The foot drawing method: reliability of measuring foot length and outward rotation in children with clubfoot.

BACKGROUND: The Ponseti method is the gold standard for clubfoot treatment. However, relapse and residual gait deviations are common, and follow-up until 7 years of age is recommended. We evaluated the reliability of the foot drawing method, a new instrument for the follow-up of clubfoot. The method uses drawings of the foot in the neutral position and external rotation to measure foot length and outward rotation. METHODS: Nineteen children aged 2.5-7 years who were treated with the Ponseti method for congenital clubfoot were included. Two raters made the drawings twice (D1 and D2). Each rater measured foot length, foot rotation, and foot-tibial rotation independently (D1). Later, the raters repeated the measurements (D2). Interrater reliability was assessed using the D1 from each rater. Intrarater reliability was assessed using the measurements from each rater's D1 and D2. Bland-Altman plots were used to visualize the limits of agreement (LoA). The mean, 95% confidence interval, and one standard deviation of the differences in all measurements were calculated. RESULTS: The mean differences between and within raters were: foot length < 1 mm, foot rotation < 1°, and foot-tibia rotation < 2°, which indicated no systematic differences. The LoA for foot length were: 4.5 mm and 5.9 mm between raters for D1, - 4.8 mm and 5.9 mm for rater 1 (D1-D2), and - 5.1 mm and 5 mm for rater 2 (D1-D2). The LoA for foot rotation: were - 12° and 10.6° between raters (D1), - 8.4° and 6.6° for rater 1 (D1-D2), and - 14° and 14.1° for rater 2 (D1-D2). The LoA for foot-tibia rotation were: - 17.8° and 14.3° between raters (D1), - 12° and 12.2° for rater 1 (D1-D2), and - 12.7° and 13.6° for rater 2 (D1- D2). CONCLUSIONS: The absence of systematic differences between and within raters, and LoA observed indicate that the foot drawing method is applicable in clinical practice and research. However, the results of the foot and foot-tibia rotation analyses imply that caution is needed when interpreting changes in foot rotation in feet with higher degrees of rotation.

Development of foot length in children with congenital clubfoot up to 7 years of age: a prospective follow-up study.

BACKGROUND: Clubfeet are typically shorter than normal feet. This study aimed first to describe the development of foot length in a consecutive series of children with congenital clubfoot and second to relate foot length to development of relapse and motion quality. METHODS: Foot length was measured every 6 months in 72 consecutive children with congenital clubfoot (29 bilateral) aged from 2 to 7 years. The initial treatment was nonsurgical followed by standardized orthotic treatment. Foot length growth rate was calculated every half year. In children with unilateral clubfeet, the difference in foot length between the clubfoot and the contralateral foot was calculated. Motion quality was evaluated by the Clubfoot Assessment Protocol (CAP). Student's t test, the Mann-Whitney U test and Spearman's correlation were used for group comparisons. Bonferroni correction was used when multiple comparisons were performed. RESULTS: Clubfeet were smaller (P < 0.001) than reference feet at all ages but had a similar growth rate up to age 7. Unilateral clubfeet with greater difference in size compared with the contralateral foot at the first measurement, relapsed more frequently (P = 0.016) and correlated with poorer motion quality (r = 0.4; P = 0.011). CONCLUSIONS: As previously reported, clubfeet were smaller than reference feet at all ages. The growth rate, however, was similar between clubfeet and reference feet. Children with unilateral clubfeet and greater foot length difference at 2 years of age had a higher tendency to relapse and poorer motion quality at 7 years of age, indicating that foot length could be used as a prognostic tool.

Neurodevelopmental difficulties in children with idiopathic clubfoot.

