Abstract
Purpose
Above-knee casts pose a major challenge in the day-to-day activities among walking age clubfoot patients due to complete restriction of knee movement. This current study investigates the effectiveness of below-knee casts compared to above-knee casts for managing walking age clubfoot deformity.
Methods
After approval from the institutional ethical committee, we enrolled walking age clubfoot patients for deformity correction through corrective manipulation and casting through below-knee casts over 2 years. The corrective manipulation was performed using the Ponseti technique. The patients were followed for a minimum of 2 years period. To compare the effectiveness of below-knee casts over above-knee casts, we enrolled equal numbers of walking age clubfeet matched for age and gender. We compared the two groups in terms of initial and post-correction Dimeglio scores, individual deformities corrections (maximum ankle dorsiflexion, heel varus correction, foot abduction), failure rates, relapses, and complication rates.
Results
56 patients with 80 clubfeet with a mean follow-up of 39.98 months were considered for the final analysis. There were 29 patients in the below-knee cast group and 27 in the above-knee cast group, with 40 clubfeet each. The patients in the above-knee casting group had significantly better post-correction Dimeglio scores and individual deformity components corrections than the below-knee cast group. There were nil failures in the above-knee casting group and 7.5% in the below-knee cast group. The relapse rate was 15% in both groups, with none requiring any extensive soft tissue procedure. We did not encounter any major complications during the treatment and follow-up.
Conclusion
The deformity correction and maintenance are suboptimal with the below-knee casts. Therefore, above-knee casts should be the preferred management modality for correction of walking age clubfoot deformities.
Keywords: Above-knee, Below-knee, Cast, Clubfoot, Cohort study, Deformity, Walking, Ponseti
Introduction
Adequate, appropriate and timely management are key factors in successful outcomes of clubfoot deformity [1]. Their lack results in rigid and resistant foot deformities when the child attains a walking age [1]. Factors contributing to the walking age clubfoot burden include limited healthcare facilities, lack of awareness among parents, lack of trained specialists in remote areas, and missed follow-ups [2]. The deformity worsens because of constant stress on the lateral aspect of the foot and resultant abnormal remodelling of the soft tissues and bones around the foot and ankle [3]. The patients often develop painful callosities and are unable to wear standard footwear. Both surgical and, recently, non-surgical treatments have been advocated for the treatment of walking age clubfoot [3–8]. The surgical treatment includes the bony and soft tissue procedures around the midfoot and hindfoot [3–8]. The extensive soft tissue release procedures are associated with deep scarring. The long-term outcomes following extensive surgical releases around the foot are not favourable [9]. The patients are often left with painful, scarred feet with arthritic joints and recurrence with rigid deformities [9].
Furthermore, many authors have demonstrated overwhelming results using standard and modified Ponseti techniques in walking age clubfeet [8, 10–13]. The Ponseti method is advantageous over surgical methods considering a low cost and less workforce-requiring method with superior clinical outcomes [14]. However, it requires a prolonged knee immobilisation in a flexed position in an above-knee cast. We have observed that older children are often reluctant to get the long leg casts applied due to limitations of their daily routine activities. These children depend on their guardians for all day-to-day activities, including perineal hygiene and toilet activities. We feel these factors can potentially contribute to non-compliance, missed follow-ups, and a late presentation with more rigid deformities. The above-knee casts are crucial for calcaneo-pedal unit stabilisation in young children [15]. Assuming that the contours of the bones in the leg and ankle are well established in the walking age group, we expected that a below-knee cast should maintain the correction of the deformed foot in the walking age group. We anticipated better compliance and follow-up with below-knee casts since the children with unrestricted knee movements do not necessarily need to be confined to bed; they can sit normally and are not completely dependent on others for basic activities like toilet transfer. However, the effectiveness of below-knee casts in clubfoot in walking age group children has not been studied previously. The present study aims to analyse the effectiveness of below-knee casts over above-knee casts using Ponseti’s foot manipulation technique to manage walking age clubfeet.
Materials and Methods
The study was prospectively conducted in the clubfoot clinic of a tertiary care centre catering to a major clubfoot load in India after approval from the institutional ethical committee. All cases with clubfoot deformity that had received inadequate/nil treatment before the child started walking and their parents willing to participate in the study were enrolled over 2 years. The minimum age for inclusion in the study was 2 years, considering children’s active and independently mobile status by the end of this age. The included patients were followed for a minimum of 2 years period. The patients with associated congenital anomalies, neurological conditions, and syndromic associations were excluded. The children fulfilling the inclusion criteria were managed by foot manipulation using Ponseti’s manipulation technique. In the test group, serial below knee casts were applied after manipulation to maintain the correction of foot. We created a control group to enrol an equal number of walking age clubfoot patients, and they were treated with similar manipulation but used above-knee casts. The controls were matched for age years and gender. We enrolled patients in the below-knee and above-knee cast groups every month during the 2-year enrolment period. We calculated a minimum sample size of 23 feet per group based on standard deviation data of Laaveg SJ and Ponseti IV on Long-term results of treatment of congenital club foot [16] and for a difference of two casts among the two groups with a power of 80%, confidence interval of 95%, and a significance level of 0.05.
