Early results of the Ponseti method using the Steenbek foot abduction brace: a prospective study of 95 feet

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.     

Ponseti Idiopathic and Nonidiopathic Clubfoot Correction With Secondary Surgeries

The Ponseti method has revolutionized clubfoot treatment for not only idiopathic clubfoot but also non-idiopathic clubfoot. This study aimed to validate the existing literature with respect to the Ponseti method serving as first line treatment for clubfoot. The purpose of this study was to compare clubfoot type and recurrence with secondary surgical procedures following Ponseti method. Kaiser Permanente Northern California database was queried to identify clubfoot children under 3 years old with a consecutive 3-year membership. Associated comorbidities and operative procedure codes were identified. Chart review was performed on all surgical clubfoot patients who completed Ponseti method. Patients’ average age at time of surgery, frequency of surgeries, and types of procedures performed were recorded. A logistic regression analysis assessed the adjusted association between surgery status and clubfoot type. Clubfoot incidence was about 1 in 1000 live births. Of the 375 clubfoot children, 334 (89%) were idiopathic and 41 (11%) were non-idiopathic. In the total study population, 82% (n = 309) patients maintained Ponseti correction without a secondary surgery; 66 patients (18%) underwent subsequent secondary surgeries. The non-idiopathic clubfoot underwent surgery more frequently compared to idiopathic clubfoot patients (41.5% vs 14.7%, respectively, p = .0001). Non-idiopathic clubfoot children underwent surgery at a younger age. This study validates the Ponseti method is the first line treatment for clubfoot correction despite etiology. However, patients with recurrent clubfoot may require secondary surgery following Ponseti method. Clubfoot recurrence surveillance is key for identifying early symptomatic recurrence in order to minimize foot rigidity and the need for osseous procedures.     

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.     

Ponseti method compared with soft-tissue release for the management of clubfoot: A meta-analysis study

AIM: To compare the functional outcomes of patients who underwent open surgery vs Ponseti method for the management of idiopathic clubfoot and to determine whether correlations exist between functional outcome and radiographic measurements.METHODS: A meta-analysis of the literature was conducted for studies concerning primary treatment of patients with idiopathic clubfoot. We searched PubMed Medline, EMBASE, and the Cochrane Library databases from January 1950 to October 2011. Meta-analyses were performed on outcomes from 12 studies. Pooled means, SDs, and sample sizes were either identified in the results or calculated based on the results of each study.RESULTS: Overall, 835 treated idiopathic clubfeet in 516 patients were reviewed. The average follow-up was 15.7 years. Patients managed with Ponseti method did have a higher rate of excellent or good outcome than patients treated with open surgery (0.76 and 0.62, respectively), but not quite to the point of statistical significance (Q = 3.73, P = 0.053). Age at surgery was not correlated with the functional outcome for the surgically treated patients (r = -0.32, P = 0.68). A larger anteroposterior talocalcaneal angle was correlated with a higher rate of excellent or good outcomes (r = 0.80, P = 0.006). There were no other significant correlations between the functional and radiographic outcomes.CONCLUSION: The Ponseti method should be considered the initial treatment of idiopathic clubfeet, and open surgery should be reserved for clubfeet that cannot be completely corrected.     

Ponseti method treatment of neglected idiopathic clubfoot:Preliminary results of a multi-center study in Nigeria

AIM To evaluate the effectiveness of the Ponseti method for initial correction of neglected clubfoot cases in multiple centers throughout Nigeria.METHODS Patient charts were reviewed through the International Clubfoot Registry for 12 different Ponseti clubfoot treatment centers and 328 clubfeet(225 patients) met inclusion criteria. All patients were treated by the method described by Ponseti including manipulation and casting with percutaneous Achilles tenotomy as needed.RESULTS A painless plantigrade foot was obtained in 255 feet(78%) without the need for extensive soft tissue release and/or bony procedures.CONCLUSION We conclude that the Ponseti method is a safe, effective and low-cost treatment for initial correction of neglected idiopathic clubfoot presenting after walking age. Longterm follow-up will be required to assess outcomes.     

