J Pediatr Orthop B. 2018 Sep;27(5):428-434.
Complex iatrogenic clubfoot: is it a real entity?
Dragoni M, Gabrielli A, Farsetti P, Bellini D, Maglione P, Ippolito E.
In our study, we aimed to demonstrate whether a complex iatrogenic clubfoot really exists; identify the causative mechanisms; and determine the outcome if properly treated. We observed 54 clubfeet previously treated unsuccessfully by manipulation and casting elsewhere. All the feet had been classified at diagnosis as typical clubfeet. In 26 cases, the cast had slipped down, entrapping the foot in a plantar-flexed position. Nine clubfeet out of those 26 cases presented the clinical features of a complex iatrogenic deformity. These were treated with the modified Ponseti protocol and evaluated at follow-up according to the International Clubfoot Study Group Score. The length of follow-up averaged 7.2 years. Two feet showed an excellent result, five feet showed a good result, and two feet showed a fair result. The relapse rate was 55% in complex clubfeet. Relapsed clubfeet were treated by Achilles tenotomy or lengthening and anterior tibial tendon transfer. We believe that faulty manipulation and a poor casting technique may convert a typical clubfoot into a complex iatrogenic deformity. Risk factors include severe clubfoot, short and stubby foot, and unmolded casts slipping down.
J Bone Joint Surg Am. 2016 Oct 19;98(20):1706-1712.
Ponseti Treatment of Rigid Residual Deformity in Congenital Clubfoot After Walking Age.
Dragoni M, Farsetti P, Vena G, Bellini D, Maglione P, Ippolito E.
There is no established treatment for rigid residual deformity of congenital clubfoot (CCF) after walking age. Soft-tissue procedures, osseous procedures, and external fixation have been performed with unpredictable results. We applied the Ponseti method to patients with this condition in order to improve the outcomes of treatment.
We retrospectively reviewed the cases of 44 patients (68 feet) with congenital clubfoot whose mean age (and standard deviation) at treatment was 4.8 ± 1.6 years. All patients had been previously treated in other institutions by various conservative and surgical protocols. Residual deformity was evaluated using the International Clubfoot Study Group Score (ICFSGS), and stiffness was rated by the number of casts needed for deformity correction. Ponseti manipulation and cast application was performed. Equinus was usually treated with percutaneous heel-cord surgery, while the cavus deformity was treated with percutaneous fasciotomy when needed. Tibialis anterior tendon transfer (TATT) was performed in patients over 3 years old. At the time of follow-up, the results were evaluated using the ICFSGS.
Before treatment, 12 feet were graded as fair and 56, as poor. Two to 4 casts were applied, with each cast worn for 4 weeks. Stiffness was moderate (2 casts) in 23 feet, severe (3 casts) in 30 feet, and very severe (4 casts) in 15 feet. Percutaneous heel-cord surgery was performed in 28 feet; open posterior release, in 5 feet; plantar fasciotomy, in 30 feet; and TATT, in 60 feet. The mean length of follow-up was 4.9 ± 1.8 years. Eight feet had an excellent result; 49 feet, a good result; and 11 feet, a fair result. No patient had pain. All of the feet showed significant improvement.
Ponseti treatment with TATT, which was performed in 88% of the feet, was effective, and satisfactory results were achieved in 84% of the feet. At the time of follow-up, no patient showed an abnormal gait, all feet were plantigrade and flexible, but 2 feet (2.9%) had relapsed.
LEVEL OF EVIDENCE:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
J Child Orthop. 2012 Oct;6(5):433-8. Epub 2012 Oct 5.
An MRI volumetric study for leg muscles in congenital clubfoot.
Ippolito E, Dragoni M, Antonicoli M, Farsetti P, Simonetti G, Masala S.
To investigate both volume and length of the three muscle compartments of the normal and the affected leg in unilateral congenital clubfoot.
