Subjective and Objective Outcome in Congenital Clubfoot; a Comparative Study of 204 Children

David Chesney; Simon Barker; Nicola Maffulli

BMC Musculoskelet Disord

Abstract and Background

Abstract

Background: Outcome following management of congenital talipes equinovarus (clubfoot) can be assessed in a number of ways. Bjonness stated simply that "the patient is the final judge of whether he has a good foot"; a purely subjective assessment. Others have employed objective measures. Combining subjective evaluation with a more objective assessment of movement and position of the foot, is likely to give a more comprehensive picture of the final result of clubfoot. The purpose of this study was to compare subjective and objective outcome following management of clubfoot, and evaluate sex differences in outcome.
Methods: We used a patient-administered subjective assessment of outcome following treatment of clubfoot and compared it with objective anthropometry and range of movement of the ankle to assess and compare subjective and objective outcome in clubfoot. Statistical analysis was performed using Pearson correlation coefficients. Significance was tested using Student's t-test test.
Results: Objective outcome can be assessed using length of the foot, calf circumference and range of movement at the ankle. These are easy to measure, reproducible, and correlate well with subjective outcome. Objective outcome is comparable for boys and girls. However, subjectively, female patients and their parents are less happy with the results of management of clubfoot.
Conclusion: There is a correlation between the anthropometric measures and the subjective outcome and an objective grading can be designed using foot length, calf muscle bulk and range of movement at the ankle.

Background

Although some authors believe that patients themselves are the ultimate judges of whether they have a 'good foot,^[1,2,3,4] the need to evaluate outcome of management of clubfoot has traditionally employed objective measures.^[3] Combining subjective evaluation of cosmetic acceptability with a more objective assessment of movement and position of the foot is likely to give a more comprehensive picture of the final result of clubfoot.

Objective measures to assess outcome include; range of movement at the ankle,^[3] leg and foot muscle strength,^[4] pressure distribution under the sole of the foot,^[5] calf circumference, gait,^[6] skinfold thickness, foot length, foot width,^[7] and shoe size.^[8] Radiographic assessment has also been advocated by some, with a number of measurements reported,^[9] although the use of radiographs is not universally accepted.

As far as we are aware, comparison of objective and subjective measures has, however, not been performed, hence the correlation between the two is unknown. We employed a simple patient-administered subjective assessment compared to an objective assessment using anthropometry and ankle range of movement to compare subjective and objective outcome in clubfoot.

1 2 3 4 5

Next Section

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this: Subjective and Objective Outcome in Congenital Clubfoot; a Comparative Study of 204 Children - Medscape - Jun 28, 2007.

Abstract and Background
Methods
Results
Discussion
Conclusion
References

Table 1. Questions Posed on Subjective by Postal Questionnaire
Are you satisfied with the outcome of treatment? (please choose one of the following that best describes what you think)
□ very satisfied □ satisfied □ neither satisfied or dissatisfied □ dissatisfied □ very dissatisfied
♦ Does the affected foot function well? (please choose one of the following that best describes what you think)
□ there is no limit to daily routine □ occasionally limited by strenuous exercise □ usually limited by strenuous exercise □ occasionally limited by daily routine □ walking limited
♦ Does the foot ever seem to cause pain? (please choose one of the following that best describes what you think)
□ never □ occasionally on strenuous exercise □ usually on strenuous exercise □ occasionally on routine exercise □ pain on walking

Table 1. Questions Posed on Subjective by Postal Questionnaire
Are you satisfied with the outcome of treatment? (please choose one of the following that best describes what you think)
□ very satisfied □ satisfied □ neither satisfied or dissatisfied □ dissatisfied □ very dissatisfied
♦ Does the affected foot function well? (please choose one of the following that best describes what you think)
□ there is no limit to daily routine □ occasionally limited by strenuous exercise □ usually limited by strenuous exercise □ occasionally limited by daily routine □ walking limited
♦ Does the foot ever seem to cause pain? (please choose one of the following that best describes what you think)
□ never □ occasionally on strenuous exercise □ usually on strenuous exercise □ occasionally on routine exercise □ pain on walking

Table 2. Gamma Correlation for Inter-observer Variation
	Gamma correlation	Standard error	P value
Calf circumference	0.93	0.031	P < 0.001
Foot width	0.77	0.056	P < 0.001
Foot length	0.95	0.024	P < 0.001

Table 3. Pearson Correlation Coefficients for Anthropometric Measures From the Unaffected Feet, Correlated With Height
	Height	Foot length	Foot Width	Calf circumference
Height	1	0.976**	0.857**	0.876**
Foot length		1	0.386**	0.868**
Foot width			1	0.112
Calf circumference				1

n = 69 feet
** significant at the 0.01 level

Table 3. Pearson Correlation Coefficients for Anthropometric Measures From the Unaffected Feet, Correlated With Height
	Height	Foot length	Foot Width	Calf circumference
Height	1	0.976**	0.857**	0.876**
Foot length		1	0.386**	0.868**
Foot width			1	0.112
Calf circumference				1

n = 69 feet
** significant at the 0.01 level

Table 4. Correlation Between Objective and Subjective Measures of Outcome for Children With Unilateral CTEV
	Satisfaction	Function	Pain	Total
Circumference	0.056	0.289*	0.272*	.271*
Skin fold	-0.070	-0.070	0.125	-0.012
Foot length	0.289*	-0.040	-0.040	-0.102
Foot width	0.201	0.201	-0.052	0.035

n = 65 feet
* correlation significant at 0.05 level

Table 5. Correlation Between Objective and Subjective Measures of Outcome for Children With Bilateral CTEV
	Function	Pain	Satisfaction	Total
Circumference	.254*	.260**	-.155	.189
Fold	.010	.041	-.050	-.004
Length	.050	.124	.256**	.009
Width	.059	.226*	-.252**	.061

n = 193 feet
** correlate at .01 level
* correlate at .05 level

Table 6. Correlation Between Objective and Subjective Measures of Outcome for All Children With CTEV
	Function	Pain	Satisfaction	Total
Length	-.017	.025	-.198*	-.044
Width	.109	.125	-.227**	.05
Circumference	.256**	.260**	-.091	.210**
Fold	.007	.054	-.028	.011

n = 258 feet
** correlate at .01 level
* correlate at .05 level

Table 6. Correlation Between Objective and Subjective Measures of Outcome for All Children With CTEV
	Function	Pain	Satisfaction	Total
Length	-.017	.025	-.198*	-.044
Width	.109	.125	-.227**	.05
Circumference	.256**	.260**	-.091	.210**
Fold	.007	.054	-.028	.011

n = 258 feet
** correlate at .01 level
* correlate at .05 level

Table 7. Inter- and Intra-observer Variation for Ankle Range of Movement
Interobserver variation	Mean	2.9°
Interobserver variation	Standard deviation	2.2°
Intraobserver variation	Mean	3.1°
Intraobserver variation	Standard deviation	3.1°

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

Return to Article

Post as: