Journal of Foot and Ankle Surgery (Asia Pacific)

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VOLUME 8 , ISSUE 3 ( July-September, 2021 ) > List of Articles

Current Concepts Review

Current Concepts in the Etiology, Diagnosis, and Management of Relapsed Clubfoot

Sameer S Desai, Ashish S Ranade, Ankit B Waghela

Citation Information : Desai SS, Ranade AS, Waghela AB. Current Concepts in the Etiology, Diagnosis, and Management of Relapsed Clubfoot. J Foot Ankle Surg Asia-Pacific 2021; 8 (3):126-131.

DOI: 10.5005/jp-journals-10040-1169

License: CC BY-NC 4.0

Published Online: 08-07-2021

Copyright Statement:  Copyright © 2021; The Author(s).


Abstract

Relapse is a recurrence of deformities in a previously corrected clubfoot. The incidence of relapse after the Ponseti method is reported between 26% and 48%. The etiology of relapse can be variable. Some of the predisposing factors that are predictive of relapse are drop toe signs, a lower ratio of correction improvement, and muscle imbalance. Relapse can be broadly categorized into decreased dorsiflexion, cavus, equines, adduction, heel varus, and dynamic supination deformity. The principles to be followed in the treatment of relapsed clubfoot are—restarting foot abduction brace protocol, extended Ponseti method and/or soft tissue surgery, bony procedures, and external fixation devices. The Ponseti method can be used even in older children with relapse or after soft tissue surgery. Split tibialis anterior transfer may be required in a child with dynamic supination deformity. It should be performed in children above 3 years. Many children may require >2 procedures. Soft tissue surgery carries the risk of over- and under-correction. The external fixator can be used in children with scarring due to multiple surgeries and severe rigid deformities. Salvage procedures may be required in older children or syndromic clubfeet. Conclusion: Children with clubfoot need to be followed up for a minimum of 5–6 years or maybe longer to diagnose and treat relapsed. Some feet are “deemed” to relapse. However, it is very difficult to identify these feet beforehand. An a la carte approach is required in the management of relapse and a surgeon treating these feet should be well versed with all the different procedures.


