The mean length of follow-up was 4.9 ± 1.8 years (range, 2.5 to 10 years). The mean age of the patients at the time of follow-up was 9.8 ± 1.8 years (range, 4.8 to 13.2 years). At the time of follow-up, 8 feet had an excellent result, 49 had a good result, and 11 had a fair result; the improvement was significant (p < 0.05) (Table I, Figs. 1-A through 2-C). All children had plantigrade and flexible feet, could wear normal shoes, had a normal gait, and were able to run. Six of the 8 feet managed with bracing had maintained a good correction and presented no indication for TATT, whereas 2 showed a dynamic relapse and were scheduled for TATT. Dorsal subluxation of the navicular continued to be evident in 6 feet; however, the associated cavus deformity was corrected and the patients were asymptomatic (Figs. 2-A, 2-B, and 2-C). No patient had pain.
Unlike recurrence, in which CCF deformity reappears months or years after a documented correction3,13, a rigid residual deformity has never been corrected by previous treatment6,16,22,34. A recurrence may be superimposed on a residual deformity, but the latter is stiff whereas the former appears initially as a dynamic foot supination27. The amount of time elapsed since treatment, as well as previous imaging and the parents’ judgment, may also help to differentiate the 2 conditions34.
Our patients had been originally treated by unsuccessful conservative and surgical protocols, and over 40% of uncorrected deformities were observed after a faulty application of the Ponseti method. Clinical classification of residual deformities is difficult because some mild deformities are masked by others that are prevalent. We adopted the validated ICFSGS by Bensahel et al.32 that allows a comprehensive evaluation of CCF deformity by including all of its morphologic, radiographic, and functional aspects. We do not believe that the Pirani score used by others26 is ideal to assess residual deformity in children with CCF after 3 years of age when skin creases are barely visible and masked by scars of previous surgery.
In accordance with previous studies2,6,7,10,16, we observed mostly adduction and cavovarus, whereas equinus was less frequent and supination was rare. CCF deformity was severe at birth, as shown by the records of our patients, which partly explains the resistance to treatment.
Various treatments have been proposed for residual CCF deformity: (1) soft-tissue procedures5-8, (2) osseous procedures9-19, (3) a combination of soft-tissue and osseous procedures6,7,16,18, and (4) correction by external fixators20-24. The results of those procedures are difficult to evaluate because preoperative classifications are often missing or not uniform, the length of follow-up is either short or not reported, and postoperative results are assessed either subjectively or by different evaluation scales that are hardly comparable with each other. Foot stiffness and a high recurrence rate reported in longer follow-up studies6,12 negatively affect those treatments. Moreover, extensive surgical releases and osteotomies, especially when repeated, may result in stiff, painful, and shortened feet after the end of growth35.
We applied the Ponseti method to our patients, owing to the good results obtained with this method in patients with CCF who have a recurrence of stiffness36,37, in older infants with untreated CCF38,39, and in patients with neglected CCF40-42. We are aware of only 2 studies published on the application of the Ponseti method to rigid residual CCF deformity and/or recurrence after surgical treatment in children older than 2 years. Garg and Dobbs25 treated 11 children with a mean age of 4.6 years who had a rigid residual deformity following a posteromedial release. The number of casts applied weekly ranged from 1 to 8, and all of the patients had TATT. At the time of follow-up, the initial results were considered excellent. Nogueira et al.26 treated 58 children, at a mean age of 5 years and 2 months, with extensive soft-tissue release, which was associated in a few cases with osseous procedures. Residual deformity was classified by the Pirani score. Casts were changed every week, and the number of plaster casts applied ranged from 1 to 10. At the time of follow-up, only 89% of the feet were plantigrade, but all had a substantial reduction of the Pirani score. However, 20% of them had <30° of subtalar motion, while an unspecified number had 0° of either plantar flexion or dorsiflexion of the foot. Recurrence occurred in 14% of the feet.
We found it necessary to modify the Ponseti method to some extent in our patients with very stiff feet and in those who were older.
Since the majority of our children were worried and uncooperative before entering the plaster cast room, regardless of the presence and reprimands of their parents, it was decided to perform manipulations and cast application with the child under sedation to allow greater stretching of the rigid soft tissues. We increased the manipulation time to 5 to 10 minutes as previously recommended40. However, in no case was manipulation performed forcefully, so as to avoid tearing of the retracted and stiff fibrotic structures that might in turn have caused edema and subsequent scarring. Moreover, no patient had pain after recovery from the sedation. We are aware of the different, cooperative behavior shown by children of other nationalities who have undergone a similar procedure at a similar age but without sedation25,26,36-42. We believe that a different social, cultural, and parental educational background might have played an important role in explaining the different attitude demonstrated by our children.
