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Early results of the Ponseti method using the Steenbek foot abduction brace: a prospective study of 95 feet.
Bouchoucha S, Smida M, Saïed W, Safi H, Ammar C, Nessib MN, Ghachem MB. J Pediatr Orthop B. 2008 May;17(3):134-8.
The purpose of this study is to evaluate the early results of the Ponseti method and the effectiveness of the Steenbek foot abduction brace. A total of 74 patients with 110 idiopathic clubfeet were included in this prospective study. The feet were evaluated according to the Dimeglio-Bensahel classification, the Catteral-Pirani classification and the functional classification of the Hospital for Joint Diseases. Ninety-eight feet (89%) had a good result after the casting period. All the feet evaluated after the period of full-time bracing and during the period of part-time bracing showed a good correction. The Ponseti method using the Steenbek foot abduction brace is effective in correcting idiopathic clubfeet.
BACKGROUND: Popular initial treatment for congenital clubfoot includes the use of serial manipulations and casting as described by Ponseti et al. Plaster of Paris and semirigid fiberglass are 2 materials commonly used for casting. To our knowledge, no study to date has compared the clinical results of these 2 materials. The objective of this randomized prospective study was to compare the effectiveness of these materials in the initial management of clubfoot.
METHODS: All clubfeet presenting to the 2 senior authors' outpatient clinics over a 15-month period were offered enrollment. Patients were randomly assigned for treatment with either plaster or semirigid fiberglass casts. The severity of the clubfoot deformity was documented using the scoring system devised by Diméglio et al. Serial casts were applied according to the technique described by Ponseti et al. At the completion of nonsurgical treatment, the final clubfoot severity was documented.
RESULTS: A total of 42 clubfeet in 34 patients were enrolled in the study. After exclusion of 3 patients, 13 patients (16 feet) received fiberglass, and 18 patients (23 feet) received plaster casts. The mean baseline severity scores of the 2 groups were not significantly different. The mean final severity score was significantly higher in the feet treated with fiberglass than those treated with plaster (6.4 vs 4.1; P = 0.037). There was a trend toward higher scores for cast tolerance, durability, and parent satisfaction in the fiberglass group, but this did not reach significance.
CONCLUSIONS: This study supports the use of plaster casting with the Ponseti technique. The use of plaster casts resulted in a statistically lower Diméglio-Bensahel score at the completion of serial casting. There was a trend toward higher patient satisfaction in the fiberglass-treated group. Whether this difference has an effect on long-term outcomes and recurrence remains to be studied.
LEVEL OF EVIDENCE: Level II. Nonblinded randomized controlled prospective study.
Comparison of serial casting and stretching technique in children with congenital idiopathic clubfoot: evaluation of a new assessment system.
Andriesse H, Hägglund G. Acta Orthop. 2008 Feb;79(1):53-61.
BACKGROUND AND PURPOSE: The outcome of clubfoot treatment is the result of several factors such as severity, type of treatment, and measurement instruments. We compared two intervention groups with two assessment procedures.
PATIENTS AND METHODS: 16 children were treated consecutively with intensive stretching according to the Copenhagen method and 16 children consecutively with casting according to the Ponseti technique, during their first 2 months of age. The need for surgery was then assessed. At 4 months of age, all children used a dynamic Knee Ankle Foot Orthosis. The Clubfoot Assessment Protocol (CAP) and the Dimeglio Classification System (DCS) were used and compared during treatment and at 2 years of age.
RESULTS: According to the CAP (but not the DCS) the casting technique was superior in clubfoot correction, apparent as better mobility and better quality of motion at 2 years of age. These children also required less surgery. The orthotics management functioned well in both groups, with high compliance and maintenance or slight improvement of the clinical status except for morphology. DCS score changed over time but not between the groups. Because of its multidimensional and narrower scoring interval construct, the CAP enabled us to elucidate and evaluate different clinical functions.
