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.     

Comparative evaluation and analysis of outcomes in non-idiopathic and idiopathic clubfeet with Ponseti method at a tertiary care centre of a developing country

BackgroundIdiopathic clubfoot (congenital talipes equinovarus, CTEV) is being managed worldwide by Ponseti method with high success rates, while for non-idiopathic clubfoot surgical interventions is being widely used with variable results. This study evaluated the effectiveness of Ponseti method in non-idiopathic clubfoot and compared the results with idiopathic clubfoot.MethodsThe paper evaluated the epidemiological incidence and demographic profile of non-idiopathic clubfoot in a tertiary centre of developing country. A total of 108 subjects with 85 having idiopathic (group I;125 feet) and 23 having non-idiopathic variety (group II;34 feet) were managed with Ponseti method and were followed for a mean duration of 38.33 (12–62) and 36.27 months (12–58) in group I and II respectively. The most common associations were meningomyelocele (MMC/spina bifida,5), arthrogryposis multiplex congenita (AMC,4), developmental dysplasia of hip (DDH,3) and Down’s syndrome and amniotic band syndrome (2 each).ResultsPrimary correction was achieved in both the groups in 98% and 87% in group I and II respectively, while recurrences of at least one deformity was observed in 11 (9%) and 12 (40%) feet in group I and II respectively. Favourable outcomes were noticed in 22 (65%) feet in non-idiopathic group and 12 feet (35%) underwent extensive soft tissue release as compared to 3 feet (2.4%) in idiopathic variety.ConclusionDeformities improved significantly in non-idiopathic clubfeet with Ponseti methods although complete correction was not possible. Extensive surgical interventions were reduced in up to 35% feet in non-idiopathic variety and hence, it is recommended as primary treatment for all variety of clubfeet, irrespective of their etiology.     

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.     

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.     

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.     

Early results of treatment for congenital clubfoot using the Ponseti method

The purpose of this study was to evaluate the early results of the Ponseti method in reducing extensive corrective surgery rates for congenital idiopathic clubfoot in patients treated in Children's Orthopaedic Clinic and Rehabilitation Department Medical University of Lublin between the years 2007-2011. Thirty-five patients with 47 idiopathic clubfeet were followed prospectively while being managed with the Ponseti method. Clubfoot severity was graded with use of the Dimeglio system. The initial correction was achieved, and early results were measured by using Pirani scoring method.     

Klumpfußbehandlung im Wandel der Zeit

Clubfoot is one of the most common congenital deformities of the musculoskeletal system with incidence rates ranging from 0.6 to 6.8 per 1,000 live births. The treatment of clubfoot historically belongs to one of the oldest orthopedic therapies. By the end of the nineteenth century redressement with various tools, such as clamps, braces and casts was the standard treatment of clubfoot. Through further development of operational capabilities and the fact that soft tissue structures show amore resistant reaction to pressure and strain than the surrounding cartilage and bone, operative therapy was favored in the late twentieth century. Surgical correction involves the release of contracted capsular and ligamentous structures to varying degrees and the lengthening of tendons. In 1963 Ponseti published his method. He recognized that the internal rotation and plantar flexion of the calcaneus is the key deformity. However, his method first became known worldwide at the turn of the millennium as long-term results of release operations showed stiff scar healing and the risk of over-correction as problems in these operations. Many comparative studies have shown the superiority of the Ponseti method regarding invasiveness, primary correction rate, functional outcome and recurrence rate in both idiopathic and non-idiopathic clubfoot. In this article the current literature regarding this will be presented as well as prominent landmarks in the development of clubfoot treatment.     

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.     