AIM: To evaluate neurodevelopmental difficulties in children with idiopathic clubfoot. METHOD: A cross-sectional study of 106 children (29 females, 77 males; aged 8-10y) with idiopathic clubfoot and 109 age-, sex-, and residential area-parallelized children from the general population. Neurodevelopmental difficulties were assessed using the parent-report Five to Fifteen (FTF) questionnaire. Group differences were analysed for FTF domains, subdomains, and items. The 90th centile cut-off of the general population on FTF and the parent-based disease-specific instrument (DSI) were used to evaluate clinical relevance of neurodevelopmental symptoms in idiopathic clubfoot. RESULTS: Modest group differences were found for several FTF domains (motor skills, perception, and language) and subdomains (gross and fine motor skills, relation in space, comprehensive and expressive language skills). Thirty-one per cent of the children with idiopathic clubfoot scored in the clinically significant range on 2 or more FTF domains. DSI scores were lower in this subgroup. INTERPRETATION: Findings indicate a moderate and selective increase of neurodevelopmental difficulties in children with idiopathic clubfoot as a whole, especially in the areas of motor skills, perception, and language. Idiopathic clubfoot with marked neurodevelopmental symptoms are associated with less satisfaction of the clubfoot treatment. Our results recommend awareness of neurodevelopmental difficulties in the assessment and treatment of idiopathic clubfoot. WHAT THIS PAPER ADDS: A substantial minority of children with idiopathic clubfoot show neurodevelopmental difficulties. Children with idiopathic clubfoot might present additional difficulties in motor skills, perception, and language. Children with idiopathic clubfoot and marked neurodevelopmental symptoms show poorer parent-reported clubfoot treatment satisfaction. Neurodevelopmental difficulties should be considered in clinical practice of idiopathic clubfoot.

Neurodevelopmental difficulties negatively affect health-related quality of life in children with idiopathic clubfoot.

AIM: To study health-related quality of life (HRQoL) in children with idiopathic clubfoot (IC) and the influence of sex, clubfoot laterality and neurodevelopmental difficulties (NDD) on HRQoL. METHODS: A cross-sectional questionnaire-based study in Stockholm and Skåne Counties, Sweden, of 106 children with IC born 2004-2007 (mean 9.4 ± 0.6 years) and a general population sample of 109 schoolchildren (mean 9.5 ± 0.6 years). The children and their caregivers answered the EQ-5D-Y (Youth) and Five to Fifteen questionnaires to operationalise HRQoL and NDD, respectively. RESULTS: No reduced HRQoL on the EQ-5D-Y dimensions were reported by 51% of the children with IC, and 71% in the general population sample, with significant more problems in the IC sample regarding 'mobility', 'doing usual activities' and 'having pain or discomfort', despite similar overall health status. Neither sex nor clubfoot laterality affected HRQoL. Children with IC and NDD combined reported more problems in three out of five dimensions and lower overall health status compared with children with IC alone. CONCLUSION: Despite similar overall health status, children with IC had more HRQoL problems compared with the general population, being associated with coexisting NDD but not sex or clubfoot laterality.

Gross Motor Skills in Children With Idiopathic Clubfoot and the Association Between Gross Motor Skills, Foot Involvement, Gait, and Foot Motion.

BACKGROUND: Little is known regarding gross motor skills (GMS) in children with idiopathic clubfoot (IC). This study describes GMS, specifically foot involvement and asymmetries, and analyses the association between GMS, gait, and foot status in children with IC. METHODS: Gross motor tasks and gait were analyzed in children with IC and typically developed (TD) children. GMS were assessed using videotapes and the Clubfoot Assessment Protocol (CAP). The Gait Deviation Index (GDI) and GDI-Kinetic were calculated from gait analyses. Children were divided into bilateral, unilateral clubfoot, or TD groups. To analyze asymmetries, feet within each group were further classified into superior or inferior foot, depending on their CAP scores. Correlations identified associations between CAP and GDI, GDI-Kinetic, passive foot motion, and Dimeglio Classification Scores at birth in the clubfeet. RESULTS: In total, 75 children (mean age, 5 years) were enrolled (bilateral n=22, unilateral clubfoot n=25, TD=28). Children with clubfeet demonstrated significantly lower GMS, gait, and foot motion compared with TD children. One leg standing and hopping deviated in 84% and 91%, respectively, in at least one foot in children with clubfoot. Gross motor asymmetries were evident in both children with bilateral and unilateral involvement. In children with unilateral clubfoot, contralateral feet showed few deviations in GMS compared with TD; however, differences existed in gait and foot motion. The association between GMS and gait, foot motion, and initial foot status varied between poor and moderate. CONCLUSIONS: Gross motor deficits and asymmetries are present in children with both bilateral and unilateral IC. Development of GMS of the contralateral foot mirrors that of TD children, but modifies to the clubfoot in gait and foot motion. The weak association with gait, foot motion, and initial clubfoot severity indicates that gross motor measurements represent a different outcome entity in clubfoot treatment. We therefore, recommend gross motor task evaluation for children with IC. LEVEL OF EVIDENCE: Level II-prognostic studies.

