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.

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The significance of foot length at the initiation of the Ponseti method: a prospective study

Journal of Children s Orthopaedics ◽

10.1302/1863-2548.13.190075 ◽

2019 ◽

Vol 13 (3) ◽

pp. 252-257 ◽

Cited By ~ 2

Author(s):

Y. Hemo ◽

A. Yavor ◽

R. Gigi ◽

S. Wientroub

Keyword(s):

Prospective Study ◽

Ponseti Method ◽

Functional Score ◽

Idiopathic Clubfoot ◽

Level Of Evidence ◽

Results Of Treatment ◽

Foot Length ◽

Pirani Score ◽

Additional Surgery ◽

A Prospective Study

Objectives We sought to evaluate foot length (FL) and forefoot circumference (FC) and their impact on the severity of idiopathic clubfoot (CF) and results of treatment. We hypothesized that a smaller foot size at birth that represents a lesser than term newborn may affect the response of the CF to the treatment. Methods We conducted a prospective study documenting FL and FC of all neonates presented with idiopathic CF. Additional demographic information was collected. Outcome measures were number of casts needed for correction, need for recasting, additional surgery and functional score. Results In all, 52 children with 73 CF with a minimum mean follow-up of two years (2.0 to 5.6; sd 1.08) were evaluated. Mean gestational age was 38.63 weeks and mean birth weight (BW) was 3184 g. The mean FL at presentation was 74 mm (5.70 to 9.00), initial Pirani score was 5.5 (2.5 to 6.0) while number of casts was 6.9 (4.0 to 11.0). The FL was significantly correlated both to initial Pirani score (r = -0.35; p < 0.01) and number of casts (r = -0.33; p < 0.05). Positive correlation was found between the number of casts to Pirani score and number of additional procedures (r = 0.39; r = 0.36; p < 0.01, respectively). A foot size of up to 8 cm, needed 7.3 casts (4 to 7) compared with a FL of 8 cm or longer who needed 4.7 casts (4 to 6; t = 7.11; p < 0.001). Conclusion FL is a simple approach to identify preterm babies. It can be used as part of the initial evaluation of CF and help in predicting the course of treatment. We recommend adding FL to the existing classification. Level of Evidence I - Prognostic study

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Are bilateral idiopathic clubfeet more severe than unilateral feet? A severity and treatment analysis

Journal of Orthopaedic Surgery ◽

10.1177/2309499018772364 ◽

2018 ◽

Vol 26 (2) ◽

pp. 230949901877236 ◽

Cited By ~ 4

Author(s):

Anil Agarwal ◽

Nargesh Agrawal ◽

Sitanshu Barik ◽

Neeraj Gupta

Keyword(s):

Treatment Outcomes ◽

Deformity Correction ◽

Idiopathic Clubfoot ◽

Achilles Tenotomy ◽

Female Patients ◽

Bilateral Group ◽

Pirani Score ◽

The Mean ◽

Treatment Analysis ◽

Unilateral Group

Introduction: Evidences suggest that different subgroups of idiopathic clubfoot exist with differences in severity and treatment outcomes. This study compares the severity and treatment outcomes of unilateral and bilateral clubfoot. Material and methods: We retrospectively studied 161 patients (bilateral 66, unilateral 95) with primary idiopathic clubfeet to evaluate the differences in severity and treatment. The parameters analyzed were precasting Pirani score, number of casts required, pretenotomy Pirani score, pretenotomy dorsiflexion, rate of tenotomy, and post-tenotomy dorsiflexion achieved. A Pirani score of at least 5 was classified as very severe and 4.5 or less was classified as less severe. Results: There were 49=(74.24%) male and 17 (25.75%) female patients in the bilateral group and 76 (80%) male and 19 (20%) female patients in the unilateral group. Out of 95 unilateral patients, 34 were left sided (35.8%). Comparing severity, the mean precasting Pirani score in bilateral patients (5.4 ± 0.6) was statistically more than the unilateral patients (4.9 ± 0.7). The number of casts required was significantly more in bilateral feet compared to unilateral (bilateral 5.3 ± 1.7, unilateral 4.7 ± 1.7; p < 0.011). Achilles tenotomy was required in all feet. Post Ponseti treatment, the foot deformity correction achieved (pretenotomy Pirani score, pretenotomy, and post-tenotomy dorsiflexion) was statistically similar in both unilateral and bilateral feet. Conclusions: Idiopathic bilateral clubfoot was more severe than unilateral foot at initial presentation and required more number of corrective casts. Post Ponseti treatment, the deformity correction in bilateral foot was similar to unilateral foot.

