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Calcaneocuboid arthrodesis for recurrent clubfeet: what is the outcome at 17-year follow-up?

Chu, Alice; Chaudhry, Sonia; Sala, Debra A; Atar, Dan; Lehman, Wallace B
PURPOSE: Calcaneocuboid arthrodesis was used during revision clubfoot surgery in order to maintain midfoot correction. The purposes of this study were to determine: (1) functional level at 17-year follow-up compared to 5-year follow-up; (2) patients' current functional level, satisfaction, and pain; and (3) current arthropometric measurements. METHODS: Twenty patients (27 clubfeet) with clubfoot relapse underwent revision soft tissue release and calcaneocuboid fusion between 1991 and 1994. They were previously evaluated at a mean follow-up of 5.5 years. Ten out of 20 patients (13 clubfeet), mean age of 24 years, were reevaluated at mean follow-up of 17.5 years. The Hospital for Joint Diseases Functional Rating System (HJD FRS) for clubfoot surgery, Outcome Evaluation in Clubfoot developed by the International Clubfoot Study Group, the Clubfoot Disease-Specific Instrument, American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire, Laaveg and Ponseti's functional rating system for clubfoot and pain scale were completed by patient and/or surgeon to assess function, patient satisfaction and pain. Foot and ankle radiographs and anthropometric measurements were reviewed. For HJD FRS, scores from original follow-up were compared to current ones. RESULTS: The HJD FRS score of all feet was 65.9, demonstrating a significant decline from the original mean score of 77.8 (p = 0.03). Excellent/good HJD FRS scores went from 85 to 38 %. Mean AAOS Foot Ankle Outcomes Questionnaire standardized core and shoe comfort scores were 84.6 and 84.5, respectively. Average foot pain was 1.8 on a scale of 1-10. Patients were very/somewhat satisfied with status of foot in 76 % of feet and appearance of foot in 46 % of feet, based on Clubfoot Disease-Specific Instrument questions. CONCLUSIONS: Revision clubfoot surgery with calcaneocuboid fusion in patients 5-8 years of age showed an expected decline in functional outcome measures over a 17-year follow-up period. It still produced comparable results to other studies for a similar population of difficult, revision cases, and should have a place in current surgical treatment techniques.
PMID: 24504417
ISSN: 1863-2521
CID: 820552

Idiopathic Clubfoot Treated with the Ponseti Method: Factors Associated with Patient Follow-up

Kim, Suezie; Goldstein, Rachel Y; Park, Justin; Shapiro, Peter; Boo, Andrew E; Sala, Debra A; Chu, Alice; Lehman, Wallace B
BACKGROUND: Follow-up after treatment with the Ponseti method is important because of the known association be- tween lack of brace wear and recurrence. This study was designed to ascertain factors associated with patients who did not return for the recommended follow-up versus those who did. METHODS: Between January 1, 2000, and December 31, 2009, 222 patients were treated for idiopathic clubfoot at the New York Ponseti Clubfoot Center at NYU Hospital for Joint Diseases, of which 93 patients (143 feet) were poten- tially available for follow-up (i.e.,
PMID: 25429388
ISSN: 2328-4633
CID: 1359992

Achievement of gross motor milestones in children with idiopathic clubfoot treated with the ponseti method

Sala, Debra A; Chu, Alice; Lehman, Wallace B; van Bosse, Harold J P
BACKGROUND: : The Ponseti method of idiopathic clubfoot treatment involves a series of weekly casts, a percutaneous Achilles tenotomy if needed, followed by wearing a foot abduction orthosis (FAO). Gross motor development of children with idiopathic clubfoot has not been examined. The purposes of this study were to determine the ages of achievement of gross motor milestones in children with clubfoot treated with Ponseti method and to compare those ages with historical normative developmental data. METHODS: : In this prospective study, 51 children with idiopathic clubfoot who had their first cast applied when
PMID: 23232380
ISSN: 0271-6798
CID: 210152

