Prospective Study of Gross Motor Milestones in Children with Severe Idiopathic Clubfoot Treated by Ponseti Method

Abstract

Background

A prospective study of motor milestones achieved in severe clubfeet treated by Ponseti method and comparison between unilateral and bilateral clubfoot will help us gain further insight of motor milestones in these children.

Methods

Prospective study of 150 consecutive children with idiopathic clubfoot who were treated by Ponseti method and in whom percutaneous tendoachilles tenotomy was performed. The gross motor milestones recorded were: rolls from back to stomach, sitting without support, standing with assistance, walks with assistance, standing alone, walking alone. This was compared with published regional and World Health Organization (WHO) normal data.

Result

15 patients were excluded due to non-compliance and recurrence. Children with unilateral clubfoot (80 children) and bilateral clubfoot (55 children) showed a delay of 0.2–2.1 months in various milestones, and this was statistically significant when compared with both normal data. 95% children with unilateral clubfoot had independent ambulation by 17 months and in bilateral ambulation by 17.8 months. There was also a statistically significant difference in unilateral and bilateral clubfeet in all variables except sitting without support and walking with support.

Conclusion

There is a delay in achievement in all children with clubfoot, with more delay in bilateral clubfoot as compared to unilateral clubfoot. The probable reasons could be plaster treatment, possible weakness due to tendoachilles tenotomy, use of orthosis or the inherent pathology associated with clubfeet. Parents hence need to be explained about this delay.

Introduction

Ponseti method of correction is currently the most widely used method for the treatment of clubfoot [1–3]. Treatment includes serial plasters followed by percutaneous tendoachilles tenotomy and use of foot abduction orthosis for a minimum of 3–4 years. Bracing is an integral and important part of the treatment and it has been shown to decrease the relapse rate [4]. As parents are usually concerned about the motor milestones of these children, proper information about motor milestones given to these parents based on the published data will help decrease their apprehensions. There are very few prospective studies performed on motor milestones in children with clubfoot and its comparison with published normal regional growth along with World Health Organization (WHO) multi-centric growth reference standards [5–7]. Hence we decided to undertake a prospective study using a selected subset of children with severe idiopathic clubfoot in whom tendoachilles tenotomy was performed.

Materials and Methods

178 consecutive children diagnosed with idiopathic clubfoot attended our clinic from 2013 to 2017. Approval of our ethics committee and institutional review board was taken. Informed consent was taken from parents. To avoid selection bias, it was decided to include only those children in whom tendoachilles tenotomy was performed. Out of these, 158 children underwent a percutaneous tendoachilles tenotomy. Inclusion criteria were: children less than 3 months old with no previous treatment for clubfoot, no other orthopaedic condition like dislocation of hip or torticollis, full-term babies weighing more than 2 kg with no history of any birth injuries or neonatal complications. 8 children did not meet the above criteria. Hence we had 150 children who underwent a percutaneous tendoachilles tenotomy and did not have any other complicating factors and were included in the study group. The children were divided in two groups. Group 1: unilateral clubfoot, Group 2: bilateral clubfoot. All children were treated by serial plasters using the Ponseti method. All plasters were applied by the principal investigator who is a fellowship-trained Paediatric Orthopaedic Surgeon. 150 children underwent a percutaneous tendoachilles tenotomy when foot abduction of 40°–50° was achieved and the Pirani midfoot score was zero. This plaster was applied for 3 weeks. A foot abduction orthosis was used for 23 h for 3 months followed by 12 h every night for 3 years.

After removal of the final plaster, parents were taught about the motor milestones and printed graphical information about the milestones was given to them. They were followed up every 15 days where the principal investigator or co-authors would confirm the milestones achieved by the child and would answer all their doubts. The motor milestones were recorded till the child started walking independently, which was the endpoint of our study. The children were from surrounding location and parents were motivated to come for followup for the study. They were charged as per their income status for followup visits. If there was a discrepancy in the reading of milestones by the parents and the author then the date recorded and personally observed by one of the authors was considered. The motor milestones that were recorded were (1) rolls from back to stomach, (2) sitting without support, (3) standing with assistance, (4) walks with assistance, (5) standing alone (6) walking alone. These were then compared with the historical and published normative data from developmental assessment scales for Indian infants (DASII) and WHO published data. Rolling from back to stomach was not studied in the WHO group and hence it could not be compared. Hand and knee crawling was studied in the WHO group, but was not done in our group. Hence it could not be compared. All other milestones were compared.