Volumetric magnetic resonance imaging (VMRI) of the anterior, lateral and postero-medial muscular compartments of both the normal and the clubfoot leg was obtained in three groups of seven patients each, whose mean age was, respectively, 4.8 months, 11.1 months and 4.7 years. At diagnosis, all the unilateral congenital clubfeet had a Pirani score ranging from 4.5 to 5.5 points, and all of them had been treated according to a strict Ponseti protocol. All the feet had percutaneous lengthening of the Achilles tendon.
A mean difference in both volume and length was found between the three muscular compartments of the leg, with the muscles of the clubfoot side being thinner and shorter than those of the normal side. The distal tendon of the tibialis anterior, peroneus longus and triceps surae (Achilles tendon) were longer than normal on the clubfoot side.
Our study shows that the three muscle compartments of the clubfoot leg are thinner and shorter than normal in the patients of the three groups. The difference in the musculature volume of the postero-medial compartment between the normal and the affected side increased nine-fold from age group 2 to 3, while the difference in length increased by 20 %, thus, showing that the muscles of the postero-medial compartment tend to grow in both thickness and length much less than the muscles of the other leg compartments.
Congenital clubfoot; Muscle atrophy; Muscle growth; Pathogenesis of congenital clubfoot; Volumetric MRI muscle study
J Pediatr Orthop B. 2012 Jan;21(1):47-51.
Tibiofibular torsion in congenital clubfoot.
Farsetti P, Dragoni M, Ippolito E.
Tibiofibular torsion was measured by computed tomography in three series of patients affected by congenital clubfoot who were treated with different protocols. The normal leg of unilateral deformities served as the control. For the bilateral cases, only the right side was included in the study. The angle between the bicondylar axis of the tibia and the bimalleolar axis was the index of tibiofibular torsion. There were 34 clubfeet in the first series, treated with a posteromedial release, and 40 clubfeet in the second series, treated with a modified Ponseti method, whereas the third series included 16 clubfeet, treated with the original Ponseti method. All 90 clubfeet were graded at birth as group 3 according to the Manes classification. No patient had previous treatment. The patients of the first and the second series were followed up to maturity, whereas the patients of the third series were followed up to a maximum of 11 years of age. In the congenital clubfoot, the tibia and the fibula were externally rotated, in comparison with the normal leg; in fact, the average value of the angle of tibiofibular torsion was 32.2° in the first series, 23.9° in the second series, and 21.1° in the third series. In the normal tibiae, the average value of the angle of tibiofibular torsion was 21.4°. The difference between the first series and the normal controls was statistically significant, as was the difference between the first one and the other two series. The value of the tibiofibular torsion angle seems to be related to the manipulation technique used to treat clubfoot: when the manipulation does not allow a progressive eversion of the talus underneath the calcaneus, the external tibial torsion increases. At follow-up, an intoeing gait was present in seven treated clubfeet of the first series. In all of them except one, the highest value of the external tibial torsion angle was observed, with a low value of the Kite’s angle and/or residual forefoot adduction. In the treated congenital clubfoot, persistent intoeing is not related to the angle of tibial torsion but rather to the amount of correction of calcaneal inversion and residual forefoot adduction.
J Child Orthop. 2009 Jun;3(3):171-8. Epub 2009 May 6.
Leg muscle atrophy in idiopathic congenital clubfoot: is it primitive or acquired?
Ippolito E, De Maio F, Mancini F, Bellini D, Orefice A.
To investigate whether atrophy of the leg muscles present in congenital clubfoot (CCF) is primitive or secondary to treatment of the deformity.