Persistent clubfoot deformity following treatment by the Ponseti method

Chu, Alice; Lehman, Wallace B
The Ponseti method of clubfoot correction is now widely practiced worldwide. Initial correction rates are nearly 100%, but subsequent relapses may occur in up to one-third of patients. Very little has been written by anyone other than Dr Ponseti about the characterization and treatment of recurrent clubfoot deformity following use of the Ponseti method. This review paper is the first one which draws together the current literature on the topic
PMID: 22134651
ISSN: 1473-5865
CID: 145771

Progression of idiopathic clubfoot correction using the Ponseti method

Chaudhry, Sonia; Chu, Alice; Labar, Amy S; Sala, Debra A; van Bosse, Harold J P; Lehman, Wallace B
The Ponseti technique involves sequential clubfoot correction by abduction, supination, and finally dorsiflexion. Although shown to be effective, correction progression has not been examined. The Dimeglio/Bensahel classification system was used to analyze heel equinus, varus, midfoot rotation, adduction, posterior crease, medial crease, and cavus initially and after each casting. From 2000 to 2008, 123 patients (185 feet) with idiopathic clubfeet, aged below 60 days, without prior treatment were grouped by number of casts required. Successive castings achieved goals of reducing cavus and medial crease first, then gradually correcting midfoot rotation, adduction, and heel varus. Unexpectedly, heel equinus improved simultaneously with midfoot variables, as well as with final casting
PMID: 21527859
ISSN: 1473-5865
CID: 149792

Revision clubfoot surgery with calcaneocuboid fusion: Results at long-term follow-up [Meeting Abstract]

Lehman W.; Chaudhry S.; Chu A.; Atar D.; Sala D.
Purpose: Calcaneocuboid fusion has been used to supplement soft tissue revision clubfoot surgery to tether growth of the outer column of the foot. The purpose of the present study was to reevaluate the clinical and radiographic long-term outcomes of 20 patients (27 clubfeet), treated with this procedure, who were previously examined at mean follow-up of 5.5 years. Methods: Ten patients (13 clubfeet) who underwent this procedure from 1991-1994 returned for radiographs and reevaluation by the original surgeon. Results: Patients had a mean age of 24 years (range 23-26) and an average of 18 years follow-up (range 16-19). The procedure was performed at an average age of 7 years (range 5-8). Eleven of thirteen feet (85%) demonstrated radiographic fusion. The two failed fusions occurred unilaterally in bilaterally treated patients. No patient required major additional procedures. Comparison of Hospital for Joint Diseases Functional Rating System results from earlier to current follow-up for all 13 feet demonstrated: (a)significant decline in mean score, 77.8 versus 65.9 (P=0.03), and (b)number of good/excellent ratings went from 85% to 38%. At long-term follow-up: (a) average Foot Ankle Outcomes Questionnaire standardized shoe comfort and core scores were 84.5 (range 25-100) and 85.6 (range 44-100), respectively, and (b)average foot pain was 1.38 (range 0-8) on a scale of 1 to 10. Conclusion: At long-term follow-up, revision clubfoot surgery with calcaneocuboid fusion in patients 5 to 8 years of age produces relatively painless, plantigrade feet with moderate functional outcomes
ISSN: 1060-152x
CID: 147741