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  1. Hosseinzadeh P, Kiebzak GM, Dolan L, et al. Management of clubfoot relapses with the Ponseti method: results of a survey of the POSNA members. J Pediatr Orthop 2019;39(1):38–41. DOI: 10.1097/BPO.0000000000000953.
  2. Sangiorgio SN, Ebramzadeh E, Morgan RD, et al. The timing and relevance of relapsed deformity in patients with idiopathic clubfoot. J Am Acad Orthop Surg 2017;25(7):536–545. DOI: 10.5435/JAAOS-D-16-00522.
  3. van Praag VM, Lysenko M, Harvey B, et al. Casting is effective for recurrence following Ponseti treatment of clubfoot. J Bone Joint Surg Am 2018;100(12):1001–1008. DOI: 10.2106/JBJS.17.01049.
  4. Edmonds EW, Frick SL. The drop toe sign: an indicator of neurologic impairment in congenital clubfoot. Clin Orthop Relat Res 2009;467(5):1238–1242. DOI: 10.1007/s11999-008-0690-9.
  5. Dietz FR. Treatment of a recurrent clubfoot deformity after initial correction with the Ponseti technique. Instr Course Lect 2006;55: 625–629.
  6. Gelfer Y, Dunkley M, Jackson D, et al. Evertor muscle activity as a predictor of the mid-term outcome following treatment of the idiopathic and non-idiopathic clubfoot. Bone Joint J 2014;96-B(9):1264–1268. DOI: 10.1302/0301-620X.96B9.33755.
  7. Moon DK, Gurnett CA, Aferol H, et al. Soft-tissue abnormalities associated with treatment-resistant and treatment-responsive clubfoot: findings of MRI analysis. J Bone Joint Surg Am 2014;96(15):1249–1256. DOI: 10.2106/JBJS.M.01257.
  8. Zhao D, Li H, Zhao L, et al. Prognosticating factors of relapse in clubfoot management by Ponseti method. J Pediatr Orthop 2018;38(10):514–520. DOI: 10.1097/BPO.0000000000000870.
  9. Luckett MR, Hosseinzadeh P, Ashley PA, et al. Factors predictive of the second recurrence in clubfeet treated by ponseti casting. J Pediatr Orthop 2015;35(3):303–306. DOI: 10.1097/BPO.0000000000000248.
  10. Masrouha KZ, Morcuende JA. Relapse after tibialis anterior tendon transfer in idiopathic clubfoot treated by the Ponseti method. J Pediatr Orthop 2012;32(1):81–84. DOI: 10.1097/BPO.0b013e31823db19d.
  11. Lovell ME, Morcuende JA. Neuromuscular disease as the cause of late clubfoot relapses: report of 4 cases. Iowa Orthop J 2007;27:82–84.
  12. Böhm S, Sinclair MF. The PBS score - a clinical assessment tool for the ambulatory and recurrent clubfoot. J Child Orthop 2019;13(3):282–292. DOI: 10.1302/1863-2548.13.190077.
  13. Eidelman M, Kotlarsky P, Herzenberg JE. Treatment of relapsed, residual, and neglected clubfoot: adjunctive surgery. J Child Orthop 2019;13(3):293–303. DOI: 10.1302/1863-2548.13.190079.
  14. Bhaskar A, Patni P. Classification of relapse pattern in clubfoot treated with Ponseti technique. Indian J Orthop 2013;47(4):370–376. DOI: 10.4103/0019-5413.114921.
  15. Ponseti IV. Relapsing clubfoot: causes, prevention, and treatment. Iowa Orthop J 2002;22:55–56.
  16. Zhao D, Liu J, Zhao L, et al. Relapse of clubfoot after treatment with the Ponseti method and the function of the foot abduction orthosis. Clin Orthop Surg 2014;6(3):245–252. DOI: 10.4055/cios.2014. 6.3.245.
  17. Desai L, Oprescu F, DiMeo A, et al. Bracing in the treatment of children with clubfoot: past, present, and future. Iowa Orthop J 2010;30:15–23.
  18. Janicki JA, Wright JG, Weir S, et al. A comparison of ankle-foot orthoses with foot abduction orthoses to prevent recurrence following correction of idiopathic clubfoot by the Ponseti method. J Bone Joint Surg Br 2011;93(5):700–704. DOI: 10.1302/0301-620X.93B5.24883.
  19. Morin ML, Hoopes DM, Szalay EA. Positive communication paradigm decreases early recurrence in clubfoot treatment. J Pediatr Orthop 2014;34(2):219–222. DOI: 10.1097/BPO.0000000000000080.
  20. Nogueira MP, Ey Batlle AM, Alves CG. Is it possible to treat recurrent clubfoot with the Ponseti technique after posteromedial release?: a preliminary study. Clin Orthop Relat Res 2009;467(5):1298–1305. DOI: 10.1007/s11999-009-0718-9.
  21. Al-Hilli AB. Ponseti method in the treatment of post-operative relapsed idiopathic clubfoot after posteromedial release. A short term functional study. Foot (Edinb) 2020;45:101721. DOI: 10.1016/j.foot.2020.101721.
  22. Shabtai L, Hemo Y, Yavor A, et al. Radiographic indicators of surgery and functional outcome in Ponseti-treated clubfeet. Foot Ankle Int 2016;37(5):542–547. DOI: 10.1177/1071100715623036.
  23. Kang S, Park SS. Lateral tibiocalcaneal angle as a determinant for percutaneous achilles tenotomy for idiopathic clubfeet. J Bone Joint Surg Am 2015;97(15):1246–1254. DOI: 10.2106/JBJS.O.00076.
  24. Mangat KS, Kanwar R, Johnson K, et al. Ultrasonographic phases in gap healing following Ponseti-type Achilles tenotomy. J Bone Joint Surg Am 2010;92(6):1462–1467. DOI: 10.2106/JBJS.I.00188.
  25. Mahan ST, Spencer SA, May CJ, et al. Clubfoot relapse: does presentation differ based on age at initial relapse? J Child Orthop 2017;11(5):367–372. DOI: 10.1302/1863-2548.11.170016.