Magnetic resonance imaging (MRI) of both legs was taken in three cohorts of patients with unilateral congenital clubfoot (UCCF): eight untreated newborns (age range 10 days to 2 weeks); eight children who had been treated with the Ponseti method (age range 2-4 years); eight adults whose deformity had been corrected by manipulation and casting according to Ponseti, followed by a limited posterior release performed at age 2-3 months (age range 19-23 years). All of the treated patients wore a brace until 3 years of age. Muscles were measured on transverse MRI scans of both legs taken midway between the articular surface of the knee and the articular surface of the ankle, using a computer program (AutoCAD 2002 LT). The same program was used to measure leg muscles in the histologic cross sections of the legs of two fetuses with UCCF, spontaneously aborted at 13 and 19 weeks of gestation, respectively. Measurements of the whole cross section of the leg (total leg volume: TLV), of the muscular tissue (muscular tissue volume: MTV), and of the adipose tissue (adipose tissue volume: ATV) of the tibia, fibula, and of the other soft tissues (tendons, nerves, and vessels) were taken by using an interactive image analyzer (IAS 2000, Delta System, Milan, Italy).
Marked atrophy of the leg muscles on the clubfoot side was found in both fetuses and untreated newborns, with a percentage ratio of MTV between the normal and the affected leg of 1.3 and 1.5, respectively. Leg muscle atrophy increased with growth, and the percentage ratio of MTV between the normal and the affected leg was, respectively, 1.8 and 2 in treated children and adults. On the other hand, fatty tissue tended to increase relatively from birth to adulthood, but it could not compensate for the progressive muscular atrophy. As a result, the difference in TLV tended to increase from childhood to adulthood.
Our study shows that leg muscular atrophy is a primitive pathological component of CCF which is already present in the early stages of fetal CCF development and in newborns before starting treatment. Muscular atrophy increases with the patient’s age, suggesting a mechanism of muscle growth impairment as a possible pathogenic factor of CCF.
Clin Orthop Relat Res. 2009 May;467(5):1243-9. Epub 2009 Feb 4.
CT study on the effect of different treatment protocols for clubfoot pathology.
Farsetti P, De Maio F, Russolillo L, Ippolito E.
In congenital clubfoot, residual deformities are not well-documented and they may change depending on different treatments. To identify the treatment that provides better outcome at maturity, we studied the computed tomography of two cohorts of patients affected with congenital clubfoot who were treated using two distinct protocols. Forty-seven clubfeet were treated according to the traditional protocol of our hospital and 61 were treated according to the Ponseti technique. The normal feet of the unilateral deformities served as controls. All patients were followed to skeletal maturity. The ankle torsion angle and the declination angle of the neck of the talus were higher than normal but different only in patients treated with the traditional method. The calcaneocuboid angle was lower but only in patients treated with the Ponseti method. The shape of the talar joints was altered in many feet regardless of protocol. The CT images suggest the modifications of the torsion angle of the ankle, the declination angle of the neck of the talus, and the calcaneocuboid angle at maturity are related to the treatment protocol followed. The Ponseti manipulative technique provided better anatomical results in comparison to our traditional technique.
J Pediatr Orthop. 2006 Jan-Feb;26(1):83-90.
Anterior tibial tendon transfer in relapsing congenital clubfoot: long-term follow-up study of two series treated with a different protocol.
Farsetti P, Caterini R, Mancini F, Potenza V, Ippolito E.
Two series of patients with relapsing congenital clubfoot were treated by transfer of the anterior tibial tendon to the third cuneiform under the extensor retinaculum. The two series were reviewed at the end of skeletal growth to evaluate the effectiveness of the surgical procedure. The first series included 19 clubfeet and the second 16. The two series of clubfeet were initially treated by two different manipulative techniques and two different complementary soft tissue release operations. In relapsing clubfeet, the foot dorsiflexion/eversion activity of the tibialis anterior was suppressed and the muscle functioned as an invertor. At follow-up the functional results of the second series of patients, in whom the relapsing deformity was passively correctable at the time of surgery, were better than those of the first series of patients, in whom the relapsing deformity was sometimes less passively correctable. None of the operated patients had a further relapse. In both series, the angles formed by the longitudinal axis of the navicular and the first cuneiform, the calcaneus and the fifth metatarsal, and the calcaneus and the cuboid, evaluated both by plain radiographs and by CT scan, were smaller than in normal feet and in the clubfeet that did not relapse. Transfer of the anterior tibial tendon to the third cuneiform underneath the extensor retinaculum corrects and stabilizes relapsing clubfeet by restoring their normal function of foot dorsiflexion/eversion. As a consequence, the cuneiforms and the cuboid were shifted more laterally than normal, as shown by both x-rays and CT scan.
