European Journal of Cardiovascular Medicine

Back ground onTalipes Equinovarus (Club foot)

Idiopathic congenital talipes equinovarus (CTEV), commonly known as club foot, is a congenital deformity characterized by four main deformities: equinus, varus, adductus, and cavus.1This condition affects about 1 in 1000 live births, making it one of the most common congenital musculoskeletal deformities. Early diagnosis and treatment are critical to prevent long-term disabilities and to ensure normal foot function and mobility.2

Incidence and Prevalence

Club foot is a major congenital anomaly affecting approximately1in every1000 live births worldwide. It has a higher prevalence in males than females, with a male-to-female ratio of2:1.The condition can present unilaterally or bilaterally, with bilateral cases constituting about 50% of all instances. The exact etiology remains unclear, although genetic and environmental factors are believed to play a significant role.3

Clinical Presentation and Diagnosis

CTEV is typically diagnosed at birth or prenatally via ultrasound. The affected foot is characteristically shorter and broader with a high medial longitudinal arch and the fore foot turned inward. The calf muscles are usually underdeveloped, leading to noticeable atrophy.4Clinical examination remains the primary diagnostic tool, supplemented by imaging techniques like radiography to assess the severity and guide treatment planning.5.

Importance of Early Diagnosis and Treatment

Timely intervention is paramount in the management of clubfoot. Early treatment can significantly improve the functional outcomes and prevent the need for more invasive procedures later in life. The primary goals are to correct the deformity, ensure the foot's functionality, and enable normal ambulation.6

AIMS AND OBJECTIVES

To study the outcome following the use of Ponseti technique for management of congenital talipes equinovarus.

To evaluate the efficacy of the Ponseti method in reducing extensive corrective surgery rates for congenital idiopathic clubfoot

TYPE OF STUDY: This is a prospective study which will be conducted in Kakatiya Medical College/ Mahatma Gandhi Memorial Hospital – Warangal.

PERIOD OF STUDY: During a period from November 2023 – October 2024.

SOURCE OF THE DATA: Children with congenital club foot consulted at MGM Hospital, Warangal, attached to Kakatiya Medical College, Warangal, in the period from November 2023- October 2024.

SAMPLE SIZE: 30 patients have been taken

The number of casts required to obtain correction and the need for tenotomy will be also recorded.

INCULSION AND EXCLUSION CRITERIA

Inclusion criteria:

Children between 7 days to 1 year of age with idiopathic club foot

Exclusion criteria:

• Patients aged more than1year of age
• Club foot secondary to syndromic involvement
• Patients that have undergone prior surgical intervention for club foot
• Technical failure

METHODOLOGY

The study proposes to include patients with congenital club foot examined according to the protocol.

Associated deformities will be noted.

This verity of foot deformity will be assessed according to Pirani scoring system, before and after treatment.

Serial to etogroin castings will be applied.

This prospective study, conducted at Kakatiya Medical College and Mahatma Gandhi Memorial Hospital in Warangal, spans from November 2023 to October 2024 and focuses on children with congenital clubfoot consulted at MGM Hospital during this period. The sample size consists of 30 patients.

Table1: Age Distribution of Patients with Congenital Clubfoot

Observations

Age Group<1 Month: This group has the highest number of patients,with12 out of 30 (40.00%).This indicates that congenital club foot is often identified and treated very early, typically within the first month of life.

AgeGroup1-3Months: This group has 9 patients, accounting for 30.00%.This suggests that a significant number of cases are also diagnosed and managed within the first three months.

Age Group 4-6 Months: This group includes 5 patients, representing16.70% of the total. This shows a decline in the number of diagnoses as the age increases.

Table2: Laterality of Club foot Affected Side

Right Side Affected: This group includes 8 patients, accounting for 26.70%ofthetotal. This indicates that a notable portion of patients have the right side of their foot affected by congenital clubfoot.

Left Side Affected: This group has 7 patients, representing 23.30%.Thisshowsthat the left side is slightly less frequently affected compared to the right side.

Bilateral (Both Sides) Affected: This is the largest group, with 15 patients (50.00%). This indicates that half of the patients have congenital clubfoot affecting both feet, making bilateral cases the most common.

Table3: Birth Sequence

Table 4: Agevs.Number of Casts Required in Club foot Patients Treated with the Ponseti Method

Table5: Tenotomy Needed

Table6: Initial Pirani Score

Table 7: Number of Casts

Table 8: Initial Pirani Score vs Number of Casts

Table 9: Consanguinity

Table 10: History of LSCS (Lower Segment  Cesarean Section)

In this study, none of the patients (0%) had a history of LSCS delivery. All30 patients (100%) were delivered vaginally. This indicates that, in this sample, LSCS was not a contributing factor to the occurrence of clubfoot.

In the current study, the age of patients ranged from 7 days to 1 year at the start of treatment. This early intervention aligns with the general consensus that the Ponseti method is most effective when started as early as possible.

Gelfer et al. (2020) 7 conducted a systematic review and found that the majority of studies included patients who began treatment in the neonatal period, typically within the first few weeks of life. This study highlighted that ‘starting treatment early, ideally within the first month, leads to better outcomes in terms of correction and lower relapse rates

In the current study, the total number of patients was 30, with a sex distribution of 20 males and 10 females, giving a male-to-female ratio of 2:1. Gelfer et al. (2020) 7 conducted a systematic review and reported a male predominance in idiopathic clubfoot cases, with sex distribution values of 107 males and 44 females among the 151 children studied, which also gives a male-to-female ratio close to 2:1.

