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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 49-54

How much remodeling is possible in a clubfoot treatment? Magnetic resonance imaging study in a 7-year-old child


1 Assistant Professor at State, Hospital of São Paulo (HSPE), São Paulo - SP, Brazil
2 Radiologic Department, Sirio Libanes Hospital, São Paulo - SP, Brazil

Date of Web Publication3-May-2018

Correspondence Address:
Dr. Monica Paschoal Nogueira
426 Maracatins Avenue, Apt. 402, Sao Paulo 04089-000
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_18_17

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  Abstract 


Background: The Ponseti method for clubfoot treatment was initially described for children up to 6 months. Remodeling of cartilage in infants undergoing treatment by Ponseti method has already been studied with magnetic resonance imaging (MRI). “Neglected” or after walking age clubfeet was also shown to be corrected with the Ponseti method. Remodeling in those patients has not yet been sequentially documented. Questions/Purposes: To document cartilage anlage changes at 2. 5 and 18 weeks during treatment in a 7-year-old child, and verify if those changes are maintained 2.5 years after Ponseti treatment. Does the Achilles tendon also heal and remodel? Materials and Methods: A 7-year-old with bilateral clubfeet is treated with Ponseti method with ten casts, followed by complete percutaneous tenotomy and anterior tibial transfer to the third cuneiform. Cartilage and bone remodeling are studied through MRI sequences at the beginning of treatment, 5, 18 weeks and 2.5 years after Ponseti clubfoot treatment. Results: Images before treatment show severe tibiotalar plantar flexion, plantar talar neck inclination, and inferior talonavicular subluxation. After 5 weeks images show the correction of hindfoot equinus. After 18 weeks images demonstrate correction of the tibiotalar plantar flexion, normal congruency of the talonavicular and subtalar and complete healing of Achilles tendon. These cartilage/bone changes are maintained after 2.5 years, and the foot is plantigrade. MRI studies after treatment show good congruency, and reduction of talonavicular, talocalcaneal, and calcaneocuboid joints. Healing of Achilles tendon is documented after 8 weeks of complete tenotomy, and anterior tibial tendon transfer can be identified inserted to the third cuneiform. Conclusions: The observed changes can justify application of Ponseti Method for children with clubfeet after walking age. Clinical Relevance: Ponseti treatment can be applied to children over walking age resulting in correction of clubfeet due to cartilage remodeling.

Keywords: Child, clubfoot, magnetic resonance imaging


How to cite this article:
Nogueira MP, Amaral DT. How much remodeling is possible in a clubfoot treatment? Magnetic resonance imaging study in a 7-year-old child. J Limb Lengthen Reconstr 2018;4:49-54

How to cite this URL:
Nogueira MP, Amaral DT. How much remodeling is possible in a clubfoot treatment? Magnetic resonance imaging study in a 7-year-old child. J Limb Lengthen Reconstr [serial online] 2018 [cited 2018 Dec 18];4:49-54. Available from: http://www.jlimblengthrecon.org/text.asp?2018/4/1/49/231786


  Introduction Top


The Ponseti method for clubfoot treatment was described for children up to 6 months by Ponseti, 1996.[1] In 2004, Morcuende et al.,[2] concluded that the treatment was also efficient for children up to 2 years old.

In older children, reshaping is not expected to be as effective as in neonates. However, clinical results obtained by various groups, mostly in developing countries, are surprisingly good, demonstrating that correction of the congenital clubfoot deformity can be achieved in older children.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29]

In 2001, Pirani[30] studied the remodeling of cartilage in infants undergoing treatment with the Ponseti method. A magnetic resonance imaging (MRI) protocol was developed. Joint congruency is maintained while remodeling occurs through serial casts.

”Neglected” or after walking age clubfeet can also be corrected with the Ponseti method as shown in the recent literature.[24],[25],[26],[27],[28],[29] Remodeling in those patients has not yet been sequentially documented concerning joint congruency and morphologic changes in cartilage anlagen.

Four sequential MRI studies are studied following Pirani's protocol[30] for infants, taken before, during and two of them after Ponseti treatment of a 7-year-old child and cartilage changes, joint orientation and position of the foot are compared.

