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Long-Term Follow-up of Patients with Clubfeet Treated with Extensive Soft-Tissue Release
Matthew B. Dobbs, MD1; Ryan Nunley, MD1; Perry L. Schoenecker, MD1
1 Department of Orthopaedic Surgery, Washington University School of Medicine, One Children's Place, Suite 4S20, St. Louis, MO 63110. E-mail address for M.B. Dobbs: dobbsm@wudosis.wustl.edu
View Disclosures and Other Information
In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the Ronald McDonald House Charities and Barnes-Jewish Hospital Foundation. They did not receive 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.
Investigation performed at Washington University School of Medicine, St. Louis Children's Hospital, and St. Louis Shriners Hospital for Children, St. Louis, Missouri

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 May 01;88(5):986-996. doi: 10.2106/JBJS.E.00114
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Abstract

Background: Although long-term follow-up studies have shown favorable results, in terms of foot function, after treatment of idiopathic clubfoot with serial manipulations and casts, we know of no long-term follow-up studies of patients in whom clubfoot was treated with an extensive surgical soft-tissue release.

Methods: Forty-five patients (seventy-three feet) in whom idiopathic clubfoot was treated with either a posterior release and plantar fasciotomy (eight patients) or an extensive combined posterior, medial, and lateral release (thirty-seven patients) were followed for a mean of thirty years. Patients were evaluated with detailed examination of the lower extremities, a radiographic evaluation that included grading of osteoarthritis, and three independent quality-of-life questionnaires, including the Short Form-36 Medical Outcomes Study.

Results: At the time of follow-up, the majority of patients in both treatment groups had significant limitation of foot function, which was consistent across the three independent quality-of-life questionnaires. No significant difference between groups was noted with regard to the results of the quality-of-life measures, the range of motion of the ankle or the position of the heel, or the radiographic findings. Six patients who had been treated with only one surgical procedure had better ranges of motion of the ankle and subtalar joints (p < 0.004) than those who had had multiple surgical procedures.

Conclusions: Many patients with clubfoot treated with an extensive soft-tissue release have poor long-term foot function. We found a correlation between the extent of the soft-tissue release and the degree of functional impairment. Repeated soft-tissue releases can result in a stiff, painful, and arthritic foot and significantly impaired quality of life.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

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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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    Matthew B. Dobbs
    Posted on July 25, 2006
    Long-Term Follow-Up of Patients with Clubfeet Treated with Extensive Soft-Tissue Release
    Washington University School of Medicine, St. Louis, MO 63110

    We appreciate the interest of Dr.Goyal and colleagues in our recent article (1). They have raised two valid points that we will address. Their first point was the importance of having an accurate preoperative classification system to document the severity of the clubfoot deformity. We agree that this would be the ideal situation. However, the patients in this study were initially seen and evaluated a minimum of 25 years ago, and no uniform classification system was being used at that time. All patients in this study were treated with extensive soft-tissue release surgery, which gives some indication to the severity of the initial deformity.

    Their second point was that the poor long-term results may not be due to the surgical technique alone; the duration of cast immobilization and the bracing protocol may have contributed to the poor outcomes. Unfortunately, we have no way to anaylze how much each of these factors contributed to the end result. We tried to emphasize in our discussion that we were reporting the results of a treatment method for clubfoot that was being widely used at the time in North America. It included preoperative casting, the described extensive soft-tissue release operation, and postoperative bracing. We also discussed the importance of future studies assessing the long-term results of clubfeet treated with more modern surgical techniques, which include less lengthy postoperative immobilization as well.

    It should be noted that presently, there are very few treatment centers anywhere that offer a chance to study long-term outcomes (greater than twenty-five years) with sufficient numbers of patients and follow-up examinations. We have had the opportunity to see these patients and compare them with clubfoot patients treated with modern surgical techniques. We sense that our more modern surgical techniques lead to better short-term outcomes and will lead to better long-term outcomes when compared to patients treated with the protocol described in the current study(1), but to date, we have not formally completed this analysis.

    1. Dobbs MB, Nunley R, Schoenecker PL. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am. 2006;88:986-996.

    Ravi Goyal
    Posted on May 25, 2006
    Long-Term Follow-Up of Patients with Clubfoot Treated with Extensive Soft-Tissue Release
    Blackburn Royal Infirmary, Blackburn, UK

    To The Editor:

    In the paper “Long-Term Follow-Up of Patients with Clubfoot Treated with Extensive Soft-Tissue Release”(1) the authors have reviewed the long term outcome in which an aggressive surgical release was undertaken following failed conservative management. Neonatal and /or pre -operative clubfoot classification is important in order to identify those feet that may have a poor prognosis with conservative treatment(2). Non iatrogenic constitutional stiffness of the foot may functionally deteriorate in the long term, independent of the treatment modality employed. The poor results reported may be due in part to the conservative approach utilised. The Kite method(3) has been criticized by Ponseti(4) as resulting in a spurious correction (Kite’s error). Plaster casts (4 months) and orthotics (2-4years) were used for an extensive period of time following surgical release in the current paper. This long- term immobilisation has the potential to stiffen the joint secondary to the fibrosis that occurs following surgery.

    The combination of a lack of an accurate assessment of the pre- operative severity of the clubfoot, a suboptimum method of conservative treatment and long-term post operative immobilization makes it difficult to attribute the poor results purely to the surgical approach.

    References:

    1. Dobbs MB, Nunley R, Schoenecker P. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am. 2006; 88A:986-995.

    2. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. Pediatr Orthop B. 1995;4(2):129-36.

    3 . Kite JH. Conservative treatment of the resistant recurrent clubfoot. Clin Orthop Relat Res. 1970 May-Jun;70:93-110.

    4. Ponseti IV. Treatment of Clubfoot. http://www.uihealthcare.com/topics/medicaldepartments/orthopaedics/clubfeet/forproviders/index.html

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