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.     

Expanded Age Indication for Ponseti Method for Correction of Congenital Idiopathic Talipes Equinovarus: A Systematic Review

The deformity known as congenital idiopathic talipes equinovarus (CTEV) is probably the most common (1 to 2 in 1000 live births) congenital orthopedic condition requiring intensive treatment. With the perception that the treatment of idiopathic CTEV by extensive soft tissue release is often complicated by stiffness, recurrence, and the need for additional procedures, the minimally invasive Ponseti method has been accepted as the first line of treatment, which has achieved excellent results globally. The Ponseti method has achieved excellent results in children with idiopathic CTEV aged ≤2 years. However, the upper age limit for the Ponseti treatment has not yet been defined. We reviewed the published data to determine the efficacy of the Ponseti method in older children with neglected CTEV.     

A 14-year longitudinal comparison study of two treatment methods in clubfoot: Ponseti versus traditional

The optimal management of idiopathic clubfoot has changed over three decades. Recently there has been an enthusiastic embracing of the Ponseti technique with a move away from the traditional stretch and strap technique. The purpose of this 14-year comparative prospective longitudinal study was to directly assess the differences in results between these two treatment methods. Over the period of this study there were 52,514 births in the local population and all newborns with clubfoot were referred directly to the paediatric orthopaedic surgeon. Patient demographics, the Harrold & Walker Classification, and associated risk factors for clubfoot were collected prospectively and analyzed. If conservative treatment failed to correct the deformity adequately, a radical subtalar release (RSR) was undertaken (the primary outcome measure of the study). There were 114 feet (80 patients): 64 feet treated 'traditionally' and 50 feet with the Ponseti technique. Idiopathic clubfoot was present in 76.25% of patients. Mean time to RSR was 333 and 44.1 weeks for the traditional and Ponseti groups respectively. In the traditional group 65.6% (CI: 53.4 to 76.1%) of feet underwent RSR surgery compared to 25.5% (CI : 15.8 to 383%) in the Ponseti group. When idiopathic clubfoot alone was analysed, these rates reduce to 56.5% (CI: 423 to 69.8%) and 15.8% (CI: 7.4 to 30.4%) respectively. The Relative Risk of requiring RSR in traditional compared to Ponseti groups was 2.58 (CI: 1.59 to 4.19) for all patients and 3.58 (CI: 1.65 to 7.78) for idiopathic clubfoot. Introduction of the Ponseti technique into our institution significantly reduced the need for RSR in fixed clubfoot.     

Mid-term results of ponseti method for the treatment of congenital idiopathic clubfoot - (A study of 67 clubfeet with mean five year follow-up)

Background  

Long-term success reports by Dr. Ponseti with the Ponseti method in the treatment of congenital idiopathic clubfoot have led to a renewed interest in this method among pediatric orthopedists. The purpose of this study is to evaluate mid-term effectiveness of Ponseti method for the treatment of congenital idiopathic clubfoot.     

Correction of neglected idiopathic club foot by the Ponseti method

The Ponseti method of treating club foot has been shown to be effective in children up to two years of age. However, it is not known whether it is successful in older children. We retrospectively reviewed 17 children (24 feet) with congenital idiopathic club foot who presented after walking age and had undergone no previous treatment. All were treated by the method described by Ponseti, with minor modifications. The mean age at presentation was 3.9 years (1.2 to 9.0) and the mean follow-up was for 3.1 years (2.1 to 5.6). The mean time of immobilisation in a cast was 3.9 months (1.5 to 6.0). A painless plantigrade foot was obtained in 16 feet without the need for extensive soft-tissue release and/or bony procedures. Four patients (7 feet) had recurrent equinus which required a second tenotomy. Failure was observed in five patients (8 feet) who required a posterior release for full correction of the equinus deformity. We conclude that the Ponseti method is a safe, effective and low-cost treatment for neglected idiopathic club foot presenting after walking age.     