Quantification of various deformity components was done using Pirani and Dimeglio scores at presentation and every follow-up visit. However, only Dimeglio scores were considered for the current analysis considering their appropriateness for the walking age group [17]. Two orthopaedic trainees who were well trained in making clubfoot clinical assessments measured the scores and had high intraclass correlation coefficients for interobserver (0.89) and intra-observer variations (0.92, 0.93). Patients underwent weekly cast applications in our day care clinic. We applied a thin layer of cotton padding throughout the casting area to allow the proper moulding of bony prominences. We used standard Plaster of Paris (POP) casts in this study. The following protocol was used for serial manipulation and casting:
We simultaneously corrected all components of clubfoot deformity except the equinus, which was the last one to be corrected. The cavus was thus corrected simultaneously with the abduction of the calcaneo-pedal block.
Tenotomy of the tendon-achilles was performed to correct the resistant dorsiflexion after correcting the remaining deformity components. All enrolled patients underwent percutaneous tenotomy of Tendo Achilles under general anaesthesia. Following the tenotomy, two biweekly above-knee casts were applied in both groups. Further passive dorsiflexion was attempted before the application of the second biweekly cast.
After removing the second post-tenotomy cast, all children (in both groups) were provided with two biweekly below-knee weight-bearing casts in maximal dorsiflexion.
After removing the weight-bearing casts, a nap and night-time bracing were advised using a Steenbeek splint for 5 years. We feel that such bracing protocol prevented any limitation of the child’s activity during the daytime and active hours. Besides regular visits during cast removal and application, the first follow-up visit after the steenbeek splint application was at one week, followed by a visit every four weeks for the next three months and then at six-monthly intervals. We considered Dimeglio scores and individual deformities correction (maximum ankle dorsiflexion, heel varus correction, foot abduction) at the time of the first presentation, at the removal of the final cast and during the last follow-up for the final analysis. Non-improvement of Dimeglio scores after three serial casts and before achieving a plantigrade foot was considered the treatment’s failure. The reappearance of equinus and varus deformities, dynamic supination, forefoot adduction, and cavus of the affected foot was considered a relapse.
Statistical Analysis
The continuous variables: follow-up duration, number of casts required before tenotomy of tendon-achilles, and Dimeglio scores, and individual deformities measurements were expressed as mean ± standard deviation for each group and were compared among the two groups using a t test for two independent means. In addition, the categorical variables, i.e., unilateral/bilateral involvement, Dimeglio stiffness classification, failure rates, relapse rate, and any treatment-related complications, were expressed as proportions and compared among the two groups using Fisher’s exact test. A p value of less than 0.05 was considered statistically significant. The IBM SPSS Statistics for Windows (Version 22.0. Armonk, NY: IBM Corp.) was used for statistical analysis.
Results
Fifty-six patients with eighty walking age clubfeet were enrolled in the study. Three patients in the below-knee cast group and two in the above-knee cast group were lost to follow-up. The mean follow-up duration was 39.25 months. The mean age of the subjects was 39.98 months. Twenty-nine patients were treated with the below-knee cast application, and 27 were treated with the above-knee cast application. Approximately 43% of the included patients had bilateral clubfeet. The study cohort predominantly included male patients (77%). The details of the number of casts required before tenotomy of tendon-achilles, Dimeglio scores at presentation, and the last follow-up are provided in Table 1. Index cases from each group are shown in Figs. 1 and 2. The mean number of casts required before tenotomy was 6.58. The mean Dimeglio score at initial presentation was 11.72, which improved to 1.83 at final cast removal. However, it increased to 2.14 ± 1.15 at the last follow-up.
Table 1.
The overall characteristics of the patients with walking age clubfeet in the cohort
| Parameters | Observations |
|---|---|
| Total number of cases | 56 patients (80 clubfeet) |
| Age (in months), mean ± SD | 39.98 ± 20.25 |
| Number of patients with bilateral clubfeet | 24 |
| Male–female distribution |
43 male patients 13 female patients |
| Number of casts required before tenotomy of tendon-achilles, mean ± SD (range) | 6.85 ± 2.18 |
| Mean Dimeglio score at presentation, mean ± SD | 11.72 ± .175 |
| Mean Dimeglio score after final cast removal, mean ± SD | 1.83 ± 1.11 |
| Dimeglio score at the last follow-up, mean ± SD | 2.14 ± 1.15 |
Fig. 1.
Before and after correction-clinical photographs of heel varus (a case of bilateral clubfeet in a walking age child treated with below-knee cast method
Fig. 2.
