Treatment of Foot Deformities in Children under 3

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Introduction

Pathology of the foot of congenital etiology is represented by such nosologies as Pes equino-varus (clubfoot), metatarsus varus (reduced foot), vertical talus (vertical RAM), pes varus (varus foot), pes planovalgus (flat foot), pes cavus (hollow foot). According to ICD-10 code Q66. 5. the Epidemiology of pes equino-varus is 1 per 1000 newborns [4], while vertical talus and metatarsus varus are quite rare [3, 8].

These nosologies are accompanied by a pronounced pain syndrome, functional changes in the foot, which forces the patient to use orthopedic shoes. In the absence of proper surgical correction, the risk of disability is high. Functional disorders affect the patient's quality of life and determine the high social significance of these nosologies [5].

To date, there are a number of classifications of congenital foot pathology. According to Zatsepin-Bohm, there are two clinical forms of Pes equino-varus: typical and atypical [6]. Based on the literature available to us, the typical type of deformation accounts for 80% of cases. This type of deformity lends itself well to such treatment methods as bandaging and plaster casting.

There are also three types of soft tissue component involvement - soft tissue and bone (rigid). Belonging to a particular type of pathology is distinguished by the possibility and effectiveness of a conservative method of treatment. A number of soft-tissue types of deformations are described in the literature as the most common [1].

The aim of the study was to improve the results of treatment of pes equino-varus using the Ponseti procedure, as well as vertical talus correction by Dobbs in children in combination with massage, physiotherapy and physical therapy.

Material and methods

In the period from 2015 to 2020, a double prospective cohort study was conducted at the clinical base of the Moscow state medical UNIVERSITY named after N. F. Filatov. 109 children with congenital deformities of the feet were selected for treatment with the proposed methods.

During the examination, 102 children (93.6%) were diagnosed with a typical and 7 (6.4%) with an atypical form of pes equino-varus. The soft tissue form was found in 51.4% of cases (in 56 children), and in 48.6% - the bone form (53 children). In 22.0% of cases, we found a left - sided type of deformity (24 children), in 18.3% - a right-sided type (20 children), and in 59.6% of cases (65 children), a bilateral lesion.

According to the age at which the deformity was detected, the patients were distributed as follows. In 73.4% of cases, deformity was diagnosed before 3 months (80 children), in 6.4% of cases from 3 to 6 months – (7 children), in 20.2% of cases over the age of 6 months (22 children). The average start time of clinical follow-up was 1.0 (1.0; 3.5) months. The average start time of treatment was 1.0 (1.0; 4.0) months. The average duration of surgical intervention was 3.0 (2.0; 4.25) months.

Surgical correction was performed in 100% of cases (91 children) with pes equino-varus and in 50% of cases (3 children) with vertical talus. Metatarsus varus in 100% of cases were subjected to conservative treatment. Surgical treatment was performed in 94 children (achillotomy was performed in 91 children with pes equino-varus and 3 with vertical talus).

All children with PES equino-varus and 11 (91.7%) of 12 children with metatarsus varus used the Ponseti procedure. This is a conservative technique of plastering congenital clubfoot, which consists in gradually removing all components of the deformity to the correction position, based on the biomechanics of the ankle joint and supplemented by percutaneous achillotomy.

All children with vertical talus had the Dobbs technique applied. This is a conservative technique of plaster cast for congenital equinovalgus deformity of the feet, which consists in gradually removing all components of the deformity to the correction position, based on the biomechanics of the ankle joint, supplemented by percutaneous achillotomy and in some cases fixing the 1st leg of the foot with a Kirschner spoke.

Complex treatment of children with metatarsus varus included massage procedures. Also, 5 out of 6 children (83.3%) with vertical talus had massage. Children with pes equino-varus were not given massage treatments. Courses of physiotherapy procedures were used in 16.7% of children with metatarsus varus (2 out of 12). Complex physical therapy sessions with metatarsus varus were conducted in 70.3% of cases (64 children out of 91) and in 33.3% of cases with vertical talus (4 out of 6 children). Children with pes equino-varus did not receive comprehensive physical therapy classes.

Results

Criteria of effectiveness of treatment was: emptiness of the heel, the degree of rigidity of the Cavus the medial folds form the lateral bending of the arch of the foot, its aquinos and degree of dorsiflexion. Changes of the foot were determined according to the classification Pirani:

1. the condition of the posterior part of the foot according to Pirani before correction had more pronounced statistical differences than after correction (according to the Wilcoxon criterion = -8.955, p<0.001);
2. the degree of Cavus rigidity according to the piranha classification before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 9.125; p<0.001);
3. Assessment of the medial fold of the foot before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 9.105; p<0.001);
4. the Bending of the outer edge of the foot before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 9.364; p<0.001);
5. the Equinus of the foot before correction had more pronounced characteristics than after correction (Wilcoxon criterion = - 8.879; p<0.001);
6. The evaluation of the posterior heel fold according to the Pirani system before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 8.791; p<0.001).

