LOW TEMPERATURE THERMOPLASTIC SPLINTING IN THE MANAGEMENT OF CONGENITAL TALIPES EQUINOVARUS

Congenital talipes equinovarus (CTEV) is one of the most common congenital deformities. Treatment of clubfoot should begin at the earliest to have the best outcome. The goal of treatment is to eliminate all deformities of CTEV so that patient has a functional, pain free, plantigrade foot with good mobility within minimum time duration. Treatment includes non-surgical and surgical methods. Conventionally Plaster of Paris (POP) is used for splinting though leather, polypropylene and rubber are also used. Objective of this study is to evaluate the effectiveness of low temperature thermoplastic (LTTP) splinting in CTEV management. This is an on observational study over a period of one year in Thirty-two CTEV patients with Pirani score of less than three. Effectiveness of LTTP splinting was evaluated in detail. It was found that LTTP splinting was cost effective, cosmetically better, reusable, demoldable, and easier to apply. It was of light weight, and required lesser time. It avoids the need for repetitive casting and same splint can be used as maintenance splint also. Pirani score lowered from 3 to 0 after 6 months of splinting. Conclusion –The compliance in donning the splint was high and acceptable among the children studied. Parental satisfaction regarding the splint wearing time and correction of deformity factor was high. Skin complications associated with POP casting were absent in the study population. Hence correction of CTEV with LTTP splinting was more effective than conventional POP casting

Pie bot: conceptos actuales / Clubfoot: current concepts

El pie bot es la deformidad congénita más frecuente de las extremidades inferiores del ser humano, afectando a 1 de cada 1000 recién nacidos vivos. Consiste en la presencia de cuatro deformidades estructurales en el pie y el tobillo: cavo del medio pie, aducto del antepié, varo del retropié y pie en equino.Su registro en la humanidad data del siglo XII A.C. en momias del antiguo Egipto.La fisiopatología de esta deformidad aún no está aclarada. El diagnóstico puede ser prenatal mediante visualización ecográfica, pero la forma más común de diagnóstico es postnatal. La evaluación de estos pacientes se basa en la exploración clínica. Entre las clasificaciones más utilizadas se encuentran: Diméglio, que enfatiza lo reductible ante maniobras manuales de la deformidad; Pirani, que evalúa la gravedad inicial y el progreso del tratamiento; y Ponseti International Association (PIA), que clasifica según etiología.Durante el siglo pasado se describieron numerosos procedimientos quirúrgicos, muchos de los cuales fueron quedando en desuso ante sus resultados insatisfactorios, pies rígidos y dolorosos, con función limitada. Actualmente el método Ponseti es el Gold estándar para su tratamiento, consistiendo en una manipulación y enyesado seriado buscando la corrección sistemática del pie, basado en los fundamentos de la cinemática y la fisiopatología de la deformidad.

Clubfoot is the most frequent congenital deformity of the lower extremities of humans, affecting 1 out of 1000 live newborns. It consists of the presence of four structural deformities in the foot and ankle: midfoot cavus, forefoot adductus, hindfoot varus, and equinus foot.Its records in humanity date from the 12th century B.C., in ancient Egyptian mummies.The pathophysiology of this deformity is still unclear. Prenatal diagnosis by ultrasound imaging is feasible, but most common diagnosis is postnatal. The evaluation of these patients is based on clinical examination. Among the most used classifications are: Diméglio, which emphasizes the reductibility with manual maneuvers; Pirani, who assesses initial severity and progress of treatment; and Ponseti International Association (PIA), which classifies according to etiology.During the last century, numerous surgical procedures were described, many of which were disused due to their unsatisfactory results, stiffness and painful feet, with limited functionality. Currently the Ponseti method is the gold standard for its treatment. It consists of serial manipulation and casting, looking for a systematic correction of the deformity, based on the fundamentals of kinematics and pathophysiology of the deformity.

