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Functioning in children consists of different aspects, including their ability to execute activities and participate in life situations. Several studies on children with clubfeet showed limited motor abilities and walking capacity compared with healthy control children, while other studies showed comparable athletic abilities and gross motor development. Although participation in activities of daily life plays an important role in the development of children, this has not yet been investigated in children with clubfeet. The study aims to determine the level of parents' perceived motor ability and participation in Ponseti-treated children with clubfeet compared with age-matched healthy controls.Parents of children aged 5 to 9 years with and without idiopathic Ponseti-treated clubfeet were asked to complete an online questionnaire about their child's motor abilities and participation level using the Dutch version of the Assessment of Life Habits for Children (LIFE-H) version 3 to assess participation and the Dutch Movement Assessment Battery for Children-2 Checklist (MABC-2 Checklist) to assess motor abilities. Statistical analysis focused on differences between groups and the relationship between motor abilities and level of participation.Questionnaires of 86 children with clubfeet (mean age 7.1, 73% boys) and 62 controls (age 6.7, 53% boys) were analyzed. Despite a large variation, results showed no significant differences between groups on the total scores of the LIFE-H and the MABC-2 Checklist. Children with clubfeet, however, scored lower on Mobility and better on the categories Communication and Responsibility of the LIFE-H. Furthermore, children with clubfeet showed lower scores on the MABC-2 Checklist subscale "movement in a static and/or predictable environment." High levels of the parents' perceived participation correlate with good results, as perceived by the parents, in motor ability.Although differences on some aspects of motor ability and participation existed, children with clubfeet in general showed high levels of parents' perceived motor ability and participation. High levels of participation correlated with good results in motor ability.Level II.

BACKGROUND: Objective gait analysis that fully captures the multi-segmental foot movement of a clubfoot may help in early identification of a relapse clubfoot. Unfortunately, this type of objective measure is still lacking in a clinical setting and it is unknown how it relates to clinical assessment. RESEARCH QUESTION: The aim of this study was to identify differences in total gait and foot deviations between clubfoot patients with and without a relapse clubfoot and to evaluate their relationship with clinical status. METHODS: In this study, Ponseti-treated idiopathic clubfoot patients were included and divided into clubfoot patients with and without a relapse. Objective gait analysis was done resulting in total gait and foot scores and clinical assessment was performed using the Clubfoot Assessment Protocol (CAP). Additionally, a new clubfoot specific foot score, the clubFoot Deviation Index (cFDI*), was calculated to better capture foot kinematics of clubfoot patients. RESULTS: Clubfoot patients with a relapse show lower total gait quality (GDI*) and lower clinical status defined by the CAP than clubfoot patients without a relapse. Abnormal cFDI* was found in relapse patients, reflected by differences in corresponding variable scores. Moderate relationships were found for the subdomains of the CAP and total gait and foot quality in all clubfoot patients. SIGNIFICANCE: A new total foot score was introduced in this study, which was more relevant for the clubfoot population. The use of this new foot score (cFDI*) besides the GDI*, is recommended to identify gait and foot motion deviations. Along with clinical assessment, this will give an overview of the overall status of the complex, multi-segmental aspects of a (relapsed) clubfoot. The relationships found in this study suggest that clinical assessment might be indicative of a deviation in total gait and foot pattern, therefore hinting towards personalised screening for better treatment decision making. ispartof: GAIT & POSTURE vol:97 pages:210-215 ispartof: location:England status: published

Background and purpose — After initial clubfoot correction through Ponseti treatment, recurrence rates range from 26% to 48%. Even though various factors have been associated with increased recurrence risk, systematic assessments of the prognostic capacity of recurrence risk factors and their clinical relevance are lacking. Therefore we assessed clinically relevant prognostic factors for recurrent idiopathic clubfoot deformity after initial correction through Ponseti treatment. Methods — PubMed, Embase, Cinahl, and Web of Science were systematically searched for studies investigating the association between clinically relevant factors and recurrence rates. Prognostic factors were qualitatively assessed and included in the meta-analysis if ≥ 2 studies investigated the same factor and methods were comparable. Results — 34 articles were included in the qualitative synthesis, of which 22 were also included in the meta-analysis. Meta-analysis revealed that poor evertor muscle activity (OR = 255, 95% CI 30–2,190), brace non-compliance (OR = 10, CI 5–21), no additional stretching (OR = 31, CI 10–101), more casts (OR = 3.5, CI 1.6–7.8), lower education level of parents (OR = 1.8, CI 1.2–2.6), non-marital status of parents (OR = 1.8, CI 1.1–3.0), and higher Dimeglio scores (OR = 1.9, CI 1.2–3.3) were associated with higher recurrence rates. Interpretation — Brace non-compliance and poor evertor muscle activity have been identified as main recurrence risk factors and are therefore important to be closely monitored during clinical follow-up of clubfoot patients. Adding additional stretching during the bracing protocol might be promising in the quest to prevent relapse, but scientific evidence for clear clinical treatment recommendations is still limited.