Statistical Analysis

Statistical analysis was performed using SPSS version 20.0. Independent sample t test was used to compare the clinical variable in these two groups (unilateral clubfoot patients and bilateral clubfoot patients). Comparison of each group with published normal data of Development Assessment of Indian Infants (DASII) and with WHO published normal data was done. Since all the clinical variables are nominal variables with parametric data, independent sample t test was the appropriate test to compare their mean. For the two comparisons, p < 0.05 was considered to be the significance threshold.

Results

Ten patients were excluded from the study as they were not compliant with brace wear and were not regular with their follow-up. Five patients were excluded as there was a recurrence and they had to undergo repeated plasters or surgery. Hence a total of 135 children were included in the study. There were 80 children with unilateral clubfoot (Group 1). There were 55 children with bilateral clubfoot (Group 2). Both groups were comparable in terms of demographic data. The mean age at which the plaster was first applied in both groups was 13.5 days (range 7–90 days). In group 1, 48 (60%) were males and 32 (40%) were females. In group 2, 30 (55%) were males and 25 (45%) were females. The mean pre-operative Pirani score in Group 1 was 5.4 (range 4–6) and in Group 2 was 5.3 (range 4–6). The average duration of plaster treatment in both groups was for 2 months, with children in both groups requiring a mean of 5.7 plasters (range 5–8).

Comparison of typically developing children (regional data reference) and children with unilateral clubfoot (Table 1): Rolling from back to stomach was the same as in normal children. Sitting without support showed a delay of 1.3 months. Standing holding to a chair showed a delay of 0.3 months and walks with support showed a delay of 1.1 months. Standing alone showed a delay of 1.6 months and walking alone showed a delay of 0.7 months. All these differences were statistically significant.

Table 1.

Comparison of children with unilateral clubfoot, bilateral clubfoot and typically developing children using the Developmental assessment scales for Indian infants

Motor milestone	typically developing child (months)	Unilateral clubfoot (months)	Comparison of typically developing child and unilateral clubfoot (p value)	Bilateral clubfoot (months)	Comparison of typically developing child and bilateral clubfoot (p value)	Comparison of unilateral and bilateral clubfoot (p value)
Roll	4.684	4.684	0.03	4.85	0.001	0.03
Sitting without support	5.7	7.067	0.0001	6.96	0.001	0.183
Stand with support	7.9	8.249	0.0001	8.5	0.001	0.041
Walks with support	8.5	9.663	0.0001	9.67	0.001	0.4
Stand alone	10.1	11.722	0.0001	12.20	0.001	0.029
Walk alone	12	12.787	0.0001	13.77	0.001	0.004

The results are ages of children in months

Comparison of typically developing children (regional data reference) and children with bilateral clubfoot: Rolling from back to stomach showed a delay of 0.2 months, sitting without support showed a delay of 1.2 months. Standing next to the chair showed a delay of 0.5 months and walks with support showed a delay of 1.1 months. Standing alone showed a delay of 2.1 months and walking alone showed a delay of 1.7 months. All these differences were statistically significant.

There was also a statistically significant difference in unilateral and bilateral clubfeet in all variables except sitting without support and walking with support.

Our study group was then compared with the WHO group (Table 2). Sitting without support (delay of 1.01–1.1 month), standing next to chair (delay of 0.8–1.1 months), walking with support (delay of 0.6 months), standing alone (delay of 0.9–1.4 months) and walking alone (delay of 0.7–1.7 months) showed a statistically significant difference and a delay.

Table 2.

