The effectiveness of the Ponseti method for treating clubfoot associated with arthrogryposis: up to 8 years follow-up

Purpose

To evaluate the effectiveness of the Ponseti method in treating clubfoot associated with arthrogryposis.

Methods

Retrospective consecutive review over a 10-year period in a tertiary centre of all patients with arthrogrypotic clubfoot treated with the Ponseti method. The primary outcome measure at final follow-up was the functional correction of the deformity.

Results

There were ten children with 17 arthrogrypotic clubfeet, with an average follow-up of 5.8 years (range 3–8 years). The average age at presentation was 5 weeks (range 2–20 weeks). Deformities were severe, with an average Pirani score of 5.5 (range 3–6). Initial correction was achieved in all children with an average of 8 (range 4–10) Ponseti casts and a tendo-Achilles tenotomy (TAT) was performed in 94.1 %. Two-thirds of patients had a satisfactory outcome at final follow-up, with functional plantigrade, pain-free feet.

Conclusions

The Ponseti method is an effective first-line treatment for arthrogrypotic clubfeet to achieve functional plantigrade feet. Children will often require more casts and have a higher risk of relapse.

     

Does initial Pirani score and age influence number of Ponseti casts in children?

Purpose

The prediction of number of casts in the Ponseti method has always remained a subject of interest. We investigated the correlation of the number of casts before tenotomy with the age and initial Pirani score in Ponseti treatment of club foot.

Methods

Inclusion criteria were idiopathic clubfeet corrected by Ponseti method requiring tenotomy for equinus correction in children up to ten years of age. Defaulters (noncompliance with serial casting schedule), children with postural, non idiopathic, previously surgically treated, recurrent clubfoot and clubfoot not requiring tenotomy were not included in this study. Further, children who did not require tenotomy were also excluded. ANOVA regression analysis was used for finding correlation between initial Pirani score, age in months and number of corrective casts prior to tenotomy.

Results

There were a total of 297 children (442 feet) in the study. The average age of the child at presentation was 10.3 months and the average initial Pirani score was 4.8. The average number of corrective casts was seven per child (range, two to18). The regression analysis showed both Pirani and age had positive correlation with number of casts, although weak (r² = 0.05–0.20). The initial Pirani scoring correlated ten times more than age (in months) to the number of casts.

Conclusion

The number of casts for correction in idiopathic clubfoot, although variable, is influenced by both initial Pirani score and age.     

Good results with the Ponseti method: a multicenter study of 162 clubfeet followed for 2-5 years

Background and purpose

In 2002–2003, several hospitals in Norway introduced the Ponseti method for treating clubfoot. The present multicenter study was conducted to evaluate the initial results of this method, and to compare them to the good results reported in the literature.

Patients and methods

116 children with 162 congenital idiopathic clubfeet who were born between 2004 and 2006 were treated with the Ponseti method at 8 hospitals in Norway. All children were prospectively registered at birth, and 116 feet were assessed according to Pirani before treatment was started. 63% used a standard bilateral foot abduction brace, and 32% used a unilateral above-the-knee brace. One of the authors examined all feet at a mean age of 4 years. At follow-up, all feet were assessed by Pirani’s scoring system, and range of motion of the foot and ankle was measured.

Results

At follow-up, 77% of the feet had a Pirani score of 0.5 or better, good dorsiflexion and external rotation, and no forefoot adduction. An Achilles tenotomy had been performed in 79% of the feet. Compliance to any brace was good; only 7% were defined as non-compliant. Extensive soft tissue release had been performed in 3% of the feet.We found no statistically significant differences between the two braces, except a tendency of better Pirani score in the group using the bilateral foot abduction brace, and a tendency of better compliance in patients using the unilateral brace. Better Pirani scores were found in children who were treated at the largest hospitals.