INTERPRETATION: The casting technique according to Ponseti seems to be the better of the two for clubfoot correction, regarding mobility and quality of motion. The Clubfoot Assessment Protocol (but not the Dimeglio Classification System) was able to reveal differences between the Copenhagen and Ponseti treatment methods.
Background: Currently, clubfoot is initially treated with nonoperative methods including the Ponseti cast technique and the French functional physical therapy program. Our goal was to evaluate the function of children treated with these techniques.
Methods: We reviewed the cases of 182 patients with idiopathic clubfoot (273 feet) who were initially treated nonoperatively. Seventy-seven patients (119 feet) were excluded because they had either received a combination of nonoperative treatments or had undergone surgery prior to testing. Gait analysis was performed when the children were approximately two years of age. Temporal and kinematic data were classified as abnormal if they were more than one standard deviation from normal.
Results: Gait analysis was performed on 105 patients (fifty-six treated with casts and forty-nine treated with physical therapy) with 154 involved feet (seventy-nine treated with casts and seventy-five treated with physical therapy). These patients were an average of two years and three months of age, and their initial Diméglio scores ranged between 10 and 17. No significant differences in cadence parameters were found between the two groups. The rate of normal kinematic ankle motion in the sagittal plane was higher in the group treated with physical therapy (65% of the feet) than it was in the group treated with the Ponseti cast technique (47%) (p = 0.0317). More children treated with physical therapy walked with knee hyperextension (37% of the feet) (p < 0.0001), an equinus gait (15%) (p = 0.0051), and footdrop (19%) (p = 0.0072); only one patient treated with casts walked with an equinus gait, and only three demonstrated footdrop. In contrast, more of the patients in the cast-treatment group demonstrated excessive stance-phase dorsiflexion (48% of the feet) (p < 0.0001) and a calcaneus gait (10%). More feet in the physical therapy group had an increased internal foot progression angle (44% compared with 24% in the cast-treatment group; p = 0.0144) and increased shank-based foot rotation (73% compared with 57% in the cast-treatment group; p = 0.05).
Conclusions: While the rate of normal kinematic ankle motion in the sagittal plane was 65% in the group treated with physical therapy, the gait abnormalities that were seen in that group were characterized by mild equinus and/or footdrop. The rate of normal kinematic ankle motion in the sagittal plane was 47% in the cast-treatment group, but the most common gait abnormality in this group was mildly increased dorsiflexion in the stance phase. The rates of calcaneus gait and equinus gait were 15% in each nonoperative group. The differences between the physical therapy and cast-treatment groups may, in part, be the result of the percutaneous Achilles tendon lengthening that is performed as part of the Ponseti cast technique but not as part of the physical therapy program
Evaluation of the utility of the Ponseti method of correction of clubfoot deformity in a developing nation.
Gupta A, Singh S, Patel P, Patel J, Varshney MK. Int Orthop. 2008 Feb;32(1):75-9.
Clubfoot is the commonest congenital deformity in babies. More than 100,000 babies are born worldwide each year with congenital clubfoot. Around 80% of the cases occur in developing nations. We treated 154 feet [mean Pirani score (total) 5.57] in 96 children (78 males, 18 females) by the Ponseti method from January 2003 to December 2005. A prospective follow-up for a mean duration of 19.5 months (range 6-32 months) was undertaken. After six months of treatment the Pirani score was reduced to zero for all patients. The results show that corrective surgery, sometimes multiple, can be avoided in most cases which are usually associated with the development of a stiff, painful foot. Low socio-economic status and illiteracy prevailing in developing nations increases the prevalence of neglected clubfoot that is still harder to correct. Integration into various programs and proper use of available resources can decrease neglected clubfoot and improve chances of successful and timely correction of deformity. Bracing constitutes an important part of treatment and proper motivation and education of the parents mitigates the chances of losing correction. The Ponseti method of correcting clubfoot is especially important in developing countries, where operative facilities are not available in the remote areas and well-trained physicians and personnel can manage the cases effectively with cast treatment only.
