| Congenital clubfoot(CCF)is a common birth defect and bone and joint deformity in children.The deformity consists of forefoot adduction,cavus,hindfoot varus and equinus at the ankle.By definition,the neglected congenital clubfoot(NCCF)is a CCF that has not received any treatment by the time the child starts to walk,which is common in undeveloped areas and seriously affects the appearance and function of the foot.Ponseti treatment is a minimally invasive method,consists of a series of manipulations and longleg casts followed by foot abduction orthosis use.It is mainly used in the patients presenting with CCF at younger than 1 year of age.The traditional treatment of NCCF is surgery,including various soft tissue releases,different bony osteotomies,or even different types of external fixators.These procedures have the disadvantages of high medical costs,stiff feet and high recurrence rate.In recent years,Ponseti method has been gradually used in the treatment of NCCF and achieved satisfactory results.However,after deformity correction,patients with NCCF still have risk of recurrence.At present,the treatment outcomes for NCCF were assessed mainly by clinical and functional examinations using scores and questionnaires,and it is difficult to achieve objective and quantitative evaluation in the state of motion.Plantar pressure analysis can provide dynamic loading information during the rollover process and is widely used in the assessment and diagnosis of walking-related diseases.However,no studies to date have reported the application of plantar pressure analysis in evaluating the treatment outcome and predicting recurrence in patients with NCCF after Ponseti treatment.In this study,plantar pressure analysis was used in the long-term follow-up of patients with NCCF following Ponseti treatment.Plantar pressure tests were performed on three occasions:after the first Ponseti treatment,before and after the treatment of recurrence.The treatment outcomes were evaluated objectively,dynamically and quantitatively,which provided a biomechanical foundation for the selection and adjustment of the treatment protocols.At the same time,the plantar pressure parameters which can predict the recurrence of deformities were screened and validated,providing valuable biomechanical information for the early detection and intervention of deformity recurrence.1.Plantar pressure analysis in patients with unilateral NCCF after the first Ponseti treatmentObjective:This study was designed to investigate the plantar pressure distribution in patients with NCCF after the first Ponseti treatment,to evaluate the treatment outcomes and to explore the clinical factors affecting the plantar pressure distribution,so as to provide biomechanical evidence for the adjustment of treatment protocols.Methods:(1)Clinical and functional examinations were performed in 29 patients with unilateral NCCF following Ponseti treatment;(2)Plantar pressure tests were conducted using a Footscan~?pressure plate for the patients with NCCF and control group,and the percentage of contact time(CT%),percentage of contact area(CA%),peak pressure(PP)and pressure-time integral(PTI)data were collected in 10 masked zones of the foot;(3)the data of unaffected side,affected side and control group were compared to describe the characteristics of plantar pressure distribution;(4)NCCF patients were grouped according to the pretreatment severity of deformity factors in Dimeglio score and subgroup analysis of plantar pressure outcomes were performed to find out the clinical factors affecting the plantar pressure distribution.Results:Dimeglio scores of patients with NCCF were improved significantly after the Ponseti treatment.The results of plantar pressure analysis showed that compared with the control group,the affected side had a significantly higher CT%,CA%,PP and PTI in the fifth metatarsal(M5)and midfoot(MF)zones,while PP and PTI in the first metatarsal(M1),second metatarsal(M2)and medial hindfoot(MH)zones decreased significantly.Compared with the unaffected side and the control group,the affected side showed a higher proportion of inward foot progression angle(FPA).Compared with the control group,the unaffected side also showed significant differences in some plantar pressure parameters.Subgroup analysis showed that PP in M5 zone of the affected side in severe group of adduction deformity and PP in MF zone of the affected side in severe group of varus deformity were significantly higher than those in mild to moderate group and control group.Conclusion:Although satisfactory clinical outcomes have been achieved in patients with unilateral NCCF following the first Ponseti treatment,the plantar pressure distribution still has not returned to normal level.For patients with severe deformity of forefoot adduction and hindfoot varus,intensive correction of the deformity should be carried out during the Ponseti treatment to reduce the load on the lateral forefoot and lateral midfoot.2.Predictive plantar pressure parameters for recurrence in patients with unilateral NCCF following the first Ponseti treatmentObjective:To study the recurrence rate in patients with NCCF after the first Ponseti treatment,and to find out the predictive plantar pressure parameters for recurrence by analyzing the clinical characteristics and plantar pressure data of the patients collected after the first Ponseti treatment.Methods:(1)The recurrence rate in 29 patients with NCCF after Ponseti treatment was determined and the plantar