Interpretation

After introducing the Ponseti method in Norway, the clinical outcome was good and in accordance with the reports from single centers. Only 5 feet needed extensive surgery during the first 4 years of life.The methods of treating clubfoot have varied over the years and between the different hospitals in Norway. The results reported have not been satisfactory, as 75% of the feet needed posterior or postero-medial release (Nesse et al. 1996). Thus, orthopedic surgeons treating clubfoot in Norway decided to start with the Ponseti method, which has shown promising short-term and long-term results (Laaveg and Ponseti 1980, Cooper and Dietz 1995, Herzenberg et al. 2002). The Ponseti method of treating clubfoot was introduced at several hospitals in Norway in 2002 and 2003.A foot abduction brace is a crucial part of the Ponseti treatment, and it is well documented that the brace prevents a clubfoot from relapsing (Dobbs et al. 2004, Morcuende et al. 2004). The brace recommended by Ponseti is a bilateral foot abduction brace. Many hospitals in Norway have traditionally used a custom-made unilateral above-the-knee dynamic brace to prevent relapse. Some of these hospitals continued to offer this brace to children with clubfoot, even after the introduction of the Ponseti casting method.Norway is a small country regarding population (4.9 million inhabitants), but it has a relatively large area and none of the hospitals were responsible for treating more than 10 newborns with clubfoot every year in this study.We evaluated our results and compared them to the good short-term and long-term results reported in the literature. We also compared the unilateral above-the-knee brace with the standard bilateral foot abduction brace regarding both clinical outcome and compliance to brace use. Finally, we determined whether the results were influenced by the number of clubfeet treated at each hospital.     

Ultrasonographic observation of the healing process in the gap after a Ponseti-type Achilles tenotomy for idiopathic congenital clubfoot at two-year follow-up

Background

Ponseti management usually requires Achilles tenotomy during the final stage of serial casting. However, we lack a good understanding of the sequential tendon healing process after tenotomy in the Ponseti bracing protocol. The purpose of this study was to clarify the ultrasonographic process of tendon healing in the gap for up to two years after Ponseti-type Achilles tenotomy in patients with clubfeet.

Methods

We conducted an ultrasonographic study to clarify the sequential changes in gap healing for up to two years after tenotomy. The subjects were 23 patients with 33 clubfeet. Achilles tenotomy was performed at mean 10.4 (8–16) weeks after birth. Dynamic and static ultrasonography was performed before tenotomy and at 1, 2, 3, 4, 6, 8, and 12 weeks as well as at 4, 6, 12, 18, and 24 months after tenotomy.

Results

Continuity and gliding were noted within four weeks. The united portion continued to thicken for up to three months after tenotomy. Starting from the fourth month, the healed portion began to lose its thickness, and this process continued into the sixth month. At one year, the thickness of the tendon did not differ much from that of the tendon on the opposing foot. In cases where patients had clubfoot on both feet and underwent simultaneous tenotomies, measurement of the tendons could not be accurately compared. At two years after tenotomy, slight irregularity of the internal structure persisted when compared with the unaffected foot. In addition, clinical and X-ray findings were evaluated simultaneously, and no recurrence was confirmed.

Conclusions

To our knowledge, our results are the first to describe the process of gap healing in the tendon after tenotomy up to and beyond two years, as recommended in the Ponseti bracing protocol. Level of evidence IV.     

先天性马蹄内翻足Ponseti治疗初跟腱手术的预测

目的探讨先天性马蹄内翻足（CCF）患儿治疗前预测患儿行跟腱手术的可行性。方法96例CCF（148足）患儿,均依据Ponseti方法治疗,平均（5.7±1.3）次石膏矫正后,背屈活动≤15°或Pirani评分HS（后足评分）≥1,MS（中足评分）〈1的患足需行跟腱切断手术。石膏去除后需佩戴外展支具。结果经过系列石膏矫正后,148足中125足（84.5%）行跟腱切断术,23足（15.5%）未行跟腱手术。在治疗初有102足（68.9%）Pirani评分≥5分,其中93足（91.2%）经系列石膏矫正后行跟腱手术。手术组跟腱愈合佳,跖屈有力。结论在治疗初Pirani评分≥5分时91.2%患儿需要跟腱手术,CCF患儿初次来诊时,对患足行Pirani评分,即可预测其是否需行跟腱手术。在治疗初预先判断患儿是否需行跟腱手术则既有利于医师了解治疗进展,又能更好地与家长沟通配合治疗进程。     