Background: In the treatment of idiopathic clubfeet, the Ponseti method and the French functional method have been successful in reducing the need for surgery. The purpose of this prospective study was to compare the results of these two methods at one institution.
Methods: Patients under three months of age with previously untreated idiopathic clubfeet were enrolled. All feet were rated for severity prior to treatment. After both techniques had been described to them, the parents selected the treatment method. Outcomes at a minimum of two years were classified as good (a plantigrade foot with, or without, a heel-cord tenotomy), fair (a plantigrade foot that had or needed to have limited posterior release or tibialis anterior transfer), or poor (a need for a complete posteromedial surgical release). Two hundred and sixty-seven feet in 176 patients treated with the Ponseti method and 119 feet in eighty patients treated with the French functional method met the inclusion criteria.
Results: The patients were followed for an average of 4.3 years. Both groups had similar severity scores before treatment. The initial correction rates were 94.4% for the Ponseti method and 95% for the French functional method. Relapses occurred in 37% of the feet that had initially been successfully treated with the Ponseti method. One-third of the relapsed feet were salvaged with further nonoperative treatment, but the remainder required operative intervention. Relapses occurred in 29% of the feet that had been successfully treated with the French functional method, and all required operative intervention. At the time of the latest follow-up, the outcomes for the feet treated with the Ponseti method were good for 72%, fair for 12%, and poor for 16%. The outcomes for the feet treated with the French functional method were good for 67%, fair for 17%, and poor for 16%.
Conclusions: Nonoperative correction of an idiopathic clubfoot deformity can be maintained over time in most patients. Although there was a trend showing improved results with use of the Ponseti method, the difference was not significant. In our experience, parents select the Ponseti method twice as often as they select the French functional method
We have modified the Ponseti casting technique by using a below-knee Softcast instead of an above-knee plaster of Paris cast. Treatment was initiated as soon as possible after birth and the Pirani score was recorded at each visit. Following the manipulation techniques of Ponseti, a below-knee Softcast was applied directly over a stockinette for a snug fit and particular attention was paid to creating a deep groove above the heel to prevent slippage. If necessary, a percutaneous Achilles tenotomy was performed and casting continued until the child was fitted with Denis Browne abduction boots. Between April 2003 and May 2007 we treated 51 consecutive babies with 80 idiopathic club feet with a mean age at presentation of 4.5 weeks (4 days to 62 weeks). The initial mean Pirani score was 5.5 (3 to 6). It took a mean of 8.5 weeks (4 to 53) of weekly manipulation and casting to reach the stage of percutaneous Achilles tenotomy. A total of 20 feet (25%) did not require a tenotomy and for the 60 that did, the mean Pirani score at time of operation was 2.5 (0.5 to 3). Denis Browne boots were applied at a mean of 10 weeks (4 to 56) after presentation. The mean time from tenotomy to boots was 3.3 weeks (2 to 10). We experienced one case of cast-slippage during a period of non-attendance, which prolonged the casting process. One case of prolonged casting required repeated tenotomy, and three feet required repeated tenotomy and casting after relapsing while in Denis Browne boots. We believe the use of a below-knee Softcast in conjunction with Ponseti manipulation techniques shows promising initial results which are comparable to those using above-knee plaster of Paris casts.
Although the Ponseti method has been effective in patients up to 2 years old, limited information is available on the use of this method in older patients. We retrospectively reviewed the records of 171 patients (260 feet) 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 1 and 6 years. A mean of seven casts was required, and there were no differences in the number of casts between the different age groups. Two hundred fifty (95%) of the 260 feet were treated surgically for residual equinus after a plateau in casting, and procedures included percutaneous tendo-Achilles release (n = 205 [79%]), open tendo-Achilles lengthening (n = 8 [3%]), posterior release (n = 21 [8%]), and extensive soft tissue release (posteromedial release, n = 16 [6%]). The mean dorsiflexion after removal of the last cast was 12.5 degrees for the entire group and was greater in 1 year olds compared with 3 year olds. Although all patients achieved a plantigrade foot, the importance of the mild loss of passive dorsiflexion remains to be determined. An extensive soft tissue release was avoided in 94% of patients using the Ponseti method. We intend a followup study to ascertain whether the correction is maintained.