We decided to maintain the cast for 4 weeks for clinical and basic-science reasons. Increasing the immobilization time in the cast up to 3 weeks was previously recommended for older children treated with the Ponseti method36,40,43. In growing rat ligaments, the load-deformation curve quickly becomes steeper because of the increase of intermolecular collagen cross-links44,45. Moreover, a “creep” phenomenon occurs in both tendons and ligaments, causing gradual yielding of the tissue under constant loading. Therefore, to obtain a permanent elongation, the duration of tissue loading should also be increased according to the increased age-related collagen cross-links46,47. Similar age-related changes also occur in growing osteocartilaginous anlagen in CCF, influencing their biomechanical properties48. Collagen turnover slows down with growth. Therefore, an increasingly longer time is needed for the fibroblasts to remodel the elongated collagen fibers49.
The number of casts we applied was strictly related to the amount of correction obtained. The stiffness of the residual deformity was also rated by the number of casts needed to provide the foot with a flexible correction. Children with CCF who had not had previous operative treatment or those under 6 years old who were treated with minimally invasive surgery had a faster correction (2 casts) in comparison with children with CCF who were more than 6 years old and treated with extensive surgery. The original treatment also partially influenced the final result. Despite their usually good functional result, clubfeet with extensive surgical release showed more radiographic abnormalities than those treated by either the Ponseti or the French method.
Some authors have applied up to 12 weekly casts to correct rigid residual deformity in older children25,26,38,39. We applied a maximum of 4 casts, with 1 applied every 4 weeks. If we consider the traveling involved for the families, the commitment, and the discomfort as well as the cost of the whole procedure, it remains a matter of debate whether 12 casts within 12 weeks are more convenient than 4 casts within 16 weeks.
Although manipulations and cast application were uniformly performed for all of our patients, additional surgery varied depending on the correction obtained at the end of cast immobilization. Percutaneous plantar fasciotomy was performed for cavus correction in 44% of the feet, either percutaneous tenotomy or percutaneous lengthening of the Achilles tendon was performed for equinus correction in 48.5%, and a posterior release was required in 7% because of a previous posteromedial release. In accordance with Garg and Dobbs25, we performed TATT in 88% of the feet as part of the treatment protocol to avoid a recurrence that might have had devastating psychological effects, particularly in children who had already had repeated surgery and/or who might not have easily accepted bracing. In 8 feet, TATT was not performed because the ossification center of the third cuneiform had not yet appeared. Those feet were managed with bracing, but 2 feet (2.9% of the whole series) had recurrence, confirming indirectly that TATT may prevent recurrence, which is particularly a risk in CCF treated for residual deformity and/or recurrence6,12,23,25,26,50. Our overall treatment protocol might not seem to be uniform; however, all of the surgical procedures are part of the Ponseti general management of clubfoot27, except for percutaneous Achilles tendon lengthening and posterior release that were imposed because of the patient age or previous extensive surgery.
At the time of follow-up, we used the same ICFSGS rating system for uniform assessment32: 84% of the feet had achieved excellent or good results, and no foot showed a lack of plantar flexion or was not plantigrade, as has been observed by others26. Deformity correction was also confirmed by the significant improvement of the CCF in our patients after treatment. Radiographic evaluation was particularly useful to assess correction of cavus and adduction that cannot be objectively graded by clinical means.
Dorsolateral subluxation of the navicular was still present in 6 feet, but they were all asymptomatic, as was observed in the study by Thompson et al.50. However, Kuo and Jansen reported additional surgery was needed in 7 (58%) of 12 feet in their study to address this deformity51.
As emphasized by Ponseti27, pain was absent in our patients both before treatment and at the time of follow-up because no foot was fully grown.
Our study has several limitations. It is a retrospective study of a single center, and the number of feet with CCF that were treated is not very large. Moreover, the original clinical records of 10 children were missing as was previous imaging of 16 feet. For all of those patients, we had to rely on the discharge notes, photographs, videos, and parents’ judgment to ascertain the previous clinical history and the evolution of the deformity. A third limitation is the relative shortness of follow-up that does not allow evaluation of the longer-term implications of our treatment. Detection bias is also possible with our outcome evaluation protocol.
In conclusion, we believe that the Ponseti method with some necessary modifications is effective for the treatment of rigid residual CCF deformity in children from 2 to 8 years of age, regardless of the previous treatment, and our results seem to be better than those reported for other surgical procedures. We faced a major problem with older children for whom both walking and mobility were restricted by the application of long leg casts. However, the families enthusiastically agreed to continue the Ponseti treatment as soon as they looked at the improved shape of their child’s foot after removal of the first plaster cast.
Investigation performed at the University of Rome “Tor Vergata,” Rome, Italy
Disclosure: There was no external funding source. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article.
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