Gait in 5-year-old children with idiopathic clubfoot: A cohort study of 59 children, focusing on foot involvement and the contralateral foot.

Background and purpose - Idiopathic clubfoot can be bilateral or unilateral; however, most studies of gait have assessed clubfoot cases as one uniform group. The contralateral foot in children with unilateral clubfoot has shown deviations in pedobarographic measurements, but it is seldom included in studies of gait. We evaluated gait in children with idiopathic clubfoot, concentrating on foot involvement. Patients and methods - Three-dimensional gait analyses of 59 children, mean age 5.4 years, with bilateral (n = 30) or unilateral (n = 29) idiopathic clubfoot were stratified into groups of bilateral, unilateral, or contralateral feet. Age-matched controls (n = 28) were evaluated for comparison. Gait assessment included: (1) discrete kinematic and kinetic parameters, and (2) gait deviation index for kinematics (GDI) and kinetics (GDI-k). Results - No differences in gait were found between bilateral and unilateral idiopathic clubfoot, but both groups deviated when compared to controls. Compared to control feet, contralateral feet showed no deviations in discrete gait parameters, but discrepancies were evident in relation to unilateral clubfoot, causing gait asymmetries in children with unilateral involvement. However, all groups deviated significantly from control feet according to GDI and GDI-k. Interpretation - Bilateral and unilateral idiopathic clubfoot cases show the same persistent deviations in gait, mainly regarding reduced plantarflexion. Nevertheless, knowledge of foot involvement is important as children with unilateral clubfoot show gait asymmetries, which might give an impression of poorer deviations. The results of GDI/GDI-k indicate global gait adaptations of the contralateral foot, so the foot should preferably not be used as a reference for gait.

Epidemiology of clubfoot in Sweden from 2016 to 2019: A national register study.

BACKGROUND: This study aimed to estimate the birth prevalence of children born with isolated or non-isolated clubfoot in Sweden using a national clubfoot register. Secondarily we aimed to describe the clubfoot population with respect to sex, laterality, severity of deformity, comorbidity and geographic location. METHODS: A national register, the Swedish Pediatric Orthopedic Quality register, was used to extract data on newborn children with clubfoot. To calculate the birth prevalence of children with isolated or non-isolated clubfoot between 1st of January 2016 and 31st of December 2019, we used official reports of the total number of Swedish live births from the Swedish Board of Statistics. The Pirani score and predefined signs of atypical clubfoot were used to classify clubfoot severity at birth. RESULTS: In total 612 children with clubfoot were identified. Of these, 564 were children with isolated clubfoot, generating a birth prevalence of 1.24/1000 live births (95% confidence interval 1.15-1.35). About 8% were children with non-isolated clubfoot, increasing the birth prevalence to 1.35/1000 live births (95% confidence interval 1.25-1.46). Of the children with isolated clubfoot, 74% were boys and 47% had bilateral involvement. The children with non-isolated clubfoot had more severe foot deformities at birth and a greater proportion of clubfeet with atypical signs compared with children with isolated clubfoot. CONCLUSION: We have established the birth prevalence of children born with isolated or non-isolated clubfoot in Sweden based on data from a national register. Moreover, we have estimated the number of children born with atypical clubfeet in instances of both isolated and non-isolated clubfoot. These numbers may serve as a baseline for expected birth prevalence when planning clubfoot treatment and when evaluating time trends of children born with clubfoot.

Motor ability in children treated for idiopathic clubfoot. A controlled pilot study.