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Prone versus modified supine percutaneous nephrolithotomy: which is more cost effective in an Australian tertiary teaching hospital?

Journal of Clinical Urology ◽

10.1177/2051415818817131 ◽

2018 ◽

Vol 12 (5) ◽

pp. 391-395

Author(s):

Isabel E-Hui Chu ◽

Weranja Ranasinghe ◽

Madeleine Nina Jones ◽

Philip McCahy

Keyword(s):

Percutaneous Nephrolithotomy ◽

Treatment Options ◽

Cost Effective ◽

Renal Stones ◽

Level Of Evidence ◽

Tertiary Teaching ◽

Significant Difference ◽

Chi Squared ◽

Recovery Times ◽

Operative Costs

Introduction: Percutaneous nephrolithotomy is currently one of the main treatment options for large renal stones, but the effect of positioning on comparative costing has been scarcely documented. We aimed to compare the cost effectiveness of modified supine with traditional prone percutaneous nephrolithotomy procedures in the context of Victoria, Australia. Materials and methods: A prospective group of 236 renal units (224 patients) was included in the two-site study, with 76 performed in the prone position and 160 performed in the modified supine position. Costing was calculated using a ‘bottom-up’, all-inclusive framework that generates per-hour costs for theatre, recovery unit and ward costs from base costs and maintenance costs. Percutaneous nephrolithotomy-specific equipment was added to calculate comparative costs of modified supine versus prone procedures. Chi squared and T tests were used for statistical analysis. Results: There was a significant difference in the overall costing between the modified supine and prone groups. The modified supine group had a lower total cost (AUD$6424.29) compared to the prone group (AUD$7494.79) ( P=0.007), lower operative costs (AUD$4250.93 vs. AUD$5084.29, P=0.002) and lower ward costs (AUD$533.55 vs. AUD$1130.20, P<0.001). There was no significant difference in recovery times in the modified supine and prone groups, although the modified supine group appeared to have shorter recovery times (AUD$690.69 vs. AUD$586.05, P=0.209). Conclusions: Modified supine percutaneous nephrolithotomy has significantly lower total costs, operative costs and ward costs compared to prone percutaneous nephrolithotomy. Larger randomised trials are needed to assess these findings further. Level of evidence: Not applicable for this multicentre audit.

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Tibial Plateau Cysts at the Meniscal Root Insertions: Incidence and Association

The Duke Orthopaedic Journal ◽

10.5005/jp-journals-10017-1007 ◽

2011 ◽

Vol 1 (1) ◽

pp. 45-49 ◽

Cited By ~ 3

Author(s):

Manjiri M Didolkar ◽

Emily N Vinson

Keyword(s):

Retrospective Study ◽

Tibial Plateau ◽

Posterior Horn ◽

Anterior Horn ◽

Level Of Evidence ◽

Meniscal Root ◽

Knee Mri ◽

Institutional Review ◽

Level Ii ◽

Meniscal Pathology

ABSTRACT Background The purpose of this study is to identify a possible relationship between high T2-signal cyst-like foci in the tibial plateau at the meniscal root insertions and meniscal pathology. Methods Institutional review board approval was obtained for this retrospective study. HIPAA compliance was maintained throughout this study. Two radiologists reviewed 200 knee MRI examinations for tibial plateau cysts at the meniscal root insertion sites; meniscal tears and intrameniscal cysts were also noted. The knee MRI examinations were also evaluated for articular cartilage abnormalities of the medial and lateral tibial plateaus. Results Of the 200 knee examinations, 83(41.5%) demonstrated medial meniscal pathology and 47(23.5%) demonstrated lateral meniscal pathology. Twenty (10%) demonstrated cysts in at least one of the described locations; two knees had cysts in two separate locations. four (2%) examinations had cysts at the anterior horn medial meniscal insertion, and all four (100%) had medial meniscal pathology (p = 0.028). Eleven (5.5%) examinations demonstrated cysts at the posterior horn medial meniscal insertion, and eight (72.7%) had medial meniscal pathology (p = 0.031). five (2.5%) examinations demonstrated cysts at the anterior horn lateral meniscal insertion, and one (20%) had lateral meniscal pathology (p = 0.374). Two (1%) examinations demonstrated cysts at the posterior horn lateral meniscal insertion, and one (50%) had lateral meniscal pathology (p = 0.852). Conclusions Cysts at the meniscal insertions are often seen on knee MRI. Cysts located at the insertions of the medial meniscus have a statistically significant association with meniscal pathology. Level of evidence Level II, retrospective study with development of diagnostic criteria on the basis of consecutive patients.