  26. Ponseti IV, Zhivkov M, Davis N, et al. Treatment of the complex idiopathic clubfoot. Clin Orthop Relat Res 2006;451:171–176. DOI: 10.1097/01.blo.0000224062.39990.48.
  27. Matar HE, Beirne P, Bruce CE, et al. Treatment of complex idiopathic clubfoot using the modified Ponseti method: up to 11 years follow-up. J Pediatr Orthop B 2017;26(2):137–142. DOI: 10.1097/BPB.0000000000000321.
  28. McHale KA, Lenhart MK. Treatment of residual clubfoot deformity--the “bean-shaped” foot--by opening wedge medial cuneiform osteotomy and closing wedge cuboid osteotomy. Clinical review and cadaver correlations. J Pediatr Orthop 1991;11(3):374–381. DOI: 10.1097/01241398-199105000-00017.
  29. DWYER FC. Osteotomy of the calcaneum for pes cavus. J Bone Joint Surg Br 1959;41-B(1):80–86. DOI: 10.1302/0301-620X.41B1.80.
  30. Evans D. Calcaneo-valgus deformity. J Bone Joint Surg Br 1975;57(3):270–278. DOI: 10.1302/0301-620X.57B3.270.
  31. Evans D. Relapsed clubfoot,. J Bone Joint Surg Br 1961;43B(4):722–733. DOI: 10.1302/0301-620X.43B4.722.
  32. Shingade V, Shingade R, Ughade S. Correction of neglected or relapsed clubfoot deformity in an older child by single staged procedure-early results. Curr Ortho Pract 2012;23(2):122–129. DOI: 10.1097/BCO.0b013e318245202e.
  33. Napiontek M, Nazar J. Tibial osteotomy as a salvage procedure in the treatment of congenital talipes equinovarus. J Pediatr Orthop 1994;14(6):763–767. DOI: 10.1097/01241398-199414060-00014.
  34. Nelman K, Weiner DS, Morscher MA, et al. Multiplanar supramalleolar osteotomy in the management of complex rigid foot deformities in children. J Child Orthop 2009;3(1):39–46. DOI: 10.1007/s11832-008-0157-2.
  35. Al-Aubaidi Z, Lundgaard B, Pedersen NW. Anterior distal tibial epiphysiodesis for the treatment of recurrent equinus deformity after surgical treatment of clubfeet. J Pediatr Orthop 2011;31(6):716–720. DOI: 10.1097/BPO.0b013e31822109b6.
  36. Park SS, Kim SW, Jung BS, et al. Selective soft-tissue release for recurrent or residual deformity after conservative treatment of idiopathic clubfoot. J Bone Joint Surg Br 2009;91(11):1526–1530. DOI: 10.1302/0301-620X.91B11.22327.
  37. Penny JN. The neglected clubfoot. Tech Orthop 2005;20(2):153–166. DOI: 10.1097/01.bto.0000162987.08300.5e.
  38. Morcuende JA, Dobbs MB, Frick SL. Results of the Ponseti method in patients with clubfoot associated with arthrogryposis. Iowa Orthop J 2008;28:22–26.
  39. Suresh S, Ahmed A, Sharma VK. Role of Joshi's external stabilization system fixator in the management of idiopathic clubfoot. J Orthop Surg (Hong Kong) 2003;11(2):194–201. DOI: 10.1177/230949900301100216.
  40. Devadoss A, Devadoss S, Kapoor A. Differential distraction for relapsed clubfoot deformity in children. J Orthop Surg (Hong Kong) 2010;18(3):342–345. DOI: 10.1177/230949901001800317.
  41. Dhawan M, Rana N. Management of neglected, recurrent, and resistant congenital talipes equinovarus by controlled differential fractional distraction using the Joshi's external stabilization system. Curr Med Res Pract 2019;9(2):176–181. DOI: 10.1016/j.cmrp.2019.08.002.
  42. Tripathy SK, Saini R, Sudes P, et al. Application of the Ponseti principle for deformity correction in neglected and relapsed clubfoot using the Ilizarov fixator. J Pediatr Orthop B 2011;20(1):26–32. DOI: 10.1097/BPB.0b013e32833f33fe.
  43. Ganger R, Radler C, Handlbauer A, et al. External fixation in clubfoot treatment - a review of the literature. J Pediatr Orthop B 2012;21(1):52–58. DOI: 10.1097/BPB.0b013e32834adba7.
  44. Grant AD, Atar D, Lehman WB. The Ilizarov technique in correction of complex foot deformities. Clin Orthop Relat Res 1992(280):94–103. DOI: 10.1097/00003086-199207000-00012.
  45. Grill F, Franke J. The Ilizarov distractor for the correction of relapsed or neglected clubfoot. J Bone Joint Surg Br 1987;69(4):593–597. DOI: 10.1302/0301-620X.69B4.3611163.
  46. Ferreira RC, Costa MT. Recurrent clubfoot--approach and treatment with external fixation. Foot Ankle Clin 2009;14(3):435–445. DOI: 10.1016/j.fcl.2009.03.009.
  47. Kocaoğlu M, Eralp L, Atalar AC, et al. Correction of complex foot deformities using the Ilizarov external fixator. J Foot Ankle Surg 2002;41(1):30–39. DOI: 10.1016/s1067-2516(02)80007-2.
  48. Lamm BM, Standard SC, Galley IJ, et al. External fixation for the foot and ankle in children. Clin Podiatr Med Surg 2006;23(1):137–166., ix 10.1016/j.cpm.2005.10.007 Erratum in. Clin Podiatr Med Surg 2006;23(2):485–6.
  49. Gourdine-Shaw MC, Lamm BM, Paley D, et al. Distraction osteogenesis for complex foot deformities: U-osteotomy with external fixation. J Bone Joint Surg Am 2012;94(15):1420–1427. DOI: 10.2106/JBJS. K.00360.
  50. Lamm BM, Gourdine-Shaw MC, Thabet AM, et al. Distraction osteogenesis for complex foot deformities: Gigli saw midfoot osteotomy with external fixation. J Foot Ankle Surg 2014;53(5):567–576. DOI: 10.1053/j.jfas.2014.04.008.
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