J Pediatr Orthop B. 2005 Sep;14(5):358-61.
A comparison of resultant subtalar joint pathology with functional results in two groups of clubfoot patients treated with two different protocols.
Ippolito E, Mancini F, Di Mario M, Farsetti P.
Two series of patients with congenital clubfoot treated by different manipulation techniques and by different complementary soft tissue release operations were evaluated at the end of skeletal growth. The severity of the deformity was graded at diagnosis, and the functional results were graded at follow-up with a functional rating system. Computed tomography scans of the subtalar joint were also obtained at follow-up for each patient in order to evaluate the joint morphology. A linear regression model was constructed to study the statistical correlation between the rating score of the treated clubfeet and the shape of the subtalar joint. A statistically significant correlation was found between the clubfeet rating score and the subtalar joint morphology. However, the rating score values of the second series were consistently higher than those of the first series when compared with the same morphological category of the subtalar joint.
J Bone Joint Surg Br. 2004 May;86(4):574-80.
The influence of treatment on the pathology of club foot. CT study at maturity.
Ippolito E, Fraracci L, Farsetti P, Di Mario M, Caterini R.
We performed CT to investigate how treatment may modify the basic skeletal pathology of congenital club foot. Two homogenous groups of patients treated by one of the authors (EI) or under his supervision were studied. The first included 32 patients with 47 club feet reviewed at a mean age of 25 years and treated by manipulation, application of toe-to-groin plaster casts and an extensive posteromedial release. The second included 32 patients with 49 club feet reviewed at a mean age of 19 years and treated by the Ponseti manipulation technique, application of toe-to-groin plaster casts and a limited posterior release. At follow-up the shape of the subtalar, talonavicular and calcaneocuboid joints was found to be altered in many feet in both groups. This did not appear to be influenced significantly by the type of treatment performed. Correction of the heel varus and the increased declination angle of the neck of the talus was better in the club feet of the second group, whereas reduction of the medial subluxation of the navicular was better in the first. There was a marked increase in the external ankle torsion angle in the first group and a moderate increase of this angle in the second group, in which medial subluxation of the cuboid on the anterior apophysis of the calcaneum was always corrected. Equinus was corrected in both groups but three-dimensional CT reconstruction of the whole foot showed that cavus, supination and adduction deformities were corrected much better in the second group.
AJR Am J Roentgenol. 2004 May;182(5):1279-82.
Validity of the anteroposterior talocalcaneal angle to assess congenital clubfoot correction.
Ippolito E, Fraracci L, Farsetti P, De Maio F.
The anteroposterior talocalcaneal angle (Kite’s angle) is still considered a common parameter for assessing clubfoot correction, although some dissenting opinions about its accuracy have been expressed. The purpose of this study was to evaluate the validity of the anteroposterior talocalcaneal angle for assessing correction of congenital clubfoot in adults who received the treatment as children. SUBJECTS AND METHODS. The anteroposterior talocalcaneal angle was measured in 48 treated idiopathic congenital clubfeet and 28 normal feet of 38 patients at the end of skeletal growth using both standing anteroposterior radiographs and 3D CT scan reconstructions. All the patients had been treated by manipulation, above-the-knee casting, and a complementary posteromedial release operation.
