Follow-up of children with congenital clubfoot. Development of a new evaluation instrument.

Abstract

Clubfoot is a congenital disorder, affecting about one of 1000 children. Treatment consists of initial correction of the deformity, followed by prolonged orthosis treatment to maintain the correction obtained. There are several different treatment options. Outcome studies, using reliable and valid instruments are rare. In this thesis an assessment instrument, Clubfoot Assessment Protocol (CAP) was developed for longitudinal follow up of children with clubfoot. The CAP provides information on the development of different functional domains (mobility, muscle function, morphology and motion quality) over time. The reliability, validity, responsiveness and clinical utility was analysed in a prospective sample of 73 consecutive children. The clinical utility was analysed by comparing Ponseti casting technique vs Copenhagen stretching method and by studying developmental motor problems in children born with clubfoot. The methodological studies showed that the CAP can be used with sufficient reliability and validity. For research purposes, experience of the CAP and data on actual inter observer differences should be described. The CAP showed a stronger ability to discriminate foot status than the Dimeglio Classification system (DCS). The CAP is more sensitive to change especially in the moderate to severe range. Thus, the CAP is an important contribution to clubfoot evaluation in clinical and in research settings. The casting technique according to Ponseti was superior in clubfoot correction regarding mobility and motion quality according to the CAP at age two years. Furthermore, less surgery was needed. The orthosis management showed maintenance or slight improvement of the clinical status along with good compliance. Developmental motor ability problems were found more often than expected among seven year old children treated for idiopathic clubfoot. This finding could not be explained by previous surgery or foot function. The ability to stand on one leg correlated strongest to motor problems and could serve as a screening test in clinical settings of clubfoot evaluation