Medical Journal of Babylon
Vol. 12- No. 4:1154 -1160 , 2015
ISSN 2312-6760©2015 University of Babylon
Original Research Article
Idiopathic TalipesEquinovarus
Effect of Age and Severity on Type of Management
Sherwan AhmedHamawandi* Ghazi Mohammed Al-Shahwani
Ali Mahdi Al-Shadedi
College of Medicine, HawlerMedical University,Erbil, IRAQ
*E-mail:
Accepted 13October, 2015
Abstract
This study is dealing with the influence of the degree of severity and the age of the patients at the time of referral to the treatment.
We report the result of management of forty eight patients with seventy one idiopathic club feet treated during the first six months of their lives. All patients underwent conservative treatment, surgery were planned for severe resistant cases especially with late referral to the treatment and those cases which didn't respond to conservative treatment.
35.6% of forty five feet referred with age less than four weeks ultimately needed some kind of soft tissue release, 73.1% out of 26 cases with age of referral more than four weeks needed surgery.
All severe resistant cases finally required surgery, while all mild cases were resolved by conservative treatment. 5.6%out of 21 cases of moderate severity were treated by surgery.
By conclusion, early start of treatment (i.e. less than four weeks of age) is essential for better response to the conservative treatment and for reducing the number of cases needed surgery. The method of treatment depends very much on the degree of severity of the deformity.
الخلاصة
يهدف البحث بصورة رئيسية الى دراسة تاثير شدة الاصابة و كذلك عمر الطفل عند بداية العلاج على نتائج العلاج.تم تسجيل النتائج العلاجية لثمانية واربعون مريضا حيث تشمل الدراسة احدى و سبعون قدما مصابا بحنف الاطفال تم علاجها خلال الستة اشهر الاولى من اعمارهم ,جميع المرضى ابتدا علاجهم تحفظيا اما الجراحة فقد تم التخطيط لها بصورة اساسية للحالات عالية الشدة و خاصة تلك التي تم احالتها بصورة متاخرة عمريا, والحالات التي لم تستجب للعلاج التحفظي.
35.6 % من مجموع خمس و اربعون قدما تمت احالتها لأطفال تحت عمر اقل من اربعة اسابيع قد احتاجت في النهاية الى نوع اخر من الجراحة للانسجة الرخوة.
من مجموع ستة وعشرون حالة في مرحلة عمرية تزيد على اربعة اسابيع73.1% تمت احالتها الى الجراحة كل الحالات الشديدة القسوة تم معالجتها بواسطة العمليات الجراحية كحل نهائي لها,بينما كل التشوهات الخفيفة تم معالجتها بنجاح بواسطة الوسائل العلاجية غير الجراحية (التحفظية),بينما 5.6% من مجموع واحد و عشرون حالة متوسطة الشدة استعملت الجراحة كحل نهائي لعلاجهم.
كان الاستنتاجانالبداية المبكرة للعلاج (اي اقل من اربعة اسابيع من العمر)ضروري جدا للاستجابة الجيدة للعلاج التحفظي اللاجراحي و كذلك من اجل تقليل عدد الحالات التي تم التعامل معها جراحيا, وان اسلوب العلاج يعتمد بصورة اكيدة على درجة الشدة للتشوهات الولادية للمرضى المحالين.
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Introduction
T
he word talipes is derived from the Latin talus (ankle bone) and pes (foot).
Congenital clubfoot is a term used to describe a variety of ankle and foot deformities present at birth. The bones, joints, muscles, and blood vessels of the foot are incorrectly positioned. The defect may be mild or severe and affect one or both feet. The foot of an affected child has been described as ‘kidney shaped’ the foot and calf are also often noticeably smaller. A clubfoot is usually turned in, stiff, and lacks the normal range of motion. It is well known that clubfoot is one of the most common congenital deformities. Some cases are associated with neuromuscular diseases, chromosomal abnormalities and varied syndromes [1,2]
The aim of the study was to show the effect of age and severity on early management of idiopathic talipusequinivarus, in order to obtain satisfactory results and avoid iatrogenic complications and repeated surgery.
Materials and Methods
The study was conducted in the department of orthopedics at AL-Yarmouk teaching hospital, the period from Oct. 2003-Nov. 2005.
Forty eight patients with Seventy one affected feet, their ages ranging between few days and six months. 31 males and 17 females with sex ratio of 1.8:1 male predominance, the mean age was 6.5 weeks, forty five feet were seen and their treatment started within the first four weeks of their lives ,26 patients were seen between four and 24 weeks. The deformity was bilateral in 23 patients (47.92%) and unilateral in 25 cases (52.08%). In unilateral involvement right foot was involved in 12 patients and left foot was involved in 13 patients.
There were inevitable variation in the degree of severity and the age at which the children were presented to the treatment. Each foot was assessed clinically and radiologically before the initiation of treatment.
The radiological evidence of deformities is based on criteria obtained from lateral and anteroposterior views of the foot.
