Title: The results of surgical treatment of clubfoot in children under one year of age
Author(s): Seyyed Mohammad Jazayery MD, Mahdie Kerdari MD, Mehrnoush Hassass Yeganeh MD*
Affiliattion(s): Shahid Beheshti University of Medical Sciences, Tehran, Iran
* Corresponding Author
Vol 2, Num 1, January 2015
Introduction:Clubfoot is one the most common congenital deformities in children. This deformity is characterized by forefoot adduction, hindfoot equinus and varus and internal tortion of the leg. This disease causes many functional, social and emotional problems for the affected child and his family. If it is not treated in a correct and timely manner, the consequences will be catastrophic.
Materials and Methods:We assessed the archive of Akhtar orthopaedic hospital for the files of the children with clubfoot treated between 1994 and 2004 under the age of one. We asked the patients to attend the clinic and evaluated them by functional rating score (FRS), clinical examination and radiographic assessment after obtaining informed consent from the child or his parents. For each child we filled in a form of FRS.
Results:Our results show that different surgical techniques do not have the same results based on FRS.(p<0.05) We also found that in those children who had failed results, the Carroll technique was 2 times more common than those with successful results.
Conclusion:We conclude that treating the clubfoot in female children before the age of 6 months, using those techniques with wider exposure and performing perfect correction at the time of surgery, lead to best midterm functional and radiographic results.
Keyword:Clubfoot, Treatment, McKay technique, Turco technique, Carroll technique
Clubfoot is one the most common congenital deformities in children. This deformity is characterized by forefoot adduction, hindfoot equinus and varus and internal tortion of the leg. This disease causes many functional, social and emotional problems for the affected child and his family. If it is not treated in a correct and timely manner, the consequences will be catastrophic.(1)
The prevalence of clubfoot differs in both sexes and various ethnic groups and is near 1-2 in 1000 live births.(1) Clubfoot is usually a primary deformity, but it can also occur as a result of arthrogryposis, streeter dysplasia or diastrophic dysplasia.(2,3) The accurate diagnosis of clubfoot is by clinical examination and radiographic assessment of the affected foot.
Treatment options for this disease are basically divided into nonoperative and operative methods. Nonoperative treatment methods include stretching, taping, serial casting and bracing.
Surgical management of a resistant, persistent, or relapsed clubfoot deformity (that does not respond to further nonoperative treatment) will be required to obtain a plantigrade foot. The surgical release must address all of the pathoanatomic structures in a resistant clubfoot, including a complex release of the hindfoot and midfoot. There are three McKay, Turco and Carroll surgical techniques, each of which has its own benefits and drawbacks.(1)
Turco is credited with describing the first complete one-stage posteromedial release. He emphasized correcting the deformity of the calcaneus beneath the talus, which required complete subtalar release (lateral, posterior, and medial), as well as release of the calcaneofibular ligaments.
Carroll emphasized plantar fascial release and capsulotomy of the calcaneocuboid joint, because forefoot adduction and supination (actual cavus) were not addressed by Turco's procedure. Thus, through a medial incision with the patient prone (or supine), the abductor hallucis is identified and released, and deep to it, the plantar fascia is divided; after sufficient dissection of the inferior talonavicular and anterior talocalcaneal area, the peroneus longus tendon is protected and the calcaneocuboid joint is opened from the media] side and fully released. This follows posterolateral release through a posterior longitudinal incision paralleling the lateral edge of the heel cord, through which the Achilles tendon is Z-lengthened and a posterior capsulotomy of the ankle joint, including the medial and lateral ligaments, is performed to mobilize the talus and reduce the talonavicular joint, which is done by internally rotating the talus with a longitudinal K-wire as the "handle" to perform this derotation.(4,5)
More extensive procedures are performed by McKay who used the Cincinnati incision with the patient supine. The majority of peritalar structures, including all hindfoot and mid foot joints are released. A medial and lateral circumferential talocalcaneal release is performed, with the lateral talocalcaneus being released from the attachment of the calcaneocuboid joint laterally to the sheath of the flexor hallucis longus posteromedially. Complete release of the talonavicular and calcaneocuboid is included, and both these structures are pinned. Once the calcaneus has been adequately derotated by pushing the anterior end laterally and the posterior tuberosity medially and downward, the interosseous ligament is internally fixed. (6.7)
According to literature, poor results following both operative and nonoperative methods are not uncommon. In our country there are few studies addressing the results of the different treatment methods for clubfoot. We decided to perform this study on the children treated operatively for clubfoot in order to assess the results of different surgical methods in the disease.
Materials and Methods
We assessed the archive of Akhtar orthopaedic hospital for the files of the children with clubfoot treated between 1994 and 2004. We selected the files of those children that were treated surgically before 1 year of age.
Inclusion criteria were:
1- Definitive clinical diagnosis of clubfoot
2- Surgical treatment by one of the mentioned techniques under 1-year old age.
3- Treatment performed between 1994 – 2004
Exclusion criteria include:
1- Those who were treated after the age of 1 year
2- Previous surgeries on the same foot
3- Clubfoot is a component of a syndrome affecting the child
Then we asked the patients to attend the clinic and evaluated them by functional rating score (FRS)(Table 1), clinical examination and radiographic assessment after obtaining informed consent from the child or his parents. For each child we filled in a form of FRS, which is the most widely accepted method of evaluation of the results of clubfoot treatment.
