Good results after Ponseti treatment for neglected congenital clubfoot in Ethiopia: A prospective study of 22 children (32 feet) from 2 to 10 years of age

Background and purpose —

Neglected clubfoot deformity is a major cause of disability in low-income countries. Most children with clubfoot have little access to treatment in these countries, and they are often inadequately treated. We evaluated the effectiveness of Ponseti’s technique in neglected clubfoot in children in a rural setting in Ethiopia.

Patients and methods —

A prospective study was conducted from June 2007 through July 2010. 22 consecutive children aged 2–10 years (32 feet) with neglected clubfoot were treated by the Ponseti method. The deformity was assessed using the Pirani scoring system. The average follow-up time was 3 years.

Results —

A plantigrade functional foot was obtained in all patients by Ponseti casting and limited surgical intervention. 2 patients (4 feet) had recurrent deformity. They required re-manipulation and re-tenotomy of the Achilles tendon and 1 other patient required tibialis anterior transfer for dynamic supination deformity of the foot.

Interpretation —

This study shows that the Ponseti method with some additional surgery can be used successfully as the primary treatment in neglected clubfoot, and that it minimizes the need for extensive corrective surgery.Many children with congenital talipes equino varus (CTEV) in low-income countries end up with neglected clubfoot deformity (untreated children > 2 years) because of the lack of treatment capacity. In Ethiopia, it is estimated that there are 3,000–5,000 new CTEV cases per year, but there are no reliable data available.Neglected clubfoot is a common, disabling problem in Ethiopia. For many years, the treatment for clubfoot in Ethiopia has been nonoperative treatment with Kite’s technique, followed by a posteromedial release, with significant surgical complications and poor results (personal observations by the authors). A dramatic reduction in radical clubfoot operation has been reported in parts of the world where Ponseti treatment has been introduced (Morquende et al. 2004, Zionts et al. 2010). We have the same subjective impression in Ethiopia, but there are no published data.Ponseti treatment was introduced in Ethiopia in June 2005 at the Orthopaedic Department, Black Lion Hospital (BLH), University of Addis Ababa. It has gradually been adopted in several places in a cooperation between BLH and Cure International, Ethiopia. Several thousand children have been involved.In the past decade, the Ponseti method has become recognized globally as the gold standard for clubfoot treatment in younger children (< 2 years old) (Cooper et al. 1995, Bor et al. 2009, Pirani et al. 2009, Sætersdal et al. 2012).There have been some reports of Ponseti treatment being given successfully to children with neglected clubfoot (Verma et al. 2012, Laurenco et al. 2007, Alves et al. 2009), but there has been no general acceptance of treating children older than 2 years with this method. Today, these children are probably treated with radical operations or left untreated (De Rosa and Norrish 2012).Inspired by the results of A. F. Laurenco, which were communicated personally before his article was published in 2007, we treated some neglected children over the age of 2 years when the Ponseti treatment was started in Addis Ababa (at BLH), and the initial results were encouraging.The objective of this study was to prospectively evaluate the short-term results of using the Ponseti technique for treatment of children with neglected clubfoot deformity in a rural hospital in Ethiopia.     

Use of the Ponseti method for recurrent clubfoot following posteromedial release

Background:

A child with recurrent or incompletely corrected clubfoot after previous extensive soft tissue release is treated frequently with revision surgery. This leads to further scarring, pain and limitations in range of motion. We have utilized the Ponseti method of manipulation and casting and when indicated, tibialis anterior tendon transfer, instead of revision surgery for these cases.

Materials and Methods:

A retrospective review of all children treated since 2002 (n = 11) at our institution for recurrent or incompletely corrected clubfoot after previous extensive soft tissue release was done. Clinical and operative records were reviewed to determine procedure performed. Ponseti manipulation and casting were done until the clubfoot deformity was passively corrected. Based on the residual equinus and dynamic deformity, heel cord lengthening or tenotomy and tibialis anterior transfer were then done. Clinical outcomes regarding pain, function and activity were reviewed.