Using standard A-P view with forefoot in 15° degree of equines and the sole on the cassettes, normally the axis of talus is directed toward the first ray of the foot while the axis of the calcaneum is between the fourth and fifth rays. In lateral view of normal foot both axes of calcaneum and talus are crossing each other in mid foot [1,2,3]
In clubfoot these lines are nearly parallel on lateral film, while on A-P view both axes are deviated laterally and both talus and calcaneum are overlapping each other.
Foot deformities were measured by the degree of correction obtained by manipulation on the first visit and classified clinically and radiologically into sever, moderate and mild degrees [4,5]
A-Severe Degree
The forefoot was in varus,the hind in equines and supination with short tendo-achillis. The deformities were resistant and not responding to manual correction.
Radiologicaly on A-P view both talus and calcaneum are overlap-ping each other with their axes are even outside the fifth metatarsal bone laterally.
B-Moderate Degree
Forefoot deformity could be corrected manually to a reasonable position, but tendo-achillis is short with persistentHind foot equines.
Radiological on A-P view the axis of the talus is directed to the third or between the third and fourth metatarsal bones.
C-Mild Degree
The fore and hind foot deformities could be brought almost to a normal position by passive manual correction.
Radiologically on A-P view the axis of talus is directed toward the second or between the second and third metatarsal bones.
Non-surgical Treatment
After full evaluation of the foot, several manipulation and casting started to all patients in following order:-
First the forefoot must be brought into rotational alignment with hind foot by increasing the supination deformity of the forefoot so that it corresponds with relatively more supinated hind foot.
Next both hind foot and forefoot are together gradually brought out of varus and supination; correction is assisted by keeping the pressure on the lateral side of the head of the talus.
Finally, equinus is corrected by bringing the heel down and dorsiflexing the ankle.
The POP casting changed weekly until the age of 6 weeks then every 2 weeks. POP casting done above knee with 90° knee flexion to relax tendocalcaneus[1,2].
Surgical Treatment
The degree of deformities determines the extent of soft tissue release. If the hind foot deformity is the only residual deformity left then limited posterior soft tissue release is used. For the hind foot and forefoot deformities an extended posteromedial release is used. Extended posteromedial release is used when the operative procedure involves releasing of all the restraining elements in the posterior, medial, plantar and lateral aspects of the foot while the limited posteromedial release is used when the operative procedure involves releasing of some of the restraining elements such as only elongation of the tendoachillis[1,2,6,7]
Post operatively, along leg cast was applied with knee flexion 90°. After two weeks, removal of sutures was done and the foot was placed in fully converted position with POP cast above knee for 12 weeks.
Denis-Brown splint was used after that period full time for three months then at night for three years.
Results
Gender: 31 males and 17 females in a ratio of 1.8/1
Inheritance:From the data collected it was evident that there is a clear family history,16 positive cases equal to about (33.3%)of the total has been subdivided to their parental side of inheritance, the positive cases has been subdivided according to their parental side of inheritance. [8]
Mother side (3 cases) 6.25% of cases
Father side (6 cases) 12.5% of cases
Both sides (4 cases) 8.3% of cases
Brothers also affected in (3 cases) 6.25% of cases
Sides of Foot Involved:[9]
Unilateral involvement 52.08% of cases.
Bilateral involvement 47.92% of cases.
The Severity
The severity was classified into three degrees.( Figure 1)
The severe degree (31 case) 43.7% of total cases
The moderate degree (21 case) 29.5% of total cases
The mild degree (19 case) 26.8% of total cases
The study has also dealt with the degree of severity of one foot as compared with its fellow foot in bilateral involvement it shows the left foot is more severe in 45% of cases, and they are equal in 35% of cases.
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Figure 1: Severity of involvement
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The Age of Starting of Treatment and the Methods of Treatment (Table 1)
The cases have been divided into two groups, those who were presented to the treatment before the age of four weeks amount to 45 feet and the 26 cases were presented after the age of 4 weeks.
As the treatment proceeded 29 cases (64.4%) of the first group responded very well to the conservative treatment and the rest (16) refereed to the surgery (35.6%).
Twenty six feet were treated after the age of four weeks, 19 cases (73.1%) of them needed surgery as a final solution for their problem, while the rest of these 26 cases were successfully treated by conservative means (26.9%).
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Table 1:Age of starting of treatment and the method of treatment
Age of starting treatment / Operative treatment / Non-operative treatment / Total< 4 weeks / 16 (35.6%) / 29 (64.4%) / 45
> 4 weeks / 19 (73.1%) / 7 (26.9%) / 26
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The Degree of Severity and Method of Treatment: (Table 2)
All resistant cases (31 feet) in our study were treated finally by operative method while mild cases (19 feet) were handled successfully by non-operative mean.
The moderate cases (21 feet) needed to be segregated during the course of conservative treatment, 5.6% of these moderate feet underwent surgery raising the total cases treated by surgery to 49.3%.