Results of Ponseti Casting for Clubfoot in a Tertiary Public Hospital

@#INTRODUCTION: Congenital talipes equinovarus (CTEV), also called clubfoot, is one of the most common orthopedic congenital anomalies. However, there is no formal study of the condition here in the Philippines, and data is sparse regarding the epidemiology, treatment, and outcomes in similar third-world countries. METHODS: Retrospective review of data of clubfoot patients seen at the Philippine General Hospital (PGH) Clubfoot Clinic from 2006 up to the present. RESULTS: Records from 75 patients treated at the PGH Clubfoot Clinic from 2010-2016 were reviewed. Idiopathic clubfoot comprised 76% of the patients, while syndromic clubfoot comprised 24%. A good outcome of the Ponseti method was seen in 82% and 88% of the idiopathic and syndromic clubfoot patients, respectively. Idiopathic clubfoot cases that had good outcomes required an average of 11.84 casts to tenotomy or bracing, which was not statistically significant compared to 9.55 average sessions for syndromic clubfoot (p=0.21). The initial Pirani scores for both cases were not significantly different (p=0.95). Idiopathic cases with poor outcomes needed less casting sessions (4.45) because the decision to operate was made early. Age was not found to significantly affect the outcome of treatment for idiopathic clubfoot (p=0.20) and syndromic clubfoot (p=0.64). CONCLUSION: Ponseti casting was found to be effective in treating both idiopathic and syndromic clubfoot patients. The number of sessions did not differ significantly between the two.

Popliteal pterygium syndrome: case report from rural India

The popliteal pterygium syndrome is a congenital malformation that includes orofacial, musculoskeletal and genitourinary anomalies. It is also known as faciogenitopopliteal syndrome. It is autosomal dominant disorder. It has highly variable expressivity and incomplete penetrance. The incidence of the popliteal pterygium syndrome is 1/300000, which makes it an extremely rare condition. The most striking characteristic of this syndrome is popliteal pterygium, which consists of a net of connective tissue spreading from the ischial tuberosity to the calcaneus.In this study, authors present the case of a 1 day old male patient with cleft upper lip, cleft palate, bifid scrotum, popliteal pterygium and congenital talipes equinovarus (CTEV).

Outcome of clubfoot treatment in the pre-ponseti period in a Nigerian teaching hospital: a 14 year review

Background: Congenital Talipes Equinovarus (CTEV) is a common musculoskeletal congenital disorder. Historically, surgical treatment of various types was popular; however, currently the gold standard of treatment is non-operative care using the Ponseti method. This work evaluates the outcome of this former method of managing CTEV before author adopted the Ponseti Method and compares it with the reported outcomes of the Ponseti method in published literature.Methods: A retrospective review of this data from January 1990 to December 2003 was done, the patients demographics, treatment given, duration and outcome of care were analysed using descriptive statistics. This finding was then compared with outcomes of Ponseti method in literature.Results: Here, 145 patients had initial non operative care; eighteen of those patients (12.4%), eventually require either a posteromedial release, a combined posteromedial and posterolateral releases or a triple arthrodesis.Conclusions: The study shows that the success rate of this method of manipulation preceding the adoption of the Ponseti method is 87.6%. This outcome is inferior when compared to the outcome of Ponseti method in published literature. Also, the extensive nature of eventual surgical intervention required to achieve correction is in contrast to the minimal surgeries needed achieve correction of residual deformities following the use of the Ponseti method.

Comparative Study Of Surgical Correction Of Congenital Talipes Equino Varus Deformity With And Without Internal Fixation (using K-wires)

