SLR - May 2021 - Rahim R. Lakhani
Quantification of Ankle Dorsiflexion in Ponseti-managed Unilateral Clubfoot Patients During Early Childhood
Reference: Tougas M Caroline, Ballester M Andrew, Morgan D Rebecca, Ebramzadeh Edward, Sangiorgio N Sophia, Zionts E Lewis. Quantification of Ankle Dorsiflexion in Ponseti-managed Unilateral Clubfoot Patients During Early Childhood. J Pediatr Orthop. 2021 Feb 1;41(2):83-87.
Level of Evidence: Level IV-Retrospective Case Series
Scientific Literature Review
Reviewed By: Rahim R. Lakhani, DPM
Residency Program: Our Lady of Lourdes Memorial Hospital – Binghamton, NY
Podiatric Relevance: Clubfoot deformities are often treated using casting techniques like the Ponseti Method, which have been shown to have successful long-term outcomes. However, one of the major complications seen in casting correction is recurrence. The purpose of this study was to determine whether the decrease in passive ankle dorsiflexion over time is due to the relapse of the deformity or due to other variables attributing to the decrease in motion. There is disagreement within the literature on what range of ankle dorsiflexion would indicate impending relapse of Clubfoot, thus warranting treatment intervention. The authors in this study measure passive ankle dorsiflexion in the Ponseti-managed limb and contralateral limb and compare the measurements to multiple variables to determine if there is an underlying correlation.
Methods: A retrospective case series was performed on 132 idiopathic unilateral clubfoot patients (98 males, 34 females), who all underwent correction utilizing the Ponseti method. Patients who underwent surgical correction other than an Achilles tenotomy were excluded from the study. After the Ponseti cast, infants were placed in a Mitchell-Ponseti Brace for 23 hours a day over a three-month period followed by night and nap time use for at least four to five years. Passive ankle dorsiflexion measurements were performed using a goniometer on both limbs at each visit. Severity of each deformity was calculated using the Dimeglio scale. Linear model and paired t-tests were created to evaluate the relationship between dorsiflexion measurements to variables such as yearly age intervals, sex, severity of deformity, and laterality.
Results: In the unaffected limb, the mean ankle dorsiflexion between zero to one year of age was 53 ± 6 degrees and that decreased to 39 ± 7 degrees by 4-5 years of age and then to 34 ±9 degrees by 8-9 years of age. In the Ponseti treated contralateral limb, the mean ankle dorsiflexion between zero to one year of age was 44 ± 7 degrees and that decreased to 29 ± 7 degrees by 4-5 years of age and then to 25 ± 9 degrees by eight to nine years of age. The measured dorsiflexion difference between both limbs averaged approximately 10 degrees for every age interval through the age of 9. It was also established that 95 percent of clubfeet ankle dorsiflexion between the age of zero to two was at least 20 degrees and 95 percent of clubfeet ankle dorsiflexion between the age of three to five was at least 15 degrees.
Conclusions: The authors concluded that patient’s age and severity of the deformity were the two factors that were significantly associated with decrease in dorsiflexion over time. Sex of the patient and laterality of the deformity did not play a role in affecting ankle dorsiflexion measurements. If the ankle dorsiflexion is found to be below 20 degrees in patient’s aged zero to two years old or below 15 degrees in patient’s aged three to five years old, one can deduce that there is recurrence of the deformity. Additionally, relapse could be predicted if patients nine years or younger have a greater than 10-degree ankle dorsiflexion difference between both limbs.