A Study of Treatments of Congenital Clubfoot in Cerebral Palsy: A Systematic Review

Abstract

Category: Ankle; Other Introduction/Purpose: Cerebral palsy (CP) can lead to various foot deformities, including equinovarus, or clubfoot position. Patients with CP present a challenge when treating clubfoot as there is aberrant muscle tone and motor dysfunction. Many interventions with variable outcomes are available for patients with clubfoot and cerebral palsy, however, no studies exist that compare existing treatments and outcome measures. The purpose of this study is to investigate the existing body of evidence surrounding the treatments and outcomes of clubfoot in cerebral palsy by way of a systematic review. Methods: Using PRISMA guidelines a comprehensive search was conducted of PubMed, Cochrane, CINAHL, Scopus, and Web of Science. Publications were collected which represent all available literature on clubfoot. Articles were screened at the title, abstract, and then full-text level. Only articles that detailed the treatment of pediatric patients with clubfoot, CP, and contained three or more human subjects were included. Publications were excluded from further screening if they were found to be duplicate articles, historical reviews, professional opinions, case reports, or if subjects were non-human. At each level of screening, articles were screened by two independent reviewers to verify that each paper met the predetermined inclusion criteria. Following this, data extraction from primary sources was conducted for; number of patients, age of patients, follow-up length, treatment modality applied, and outcome measures. T-tests were performed using SAS statistical software to determine the relationship between age and type of intervention. Results: An initial search yielded 6,469 articles, after review and cross selection, 32 remained as shown in Table 1. Of these, 53.13% (n=17) articles documented surgical tibial tendon transfer (TT): anterior TT (n=5) (mean-age 10.12 +-3.40yrs), posterior TT (n=12) (mean-age 9.30 +-2.57yrs). Botox & casting was referenced in 15.63% (n=5) articles (mean age 5.34 +-1.21yrs), lengthening of tendon or muscle procedures 12.50% (n=4) (mean age 6.30 +-1.69yrs), botox alone 12.50% (n=4) (mean age 6.83 +-1.72yrs), and osteotomy 6.25% (n=2) (mean age 10.94 +-1.51yrs). There was a difference in age for patients receiving TT versus those receiving botox & casting (9.54+-2.75 years old vs 5.34 +-1.21yrs years, p<.05). Conclusion: These results indicate the preferred modality of clubfoot correction in the setting of cerebral palsy is tibial transfer. The average age of patients receiving surgical treatments was higher than those with casting, Botox, or orthotics. Due to a lack of standardized outcome measurements reported across studies, we recommend further research aimed specifically at evaluating intervention selection based on patient desired functional outcomes.