The purpose of this study was to evaluate prospectively the results of the Ponseti technique in the treatment of congenital idiopathic clubfoot, to assess the factors that influenced the results and to report the complications that occurred. Seventy one congenital idiopathic clubfeet in 45 patients were treated with serial casting performed at weekly intervals, as described by Ponseti. The mean age at presentation was 64.6 days (range: 3 to 346 days). The average follow-up period was 26.3 months (range: 24-29 months). The results were considered good when there was no residual equinus in the hindfoot, a clear valgus position of the calcaneus, no residual internal rotation in the hindfoot and a fully restorable adduction of the forefoot by slight pressure on the medial side of the first metatarsal. A residual deformity of one of these criteria was considered to be a failure and resulted in a decision for operative treatment. Correction was obtained in 43 patients (95.5%), with 2 to 10 casts, with minimal complications. In conclusion, the Ponseti method is a very safe, efficient treatment for correction of clubfeet that radically decreases the need for extensive surgery
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.
The purpose of this study was to evaluate the early results of treatment of idiopathic congenital talipes equinovarus (CTEV) by the Ponseti method and compare the results with those of other manipulation techniques and surgical treatment reported in the literature. A total of 100 patients with 156 clubfeet (80 males, 20 females), were treated for idiopathic CTEV by the Ponseti method. The average age at presentation was 4.5 months. Scoring of each foot was done according to the Pirani score. Photographs showing the deformity and podograms were taken to have an objective record against which the results were compared. The mean total Pirani score at the start of treatment was 4.26 and mean foot print angle (FPA) was 14.2 degrees . Post correction, there was a significant difference (P < .001, z = 18.638) in the mean FPA. There was also a statistically significant difference between the pre- and postcorrection Pirani scores (P < .001, z = 55.427). In 95% of the patients correction of the deformity was achieved. The Ponseti technique is based on sound understanding of the pathoanatomy of clubfoot. The good results obtained by the Ponseti technique show that posteromedial soft tissue release may no longer be required for most cases of idiopathic CTEV
Over the past 15 years, the reemergence of nonoperative treatment of clubfeet throughout the world has been profound. Two methods have been utilized-the Ponseti method and, to a lesser extent, the French functional method. Our review presents one institution's experience using both methods. Satisfactory initial correction was achieved in 95% of idiopathic clubfeet, regardless of method. However, maintenance of the correction was challenging as relapses occurred in 37% of feet treated by the Ponseti method and 29% of feet treated by the French functional method. At an average 4.3 year followup, using either method, posteromedial releases were avoided in 84% of our patients. Using gait analysis to evaluate the function of children treated with these techniques, there was no difference in cadence parameters between the two groups. More of the children treated with the French method walked with knee hyperextension, a mild equinus gait, and mild footdrop. In contrast, more of the patients in the Ponseti group demonstrated mildly increased stance-phase dorsiflexion and a calcaneus gait.
Background: Nonoperative management of clubfoot with the Ponseti method has proven to be effective, and it is the accepted initial form of treatment. Although several studies have shown that problems with compliance with the brace protocol are principally responsible for recurrence, no distinction has been made with regard to whether the distance from the site of care affects the early recurrence rate. We compared early recurrence after Ponseti treatment between rural and urban ethnically diverse North American populations to analyze whether distance from the site of care affects compliance and whether certain patient demographic characteristics predict recurrence.
Methods: One hundred consecutive infants with a total of 138 clubfeet treated with the Ponseti method were followed prospectively for at least two years from the beginning of treatment. Early recurrence, defined as the need for subsequent cast treatment or surgical treatment, and compliance, defined as strict adherence to the brace protocol described by Ponseti, were analyzed with respect to the distance from the site of care, age at presentation, number of casts needed for the initial correction, need for tenotomy, and family demographic variables.
Results: Of eighteen infants from a rural area who had early recurrence, fourteen were Native American. The families of these children, like those of all of the children with early recurrence, discontinued orthotic use earlier than was recommended by the physician. Discontinuation of orthotic use was related to recurrence, with an odds ratio of 120 (p < 0.0001), in patients living in a rural area. Native American ethnicity, unmarried parents, public or no insurance, parental education at the high-school level or less, and a family income of less than $20,000 were also significant risk factors for recurrence in patients living in a rural area. Intrinsic factors of the clubfoot deformity were not correlated with recurrence or discontinuation of bracing.
Conclusions: Compliance with the orthotic regimen after cast treatment is imperative for the Ponseti method to succeed. The striking difference in outcome in rural Native American patients as compared with the outcomes in urban Native American patients and children of other ethnicities suggests particular problems in communicating to families in this subpopulation the importance of bracing to maintain correction. An examination of communication styles suggested that these communication failures may be culturally related.
Current methods of treating congenital clubfeet provide high rates of functional outcomes. Despite the clinical outcomes, radiographic assessment suggests residual equinus deformity of the hindfoot. It is unclear whether these deformities result in abnormal foot-floor pressures and whether they correlate with clinical outcome. We evaluated 28 feet in 20 patients following Ponseti treatment for clubfoot by clinical and pedobarographic examination a mean of 33 months after removal of the last cast. The data were compared to age- and weight-matched normal subjects and to the unaffected foot in the unilaterally affected patients. Despite ankle range of motion of 30 degrees and a physiologic hindfoot valgus alignment in 19 cases, pedobarography suggested differences in maximum force, impulse, contact area, and peak pressure compared to normal subjects. Compared to the unaffected foot the only difference was reduced peak pressure over the medial hindfoot and forefoot with increased pressure over the lateral midfoot. Similar to radiographic abnormalities in studies on treated clubfeet with good functional outcome, pedobarographic analyses show differences compared to a control group. The value of pedobarographic analysis for predicting successful treatment of congenital clubfoot is questionable since it does not correlate with the clinical outcome in patients treated with the Ponseti method
The Ponseti method has become a well-established technique for the treatment of clubfoot presenting in the neonatal period. A few reports have discussed the result of this method in older age group. The purpose of this study is to present the results and clinical experience of using the Ponseti method in the treatment of idiopathic congenital talipes equinovarus in infants presented between 4 and 13 months of age with a history of failed manipulations. Thirty-two feet in 20 infants (12 males; eight females) with idiopathic congenital clubfeet were treated using the Ponseti method with minor modifications. The average age at presentation was 7 months (range from 4 to 13 months). We used the Pirani scoring system to assess the feet. After an average follow-up of 19 months, the ultimate overall results were satisfactory in 31 feet. The Pirani score improved from an average of 4.3 (range: 3-6) at presentation to a final follow-up average of 0.5 (range: 0-1). One foot had unsatisfactory result with a pretreatment score of 5.5 and a final score of 3. The results were also presented in terms of the number of casts applied, the need for tenotomy of tendo Achillis, recurrence of the deformity and the ultimate requirement for surgical release. The use of the Ponseti method in older-aged infants with idiopathic congenital clubfoot seems to be an effective method of treatment, obviating the need for extensive surgery.