 Goksan SB et al., (2006) 8 analyzed relapses in clubfoot treated with the Ponseti technique. In their study, out of 120 children, there were 84 males and 36 females, maintaining a 2:1 male-to-female ratio, similar to other studies.

Comparative Analysis of Side Affected in Ponseti Method Studies

In the current study, the distribution of the side affected in patients was recorded as follows:18 patients had bilateral club foot,7 patients had the right side affected, and 5 patients had the left side affected. In the systematic review by Gelfer et al., 7 among 151 children with clubfoot, 91 (60%) had bilateral involvement, 36 (24%) had right-sided involvement, and24 (16%) had left-sided involvement. This study showed a higher prevalence of bilateral cases, similar to the current study.

Goksan SB et al (2006) 8 reported on 120 children with clubfoot, with 72 (60%) having bilateral involvement, 30 (25%) having the right side affected, and 18 (15%) having the left side affected. The results align closely with the distribution seen in the current study, showing a predominance of bilateral cases.

In the current study, birth sequence data was recorded as follows: 12 patients were first-born, 10 patients were second-born, and 8 patients were third-born or later. In the systematic review by Gelfer et al., 7 among 151 children with club foot, 70 were first-born, 55 were second-born, and 26 were third-born or later. This study highlights a higher incidence of clubfoot in first-born children.

In the current study, family history data was recorded as follows: 8 patients had a positive family history of club foot, and 22 patients had no family history of the condition. Abbas M, et al., (2008) 9 studied 50 patients and found that 12 had a positive family history, while 38 had no family history. This distribution supports the trend observed in other studies that a smaller proportion of cases have a familial link.

Richards et al. (2008) 10  conducted study out of 60 patients, 15 had a positive family history, and 45 had no family history. Their findings further support the role of genetic factors in a subset of cases.

In the current study, the age of patients ranged from 7 days to 1 year at the start of treatment. The number of casts required per patient varied from 6 to 8. This range indicates that younger patients tend to require fewer casts, a common observation in Ponseti method studies. Richards et al. (2008) 10   included infants aged 2 weeks to 1 year. The study found that those treated within the first two weeks required an average of 5 casts, while those treated later required up to 8 casts. The findings are consistent with other studies showing fewer casts needed for earlier treatment.

In the current study, out of 30 patients, 21 (70%) required a percutaneous A chilles tenotomy to achieve full correction. Morcuende et al. (2004) 11 found that in their study of 200 patients, 150 (75%) required tenotomy. This rate is consistent with the broader literature and the current study’s findings.

In the current study, the initial Pirani score for patients was recorded as an average of5.8.This high initial score indicates severe deformity, which his consistent with the population typically treated using the Ponseti method. Lampasi M (2010) 12 meta-analysis included studies with initial Pirani scores ranging from 5.3 to 5.7, averaging 5.5 across 150 patients. This average aligns well with the current study’s score, indicating a general trend in the severity of cases treated.

In the current study, each patient required an average of 6-8 casts to achieve the desired correction. Richards et al. (2008)10 compared the Ponseti method with the French functional method and included an average of 6 casts per patient, ranging from 5 to7. This study's findings are consistent with the lower end of the range observed in the current study.

In the current study, consanguinity among parents was recorded as follows: 6patients had parents who were consanguineous, while 24 patients had parents who were not. Haft et al. reported that among 80 patients, 12 had consanguineous parents, while 68 did not. Their findings were consistent with other studies suggesting a potential association between consanguinity and higher incidences of congenital conditions like clubfoot.

In the current study, out of 30 patients, 10 had a history of delivery via Lower Segment Cesarean Section (LSCS).  Abbas M, et al., (2008) 9included 50 patients in their study, reporting that 20 had a history of LSCS delivery. This higher proportion suggests a possible link between cesarean deliveries and clubfoot, warranting further investigation.

In the current study, 10 out of 30 patients (33%)had a history of LSCS delivery. Gelfer et al. (2020) conducted a systematic review and found that among 151 children with club foot, 45 (30%) had a history of LSCS, suggesting a possible link between LSCS and clubfoot occurrence. Similarly,  Goksan SB et al (2006) 8 analyzed 120 children treated with the Ponseti  technique and reported that 36 (30%) were born via LSCS, indicating that the method of delivery might influence club foot development, though the exact mechanism remains unclear. Ferrando et al.(2020) included 50 patients in their study and found that 20(40%) had a history of LSCS delivery, a higher proportion that further supports this potential association.

In a study by Morcuende et al.(2004) 11  involving 200 patients, 60 (30%)were delivered via LSCS, supporting the hypothesis that caesarean delivery might be associated with a higher incidence of club foot.

The study demonstrated the efficacy of the Ponseti method in achieving significant correction of clubfoot deformities with minimal complications. Early diagnosis and treatment, particularly within the first month of life, were prevalent among the patients, emphasizing the importance of early intervention. Overall, the Ponseti method proved to be an effective, non-invasive approach for managing congenital club foot, ensuring high rates of correction and low recurrence when initiated early. This study supports the continued use and promotion of the Ponseti method as the gold standard for clubfoot treatment, particularly in resource-limited settings like Warangal, India.

Conflict of Interest: None

Funding Support: Nil

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