Early clubfoot recurrence after use of the Ponseti method in a New Zealand population

BACKGROUND: Nonoperative treatment of idiopathic clubfoot has become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular as a result of published short and long-term success rates in North America. The purpose of the current study was to examine the early rate of clubfoot recurrence following the use of the Ponseti treatment method in a New Zealand population and to analyze patient characteristics to identify factors predictive of recurrence. METHODS: Fifty-one consecutive babies with a total of seventy-three clubfeet treated by the Ponseti technique were followed prospectively for a minimum of two years from the start of treatment. Recurrence, defined as the need for any subsequent operative treatment, was analyzed with respect to the severity at presentation, the time of presentation, the number of casts needed to obtain the initial correction, any family history of clubfoot, ethnicity, and the compliance with postcorrection abduction bracing. Recurrence was classified as minor, defined as requiring a tendon transfer or an Achilles tendon lengthening, or major, defined as requiring a full posterior or posteromedial surgical release to achieve a corrected plantigrade foot. RESULTS: Twenty-one (41%) of the fifty-one patients had a recurrence, which was major in twelve of them and minor in nine. The parents of twenty-six babies (51%) complied with the abduction bracing protocol, and only three of these children had a major recurrence. Compliance with abduction bracing was associated with the greatest risk reduction for recurrence (odds ratio, 0.2; p = 0.009). When the parents had not complied with the bracing protocol, the patient had a five times greater chance of having a recurrence. With the numbers studied, no significant relationships were found between recurrence and the severity at presentation, the time of presentation, the number of casts needed to obtain correction, ethnicity, or a family history of clubfoot. CONCLUSIONS: Compliance with the postcorrection abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformity treated with the Ponseti method. When the parents comply with the bracing protocol, the Ponseti method is very effective at maintaining a correction, although minor recurrences are still common. When the parents do not comply with the bracing protocol, many major and minor recurrences should be expected.     

Management of idiopathic clubfoot in toddlers by Ponseti's method

The Ponseti method has been reported to have successful results in clubfoot patients less than 6 months of age but the literature on its efficacy in older clubfoot patients still remains sparse. In our study, we prospectively evaluated 55 clubfeet (37 patients) to determine clinically whether the Ponseti method is effective in the management of clubfoot in older children between the age of 12 and 36 months (mean: 24.8 months). All the patients belonged to moderate or severe grades of deformity as per the Pirani scoring. Painless, supple, plantigrade and cosmetically acceptable feet were achieved in 49 clubfeet. Seven patients (seven feet) developed recurrence of adduction, varus and equinus deformity whereas three patients (five feet) developed isolated recurrence of equinus deformity. These seven patients responded to repeat treatment and obtained satisfactory outcome. Four of these seven patients underwent tibialis anterior transfer to third cuneiform for dynamic supination. Three patients, those developed isolated recurrence of equinus deformity, underwent repeat tenotomy. One foot achieved satisfactory amount of dorsiflexion, three feet underwent tendoachilles lengthening whereas another foot underwent posterior release to obtain satisfactory dorsiflexion. Six to 12 numbers of casts (mean: 10) were required to obtain correction of clubfoot deformities. Mean period of immobilization in a cast was 13.9 weeks (10-15 weeks). We found that the Ponseti method is effective in children between the age of 12 and 36 months.     

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.     

Relapses in clubfoot treated with Ponseti technique and standard bracing protocol- a systematic analysis

