Diversity Of Processes In Treating The Different Types Of Recurrent Clubfoot Using Ponseti Method And Their Functional Outcomes With A Reference To The Potential Mechanism

Part I. Seasonal Variation of Incidence of Idiopathic Clubfoot in Patientsfrom Southeastern China and its Association with the Incidence ofDevelopmental Dysplasia of the HipPurpose: Seasonality in the month of birth has been or was previously related to theincidence of idiopathic congenital talipes equinovarus (CTEV), but little is known aboutthe seasonality of CTEV in Chinese populations. As the most common musculoskeletalabnormalities in the field of pediatric orthopedics, the association between CTEV anddevelopmental dysplasia of the hip (DDH) is unclear. This study was designed to evaluatewhether the births of patients with CTEV followed a seasonal pattern in a population fromsoutheastern China, and to investigate the incidence of DDH in infants with idiopathicCTEV.Methods: We reviewed a consecutive series of patients with CTEV who were treated inour medical centre between2009and2013. Inclusion criteria of seasonal incidence pattern:(1) clinical diagnosis of idiopathic CTEV and absence of any other abnormalities;(2) dateof birth was from September1,2009to August31,2013;(3) mothers of the patients livedin southeastern China when they were pregnant;(4) partus maturus neonates;(5) patientsof Han Chinese. We also reviewed the monthly neonatal population data of the sixthChinese census from2009to2010as comparison data. Inclusion criteria of DDHincidence in idiopathic CTEV:(1) clinical diagnosis of idiopathic CTEV;(2) the absenceof any other abnormalities and family history; and (3) no previous treatment. Chi-squaredtest, Kruskal Wallis Test and Wilcoxon rank sum test were used for statistical analysis in two studies. SAS software version9.2(SAS Institutes, Cary, North Carolina, USA) wasused for statistical analysis. The value of p <0.05was considered significant.Results:239CTEV patients,177males and62females, were included. Of the239children with CTEV,224did not receive any treatment prior to referral while only15patients had some forms of treatment before their initial visit to our institution.191patients were first-born and all the maternal age of first-born baby in our study was underthirty-year old. There were107cases with bilateral clubfeet and132cases with unilateralclubfeet, including81on the right side and51on the left side. With the particularreference to monthly CTEV neonates calculated on the data from the sixth nationalpopulation census of China, the peak prevalence of clubfoot was in fall. We did not findany statistically significant difference in the severity of CTEV among the12months.184patients were diagnosed with idiopathic CTEV and underwent hip sonography. In total,seven hips from five individuals underwent treatment. The results indicated that2.7%(5/184) of babies with idiopathic CTEV had DDH. However, we did not find anystatistically significant difference of the Pirani scores between the DDH group and groupwith normal hips.Conclusions: The seasonal variation of CTEV was presumed to be related to geneticbackground and local environmental factors predisposing patients to the incidence ofCTEV in southeastern China. The discrepancy between the CTEV population and theChinese neonatal population in monthly and seasonal terms is useful to furtherunderstanding the aetiology and pathogenesis of CTEV in southeastern China. And it isrevealed that the CTEV group had a much greater incidence of DDH in comparison withthe general population. It is recommended that CTEV patients should be the candidatesparticularly for selective hip screening. The factors resulted in severity of clubfoot did notimpact incidence of DDH in patients with CTEV. Part II. Assessment of Treating Processes and Functional Outcomes for the Different Types of Recurrent Clubfeet after Management UsingPonseti MethodPurpose: Although extensive posterior or posteromedial soft tissue release used to playthe leading role in the management of congenital clubfoot, the long-term follow-up studiessuggested that they frequently had residual deformity or relapse with stiffness, pain,limited range of motion and even early arthritis. Repeated soft tissue release for recurrencewas correlated with the degree of functional impairment. In an effort to treat recurrentclubfoot following failed posterior or posteromedial release with Ponseti method, thecurrent study involved three rating systems for evaluation of functional outcomes andfurther investigated which system resulted in exact and objective evaluation of thefunction of clubfoot.Methods: Patients older than7years with idiopathic clubfoot managed using Ponsetimethod and with terminated foot abduction orthosis at least one year were included in thisstudy. Group I is neonatal clubfoot treated by Ponseti method under1year old withoutrecurrence. Group II is relapse clubfoot, which had Ponseti management, treated by thesame method again. Group III is relapse clubfoot, which had extensive posterior orposteromedial release, treated by Ponseti method in turn. The collected data includedinformation on sex, laterality, date of birth, treatment history, age at Ponseti managementand number of casts. All the patients in this study use the same bar-connected footabduction orthosis, but we prescribed the patients in group III different brace protocolwhich is full-time for the first3months and then12to14hours for one year. Threeoutcome rating systems, included system of Laaveg and Ponseti, ICFSG and Huang etal.