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Driving After Hallux Valgus Surgery

Foot & Ankle International ◽

10.1177/1071100717711926 ◽

2017 ◽

Vol 38 (9) ◽

pp. 982-986 ◽

Cited By ~ 10

Author(s):

Elizabeth McDonald ◽

Rachel Shakked ◽

Joseph Daniel ◽

David I. Pedowitz ◽

Brian S. Winters ◽

...

Keyword(s):

Reaction Time ◽

Hallux Valgus ◽

Control Group ◽

Metatarsal Osteotomy ◽

Level Of Evidence ◽

First Metatarsal ◽

Institutional Review ◽

Level Ii ◽

Survey Results ◽

Correction Surgery

Background: The purpose of the study was to determine when patients can safely return to driving after first metatarsal osteotomy for hallux valgus correction. Methods: After institutional review board approval, 60 patients undergoing right first metatarsal osteotomy for hallux valgus correction surgery were recruited prospectively. Patients’ brake reaction time (BRT) was tested at 6 weeks and repeated until patients achieved a passing BRT. A control group of twenty healthy patients was used to establish as passing BRT. Patients were given a novel driver readiness survey to complete. Results: At 6 weeks, 51 of the 60 patients (85%) had BRT less than 0.85 seconds and were considered safe to drive. At 6 weeks, the passing group average was 0.64 seconds. At the 8 weeks, 59 patients (100%) of those who completed the study achieved a passing BRT. Patients that failed at 6 weeks had statistically greater visual analog scale (VAS) pain score and diminished first metatarsophalangeal (MTP) range of motion (ROM). On the novel driver readiness survey, 8 of the 9 patients (89%) who did not pass disagreed or strongly disagreed with the statement, “Based on what I think my braking reaction time is, I think that I am ready to drive.” Conclusion: Most patients may be informed that they can safely return to driving 8 weeks after right metatarsal osteotomy for hallux valgus correction. Some patients may be eligible to return to driving sooner depending on their VAS, first MTP ROM, and driver readiness survey results. Level of Evidence: Level II, comparative study

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Reconstructive surgery in recurrent deformity (clubfoot relapse)

Genij Ortopedii ◽

10.18019/1028-4427-2021-27-4-435-440 ◽

2021 ◽

Vol 27 (4) ◽

pp. 435-440

Author(s):

P. Lascombes ◽

◽

D.A. Popkov ◽

S.S. Leonchuk ◽

◽

...

Keyword(s):

Reconstructive Surgery ◽

Severe Disease ◽

Functional Results ◽

Surgical Approaches ◽

Idiopathic Clubfoot ◽

Achilles Tenotomy ◽

Anterior Tibial ◽

History Of ◽

Initial Correction ◽

Recurrent Deformity

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.

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Clubfoot treatment with Ponseti method – Parental distress during plaster casting

10.21203/rs.3.rs-21711/v1 ◽

2020 ◽

Author(s):

Christian Walter ◽

Saskia Sachsenmaier ◽

Markus Wünschel ◽

Martin Teufel ◽

Marco Götze

Keyword(s):