PurposeThe analysis determined the relapses in clubfoot children treated with Ponseti technique and standard bracing protocol and their correlation with overall follow up duration using pooled data from various series. It also tested the prescribed timelines of 5 and 7 years for slow-down/cessation of relapses in clubfoot children.MethodsA systematic literature search was performed for articles published in “Pubmed (includes Medline indexed journals)” electronic databases using key words: “Clubfoot or CTEV or congenital talipes equinovarus”, “Ponseti” for years 1^st January 2001 to 15^th November 2020. Included were studies that addressed treatment of idiopathic clubfoot using the standard Ponseti technique, followed a well defined brace protocol (maintenance of corrected deformity using a central bar based brace and prescribed duration mentioned), reported a minimum mean follow up of 4 years and having relapse as one of their outcome measure. Studies reporting Ponseti technique for non-idiopathic clubfoot, child's age older than 1 year at the time of primary treatment, clubfoot with previous interventions before Ponseti treatment, where relapse and residual deformities were not identified distinctly in follow up, abstract only publications, letter to the editors, case reports, technique papers and review articles were excluded. The following characteristics of clubfoot patients in the selected articles were included for analysis: Patient numbers/feet treated with Ponseti technique; follow up years (<5; 5-7 and >7 years; overall) and corresponding relapse percentages for patients.ResultsThere were total 2206 patients in the included 24 studies. Average follow up was 6 years. The average relapse rates for clubfoot patients in the pooled data stood at 30%. The overall relapse rates increased with a longer follow up and the curve befitted a linear regression equation with weak positive correlation (Pearson correlation coefficient = 0.08). The relapse rates in follow up categories of <5 years (26.6 ± 15.6%), 5-7 years (30.8 ± 16.3%) and >7 years (28.4 ± 6.2%) were similar statistically (Analysis of variance, ANOVA).ConclusionsApproximately 1 in 3 clubfoot patients suffer relapse post Ponseti technique and standard bracing protocol. A weak positive correlation was observed for relapses when correlated with increasing follow up years. The relapses however tend to slow down after initial growth years. There is a need to educate the care receivers regarding the possibility of late relapses despite proper Ponseti treatment and accordingly to keep them under supervised follow up for longer periods.     

Evaluation of the utility of the Ponseti method of correction of clubfoot deformity in a developing nation

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.     

Short-term experience with Ponseti casting and the Achilles tenotomy method for clubfeet treatment in arthrogryposis multiplex congenita

Purpose  This study presents our experience with the Ponseti method of manipulation and casting followed by Achilles tenotomy (AT) in children with arthrogryposis multiplex congenita (AMC). Methods  Five children (ten feet) were followed for at least 24 months after the AT and are the cohort for this study. Their mean age at follow-up was 38.4 months (26 to 48 months), and the average follow-up period was 35.8 months (24–44 months). Treatment was begun within the first months of life. The AT to correct rigid equinus was performed at a mean of 14.4 weeks of life, after 7–10 cast changes (mean 8.4). Clinical criteria by Niki et al. and standard standing AP and lateral radiographs were analyzed for final evaluation. Efficacy of Ponseti casting and AT tenotomy was assessed according to the amount and continuance of the achieved correction. Results  Seven feet had clinically satisfactory results. Among the three unsatisfactory feet, there were two (one child) with rocker-bottom pseudocorrections after repeated bilateral AT and one recurrent clubfoot (one child). Six feet required soft tissue releases at 3, 12 and 21 months after the AT due to recurrence of moderate equinus and adductus. Three feet (two children) underwent repeat AT at 10 and 15 months after the primary procedure. The mean interval between initial AT and redo surgical procedures was 11.8 months (range 3–21 months). Two feet (20%) remained without significant deformity after AT. Conclusion  Clubfoot in AMC responds initially to the Ponseti method of casting, and deformity may be corrected or diminished. In some children, more extensive surgical treatment can be avoided and in others, delayed. Despite the need for additional surgical intervention, the Ponseti method of casting and AT does seem to be an alternative for initial treatment in children with AMC.     

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.     

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.     

Comparative results of the conservative treatment in clubfoot by two different protocols

The current study aims at presenting the results of the two methods of conservative treatment in clubfoot: the Romanian traditional method and the Ponseti method. The study population included 103 children (148 clubfeet) treated in our department between 1998 and 2005. Between 1998 and 2003, the conservative treatment protocol was based upon the Romanian method. The Ponseti method has been used since 2004. The main criterion for the assessment of the efficiency of the two conservative methods in clubfoot is the number of feet requiring surgical treatment - posteromedial release at 18 months. This criterion is clearly in favor of the Ponseti method: four feet (5%) needed posteromedial release in Ponseti group patients versus 13 feet (18%) in Romanian group patients (P=0.0193). The Ponseti method is safe, efficient in the conservative treatment of clubfoot and decreases the number of surgical interventions needed for the correction of the deformation compared with our traditional method.     