In the form, 10 radiographic and clinical criteria are assessed and each gets a score. According to the sum of these points, the results are classified into four groups; excellent, good, fair and poor. We classified the results as successful treatment for those who were in excellent and good groups and as failed treatment for those in fair and poor groups. Then we analyzed the results by Chi-square test.
In the archive, we found 297 files of children fulfilling the inclusion and exclusion criteria. 267 of these children attended the clinic for evaluation. There were 157 male (58.8%) and 110 female (41.2%) children.
There were 47 (17.6) children operated by Carroll technique, 156 (58.6) by Turco technique and 64 (24%) by McKay technique. According to the results of the treatment by FRS, 3% of children had excellent results, 46.1% had good results, 37.1% had fair and 16.8% had poor results. (Figure 1) When we classified the results into successful and failed, there were 123 children (46.1%) with successful and 144 children (53.9%) with failed results.
We separately analyzed the success in the treatment with respect to the operative technique employed and found that following the Carroll technique, the successful results was much less than the failed results. (12.2% versus 22.2%), but in children undergoing Turco and McKay techniques, the successful results were significantly more than failed results. These results show that different surgical techniques do not have the same results based on FRS. (p<0.05) We also found that in those children who had failed results, the Carroll technique was 2 times more common than those with successful results. (Table 2)
We analyzed the relationship between the ages of children at the time of operation and the treatment results. We found that 29 children (10.9%) were treated before the age of 3 months, 48 children (18%) between the age of 3 and 6 months, 114 children (42.7%) between 6 and 9 months and 76 children (28.4%) between 9 and 12 months. When we analyzed this age distribution with the results, we found no statistically significant relationship between the age at the time of treatment and the treatment results.(Table 3)
The results show that 43.9% of those with successful results and 71.5% of those with failed result were male. So there are statistically significant relationship between the results of treatment and the sex distribution. (p<0.005) The failure in treating the boys is 3.20 times more probable than girls.(Table 4)
Clubfoot is one of the most common congenital deformities in children, which mainly affects all the tissues distal to knee joints and may be uni- or bilateral. The clubfoot deformities consist of forefoot supination and adduction, hind foot equinus and varus and leg internal torsion.(8,9)
The long-term aim of treatment of clubfoot is to obtain near normal function and acceptable shape of the affected foot with minimal pain and no need to long-term bracing. (10) Whenever nonoperative treatments fail, the child must be treated by operative methods.
The main principals of the surgical treatment include beginning the treatment as soon as possible, performing a perfect correction in order to avoid repeated surgeries and obtaining the best result in the first surgery.(11)
The earlier the treatment is begun, the better the foot develops and the more perfectly the bone deformities are corrected. (12,13) The best time for surgical treatment of the clubfoot is when the child begins to walk. In this way, the pressure applied to the foot during walking helps to maintain the correction obtained at the time of surgery. (14,15) By employing the Cincinnati approach, which provides a wide exposure of the posterior, medial and lateral parts of the hind- and midfoot to address all the pathologies of the clubfoot, good to excellent short-term results were reported by McKay in 71%, by Simons in 72% and by Turco in 84%. (16,17,18)
Our study is performed on 267 children who were treated by one of three surgical methods of Carroll, Turco and McKay. The patients were followed for at least 5 years postoperatively and the results were assessed by Functional Rating Score (FRS). The results of this study show that 46.1% of our patients had good to excellent results and only 16.8% of them had poor results. Compared to the reports by Torco, which reports 83.3% good to excellent results, our results are significantly different. This difference can be attributed to employment of three different surgical methods.
22.2% of those with failed results and 12.2% of those with successful results were operated by Carroll technique, but in those who were operated by Torco and McKay techniques, the percentage of successful results was more than failed results. The statistical analysis of these results shows the there is significant difference between the results of different surgical techniques.(p<0.05)
The Carroll technique was 2 times more common in children with failed results compared to those with successful results. This can be attributed to more limited exposure and consequently less perfect correction at the time of surgery in this technique. In this study, most of the successful results are seen following Torco and McKay techniques. Following McKay technique, these results were slightly better than Torco technique, which have no statistically significant difference.
In a study on Torco technique, least complications were seen in patients under the age of 2 years. (18) According to the studies by Main and Franke, the best results were obtained when the surgery was performed before 6 months of age. (19, 20) DePuy, in a study on 44 children with clubfoot who were classified according to their age to 3 groups (4 months, 9 months and 16 months), reported no statistically significant differences between the functional and radiographic results after posteromedial release. (21) In our study, the best treatment results were in those who were treated after the age of 6 months. But it was not statistically different from those who were treated after the age of 6 months. (p<0.9) Our study also shows that the treatment failure was more common in male children than female children. (p<0.05)
It seems that treating the clubfoot in female children before the age of 6 months, using those techniques with wider exposure and performing perfect correction at the time of surgery, lead to best midterm functional and radiographic results.
Seyyed Mohammad Jazayery MD Orthopaedic surgeon, Associate professor, Shahid Beheshti Medical Univerity, Tehran, Iran email@example.com
Mahdie Kerdari MD Orthopaedic Research Fellow, Shahid Beheshti University of Medical Sciences, Tehran, Iran firstname.lastname@example.org
Mehrnoush Hassass Yeganeh MD Assistant Professor, Paediatric rheumatologist, Shahid Beheshti University of Medical Sciences, Tehran, Iran Corresponding author email@example.com
Acknowledgements: None declared.
Financial disclosure: None declared.
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