Congenital Talipes Equino Varus is one of the most common congenital deformity which occurs in 1/1000 live birth worldwide. Regarding management of this clubfoot ,most orthopaedic surgeons agree that approach management of children with congenital talipes equino varus deformity of foot should begin with conservative measures i.e, manipulation and serial casting in position of correction. One or more surgical procedures are often required in patients who had incomplete correction , recurrent deformity , syndromic correction and after repeated manipulation and casts. Recurrence is a common problem following the club foot surgery one of the reason for recurrence can be redisplacement of tarsal bones .This study aims to compare prospectively the functional and cosmetic outcome of two groups of club foot-one in whom tarsal joint were fixed with k-wires after doing posteromedial soft tissue release and one in whom tarsal joint were not fixed after soft tissue release .To know the incidence of congenital talipes equino varus with respect to age and sex predilection over a period of two years which were admitted between October 2017 to October 2019, 28 idiopathic club foot in 20 children range from 4 months to 3 years were treated out of 20 cases 12 were males,8 were females.8 patients had bilateral deformity out of 12 unilateral deformities 8 were on right side and 4 were on the left side. Male and female ratio 1.5:1 and unilateral to bilateral 1.5 :1.In 12 feet turco's posteromedial soft tissue release and internal fixation of tarsal joints with k-wires was done in 16 feet only turco's posteromedial soft tissue release was done. The period of follow up ranges from 6 months to 2 years

Clinical, Radiological, and Functional Outcome of Delayed Presenting Congenital Talipes Equinovarus Cases Managed by Joshi’s External Stabilization System: A Prospective Study

introduction: Clubfoot and its management have been the topic of keen interest to the orthopedics field ever since timeimmemorial and many techniques in the successful management of these have been advocated till date. This study discussesone such technique of management in children with Joshi’s external stabilization system (JESS) fixator.Aim: This study aims to evaluate the role of JESS in the management of neglected, resistant and relapsed congenital talipesequinovarus (CTEV), in the age group of 1–6 years.Materials and Methods: A total of 20 feet in 20 children underwent JESS fixation surgery at the Department of Orthopaedics,Government Rajaji Hospital, Madurai Medical College, from October 2015 to September 2018.Results: Four patients had excellent results, 12 patients had good results with an average score of 78, three patients had fairresults, and poor results in one patient. The average pre-operative Pirani score was 4.5 and post-operative score of 0.93 withP < 0.001 which was statistically significant. The average pre-operative Dimeglio score was 12 (Stage III) which statisticallyimproved post-operative (P < 0.001) to 5 (Stage 1).Conclusion: By controlled differential distraction using JESS apparatus, a painless, Pliable, plantigrade. The perfect sized andcosmetically acceptable foot has been obtained even in children 1 year–6 years. Controlled differential distraction using JESSfixator has got a definite role in the management of relapsed and neglected CTEV and it does not prevent the foot from beingtreated surgically at a later date if needed.

Major Predisposing Factors Influencing the Suicide by Hanging: A Retrospective Study from a Tertiary Care Government Hospital in Kerala State, South India

Introdcution: A variable incidence of hanging is found assecond major group among the total number of autopsiesdone in the Department of Forensic Medicine, Govt. MedicalCollege, Calicut, Kerala state, South India. The incidences arefound to be varying according to the social and economic statusof the society. This retrospective study was done in a tertiarycare Government Hospital to find the major predisposingfactors influencing the suicide by hanging.Material and Methods: Case history were taken in detailfrom questionnaires to the relations of the deceased and fromPolice. The results were analyzed on the basis of history,postmortem findings and results of laboratory investigations.Results: The age group 16-25 was found to be the mostprevalent (75%) for suicidal hanging. Among the religion,Hindu religion showed the highest (80%) number. Morecases were found among the manual labourers and lowermiddle class people. People without children were moreprone to suicide by hanging. Among the precipitating factors,mental illness was the highest factor. Fracture of hyoid bonewas found during autopsy in majority of cases of completehanging.Conclusion: Psychological upset and educational statusplayed an important role in suicidal hanging. The highestincidence was seen among those with lower educational status.Hence, proper identification of such people and presentingthem to effective counselling may reduce the incident rate.