Evertor muscle activity as a predictor for recurrence in idiopathic clubfoot

Background

Clubfoot is a complex three-dimensional deformity. Although brace compliance after initial correction was previously found to be significantly associated with recurrence in clubfoot, few previous studies have specifically examined evertor muscle function as a factor that contributes to recurrence in children with idiopathic and non-idiopathic clubfoot. The aim of this study was to investigate the relationship among brace compliance, evertor muscle grading, and recurrence rate in pediatric clubfoot patients.

Methods

Children with idiopathic clubfoot who were treated and followed for a minimum of 2 years were included. Patients who used their brace <20–23 h a day for the first 3 months and then <8–10 h per day during sleep and nap times thereafter were classified as group I. Patients who complied fully by using the brace 23 h a day for the first 3 months and then 8–10 h per day during sleep and nap times thereafter were classified as group II. Demographic and clinical data including age, gender, follow-up time, recurrence, evertor muscle grading, types of surgery, brace compliance, severity of initial deformity, age at onset, number of casts required for initial correction, and the need for Achilles tenotomy were collected and analyzed.

Results

Seventy-nine children with clubfoot were included. There were 47 males and 32 females, mean age was 3.2 years (range 2.1–6.3), and the mean follow-up time was 31.4 months. All patients had follow-up of at least 2 years. Primary correction was obtained in all children. There was no significant difference in mean age, mean follow-up time, or recurrence rate between groups. There was, however, a statistically significant difference in mean brace time between groups (p = 0.002). The recurrence rate was 26.2% in group I and 22.2% in group II. The recurrence rate in group a (Pirani score 0) was 3.9%, group b (Pirani score 0.5) 43.8%, and group c (Pirani score 1) 75% (p < 0.001). No significant association was found between severity of the initial deformity, age at the onset of treatment, number of casts required for correction, or reported brace compliance and recurrence or rates of surgery. Only poor or absent evertor muscle activity was found to be statistically significantly associated with risk of recurrence.

Conclusion

Good evertor muscle grading was found to be a significant protective factor against recurrence of idiopathic clubfoot. Thus, improvement in muscle balance around the ankle, especially the evertor muscle, should be emphasized to parents after the casting regimen is completed and correction is achieved.

     

Improved bracing compliance in children with clubfeet using a dynamic orthosis

Purpose  Non-compliance with foot abduction bracing in children with clubfeet treated with the Ponseti method is the leading risk factor for deformity recurrence. A dynamic foot abduction orthosis is believed to result in improved compliance, fewer skin complications, and fewer recurrences. A case–control trial was conducted to test this hypothesis. Methods  A prospective cohort of children with idiopathic clubfoot using a dynamic brace was compared to a historical control group treated with a standard orthosis. Compliance, skin complications, recurrence, and the need for surgical soft tissue release were compared between groups at equivalent follow-up. Results  The dynamic and standard brace groups are equivalent in age at the start of treatment (1.9 vs. 2.9 months), number of affected feet (97 vs. 92), and severity (average of four casts required for correction in each group). Fifty-seven children were followed in each group for an average of 2 years. All were corrected initially with the Ponseti method. Compliance is higher using the dynamic brace (47/57, 81%) compared to the standard brace (21/57, 47%) (P < 0.001). The recurrence rate is lower using the dynamic brace (11/57, 19%) compared to the standard brace (22/57, 39%) (P < 0.02). Skin complications are fewer in the dynamic brace (2/57, 3%) compared to the standard brace (11/57, 19%) (P < 0.008). Most importantly, five children using the standard brace underwent posteromedial release within 2 years of treatment, compared to none in the dynamic brace group. Conclusion  The dynamic foot abduction brace results in improved compliance, fewer recurrences, fewer skin complications, and reduced rates of surgery in idiopathic clubfoot than the traditional brace after non-operative correction with the Ponseti method.