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The Ponseti method of idiopathic clubfoot treatment involves a series of weekly casts, a percutaneous Achilles tenotomy if needed, followed by wearing a foot abduction orthosis (FAO). Gross motor development of children with idiopathic clubfoot has not been examined. The purposes of this study were to determine the ages of achievement of gross motor milestones in children with clubfoot treated with Ponseti method and to compare those ages with historical normative developmental data.
In this prospective study, 51 children with idiopathic clubfoot who had their first cast applied when ≤90 days old, were full-term with no other orthopaedic conditions or previous clubfoot treatment, and were compliant with wearing FAO were enrolled. Parents were interviewed repeatedly to acquire the ages of achievement of 8 gross motor milestones.
Fifteen children were excluded for reasons such as noncompliance with FAO, and not returning for follow-up. Thirty-six children, mean age of 15.2 days at first casting, achieved rolling prone to supine at a mean age of 5.1 months, rolling supine to prone at 5.1 months, sitting without support at 6.6 months, crawling on stomach at 7.1 months, crawling on hands and knees at 8.6 months, pull-to-stand at 9.0 months, cruising at 10.2 months, and ambulating independently at 13.9 months. When compared with previously published values for unaffected children, the mean ages of achievement for 6 of 8 milestones were significantly greater (P<0.05) for the children with clubfoot. The preambulatory milestones were achieved from 0.7 to 1.5 months later and independent ambulation up to 2.2 months later. Fifty percent of children with clubfoot were ambulating at 13.8 months; 90% at 17.7 months.
Minimal delays in gross motor milestone achievement were found in children with idiopathic clubfoot treated with the Ponseti method. Delays were, at most, 1.5 months, except for independent ambulation, which was approximately 2 months. These findings should enable pediatric clinicians to alleviate the concerns of parents of children with idiopathic clubfoot regarding gross motor milestone achievement.
PURPOSE OF THE STUDY To assess outcomes of the Ponseti method for treatment of talipes equinovarus in relation to patient age at its start.
MATERIAL AND METHODS In the 2006-2010 period, 115 children (163 feet) with talipes equinovarus were treated using the principles of Ponseti. The right foot was affected in 44, the left foot in 23, and the bilateral form was treated in 48 patients. In order to obtain results for at least 3 years of follow-up, we included the patients treated by the Ponseti method between 2006 and 2008, in whom 83 affected feet were analysed (23 isolated right feet, 14 left feet, 23 bilateral forms). According to the Dimeglio scoring system used to assess the severity of clubfoot deformity, there were four feet in group II, 37 feet in group III and 42 feet in group IV.
RESULTS Subtalar release was performed in 29 feet (34.9%), in two feet being only posterior. Moreover, foot deviations, e.g. adduction of the forefoot less than 10° (5 feet, 6%), varus deformity of the heel less than 5° (6 feet, 7.2%), and failure to complete the Ponseti treatment (3 feet, 3.6%) were recorded. For assessment of the effect of age at start of casting on the outcome, two patient subgroup were distinguished: group 1, the treatment stared and continued in the first 8 postnatal weeks; group 2, the treatment was initiated and carried out between 9 and 20 weeks postnatally. Subsequently, subtalar release was performed in 18 of 61 feet (29.5%) in group 1, and in 11 of 21 feet (52.4 %) in group 2. Using Fischer's exact test, the difference was found statistically significant. (p<0.05). Of the three patients with an unfinished course of initial treatment, two underwent subtalar release later and one was lost to follow-up.
DISCUSSSION Contrary to many recent reports, the frequency of Ponseti treatment failure in this study is substantially higher. Nevertheless, we adhered strictly to the Ponseti protocol of treatment, tenotomy was performed under general anaesthesia and Ponseti splinting was maintained properly in all but seven patients (8.4%).
CONCLUSIONS Irrespective of rather frequent failure of the initial Ponseti treatment, its contribution for the patient is beneficial as it can reduce the extent of subtalar release required. However, a modern family will hardly accept several years of applying splints every night, irrespective of maximally sophisticated bracing. This becomes critical usually at the age when the child starts walking. Nowadays, families cooperate quite well due to the fact that a new method with high mass-media coverage has been offered to them. Key words: talipes equinovarus congenitus, Ponseti treatment, follow-up, critical analysis, failure of Ponseti treatment.
The purpose of this paper is to present the experience of the hospital using the Ponseti method in patients with congenital adduct clubfoot.
Material and methods: The study was conducted between January 2007 and December 2009. Children of both sexes were included; the Dimeglio classification was applied before surgery and their course was later assessed with the Simons scale when they resumed gait. Patients with postural clubfoot (Dimeglio I) and those with neuromuscular disease (Dimeglio IV) were excluded. Casts were placed as of 15 days of age using the Ponseti technique and then percutaneous tenotomy of the calcaneous tendon was performed in the operating room.
