SLR - April 2014 - Priscilla Zinyemba
Reference: Chu A, Chaudhry S, Sala DA, Atar D, Lehman WB. Calcaneocuboid Arthordesis for Recurrent Clubfeet: What is the outcome at 17- year Follow-up? Journal of Children's Orthopaedics 2014 online
Scientific Literature Review
Reviewed By: Priscilla Zinyemba, DPM
Residency Program: Temple University Hospital, Philadelphia PA
Podiatric Relevance: The topic of addressing the difficult surgical situation of a stiff, relapsed clubfoot has been debated for decades with many procedures being proposed. The purpose of the study was to determine: 1) functional level at 17 year follow up, 2) patient’s current functional level, satisfaction and pain, and 3) current arthropometric measurements of those that had undergone revisional clubfoot surgery consisting of the Dilwyn Evans procedure (posteriomedial soft tissue release with calaneocuboid fusion). The authors’ institution had prior published mean follow up at 5.5 years (range 2.1-14.7) where eight feet rated excellent, 14 good and four fair and one as poor based on the Hospital for Joint Diseases Functional Rating System (HJD FRS). This study aimed to assess the 17 year follow up compared to this five-year follow up data.
Methods: The cohort for this study was obtained from a prior series published by the authors’ institution in 1999. The original cohort consisted of 20 patients (27 feet) that underwent the Dillwyn Evans procedure at a mean age of 6.2 years with their first surgery having been performed at mean age of 0.6 years. The procedure consisted of soft tissue release in 21 feet, a tendo-Achilles lengthening in 5 feet and a tendo-Achilles lengthening/medial capsulotomy in one foot.
Ten of the 20 patients (13 feet) were available for this 17 year follow-up. Examination included clinical, radiographic, self report of functional abilities and pain assessments. The HJD FRS, which assesses all of the above areas, was repeated for comparison to the original study's scores. The Outcome evaluation in Clubfoot Study Group (ICFSG) scored clinical and radiographic findings. Patients completed: 1) the Clubfoot Disease-Specific Instrument (DSI); 2) American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire; 3) Three of six questions on Laaveg and Ponseti's functional rating system for club foot, with the surgeon answering the remaining three questions. Also a verbal pain scale score, leg length, calf circumference, foot length and width and maximum passive dorsiflexion were measured and recorded.
Results: The participants that were available for follow up included 10 patients (13 feet). All were males who were ambulatory without assistance, and had no other definitive surgeries. The calcaneocuboid joint was radiographically fused in 11 of the 13 feet. Both of the unfused feet occurred in one foot of the bilateral case.
For all 13 feet the current HJD FRS score decreased significantly to a mean of 69.9 from 77.8 (p=0.03) with Excellent/good HJD FRS scores going from 85 to 38 percent. The mean AAOS Foot Ankle Outcomes Questionnaire standardized core and shoe comfort scores were 84.6 and 84.5, respectively. Average foot pain was 1.8 (1-10 scale). Based on the Clubfoot Disease-Specific instrument questions, patients were very satisfied/somewhat satisfied with the status of the foot in 76 percent and with appearance of foot in 46 percent of feet.
Conclusions: The authors conclusions included that revision clubfoot surgery with calcaneocuboid fusion in patients aged 5-8 years showed an expected decline in the functional outcome measures over the 17 year follow up period. The study was limited by its inability to address the Dillwyn Evans procedure's durability as the patient age is relatively young, also the follow up cohort was very small with a 50 percent loss to follow up from the original cohort.
They noted that this procedure produced comparable results to other studies for a similar population of difficult, revision cases and should be considered as a surgical option. It would have been of greater value if the study would have been able to address specifically that the calcaneocuboid fusion or specifically the posteriomedial soft tissue release quantitatively contributed to improved or sustainable outcomes. A comparison of other procedures available would also be of value in this determination.