SLR - December 2020 - Samantha M. Ralstin
Reference: Ebert N, Ballhause TM, Babin K, Schelling K, Stiel N, Stuecker R, Spiro AS. Correction of Recurrent Equinus Deformity in Surgically Treated Clubfeet by Anterior Distal Tibial Hemiepiphysiodesis. Journal of Pediatric Orthopaedics. 2020 Oct;40(9):520-525. doi: 10.1097/BPO.0000000000001609. PMID: 32555046.Level of Evidence: IV
Scientific Literature Review
Reviewed By: Samantha M. Ralstin, DPM
Residency Program: John Peter Smith Hospital – Fort Worth, TX
Podiatric Relevance: Clubfoot is one of the most common congenital lower extremity deformities with 1-3/1000 live births. Recurrent deformity is not as prevalent after the development of Ponseti casting; however, in surgically treated clubfoot, recurrence is documented to be from 25-45%. Podiatrists with a heavy pediatric practice may encounter patients later in their childhood seeking surgical consultation for their recurrent deformity. Anterior Distal Tibial Hemiepiphysiodesis (ADTE) is a surgical option for those patients with recurrent or residual equinus deformity with increased Anterior Distal Tibial Angle (ADTA). This study retrospectively reviewed a series of 18 patients (23 feet) who underwent ADTE using 8-plates. Primary outcomes of the study included correction of ADTA and increase of ankle dorsiflexion after treatment completion.
Methods: This was a level IV retrospective case series with 18 children (23 feet) who had previous surgical treatment for clubfoot and developed an equinus deformity with an increased ADTA. For patients to undergo ADTE, patients had to have an increased ADTA (normal 78-82 degrees) measured on lateral radiographs, and inability to dorsiflex the ankle (< 0 degrees of dorsiflexion) which was measured with a goniometer. ADTE was completed with an anterior eight-plate over the physis, and eight plates were removed following improved dorsiflexion of the ankle, correction/overcorrection of ADTA, or skeletal maturity.
Results: All children completed treatment with implant removal at an average of 20.3 months after initial procedure, and the average final follow up was 43.9 months. Ankle dorsiflexion and ADTA were both shown to significantly improve after ADTE at the time of implant removal. Average improvement in ADTA was 11.7 degrees, and Ankle dorsiflexion was 9.4 degrees. However, decrease in ADTA did not correlate with increase in ankle dorsiflexion. There was deterioration of ADTA and ankle dorsiflexion after implant removal in seven patients. Complications of the procedure were limited to screw loosening noted in one patient; there were no incidences of implant associated infections, skin irritation, malpositioned screws, prolonged postoperative pain, premature physeal closure, or physeal damage in this cohort.
Conclusions: This study is limited by its retrospective nature and small sample size of surgically treated clubfeet, thus not including recurrent deformities after casting. Patient’s age and skeletal maturity are important when considering guided growth procedures like ADTE. All patients in this study completed treatment with implant removal, and at their final follow up all children reached the neutral position of the ankle joint. Overall, ADTE is a safe, and effective surgical option for the treatment of recurrent equinus deformity in clubfeet with increased ADTA. One aspect this article does not address is the type of clubfoot that was treated and if cases of arthrogryposis or syndromic variants of clubfoot would correct similarly.