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.     

Minimal-invasive Therapieverfahren angeborener Fußdeformitäten im Säuglingsalter

In the last decade treatment of foot deformities has changed from extensive surgery to casting and minimally invasive surgery. The Ponseti method has become the most preferred treatment for clubfoot deformities and early evaluations showed promising results. Mid-term results for idiopathic clubfoot revealed the need for additional surgery by anterior tibial tendon transfer in 11–32?% of cases depending on the duration of bracing. Anterior tibial tendon transfer is the most important surgical procedure for relapses in the Ponseti concept. Casting, recasting in cases of relapses, bracing and anterior tibial tendon transfer altogether represent the Ponseti method and cannot be considered as single entities. The Dobbs method is a new concept for the treatment of vertical talus. Treatment of vertical talus should start with the Dobbs method but in comparison to clubfoot treatment there has not been a complete change to minimally invasive treatment. Especially in non-idiopathic vertical talus cases open reduction of the talonavicular and calcaneocuboid joint are often necessary.     

Correction results of atypical clubfeet managed with modified Ponseti technique: A meta-analysis of 354 feet

Background/purposeAtypical clubfeet are distinct from idiopathic clubfeet. It is resistant to correction by conventional casting methods and often requires a modification of Ponseti's casting technique. Although the initial correction rates are reasonable, relapse and complications are frequent. There is limited literature on the results of modified Ponseti casting of these feet. We conducted this meta-analysis to study a few important aspects of atypical/complex clubfeet treatment by the modified Ponseti technique.Research questionWhat are the results of atypical or complex clubfeet after treatment by the modified Ponseti technique?MethodologyFive electronic databases (PubMed, Embase, Scopus, Ovid, and Cochrane Library) were searched for articles reporting on the results of atypical/complex clubfeet treated by the modified Ponseti technique. Details of the number of casts required for correction, rate of percutaneous Achilles tenotomy (PAT), other soft tissue procedures required, complications, and relapse rates were extracted into spreadsheets, and meta-analysis was carried out using OpenMeta Analyst software.ResultsTen studies were included for analysis with a total of 240 patients with 354 clubfeet. The initial correction was achieved in all feet. A pooled analysis of the data showed that a mean of six casts was required for the initial correction. The rate of PAT was 98.3%. The overall complication rate was 16.8%. 7.2% required an additional soft tissue procedure apart from the PAT, and relapse of the deformity was observed in a mean of 19.8% cases.ConclusionModified Ponseti technique is effective in the initial management of atypical/complex clubfeet. Although the PAT rate is slightly higher in the Modified Ponseti technique, the remaining result parameters are comparable with the results of idiopathic clubfoot managed with the Ponseti method of casting. However, these children should be kept under follow-up for a longer duration to find the exact relapse rates.     

Results of Modified Ponseti Technique in Difficult Clubfoot and a review of literature

IntroductionSerial Ponseti casting achieves deformity correction in early presenting idiopathic clubfoot cases normally in around 7 casts. However, there are resistant patients where correction requires more casts than usual. In such patients a modification in standard technique might be required right from the beginning. Such patients were collectively called as difficult clubfoot. The aim of this study was to assess the outcome of our modification to Ponseti technique in difficult clubfoot.MethodsAll idiopathic clubfoot cases who were 75th percentile or more in WHO age for weight chart (chubby infants) or untreated clubfoot patients presenting for first time to our clinic at more than 5 months age (late presenters and neglected cases) were included in the study. Patients who had been previously surgically intervened elsewhere, patients over 7 years of age, patients with syndromic clubfoot or clubfoot associated with neurological conditions were excluded from the study. The patients were treated by early tenotomy of tendoachillis and a plantar fascia release before starting serial casting by Ponseti technique. Post correction, strict bracing protocol was followed with regular follow up. Pirani scoring was done at each stage. Measurement of Talocalcaneal angle on AP radiograph, maximum degree of abduction and dorsiflexion was noted once every year.ResultsThere were total 28 patients in our study. In all, 47 feet were subjected to modified Ponseti protocol. There were 21 male patients. Median age at presentation was 4 months. Mean centile of weight for age as per WHO growth chart was 64. Mean Pirani score at presentation was 5.86 (S.D. ± 0.34). Mean number of casts required for correction was 3.75 ± 1.10. Maximum followup period was 25 months.ConclusionThis modification of Ponseti casting for difficult clubfoot patients achieves correction in shorter duration with less number of casts.     