pressure parameters,brace compliance,initial severity of the deformity,level of parents’education,sex,laterality,gestational age,family income and other information were retrospectively analyzed;(2)ROC curves were drawn for each parameter,and Kaplan-Meier survival analysis was used to draw survival curve for the predictive parameters for recurrence;(3)Single factor Logistic regression analysis was used to calculate the relative effect of each parameter on recurrence.Results:Average follow-up period was 63.8 months and recurrence was seen in 7 of29 patients with NCCF.Controlling for all other variables in the analysis,the odds of recurrence in patients with poor brace compliance were 15.8 times as much as that of patients with good brace compliance.The odds of recurrence in patients with very severe deformity were 12.9 times as much as that of patients with moderate to severe deformity.The predictive plantar pressure parameter for recurrence is the difference of the contact time%between the two feet(DCT%)in MF zone.When the CT%of the affected side was more than 20.69 percent higher than that of the unaffected side,the odds of recurrence increased by 8.5 times.In addition,the difference of the peak pressure between the two feet(DPP)in MF zone is also a predictive plantar pressure parameter.When the PP of the affected side was more than 159 percent higher than that of the unaffected side,the odds of recurrence increased by 10.5 times.Conclusion:Poor brace compliance and high initial severity are risk factors for recurrence in patients with NCCF.DCT%and DPP in MF zone can be used as plantar pressure predictors for recurrence in NCCF patients.3.Treatment options and plantar pressure analysis after recurrence of unilateral NCCFObjective:To analyze the plantar pressure distributions in patients with NCCF before and after the treatments for recurrence,so as to evaluate the treatment options and outcomes.To compare the changes of DCT%and DPP in MF zone collected at three time points(after the first Ponseti treatment,before and after the treatments for recurrence)in patients with NCCF,so as to further verify their predictive effect on recurrence.Methods:(1)Plantar pressure tests were performed for the 7 patients with unilateral NCCF before treatments for recurrence;(2)Serial manipulation and casting were performed again for patients with recurrence,and further treatment plans were made according to the treatment effects;(3)One year after the treatments for recurrence,the plantar pressure tests were conducted for the 7 recurrent patients and control group;(4)Comparisons of the plantar pressure parameters were made among the values of patients before and after the recurrent treatments and control group;(5)Comparisons of the DCT%and DPP in MF zone collected at three time points(after the first Ponseti treatment,before and after the treatments for recurrence)were made.Results:Recurrences of forefoot adduction and equinus at the ankle were found in all7 patients,and recurrences of hindfoot varus were found in 3 patients.After the casting treatment,only one patient achieved satisfactory correction and foot abduction brace was used for the following treatment.The other 6 patients underwent an anterior tibial tendon transfer(ATTT)and a concomitant Achilles tendon lengthening.All the deformities were corrected after the treatments.The results of plantar pressure analysis showed that,compared with the values collected before the recurrent treatment,the CT%,CA%,PP and PTI of the affected side increased significantly in M1 and MH zones,the CA%,PP and PTI decreased significantly in M5 zone,and the PP decreased significantly in MF zone after the treatment.Compared with the values of control group,the CA%of the affected side decreased significantly in M1 zone,the CT%increased significantly in M5 zone,the PTI increased significantly in MF zone and no significant difference was found in PP after the treatment.Compared with the values collected after the first Ponseti treatment,the DCT%and DPP in MF zone increased significantly before the recurrent treatment and the DPP in MF zone decreased significantly after the recurrent treatment.While compared with the values collected before the recurrent treatment,the DCT%and DPP in MF zone decreased significantly after the recurrent treatment.Conclusion:After Serial manipulation and casting,foot abduction brace or ATTT combined with Achilles tendon lengthening can correct recurrent deformities and significantly improve the plantar pressure distributions in recurrent patients.The changes of DCT%and DPP in MF zone after the recurrence and treatment further verify their predictive effect on recurrence.To sum up,by long-term follow-up using the plantar pressure analysis,this study made objective,dynamic and quantitative evaluations of the treatment outcomes for patients with unilateral NCCF after the Ponseti treatment.We found that although satisfactory clinical outcomes were achieved in patients with unilateral NCCF after the first Ponseti treatment,the plantar pressure distribution still has not returned to normal level,which may predict future recurrence.DCT%and DPP in MF zone can be used as plantar pressure predictors for recurrence in patients with NCCF.Combination of Ponseti treatment,ATTT and Achilles tendon lengthening can effectively correct the recurrent deformities and significantly improve the plantar pressure distributions in recurrent patients with NCCF. |
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