In the comparison/observation the study focused on:

  1. How does cartilage anlage change at 2, 5, and 18 weeks during treatment?
  2. Are those changes maintained after 2.5 years?
  3. Is joint congruency maintained during Ponseti treatment?
  4. Does the Achilles tendon heal and remodel as well as the cartilage?



  Materials and Methods Top


This a prospective study performed in Sao Paulo, Brazil.

A 7-year-old child with untreated bilateral clubfoot was treated with the Ponseti method in 2010 after informed consent was obtained. The treatment followed the same principles as applied in infants by Laaveg and Ponseti[31] and Ponseti:[1] elevation of the first ray to correct cavus deformity followed by abduction of the foot, always with counter pressure in the lateral part of the talar head. The abduction at the last cast should be maximum, with the talar head completely covered. Long leg casts with the knee in 90° of flexion were changed every week.

Seventy degrees of abduction was the position obtained in the last pair of casts (10th). After that, the patient underwent bilateral complete Achilles tenotomy and anterior tibial tendon transfer to the third cuneiform. Long leg casts were applied after surgery and kept for 6 weeks. Foot abduction brace was recommended for night time use for a year postoperatively.

The same MRI protocol devised by Pirani[30] to image the anatomical abnormalities in newborns was used in this study. General anesthesia was not needed nor was sedation. The feet were placed within an adult knee coil. Fast spin echo T1- and T2-weighted sequences were used (short in duration) with good contrast between bone and cartilage. Slice thickness was 3 mm. Studies were performed in a high field strength magnet (Avanto/Skyra; Siemens 3.0 Tesla, Erlangen, Germany).

Images were obtained based on a perpendicular plane from the joint of interest (calcaneocuboid, ankle, talonavicular, and subtalar joint) [Figure 1].
Figure 1: (A) Tridimensional reconstructions of a normal foot, demonstrating: Axial plane (bimalleolar orientation for sagittal plane) and lateral showing the three orientations of the following cuts; (B) oblique axial images perpendicular to the talonavicular joint; (C) oblique axial images perpendicular to the calcaneocuboid joint and; (D) oblique coronal images perpendicular to the subtalar joint

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Sagittal plane images were obtained from a coronal scout perpendicular to bimalleolar axis. Oblique axial images from a coronal scout perpendicular to talonavicular joint and oblique axial images from a coronal scout perpendicular to calcaneocuboid joint. Oblique coronal images were taken from a coronal scout perpendicular to subtalar joint.

The first images of both feet were obtained before treatment, the second after the 5th cast (5th week), the third on the 18th week, 2 weeks after the removal of the last cast and postanterior tibial tendon transfer and Achilles tenotomy. The last MRI was performed 2.5 years posttreatment.

Sequential images were compared concerning:

  • Cartilage remodeling
  • Joint orientation
  • Reduction of dislocated or subluxated joints
  • Healing of Achilles tendon and
  • Foot position.



  Results Top


Characterization of clubfoot deformity shows important talus plantar flexion in the sagittal view. The ossific nucleus of the talus is not central in the talus cartilage anlage, talar neck has an abnormal inclination. The oblique coronal plane shows the navicular bone dislocated medially and wedge shape and the cuboid is also medially dislocated. In the axial view, the navicular and anterior calcaneus are cartilaginous [Figure 2].
Figure 2: Sagittal plane fast spin echo (FSE) T2 fat sat (a) clubfoot deformity: important talus plantar flexion. (b) Axial plane perpendicular to the talonavicular joint navicular bone dislocated medially with a wedge shape. (c) Axial plane perpendicular to the calcaneocuboid joint the cuboid bone is also medially dislocated and rotated. (d) Coronal plane perpendicular to the subtalar joint the navicular is dislocated and medially rotated

Click here to view


In the sagittal plane intense remodeling can be observed, and maintenance of joint congruency is shown in four phases: pretreatment, in the 5th week, at 18 weeks (2 weeks after removal of surgical casts) and 2.5 years follow-up. Healing after Achilles tenotomy is complete at 18 weeks [Figure 3] and [Figure 4].
Figure 3: Sagittal plane FSE T2 fat sat before treatment (a) severe tibiotalar plantar flexion, plantar talar neck inclination and inferior talonavicular subluxation. (b and c) After 5 weeks of treatment sagittal plane (T1/FSE T2 fat sat): Reduction of tibiotalar flexion. (d) After 18 weeks sagittal T1 correction of the tibiotalar plantar flexion, normal congruency of the talonavicular and subtalar. (e) 2.5 years of follow up − sagittal T1: Complete ossification of the talus and calcaneus. Remodeling of the navicular and talus head

