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Clubfoot Treatment in High and Low-Income Regions Produces Functional Feet

2018; Wolters Kluwer; Volume: 100; Issue: 23 Linguagem: Inglês

10.2106/jbjs.18.00948

1535-1386

James G. Wright,

Cerebral Palsy and Movement Disorders

Commentary Clubfoot is one of the most common nontraumatic disorders in pediatric orthopaedics. The treatment of clubfoot has undergone several paradigm shifts over the past 60 years. Historically, different nonoperative regimens were largely the mainstay of the initial treatment for clubfeet. The techniques were described eponymically and often involved long periods, even years, of cast immobilization. After treatment, the feet were often stiff with high rates of incomplete correction. The treatment then shifted from nonoperative to extensive surgical release. Extensive surgery achieved a plantigrade foot immediately but later follow-up revealed stiff, sometimes painful feet. While practiced in Iowa for many decades, the Ponseti treatment protocol has subsequently become the standard of treatment for clubfoot worldwide. The Ponseti protocol has completely changed the treatment of clubfeet with results so obviously superior to extensive surgical release that a randomized controlled trial would not be appropriate. Furthermore, the technique can be administered by non-physicians and therefore has wide applicability in low-resource countries. Jeans et al. and Banskota et al. evaluated outcomes of clubfeet, in late childhood, after treatment with the Ponseti protocol. Jeans et al. reported on 175 patients with a total of 263 idiopathic clubfoot. In their study, children who underwent initial nonoperative treatment with the Ponseti or French technique demonstrated, at 10 years of age, loss of ankle motion and strength compared with controls without clubfoot. The conclusions of this paper rely heavily on motion analyses, raising uncertainty regarding how meaningful such impairments are in terms of children’s overall function in activities of daily living. The study also compared the outcomes between children who had received intra-articular surgery after the initial nonoperative treatment and those who received extra-articular surgery or only nonoperative treatment. The authors stated, on the basis of worse results in the subgroup treated with intra-articular surgery, that their finding “lends support to efforts to minimize intra-articular surgery.” The difficulty with this conclusion is that surgeons have clearly recognized that clubfoot varies enormously in severity and therefore the risk of recurrence. Thus, it is entirely plausible that the surgical group consisted of the most severe cases of clubfoot and their worse outcomes reflect severity, not the performance of intra-articular surgery. This is important to recognize because in the past minimal surgery may have actually resulted in more surgery in childhood because of incomplete correction of all deformities and worse overall results in the long term1. The study by Jeans et al. does, however, provide reassurance that despite a need for surgery in 44% of the feet and abnormalities on motion analyses, functional outcomes were close to those of the controls. In the second article, Banskota et al. also evaluated the results of Ponseti treatment in late childhood, but in a different patient group and in a different setting. Given that the children presented for treatment at 1 to 5 years of age, rather than in infancy, one would expect a higher rate of treatment failure. The risk may have been partially offset by routine admission to a rehabilitation facility that would have enforced greater treatment compliance than can be achieved with the typical outpatient treatment regimen. The authors reported a 95% rate of plantigrade feet with favorable scores on the Oxford Ankle Foot Questionnaire for Children, and thus concluded that the Ponseti technique provides satisfactory results in a “low-income country.” The low rate of 3% for overt relapse, however, is at odds with other studies such as the one described above, in which the surgical rate was 44%. Many of the Nepalese children in the study by Banskota et al. had residual deformity despite a plantigrade foot. The good functional outcome scores, despite residual deformity, may be due to the lower functional expectations in Nepal. However, it also raises the question of whether some of the deformities that prompt surgery at a young age in high-income settings, such as the one in the study reported above, do not require surgery and that some residual deformity is compatible with good function. In conclusion, Ponseti treatment does not result in a normal foot but irrespective of whether additional surgery is performed or the regimen is used for older children in a low-income country, patient function is generally good.