Introduction

Congenital Talipes Equino Varus (CTEV), more commonly known as clubfoot, with estimated incidence 1-2 per 1000 live births is most common congenital anomaly of the musculoskeletal system. The CTEV can be easily recognized at birth and can present in two forms.

Idiopathic CTEV and Non-idiopathic CTEV in which other malformations are present such as arthrogryposis, spina bifida, congenital dislocation of the hip, spinal muscular atrophy, ray anomalies of the foot, sacral agenesis, the absence of some tarsal bones, or joint laxity, tibial torsion. Various theories have been proposed including effect of the position in utero, anatomical, viral infections, vascular, environmental, genetic factors, following a compartment syndrome etc.

History includes birth order, maternal age, history of amniocentesis, TORCH infection, maternal thyroid anomalies, normal and caeserian deliveries etc. Examination includes look for number of fingers status, of other limb anomalies (e.g. club hand, transverse or longitudinal limb defect, syndactyly etc.), stiffness of joint movements and exclude cerebral palsy.

In various studies the prevalence of associated congenital anomalies in patients with CTEV varied from 10 to 40%, depending on the population and method of study.[1,2] The aim of our study was to determine demographic characteristic of CTEV with respect to gender, laterality, presence of other congenital anomalies and maternal obstetric history in central rural India (Bundelkhand area of Madhyapradesh Distt Sagar).

The second purpose of this study was to determine whether the Ponseti method can correct non-idiopathic CTEV with low recurrence risk, similar to idiopathic CTEV with Null hypothesis stating there was no difference between the two groups treated by Ponseti method.

Material and Methods

This study was prospective study done at tertiary centre, Department of Orthopaedics Bundelkhand Medical College & Associated Hospitals, Sagar from November 2012 to March 2016. All the patients of CTEV presenting at the Outpatient department were registered. All parents were informed and counselled about the CTEV cast procedure.

Each CTEV patients was seen by a single paediatrician to detect congenital anomaly or associated syndrome. Proper history and thoroughly examination for other anomalies were carried out. There name, age, sex, father and mother name, residential address and contact number, maternal antenatal history, birth weight, order, mode of delivery and significant birth events were also recorded.

We looked for laterality, arthrogryposis, neural tube defects, constriction bands of limbs, urogenital anomalies, cleft lip, cleft palate, developmental dysplasia of hip, knee subluxation and dislocation etc.

Gestation Period: 5 out of 108 patients with clubfeet were preterm, out of which 4 had idiopathic clubfeet and one had clubfeet associated with imperforate anus. 101 children with clubfeet were born at term, whereas two patient was post-term and associated with genu recurvatum and microcephalus.

In our study, no mother had history of alcohol consumption or cigarette smoking. Age of presentation was 01 day to 210days with mean age 62.06 days.

Treatment was started at a mean age of 87.5days with range from 14days to 168days.

Out of the 159 feet in 108 patients, 141 (88.6%) feet were corrected whereas eighteen feet have recurrence of CTEV. Idiopathic variety had 7.6% recurrence (10 out of 131) while non-idiopathic variety had 28.5% recurrence (8 out of 28). 8 feet (in 5 patients) required soft tissue procedure. Those who required, soft tissue procedure 6 were non-idiopathic and 2 were idiopathic.

Table 1: Showing results of Ponseti Casting

On applying Chi-Square Test X2 value came out to be 9.99 and degree of freedom was 1.[5] On referring to X2 table, with 1 degree of freedom the value of probability (P-value) of 0.05 is 3.84. since the observed value (9.99) is much higher we conclude that null hypothesis is wrong and nonidiopathic CTEV has more recurrence rates as compared to idiopathic variety. In 141 corrected feet, total 988 cast were applied mean 7.83. Tenotomy was performed on 35 feet (23.6%). Mean Pirani score at presentation was 4.8 SD ± 0.4 mean mid foot score was 2.2 SD ± 0.2 and mean hind foot score was 2.6 SD ± 0.4. After treatment the mean Pirani score was 0.5. There was only a few complications 03 patients develop plaster sore and 01 has develop post tenotomy transient discolouration which resolved and 02 patient develop tight cast treated with removal of cast.

In our study we found 88.6% correction rate R.A. Agrawal reported 96%, and Bhaskar 80% correction rate. While percutaneous tenotomy of tendo achillis done in 35 feet in 141 corrected feet Changulani et al performed tenotomy in 85 feet in 100 feet and R. A Agrawal performed in 58 of 60 feet. [9,12,13] Maintenance of deformity is challenging and important because ill-fitting splint and noncompliance to splint is the major cause for recurrence. In our study eighteen feet had recurrence of CTEV because of non compliance to splint. Those who requires, soft tissue procedure six out of twenty-eight feet (17.8%) were nonidiopathic type ( one unilateral and two bilateral) because the feet were stiff and contracted. In idiopathic CTEV two out of hundred and thirty one feet (1.5%) requires soft tissue release. Chi-Square test value comes out to be 9.99 which is quiet significant. Suggesting nonidiopathic CTEV frequently requires soft tissue surgeries for correction as compared to idiopathic variety.

Conclusion

In our study majority of patients with CTEV (84%) are idiopathic, 16% were non-idiopathic. We found that Ponseti method is an excellent method of correction for idiopathic clubfeet in infants. We demonstrated here that non-idiopathic CTEV can be treated with the Ponseti method with higher recurrence rates as compared to non-idiopathic variety.

References