Introduction

Clubfoot (CTEV) is one of the most common congenital orthopedic anomalies, first described by Hippocrates in the year 400 BC [1,2]. The aim of treatment in CTEV is to achieve cosmetic, anatomical and functional foot which is acceptable to the child and to the parents [3,4].

Despite this long experience in treating clubfoot deformities, there still exist controversies regarding both the treatment methods i.e. conservative or surgical. Comparison between the groups is further complicated by lack of standards for evaluating the functional outcomes. Conservative method, as developed by Ponseti, which begins immediately after birth and is based on the fundamentals of kinematic coupling and patho-anatomy of the deformity, and is quiet successful and well accepted initial step in realignment of clubfoot deformity in infants without the need of extensive and major surgeries [3-8].

But, still there are few deformities that do not respond at all to the conservative line of treatment even after serial manipulation and casting (rigid clubfoot), or some deformities recur after initial correction by conservative management (relapsed clubfoot) orrecur after the completion of the treatment (recurrent clubfoot) [2,9].

All of these feet along with the feet which had never received any treatment (neglected clubfoot), require surgical correction. During the early years of infancy, the deformity can be surgically corrected by single stage posteromedial soft tissue release. Hence we evaluated the outcomes of single stage posteromedial soft tissue release in rigid, relapsed, resistant or neglected clubfoot deformity children in early infancy.

Material and Methods

This prospective study was conducted at our center between 2014 to 2016 in 31 CTEV children. Primary idiopathic rigid, relapsed, recurrent or neglected CTEV aged between 6 months to 5 years were included in the study. Initially in all these cases Ponseti’s method [5,6] of cast correction was attempted, and when it failed due to late presentation of child, lack of compliance, walking of child on the cast, illiterate parents, irregular weekly follow-up and inconsistent use of brace after correction, these cases were included for the study.

In some of the bilateral cases, one side foot deformity was corrected by serial casting and hence only the other side, which was not corrected or relapsed was only included. Secondary clubfoot, previously operated feet, atypical clubfoot, clubfoot with non-healing ulcers over callosities, and children more than 5-year age and less than 6 months were excluded from the study.

6 feet had superficial infection or wound gaping at the incision site, all of which healed with oral antibiotics and regular dressings. Plaster sore and skin blisters were seen in 4 feet, which were due to improper padding or due to tight cast or sweating inside the cast, all of which healed spontaneously with cast holiday, antiseptics and antibacterial/antifungal dusting powder and none of the sores deepened.

Discussion

Neglected, rigid, resistant or relapse CTEV cases, have always been a difficult challenge to treat, because of many reasons, like late presentation, walking child, already longer treatment duration, soft tissue contractures and remodelling and alteration of the deformed tarsal bones [9].

Hence, these clubfeet require surgical treatment, by soft tissue release in early years of infancy or bony procedure in an older child [2].

We evaluated the outcome of rigid, relapse, resistant or neglected 39 clubfeet deformities in children between 6 months to 5 years’ age, treated by single stage posteromedial soft tissue release. Our study was comparative to other studies in terms of mean age, number of cases, laterality and male to female ratio [12-15].

These studies differ in assessment criteria and scoring systems making the comparison, difficult [12-15]. Hussain et al [16] used modified Mckay rating system; Ajmera[9] used Ferreira score whereas Menezes et al [12]in his study used Wayne-davis scoring system for assessment. We used both Pirani and Green, Lloyd-Roberts clinical criteria for assessment [10,11].

Since Pirani score is most commonly and widely used system [17], but its use in older child can be debatable and Green, Lloyd- Roberts clinical criteria based on appearance, function and pain during activity, is reliable in older child, hence we used both Pirani and Green, Lloyd- Roberts’s criteria for assessment.

In our study, overall mean pre-operative Pirani score improved from 4.8to 1.4 at final follow up, which was statistically significant. Since these feet were rigid, relapsed, neglected or resistant in an older child, even the postoperative score remained a little bit higher as compared to other studies [9, 12-16].

In our series, the mean preoperative Pirani score in neglected cases (prior no cast application) was significantly higher than rigid, relapsed or resistant cases (previous casting done).

This higher Pirani score in neglected cases was maintained in the postoperative period as well, although it was not significant.

Conclusion

We found that good to excellent short term results can be obtained with one stage posteromedial release, in rigid, relapse, resistant or neglected CTEV. The poor results are due to late presentation or without prior casting treatment. Improved surgical results can be obtained by prior cast treatment, surgery between 6 months to 2 years’ age, complete single stage soft tissue release and regular checkups for earlier identification of complications if any.

References