Treatment of Complicated Clubfoot Using External Fixation: A Scoping Review

Abstract

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: The treatment of relapsed, resistant, or neglected clubfoot presents a challenge — some patients may not respond to the traditional Ponseti method. Studies involving gradual distraction using external fixators for treatment of these cases have been performed, but no systematic review has been conducted on the subject. Methods: A comprehensive search was conducted of PubMed, Cochrane, CINAHL, Scopus, and Web of Science according to PRISMA guidelines. Only articles that pertained to the treatment of pediatric patients with clubfoot using external fixation and contained three or more human subjects were included. Reviews, professional opinions, and studies with non-human subjects were excluded. Results: Of 6,469 articles generated from the initial search, 25 met inclusion criteria. 609 total feet (490 total patients) were included, and 533 of these feet (445 patients) were treated with external fixation. The mean age of patients was 8.5 [2-18] years with a mean follow-up length of 40.9 [5-126] months. 21 (84%) studies used the Ilizarov apparatus, two used Joshi’s external stabilization system, and one used the Taylor spatial frame. The most reported primary scoring systems were the 60-point International Clubfoot Study Group (ICFSG) score (20%), Dimeglio classification (12%), Pirani score (8%), and Reinker and Carpenter scales (8%). All but one study found significantly improved primary outcomes for the majority of respective patients. Conclusion: External fixation, which may or may not include open surgery, is a promising intervention for neglected or relapsed clubfoot. However, encouraging more standardized outcome measurements would allow for more thorough comparisons between studies.