Clubfoot protocol allows early correction of severe, rigid deformity
MedWire News: Multiple tenotomies and posterior ankle capsulotomy can successfully correct severe clubfoot, shows research indicating that the procedures, when combined with hyperabduction brace, allow full correction of the deformity by walking age.
Hazem Eltaybe, from Menofyia University in Egypt, describes the protocol in the Journal of Foot and Ankle Surgery as "safe and effective," noting that by limiting the time a hyperabduction brace is required, the procedure relieves the "growing, active child from any constraints."
He describes the outcome of the protocol in 18 children who were born between November 2002 and December 2004 with 30 severe, rigid idiopathic clubfeet. The patients were treated with the Ponseti method between the ages of 2 and 24 days, until full correction except equinus was achieved.
Surgery was performed on removal of the last plaster cast. Tenotomy of the Achilles tendon, tibialis posterior, and flexor digitorum longus was performed through two small (2 cm) incisions. Posterior capsulotomy was required in 26 feet to achieve 30° or greater dorsiflexion.
An above-knee plaster cast was then applied to create extreme dorsiflexion and 70° hyperabduction for 6-8 weeks. Following removal of the cast, a hyperabduction brace was applied for 23 hours per day for 6 months.
Follow-up of the children at an average of 3.8 years, demonstrated that the protocol achieved a satisfactory outcome in 29 of the patients, defined as plantigrade foot with straight later border and normal hindfoot valgus during weight-bearing. The patients were able to wear regular shoes and had at least 10° (5° at age 2-5 years) ankle dorsiflexion with the knee extended.
The patients' Pirani score fell from 5-6 at presentation to 0-0.25. Final passive dorsiflexion of the ankle was 10-20° in patients who required posterior capsulotomy versus 5-10° in those who had not.
One patient experienced recurrent deformity, resulting in the child walking on the lateral border of the foot. The patient underwent remanipulation and casting, and later posteromedial release and tibialis anterior transfer correction.
"The satisfactory results in the present study resulted from two main factors: elimination of the deforming forces thought to cause relapse after successful correction using the Ponseti method, and maintenance of the corrected foot in hyperabduction for double the period recommended by most investigators, thus ensuring total remodeling of the deformed tarsal bones," Eltaybe comments.
"Although the deformity was severe and rigid, beginning early allowed correction to be achieved, with removal of the hyperabduction brace before walking age."
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By Lynda Williams