Before and after correction-clinical photographs of a case of left clubfoot in a walking age child treated with above-knee cast method
The number of clubfeet, bilateral cases, failure rates, number of casts required before tendon achilles tenotomy, Dimeglio scores and stiffness classification at presentation, and Dimeglio scores at final cast removal were not significantly different between the two casting groups. However, Dimeglio scores at the final follow-up were significantly higher in the below-knee casting group (2.45) compared to the above-knee cast group (1.84) (Table 2).
Table 2.
Comparative analysis between the above-knee cast application and below-knee cast application groups
| Parameter | Group 1 (above-knee cast) | Group 2 (below-knee cast) | Remarks |
|---|---|---|---|
| Number of cases | 27 patients (40 clubfeet) | 29 patients (40 clubfeet) | – |
| Number of bilateral cases | 13 | 11 | No significant difference (p > 0.05) |
| Failure rates (in %) | Nil | 7.5% | No significant difference (p > 0.05) |
| Number of casts required before tenotomy of tendon achilles, mean ± SD | 6.72 ± 2.11 | 6.97 ± 2.27 | No significant difference (p > 0.05) |
| Mean Dimeglio score at presentation, mean ± SD | 11.87 ± 1.60 | 11.57 ± 1.90 | No significant difference (p > 0.05) |
| Dimeglio stiffness classification |
9 soft > stiff 31 stiff > soft |
8 soft > stiff 31 stiff > soft 1 stiff-stiff |
No significant difference (p > 0.05) |
| Mean Dimeglio score at final cast removal, mean ± SD | 1.62 ± 1.23 | 2.05 ± 0.95 | No significant difference (p > 0.05) |
| Dimeglio score at last follow-up, mean ± SD | 1.84 ± 1.32 | 2.45 ± 0.86 | A significant difference (p < 0.05) |
At the initial presentation, there were no significant differences in the individual correction parameters (heel varus, equinus and forefoot adduction). However, significantly higher ankle dorsiflexion (22.3° vs 16.8°) and heel valgus correction (17.5° vs 14.1°) was observed in the above-knee cast group compared to the below-knee cast group at the final cast removal. In addition, significantly better maintenance of correction parameters was observed in correct parameters in above-knee casting groups compared to the below-knee casting group (ankle dorsiflexion: 18.2° vs 15.7°, heel valgus: 15.0° vs 11.7°, foot abduction 19.5° vs 17.1°). The detailed results are presented in Table 3.
Table 3.
Individual deformities correction assessment among the two cast groups
| Individual deformity component | Stage of measurement | Group 1 (above-knee cast) | Group 2 (below-knee cast) | Remarks |
|---|---|---|---|---|
| Maximum ankle dorsiflexion at (°) | At presentation | − 35.4 ± 14.7 | − 32.6 ± 13.3 | No significant difference (p > 0.05) |
| At final cast removal | 22.3 ± 7.3 | 16.8 ± 2.7 | A significant difference (p < 0.05) | |
| At last follow-up | 18.2 ± 5.2 | 15.7 ± 2.5 | A significant difference (p < 0.05) | |
| Heel varus (°) | At presentation | − 15.2 ± 8.3 | − 15.6 ± 7.7 | No significant difference (p > 0.05) |
| At final cast removal | 17.5 ± 4.2 | 14.1 ± 3.9 | A significant difference (p < 0.05) | |
| At last follow-up | 15.0 ± 5.4 | 11.7 ± 4.2 | A significant difference (p < 0.05) | |
| Foot abduction (°) | At presentation | − 17.6 ± 7.4 | − 16.5 ± 8.5 | No significant difference (p > 0.05) |
| At final cast removal | 21.2 ± 6.2 | 20.8 ± 4.1 | No significant difference (p > 0.05) | |
| At last follow-up | 19.5 ± 5.9 | 17.1 ± 5.3 | A significant difference (p < 0.05) |
Relapse Rates
There were six feet (15%) with relapses in each group. Two patients in the above-knee cast group and three in the below-knee cast group required split tibialis anterior tendon lateral transfer for dynamic supination. Loss of dorsiflexion limiting the squatting activity of the patients required repeat tenotomy of the Achilles tendon in two patients in the above-knee cast group and one patient in the below-knee cast group. Two patients in each group had a combined relapse of loss of dorsiflexion with cavus, and those were managed with repeat tenotomy of the Achilles tendon and percutaneous plantar fascia release. None of the patients required any extensive soft tissue procedure. These patients were then resubjected to the afore-described corrective manipulation and casting protocol. There was a history of non-compliance to the bracing protocol in all patients who experienced a deformity relapse. There was no history of non-compliance to braces in all patients without relapse.
Complications
Three patients in the above-knee casting group and two in the below-knee casting group had developed plaster sores that healed spontaneously following occlusive dressing. In addition, one patient had developed erythema around the plastered area in the below-knee casting group that resolved spontaneously without any intervention.