Quantifying the quality of life in clubfoot patients during bracing following the Ponseti method compared with healthy controls.Data collected during the brace period of the Ponseti method and of a reference sample was retrospectively analyzed to investigate health-related quality of life scale (TAPQOL) in clubfoot patients compared with healthy controls. The TAPQOL instrument consists of 12 subscales comprising the 4 domains of health-related quality of life namely physical, social, emotional and cognitive functioning.Responses of 80 parents of clubfoot patients and 238 parents of healthy controls were analyzed. On average both study groups scored high on the 4 domains of the TAPQOL instrument. The clubfoot group scored significantly (p0.0125) lower on the subscales motor functioning, sleep, lung and skin problems during bracing. No difference was observed between the study groups in the year the bracing had ended.Dutch clubfoot patients show an overall good health related quality of life. However, during the brace phase of the Ponseti treatment they score lower in subscales in the physical functioning domain. These results can be used in the counselling of parent and might alleviate some concerns that parents have about the bracing period.Level III, Case control study.

BACKGROUND: Understanding the kinematic characteristics of relapse clubfoot compared to successfully treated clubfoot could aid early identification of a relapse and improve treatment planning. The usage of a multi segment foot model is essential in order to grasp the full complexity of the multi-planar and multi-joint deformity of the clubfoot. RESEARCH QUESTION: The purpose of this study was to identify differences in foot kinematics, using a multi-segment foot model, during gait between patients with Ponseti treated clubfoot with and without a relapse and age-matched healthy controls. METHODS: A cross-sectional study was carried out including 11 patients with relapse clubfoot, 11 patients with clubfoot and 15 controls. Gait analysis was performed using an extended Helen Hayes model combined with the Oxford Foot Model. Statistical analysis included statistical parametric mapping and discrete analysis of kinematic gait parameters of the pelvis, hip, knee, ankle, hindfoot and forefoot in the sagittal, frontal and transversal plane. RESULTS: The relapse group showed significantly increased forefoot adduction in relation with the hindfoot and the tibia. Furthermore, this group showed increased forefoot supination in relation with the tibia during stance, whereas during swing increased forefoot supination in relation with the hindfoot was found in patients with relapse clubfoot compared with non-relapse clubfoot. SIGNIFICANCE: Forefoot adduction and forefoot supination could be kinematic indicators of relapse clubfoot, which might be useful in early identification of a relapse clubfoot. Subsequently, this could aid the optimization of clinical decision making and treatment planning for children with clubfoot. ispartof: GAIT & POSTURE vol:90 pages:415-421 ispartof: location:England status: published

A 14-year-old boy presented to the emergency department with pain in his right buttock after a breakdance move. He got injured while simultaneously hyperflexing his hip and extending his knee. Upon physical examination he had tenderness over his right ischial tuberosity and an inability to perform combined hip extension and knee flexion. Radiography and CT-imaging showed an avulsion fracture of the ischial tuberosity.

The aim of this study was to evaluate the results of open reduction and internal fixation through the extended lateral approach (ELA) in displaced intra-articular calcaneal fractures and to determine whether this approach should remain part of standard therapy. This retrospective cohort study included 60 patients with 64 displaced intra-articular calcaneal fractures who underwent surgical treatment through the ELA. Outcome measures were the visual analog scale foot and ankle (VAS FA), the American Orthopedic Foot and Ankle Society (AOFAS) score, surgical site infections (SSIs), and reoperations. We determined the AOFAS score for 40 patients with 42 fractures, and 42 patients with 44 fractures completed the VAS FA questionnaire. The mean VAS FA score was 61.0 ± 23.4 and the median AOFAS score was 83 (range 33 to 100), with 55% good to excellent scores. We found 10.9% superficial SSIs successfully treated with antibiotics. In 4.7% of patients a deep SSI was diagnosed, wherefore premature implant removal was necessary. Patients with an SSI did not have significantly lower VAS FA or AOFAS scores than did patients without an SSI (p = .318 and p = .766, respectively). Implant removal in absence of SSIs was necessary in 17 patients because of pain, and 3 patients needed secondary arthrodesis because of persistent pain. We concluded that the ELA proved to be a safe procedure, and moreover the most common complications did not influence the long-term outcomes of patients. However, recent literature demonstrates that less invasive techniques seem to exceed the ELA with respect to wound complications.