BARRIERS AFFECTING CLUBFOOT TREATMENT IN SARAWAK

@#Congenital talipes equinovarus (CTEV), also known as clubfoot is the most common lower limb congenital deformity among paediatric patients. The outcome of starting clubfoot treatment early is very promising. Patient retention throughout the treatment programme is challenging in Sarawak. In this study, we explored the barriers that parents/caregivers face when seeking clubfoot treatment in Sarawak, Northwest Borneo. A better understanding of the barriers will provide us with the information to formulate effective programmes for clubfoot treatment in this region.Methods: We conducted a questionnaire-based quantitative cross-sectional descriptive survey. We adapted a set of closed-ended questionnaires originally designed by Kazibwe and Struthers in a study done in Uganda in the year 2006.Results: A total of 53 parents/caregivers of children with idiopathic clubfoot were recruited in this study, with 16 defaulter cases and 37 non-defaulter cases. We found 2 statistically significant barriers to clubfoot treatment in Sarawak, with p-value < 0.05, namely the geographical factor (p = 0.019) and logistic factor (p = 0.017).Conclusion: Barriers to clubfoot treatment that influence the compliance to treatment identified in this study are long distance travel, logistics limitations, uncooperative patients during treatment, parents/caregivers having other commitments, unsupportive family members, lack of understanding regarding clubfoot and its treatment, inadequate specialists in clubfoot, traditional socio-cultural beliefs and practices and economic constraints. Enhanced understanding in this matter will guide us in devising culturally admissible ways to increase awareness in parents/caregivers regarding clubfoot and its treatment. A sustainable national clubfoot program will be very beneficial in providing a holistic approach to tackle barriers to treatment in our country

Biomechanical Parameters in Children with Unilateral and Bilateral Clubfoot during Vertical Jumps

Abstract Gait analysis may offer information to choose the best exercise-based clinical intervention for the children with clubfoot. However, other motor abilities are not commonly investigated. The aim of this research was to analyze the biomechanics of countermovement vertical jumping in clubfooted children who had undergone surgery. Fourteen children with idiopathic clubfoot were selected and the control group consisted of 11 children. Clubfooted children showed less dorsiflexion in the jump preparation phase. In the impulse phase, this group showed more knee flexion and less plantarflexion associated with less magnitude of vertical reaction force and less muscular activity in the gastrocnemius medialis. In the landing phase, for clubfoot group, we found high loading rate for the first peak of vertical force, less plantarflexion and more knee flexion. Understanding the biomechanical changes of vertical jump landing should assist in better targeting of physical and sporting activities of this population.(AU)

Dynamic Adduction Angle of Forefoot Measured With a Novel Technique And Its Relationship With Functional Outcomes

Background: Idiopathic clubfoot is commonly treated with the Ponseti method with the extent of invasive treatment involving tendon-Achilles lengthening. Forefoot adduction is a common complication in surgically treated clubfeet. Yet, no method has been described to measure dynamic (walking) forefoot adduction. The aim of this study was to assess the persistent pes adductus in children whose clubfeet were surgically treated using a dorsomedial soft tissue release and to find out correlations between forefoot adduction and clinical outcome measures. Methods: We analysed the dynamic adduction angle in 33 clubfeet using a pressure-sensitive foot platform and compared it to the healthy feet of an age- and weight-matched group of children without congenital foot deformities. The clinical outcome was analysed using the McKay score. Results: Mean dynamic adduction angle was 4.1o in the surgically corrected clubfeet, whereas it was 6.4º in unaffected feet of patients with unilateral clubfoot and 7.1o in control group. The McKay score were excellent in 1 patient, good in 5, average in 13, and fair in 4 of the 23 patients. There was no correlation between dynamic adduction angle and McKay score using paired t test (P > 0.05). Conclusion: High occurrence of dynamic adduction angle in surgically treated clubfeet was detected. In conclusion, no correlation between forefoot adduction, dynamic forefoot adduction angle and clinical outcome measures within the study was observed.

Expression of Col9a1 Gene in Ankle Tissue of Rat Model of Idiopathic Congenital Talipes Equinovarus / 沈阳医学院学报

Objective:To investigate the expression of Col9a1 gene in ankle tissue of rat model of idiopathic congenital talipes equinovarus (ICTEV) . Methods:ICTEV rat model was established. Immunofluorescence staining and immunohistochemical dyeing technology were used to detect the expression of Col9a1 protein in ankle tissue of model group and control group. Results:The expression level of Col9a1 protein in ankle tissue in model group was higher than that in the control group (P<0.05),Col9a1 gene expressed primarily in soft tissue and cartilage membrane. Conclusion:The increasing expression level of Col9a1 gene in ankle tissue of ICTEV rats may be related to clubfoot deformity.