Discussion
The current study supports above-knee casts to correct walking age clubfeet following an aggressive corrective manipulation. Although correction was achieved with both above-knee and below-knee casting patterns, the correction after the last cast and at the last follow-up was less in the below-knee casting group. Another important point highlighted in our analysis is the importance of Dimeglio scores and individual deformity parameters in the clinical assessment of older patients. The significant differences were evident in Dimeglio scores and the individual deformity assessments. Therefore, a comprehensive clinical assessment must follow walking age clubfoot to predict the recurrence timely. In addition, although the failure rates were low, all of them were observed in below-knee casting, which further strengthens the superiority of above-knee casts.
The currently available evidence suggests superior functional outcomes with Ponseti’s technique-based manipulation and casting to correct walking age clubfoot [8, 10, 11, 17–25]. We used an aggressive approach of foot manipulation after Tendo-Achilles tenotomy in walking age clubfeet to gain further dorsiflexion. Such an approach was described by Mehtani et al. [11], which involved additional casts after the tendon-achilles tenotomy. Their results were superior compared to the previous studies. There were few relapses, but they got corrected either by recasting, re-tenotomy of tendon achilles, or tibialis anterior transfer. None of them required any extensive surgical procedure. The same technique also forms the basis of our methodology, considering that the walking age group clubfoot may be stiffer due to abnormal weight-bearing [2]. The standard casting procedure involves applying a long leg (above-knee) cast at a weekly interval until the complete correction is achieved. We feel that one major drawback it poses in the walking age clubfoot is the sudden restriction of the child’s activities rendering him dependent on others for basic needs. A short leg (below-knee) cast appears to be an attractive alternative to long leg casts. The debate regarding the slippage of a short leg cast or its loosening can be well addressed by the appearance of more mature bony contours in a walking child. We feel that the below-knee casts can help the child have lesser activity restriction, easy bed transfer, better perineal care, and only partially dependent on others. The child can also remain involved in recreational activities that need free knee motion.
The mean age in our study was comparable to most of the previous studies that analysed the effectiveness of corrective casting and manipulation in walking age clubfoot. Our review found only six studies that have analysed the role of manipulation and casting in children older than 6 years [13, 19, 21, 25–27]. The failure rate has been observed to be higher in older children. The younger age group seems to benefit most from the corrective casting for walking age clubfoot [10, 11, 17, 18, 20, 22–25]. Only three studies have observed a failure in younger children (ranging from 6 to 13%) [17, 22, 27]. Minor skin complications following cast application are quite common in the walking age clubfeet and resolve uneventfully [10, 11, 27]. Our study’s number of casts required for complete correction (excluding the two final casts after correction) is comparable to most other studies ranging from six to ten casts [11, 17, 18, 20, 22–25]. The number of casts required to correct walking age clubfeet in the younger population is low [13]. The mean number of casts required for the correction was higher than twelve in the studies by Sinha et al. [10] and by Khan et al. [19]. While in the former, a previously non-intervened walking age clubfoot could have contributed to a higher number of casts. In the latter, a predominantly older age group could have contributed to a higher number of corrective casts. The study by Bashi et al. [25] also had a predominantly older age group but had the required number of casts to be less than ten. A small sample size of eleven patients could probably have masked the large volume figures. In observations by Banskota et al. [21], the number of casts required in older children was less than ten. However, those reached a plateau phase of correction much before the complete correction was achieved, as evident in their final clinical scores.
In our study, there were few relapses in both the groups (six each), the recurring components of which were flexible ones. All of them were managed with minor soft tissue procedures and manipulation and recasting. None of the patients required any extensive soft tissue release. However, Lourenço et al. [8] reported a high relapse rate of 62% (15 out of 25 feet). A less aggressive approach towards serial casting (one cast in 2 weeks) and a smaller sample size could potentially contribute to a high relapse rate. In most of the studies in the past, very few relapses required any major soft tissue release. However, in the study by Khan et al. [19], all recurrences required a major soft tissue release. A predominantly older age group (mean = 8.9 years) with resistant deformity could have contributed to the need for posteromedial soft tissue release. Agarwal et al. [26] attempted to find the correlation of Pirani and Dimeglio score severity on the number of casts required for correction in walking age clubfoot. The authors observed that both scores do not correlate well with the number of casts required for correction, but cavus deformity had a significant positive correlation with cast numbers. Such analysis was not performed in our study. de Podesta Haje et al. [27] found an 87% success rate with the Ponseti method of correction in their retrospective multicentric study on clubfoot management in walking age group children.
The relapse rates were higher (31%) than 15% in our study. The inclusion of relatively older patients, including those more than 15 years old, could have resulted in a higher relapse rate. The mean number of casts required was 6.8. The number of casts was comparable to our observations in both groups when excluding the additional casts after the first post-Tendo Achilles tenotomy cast. Non-compliance to the bracing protocol was observed in around half of the relapse cases. Around one-fifth of the patients without any relapse also had compliance issues with braces. On the contrary, in our study, compliance issues were not observed in any non-relapsing case. Easy and free-of-cost brace availability in our institute could be a contributing factor which was not the case in the study by de Podesta Haje et al. [27].