— A delegation of 6 pediatric orthopedic surgeons from the Dutch Orthopedic Association (NOV) and 2 members of the board of the Dutch Parents’ Association for children with clubfoot created the guideline "The diagnosis and treatment of primary idiopathic clubfeet" between April 2011 and February 2014. The development of the guideline was supported by a professional methodologist from the Dutch Knowledge Institute of Medical Specialists. This evidence-based guideline process was new and unique, in the sense that the process was initiated by a parents’ association. This is the first official guideline in pediatric orthopedics in the Netherlands, and to our knowledge it is also the first evidence-based guideline on clubfoot worldwide. The guideline was developed in accordance with the criteria of the international AGREE instrument (AGREE II: Appraisal of Guidelines for Research and Evaluation II). The scientific literature was searched and systematically analyzed. In the second phase, conclusions and recommendations in the literature were formulated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Recommendations were developed considering the balance of benefits and harms, the type and quality of evidence, the values and preferences of the people involved, and the costs. The guideline is a solid foundation for standardization of clubfoot treatment in the Netherlands, with a clear recommendation of the Ponseti method as the optimal method of primary clubfoot treatment. We believe that the format used in the current guideline sets a unique example for guideline development in pediatric orthopedics that may be used worldwide. Our format ensured optimal collaboration between medical specialists and parents, and resulted in an important change in clubfoot care in the Netherlands, to the benefit of medical professionals as well as parents and patients. In this way, it is possible to improve professional collaboration between medical specialists and parents, resulting in an important change in clubfoot care in the Netherlands that will benefit medical professionals, parents, and patients. The guideline was published online, and is freely available from the Dutch Guideline Database (www.richtlijnendatabase.nl).

The incidence of clubfoot patients is an important factor for centralization of care. Medical records of 21 accredited clubfoot centers were selected using the diagnosis treatment codes and checked to confirm diagnosis. All idiopathic clubfoot cases born during 2013-2014 were analyzed with respect to sex, affected foot, regional distribution, and seasonal variation. Among the 346 522 live births, 377 idiopathic clubfoot cases were registered. The incidence of the congenital idiopathic clubfoot in the Netherlands during 2013 and 2014 was 1.09 per 1000 live births, indicating that every year, ~200 children with one or two clubfeet are born in the Netherlands. On the basis of this finding, we can start to refine clubfoot care.

Background Clubfeet are commonly treated using the Ponseti method. This method involves weekly manipulation and casting which gradually corrects the position of the foot. However, the reasons for following a weekly interval are not clear. Question / Purpose The aim is to investigate the influence of the cast change interval on treatment outcomes in the Ponseti method. Methods We performed a systematic review of comparative studies in which the cast change interval was varied. Scientific databases were searched for relevant publications, screened for eligibility and assessed for a risk of bias. A 'best evidence' synthesis tool was used to synthesize the results of the included studies and draw conclusions from relevant clinical outcomes. Results Nine papers matched the inclusion criteria, which provided data of 587 subjects who had a total of 870 clubfeet. There is strong evidence for a positive relation between cast change interval and treatment duration. However, there is no evidence for any relation between the cast change interval and the required number of casts, tenotomy rate, required surgery or failure rate. Conclusions Accelerated versions are as effective and safe as the traditional Ponseti method. However, more research is needed to assess the long-term results and to identify an optimal cast change interval.