The total number of points according to the piranha criteria before the correction was 4.5 (3.0; 6.0), after the correction 0 (0;0) points. The obtained differences are statistically significant (we used Friedman's analysis of variance for related samples, p<0.001).

In our study, 61 patients received outpatient surgical treatment and 45 patients received inpatient treatment (n = 106).

The results of the outpatient surgical treatment. Changes in the foot according to the piranha classification were distributed as follows:

1. heel Emptiness according to the Pirani classification before correction revealed statistically significant differences than after correction (Wilcoxon criterion = -6.705, p<0.001, 1.0 (0.5; 1.0) before correction versus 0.0 (0.0; 0.0) after correction);
2. the rigidity of the Cavus according to the Pirani classification before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 6.628; p<0.001, 1.0 (0.5, 1.0) before correction versus 0.0 (0.0; 0.0) after correction);
3. Assessment of the medial fold of the foot before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 6.628; p<0.001, 1.0 (0.5, 1.0) before correction vs. 0.0 (0.0; 0.0) after correction);
4. the Bending of the outer edge of the foot before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 6.683; p<0.001, 1.0 (0.5, 1.0) before correction vs. 0.0 (0.0; 0.0) after correction);
5. Equinus of the foot before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 6.753; p<0.001, 1.0 (0.5, 1.0) before correction vs. 0.0 (0.0; 0.0) after correction);
6. The assessment of the back heel fold according to the Pirani classification before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 6.662; p<0.001, 1.0 (0.5, 1.0) before correction versus 0.0 (0.0; 0.0) after correction).

Thus, the total score for the piranha classification before correction was 5.0 (4.0; 6.0), after correction 0 (0;0) points. The obtained differences are statistically significant (we used Friedman's analysis of variance for related samples, p<0.001).

The results of the hospital surgical treatment. Changes in the foot according to the piranha classification were distributed as follows:

1. heel Emptiness according to the Pirani classification before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = -5.665, p<0.001, 1.0 (0.5;1.0) before correction versus 0.0 (0.0; 0.0) after correction);
2. the rigidity of the Cavus according to the Pirani classification before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 5.557; p<0.001, 1.0 (0.5, 1.0) before correction versus 0.0 (0.0; 0.0) after correction);
3. Assessment of the medial fold of the foot before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 5.516; p<0.001, 1.0 (0.5, 1.0) before correction vs. 0.0 (0.0; 0.0) after correction);
4. the Bending of the outer edge of the foot before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 5.631; p<0.001, 1.0 (0.5, 1.0) before correction vs. 0.0 (0.0; 0.0) after correction);
5. Equinus of the foot before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 5.674; p<0.001, 1.0 (0.5, 1.0) before correction vs. 0.0 (0.0; 0.0) after correction);
6. the evaluation of the posterior heel fold according to the Pirani classification before correction had more pronounced statistical differences than after correction (Wilcoxon criterion = - 5.631; p<0.001, 1.0 (0.5, 1.0) before treatment versus 0.0 (0.0; 0.0) after treatment).

Thus, the total score for the piranha classification before correction was 5.5 (4.0; 6.0), after correction 0 (0;0) points. The differences are statistically significant (two-factor Friedman analysis for related samples, p<0.001).

Comparison of inpatient and outpatient treatment groups. Prior to treatment, the inpatient and outpatient treatment groups were comparable in all piranha classification criteria:

1. The emptiness of the heel (the Mann-Whitney test, p=0,466);
2. Cavus Rigidity (Mann-Whitney test, p=0.611);
3. Medial fold of the foot (Mann-Whitney test, p=0.986);
4. Bending of the outer edge of the foot (Mann-Whitney test, p=0.978);
5. Equinus of the foot (Mann-Whitney test, p=0.663);
6. Back heel folds (Mann-Whitney test, p=0.671).

By total score (Mann-Whitney test, p=0.917). Thus, the groups are comparable to each other in terms of these indicators. Based on the criteria for the effectiveness of treatment according to the Pirani classification, it is possible to compare clinical comparison groups by the degree of dorsiflexia achieved.

Achieved dorsiflexia greater than 15 degrees was observed in 51 cases of surgical treatment (83.6%) in outpatient settings and in 39 cases (86.6%) of surgical treatment in inpatient settings (table 1).

 

Table 1 – Achieved dorsiflexia in comparison groups.