The radiographic measurement of the anteroposterior talocalcaneal angle corresponded to the measurement of the same angle on the 3D CT scan reconstructions in only the normal feet and 12 clubfeet. In the other 36 clubfeet, a statistically significant difference of a mean of 15 degrees between the two measurements was noted, and the 3D CT scan reconstructions showed a superimposition of the talus and calcaneus, which had lost their normal anatomic divergence. In these cases, the marked medial angulation of the talar neck allowed a positive measurement of the anteroposterior talocalcaneal angle in the anteroposterior radiographic projection.
According to our findings, the measurement of the anteroposterior talocalcaneal angle on radiography was misleading for assessing the degree of hindfoot correction in 75% of the treated congenital clubfeet. We believe that other imaging parameters should be considered instead of this angle to evaluate clubfoot correction.
J Bone Joint Surg Am. 2003 Jul;85-A(7):1286-94.
Long-term comparative results in patients with congenital clubfoot treated with two different protocols.
Ippolito E, Farsetti P, Caterini R, Tudisco C.
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.
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.
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.
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.
Long-term comparative results in patients with congenital clubfoot treated with two different protocols. [J Bone Joint Surg Am. 2004]
Skeletal Radiol. 2003 Aug;32(8):446-53. Epub 2003 May 3.
A radiographic comparative study of two series of skeletally mature clubfeet treated by two different protocols.
Ippolito E, Fraracci L, Caterini R, Di Mario M, Farsetti P.
To compare the radiographic features of two series of congenital clubfeet to determine whether a different treatment protocol may influence the radiographic results at the end of skeletal growth.
DESIGN AND PATIENTS:
Two series of patients with congenital clubfeet, treated by two different manipulative techniques and by two different complementary soft tissue release operations, were radiographically studied at skeletal maturity. Twenty-one normal feet of the unilateral cases in both series served as controls. Anteroposterior and lateral radiographs of the feet were taken with the patient standing, and several radiographic parameters were studied.
RESULTS AND CONCLUSIONS:
The size of the talus and calcaneus and the height of the talar trochlea were smaller than normal in all cases of clubfeet, were similar in both series and were not influenced by treatment, whereas all the other radiographic parameters studied were more or less different between the two series and seemed to be influenced by treatment. In no treated clubfoot of either series was a normal radiographic foot anatomy restored, not even in those feet that had an excellent clinical result.
J Pediatr Orthop B. 1995;4(1):17-24.
Update on pathologic anatomy of clubfoot.
Serial histological sections in three planes (frontal, sagittal, and transverse) in four cases of clubfoot in fetuses aborted at 16-20 weeks were studied and compared to identical sections obtained in three normal feet. The talus was deformed, with its neck medially angulated and its head dome shaped. The body of the calcaneus was medially bowed and was tilted and rotated medially underneath the talus, and both the talus and the calcaneum were in plantar flexion. The tilting of the talus and the medial tilting and rotation of the calcaneus accounted for the varus deformity of the hindfoot. The varus and adduction deformity of the heel and midfoot caused the supination seen in clubfoot. The skeletal components of the forefoot were adducted as a result of the medial displacement of the navicular and cuboid. Ligamentous and tendon abnormalities were also observed with increased fibrosis of muscle tissue, which may be an important factor in causation of clubfoot.
Ital J Orthop Traumatol. 1985 Jun;11(2):171-7.
The treatment of relapsing clubfoot by tibialis anterior transfer underneath the extensor retinaculum.
Ippolito E, Ricciardi-Pollini PT, Tudisco C, Ronconi P.
Nineteen patients with 22 relapsing clubfeet were treated by tibialis anterior transfer underneath the extensor retinaculum. This operation is indicated in cases of relapse in which the clubfoot is still supple. It is not indicated in cases with subtalar rigidity. The results were excellent in 19 cases, fair in 2 and poor in one. The fair and poor results were attributable to faulty technique or errors of indication.
Foot Ankle. 1984 Nov-Dec;5(3):107-17.
Congenital clubfoot: results of treatment of 54 cases.
Ricciardi-Pollini PT, Ippolito E, Tudisco C, Farsetti P.