Recently, Ferreira et al. [12], in their systematic review on the Ponseti method in the walking age group, highlighted the lack of prospective studies and most studies being case series only. Their pooled analysis suggested a success rate of approx. 87%, which is comparable to both groups in our study. However, the relapse rate was 18%, slightly higher than our study. Like our findings, non-adherence to the bracing protocol was considered a decisive factor for relapses in most included studies. Meanwhile, Shah et al. [13] also reviewed the outcomes of the Ponseti technique in walking age children with clubfeet. The authors suggested that standard Ponseti methods without major modifications like open Tendo Achilles lengthening, posterior releases, plantar fasciotomy or cast change every 2–4 weekly is sufficient for walking age clubfoot management. The only minor modification suggested by the authors was reducing bracing time to night and nap, which was followed in our study. The same could be the potential factor for findings of full compliance rate in non-relapse cases. Besides these, the authors observed an increase in the number of casts required for correction among older patients. In addition, recent narrative reviews by Alves et al. [28] and Penny et al. [2] have highlighted the effectiveness of the Ponseti method of manipulation and casting in walking age group children with no upper age limit defined. The detailed comparative analysis of the current study groups with the previous studies on walking age clubfoot correction using manipulation and casting has been presented in Table 4.
Table 4.
Review of major studies that investigated the effectiveness of serial manipulation and casting in the walking age clubfeet
| Authors | Year of publication | Sample size | Inclusion criteria | Mean age | Mean Dimeglio at presentation | Mean Dimeglio after at final correction | Mean Pirani score at presentation | Mean Pirani score at final correction | Mean number of casts | Relapse rate | Complications (if any) | Need for extensive soft tissue release | Follow up |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Lourenço et al. [8] | 2007 | 17 children (24 feet) | Presentation after walking age | 3.9 years | NA | NA | NA (4 or 5) | NA | 9 |
62%, 7 feet required achilles tenotomy 8 feet required posterior release |
Minor skin complications | None | 3.1 years |
| Spiegel et al. [17] | 2008 | 171 patients (260 feet) | Age between 1 and 6 years | NA | NA | NA | 5.15 | 2.07 | 7 | NA |
Posterior release wound dehiscence—5 feet Prolonged bleeding from percutaneous tenotomy site-1 Tibial bowing -2 |
6% | NA |
| Khan et al. [19] | 2010 | 21 patients (25 feet) | Age more than 7 years | 8.9 years | 14.2 | 0.95 | NA | NA | 12.1 | 24% (6 feet) | Minor skin complications | 24% (6 feet) | 4.7 |
| Yagmurlu et al. [20] | 2011 | 27 patients (31 feet) | Presentation after walking age | 1.75 years | NA | NA | NA | NA | 6 | None | NA | None | 2.66 years |
| Banskota et al. [21] | 2013 | 36 children (55 feet) | Age between five to ten years | 7.4 years | 15.9 | 5.9a | 5.1 | 2.1a | 9.5 | 16%, 9 feet | Minor skin complications | 1.8% (1 foot) | 2.62 years |
| Verma et al. [22] | 2012 | 37 patients (55 feet) | Age between 1 and 3 years | 2.06 | NA | NA | 4.95 | 0.76 | 10 | 21.8%, 12 feet | None | 10.9%, 6 feet | 2.5 years |
| Ayana et al. [23] | 2014 | 22 patients (32 feet) | Age more than 2 years | 4.4 years | NA | NA | 5 | 0 | 8 | 15.6%, 5 feet | No major complications | None | 3 years |
| Faizan et al. [24] | 2015 | 19 patients (28 feet) | Age more than 1 year | 2.7 years | 12.96 | 2.32 | 4.84 | 0.55 | 8 | 7.2%, 2 feet | Minor skin complications | None | 2.7 years |
| Bashi et al. [25] | 2016 | 11 patients (18 feet) | Age more than 6 years | 11.2 years | NA | NA | NA | NA | 9 | NA | Minor skin complications and hematoma formation following plantar fascia release | 9%, one foot | 1.25 years |
| Sinha et al. [10] | 2016 | 30 patients (41 feet) | Age more than one years without any prior treatment | 3.02 years | 15.9 | 2.07 | 5.41 | 0.12 | 12.8 | 17%, 7 feet | Minor skin complications and one flat top talus due to large number of casts | None | 2.6 years |
| Mehtani et al. [11] | 2017 | 41 patients (62 feet) | Age more than one without any prior treatment | 3.1 years | 15.9 | 0.52 | 4.23 | 0.03 | 6.9 | 10.6%, 8 feet | Minor skin complications | None | 3 years |
| Adegbehingbe et al. [18] | 2017 | 225 patients (328 feet) | Age more than 1 year | NA | NA | NA | NA | NA | 6.84 | 26 feet | NA | NA | NA |
| Shah et al. [13] | 2018 | 56 patients (81 feet) | 1–10 years | 3.16 years | 4.7 | 0.15 | NA | NA | 7.36 | 30.86%, 19 feet | None | None | 2.96 years |
| Agarwal et al. [26] | 2019 | 27 patients (39 feet) | 2–11 years | 4.78 years | 3.92 | 0.42 | 13.05 | 3.59 | 8.45 | NA | NA | NA | NA |
| de Podesta Haje et al. [27] | 2020 | 303 patients (429 feet) | Age more than 1 year | 3 years | NA | NA | 5.0 | 0.5 | 6.8 | 31%, 32 out of 103 clubfeet | Minor skin complication, one infection and one rocker-bottom deformity | 5%, (23 feet) | At least 2 years for 103 patients |