Epithelioid hemangioma of distal femoral epiphysis in a patientwith congenital talipes equinovarus

Epithelioid hemangioma (EH) is a rare benign vascular lesion of soft tissue and bone, characterized by endothelial cells with epithelioid or histiocytoid appearance. Though tubular bones, flat bones, vertebra and short bones are common sites for this lesion, the epiphyseal involvement is extremely rare. We present an unusual case of EH of the distal femur in a young boy. Case report: A 12-year-old boy who had congenital talipes equinovarus of the right foot presented with progressively increasing pain in the right lower thigh for six months. Physical examination revealed muscular atrophy of the right lower limb and a moderately tender swelling in the medial aspect of the right knee without restriction of knee movement. An X-ray revealed an osteolytic lesion, which appeared iso- and hypointense on T1W and hyperintense on T2W MRI images in the distal epiphysis and adjacent metaphysis of the right femur. A radiological diagnosis of chondroblastoma was entertained. The patient was treated with curettage and bone grafting. Histopathology showed a tumor composed of thin-walled arteriolar capillaries lined by large, polyhedral epithelioid endothelial cells with vesicular nuclei, finely distributed nuclear chromatin, and moderate amount of eosinophilic cytoplasm. The endothelial cells were strongly immunopositive for CD34. Mitotic activity was low and the Ki-67 proliferative rate was <2%. A diagnosis of EH was made. EH is a benign lesion and it should be differentiated from its histologically similar malignant counterparts such as epithelioid hemangioendothelioma and epithelioid angiosarcoma as the lesion can be successfully treated with curettage or resection.

Prevalence of talipes equinovarus, congenital dislocation of the hip, cleft lip/cleft palate, Down syndrome and neural tube defects among live newborns in Anuradhapura, Sri Lanka.

Objective To determine the prevalence of talipes equinovarus, congenital dislocation of the hip, cleft lip/cleft palate, Down syndrome and neural tube defects among live newborns at Anuradhapura General Hospital, Sri Lanka. Method Babies born from February 2002 to January 2003 were examined for the above five congenital anomalies. Anomalies were recorded in a register and live birth prevalence rate (LBPR) for each anomaly was calculated. Results 9105 newborns were examined for the 5 selected congenital anomalies. LBPR per 10,000 live births of the 5 anomalies were as follows: talipes equinovarus 31.8, congenital dislocation of hip 26.3, cleft lip/cleft palate 21.9, Down syndrome 20.8 and neural tube defects 13.2.

Improved Ilizarov technique with limited operation for correction of talipes equinovarus / 中国矫形外科杂志

[Objective]To explore the clinical efficiency,operative methods,apparatus assembly and postoperative administration of Ilizarov technique in the correction of talipes equinovarus.[Method]From January 2003 to May 2006,32 patients were corrected with QIN Si-he's orthotics devices on the Ilizarov principle of tension-stress,which involved 15 males and 17 females,the age ranged from 10 to 25 years.Among these patients,2 were caused by peroneal nerve injury,l by tumor in the vertebral canal,5 by meningocele,11 were caused by poliomyelitis,13 by congenital talipes equino-varus.In accordance with deformities,external fixator and limitied operative methods were dertermined.The limited release of soft tissue were performed in 7 patients,limited osteotomy in 25 patients.The dynamic muscle balance operation were performed in 9 patients with imbalance of muscle strength.According to the Ilizarov technique,the fixative rods were installed.The telescopic rods on the apparatus were rotated one week after the operation,the divices had corrective function in three-dimensional directions.The deformity of talipes equinovarus,internal rotation and drooping of the forefoot were gradually corrected,and the patients could bear weight and walked on the deformed foot.The mean duration of traction were 42 days,then removed the external fixator maintained with plaster for a site time.[Result]All patients were followed up from 12 months to 37 months with an average of 17 months.There was no recurrence of the deformity and feet function was good while walking on full weight-bearing.None of the complication occurred postoperatively sush as infection in the incision,neurovascular injury and ankle dislocation.[Conclusion]With Ilizarov technique to correct talipes equinovarus is a safe,minimally invasive and effective method.Combined with limited operation Ilizarov technique can correct severe talipes equinovarus which is unattainable by traditional orthopedic surgery,and shorten the treatment period,avoid severe complications.