ContextPercutaneous epiphysiodesis (PE) around the knee to reduce predicted excessive final height. Studies until now included small numbers of patients and short follow-up periods.Objective and designThis Dutch multicentre, long-term, retrospective, follow-up study aimed to assess adult height (AH), complications, knee function and patient satisfaction after PE. The primary hypothesis was that PE around the knee in constitutionally tall boys and girls is an effective treatment for reducing final height with low complication rates and a high level of patient satisfaction.Participants77 treated adolescents and 60 comparisons.InterventionPercutaneous epiphysiodesis.OutcomeAH, complications, knee function, satisfaction.ResultsIn the PE-treated group, final height was 7.0 cm (±6.3 cm) lower than predicted in boys and 5.9 cm (±3.7 cm) lower than predicted in girls. Short-term complications in file search were seen in 5.1% (three infections, one temporary nerve injury), one requiring reoperation. Long-term complications in file search were seen in 2.6% (axis deformity 1.3%, prominent head of fibula 1.3%). No significant difference in knee function was found between treated cases and comparisons. Satisfaction was high in both the comparison and PE groups; most patients in the PE group recommended PE as the treatment for close relatives with tall stature.ConclusionPE is safe and effective in children with predicted excessive AH. There was no difference in patient satisfaction between the PE and comparison group. Careful and detailed counselling is needed before embarking on treatment.

BACKGROUND: Currently, the Ponseti method is the gold standard for treatment of clubfeet. For long-term functional evaluation of this method, gait analysis can be performed. Previous studies have assessed gait differences between Ponseti treated clubfeet and healthy controls. RESEARCH QUESTION/PURPOSE: The aims of this systematic review were to compare the gait kinetics of Ponseti treated clubfeet with healthy controls and to compare the gait kinetics between clubfoot patients treated with the Ponseti method or surgically. METHODS: A systematic search was performed in Embase, Medline Ovid, Web of Science, Scopus, Cochrane, Cinahl ebsco, and Google scholar, for studies reporting on gait kinetics in children with clubfeet treated with the Ponseti method. Studies were excluded if they only used EMG or pedobarography. Data were extracted and a risk of bias was assessed. Meta-analyses and qualitative analyses were performed. RESULTS: Nine studies were included, of which five were included in the meta-analyses. The meta-analyses showed that ankle plantarflexor moment (95% CI -0.25 to -0.19) and ankle power (95% CI -0.89 to -0.60, were significantly lower in the Ponseti treated clubfeet compared to the healthy controls. No significant difference was found in ankle dorsiflexor and plantarflexor moment, and ankle power between clubfeet treated with surgery compared to the Ponseti method. SIGNIFICANCE: Differences in gait kinetics are present when comparing Ponseti treated clubfeet with healthy controls. However, there is no significant difference between surgically and Ponseti treated clubfeet. These results give more insight in the possibilities of improving the gait pattern of patients treated for clubfeet. ispartof: GAIT & POSTURE vol:66 pages:94-100 ispartof: location:England status: published

Background In clinical practice, clubfeet feel stiffer compared to healthy feet. Furthermore, the clinical impression is that stiffer clubfeet have a higher tendency to relapse. Until now, no objective measure has been available to determine the stiffness of clubfeet. The goal of the current project was to objectively quantify ankle and subtalar joint stiffness in clubfeet patients and to compare this stiffness between clubfeet patients and healthy controls using a newly developed measurement device. Methods The newly developed Torque-Displacement-Handpiece in combination with an adjusted Abduction Dorsiflexion Mechanism clubfoot-brace, made it possible to move a foot over two rotational axis, while continuously capturing the applied torque and the achieved angulation. Based on this information, stiffness of the ankle and subtalar joint were assessed for 11 clubfoot patients with 17 clubfeet and 11 healthy subjects with 22 healthy feet. Findings With the Torque-Displacement-Handpiece measuring device it was possible to measure torque, angulation and stiffness in a reliable and precise manner. Clubfoot patients showed less angulation and a higher stiffness for measurements over the ADM subtalar axis compared to controls. After adjusting for shoe size, the stiffness for measurements over the ADM tibiotalar axis was also significantly higher in clubfeet than controls. Interpretation Overall, these results indicate that clubfoot patients have a higher ankle and subtalar joint stiffness in the affected joint compared to healthy controls. In the future, the Torque-Displacement-Handpiece could be used to monitor stiffness of clubfeet during treatment, and as such, play a potential role in the early detection of relapsing clubfeet.

This study aims to identify kinematic differences between children with Ponseti treated clubfoot and age-matched healthy controls during gait, using the Oxford Foot Model. This pilot is part of a large project comparing gait kinematics between children with Ponseti treated clubfoot with and without relapse and healthy controls. Final results could identify relevant gait parameters which will allow for early detection of a relapse clubfoot. ispartof: Gait Posture vol:65 Suppl 1 pages:353-354 ispartof: location:England status: published