Results: Twenty patients (9 girls, 11 boys) and 28 feet were included in the study; they were Dimeglio II (8 children) and III (12 children). Mean age at the time of surgery was 2 months, and mean age at the time of gait assessment was 2 years. Upon applying the Simons scale, 25 feet (89.3%) had satisfactory results and 3 feet (10.7%) unsatisfactory results. Two of the latter underwent percutaneous tenotomy again and in one case the cast was applied again; they evolved properly.
Conclusions: We found in our series that the Ponseti technique is appropriate as definitive treatment for Dimeglio II and III congenital adduct clubfoot.
The Ponseti method is a widely accepted and highly successful conservative treatment of pediatric clubfoot that relies on weekly manipulations and cast applications. However, the material behavior of the cast in the Ponseti technique has not been investigated. The current study sought to characterize the ability of two standard casting materials to maintain the Ponseti corrected foot position by evaluating creep response. A dynamic cast testing device (DCTD) was built to simulate a typical pediatric clubfoot. Semi-rigid fiberglass and rigid fiberglass casting materials were applied to the device, and the rotational creep was measured at various constant torques. The movement was measured using a 3D motion capture system. A 2-way ANOVA was performed on the creep displacement data at a significance level of 0.05. Among cast materials, the rotational creep displacement was found to be significantly different (p-values ≪ 0.001). The most creep displacement occurs in the semi-rigid fiberglass (approximately 1.0 degrees), then the rigid fiberglass (approximately 0.4 degrees). There was no effect of torque magnitude on the creep displacement. All materials maintained the corrected position with minimal change in position over time.
A comprehensive outcome comparison of surgical and Ponseti clubfoot treatments with reference to pediatric norms.
Church C, Coplan JA, Poljak D, Thabet AM, Kowtharapu D, Lennon N, Marchesi S, Henley J, Starr R, Mason D, Belthur MV, Herzenberg JE, Miller F. J Child Orthop. 2012 Mar;6(1):51-9.
Isolated congenital clubfoot can be treated either operatively (posteromedial release) or conservatively (Ponseti method). This study retrospectively compared mid-term outcomes after surgical and Ponseti treatments to a normal sample and used multiple evaluation techniques, such as detailed gait analysis and foot kinematics.
Twenty-six children with clubfoot treated surgically and 22 children with clubfoot treated with the Ponseti technique were evaluated retrospectively and compared to 34 children with normal feet. Comprehensive evaluation included a full gait analysis with multi-segment and single-segment foot kinematics, pedobarograph, physical examination, validated outcome questionnaires, and radiographic measurements.
The Ponseti group had significantly better plantarflexion and dorsiflexion range of motion during gait and had greater push-off power. Residual varus was present in both treatment groups, but more so in the operative group. Gait analysis also showed that the operative group had residual in-toeing, which appeared well corrected in the Ponseti group. Pedobarograph results showed that the operative group had significantly increased varus and significantly decreased medial foot pressure. The physical examination demonstrated significantly greater stiffness in the operative group in dorsiflexion, plantarflexion, ankle inversion, and midfoot abduction and adduction. Surveys showed that the Ponseti group had significantly more normal pediatric outcome data collection instrument results, disease-specific indices, and Dimeglio scores. The radiographic results suggested greater equinus and cavus and increased foot internal rotation profile in the operative group compared with the Ponseti group.
Ponseti treatment provides superior outcome to posteromedial release surgery, but residual deformity still persists.
BACKGROUND:: Results from a comparative study of Ponseti versus surgical management for congenital talipes equino varus (CTEV), using historically managed patients, are presented. No bias existed in terms of management choice or participants recruited.
METHODS:: Twenty-three surgically treated children (31 club feet; mean age 9.1 y) and 29 treated by the Ponseti technique (42 club feet; mean age 6.5 y) agreed to participate in the study. Twenty-six typically developing children (mean age 7.9 y) were also recruited as a control group. A physical examination and 3-dimensional gait analyses were carried out on all participants, and each child and his/her parent also, independently, completed the Oxford Ankle Foot Questionnaire (OxAFQ).