Click here to view
Figure 4: Follow up after 6 weeks of Achilles tenotomy − sagittal plane T1 (a) and axial FSE T2 fat sat (b) the tendon is continuous with discrete peritendinous edema Achilles tendon is healed 8 weeks after surgery. Transposition of the anterior tibial tendon (c) fixed in the lateral third cuneiform

Click here to view


In the foot coronal sequences, the talonavicular realignment is demonstrated as well as calcaneocuboid joint realignment in the axial views [Figure 5], [Figure 6], [Figure 7].
Figure 5: Oblique axial plane FSE T2 fat sat perpendicular to the talonavicular joint before treatment (a): Severe medial displacement, adduction of the navicular. (b) After 5 weeks of treatment (c) after 18 weeks talonavicular joint realingned and (d) 2.5 years of follow up correction of the medial talar neck inclination and the medial talonavicular displacement. Wedge-shaped navicular after remodeling

Click here to view
Figure 6: (a) Oblique axial plane FSE T2 fat sat perpendicular to the calcaneocuboid joint before treatment the cuboid is displaced medially and inverted in front of the calcaneus. (b) After 5 weeks of treatment. (c) After 18 weeks and (d) 2.5 years: correction of the medial calcaneocuboid displacement and rotation. Close to cuboid, the initial hygroma (arrow) disappears in the second phase of treatment

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Figure 7: Oblique coronal plane FSE T2 fat sat perpendicular to the subtalar joint before treatment (a and b): the navicular is adducted and inverted lateral to the head of the talus and calcaneus. (c and d) After 5 weeks of treatment and (e and f) 2.5 years of follow up: Correction of the inverted calcaneus and navicular

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After 5 weeks treatment, sagittal plane images show important correction of hindfoot equinus and talus orientation and improvement of the tibial-talar contact. Calcaneocuboid joint orientation also changed about 60 degrees becoming more vertical.

After 18 weeks images demonstrate correction of the tibiotalar plantar flexion, normal congruency of the talonavicular and subtalar and complete healing of Achilles tendon.

Those cartilage/bone changes are maintained after 2.5 years and the foot is plantigrade. MRI studies after treatment show good congruency, and reduction of talonavicular, talocalcaneal and calcaneocuboid joints. Healing of Achilles tendon is documented after 8 weeks of complete tenotomy, and anterior tibial tendon transfer can be identified inserted to the third cuneiform.

Comparing the infant's images from Pirani's study (2001)[30], our study shows similar remodeling even without big cartilage anlages seen in babies. Clinical results are satisfactory, with stable and plantigrade clubfeet, with aesthetic and functional outcomes very close to normal [Figure 8]. Radiographs of pre- and post-treatment are shown in [Figure 9] and [Figure 10].
Figure 8: Clinical results and radiographs pre-(a-d), during (e) and postclubfoot treatment (f-i)

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Figure 9: Axial plane and lateral radiographs pretreatment

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Figure 10: Axial plane and lateral radiographs. after treatment

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  Discussion Top


This study was able to show and describe chondroosseous changes during treatment of a 7-year-old boy with clubfoot by Ponseti method. There are studies showing the possibility of treating children over walking age. However, the MRI documentation of bony and cartilage changes at this age has not yet been demonstrated.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[32]

Those studies elevate the upper age limit for using the Ponseti method and also the limit of remodeling of cartilage anlagen and bony structures. In the 7-year-old boy, the observed changes after the first 5 weeks of treatment are similar to the changes described in newborns.[30] This was obtained with application of Ponseti protocol with no changes and concentration on the moulding of the foot and stretching of medial and posterior and medial soft tissues.