| Current study | 2021 | above-knee cast group: 27 patients (40 feet) | Age more than two years with nil or inadequate prior management | 3.26 years | 11.87 | 1.84 | 4.81 | 0.05 | 8.72b | 15%, 6 feet | Minor skin complications | None | 3.16 years |
| Below-knee cast group: 29 patients (40 feet) | Age more than two years with nil or inadequate prior management | 3.39 years | 11.57 | 2.45 | 4.75 | 0.04 | 8.97b | 15%, 6 feet | Minor skin complications | None | 3.44 years |
NA: data not reported in the study
aBefore the tenotomy of tendon achilles
bIncluding two casts post-tenotomy of tendon achilles
The casting frequency was similar to the previous studies except for those in the study by Lourenço et al. [8], where biweekly casts were applied. Two biweekly casts were applied in the immediate post-tenotomy period in our study. This pattern was based on the observations of Mehtani et al. [11] of the additional scope of dorsiflexion correction at two weeks post-tenotomy of tendon achilles. The manipulation technique in our study was a bit more aggressive, similar to that advocated by Mehtani et al. [11] and Morcuende et al. [29] with simultaneous correction of all deformity components other than equinus. The aggressive manipulation was intended to reduce the number of casts, which obviously would be higher in number when each component is addressed separately.
The consensus regarding the use of below-knee casting over above-knee casting in walking age clubfeet or older children has not been established yet. Maripuri et al. [30] analysed the effectiveness of two casting methods in managing idiopathic clubfeet and found unacceptably high failure rates and marked longer treatment time with the below-knee casts. However, their subjects were infants aged less than a month. Short leg casts in such patients can result in slippage and loosening because of the lack of prominent bones and the presence of baby fat. Our cases, on the contrary, belonged to age more than 2 years when the bony landmarks are more prominent. Ippolito et al. [31] used below-knee casts in walking age group clubfeet after the plantigrade status of the foot was achieved through 4–5 above-knee casts. However, the impact of such treatment on correction-related outcomes was not analysed. To the best of our knowledge, there has not been any comparative study analysing the effectiveness of below-knee casts over above-knee casts in walking age clubfoot. Our analysis suggests that while the below-knee casts appear to be a potential answer to the activity restriction posed by above-knee casts, they may not match the above-knee casts in terms of deformity correction and maintenance of correction.
The current study does not analyse what went wrong with below-knee casts and focuses only on clinical correction-related outcomes. Since the manipulation technique used was the same for both groups, we feel that lack of rotational stability in the below-knee cast compared to the above-knee cast with the knee joint acting as a pivot could be the factor affecting the quality of correction achieved. While the correction might have been achieved well with below-knee casts, lack of knee joint spanning could have a potential role in the suboptimal maintenance of correction. The three failures were observed only in the below-knee cast group, possibly because of the high Dimeglio score and stiffness (two cases were stiff > soft type, one was stiff-stiff). Maybe the mature bony contours were insufficient to control the rotation of the calcaneo-pedal block. Finally, there were some limitations of this study. First, the study is based on the response of serial casting and manipulation among a subset of a regional population. The response to differing casting techniques and other populations may differ. Second, those feet that had received a prior incomplete treatment were less deformed than those with no treatment. This difference in prior treatment could have affected the overall correction variables, especially the number of casts required for correction and the nature and number of relapses. Third, the mean age of the patients in the current study cohort was around 3 years. Therefore, the effectiveness of the below-knee casts in older children cannot be predicted. Fourth, the study provides results at a mean follow-up of approximately 40 months. Long-term studies would be needed to comment upon the change in correction parameters and brace compliance in older patients. Fifth, the study reports only the correction parameters between the above knee and below-knee casting methods. The patient-reported outcomes were not part of this study. Lastly, although prospective controlled, the study is not a randomised controlled trial. Therefore, it tends to have a selection bias. Attempts were made to reduce the same by enrolling age, gender-matched controls and baseline parameters were compared to rule out any significant differences between the two groups.
