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Long-Term Comparative Results in Patients with Congenital Clubfoot Treated with Two Different Protocols
E. Ippolito, MD; P. Farsetti, MD; R. Caterini, MD; C. Tudisco, MD
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Investigation performed at the Department of Orthopaedic Surgery, University of Rome, Rome, Italy

E. Ippolito, MD
P. Farsetti, MD
R. Caterini, MD
C. Tudisco, MD
Department of Orthopaedic Surgery, University of Rome "Tor Vergata," Via Montpellier, 1-00133 Rome, Italy. E-mail address for E. Ippolito: e.ippolito@mclink.it

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Santa Lucia Foundation for Assistance and Research, which allowed them to perform all of the radiographic and computed tomography studies in its hospital. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2003 Jul 01;85(7):1286-1294
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Background: Long-term follow-up studies of adults who had been treated for congenital clubfoot as infants are rare. The purpose of this study was to review and compare the long-term results in two groups of patients with congenital clubfoot treated with two different techniques. In both groups, treatment was started within the first three weeks of life by manipulation and application of toe-to-groin plaster casts, with a different technique in each group. At the end of the manipulative treatment, a posteromedial release was performed when the patient was between eight and twelve months of age in the first group and a limited posterior release was performed when the patient was between two and four months of age in the second group.

Methods: At the follow-up evaluations, all patients were interviewed and examined, and standing anteroposterior and lateral radiographs and computed tomography scans of the foot were made. The results of treatment were graded according to the system of Laaveg and Ponseti. Numerous angular measurements were made on the radiographs, and the measurements in the two groups were compared.

Results: The first group, which included thirty-two patients (forty-seven clubfeet), was followed until an average age of twenty-five years. The second group, with thirty-two patients (forty-nine clubfeet), was followed until an average age of nineteen years. In the first group, there were two excellent, eighteen good, eleven fair, and sixteen poor results. In the second group, there were eighteen excellent, twenty good, six fair, and five poor results. According to the system of Laaveg and Ponseti, the mean rating in the first group was 74.7 points and that in the second group was 85.4 points.

Conclusions: In the second group, use of Ponseti's manipulation technique and cast immobilization followed by an open heel-cord lengthening and a limited posterior ankle release gave much better long-term results than those obtained in the first group, treated with our manipulation technique and cast immobilization followed by an extensive posteromedial release of the foot. In our hands, this operation did not prevent relapse, and neither cavovarus nor forefoot adduction was completely corrected.

Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Ernesto Ippolito
    Posted on November 15, 2003
    Dr. Ippolito responds to Dr. Altchek
    Univ ersity of Tor Vergata Rome

    Dear Dr. Altcheck,

    Thank you very much for your comment. We fully agree with your statement that extensive surgery should be avoided in congenital clubfoot treatment and that conservative treatment provides very good long-term functional results. However, according to previous pathological studies, medial subluxation of both the talo-navicular and the calcaneo-cuboid joints is a nearly constant finding in congenital clubfoot. On the contrary, medial and plantar deviation of the neck of the talus is not a constant deformity according to Waisbrod(1).

    We also know that severe deformities of the neck of the talus are found in most severe cases of congenital club-foot. However a proper manipulation may correct the talar neck deformity as recently demonstrated by Pirani et al.(2).

    Best regards.

    (1)Waisbrod H.: Congenital clubfoot. An anatomical study. J.Bone Joint Surg (Br)1973; 55:796-801.

    (2) Pirani S., Zeznik L., Hodges D.: Magnetic resonance imaging study of the congenital clubfoot treated with the Ponseti method. J.Pediatr Orthop 2001,21(6):719-726.

    Martin Altchek
    Posted on October 15, 2003
    Non Operative Treatment of Club Foot Deformity
    Martin Altchek, M.D., P.C.

    To The Editor:

    I am a general orthopedic surgeon in private practice. Since 1956, I have treated every child with congenital club foot solely with cast correction. In my opinion, the reason that correcting club foot is difficult is because the basic deformity is in the structure of the talus. The head and neck of the talus are medially and plantarly directed and the plantar surface of the talus is also deformed in inversion and equinus.(1,2). Practically all contemporary papers that address correction of club feet fail to recognize that the primary deformity is in the talus. Instead, they state that the deformity is caused by subluxation of bones about a normal talus. If this were the case, club feet would be much easier to treat, and they would not recur so often.

    Surgical correction creates a second deformity that attempts to compensate for the first. When recurrence occurs, scar that has formed about the talus makes the deformity increasingly difficult to correct. As this article(3) demonstrates, the more surgery that is performed on the foot, the worse the result.

    In my opinion, the correct treatment of club foot requires frequent accurate cast changes over a prolonged period of time(4,5,6). Even if one cannot completely accomplish the goal of remodeling the talus, one can stretch the surrounding soft tissues without causing the scarring that follows surgery.

    1 Irani RN, Sherman MS: Pathological anatomy of clubfoot, Journal of Bone and Joint Surgery, 45A:45, 1963.

    2 Settle GW, Anatomy of Congenital Talipes Equinus Varus, Journal of Bone and Joint Surgery, 45A:1341, 1963.

    3.Long Term Comparative Results in Patients with Congenital Club Feet Treated with Two Different Protocols, Journal of Bone and Joint Surgery, Vol 85A:1286-1294, July 2003.

    4. Altchek MA, Molding of the Talus: A Method of Treating Club Feet, Clinical Orthopedics, May 1972.

    5. Altchek MA, Treatment of Club Feet by Molding the Talus, Orthopaedic Review, May 1974.

    6. Altchek MA, published letters and discussions:

    a. Comments and Response on the treatment of club feet in the September 1974 issue of Orthopaedic Review.

    b. Discussion of congenital club feet in Clinical Orthopaedics January/February 1978.

    c. Letter concerning complete subtalar release in club feet: part one of a preliminary report in The Journal of Bone and Joint Surgery, Volume 68A.

    d. Correspondence regarding non-operative treatment of idiopathic club feet in The Journal of Bone and Joint Surgery, October 1996.

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