adjacent joints and little reduction of ankle and foot flexibility. The proposed midfoot osteotomy initiates forefoot abduction with center of rotation at subtalar joint eventually causing derotation of whole calcaneopedal block which also pushes calcaneum into abduction. So we can correct forefoot adduction, flexible heel varus and cavus by this dorsolateral closing wedge midfoot osteotomy. In some cases of rigid heel varus which cannot be corrected by midfoot osteotomy alone, we might require a calcaneal osteotomy or gradual correction of deformity with ilizarov ring fixator. We found that, with this surgical technique, correction of complex clubfoot deformities was achieved in almost all cases. The only complication reported by the Akron group were superficial skin sloughs in 2 patients and one case of cellulitis [19]. Giannini had 4 cases of wound dehiscence and 2 cases of non-union of the osteotomy [22]. Levitt et al, reported a 30% rate of pseudoarthrosis with a midfoot osteotomy [23]. The most severe complication we encountered was a recurrence of the deformity. No neurovascular injuries were present. The shortening of the foot was also not significant as no patient needed mismatch footwear. Other complications we had in our patients were under correction, pin tract infection and wound healing problems. The Akron group defined failure of their procedure based on the age of the patient, severity of initial deformity, muscle weakness and any forefoot or hind foot deformity requiring surgery. They had an overall satisfactory rate of 76%, while in children more than 8 years the rate was 82% [19]. We defined failure based on the recurrence of deformity. Recurrence for us is increase in dimeglio score and change in radiographic angles to preoperative values.

Conclusion 
On the basis of our study, we conclude that a procedure including percutaneous Achilles tenotomy with plantar fasciotomy and dorsolateral closing wedge osteotomy is a good alternative to conventional procedures for management of
Neglected or relapsed, late presenting clubfoot deformities. Postoperative rehabilitation protocol should be well structured and rigorously adhered to for achieving a functional foot and ankle.

Clinical relevance
The proposed midfoot osteotomy is a minimally invasive procedure done percutaneously providing excellent correction of clubfoot deformities. It is a joint sparing procedure and it does not hampers the mobility at intertarsal and tarsometatarsal joints. It is a cost-effective surgery as the osteotomy is fixed with k wires. In almost all the cases, outcome of this surgical technique is painless plantigrade functional foot.


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How to Cite this Article: Kulkarni RM, Rathore A, Negandhi R,  Kulkarni MG, Kulkarni S G, Sekhri A. Treatment Of Neglected And Relapsed Clubfoot With Midfoot Osteotomy: A Retrospective Study. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):38-43.        

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