Predicting the need for tenotomy in the Ponseti method for correction of clubfeet

The purpose of this study was to determine how to predict the need for tenotomy at the initiation of the Ponseti treatment. Fifty clubfeet (35 patients) were prospectively rated according to Pirani and Dimeglio scoring systems. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required significantly more casts (P = 0.005). Of 27 feet with initial Pirani scores > or = 5.0, 85.2% required a tenotomy and 14.8% did not; 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and did not have a tenotomy. Children with clubfeet who have an initial score of > or = 5.0 by the Pirani system or are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy.     

Outcome of Atypical & Complex Clubfoot Managed by Modified Ponseti Method—A Prospective Study

Atypical or complex clubfoot constitutes a small number of cases. Due to the difference in complexity of anatomy, standard deformity correction by Ponseti is not effective. Hence a modified Ponseti method was advised which focuses on deformity differences for treatment. We conducted a prospective study to analyze the outcome in atypical or complex clubfoot treated with the modified Ponseti method. All the children of age less than 1 year were included in the study with atypical or complex clubfoot. Every case was treated according to the modified Ponseti method and tenotomy. Pirani scores were measured at pretreatment, each visit, before application of a brace, and at the latest follow-up. Statistical analysis of all continuous and categorical variables was done. A total of 30 patients (47 feet) were included in the study. Mean Pirani score improved from 5.69 at presentation to 0.45 at time of brace application and latest follow-up 0.34 (p < .001). Six patients (9 feet) had a relapse which was managed with recasting. The mean Pirani score of relapse was 0.72, which after correction reduced to 0.11 (p = .008). Six patients had cast-related complications which were managed with conservative treatment. With an increase in popularity of the Ponseti method, a greater number of complex clubfoot cases are seen due to inadequate reduction or slippage of cast or improper cast application techniques. All these need to be identified at an early age. This helps in proper treatment and improves the quality of life as well as foot appearance.     

Mid-term results of a physiotherapist-led Ponseti service for the management of non-idiopathic and idiopathic clubfoot

BackgroundThe Ponseti method is the preferred treatment for idiopathic clubfoot. Although popularised by orthopaedic surgeons it has expanded to physiotherapists and other health practitioners. This study reviews the results of a physiotherapist-led Ponseti service for idiopathic and non-idiopathic clubfeet and compares these results with those reported by other groups.MethodA prospective cohort of clubfeet (2005–2012) with a minimum 2-year follow-up after correction was reviewed. Physiotherapists treated 91 children—41 patients (69 feet) had non-idiopathic deformities and 50 children (77 feet) were idiopathic. Objective outcomes were evaluated and compared to results from other groups managing similar patient cohorts.ResultsThe mean follow-up was 4.6 years (range 2–8.3 years) for both groups. The non-idiopathic group required a median of 7 casts to correct the clubfoot deformity with an 83 % tenotomy rate compared to a median of 5 casts for the idiopathic group with a 63 % tenotomy rate. Initial correction was achieved in 96 % of non-idiopathic feet and in 100 % of idiopathic feet. Recurrence requiring additional treatment was higher in the non-idiopathic group with 40 % of patients (36 % of feet) sustaining a relapse as opposed to 8 % (6 % feet) in the idiopathic group. Surgery was required in 26 % of relapsed non-idiopathic feet and 6 % of idiopathic.ConclusionsAlthough Ponseti treatment was not as successful in non-idiopathic feet as in idiopathic feet, deformity correction was achieved and maintained in the mid-term for the majority of feet. These results compare favourably to other specialist orthopaedic-based services for Ponseti management of non-idiopathic clubfeet.

Level of evidence

Prognostic Level III.     