Teatment of severe rigid talipes equinovarus deformity with Ilizarov technique / 中国矫形外科杂志

[Objective]To study the results of Ilizarov technique in treatment of the severe rigid talipes equinovarus deformity.[Method]The Ilizarov technique was used in 9 patients(11 feet)with the severe rigid talipes equinovarus deformity,in which one patient with syringomyelia,and the orthers with congenital club foot.[Result]Prospective goals of correction were made in all the cases.The results were assessed by Garceau criterion.For 9 patients(11 feet),6 feets achieved excellent result,4 feets good and 1 foot poor results respectively.[Conclusion]Ilizarov technique in treatment of the severe rigid talipes equinovarus deformity achieves a good clinical result.

Factors Affecting Recurrence After Soft Tissue Release for Talipes Equinovarus in Arthrogryposis Multiplex Congenita / 대한정형외과학회잡지

Talipes equinovarus deformity associated with arthrogryposis multiplex congenita(AMC) is rigid and its treatment is still controversial. The purpose of this study is to review the trend of recurrence after soft tissue release, and to delineate the risk factors affecting recurrence. Forty-one clubfeet in 24 AMC patients underwent soft tissue release as the first operation at the average age of 1 year 2 months (range, 6 months - 5 years 11 months) and were followed up for an average of 5 year 6 months (range, 2 years 1 month 14 years 5 months). Types of soft tissue release were Turcos posteromedial release (PMR) in 26 cases and posteromediolateral release (PMLR) using the modified Cincinati incision in 15 cases. Recurrences occurred in seventeen clubfeet (41%). A variety of recurrent deformity was corrected by redo PMR or PMLR, osteotomy, talectomy, arthrodesis, or Ilizarov technique. Average number of operations was 1.5 per case. Four parameters were analyzed in relation to recurrence: type of arthrogryposis, initial equinus deformity, type of primary soft tissue release, and age at the first operation. Recurrence occurred in proportion to the severity of initial equinus deformity, and was more frequent in amyoplasia type than in distal arthrogryposis type. However, neither the type of soft tissue release nor the age at the first operation was significant contributing factor to recurrence.

Surgical Correction of Neglected Clubfeet in the elder Child and Adult / 대한정형외과학회잡지

Clubfoot or talipes equinovarus is the most common congenital anomaly of the foot observed in children as well as in adults. This deformity should be treated immediately after birth, and so the cases of old neglected clubfeet are quite rare now. Moreover, in the cases of old neglected clubfoot, it is very difficult to get satisfactory results because there will be secondary adaptive changes in the tarsal bones and surrounding soft tissues. Therefore, clubfeet are considered to be one of many things requiring on or more of the many different types of treatment. The authors have experienced to treat nine cases of old neglected clubfoot from May, 1978 to April, 1988 at the Department of Orthopedic Surgery, St. Mary's Hospital, and reported herewith. 1. Their average age was 14.8 years old (3 to 25 yesrs old). There were one bilateral clubfeet, left foot in 5 cases and right foot in 4 cases. 2. According to the age of the patients and severity of deformities, two patients from three to ten years old were treated with soft-tissue release and serial casting, and seven patients after ten years old were treated by soft-tissue release, various osteotomies and triple arthrodesis. Postoperative management consisted of long leg cast for first four weeks and short leg walking cast for another four to eight weeks. 3. The results were estimated by the talo-calcaneal index according to Beatson et al(3)radiologically and their external appearance of corrected foot subjectively. The talo-calcaneal index was improved from 17.8° to 37° after operation and all of patients satisfied with the results of their operation.