Neglected clubfoot is common, disabling, and contributes to poverty in developing nations. The Ponseti clubfoot treatment has high efficacy in correcting the clubfoot deformity in ideal conditions but is demanding on parents and on developing nations' healthcare systems. Its effectiveness and the best method of care delivery remain unknown in this context. The 6-year Uganda Sustainable Clubfoot Care Project (USCCP) aims to build the Ugandan healthcare system's capacity to treat children with the Ponseti method and assess its effectiveness. We describe the Project and its achievements to date (March 2008). The Ugandan Ministry of Health has approved the Ponseti method as the preferred treatment for congenital clubfoot in all its hospitals. USCCP has trained 798 healthcare professionals to identify and treat foot deformities at birth. Ponseti clubfoot care is now available in 21 hospitals; in 2006-2007, 872 children with clubfeet were seen. USCCP-designed teaching modules on clubfoot and the Ponseti method are in use at two medical and three paramedical schools. 1152 students in various health disciplines have benefited. USCCP surveys have (1) determined the incidence of clubfoot in Uganda as 1.2 per 1000 live births, (2) gained knowledge surrounding attitudes, beliefs, and practices about clubfoot across different regions, and (3) identified barriers to adherence to Ponseti treatment protocols. USCCP is now following a cohort of treated children to evaluate its effectiveness in the Ugandan context
Multidisciplinary management of clubfeet using the Ponseti method in a district general hospital setting.
Kampa R, Binks K, Dunkley M, Coates C. J Child Orthop. 2008 Dec;2(6):463-7.
PURPOSE: Idiopathic congenital talipes equinovarus (CTEV) is a relatively common complex deformity of the foot that can be successfully managed by the Ponseti method. The purpose of this study was to see if the latter can be effectively administered by non-medical specialists outside a specialist or teaching hospital setting. METHOD: Retrospective review of 24 children (39 feet) with idiopathic congenital talipes equinovarus managed by a physiotherapist-led service in a district general hospital.
RESULTS: The median Pirani score at presentation was 4.5 (mean 4.2, range 1.5-6). The median Pirani score for feet requiring tenotomy was 6 (4.5-6), whereas feet not requiring tenotomy had a median Pirani score of 2.5 (1.5-5). A total of 18 feet (46%) underwent an Achilles tenotomy. Foot correction was achieved with an average of 3.4 (2-6) cast changes in the non-tenotomy group, and an average of 7.5 (5-13) in the tenotomy group. Successful initial correction of the deformity was achieved in 37 (95%) of the feet studied. One patient (2 feet, 5%) failed local conservative management, requiring tertiary referral. Two children (2 feet) have relapsed, requiring further serial casting. No children required open surgical release. Follow-up was for a mean of 31 months (17-50).
CONCLUSIONS: Early results suggest that a combined consultant/physiotherapist-delivered Ponseti service can be effectively and successfully administered in a district general hospital.
The Ponseti method of treatment for congenital clubfeet has gained widespread clinical acceptance. We have used manipulation, serial casting, and surgery to treat congenital clubfeet for almost 3 decades. Considering the Ponseti method of treatment to replace our traditional treatment method, we conducted a randomized, controlled trial evaluating the short-term outcome of the two treatment protocols. We evaluated foot function and applied a standardized measure of health status for children with orthopaedic problems. Nineteen patients (28 feet) were included in the trial. Nine infants (12 feet) were assigned to the Ponseti treatment group, and 10 (16 feet) were assigned to a group with initial casting and posteromedial release at the age of 6 to 8 months. The minimum followup was 3.3 years (mean, 3.5 years; range 3.3-3.8 years). Outcome measures included the Functional Rating System of Laaveg and Ponseti, the Pediatric Outcomes Data Collection Instrument (PODCI), and standardized radiographic measurements. At last followup the mean Functional Rating score was higher in the Ponseti group. Passive dorsiflexion and passive inversion-eversion were better in the Ponseti group. PODCI scales were comparable and radiographic outcome measures were similar in both groups. This trial has documented a favorable short-term outcome for the Ponseti method when compared with a traditional treatment protocol.
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
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
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.
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 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.
Background: Increasingly, the Ponseti method has been adopted worldwide as the preferred method of managing idiopathic clubfoot deformity. Following the successful implementation of the Ponseti method by orthopaedic surgeons in our institution, a clubfoot clinic was established in 2003. This clinic is directed by a physiotherapist who, using the Ponseti protocol, performs the serial cast treatment and supervises the brace management of all children with idiopathic clubfoot deformity. The purpose of this study was to compare the outcomes of physiotherapist-directed with surgeon-directed Ponseti cast treatment of idiopathic clubfeet.