BACKGROUND: To study motor ability at seven years of age in children treated for idiopathic clubfoot and its relation to clubfoot laterality, foot status and the amount of surgery performed. METHODS: Twenty children (mean age 7.5 years, SD 3.2 months) from a consecutive birth cohort from our hospital catchments area (300.000 inhabitants from southern Sweden) were assessed with the Movement Assessment Battery for Children (MABC) and the Clubfoot Assessment Protocol (CAP). RESULTS: Compared to typically developing children an increased prevalence of motor impairment was found regarding both the total score for MABC (p < 0.05) and the subtest ABC-Ball skills (p < 0.05). No relationship was found between the child's actual foot status, laterality or the extent of foot surgery with the motor ability as measured with MABC. Only the CAP item "one-leg stand" correlated significantly with the MABC (rs = -0.53, p = 0.02). CONCLUSIONS: Children with idiopathic clubfoot appear to have an increased risk of motor activity limitations and it is possible that other factors, independent of the clinical status, might be involved. The ability to keep balance on one leg may be a sufficient tool for determining which children in the orthopedic setting should be more thoroughly evaluated regarding their neuromotor functioning.

Correlations between the Gait Profile Score and standard clinical outcome measures in children with idiopathic clubfoot.

BACKGROUND: Measures of overall gait deviations such as the Gait Profile Score (GPS) and the Gait Variable Score (GVS) are used to evaluate gait in clinical practice and for research purposes. In the clinical setting, gait deviations are often visually assessed and classified using structured protocols such as the Clubfoot Assessment Protocol (CAP). RESEARCH QUESTION: Determine the relationship between measures of overall gait deviations and clinical assessments. METHODS: This cross-sectional study evaluated the usability of GPS and GVS in children with idiopathic clubfoot. Twenty consecutively born children with idiopathic clubfoot participated in this study. At 7 years of age, the children were referred for three-dimensional gait analysis and, on the same day, they also underwent a clinical examination according to the CAP. RESULTS: The overall gait deviations, expressed as the GPS (overall and affected side) and the GVS for nine key variables were calculated. The correlations between the GPS and values from CAP, its domains, and a single item called walking and between the item walking and the GVS values were analyzed using the Spearman's rank correlation coefficient (rs). The item walking correlated significantly with the GPS (rs = -0.62), and the GVS for foot progression (rs = -0.61) and foot dorsiflexion/plantarflexion (rs = -0.50). The domain "morphology" correlated with the GPS (rs = 0.64). SIGNIFICANCE: These findings indicate that the GPS index along with the GVS reflects gait deviations observed clinically in children with clubfoot.

Comparison of serial casting and stretching technique in children with congenital idiopathic clubfoot: evaluation of a new assessment system.

BACKGROUND AND PURPOSE: The outcome of clubfoot treatment is the result of several factors such as severity, type of treatment, and measurement instruments. We compared two intervention groups with two assessment procedures. PATIENTS AND METHODS: 16 children were treated consecutively with intensive stretching according to the Copenhagen method and 16 children consecutively with casting according to the Ponseti technique, during their first 2 months of age. The need for surgery was then assessed. At 4 months of age, all children used a dynamic Knee Ankle Foot Orthosis. The Clubfoot Assessment Protocol (CAP) and the Dimeglio Classification System (DCS) were used and compared during treatment and at 2 years of age. RESULTS: According to the CAP (but not the DCS) the casting technique was superior in clubfoot correction, apparent as better mobility and better quality of motion at 2 years of age. These children also required less surgery. The orthotics management functioned well in both groups, with high compliance and maintenance or slight improvement of the clinical status except for morphology. DCS score changed over time but not between the groups. Because of its multidimensional and narrower scoring interval construct, the CAP enabled us to elucidate and evaluate different clinical functions. INTERPRETATION: The casting technique according to Ponseti seems to be the better of the two for clubfoot correction, regarding mobility and quality of motion. The Clubfoot Assessment Protocol (but not the Dimeglio Classification System) was able to reveal differences between the Copenhagen and Ponseti treatment methods.

Validity and responsiveness of the Clubfoot Assessment Protocol (CAP). A methodological study.