Fifty-four patients with congenital clubfoot (total: 82 club feet) were observed at the 2nd Department of Orthopaedic Surgery of Rome University from 1970 to 1980. The conclusions of this study were the following: The patients with congenital clubfoot who had a uniform treatment from the beginning at the same hospital obtained better results than those who received previous treatments at other hospitals. A relapse was considered as a recurrence of the initial deformity after complete recovery and not as an incompletely corrected congenital clubfoot. In many of the patients with clubfoot who were treated, no direct correlations existed between the radiographic and clinical results. Of the patients with clubfoot who received an early treatment by posterior release, 89% had excellent and good results. One- or two-stage posteromedial releases did not prevent relapses, even though those done in one stage obtained better results. The transfer of the anterior tibial tendon to the third cuneiform proved to be the most effective procedure to prevent and correct relapses.
Arch Putti Chir Organi Mov. 1982;32:51-75.
Treatment of congenital clubfoot based on recent physiopathology findings and long-term follow-ups
Ippolito E, Ricciardi-Pollini PT.
The Authors favor a conservative treatment of congenital club foot completed with early complementary operations in cases which need surgery. This opinion results from pathophysiological and long-term follow-up studies. Manipulative treatment, plaster cast technique, and braces stretching the fibrotic and retracted structures of both leg and foot are very important factors to accomplish good results. Relapses, which are frequent up to 5-6 years of age, seem to be due to the retraction either of the fibrotic structures in cases treated conservatively or of the scar tissue in cases operated on. The retracting forces seem to be stimulated in many cases by an anterior tibial tendon running more medially than normally. Anterior tibial tendon transfer underneath the extensors retinaculum on the lateral aspect of the foot seems to prevent relapses that, in the Authors experience, are not prevented by early postero-medial releases. It is the Authors opinion that treatment of congenital club foot should aim to obtain a functional foot rather than to restore the normal anatomy of the foot.
Clin Orthop Relat Res. 1981 Oct;(160):30-42.
A radiographic study of skeletal deformities in treated clubfeet.
Ponseti IV, El-Khoury GY, Ippolito E, Weinstein SL.
Thirty-two patients with treated unilateral clubfoot deformity were followed for a period of 13 to 30 years. The functional results were satisfactory in 28 feet. A comparison of the skeletal features of the normal and the clubfeet was made on roentgenographs. Many clubfeet had small, slightly flattened talar heads, decreased talocalcaneal angles, undersized or misshapen facets of the subtalar joint, and medially displaced navicular. The residual deformity of the hindfoot was compensated by the lateral displacement and lateral angulation of the cuneiforms with respect to the navicular resulting in a normal alignment of the forefoot in relation to the hindfoot. The range of ankle dorsiflexion, subtalar and midtarsal joint motion was restricted in the clubfeet.
J Bone Joint Surg Am. 1980 Jan;62(1):8-22.
Congenital club foot in the human fetus. A histological study.
Ippolito E, Ponseti IV.
Five club feet and three normal feet of fetuses aborted at sixteen to twenty weeks of gestation were studied by making serial histological sections cut in the sagittal, frontal, and transverse planes. In the club feet we found gradations in the severity of the following abnormalities: 1. Altered shape, size, and relationships of the tarsal bones. 2. Decrease in the size and number of fibers in the distal third of the muscles of the posterior and medial aspect of the leg; increased fibrous connective tissue in these muscles, their tendon sheaths, and the adjacent fasciae; and shortening of the triceps surae. 3. Thickening of the distal parts of the tendo archillis and of the posterior tibial tendon. 4. Ligaments on the posterior and medial aspects of the ankle joint pulled into the joint by the severe plantar flexion and varus displacement of the talus, and marked shortening and thickening of the tibionavicular and plantar calcaneonavicular ligaments. On the basis of these pathological findings, the possibility of a retracting fibrosis as the primary etiological factor of the club-foot deformity should be considered.