(Mentions CMT 1A) Neuromuscular disease as the cause of late clubfoot relapses:

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Neuromuscular disease as the cause of late clubfoot relapses: report

of 4 cases.

Lovell ME, Morcuende JA.

The Ponseti Center for Clubfoot Treatment, Department of

Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa

52242, USA.

Following correction with the Ponseti method some idiopathic

clubfeet still will relapse even after six years of age. A better

understanding of the cause for these late relapses will greatly help

in the management of this condition. We evaluated a consecutive case-

series from 1948 through December 1984 including 209 patients (321

clubfeet). Patients were treated following the Ponseti method.

Initial number of casts, age at relapse, neurological evaluation,

and final treatment for the late-relapses were recorded. There were

12 patients (6%) having a relapse after the seventh birthday. In 4

of these patients (6 clubfeet) a neuromuscular disease was

diagnosed, representing 33% of the late relapses. These patients

were initially treated with an average of 4 casts (range: 2-6) with

2 requiring an Achilles tenotomy. Patients used the brace for an

average of 4 years. The average age at the relapse prior to the

suspicion of neuromuscular disease was 9 years (range: 8-11 years).

Two patients had family history of neuromuscular disease (myotonic

dystrophy and multiple core disease).

In the other two cases (Charcot-Marie-Tooth Disease type IA and

myasthenia gravis) neuromuscular disease was not suspected. All four

patients required an anterior tibialis transfer, three had a plantar

fasciotomy, and two had peroneus longus to brevis transfers. One

patient required a subsequent posterior tibialis transfer and

another patient a triple arthrodesis (myotonic dystrophy). In

conclusion, late relapses in patients with idiopathic clubfoot may

represent the onset of a previously undiagnosed neuromuscular

disease, and should be thoroughly evaluated.