BACKGROUND: The Clubfoot Assessment Protocol (CAP) is a multi dimensional instrument designed for longitudinal follow up of the clubfoot deformity during growth. Item reliability has shown to be sufficient. In this article the CAP's validity and responsiveness is studied using the Dimeglio classification scoring as a gold standard. METHODS: Thirty-two children with 45 congenital clubfeet were assessed prospectively and consecutively at ages of new-born, one, two, four months and two years of age. For convergent/divergent construct validity the Spearman's correlation coefficients were calculated. Discriminate validity was evaluated by studying the scores in bilateral clubfeet. The floor-ceiling effects at baseline (untreated clubfeet) and at two years of age (treated clubfeet) were evaluated. Responsiveness was evaluated by using effect sizes (ES) and by calculating if significant changes (Wilcoxons signed test) had occurred between the different measurement occasions. RESULTS: High to moderate significant correlation were found between CAP mobility I and morphology and the Dimeglio scores (rs = 0.77 and 0.44 respectively). Low correlation was found between CAP muscle function, mobility II and motion quality and the Dimeglio scoring system (rs = 0.20, 0.09 and 0.06 respectively). Of 13 children with bilateral clubfeet, 11 showed different CAP mobility I scores between right and left foot at baseline (untreated) compared with 5 with the Dimeglio score. At the other assessment occasions the CAP mobility I continued to show higher discrimination ability than the Dimeglio. No floor effects and low ceiling effects were found in the untreated clubfeet for both instruments. High ceiling effects were found in the CAP for the treated children and low for the Dimeglio. Responsiveness was good. ES from untreated to treated ranged from 0.80 to 4.35 for the CAP subgroups and was 4.68 for the Dimeglio. The first four treatment months, the CAP mobility I had generally higher ES compared with the Dimeglio. CONCLUSION: The Clubfoot Assessment Protocol shows in this study good validity and responsiveness. The CAP is more responsive when severity ranges between mild-moderate to severe, while the Dimeglio focuses more on the extremes. The ability to discriminate between different mobility status of the right and left foot in bilaterally affected children in this population was higher compared with the Dimeglio score implicating a better sensitivity for the CAP.

Evaluation of gait, relapse and compliance in clubfoot treatment with custom-made orthoses.

Relapse after successful initial correction of idiopathic clubfoot with the Ponseti method is often related to poor compliance with the foot abduction orthosis (FAO). The aim of this study was to evaluate treatment with custom-made dynamic orthoses. Twenty children with idiopathic clubfoot (30feet) who had been treated with dynamic orthoses after the correction phase according to the Ponseti casting technique were evaluated. Relapse rates during orthotic treatment were registered. A Vicon gait analysis system was used to measure gait parameters at the age of seven years. The overall gait quality was estimated with the Gait Deviation Index (GDI). Data were analyzed with a nested mixed model and compared with a control group of 16 healthy children. No relapse occurred during the orthotic treatment. High compliance with the orthoses was observed based on parents' self report and physiotherapist observations. Gait analysis showed decreased ankle power and moment, increased internal foot progression, decreased dorsiflexion during stance, and increased plantar flexion at initial contact compared with the control group. Hip and shank rotations were normal. No calcaneus or equinus gait was observed. The mean GDI was 89.7 (range 71.6-104). The gait analysis outcomes and frequency of relapse were comparable to those of previous studies. Internal foot progression originated primarily from the foot level and was not, as frequently found after FAO treatment, compensated by external rotation at knee or hip level. In children exhibiting poor compliance with an FAO, this dynamic model is considered an effective alternative.

The clubfoot assessment protocol (CAP); description and reliability of a structured multi-level instrument for follow-up.

BACKGROUND: In most clubfoot studies, the outcome instruments used are designed to evaluate classification or long-term cross-sectional results. Variables deal mainly with factors on body function/structure level. Wide scorings intervals and total sum scores increase the risk that important changes and information are not detected. Studies of the reliability, validity and responsiveness of these instruments are sparse. The lack of an instrument for longitudinal follow-up led the investigators to develop the Clubfoot Assessment Protocol (CAP). The aim of this article is to introduce and describe the CAP and evaluate the items inter- and intra reliability in relation to patient age. METHODS: The CAP was created from 22 items divided between body function/structure (three subgroups) and activity (one subgroup) levels according to the International Classification of Function, Disability and Health (ICF). The focus is on item and subgroup development. Two experienced examiners assessed 69 clubfeet in 48 children who had a median age of 2.1 years (range, 0 to 6.7 years). Both treated and untreated feet with different grades of severity were included. Three age groups were constructed for studying the influence of age on reliability. The intra- rater study included 32 feet in 20 children who had a median age of 2.5 years (range, 4 months to 6.8 years). The Unweighted Kappa statistics, percentage observer agreement, and amount of categories defined how reliability was to be interpreted. RESULTS: The inter-rater reliability was assessed as moderate to good for all but one item. Eighteen items had kappa values > 0.40. Three items varied from 0.35 to 0.38. The mean percentage observed agreement was 82% (range, 62 to 95%). Different age groups showed sufficient agreement. Intra- rater; all items had kappa values > 0.40 [range, 0.54 to 1.00] and a mean percentage agreement of 89.5%. Categories varied from 3 to 5. CONCLUSION: The CAP contains more detailed information than previous protocols. It is a multi-dimensional observer administered standardized measurement instrument with the focus on item and subgroup level. It can be used with sufficient reliability, independent of age, during the first seven years of childhood by examiners with good clinical experience.A few items showed low reliability, partly dependent on the child's age and /or varying professional backgrounds between the examiners. These items should be interpreted with caution, until further studies have confirmed the validity and sensitivity of the instrument.

