I read with interest the article entitled "Long-Term Comparative
Results in Patients with Congenital Clubfoot Treated with Two Different
Protocols"
(2003;85:1286-94), by Ippolito
et al. I wish to heartily congratulate Dr. Ippolito and his team for
convincingly demonstrating the unfavorable long-term outcome after extensive
soft-tissue release for the treatment of severe idiopathic clubfoot deformity.
Also, Ponseti's method of manipulation and limited posterior release has been
convincingly offered as a superior alternative. Certainly, this reportedly
more effective method has demonstrated a very impressive long-term outcome. In
essence, this article tends to raise doubts about the widespread and perhaps
empirical use of conventional methods of manipulation and soft-tissue
release1-6.
On the contrary, early soft-tissue release, including varying degrees of
extensive medial release, for the treatment of moderate-to-severe clubfoot
deformity has been an increasingly popular trend for the last two decades with
very promising
results1,2,4,6,7.
However, there was always a lingering suspicion that a minority of patients in
whom the clubfoot resists correction even in early infancy have relapses
repeatedly, even after extensive release, and might indeed have deterioration
in adulthood. This suspicion has now been confirmed. Admittedly, it is not
only very difficult to identify the minority early on during conservative
treatment, and thus prognosticate that the rate of relapse would be
unacceptably high, but their subsequent management is also not without
troublesome
complications5,7.
The difficulty in classifying this minority in a reproducible way has been
repeatedly
emphasized5-7.
In this minority of resistant clubfeet, wound-healing is a frequent,
well-recognized
problem5,6.
In this respect, the observations by the authors about the behavior of the
scar tissue, especially at the medial part of the incision, and its role in
relapse may be of particular relevance. The first reported longterm results of
extensive release, after more than twenty-five years of follow-up by the same
author, seem to suggest that the soft tissue in the region of the deformity
responds very unfavorably to surgery, especially in the resistant cases. It is
probably now pertinent to ask whether this observation and wound dehiscence at
the medial part of the incision are related issues? Does this inherently
dystrophic soft tissue continue to generate pathological scar tissue for a
lifetime? Again, the authors deserve our sincere laurels for this very
important finding.
It is apparent from the observations that the talocalcaneonavicular
correction was better in the first group at the time of the final follow-up.
It is noteworthy that patients in this group had satisfactory results at early
follow-up. Yet, ironically, the cosmetic result was far superior in the second
group at the time of the final followup. However, the status of the correction
of the talocalcaneonavicular malposition obtained initially and at early
follow-up was not adequately addressed in either of the groups. Correction of
this three-dimensional osseous malposition is considered to be an essential
and critical element of successful reduction of idiopathic clubfoot
deformity2-4,8,
notwithstanding the lack of correlation between radiographic indices and
functional outcome. Undoubtedly, radiographic measurements still remain
acceptable indices for postoperative comparison and
follow-up6.
Continued manipulation of rigid clubfeet, in the presence of persistent
talocalcaneonavicular malalignment, might be one of the factors responsible
for metatarsus adductus, flat-feet (especially of the rocker-bottom type), and
relapse3,4,8.
The observation that medial talonavicular subluxation does not adversely
affect functional outcome tends to question the time-honoured concept of
correction of talocalcaneonavicular malposition in the surgical management of
rigid
clubfeet1-4,8.
How do the authors propose to reconcile their findings with these
contradictions?
I am surprised that the authors chose to continue manipulation in the first
group for a much longer period and performed extensive release in selected
cases, even though only patients with "severe" and presumably
rigid deformities (thus not suitable for manipulation) were included in the
study, whereas all of the patients in the second group, apparently
irrespective of the results of manipulation or the severity of the deformity,
were subjected to earlier, although limited, posterior release followed again
by manipulation. With such diametric differences in protocol between the two
groups, marked disparity in longterm functional outcome is perhaps expected.
Lastly, is the authors' message, in effect, to suggest that
"extensive" posteromedial release be abandoned altogether or only
in severe, resistant clubfeet?
We thank Dr. Mukerjee for his letter, which honors our paper. We agree that
clubfoot classification at diagnosis is difficult and somehow not precise, but
severe cases may be easily recognized by physicians who have experience with
the condition and thus such cases are consequently included in the
"severe group" of any adopted classification. In both groups in
our study, the clubfeet were classified as group III according to the system
of Manes et al.9; we
intentionally excluded club-feet with a mild deformity so that we would have
two uniform groups of clubfeet with a severe deformity. Sixteen feet (34%) had
a poor result in the first group compared with only five feet (10%) in the
second group; this striking difference cannot be attributed to a difference in
the severity of the deformity in the two groups because we included only feet
with a severe deformity in both groups.
Dr. Mukerjee asked whether the retracted fibrous tissue, which causes the
main tarsal deformities in congenital clubfoot, may generate pathological scar
tissue for life whenever it is surgically excised. We do not have yet a
histological demonstration of this phenomenon; however, according to our
clinical results, we suspect that this is true at least during childhood.
He also stated that correction of talocalcaneonavicular malposition was
better in the first group than in the second. That is not true, as only medial
talonavicular subluxation had better correction in the first group than in the
second. Residual cavovarus deformity was very frequently observed in our first
group, and this deformity may be hidden by subcutaneous fat in many children
up to four or five years of age. Moreover, the manipulation technique
described by Ponseti and
Smoley10 corrects
heel varus at the subtalar joint, by everting the calcaneus under the talus,
as well as forefoot adduction, by shifting laterally the cuneiforms and the
cuboid, leaving the navicular in part medially subluxated. This correction
does not reestablish normal foot anatomy, but it is very good in terms of
cosmetic and functional results as was clearly shown by our results.
Dr. Mukerjee noted that the patients in the first group were treated with
manipulation and casting for a longer period of time in comparison with those
in the second group. That is true because the correction of the basic
deformities of clubfoot with our traditional manipulation technique was much
slower and was incomplete in comparison with Ponseti's technique. However, we
performed a posteromedial release in all of the feet in our first group, not
only in selected feet. In addition, in the second group, manipulations were
never performed again after the limited posterior release, which corrected
only the residual equinus.
Lastly, our message is that extensive surgery should be abandoned in
untreated cases of clubfoot and should be replaced by manipulation according
to the method described by Ponseti and Smoley. This is the current practice at
the Department of Orthopaedic Surgery at the University of Rome "Tor
Vergata," where extensive surgery is reserved only for clubfeet that
have had a poor result after operative treatment in other institutions.
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