Ponseti Method ◽

Long Term Results ◽

Congenital Defects ◽

Idiopathic Clubfoot ◽

Parental Distress ◽

Achilles Tenotomy ◽

Pirani Score ◽

Plaster Casting ◽

Initial Hypothesis ◽

Mental Resilience

Abstract Background: Clubfoot is one of the most prevalent musculoskeletal congenital defects. Gold standard treatment of idiopathic clubfoot is the conservative Ponseti method, including the reduction of deformity with weekly serial plaster casting and percutaneous Achilles tenotomy. It is well known that parents of children with severe and chronic illnesses are mentally stressed, but in recent studies regarding clubfoot treatment, parents were only asked about their satisfaction with the treatment. Largely unknown is parental distress before and during plaster casting in clubfoot.Therefore, we want to determinate first, how pronounced the parents' worries are before treatment and if they decrease during the therapy. Second, we hypothesized that parents faced with an extreme deformity (high Pirani-Score), reveal more distress, than parents whose children have a less pronounced deformity (low Pirani-Score). Therefore, we wanted to investigate weather the Pirani score correlates with the parents' mental resilience in relation to the therapy of the child as a global distress parameter.Methods: To answer this question, we developed a questionnaire with the following emphases: Physical capacity, mental resilience, motion score, parents score and child score with point scores 1 (not affected) to 6 (high affected). Subsequently, we interviewed 20 parents whose children were treated with clubfeet and determined the Pirani score of the infants at the beginning (T0) and at the end (TE) of the treatment with plaster casting.Results: High values were obtained in child score (Mean (M) = 3.11), motion score (M = 2.63) and mental resilience (M = 2.25) and. During treatment, mental resilience improved (p = 0.015) significantly. The Spearmann correlation coefficient between Pirani-Score (T0) and mental resilience (T0) is 0.21, so the initial hypothesis had to be rejected. Conclusion: The issues of the children are in the focus of parental worries concerning clubfoot treatment, especially the assumed future motion and the assumed ability to play with other children. Particular emphasis should be placed on educating parents about the excellent long-term results in the function of the treated feet especially as this topic shows the greatest parental distress.

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Clubfoot treatment with Ponseti method – Parental distress during plaster casting

10.21203/rs.3.rs-21711/v2 ◽

2020 ◽

Author(s):

Christian Walter ◽

Saskia Sachsenmaier ◽

Markus Wünschel ◽

Martin Teufel ◽

Marco Götze

Keyword(s):

Ponseti Method ◽

Long Term Results ◽

Congenital Defects ◽

Idiopathic Clubfoot ◽

Parental Distress ◽

Achilles Tenotomy ◽

Pirani Score ◽

Plaster Casting ◽

Initial Hypothesis ◽

Mental Resilience

Abstract Background Clubfoot is one of the most prevalent musculoskeletal congenital defects. Gold standard treatment of idiopathic clubfoot is the conservative Ponseti method, including the reduction of deformity with weekly serial plaster casting and percutaneous Achilles tenotomy. It is well known that parents of children with severe and chronic illnesses are mentally stressed, but in recent studies regarding clubfoot treatment, parents were only asked about their satisfaction with the treatment. Largely unknown is parental distress before and during plaster casting in clubfoot.Therefore, we want to determinate first, how pronounced the parents' worries are before treatment and if they decrease during the therapy. Second, we hypothesized that parents faced with an extreme deformity (high Pirani-Score), reveal more distress, than parents whose children have a less pronounced deformity (low Pirani-Score). Therefore, we wanted to investigate weather the Pirani score correlates with the parents' mental resilience in relation to the therapy of the child as a global distress parameter.Methods: To answer this question, we developed a questionnaire with the following emphases: Physical capacity, mental resilience, motion score, parents score and child score with point scores 1 (not affected) to 6 (high affected). Subsequently, we interviewed 20 parents whose children were treated with clubfeet and determined the Pirani score of the infants at the beginning (T0) and at the end (TE) of the treatment with plaster casting.Results High values were obtained in child score (Mean (M) = 3.11), motion score (M = 2.63) and mental resilience (M = 2.25). During treatment, mental resilience improved (p = 0.015) significantly. The Spearman correlation coefficient between Pirani-Score (T0) and mental resilience (T0) is 0.21, so the initial hypothesis had to be rejected.Conclusion The issues of the children are in the focus of parental worries concerning clubfoot treatment, especially the assumed future motion and the assumed ability to play with other children. Particular emphasis should be placed on educating parents about the excellent long-term results in the function of the treated feet especially as this topic shows the greatest parental distress.

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Early Radiographic Changes in the Lateral Talocalcaneal Angle Following Achilles Tenotomy in Children With Idiopathic Clubfoot

Foot & Ankle International ◽

10.1177/1071100719895211 ◽

2019 ◽

Vol 41 (3) ◽

pp. 350-355

Author(s):

Jingchun Li ◽

Yuanzhong Liu ◽

Yiqiang Li ◽

Zhe Yuan ◽

Hongwen Xu ◽

...