(J Bone Joint Surg Br.1999;81:858-62), were used to evaluate the functional outcomesof clubfoot. All patients were treated and examined by one doctor. Analysis of Variance,Chi-squared test and Mann-Whitney U test were used for statistical analysis. SASsoftware version9.2(SAS Institutes, Cary, North Carolina, USA) was used for statisticalanalysis. The value of p <0.05was considered significant.Results: Seven feet from4patients (3boys and1girl,3bilateral and1right clubfeet)were included in group I;9feet from5patients (3boys and2girl,4bilateral and1left clubfeet) were included in group II; and12feet from9patients (6boys and3girl,3bilateral and6unilateral clubfeet included4on the left side and2on the right side) wereincluded in group III. The average age, age at Ponseti management, number of casts ofgroup I are7.3,0.3and4.4; they are7.8,2.4and4.3in group II;9.8,7.2and7.3in groupIII. Statistically significant differences of casts were found between Group I and III as wellas Group II and III. Age at Ponseti management had statistical differences after pairedcomparison among the three groups. The outcomes of all feet in group I and II areexcellent using three outcome rating systems except2feet from1patient using ratingsystem of Laaveg and Ponseti in the two groups respectively. Using rating system ofLaaveg and Ponseti,3feet in group I were excellent,8feet were good and1feet was fair.Using system of ICFSG,8feet in group II were good and4feet were fair. Using Huang etal. system, all12feet in group III were good. No matter which rating system was used thefunctional outcomes of group III were worse than group I and II. Meanwhile, functionaloutcomes of group I and II have no difference. Moreover, the consistency of the threesystems was poor in terms of rating outcomes of feet in group III.Conclusion: Although a larger number of casts and longer duration are needed forcorrection the rigid deformity, our results demonstrated that Ponseti method was a goodchoice for treating the clubfoot relapsed from posterior or posteromedial release. It helpsto preserve the soft tissue and avoid the even worsened stiffness from the repeated softtissue releasing procedures as those in the conventional regimen. However, restoration ofappearances of clubfeet following previously failed posterior or posteromedial release isnot equal to the recovery of functions. For objective and comprehensive functionalevaluation of relapsed or uncorrected clubfeet following a previous posterior orposteromedial release, we would recommend rating system of ICFSG. Part III. Potential mechanism for longer processes using ponseti methodand worse functional outcomes in treating clubfeet relapsed afterposteromedial release. A preliminary studyPurpose: More casts and longer duration were needed for correction the rigid clubfootrelapsed from posterior or posteromedial release using Ponseti method. With this method,the foot appearance can be corrected, however the function can not be normal. The aim ofthe study was to investigate the possible mechanism of these differences regarding treatingprocesses and functional outcomes.Methods: Two different patients with recurrent idiopathic clubfeet after failed surgeriesunderwent posteromedial release surgeries. Primary fibroblast cells were established fromcontracted tissues obtained from medial aspects of talonavicular joint and plantar surfacesof calcaneocuboid joint. To assess the effect of static mechanical loading on expression ofcontracted-related ECM proteins and their genes such as COL1A1, COL1A2, COL3A1,α-SMA, TNC, vimentin, TGF-β1, TGF-β2and TGF-β3, fibroblasts after the third passagein culture were subjected to8h or16h of20%and48h or96h of10%static mechanicalstretching in FX-5000tension system. The appearances of endoplasmic reticulum andribosomes were studied by TEM. Two patients with idiopathic clubfeet, one treated withPonseti method in neonate and the other treated with Ponseti method after failure fromextensive surgery, were examined for obtaining the sagittal view of foot and ankle on bothT1WI and T2WI through3.0T MR exam.20layers with2mm thickness and1mm distancefor each patients. Boundaries of talus as well as distal tibia and fibula were outlinedmanually and two3D skeletal models were obtained using Mimics software version10.01.The talus of the models were dorsally rotated25°by means of dorsiflexion andplantarflexion axis of the talocrural joint. We analyzed supination on coronal plane andoutward rotation on transverse plane of the talus using Imageware software version13.2.One way analysis of variance was used for statistical analysis. SAS software version9.2(SAS Institutes, Cary, North Carolina, USA) was used for statistical analysis. The value ofp <0.05was considered significant.Results: According to real-time PCR, all genes were not down-regulated significantlyafter8h or16h of20%static mechanical stretching. But the mRNA of COL3A1andvimentin was significantly down-regulated after48h of10%static mechanical stretching and the protein of COL3A1and vimentin showed similar patterns according to westernanalysis. In addition, TEM showed the dilated endoplasmic reticulum and swellingribosomal significantly relieved after48h or96h of10%static mechanical stretching.Talocrural joint dorsiflexion and plantarflexion axis inclination of3D skeletal model I,which was reconstructed from MR images of patient received Ponseti management fromneonate, was13.9°and the axis inclination model II, which was reconstructed from MRimages of patient received Ponseti management after failed extensive surgery, was7.2°.After25°dorsally rotated, the talus of model I generated9.1°supination and4.5°outwardrotation, the talus of model II generated3.7°supination and2.7°outward rotation.Conclusion: The ECM had a higher expression of COL-III and vimentin in contractedtissues from the cases with idiopathic clubfoot, might be effectively down-regulated bylonger duration and shorter elongation static mechanical stretching. TGF-β mediatedsignaling pathway might play an important role in the down-regulation of these ECM. Thelimited ROM might be caused by the decreased inclination of dorsiflexion andplantarflexion axis of talocrural joint after failed posterior or posteromedial releasesurgery.