Methods: We performed a retrospective cohort study of all patients with idiopathic clubfoot deformity treated from 2002 to 2006 and followed for a minimum of two years. Twenty-five children (thirty-four clubfeet) treated by surgeons were compared with ninety-five children (137 clubfeet) treated by a physiotherapist. The outcomes that were evaluated included the number of casts required, the rate of percutaneous Achilles tenotomy, the rate of recurrence, the failure rate, and the need for additional surgical procedures.
Results: At the time of presentation, the patients in the two groups were similar in terms of age, sex distribution, laterality of the clubfoot, and history of treatment. The mean duration of follow-up was thirty-four months in the physiotherapist-directed group and forty-eight months in the surgeon-directed group. No significant difference was found between the two groups with regard to the mean number of initial casts, the Achilles tenotomy rate, or the failure rate. Recurrence requiring additional treatment occurred in 14% of the feet in the physiotherapist-directed group and in 26% of the feet in the surgeon-directed group (p = 0.075). Additional procedures, including repeat Achilles tenotomy or a limited posterior or posteromedial release, were required in 6% of the feet in the physiotherapist-directed group and in 18% of those in the surgeon-directed group (p = 0.025).
Conclusions: In our institution, the Ponseti method of cast treatment of idiopathic clubfeet was as effective when it was directed by a physiotherapist as it was when it was directed by a surgeon, with fewer recurrences and a less frequent need for additional procedures in the physiotherapist-directed group. The introduction of the physiotherapist-supervised clubfoot clinic at our institution has been effective without compromising the quality of care of children with clubfoot deformity
I am a podiatry student doing a clinical placement in a rural area which also services small remote commuities. While attending a clinic in a remote community we assessed a 2 year old aboriginal boy who had been referred to podaitry by a physiotherapist with ? R) talipes equinovarus. On assessment there was a classical looking talipes equinovarus with the exception that the we could dorsiflex his ankle to the point that his toes could touch his anterior leg. We also were unable to palpate or see any sign of an achilles tendon and he severe atropy / under-development of his R) gastrocnemius / soleus muscles. Other than this he is healthy and running around the room (albeit on the lateral / dorsal aspect of his right foot) with no apparent signs of pain or discomfort.
He had been assessed by a visiting paediatrician in late 2008 & in December 2008 travelled to a tertiary paediatric hospital where he was assessed by an orthopedic surgeon with a diagnosis of ? talipes ? tibialis anterior weakness. He was sent back to his remote community for conservative care (which appears to mean do nothing) & have an orthopedic review at the tertiary facility in December 2009.
My question is should this child have been casted & then put in shoe braces (Ponsetti Method) or is it appropriate to do nothing and wait and see as has been done in this case? I appreciate that there may have been some compliance issues in this case, but I think they could have been adequately addressed in the community. I would be interested to hear from anybody who has had experience in managing talipes.
Our OT at the hospital sometimes does an aquaplast splint for positional talipes.
I guess in a remove community, even conservative care is difficult, you only need some sand to get into a plaster cast and have a wound start. While I think there is a great number of things that could be done, even with a soft cast, but the social factors are so huge. Is there a nurse always there, is there a podiatrist there 2-3 x a week, do they even want it treated?
The other, is how much it had changed in the last year. When they saw him last year, was he walking, weight bearing etc, the ortho may not have noted the extend in the 10 minute visit they are afforded in current health system. If this child's parent weren't equipped for that environment to push for treatment there is always a wait and see approach. There may also have been the discussion of casting there at the hospital but the parents wanted to go home rather than stay for 6 weeks so they just have to wait for surgery which I dare say will be booked at the next review in Dec. However with his flexibility, he may still be casted at the next review. Don't forget, unless you have that little paper that says you are ponsetti trained (here in Australia) and an ortho likes you, you will not be trusted to do ponsitti casting. You "may" be trusted to fit a dennis brown bar, maybe.
