SLR - May 2018 - Joel Ang
Reference: Alkar F, Louahem D, Bonnet F, Patte K, Delpont M, Cottalorda J. Long-term Results After Extensive Soft Tissue Release in Very Severe Congenital Clubfeet. J Pediatr Orthop. 2017;37(7):500–503.Scientific Literature Review
Reviewed By: Joel Ang, DPM
Residency Program: Cambridge Health Alliance, Cambridge, MA
Podiatric Relevance: Congenital clubfoot remains a challenging pathology to treat in the lower extremity. The current standard of care for clubfoot is serial casting, with either the Ponseti or French functional method. Historically, however, numerous surgical interventions were utilized, each varying in their long-term success rates. This retrospective study examines the long-term results of one of the most aggressive surgical interventions for clubfoot in 66 patients. Surgical outcomes were evaluated by foot function score, patient satisfaction and radiographic findings.
Methods: A level IV retrospective case review was performed for patients who underwent an extensive soft-tissue release for severe congenital clubfoot. A total of 66 patients and 105 clubfeet were included in the study. Soft-tissue release involving the posterior, medial and plantar aspect of the foot, as described by Dr. Turco, was performed on all patients. The average follow-up time was 22 years. The Ghanem-Seringe score, a clubfoot specific scale, was used to measure foot function and patient satisfaction. Radiographic findings of surgically treated clubfeet were also compared to contralateral normal feet, if applicable to the patient.
Results: Of the 105 clubfeet, none achieved an excellent outcome. Nineteen feet were rated to have a good outcome, 16 a fair outcome and 70 a poor outcome. There was notable flattening of the talar dome in 93 feet, residual navicular subluxation in 82 feet and moderate osteoarthritis in 32 feet. In 82 percent of operated feet, there was noted to be pain after 20 minutes of ambulation. Nevertheless, 92 percent of the patients were satisfied with their surgical intervention and outcome.
Conclusions: The authors conclude that even after extensive soft-tissue releases during infancy, functional and radiographic outcomes were less than ideal. The high percentage of poor outcomes from surgical intervention is noted to be in line with other case series in literature. However, direct comparison between the case series is somewhat limited as the initial severity of each patient’s clubfoot presentation is not objectively rated. Different surgical interventions were also performed in each series. Despite discouraging objective findings, 92 percent of patients were satisfied with their feet. The authors explain some of this objective and subjective discrepancy with a theory about handicap adaptability in children in comparison to adolescents and adults. Some research suggests that children who are handicapped from a young age are more likely to have a better outlook on their condition, a phenomenon that may have been at play in this retrospective case study.