Conclusion
In the walking age group, below-knee casts have the advantage of unrestricted knee motion, and a less cumbersome mode of deformity management over the standard above-knee casts for walking age clubfoot management. However, the deformity correction and maintenance remain suboptimal with the below-knee casts. Therefore, above-knee casts should be the preferred modality for managing walking age clubfoot deformities.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declarations
Conflict of interest
None of the authors have any conflicts to declare.
Ethical approval
The study was approved by the Institutional ethics committee.
Informed consent
Informed consent was obtained from all individual participants in this study.
Footnotes
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Contributor Information
Akhil Agnihotri, Email: akhilagnihotri13@gmail.com.
Arvind Kumar, Email: arvindmamc@gmail.com.
Suresh Chand, Email: sureshdocucms@gmail.com.
Anil Mehtani, Email: dranilmehtani@gmail.com.
Alok Sud, Email: avimukta2@gmail.com.
Siddhartha Sinha, Email: siddharthasinha87@gmail.com.
References
- 1.Penny JN. The neglected clubfoot. Techniques in Orthopaedics. 2005;20(2):153–166. doi: 10.1097/01.bto.0000162987.08300.5e. [DOI] [Google Scholar]
- 2.Penny N, Aroojis A, Mehtani A, Banskota B. Clubfoot correction in walking-age children: A review. Journal of Foot and Ankle Surgery (Asia Pacific) 2021;8(3):103. [Google Scholar]
- 3.Faldini C, Traina F, Di Martino A, Nanni M, Acri F. Can selective soft tissue release and cuboid osteotomy correct neglected clubfoot? Clinical Orthopaedics and Related Research. 2013;471(8):2658–2665. doi: 10.1007/s11999-013-2977-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ferreira RC, Costo MT, Frizzo GG, da Fonseca Filho FF. Correction of neglected clubfoot using the Ilizarov external fixator. Foot and Ankle International. 2006;27(4):266–273. doi: 10.1177/107110070602700407. [DOI] [PubMed] [Google Scholar]
- 5.Grill F, Franke J. The Ilizarov distractor for the correction of relapsed or neglected clubfoot. Journal of Bone and Joint Surgery British Volume. 1987;69(4):593–597. doi: 10.1302/0301-620X.69B4.3611163. [DOI] [PubMed] [Google Scholar]
- 6.El Barbary H, Abdel Ghani H, Hegazy M. Correction of relapsed or neglected clubfoot using a simple Ilizarov frame. International Orthopaedics. 2004;28(3):183–186. doi: 10.1007/s00264-004-0540-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Angus PD, Cowell HR, Triple arthrodesis, A critical long-term review. Journal of Bone and Joint Surgery British Volume. 1986;68(2):260–265. doi: 10.1302/0301-620X.68B2.3958012. [DOI] [PubMed] [Google Scholar]
- 8.Lourenço AF, Morcuende JA. Correction of neglected idiopathic club foot by the Ponseti method. Journal of Bone and Joint Surgery British Volume. 2007;89(3):378–381. doi: 10.1302/0301-620X.89B3.18313. [DOI] [PubMed] [Google Scholar]
- 9.Dobbs MB, Nunley R, Schoenecker PL. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. Journal of Bone and Joint Surgery American Volume. 2006;88(5):986–996. doi: 10.2106/00004623-200605000-00009. [DOI] [PubMed] [Google Scholar]
- 10.Sinha A, Mehtani A, Sud A, Vijay V, Kumar N, Prakash J. Evaluation of Ponseti method in neglected clubfoot. Indian Journal of Orthopaedics. 2016;50(5):529–535. doi: 10.4103/0019-5413.189597. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Mehtani A, Prakash J, Vijay V, Kumar N, Sinha A. Modified Ponseti technique for management of neglected clubfeet. Journal of Pediatric Orthopedics Part B. 2018;27(1):61–66. doi: 10.1097/BPB.0000000000000450. [DOI] [PubMed] [Google Scholar]
- 12.Ferreira GF, Stéfani KC, Haje DP, Nogueira MP. The Ponseti method in children with clubfoot after walking age—systematic review and metanalysis of observational studies. PLoS ONE. 2018;13(11):e0207153. doi: 10.1371/journal.pone.0207153. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Shah A, Mehta R, Aroojis A. The Ponseti method of clubfoot treatment in walking age children: Is it effective? A study of 56 children from 1 to 10 years of age. Journal of Pediatric Orthopedics Part B. 2019;28(2):159–166. doi: 10.1097/BPB.0000000000000562. [DOI] [PubMed] [Google Scholar]