Vergleich der Behandlungsergebnisse bei kongenitalen idiopathischen und nichtidiopathischen Klumpfü?en

Background

Clubfoot deformity is one of the most common congenital musculoskeletal deformities and occurs in newborns with different neuromuscular diseases. To date the Ponseti method is the gold standard for the treatment of idiopathic clubfeet but not for non-idiopathic clubfeet which are associated with neuromuscular diseases. The results of the treatment for congenital idiopathic and non-idiopathic clubfeet according to Ponseti performed in our department since 2004 were compared concerning results and relapse surgery with particular reference to the compliance of the parents concerning the use of an abduction splint.

Patients and methods

A total of 101?children (28 female and 73 male) with 159 clubfeet were treated with the Ponseti method and included in this prospective non-randomized cohort study. Of these children 27 with 48 affected feet suffered from neuromuscular diseases which are associated with clubfoot deformity, such as myelomeningocele (n=4), arthrogryposis (n=9) and various other syndromes (n=14). The degree of the deformity was evaluated with the Pirani score initially, after casting and at follow-up. Parents were asked at follow-up to state subjectively how compliant they were with the abduction splint treatment. The necessity of surgical treatment of relapses was recorded. Statistical analysis was performed applying ??² and Kruskal-Wallis tests for the comparison of idiopathic and non-idiopathic clubfeet.

Results

The average period of follow-up was 36?month (range 6?C75?months) and non-idiopathic clubfeet were initially significantly more severely deformed according to the Pirani-score (p=0.013). Treatment of non-idiopathic clubfeet was started significantly later than that of idiopathic clubfeet (p=0.003) and took significantly longer (p <0.001). A correlation between the initiation of casting and the duration of casting was not found (p=0.399). At the end of the casting period no significant differences were found between correction of idiopathic and non-idiopathic clubfeet with respect to the Pirani score (p=0.8). The mean score after casting was 0.1 in both groups. At mid-term follow-up the score increased in both groups but stayed below 0.5 with non-idiopathic clubfeet showing a significantly higher score than idiopathic clubfeet (p=0.014). Relapse surgery was necessary in 11% of the patients. No significant difference in the revision rate was found between the two groups (p=0.331) and peritalar release was not necessary in either group. The rate of revisions correlated with the compliance concerning the use of the abduction splint (p <0.001). Only 61% of the parents stated that they adhered strictly to the abduction splint treatment recommendations with no significant difference between the groups (p=0.398).

Conclusion

This study shows good initial results after Ponseti treatment for idiopathic as well as non-idiopathic clubfeet. Based on the good functional results all clubfeet should initially be treated with the Ponseti method regardless of the etiology.     

Deuxieme Congres De La Socictc Internationace De Chirurgle Orthopcdique

Background and purpose In 2002–2003, several hospitals in Norway introduced the Ponseti method for treating clubfoot. The present multicenter study was conducted to evaluate the initial results of this method, and to compare them to the good results reported in the literature.

Patients and methods 116 children with 162 congenital idiopathic clubfeet who were born between 2004 and 2006 were treated with the Ponseti method at 8 hospitals in Norway. All children were prospectively registered at birth, and 116 feet were assessed according to Pirani before treatment was started. 63% used a standard bilateral foot abduction brace, and 32% used a unilateral above-the-knee brace. One of the authors examined all feet at a mean age of 4 years. At follow-up, all feet were assessed by Pirani’s scoring system, and range of motion of the foot and ankle was measured.

Results At follow-up, 77% of the feet had a Pirani score of 0.5 or better, good dorsiflexion and external rotation, and no forefoot adduction. An Achilles tenotomy had been performed in 79% of the feet. Compliance to any brace was good; only 7% were defined as non-compliant. Extensive soft tissue release had been performed in 3% of the feet.

We found no statistically significant differences between the two braces, except a tendency of better Pirani score in the group using the bilateral foot abduction brace, and a tendency of better compliance in patients using the unilateral brace. Better Pirani scores were found in children who were treated at the largest hospitals.

Interpretation After introducing the Ponseti method in Norway, the clinical outcome was good and in accordance with the reports from single centers. Only 5 feet needed extensive surgery during the first 4 years of life.     