The understanding of the chondroosseous changes during treatment by Ponseti Method can be based on the viscoelastic behavior of the ligaments and tendons, and the creep strain phenomenon that occurs during manipulation.[33] “The cast is applied with the same pressure used during manipulation. As with all viscoelastic materials, stress relaxation would take place in the cast, effectively redistributing stresses within the tissues until the next manipulation and casting…” Mosca also reinforces the importance of the unique stiffness of the individual child's foot, the age at which the treatment is initiated and the skill of the practitioner to obtain a successful correction. Extensive remodeling can occur even in the cases of mild talar flattening because the amount of talus flattening that will prevent adequate correction with serial casts is not yet documented. That is why it is so important to follow and document critically the progression of correction after each cast. Cases do not respond the same way, some will respond better and faster, others not so.

Brand et al.[34] performed an MRI volumetric study of anlagen in clubfoot correction and documented the deformation of the soft anlagen with the constant pressure of the cast and stretch of the ligaments. In 1 week, the anlagen assumed a new “deformity” shape not returning elastically to its original shape before casting. However, the tissues in clubfoot are known to grow less than in a normal foot, those authors found that the abnormal talus anlage grows faster and more than the normal, as if it would have been decompressed. This could also explain the cartilage changes during Ponseti treatment.

Complete tenotomy can be safely performed, the healing of the tendon resumes in 3−4 weeks (shown in MRI images after 8 weeks of surgery). In the clubfoot deformity, the Achilles tendon is not the only structure restricting dorsiflexion: there is an important retraction of ligaments and capsule that does not allow for free dorsiflexion, even if the Achilles is completely transected. The age limit for a complete tenotomy has yet to be defined, but mature clubfeet have been treated with total resection of the tendon, and none of those (previously non-operated feet) reported to be overcorrected to a planovalgus foot, or to have a weak Achilles tendon.

The problems in older skeletally mature clubfeet have to do with osteoporosis, long time casting, stress fractures, and contractures. Insufficiency of triceps has not been reported.[12],[29]

Tenotomy should not be replaced by posterior release. Posterior releases cause fibrosis and loss of dorsiflexion as healing occurs. Furthermore, the little extra dorsiflexion gained with this extensive procedure could be lost. Only in the case of tenotomy not been able to completely correct the equinus, then posterior release could be an option. Important to remember that abduction corrects the equinus in the subtalar joint and only of the rest of correction should depend on posterior structures in the ankle. The anterior tibial transfer is a usual procedure in recurrent cases of clubfoot[1] but can be an excellent tool to complement clubfoot treatment in older children.[8] The entrance of the anterior tibial tendon in the third cuneiform and its correct incorporation into the bone can be demonstrated by MRI images 8 weeks after surgery.

Bracing is a crucial part of the Ponseti method and proper motivation and education of parents mitigates the chances of losing correction. Not using foot abduction brace will increase the risk of relapse seventeen times[2] After 2.5 years, this patient maintained correction and used night time brace for a year.

Osteopenia after prolonged casting can be a serious problem in patients after walking age. Stress fractures can be painful and be responsible for a delay in resuming walking. The images after 8 weeks of surgery (18 weeks of treatment) show those changes − stress fractures − with a halo of inflammatory reaction. Osteopenic changes are completely resolved in the images after 2.5 years of treatment; patient recovered and walked without any complaints. Additional follow-up is necessary to observe if this remodeling in this age has a price to pay in the future, vis-a-vis arthritic changes.

This study had a number of limitations; the MRI cuts are similar but not exactly the same as the ones in newborns. However, as they are perpendicular to the plane of the specific joints, they can show remodeling and congruency. This boy had bilateral clubfeet; maybe, in unilateral disease, the contralateral normal side could be compared with the treated clubfoot.

It would be interesting to measure cartilage volumes in true three-dimensional imaging, which can document remodeling more efficiently.

Intense cartilage remodeling and maintenance of joint congruency have been shown during and after Ponseti treatment in a neglected 7-year-old clubfoot. Hence we prove that it is possible to treat older children with Ponseti Method resulting in a functional, pain-free, plantigrade foot, with good mobility.

Acknowledgments

We would like to thank Sirio Libanês Hospital Radiological Department for the MRI images studies pro bono through its philanthropic activities.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]


This article has been cited by
1 The Ponseti method in children with clubfoot after walking age – Systematic review and metanalysis of observational studies
Gabriel Ferraz Ferreira,Kelly Cristina Stéfani,Davi de Podestá Haje,Monica Paschoal Nogueira,Edward Ebramzadeh
PLOS ONE. 2018; 13(11): e0207153
[Pubmed] | [DOI]



 

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