- 14.Grimes CE, Holmer H, Maraka J, Ayana B, Hansen L, Lavy CBD. Cost-effectiveness of club-foot treatment in low-income and middle-income countries by the Ponseti method. BMJ Global Health. 2018;1(1):e000023. doi: 10.1136/bmjgh-2015-000023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Seringe R, Wicart P, French Society of Pediatric Orthopaedics The talonavicular and subtalar joints: The “calcaneopedal unit” concept. Orthopaedics and Traumatology, Surgery and Research. 2013;99(6 Suppl):S345–S355. doi: 10.1016/j.otsr.2013.07.003. [DOI] [PubMed] [Google Scholar]
- 16.Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. Journal of Bone and Joint Surgery American Volume. 1980;62(1):23–31. doi: 10.2106/00004623-198062010-00004. [DOI] [PubMed] [Google Scholar]
- 17.Spiegel DA, Shrestha OP, Sitoula P, Rajbhandary T, Bijukachhe B, Banskota AK. Ponseti method for untreated idiopathic clubfeet in Nepalese patients from 1 to 6 years of age. Clinical Orthopaedics and Related Research. 2009;467(5):1164–1170. doi: 10.1007/s11999-008-0600-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Adegbehingbe OO, Adetiloye AJ, Adewole L, et al. Ponseti method treatment of neglected idiopathic clubfoot: Preliminary results of a multi-center study in Nigeria. World J Orthop. 2017;8(8):624–630. doi: 10.5312/wjo.v8.i8.624. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Khan SA, Kumar A. Ponseti's manipulation in neglected clubfoot in children more than 7 years of age: A prospective evaluation of 25 feet with long-term follow-up. Journal of Pediatric Orthopedics Part B. 2010;19(5):385–389. doi: 10.1097/BPB.0b013e3283387cc8. [DOI] [PubMed] [Google Scholar]
- 20.Yagmurlu MF, Ermis MN, Akdeniz HE, Kesin E, Karakas ES. Ponseti management of clubfoot after walking age. Pediatrics International. 2011;53(1):85–89. doi: 10.1111/j.1442-200X.2010.03201.x. [DOI] [PubMed] [Google Scholar]
- 21.Banskota B, Banskota AK, Regmi R, Rajbhandary T, Shrestha OP, Spiegel DA. The Ponseti method in the treatment of children with idiopathic clubfoot presenting between five and ten years of age. Bone Joint Journal. 2013;95-B(12):1721–1725. doi: 10.1302/0301-620X.95B12.32173. [DOI] [PubMed] [Google Scholar]
- 22.Verma A, Mehtani A, Sural S, et al. Management of idiopathic clubfoot in toddlers by Ponseti's method. Journal of Pediatric Orthopedics Part B. 2012;21(1):79–84. doi: 10.1097/BPB.0b013e328347a329. [DOI] [PubMed] [Google Scholar]
- 23.Ayana B, Klungsøyr PJ. Good results after Ponseti treatment for neglected congenital clubfoot in Ethiopia. A prospective study of 22 children (32 feet) from 2 to 10 years of age. Acta Orthopaedica. 2014;85(6):641–645. doi: 10.3109/17453674.2014.957085. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Faizan M, Jilani LZ, Abbas M, Zahid M, Asif N. Management of idiopathic clubfoot by Ponseti technique in children presenting after one year of age. Journal of Foot and Ankle Surgery. 2015;54(5):967–972. doi: 10.1053/j.jfas.2014.05.009. [DOI] [PubMed] [Google Scholar]
- 25.Bashi RH, Baghdadi T, Shirazi MR, Abdi R, Aslani H. Modified Ponseti method of treatment for correction of neglected clubfoot in older children and adolescents—a preliminary report. Journal of Pediatric Orthopedics Part B. 2016;25(2):99–103. doi: 10.1097/BPB.0000000000000266. [DOI] [PubMed] [Google Scholar]
- 26.Agarwal A, Shanker M. Correlation of scores with number of Ponseti casts required for clubfoot correction in the older child. Journal of Clinical Orthopaedics and Trauma. 2020;11(2):232–235. doi: 10.1016/j.jcot.2019.04.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.de Podesta HD, Maranho DA, Ferreira GF, et al. Ponseti method after walking age—a multi-centric study of 429 feet: results, possible treatment modifications and outcomes according to age groups. Iowa Orthopaedic Journal. 2020;40(2):1–12. [PMC free article] [PubMed] [Google Scholar]
- 28.Alves C, Batlle AE, Rodriguez MV. Neglected clubfoot treated by serial casting: A narrative review on how possibility takes over disability. Annals of Translational Medicine. 2021;9(13):1103. doi: 10.21037/atm-21-65. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. Journal of Pediatric Orthopedics. 2005;25(5):623–626. doi: 10.1097/01.bpo.0000162015.44865.5e. [DOI] [PubMed] [Google Scholar]
- 30.Maripuri SN, Gallacher PD, Bridgens J, Kuiper JH, Kiely NT. Ponseti casting for club foot - above- or below-knee?: A prospective randomised clinical trial. Bone Joint Journal. 2013;95-B(11):1570–1574. doi: 10.1302/0301-620X.95B11.31899. [DOI] [PubMed] [Google Scholar]
- 31.Ippolito E, Farsetti P, Valentini MB. Management of clubfoot. In: Bentley G, editor. European surgical orthopaedics and traumatology. Springer; 2014. [Google Scholar]