Ultrasound assessment of early clubfoot treatment: a comparison of the Ponseti method and a modified Copenhagen method.

The purpose of this study was to sonographically compare the early anatomical outcome of a group of clubfeet treated with the Ponseti method (group A, nine clubfeet) with a group treated with an adjustable plexidur splint, the Copenhagen method (group B, 19 feet). The clinical severity was assessed using the Diméglio-Bensahel classification. The need for complementary surgery was clinically assessed at the age of about 2 months. Ultrasound investigation was made in the neonatal period, after 2-3 months of non-surgical treatment and 1-2 months post-surgically. After 2 months of non-surgical treatment the correction obtained at the talo-navicular joint, expressed as the distance between the medial malleolus and the navicular (MM-N distance), was significantly greater in group A. After surgery, tenotomy of the Achilles tendon for all group A feet, and posterior or posteriomedial release for 13 feet in group B, the correction at the talo-navicular and calcaneo-cuboid joints was similar for the two groups. Anatomical correction of the displacement in these joints can be achieved without extensive interventional procedures. Ultrasound may be a valuable tool to assess the effects of different treatment protocols quantitatively.

Walking capacity of children with clubfeet in primary school: something to worry about?

Although the main aim of clubfoot correction is to create a foot without limitations in daily activities and sport, studies on the walking capacity of children with corrected clubfeet are rare. In this cross-sectional study, the outcome of the six-minute walking test in 44 children with clubfeet (16 unilateral and 28 bilateral, mean age 8.57±2.45 years) was compared with the reference values of Geiger, clinical status measured with the Clubfoot Assessment Protocol (CAP), and regression analysis used to calculate which CAP subgroup predicts walking capacity. The mean walking capacity was decreased to 79% (P<0.001) and was not influenced by unilaterality or bilaterality (P=0.437). The subgroup CAP morphology was a significant predictor (R=0.103; P=0.034). Knowing that walking capacity is only slightly decreased can help adjust expectations and set goals for training.

Reliability and validity of motion analysis in children treated for congenital clubfoot according to the Clubfoot Assessment Protocol (CAP) using inexperienced assessors.

BACKGROUND: The Clubfoot Assessment Protocol (CAP) was developed for follow-up of children treated for clubfoot. The objective of this study was to analyze reliability and validity of the six items used in the domain CAPMotion Quality using inexperienced assessors. FINDINGS: Four raters (two paediatric orthopaedic surgeons, two senior physiotherapists) used the CAP scores to analyze, on two different occasions, 11 videotapes containing standardized recordings of motion activity according to the domain CAPMotion Quality These results were compared to a criterion (two raters, well experienced CAP assessors) for validity and for checking for learning effect.Weighted kappa statistics, exact percentage observer agreement (Po), percentage observer agreement including one level difference (Po-1) and amount of scoring scales defined how reliability was to be interpreted. Inter- and intra rater differences were calculated using median and inter quartile ranges (IQR) on item level and mean and limits of agreement on domain level.Inter-rater reliability varied between fair and moderate (kappa) and had a mean agreement of 48/88% (Po/Po-1). Intra -rater reliability varied between moderate to good with a mean agreement of 63/96%. The intra- and inter-rater differences in the present study were generally small both on item (0.00) and domain level (-1.10). There was exact agreement of 51% and Po-1 of 91% of the six items with the criterion. No learning effect was found. CONCLUSION: The CAPMotion quality can be used by inexperienced assessors with sufficient reliability in daily clinical practice and showed acceptable accuracy compared to the criterion.