The moderate cases improved by non-operative means amount to 23.9 %( 17 feet) raised conservative cases to 50.7% (36 feet).
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Table 2:The Degree of Severity and the Method of Treatment
Type of treatment / Mild / Moderate / Severe / TotalOperative / Nil / 4 (5.6%) / 31 (43.7%) / 35 (49.3%)
Non-operative / 19 (26.8%) / 17 (23.9%) / Nil / 36 (50.7%)
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The Extent of Surgical Release: (Table 3)
35 feet have been treated by surgery, 25 feet of them (71.4%) were needed extended postero-medial release, 10 feet (28.6%) of the total have been dealt with by limited posterior soft tissue release.
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Table 3:The extent of soft tissue release
Soft tissue release / Number of feetExtended postero-medial release / 25 (71.4%)
Restricted posteromedial release / 10 (28.6%)
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Discussion
Manipulation of the foot with casting has the advantage of reducing the degree of the severity and minimizing the magnitude of future surgery if needed at all (it has yet to be proved however that surgery can be avoided by the skillful application of plaster splint [10]
We found for the better result, that not only the optimum timing for surgical intervention is important, but also early start of manipulation and serial casting may reduce the extent and the number of feet presented to surgery (Table 1, 2).
In our series surgery was needed to only (35.6%), when the manipulation and serial casting was started before the age of four weeks, whereas the figure has risen significantly to (73.1%) as the age had been exceeded the four weeks of age (Table 1).
One would expect rightly that early surgery can assist in the remodeling process of the deformed foot, but it is justifiable also to postpone surgery till the tissue is large and mature enough to be handled with confidence; nonetheless surgery should not be delayed until adaptive change is appearing in the foot. The opinion of the surgeon is diverging as to the timing of surgery, but all agree that early surgery is vital.
Bensahel H.B. et al [11] advised surgery after three months of adhesive strapping by a skilled physiotherapist if treatment seem to be at standstill.
A mean age of 10 weeks was chosen for postero lateral release in a series of 59 patients presented by Huddson and Catteral[12]
Porter [10] recommended surgery when the deformity did not resolve even as an extent as six weeks of age.
Green and LIoyds-Roberts (1985) [13]founded no significant difference up to the 20 weeks, where as previously they believed that 12 weeks was the critical age.
In our study a six months of age is suitable age to be chosen for surgical intervention before any adaptive changes could occur in the tarsal bones and also to allow the child to use his muscle actively and to share early in the process of normal remodeling of the small bones of the foot [14]
From our practice we found that the degree of severity has the utmost deciding influence on the type of treatment chosen for each foot, so all the mild cases were resolved by a series of plaster of Paris casting [19 feet 26.8%], on the contrary we could not resolved the sever and resistant deformities unless by using surgery [31 feet 43.7%].
The results coincide well with those given by Sage [14] when he declared that the final figures are almost equally divided between surgically and non-surgically treated cases, the extent of soft tissue release weather it is a restricted hind foot posterior release or extended postero-medial release depended on the degree of original severity and the residual deformity after the period of manipulation and serial casting.
Early application of manipulation and serial casting, especially before the age of 4 weeks had not only taken part in reducing the number of cases needed surgery (Table 1) as compared with those their treatment started after 4 weeks of ages, but we would think rightly that it may have contributed to reducing the number of cases needed extended postero-medial release to 25 patients out of 35 cases needed surgery (Table 3) and what left was dealt with by restricted posterior release.
This shows no significant deference between our study and the study presented by Green - Lloyd Roberts (Table 3) [13].
Statistical analysis showed significant association between referral before age of 4weeks & non operative method of treatment (calculated chi 7.48, P value <0.001)
Statistical analysis showed significant association between severe cases & operative method of treatment (calculated chi 56.59, P value <0.001)
Conclusion
1. Manipulation and serial castingare integral part in the management of TalipesEquinovarus deformity. They share not only in lowering the cases needed surgery, but also in minimizing the extent of surgery.
2. Early start of the treatment is essential especially before the four weeks of age for reducing the number of cases needed surgery.
3. Six months is an appropriate age for surgery, if no good progress was made with manipulation and serial casting.
4. The degree of severity of deformity has an important role in anticipating the future line of management.
References
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- Bensahed H. B.: Csukonyi Z: Desgrippes Y. and J-P " Surgery in residual clubfoot one-stage medio-posterior release" Lacarte J. Pediatr. Orthop. 1987: vol. 7 No.2,145-148.
- Hoddson I. and Catterall A. "Postero-Lateral release for resistance clubfoot"(Br.) 1994,67-B-281-8.No.2.
- Green A. D. and Lioyds-Roberts G. C."The result of posterior release in resistant clubfoot" J. Bone and JOINT Surgery (Br.) 1985 :B. 588-93 No.
- Sage F.P. "Congenital anomalies" .Campbells op. Orthopedic. Edmonson &Greenshaw. Ed.6, p 1766.
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