Accelerated Ponseti method: First experiences in a more convenient technique for patients with severe idiopathic club feet

BackgroundCongenital Idiopathic Talipes Equinovarus (CTEV), or clubfoot, is a complex deformity that involves pathological anatomy in the foot with ankle equinus, hindfoot varus, midfoot cavus and forefoot adductus [1]. Universal agreement is established about Ponseti technique as the initial management for this deformity. This preliminary study aims to investigate the possibility of having a braceable foot through a proposed accelerated Ponseti method by which, manipulations, 5 castings and Achilles tendon tenotomy are implemented in a week.MethodsThis study included 11 patients with 16severe congenital idiopathic clubfeet treated by an accelerated Ponseti method. The method involves manipulation of the deformed foot, and 1st casting in one day, with the 2nd, 3rd, 4th, 5th castings in the 4th, 5th, 6th, 7th day post-manipulation. After the 4th cast removal, Achilles tenotomy was performed with subsequent three-week casting for all patients. Nonparametric tests were used for comparing the Pirani scores before starting the treatment and after removal of final cast.ResultsFive patients had bilateral club foot deformity. Average age at treatment was 54.8 days (range 8–150 days). All patients, who had severe congenital idiopathic club feet with a Pirani score of 6, underwent the accelerated Ponseti technique. After removal of the three-week cast, the scores median was 0.59, (range 0–1.5), indicating a correction of the deformity and having braceable feet in all patients without experiencing any short-term complication.ConclusionsThe first step accelerated Pnoseti technique was found to be safe and effective for initial correction of severe idiopathic clubfoot deformity in children below three months of age , though it is an initial study that needs more studies with more follow up data.     

Calcaneocuboid arthrodesis for recurrent clubfeet: what is the outcome at 17-year follow-up?

Purpose

Calcaneocuboid arthrodesis was used during revision clubfoot surgery in order to maintain midfoot correction. The purposes of this study were to determine: (1) functional level at 17-year follow-up compared to 5-year follow-up; (2) patients’ current functional level, satisfaction, and pain; and (3) current arthropometric measurements.

Methods

Twenty patients (27 clubfeet) with clubfoot relapse underwent revision soft tissue release and calcaneocuboid fusion between 1991 and 1994. They were previously evaluated at a mean follow-up of 5.5 years. Ten out of 20 patients (13 clubfeet), mean age of 24 years, were reevaluated at mean follow-up of 17.5 years. The Hospital for Joint Diseases Functional Rating System (HJD FRS) for clubfoot surgery, Outcome Evaluation in Clubfoot developed by the International Clubfoot Study Group, the Clubfoot Disease-Specific Instrument, American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire, Laaveg and Ponseti’s functional rating system for clubfoot and pain scale were completed by patient and/or surgeon to assess function, patient satisfaction and pain. Foot and ankle radiographs and anthropometric measurements were reviewed. For HJD FRS, scores from original follow-up were compared to current ones.

Results

The HJD FRS score of all feet was 65.9, demonstrating a significant decline from the original mean score of 77.8 (p = 0.03). Excellent/good HJD FRS scores went from 85 to 38 %. Mean AAOS Foot Ankle Outcomes Questionnaire standardized core and shoe comfort scores were 84.6 and 84.5, respectively. Average foot pain was 1.8 on a scale of 1–10. Patients were very/somewhat satisfied with status of foot in 76 % of feet and appearance of foot in 46 % of feet, based on Clubfoot Disease-Specific Instrument questions.

Conclusions

Revision clubfoot surgery with calcaneocuboid fusion in patients 5–8 years of age showed an expected decline in functional outcome measures over a 17-year follow-up period. It still produced comparable results to other studies for a similar population of difficult, revision cases, and should have a place in current surgical treatment techniques.     