Clubfoot classification: correlation with Ponseti cast treatment

Chu, Alice; Labar, Amy S; Sala, Debra A; van Bosse, Harold J P; Lehman, Wallace B
BACKGROUND: Many different clubfoot classification systems have been proposed, but no single one is universally accepted. Two frequently cited systems, developed by Dimeglio/Bensahel and Catterall/Pirani, are often used for evaluation purposes in the treatment of idiopathic clubfoot. Our hypothesis was that the initial scores would be positively correlated with the number of casts required for clubfoot correction, indicating to us that the more severe score would require more casts, and therefore truly show the accuracy and usefulness of the scoring system. METHODS: From May 2000 to April 2008, 123 patients (185 feet) with idiopathic clubfeet were treated. All patients were below 60 days of age (mean 15.3 d, range: 2 to 57 d) at the time of their initial evaluation, and had not received prior clubfoot treatment. All cast placements were under the supervision of the same pediatric orthopedic surgeon. Initial correction was achieved in all patients. RESULTS: The mean number of casts required for correction was 5.1 (range: 2 to 8). On the basis of number of casts required, no significant differences were found in final total scores (Dimeglio/Bensahel P=0.14 and Catterall/Pirani P=0.44), indicating a similar level of correction for all feet. The Dimeglio/Bensahel and Catterall/Pirani classification systems were both similarly, poorly correlated with the number of casts needed [Spearman rank correlation coefficients (rs)=0.34 vs. 0.33]. The 2 components with the highest correlations were equinus (rs=0.39) and forefoot adduction (rs=0.35) for the Dimeglio/Bensahel system and coverage of the lateral head of the talus (rs=0.40) and rigid equinus (rs=0.39) for the Catterall/Pirani system. CONCLUSIONS: When using the initial scores, both the Dimeglio/Bensahel and Catterall/Pirani classification systems had a low correlation with the number of Ponseti casts required. Analysis of the individual components revealed variability in the coefficients, with some having low-to-moderate correlation and others having none. There was no difference between the Dimeglio/Bensahel and Catterall/Pirani classification systems when measuring their correlation with the number of Ponseti casts required for clubfoot correction. An improved classification system is needed to predict the length of treatment and, ultimately, the risk of recurrence. LEVEL OF EVIDENCE: Prognostic Level IV
PMID: 20864855
ISSN: 1539-2570
CID: 113663

Correction of clubfoot deformity associated with Weber type I tibial hemimelia using the Ponseti method

Chen, Tracy S; Sala, Debra A; Chu, Alice; Chorney, Gail S; Lehman, Wallace B
The clubfoot deformity associated with Weber type I tibial hemimelia, a rare congenital disorder, is rigid and difficult to correct. Surgeons have utilized a variety of treatment methods. Since the 1960s, some adopted the Syme amputation to produce a weightbearing lower limb. Others began to explore alternatives such as the Ilizarov technique, ankle reconstruction, and casting, which salvage the foot but have produced mixed results. The current investigators suggest that the Ponseti method, a minimally invasive technique, can produce a functional weightbearing foot. Two cases were treated with the Ponseti method, including a percutaneous Achilles tenotomy and post-cast bracing. After a minimum of 2-years follow-up, both are ambulatory
PMID: 21162708
ISSN: 1936-9727
CID: 117347

Congenital tibial dysplasia (congenital pseudoarthrosis of the tibia): an atypical variation

Lehman, Wallace B; Abdelgawad, Amr Atef; Sala, Debra A
PMID: 19625879
ISSN: 1473-5865
CID: 101134

Correction of Arthrogrypotic Clubfoot With a Modified Ponseti Technique

van Bosse, Harold J P; Marangoz, Salih; Lehman, Wallace B; Sala, Debra A
Surgical releases for arthrogrypotic clubfeet have high recurrence rates, require further surgery, and result in short, painful feet. We asked whether a modified Ponseti technique could achieve plantigrade, braceable feet. Ten patients (mean age, 16.2 months; range, 3-40 months), with 19 arthrogrypotic clubfeet, underwent an initial percutaneous Achilles tenotomy to unlock the calcaneus from the posterior tibia followed by weekly Ponseti-style casts. A second percutaneous Achilles tenotomy was performed in 53%. Mean number of casts was 7.7 (range, 4-12). From pretreatment to completion of initial series of casts, mean scores of Dimeglio et al. improved from 16 to 5 (ranges, 12-18 and 2-9, respectively), Catterall scores (as modified by Pirani and colleagues) from 4.8 to 0.9 (ranges, 1.5-6.0 and 0.0-2.0), and maximum passive dorsiflexion from -45 degrees (range, -75 degrees to -20 degrees ) to 10 degrees (range, 0 degrees to 40 degrees ). Ankle-foot orthoses maintained correction. At the minimum followup of 13 months (mean, 38.5 months; range, 13-70 months), the mean maximum dorsiflexion was 5 degrees (range, -20 degrees to 20 degrees ), two patients had posterior releases and no patient's ambulatory ability was compromised by foot shape. Arthrogrypotic clubfeet can be corrected without extensive surgery during infancy or early childhood. Limited surgery may be required as the children age
PMID: 19142694
ISSN: 1528-1132
CID: 95821