RESULTS:: The Ponseti group underwent fewer joint-invasive procedures than the surgical group. Passive range of dorsiflexion and plantarflexion were significantly less in the CTEV groups when compared with the control group (P<0.001), and plantarflexion was also significantly less in the surgical than in the Ponseti group (P<0.05). The bimalleolar axis was found to be significantly less in the CTEV groups than in the control group (P<0.001) and also significantly less in the surgical than in the Ponseti group (P<0.05). The gait deviation index, a gait score based on kinematics, showed a more normal gait pattern in the Ponseti group compared with the surgical group (P<0.001). The CTEV groups did not differ significantly from each other in terms of ankle sagittal and transverse plane kinematics or kinetics, but foot progression angle for the Ponseti group was external, whereas that for the surgical group was internal. The Ponseti group also scored higher than the surgical group in terms of patient satisfaction, with significantly better parent-rated OxAFQ scores in the "emotional" and "school and play" domains.
CONCLUSIONS:: The adoption of the Ponseti technique has resulted in fewer and less-invasive operations for our CTEV population, with accompanying improvement in the overall gait pattern (gait deviation index) and parent satisfaction (OxAFQ).
Objective: The purpose of this study is to evaluate the results of Ponseti technique in the management of congenital Talipes Equino Varus (CTEV) in neonatal age group.
Methods: It is a prospective observational study, conducted during the period of July 2010 to December 2011 at the Department of Pediatric Surgery in a tertiary hospital. All the neonates with CTEV were treated with Ponseti casting technique. Neonates with other congenital deformities, arthrogryposis and myelomeningocele were excluded.
Results: Total 58 CTEV feet of 38 neonates were treated. Twenty six were males and 12 were females. Thirty seven (63.8%) feet were of rigid variety and 21(36.2 %) feet were of non-rigid variety. Twenty patients had bilateral and 18 had unilateral involvement. Mean pre-treatment Pirani score of study group was 5.57. Mean number of plaster casts required per CTEV was 3.75 (range: 2-6). Thirty five rigid and 15 non-rigid (total 86.2%) feet required percutaneous tenotomy. Out of 58 feet 56 (96.6%) were managed successfully. Three (5.2%) patients developed complications like skin excoriation and blister formation. Mean post-treatment Pirani score of the study group was: 0.36 ± 0.43.
Conclusion: The Ponseti technique is an excellent, simple, effective, minimally invasive, and inexpensive procedure for the treatment CTEV deformity. Ideally it can be performed as a day case procedure without general anesthesia even in neonatal period.
Background: Although the Ponseti method has been effective in early presented clubfoot, limited information is available on the use of this method in older patients.
Methods: We prospectively followed 20 children (30 feet) with neglected idiopathic clubfoot. We sought to determine whether initial correction of the deformity (a plantigrade foot) could be achieved using the Ponseti method in untreated idiopathic clubfeet in patients presenting between the ages of 12-36 months.
Results: Older children needed more casts than younger children. Twenty-one of 30 (70%) feet needed percutaneous tendo-Achilles tenotomy for residual equinus deformity. The mean dorsiflexion after removal of the last cast was 12.5[degrees]. Six feet relapsed (20%) and were treated with recasting and tibialis anterior transfer in four feet, and two feet needed limited medial release, tendo-Achilles tenotomy, abductor hallucis tenotomy, and tibialis anterior transfer.
Conclusion: The Ponseti technique was effective in treatment of neglected clubfoot in patients between the ages of 12-36 months.
Evaluation of cast creep occurring during simulated clubfoot correction.
Cohen TL, Altiok H, Wang M, McGrady LM, Tarima S, Krzak J, Graf A, Smith PA, Harris GF. Proc Inst Mech Eng H. 2013 Apr 26.
The Ponseti method is a widely accepted and highly successful conservative treatment of pediatric clubfoot involving weekly manipulations and cast applications. Qualitative assessments have indicated the potential success of the technique with cast materials other than standard plaster of Paris. However, guidelines for clubfoot correction based on the mechanical response of these materials have yet to be investigated. The current study sought to characterize and compare the ability of three standard cast materials to maintain the Ponseti-corrected foot position by evaluating cast creep response. A dynamic cast testing device, built to model clubfoot correction, was wrapped in plaster of Paris, semi-rigid fiberglass, and rigid fiberglass. Three-dimensional motion responses to two joint stiffnesses were recorded. Rotational creep displacement and linearity of the limb-cast composite were analyzed. Minimal change in position over time was found for all materials. Among cast materials, the rotational creep displacement was significantly different (p < 0.0001). The most creep displacement occurred in the plaster of Paris (2.0°), then the semi-rigid fiberglass (1.0°), and then the rigid fiberglass (0.4°). Torque magnitude did not affect creep displacement response. Analysis of normalized rotation showed quasi-linear viscoelastic behavior. This study provided a mechanical evaluation of cast material performance as used for clubfoot correction. Creep displacement dependence on cast material and insensitivity to torque were discovered. This information may provide a quantitative and mechanical basis for future innovations for clubfoot care.