Ponseti method in the treatment of post-operative relapsed idiopathic clubfoot after posteromedial release. A short term functional study

BackgroundRelapsed clubfeet deformity after surgical treatment by posteromedial release are frequently encountered in pediatric orthopedic practice and further revision surgery may be needed. As surgery adds more fibrosis and scaring, complication may be devastating and treatment is challenging. Ponseti method, the gold standard technique for treatment of clubfoot may be of a value in the management of postoperative relapses.Aim of the studyDetermine the effectiveness of Ponseti casting Method in treatment of relapsed idiopathic clubfoot in children after being treated with surgical posteromedial release.Materials and methodsProspective interventional study of 17 patients (25 feet) presented with a relapsed idiopathic clubfoot deformity after previous surgical posteromedial release. The patients were reviewed using Pirani and Dimeglio score. Ponseti method was done to obtain supple, flexible foot rather than a fully corrected foot, the residual deformity were treated by, heel cord lengthening or tenotomy, tibialis anterior transfer, follow up was for a minimum of 12 months.Result17 Patients (25 feet) their age ranging from 1 to 10 years were evaluated and treated. Casts were applied until the only deformities remaining were either hindfoot equinus and/or dynamic supination.22 feet required a heel cord procedure for equinus and 13 required tibialis anterior transfer for dynamic supination. The follow up (average 56.1 months) was for a minimum of one year. 4 feet had persistent heel varus deformity which required Calcaneal osteotomy later. Three feet didn’t need more casting and 2 feet were resistant cases that required further Ilizarov procedure, 4 needed lateral arch shortening and other 4 needed posterior capsulotomy. Improvement in the Pirani and Dimeglio scores was highly statistically significant.ConclusionPonseti method for treatment of relapsed clubfeet after a previous posteromedial soft tissue surgical release is an effective, non invasive, with excellent results.     

Early results of the Ponseti method for the treatment of idiopathic clubfoot

AIM: The Ponseti method for the treatment of congenital clubfeet has been propagated due to the sometimes disappointing functional results after surgical treatment. The aim of our study was to evaluate our early results and experiences with the Ponseti method. METHOD: Between December 2002 and December 2004 a total of 87 clubfeet in 59 patients were treated using the Ponseti method at our department. Only patients in whom treatment was initiated within the first three weeks of life were included in this study. Rate of successful correction without open release surgery, radiological findings, classification according to Pirani at the time of the last follow up, recurrence rate and duration of treatment were defined as outcome measures for this prospective study. RESULTS: Fifty-nine cases in 37 patients met the inclusion criteria. Ninety-three percent of all cases (55 feet) were corrected without open surgery. The mean duration of active treatment was 11.4 weeks (8-20 weeks). The mean tibiocalcaneal angle 3-4 weeks after the percutaneous tenotomy of the Achilles tendon was 69 degrees, the mean a.-p.-talocalcaneal angle measured 33 degrees and the lateral talocalcaneal angle 36 degrees. A recurrence was seen in one patient with bilateral clubfeet (3.6 %). CONCLUSION: Open release surgery can be averted in most cases of idiopathic clubfoot using the Ponseti method. Scarring of the soft tissue and especially of the joint capsule can thereby be avoided.     

Deficient dorsalis pedis flow in severe idiopathic clubfeet: Does Ponseti casting affect the outcome?

BackgroundArterial deficiency in congenital clubfoot or congenital talipes equinovarus (CTEV) was postulated as either the primary cause of deformity or secondary manifestation of other bony and soft tissue abnormalities. The objectives of the study were to find any association between arterial deficiency with severity of CTEV and its treatment.MethodThis prospective study conducted on 24 feet with CTEV (18 babies) with Pirani score ranging between 2 to 6. Eighteen normal babies (36 feet) were selected as control. We used Color Doppler Ultrasound to assess dorsalis pedis and posterior tibial arteries before initiating the treatment. Second ultrasound was performed in study group upon completion of Ponseti treatment.ResultsThe patients were from one week to 15 weeks of life. Dorsalis pedis arterial flows were absent in 7 clubfeet (29.1%) while the remaining 17 clubfeet (70.8%) had normal flow. There was a significant association between Pirani severity score and vascular status in congenital clubfoot. There was a higher proportion of clubfeet having abnormal vascularity when the Pirani severity score was 5 and more. In study group, posterior tibial arteries were detectable and patent in all feet. All normal feet in control group had normal arterial flow. There was a significant difference in vascular flow before and after the Ponseti treatment (p 0.031).ConclusionThe study concludes that there is an association between Pirani severity score and arterial deficiency in CTEV. Ponseti treatment is safe in CTEV with arterial deficiency and able to reconstitute the arterial flow in majority of cases.     