This is one of the hardest and most infuriating things about seeing complex rural patients, is the minimal amount of interventions that can be provided, and the inadequate health system setup for unemplowered patients. I understand your frustration. These are the clients that we will often try to attend the ortho appointment with to we can understand what is going on and how we can work together but we have that luxury in the community health and hospital system that is close to each other.
Cylie.... in a permanent state of confusion
The Ponseti method has proven to be successful in the treatment of idiopathic congenital talipes equinovarus (clubfoot). In particular, if plaster cast treatment as recommended by Ponseti does not show the desired correction of the foot, tarsal coalitions as a rare cause for a secondary clubfoot deformity have to be ruled out. In these cases a surgical release of the coalition in addition to the tenotomy has to be performed to achieve a satisfactory correction
BACKGROUND: The Feet for Walking clubfoot project from Australia formally introduced the Ponseti technique in Vietnam in 2004 and is based at the Da Nang Orthopedic and Rehabilitation Centre in central Vietnam.
METHODS: We provide an initial overview of the management of infant clubfoot deformity using the nonsurgical Ponseti method.
RESULTS: Early indicators of the outcome of implementing this clubfoot project are largely positive but also require ongoing review. Further analyses of the use of the Ponseti method (or obstacles preventing the same) following training of personnel is underway.
CONCLUSIONS: Recent research has improved and refined the technique that must now be both appreciated and incorporated by clinicians. This technique is used across the world in both developed and developing countries and is universally regarded as the best management method for clubfoot deformities.
PURPOSE OF THE STUDY: To provide a detailed description of the Ponseti method and report the first results of its use, including factors that played a role.
MATERIAL AND METHODS: In the 2005-2007 period, 91 patients with idiopathic rigid clubfoot (133 feet) were treated by the Ponseti method. The group comprised 62 boys and 29 girls. In most patients the Ponseti method was used as primary treatment, or by 3 months of age when previous treatment failed. In five children this treatment was started between the 3rd and 8th months of age. The result were evaluated by the criteria described by Richards et al., who distinguished four groups. The result was regarded as good when a permanent plantigrade foot was achieved (group 1). Plantigrade feet likely to require posterior release later were considered indeterminate rusults (group 2). Feet that needed posterior release, anterior tibial muscle transfer or lateral column shortening fell in the fair result group (3). Feet requiring complete subtalar release were classified as poor results (group 4). The results achieved in each year were statistically evaluated using Fisher's test (p<0.05).
RESULTS: The overall evaluation for 3 years showed good results in 70%, indeterminate in 7.5%, fair in 6.76% and poor in 15.8% of the treated feet. A detailed analysis for each year revealed that, in 2005, good results (50%) were recorded in a significantly lower number of feet than in 2006 (72.2%; p=0.032) and 2007 (93%; p<0.001). On comparison of the years 2006 and 2007, good results in 2007 were found in a significantly higher number of feet than in 2006 (p=0.019). The poor results were due to 1) very rigid feet (6%); 2) initial problems with availability of Denis-Brown splints (19 feet; 14.5%); 3) problems with shoes not made to custom and not fitting patient's little feet (20 feet; 15%) 4) faulty techniques of correcting the deformity (4 feet); 5) poor family cooperation in compliance with the bracing protocol (15 feet; 11.2%). Some of the factors were combined. A delayed beginning of the treatment had no significant effect on the results.
DISCUSSION: Our 3-year results of clubfoot treatment, by which plantigrade foot position was acheved on average in 77.5% of the patients, are in agreement with those achieved outside Ponseti centres. However, there were clear differences, with the worst results in 2005. The results comparable with those of Ponseti and his co-workers were achieved by us only in 2007. In accordance with the findings of Richards et al. we suggest that the percentage of short-term good results can change insignificantly within 4 years because of increased recurrence of deformities.
CONCLUSIONS: Although our initial results were worse than reported in the literature, it can be concluded that the Ponseti method of treating idiopathic clubfoot is more efficient that the methods used previously and can be recommended as an efficient, safe and economical technique. Good compliance with the protocol improves the therapeutic results.