SLR - November 2015 - Anthony Chesser
Factors Predictive of Second Recurrence in Clubfeet Treated by Ponseti Casting
Reference: Luckett MR, Hosseinzadeh P, Ashley PA, Muchow RD, Talwalkar VR, Iwinski HJ, Walker JL, Milbrandt TA. Factors Predictive of Second Recurrence in Clubfeet Treated by Ponseti Casting. J Pediatr Orthop. 2015 Apr-May;35(3):303-6.
Scientific Literature Review
Reviewed By: Anthony Chesser, DPM
Residency Program: Western Pennsylvania Hospital
Podiatric Relevance: The gold standard for the of talipes equinovarus for the last several decades has been the Ponseti casting technique. Despite initial success, relapses do occur, with the most common occurrence being as a result of orthotic noncompliance. The tibialis anterior tendon transfer [TATT] is commonly used to treat reoccurrence once casting can no longer be achieved. The authors in this article wanted to investigate the rate of secondary reoccurrence after a TATT procedure. This article can help the podiatric surgeon identify patient populations that are more at risk for secondary reoccurrence and to try and prevent secondary reoccurrence from happening.
Methods: Patients were originally treated as described by the Ponseti technique, which consists of gentle manipulation with serial casting and Achilles tenotomy when necessary. Patients were then placed in Denis-Browne orthosis full time for three months, followed by night and nap wearing for three years. Exclusion criteria for this study consisted of: atypical/complex clubfoot, arthrogryphosism, and other surgical interventions before the TATT. They were also required to have at least two years of follow-up post TATT.
Relapse was defined as recurrence of one or more components of the deformity (eg, equinus, hindfoot varus, forefoot adductus, and/or cavus) on physical examination that required further operative or non-operative treatment. The TATT procedures were primarily performed to correct a dynamic supination deformity. All surgeries were performed by one of five pediatric orthopedic surgeons using similar techniques. The initial incision was placed at the insertion of the tibialis anterior. The tendon was identified and released from its insertion and a tensioning suture (Bunnel, Krackow) was placed at the distal end. An incision was placed over the lateral cuneiform and the tendon was then passed through a bone tunnel in the lateral incision. With the foot in maximum eversion and dorsiflexion the tendon was tied over a button on the plantar aspect of the foot. An Achilles tenotomy was performed if indicated.
Post-operatively, a long leg non-weight bearing cast was applied on the foot in the corrected position for a period of six weeks. AFO’s were utilized in the postoperative period by some surgeons. No other modalities such as night bracing, physical therapy, or stretching regiments, were prescribed in the postoperative period.
This article is a retrospective chart review of all patients treated with TATT for recurrent clubfeet between the years of 2002-2010. The authors’ definition of recurrence was defined as any element of clubfoot deformity that required operative or non-operative treatment. Noncompliance with bracing was defined two ways: as premature discontinuation of the braces by the family before thirty-six months of wear or if the families report less wear then what the physician prescribed. Major surgery consisted of a posterior medial release, posterior release, plantar fascial release, as well as bilateral distal tibia hemiepiphysiodesis. Minor surgery was considered an Achilles tendon lengthening.
Results: Sixty patients with eighty-five clubfeet were included in the study. Sixteen feet in twelve patients (20 percent) developed recurrence after TATT procedure. Eight of the feet were treated non-operatively, and the other eight were treated with various surgical procedures. Five required major surgery, while the other three required minor surgery. Young age and brace noncompliance were the two biggest factors that contributed to the rate of secondary reoccurrence.
Conclusion: The authors’ concluded from their study that there is a twenty percent reoccurrence rate after correction of talipes equinovarus deformity with TATT. This study shows that when reoccurrence happens after TATT procedure in patients with talipes equinovarus two populations need to be closely monitored: those under two and a half years of age and those that are noncompliant with their orthotics.