Surgery more likely to alter gait
By Larry Hand
Children treated for idiopathic clubfoot by age 2 years may experience subtle changes in gait by the time they are aged 5 years, and nonoperative treatment may confer more normal movement than surgery, according to a recent study.
After treatment for idiopathic clubfoot at the Texas Scottish Rite Hospital for Children in Dallas, investigators analyzed data from 181 children seen for gait analysis when aged 2 and 5 years. Among 276 feet, 132 underwent Ponseti treatment, and 144 received French physical therapy (PT). By the time children were aged 5 years, 30 Ponseti and 61 PT feet had required surgery (47 feet before age 2 years, 44 between ages 2 and 5 years).
Among the surgically treated children, data collected at their second gait analysis showed only 17% of the Ponseti and 21% of the PT feet had normal ankle motion. The surgical PT feet had persistent in-toeing at both gait analyses; additionally, ankle power in these feet was significantly lower than in feet treated with the Ponseti method and surgery.
— Rachel Goldstein, MD, MPH
In addition, feet treated with posteromedial (PMR) tendon releases had significantly less ankle power compared with nonoperative feet and those treated with limited posterior release (PR).
“By age five, we are starting to see limited ankle motion in both the PR and PMR feet. The PMR feet are starting to show compromised ankle power compared to the nonoperative feet,” said Kelly Jeans, MS, laboratory manager and senior biomechanist at the Movement Science Lab at the Texas Scottish Rite Hospital.
She noted following up takes a team approach.
“Adherence to treatment protocols has been shown to be variable, especially in the use of the abduction brace following Ponseti casting. However, the physician or therapist’s ability to correct the deformity is another factor, as is the family’s ability to follow through with the treatment protocol once the foot has been corrected,” she said. “In certain cases where a child is unable to tolerate the abduction brace, and starts to lose correction, the foot might be recasted, or [the child] referred to the physical therapist to see if the foot can be corrected [without surgery].”
Jeans also noted plantar pressure measurement can provide useful information. “Plantar pressure measures can be very insightful as to the foot’s ability to contact the ground and how the pressure is being distributed through the foot,” she said.
Adam Graf, MS, senior motion analysis laboratory engineer at the Shriners Hospital for Children in Chicago, noted, “Gait analysis is important to fully evaluate the long-term results of clubfoot treatment. That has been its biggest contribution to date—determining that Ponseti management in general has yielded better results and is preferable to comprehensive surgical release at an early age,” he said.
The study, epublished in May in the Journal of Pediatric Orthopedics, “provides additional information to us on exactly what type of gait patterns return after nonoperative treatment for clubfoot,” said Rachel Y. Goldstein, MD, MPH, assistant professor of pediatric orthopedics at Children’s Hospital of Los Angeles. “The issue with clubfoot is really understanding the deformity and that this is almost a lifelong commitment. You can avoid complications by having a close relationship with your families and having a better understanding of the types of issues they pointed out in the study.”
For example, Jeans and colleagues noted, “residual in-toeing is easily identified by the patient, the family, and the clinician. Following these patients long term provides better understanding of interventions and the natural course after nonoperative treatment.”
Goldstein noted, “Gait studies are especially helpful in identifying specific issues that need to be addressed, so that you’re not overtreating or undertreating or treating the wrong component of gait.” However, “there are some deformities that come after clubfoot treatment that are identifiable without a gait study, such as the recurrence of the equinus,” she said.
Jeans agreed on the commitment issue. “In studying these children longitudinally, our clinicians have a better understanding of their treatments and what can be expected with growth and time. They can better address these issues and counsel new families that are presenting to the hospital for the first time with their newborn babies and continue to counsel as the child grows,” she said.
Larry Hand is a freelance writer in Massachusetts.
Jeans KA, Erdman AL, Chan-Hee J, Karol LA. A longitudinal review of gait following treatment for idiopathic clubfoot: gait analysis at 2 and 5 years. J Pediatr Orthop 2015 May 12 [Epub ahead of print]