			The comparison group
			Outpatient n=61	Stationary n=45
Achieved dorsiflexia	< 15о	Number, people	4	6
		Frequency, %	6,4%	3,4%
	> 15о	Number, people	57	39
		Frequency, %	83,6%	86,6%

 

The table shows that the differences between the groups are statistically insignificant (Fisher's exact test, exact significance (2-sided) = 0.139). By total score (Mann-Whitney test, p=0.917). Thus, the groups are comparable to each other in terms of these indicators.

Adverse outcomes of inpatient and outpatient treatment. After surgical correction in a hospital setting, one child required repeated surgery due to a relapse (an additional achillotomy was performed). Based on our experience and the literature we have studied, early detection of relapses of pathology is the key to successful elimination of secondary deformity. The cause of secondary deformity is usually a violation of the rules for using rehabilitation correctors, braces, and orthopedic shoes after the main stage of surgical correction is completed. Relapse is usually detected during the period of intensive foot growth-up to 10-13 years of age. Therefore, at the beginning of adolescence, such children should be regularly monitored by an orthopedist [10].

In 9.1% of outpatient cases (5 out of 55 children), children had limited movement in the distal part of the lower leg, while the same complication in the hospital was observed in 2.6% (1 out of 39 children). There are no statistical differences in the compared groups (Fisher's criterion, exact significance (2-sided) = 0.395).

Thus, both outpatient and inpatient treatment options for children with foot pathology had an equally significant impact on the evaluation criteria for treatment effectiveness. In 100% of cases of operative correction, satisfactory results were achieved. When choosing a treatment method (outpatient or inpatient), the principal criteria should be considered not only the degree of social adaptation of the patient, but also economic factors, since the clinical effectiveness of these treatment approaches was the same.

Discussion

In modern pediatric orthopedic practice, PES equino-Varus correction using the ponseti method is the "gold standard" of treatment. To achieve complete successful correction of PES equino-Varus with the prevention of relapses or other deformities, careful compliance with the ponseti Protocol is necessary. Initially, the ponseti procedure was used only in children under two years of age, but current research on the results of PES equino-Varus correction is already focused on older age groups of children [9].

Our research results are consistent with the data obtained by other authors. The Ponseti procedure is successful and relapse-free in 94-96% of cases [7].

We believe that the most preferable age for correction of deformities is early age and adhere to the position that it is necessary to start correction of deformities early (immediately after diagnosis). Based on the literature available to us, late initiation of treatment is directly proportional to the frequency of relapses and duration of treatment [2].

 

Conclusion.

Based on the data obtained, we recommend treating PES equino-Varus as early as possible after birth (3-5 months), to prevent relapses and ensure complete correction of the deformity. Strict compliance with the Ponset Protocol is required to prevent relapses.

When correcting vertical scree, conservative correction in combination with minimally invasive surgical techniques can prevent the development of complications that were previously observed during extensive surgical procedures.

The method of Dobbs correction used by us is simpler and more effective in young children. Our data are consistent with reports of excellent results from other authors. The Dobbs correction method is less invasive and avoids the risks associated with more extensive operations [11].

We did not find any significant differences in the choice of outpatient or inpatient treatment. Taking into account the economic factor, in conditions of statistically reliable identical clinical outcomes, outpatient treatment is most preferable.

 

Conflict of interest. The authors declare that there is no conflict of interest.

About the authors

Ivya V Krestyashin

N.F. Filatov City of Moscow Children's City Clinical Hospital
N.I. Pirogov Russian National Research Medical University

Email: krest_xirurg@mail.ru

Ph.D., associate Professor of pediatric surgery, N. I. Pirogov Russian national research medical University, doctor-pediatric surgeon DGKB № 13. N. F. Filatova

Russian Federation, Moscow, Russian Federation

Aleksander Yu Razumovskiy

N.F. Filatov City of Moscow Children's City Clinical Hospital
N.I. Pirogov Russian National Research Medical University

Email: krest_xirurg@mail.ru

M.D., Professor, corresponding member of RAS, head the Department of pediatric surgery, N. I. Pirogov Russian national research medical University, head Department of thoracic surgery of the Filatov state clinical hospital № 13

Russian Federation, Moscow, Russian Federation

Vladimir M Krestyashin

N.F. Filatov City of Moscow Children's City Clinical Hospital
N.I. Pirogov Russian National Research Medical University

Email: krest_xirurg@mail.ru

M.D., Professor, Professor of the Department of pediatric surgery of the N. I. Pirogov Russian national research medical University, doctor-pediatric surgeon of the Filatov children's hospital № 13

Russian Federation, Moscow, Russian Federation

Ivan I Kuzhelivskiy

Siberian State Medical University

Author for correspondence.
Email: kuzhel@rambler.ru

M.D., Professor, Department of childhood surgical diseases of the Siberian state medical University of Minzdrav of Russia

Russian Federation, Tomsk, Russian Federation

References

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