Research Article: Evaluation of Neglected Idiopathic Ctev Managed by Ligamentotaxis Using Jess: A Long-Term Followup

Date Published: October 19, 2011

Publisher: SAGE-Hindawi Access to Research

Author(s): Ajai Singh.


Background. This study was conducted with the aim of evaluating the role of Ligamentotaxis in the management of neglected clubfeet managed by ligamentotaxis using Joshi’s External Stabilisation System (JESS). Method & Material. Total 20 subjects (28 feet) were studied, which were corrected by differential ligamentotaxis using JESS. All were evaluated clinically, radiologically, podogrammically, and by Catterall Pirani Scoring System, both before and after the correction. Results. Severity of the deformities and clinical correction was assessed by Pirani score. All patients achieved good clinical results as per Pirani score, which was statistically significant. Radiological evaluation showed that all subjects achieved the normal range of values. The pre- and postcorrection difference in FBA was statistically significant. Conclusion. Differential distraction by fixator for the correction of neglected idiopathic CTEV is an effective and patient-friendly method of management.

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The CTEV, a hereditary foot deformity is one of the commonest congenital foot anomalies presenting to a paediatric orthopaedic surgeon. Its incidence is 5–6 per 1000 live births, varying with race and geography [1]. The goal of any type of CTEV management is to reduce, if not to eliminate all elements of the clubfoot deformity, hence achieving a functional, pain free, normal looking plantigrade, mobile, callous free, and normally shoeable foot [1]. The various factors that have been associated with the poor prognosis in CTEV management are female child, hereditary, late age of presentation, severity of deformity, rigidity of foot, associated cavus, associated clawing of toes, and small heel [2–6]. Kite [7] rationalized the whole treatment of clubfoot by conservative means. Recently, various workers have shown satisfactory results by Ponseti [8] method of manipulation and serial casting. With the fear of possible complications of open surgery, minimally invasive surgery had been advocated long back for correcting the clubfoot deformity. Percutaneous soft tissue release and tenotomy for getting the corrected foot had been advocated by various workers [5]. The method of controlled differential distraction, that is, ligamentotaxis, along with the miniexternal fixator was originally described by Dr. B. B. Joshi in 1990. Ilizarov fixator [2] has also been used for correction of CTEV deformities. Recently associations of internal talar spin and varus component of this deformity has been established [6]. Clinically the talar spin can be measured by foot bimalleolar axis [6]. We considered any clubfoot presented first time to us for the management at or after the age of 01 year. Although “neglected” cases have not been defined in the literature, we considered any patient presenting to us after the age of 03 years as late presentation/neglected cases. This study was conducted to evaluate the clinico-radiological outcomes of neglected idiopathic CTEV managed by ligamentotaxis using JESS.

This observational study was conducted on all the patients with late presentation of CTEV since July 2003 to January 2005. All patients of 03–06 years of age of both sexes with idiopathic CTEV feet fulfilling following criteria, such as presenting first time for the management of clubfoot in our OPD, patients managed earlier but not fully corrected, and all previous conservatively corrected clubfoot presented with relapse of deformity, were included. We excluded patients below 03 years and above 06 years of age and if associated with secondary causes like arthrogryposis, meningomyelocele, and so forth. All included patients were assessed and managed by author only. All patients included in this study were thoroughly assessed clinically including podograms and radiologically. In the radiological assessments, measurements of various angles were done in AP and lateral view in stress dorsiflexion in all cases. X rays were studied for talocalcaneal angle, talo-first metatarsal angle, talo-Vth metatarsal angle (all in AP view), talocalcaneal angle, Tibiocalcaneal angle and Calcaneal pitch (all in lateral view). Catterall Pirani scoring system was used in this study to assess the severity of deformity and to assess the correction achieved after final casting. Podograms were taken to assess the weight bearing portion of foot, length, and width of foot before and after completion of treatment. After keeping the foot in weight bearing position, the foot tracings were taken on a plain white paper. Simultaneously the midpoints of both malleoli were marked on the same footprint by placing a pencil on both sides. A long “axis of foot” was drawn taking 2nd toe and midpoint of most broad part of heel as the two reference points. A line joined the two medial malleoli marks known as “bimalleolar axis”, which intersect with this long axis of foot. Anteromedial angle of the intersection was taken as “Foot Bimalleolar Angle” (FBA). As described in the literature, the normal value of FBA is 82.5°. Feet were classified in groups I, II, III as per the Jain et al. study [23] (group I: >73.2°, group II: >  66.6–73.2° and group III: <66.6°). FBA was recorded before and after the treatment. After this assessment, all these feet were manipulated by Ponseti technique. Those feet showed significant clinical improvement after 04 manipulations, were excluded from the study and rest feet, not responding to the manipulations, were then included in the study, and were operated (JESS–external fixator assembly). We managed 33 neglected idiopathic CTEV feet were by Ponseti technique, out which only 5 (15.1%) feet were responded to these manipulations. Rest total 28 feet in 20 patients were included in the study. There were 14 male and 6 female patients. The minimum age was 3.4 years and maximum was 5.2 years (mean age −  4.2 years). All 28 feet had severe clinical deformities (clinical grade III, Pirani score 5-6 and FBM angle below 66 degrees). Total 22 feet were managed previously elsewhere by corrective manipulations with plaster, 02 were operated elsewhere (posteromedial soft tissue release) and rest were never received any mode of treatment. Mean precorrection FBA (60.9 degrees) was corrected to 78.7 deg. Mean preoperative TC index (19.2), improved to 63.1. All other clinico-radiological parameters were also improved (statistical significant) in all patients. Only 6 (18.7%) feet developed superficial infection (not severe enough compelling any active intervention). Only 10 (31.2%) feet presented with relapsed forefoot adduction (corrected by manipulations and retention by plasters in all cases) and all returned to orthosis. No open correction of any component of deformity in any case at any stage was done. Congenital Talipes Equinovarus is a common paediatric orthopaedic problem, which constitutes a bulk of the congenital anomalies presenting to any paediatric orthopaedic surgeon.   Source: