Abstract
Category:
Other; Ankle; Hindfoot; Midfoot/Forefoot
Introduction/Purpose:
Severe congenital talipes equinovarus (also known as clubfoot) that resists conservative treatments is managed with extensive surgical soft-tissue release and bony procedures. Residual clubfoot deformity, or relapse after a primary intervention may also warrant an open surgery. While the high relapse rate of primary and secondary invasive surgical methods has been widely reported in the literature, the question if this curve will reach a peak in time remains open. This systematic review examines the tendency of required revision surgery in management of talipes equinovarus and statistically extrapolates the result to locate a pivot point.
Methods:
A comprehensive search was conducted of PubMed, CINAHL, Web of Science, and Cochrane from inception to December 2020 to identify literature on clubfoot. Using PRISMA guidelines, the search terms clubfoot OR clubfeet OR clubbed foot OR clubbed feet OR talipes equinovarus were used. Articles containing more than three human subjects were included. The database was searched for longitudinal studies of clubfoot management by extensive surgical procedures for pediatric, idiopathic, resistant, residual, or relapsed deformity. Retrospective studies of primary and revision surgery performed on children up to ten years old with reported mean follow up of at least one year were included. Outcomes were evaluated according to scoring systems Laaveg-Ponseti, Dimeglio-Bensahel, and Magone based on clinical examination of foot function, radiographic studies, or patient satisfaction questionnaires. Relapse was defined as revision surgery needed to manage residual deformities, mobility, pain, or other complications. Probability of less than 0.05 is considered statistically significant.
Results:
The initial search yielded 2907 articles, of which 23 relevant articles, were included. The number of treated clubfeet was 1646, and the average age at operation was 13.1 (1 - 120) months. The most common surgical procedures included posterior medial and lateral soft tissue release such as Turco's posteromedial release (PMR), subtalar release, and tibialis anterior tendon transfer. Initial correction outcome was commonly evaluated clinically by physical examination with high satisfaction, evidenced by often long lapses to first revision surgery when needed. The mean follow-up period was 17.2 years (1 - 47). For very long follow- up periods, relapse rate was as high as 89% (mean 37%). There was a strong positive correlation between mean follow-up and rate of relapse (R = 0.5023, p = 0.0073).
Conclusion:
The high rate of complications that warranted revision surgery (37%) was consistent with the literature, but of more concern was the consistent statistically positive slope that continued to climb even with follow-up periods as long as five decades. The absence of a peak in relapse is most consistent with the postulations that relapse was due to muscle-bone balancing dynamics evolving with growth and activities, damage from repeated surgeries, or severity of deformity at birth that is permanently incurable. Since clinical evidence and statistical assessment indicated persistent high rate of relapse, revision surgery should be limited in managing relapsed clubfoot.