Use of Ankle Dorsiflexion and the Dimeglio and Pirani Scores in Predicting Relapse of Clubfoot Treated With the Ponseti Method

Although Dimeglio and Pirani scores are frequently employed to rate the severities of clubfoot and to evaluate treatment outcomes, it is unclear if these scores predict relapse after treatment. Ankle dorsiflexion has been suggested in recent years to be a promising predictor of relapse. The aim of this study was to investigate ankle dorsiflexion and Dimeglio and Pirani scores in predicting the relapse of clubfoot after treatment with the Ponseti method. We included patients with clubfoot previously treated by the Ponseti method, and retrospectively analyzed their initial ankle dorsiflexion, Pirani and Dimeglio scores, number of castings, and the occurrence of relapse. We analyzed 218 feet of 176 infants with clubfoot who showed an incidence of relapse of 17.0% (30/176). The mean initial Pirani and Dimeglio scores of the feet showing recurrence were significantly higher than individuals with non-recurrence (p < .001 each). We observed a robust association between Pirani and Dimeglio scores and the recurrence of clubfoot at the last follow-up (γ = 0.53, p = .001). In contrast, ankle dorsiflexion was negatively correlated with recurrence of clubfoot (γ = -0.21, p = .001). Dimeglio scores significantly predicted the recurrence of clubfoot (p = .014). Receiver operating characteristic curve analysis exhibited slightly better performance regarding the Dimeglio score relative to the Pirani score and ankle dorsiflexion in predicting recurrence. Ankle dorsiflexion and Pirani and Dimeglio scores were related to recurrence in patients with clubfoot. However, the Dimeglio score reflected superior accuracy in predicting the prognosis of clubfoot treated with the Ponseti method.     

Walk for life - the National Clubfoot Project of Bangladesh: the four-year outcomes of 150 congenital clubfoot cases following Ponseti method

Background

Congenital clubfoot deformity can cause significant disability, and if left untreated, may further impoverish those in developing countries, like Bangladesh. The Ponseti method has been strategically introduced in Bangladesh by a non-government organisation, Walk For Life (WFL). WFL has provided free treatment for over 17,500 Bangladeshi children with clubfeet since 2009, sustained by local ownership, and international support. This study assesses the 4-year results in children for whom treatment began before the age of 3 years.

Methods

A centrally located WFL clinic at Mymensingh Medical College Hospital (MMCH), representative of the larger WFL clinics, which treats >100 cases annually, was reviewed. In 2015, 99 of the 147 eligible subjects who had begun treatment in 2011 were available for follow up. Specific assessment tools enabled evaluation of parent satisfaction, gait function, and relapse cases.

Results

Results for 99/147 cases were returned after four years: 72 males, 27 females. Typical clubfeet comprised 98/99 of cases, and 55/99 were bilateral. The tenotomy rate was 80 %. Brace use after 3 months was 90 %, at 12 months was 65 %, and at 4 years post treatment was 40 %. Functionally, 98/99 of children could walk and run (99 %). Relapsing deformity was found in 13 %. Relapse severity varied: eight were flexible and partial, five were rigid. Half of the children lost to follow were due to changed phone numbers. While parents were very happy with their child’s feet (97 %), a materials cost of 3000 Taka ($US40) was deemed unaffordable by 60 %.

Conclusions

The 4-year outcomes after Ponseti treatment for clubfoot deformity, showed that 99 % of children available for follow up, were walking independently. The relapse rate was low. Parent satisfaction was high, but those whose children required further treatment were less satisfied.