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Old 22nd April 2009, 03:36 PM
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Default Re: Ponsetti Method for clubfoot

What proportion of patients need extensive surgery after failure of the Ponseti technique for clubfoot?
Willis RB, Al-Hunaishel M, Guerra L, Kontio K.
Clin Orthop Relat Res. 2009 May;467(5):1294-7.
In 1948, Professor Ignacio Ponseti began a nonoperative management form of treatment for severe talipes equinovarus. This method of manipulative treatment became attractive because long-term outcomes demonstrated the majority of feet were pain-free, plantigrade, and functioning at a high level of activity without evidence of degenerative arthrosis. We retrospectively reviewed the charts of 51 children (31 boys and 20 girls; 72 feet) with idiopathic clubfeet deformity treated with the Ponseti method from January 5, 2002, to January 5, 2007. The median age at treatment was 2 weeks (95% confidence limit, 1-2 weeks); there was no difference in age at presentation between boys and girls. The minimum followup was 4 months (mean, 19.8 months; range, 4-48 months). A total of 288 casts were applied (mean, 5.5; standard deviation, 0.92). Successful treatment was defined as a plantigrade foot with a normal hindfoot, midfoot, and forefoot on clinical examination. Correction was achieved and maintained in 90% (65 of 72) of the feet; 10% (seven of 72) of the treated feet did not improve and needed subsequent surgery. There was no difference in the proportion of children who had tenotomy or previous treatment among those who presented with residual deformity or recurrence or had surgery. However, patients who tolerated bracing had lower recurrence rates and underwent less surgery
Is it possible to treat recurrent clubfoot with the Ponseti technique after posteromedial release?: a preliminary study.
Nogueira MP, Ey Batlle AM, Alves CG.
Clin Orthop Relat Res. 2009 May;467(5):1298-305.
The Ponseti technique for treating clubfoot has been popularized for idiopathic clubfoot and more recently several syndromic causes of clubfoot. We asked whether it could be used to treat recurrent clubfoot following failed posteromedial release. We retrospectively reviewed 58 children (83 clubfeet) treated by the Ponseti technique for recurrent deformity after posteromedial release in three centers. The minimum followup was 24 months (average, 45 months; range, 24-80 months). We determined initial and final Pirani scores and range of motion of the ankle and subtalar joint. Plantigrade and fully corrected feet were obtained in 71 feet (86%); 11 feet obtained partial correction; one patient failed treatment and underwent another posteromedial release. Recurrences occurred in nine patients (12 feet or 14%). Initial Pirani scores improved in all but one patient; severity of deformity was also inferred by number of casts used for treatment. The age at treatment and numbers of casts did not influence the scores of Pirani et al. The scores were similar among the three orthopaedic surgeons
Correction of arthrogrypotic clubfoot with a modified Ponseti technique.
van Bosse HJ, Marangoz S, Lehman WB, Sala DA.
Clin Orthop Relat Res. 2009 May;467(5):1283-93.
Surgical releases for arthrogrypotic clubfeet have high recurrence rates, require further surgery, and result in short, painful feet. We asked whether a modified Ponseti technique could achieve plantigrade, braceable feet. Ten patients (mean age, 16.2 months; range, 3-40 months), with 19 arthrogrypotic clubfeet, underwent an initial percutaneous Achilles tenotomy to unlock the calcaneus from the posterior tibia followed by weekly Ponseti-style casts. A second percutaneous Achilles tenotomy was performed in 53%. Mean number of casts was 7.7 (range, 4-12). From pretreatment to completion of initial series of casts, mean scores of Dimeglio et al. improved from 16 to 5 (ranges, 12-18 and 2-9, respectively), Catterall scores (as modified by Pirani and colleagues) from 4.8 to 0.9 (ranges, 1.5-6.0 and 0.0-2.0), and maximum passive dorsiflexion from -45 degrees (range, -75 degrees to -20 degrees ) to 10 degrees (range, 0 degrees to 40 degrees ). Ankle-foot orthoses maintained correction. At the minimum followup of 13 months (mean, 38.5 months; range, 13-70 months), the mean maximum dorsiflexion was 5 degrees (range, -20 degrees to 20 degrees ), two patients had posterior releases and no patient's ambulatory ability was compromised by foot shape. Arthrogrypotic clubfeet can be corrected without extensive surgery during infancy or early childhood. Limited surgery may be required as the children age.
Ponseti method: does age at the beginning of treatment make a difference?
Alves C, Escalda C, Fernandes P, Tavares D, Neves MC.
Clin Orthop Relat Res. 2009 May;467(5):1271-7.
The Ponseti method is reportedly effective for treating clubfoot in children up to 9 years of age. However, whether age at the beginning of treatment influences the rate of successful correction and the rate of relapse is unknown. We therefore retrospectively reviewed 68 consecutive children with 102 idiopathic clubfeet treated by the Ponseti technique in four Portuguese hospitals. We followed patients a minimum of 30 months (mean, 41.4 months; range, 30-61 months). The patients were divided into two groups according to their age at the beginning of treatment; Group I was younger than 6 months and Group II was older than 6 months. All feet (100%) were initially corrected and no feet required extensive surgery regardless of age at the beginning of treatment. There were no differences between Groups I and II in the number of casts, tenotomies, success in terms of rate of initial correction, rate of recurrence, and rate of tibialis anterior transference. The rate of the Ponseti method in avoiding extensive surgery was 100% in Groups I and II; relapses occurred in 8% of the feet in younger and older children
Ponseti treatment for idiopathic clubfoot: minimum 5-year followup.
Bor N, Coplan JA, Herzenberg JE.
Clin Orthop Relat Res. 2009 May;467(5):1263-70.
Ponseti clubfoot treatment has become more popular during the last decade. We reviewed the medical records of 74 consecutive infants (117 club feet) who underwent Ponseti treatment. Minimum followup was 5 years (mean, 6.3 years; range, 5-9 years). We studied age at presentation, previous treatment, the initial severity score of the Pirani scoring system, number of casts, need for Achilles tenotomy or other surgical procedures, and brace use. We measured final ankle motion and parents' perception of outcome. Late presentation and previous non-Ponseti treatment were associated with lower initial severity score, fewer casts, and less need for tenotomy. Forty-four percent of patients had poor brace use. We observed better brace use (75%) in babies who presented late for treatment. Good brace use predicted less need for extensive surgical procedures. Twenty-four (32%) babies underwent additional surgical procedures other than tenotomy, including 21% who underwent tibialis anterior tendon transfer. At followup, 89% of feet had adequate dorsiflexion (5 degrees or greater). Parents indicated high satisfaction with the treatment results. Ankle motion was not associated with parents' satisfaction. The Ponseti method is effective, even if treatment starts late or begins after failure at other centers. Brace use influenced the success of treatment.
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