Nonsurgical management of idiopathic clubfoot

Because nonsurgical management was thought not to yield adequate correction and a durable result, most children with idiopathic clubfoot have undergone surgery with extensive posteromedial and lateral release. However, surgical management caused residual deformity, stiffness, and pain in some children; thus, the favorable long-term results with the Ponseti and French methods of nonsurgical management have garnered interest. The Ponseti method consists of manipulation and casting of idiopathic clubfeet; the French method consists of physiotherapy, taping, and continuous passive motion. Careful evaluation of the techniques and results of these two approaches may increase their use and decrease or minimize the use of surgical management and thus the associated morbidity resulting from extensile releases.     

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.     

Use of the foot abduction orthosis following Ponseti casts: is it essential?

The purpose of this study was to evaluate the need for the use of a foot abduction orthosis (FAO) in the treatment of idiopathic clubfeet using the Ponseti technique. Forty-four idiopathic clubfeet were treated with casting using the Ponseti method followed by FAO application. Compliance was defined as full-time FAO use for 3 months and part-time use subsequently. Noncompliance was failure to fulfill the criteria during the first 9 months after casting. Feet were rated according to the Dimeglio and Pirani scoring systems at initial presentation, at the time of FAO application, and at 6 to 9 months of follow-up. At the time of application, no significant differences in scores were found between the groups. At follow-up, the compliant group's scores were significantly (P < 0.01) better than those of the noncompliant group. From the time of application to follow-up, for the compliant group, the Dimeglio scores improved significantly (P = 0.005). For the noncompliant group, the Dimeglio scores deteriorated significantly (P = 0.001). The feet of patients compliant with FAO use remained better corrected than the feet of those patients who were not compliant. Proper use of FAO is essential for successful application of the Ponseti technique.     

Management issues of congenital talipes equinovarus in the neonatal intensive care unit: A systematic review

BackgroundThe Ponseti method is the standard of care for managing idiopathic congenital talipes equinovarus (clubfoot) in the outpatient setting, but there are no clinical guidelines for inpatient treatment. Children in the neonatal intensive care unit (NICU) with clubfoot often delay treatment initiation due to medical reasons.MethodsWe systematically reviewed literature related to the treatment of clubfoot in the NICU, non-idiopathic clubfoot, and older infants, as well as barriers to care.ResultsIn a mixed NICU population of syndromic and idiopathic clubfoot, the Ponseti method has good functional outcomes with minimal interference with medical management. The Ponseti method has good functional outcomes with reduced need for extensive surgical procedures in non-idiopathic clubfoot and idiopathic clubfoot with delayed presentation (under one year of age).ConclusionsIt is possible to begin Ponseti treatment in the NICU without compromising medical management. It is not clear if this confers an advantage over waiting for outpatient casting.     

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.     

Management of congenital talipes equinovarus using the Ponseti method: a systematic review

We present a systematic review of the results of the Ponseti method of management for congenital talipes equinovarus (CTEV). Our aims were to assess the method, the effects of modifications to the original method, and compare it with other similar methods of treatment. We found 308 relevant citations in the English literature up to 31 May 2010, of which 74 full-text articles met our inclusion criteria. Our results showed that the Ponseti method provides excellent results with an initial correction rate of around 90% in idiopathic feet. Non-compliance with bracing is the most common cause of relapse. The current best practice for the treatment of CTEV is the original Ponseti method, with minimal adjustments being hyperabduction of the foot in the final cast and the need for longer-term bracing up to four years. Larger comparative studies will be required if other methods are to be recommended.