Comparison of children with unilateral clubfoot and bilateral clubfoot with typically developing children as in World Health Organization Multicentre Growth Reference Study Group

Motor milestones	typically developing child (months)	Unilateral clubfoot (months)	Comparison of typically developing child and unilateral clubfoot (p value)	Bilateral clubfoot (months)	Comparison of typically developing child and bilateral clubfoot (p value)
Sitting without support	5.9	7.067	0.0001	6.96	0.0001
Stand with support	7.4	8.249	0.0001	8.5	0.0001
Walks with support	9.0	9.663	0.0001	9.67	0.0001
Stand alone	10.8	11.722	0.0001	12.20	0.0001
Walk alone	12.0	12.787	0.0001	13.77	0.0001

Results are the age of children in months

Discussion

Untreated children with unilateral or bilateral clubfoot are independent ambulators, though there are a very few published studies about the achievement of motor milestones in them. The hypothesis before the start of this study was that casts and braces wear should not affect the gross motor milestones of children with clubfoot. To mitigate the influence of other confounding variables, the children who were full-term and without any other orthopaedic problem were included in the study. We decided to include only those children with idiopathic clubfoot in whom percutaneous tendoachilles tenotomy was performed. The other strength of this study is the prospective nature of this study. There are various studies which show the pitfalls of actual and recalled ages of milestone achievement [8, 9]. To maximise the accuracy of the actual age in this study, the parents were initially taught about the milestones and a printed form with photos was given to the parents. The parents were called every 15 days for follow-up and the accuracy of the date of achievement of a particular milestone was confirmed by the author.

Ethnicity, social habits and culture also play an important role in the development of motor milestones. Hence we decided to compare our results with published normal regional standards along with WHO standards. The DASII scoring system is a simple and quick test for an outpatient clinic [10]. Six milestones as already described were studied in children with clubfoot. All these milestones are very easy to identify and parents were taught about the same at the beginning of the study. We did not compare our study with other studies of typically developing children from other countries as the cultures and habits are different. However, we have compared our results with WHO published data in typically developing children. In WHO group we studied five motor milestones. All milestones were assessed using standardized procedures.

From the current study, we can conclude that there is a delay in motor milestones in children with unilateral and bilateral clubfoot. When compared with each other, children with bilateral clubfoot showed a slight delay as compared to unilateral clubfoot. However, the reason for the delay in pre-ambulatory milestones like rolling and sitting without support cannot be explained. The probable reasons for delay in milestones in children with clubfoot could be prolonged immobilization in above knee casts during the treatment, partial restriction of movement due to use of a brace and the primary pathology of clubfoot itself.

Sala et al. have published a study on motor milestones in 51 children with idiopathic clubfoot [11]. They found a delay of 1.5–2 months in perambulatory and ambulatory milestones in their group. However, their sample size was small and they have not studied unilateral and bilateral clubfoot separately. Tendoachilles tenotomy was performed in only 59% of children studied by them. We have included only those children in whom a tenotomy was performed.

Zionts et al. also studied walking age in clubfoot children treated by Ponseti method and they observed that independent walking was seen approximately 2 months later when compared to infants without clubfoot [12]. A greater delay may be expected for those patients who have a very severe deformity or those who experience a deformity relapse. However, they did not study other milestones and did not differentiate between unilateral and bilateral clubfeet.

In a study by Garcia et al., 26 babies with clubfeet treated with various methods (Ponseti method, French method and combination) were compared with 26 babies who were typically developing children. The gross motor performance was evaluated with the Albert Infant Motor Scale for six motor milestones. The researchers found that the babies with clubfeet had a mild delay in the gross motor skills and this delay became apparent around the age of 9 months. Babies without clubfeet were significantly more likely to walk at 12 months than babies with clubfoot [13].

Loof has shown that gross motor deficits and asymmetries are known to be present in children of 5 years of age with clubfoot. In unilateral clubfoot, the normal foot modifies in gait and foot motion just as the side with clubfoot. According to them, future studies are needed to prospectively study gross motor skills in children from the period of infancy [14].

A possible delay in milestones needs to be explained to parents before the start of treatment. Though all milestones are important, usually parents are more concerned about independent ambulation. There was a delay of 0.7 months for independent walking in children with unilateral clubfoot. 95% of children were walking independently by 17 months. There was a delay of 1.7 months for independent walking in children with bilateral clubfoot. 95% of children were walking independently by 17.8 months. We have shown that there is a difference in motor milestones in children with unilateral clubfoot and bilateral clubfoot. We have also compared our results with both regional and WHO reference standards and the results show a significant delay in milestones. Parents need to be explained that these delays are mild with no long-lasting implications and they should adhere to the brace protocol to avoid recurrences.

Funding

None of the authors received financial support for this study.

Compliance with Ethical Standards

Conflict of interest

The authors declare no conflicts of interest.

Ethical standard statement

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

Informed consent was obtained of all parents about the study.