SLR - June 2017 - Stephanie R. Florence
Reference: Faldini C, Traina F, Nanni M, Sanzarello I, Borghi R, Perna F. Congenital Idiopathic Talipes Equinovarus Before and After Walking Age: Observations and Strategy of Treatment from a Series of 88 Cases. J Orthop Traumatol. 2016 Mar; 17(1), 81–87.Scientific Literature Review
Reviewed By: Stephanie R. Florence, DPM
Residency Program: Bethesda Memorial Hospital, Boynton Beach, FL
Podiatric Relevance: Talipes Equinovarus (Clubfoot) is a less commonly seen and complicated condition treated by podiatric surgeons. Both conservative and surgical treatment options are available and should be discussed with the patient’s family in order to make the best treatment decision for the most successful long-term outcome. This study examines 88 patients who received either conservative or surgical treatment for Clubfoot and the clinical outcomes, complications and relapse for a midterm follow-up.
Methods: A level IV study that included 58 patients (88 Clubfeet, 30 bilateral). Fifty-two Clubfeet (34 patients) were diagnosed at birth that included 12 ambulating children (four to 12 months) and 24 ambulating (one to three years). Evaluation of each foot was classified using the Pirani score. Newborns and toddlers were treated with the Ponseti casting technique. Two toddlers underwent Achilles lengthening (two feet) and posteromedial release (three feet). All ambulating children underwent surgery consisting of medial release with cuboid subtraction osteotomy (one foot), posteromedial release (six feet) and posteromedial release with cuboid subtraction osteotomy (17 feet). The last follow-up evaluated plantigrade position of the foot, joint stiffness, muscle function, pain, shoewear and walking. The Pirani score was used to summarize results (0–1 excellent, 1.5–2.5 good, >3 poor). If residual equinas was present, a score of poor was automatically given.
Results: Average follow-up was five years (one to six years). The average number of Ponseti casts was six for newborns and eight for nonambulating children. There were no complications after casting or with the Achilles lengthening, and all children went on to walk and wear shoes without limping. Two children who underwent posteromedial release with cuboid osteotomy had delayed wound healing, and one was treated by plastics for closure. Two ambulating children who underwent surgery presented with residual deformity and mild pain after prolonged walking. According to the Pirani score, of those who underwent casting, 42 had excellent scores, six good and four poor. In nonambulating children (four to 12 months), nine were excellent and three good. In ambulating, five were excellent, 16 good and three poor. Surgery was indicated in four feet who underwent only casting and in all poor Pirani score results. No cases of overcorrection were seen.
Conclusions: Conservative casting is a great option if the condition is seen in newborns, and often an Achilles lengthening can complement the casting. Those children not yet ambulating but older than newborn age who were treated with casting yet had stiffer deformities more difficult to treat requiring more casting and at times surgery. Surgery was always indicated in ambulating children and in severe cases, an isolated posteromedial release was not adequate alone. The release in combination with the cuboid osteotomy proved a sufficient treatment. Overall, considerations regarding surgery versus conservative care include age, ambulation, stiffness and previous treatments. Both conservative and surgical treatments are viable options for the proper candidate based on the parameters listed.