Keyword(s):

Correlation Coefficients ◽

Ponseti Method ◽

Idiopathic Clubfoot ◽

Neutral Position ◽

Level Of Evidence ◽

Positive Correlation ◽

Achilles Tenotomy ◽

Severity Of The Disease ◽

The Relationship ◽

Radiographic Changes

Background: Percutaneous Achilles tenotomy (PAT) is an important component of the Ponseti method and is performed in 85% to 90% of patients. However, there is a lack of objective data assessing early radiographic changes in children undergoing PAT. Methods: Forty-nine patients with idiopathic clubfoot treated by Ponseti casting were prospectively enrolled between October 2017 and October 2018. Preoperative and postoperative ankle dorsiflexion (pre-ADFmax, post-ADFmax) and lateral talocalcaneal angle (pre-LTCAmax, post-LTCAmax) values with the ankle in maximal dorsiflexion as well as postoperative LTCA values with the ankle in the neutral position (post-LTCAneutral) were measured. The relationship between the preoperative and postoperative ADF and LTCA values was studied using Pearson or Spearman correlation coefficients. Forty-nine patients (72 feet) were included; the mean age at initial treatment was 32.2 ± 24.1 days. Results: Post-LTCAmax improved significantly from 18.6 ± 9.2 degrees to 25.1 ± 10.5 degrees ( P < .0001). Pre-ADF and pre-LTCAmax showed a positive correlation in both the less than 28-day group ( r = 0.42; P = .015) and the Dimeglio III group ( r = 0.29; P = .035). However, post-ADF and post-LTCAmax showed a positive correlation in the Dimeglio III group ( r = 0.30; P = .028). The degree of improvement in post-LCTAmax in the Dimeglio III group was similar to that in the Dimeglio IV group ( P = .28). Conclusion: The LTCA increased immediately after PAT in clubfoot, although the improvement seemed to be unrelated to the severity of the disease. PAT led to an increase in both ADF and the LTCA, and it contributed to the improvements in subtalar joint motion and alignment. Level of Evidence: Level III, comparative study.

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A Last-Ditch Effort and Personalized Surgeon Letter Improves PROMs Follow-Up Rate in Sports Medicine Patients: A Crossover Randomized Controlled Trial

The Journal of Knee Surgery ◽

10.1055/s-0039-1694057 ◽

2019 ◽

Author(s):

Muhammad B. Tariq ◽

Morgan H. Jones ◽

Greg Strnad ◽

Elizabeth Sosic ◽

Kurt P. Spindler ◽

...

Keyword(s):

Sports Medicine ◽

Electronic Mail ◽

Controlled Trial ◽

Intervention Group ◽

Cost Effective ◽

Control Group ◽

Institutional Review ◽

Patient Reported ◽

Chi Squared

AbstractPatient-reported outcomes measures (PROMs) are important for the advancement of orthopaedic surgeries. The primary difficulty while collecting PROMs is obtaining adequate follow-up rates. Therefore, it is important to find methods to improve follow-up, especially in patients who have failed to respond to initial attempts. We hypothesized that PROMs follow-up could be effectively increased by sending a salvage-effort personalized surgeon letter to sports medicine patients who failed to respond to initial (centralized electronic, mail, and/or phone contacts) PROMs collection 1 year after surgery. Patients who failed to respond to 1-year follow-up of postoperative PROMs collection at our outpatient sports medicine surgery center were included. Patients were randomized into an intervention or control group. Patients in the intervention group were mailed PROMs form and an Institutional Review Board-approved letter that was personalized with surgical information, surgeon picture, and surgeon signature. Control group was mailed the same letter a month later. Chi-squared analysis was conducted at 5 weeks. Out of 843 surgeries, our initial 1-year PROMs follow-up rate was 65%, which allowed for 292 patients to be eligible for our study. After exclusions, 281 patients (randomized to 140 control group and 141 intervention group) were included in our study. We found a 20% response rate in the intervention group with 28 patients returning PROMs as compared with a 1.4% rate in the control group with two patients returning PROMs. The odds ratio was 17.1 (95% confidence interval: 4–73.3; p < 0.0001). A salvage-effort personalized surgeon letter is an efficient and relatively cost-effective method to increase PROMs follow-up rate, which means that a personalized surgeon letter can reach and engage patients who would otherwise be considered lost to follow-up, allowing for better outcomes monitoring after surgery.

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