Results:

Eleven children (17 feet) with ages ranging from 1.1 to 8.4 years were treated with this protocol. All were correctable with the Ponseti method with one to eight casts. Casts were applied until the only deformities remaining were either or both hindfoot equinus and dynamic supination. Nine feet required a heel cord procedure for equinus and 15 required tibialis anterior transfer for dynamic supination. Seven children have follow-up greater than one year (average 27.1 months) and have had excellent results. Two patients had persistent hindfoot valgus which required hemiepiphyseodesis of the distal medial tibia.

Conclusion:

The Ponseti method, followed by tibialis anterior transfer and/or heel cord procedure when indicated, can be successfully used to correct recurrent clubfoot deformity in children treated with previous extensive soft tissue release. Early follow-up has shown correction without revision surgery. This treatment protocol prevents complications of stiffness, pain and difficulty in ambulating associated with multiple soft tissue releases for clubfeet.     

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.     

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.

     

Comparison of cast materials for the treatment of congenital idiopathic clubfoot using the Ponseti method: a prospective randomized controlled trial

Background

The Ponseti method of congenital idiopathic clubfoot correction has traditionally specified plaster of Paris (POP) as the cast material of choice; however, there are negative aspects to using POP. We sought to determine the influence of cast material (POP v. semirigid fibreglass [SRF]) on clubfoot correction using the Ponseti method.

Methods

Patients were randomized to POP or SRF before undergoing the Ponseti method. The primary outcome measure was the number of casts required for clubfoot correction. Secondary outcome measures included the number of casts by severity, ease of cast removal, need for Achilles tenotomy, brace compliance, deformity relapse, need for repeat casting and need for ancillary surgical procedures.

Results

We enrolled 30 patients: 12 randomized to POP and 18 to SRF. There was no difference in the number of casts required for clubfoot correction between the groups (p = 0.13). According to parents, removal of POP was more difficult (p < 0.001), more time consuming (p < 0.001) and required more than 1 method (p < 0.001). At a final follow-up of 30.8 months, the mean times to deformity relapse requiring repeat casting, surgery or both were 18.7 and 16.4 months for the SRF and POP groups, respectively.

Conclusion

There was no significant difference in the number of casts required for correction of clubfoot between the 2 materials, but SRF resulted in a more favourable parental experience, which cannot be ignored as it may have a positive impact on psychological well-being despite the increased cost associated.     

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.     

An MRI volumetric study for leg muscles in congenital clubfoot

Purpose

To investigate both volume and length of the three muscle compartments of the normal and the affected leg in unilateral congenital clubfoot.

Methods

Volumetric magnetic resonance imaging (VMRI) of the anterior, lateral and postero-medial muscular compartments of both the normal and the clubfoot leg was obtained in three groups of seven patients each, whose mean age was, respectively, 4.8 months, 11.1 months and 4.7 years. At diagnosis, all the unilateral congenital clubfeet had a Pirani score ranging from 4.5 to 5.5 points, and all of them had been treated according to a strict Ponseti protocol. All the feet had percutaneous lengthening of the Achilles tendon.

Results

A mean difference in both volume and length was found between the three muscular compartments of the leg, with the muscles of the clubfoot side being thinner and shorter than those of the normal side. The distal tendon of the tibialis anterior, peroneus longus and triceps surae (Achilles tendon) were longer than normal on the clubfoot side.

Conclusions

Our study shows that the three muscle compartments of the clubfoot leg are thinner and shorter than normal in the patients of the three groups. The difference in the musculature volume of the postero-medial compartment between the normal and the affected side increased nine-fold from age group 2 to 3, while the difference in length increased by 20 %, thus, showing that the muscles of the postero-medial compartment tend to grow in both thickness and length much less than the muscles of the other leg compartments.     

Ponseti method compared to previous treatment of clubfoot in Norway. A multicenter study of 205 children followed for 8–11 years

Purpose

Despite few studies comparing Ponseti treatment and traditional treatment of clubfoot (talipes equinovarus), the Ponseti method is now accepted as standard treatment for this deformity. The Ponseti method was introduced in Norway in 2003 and the purpose of this multicenter-study was to compare the results of Ponseti treatment with the results of the previous treatment for clubfoot in Norway.

Methods

90 children (134 clubfeet) treated with previous treatment (pre-Ponseti group), were compared to 115 Ponseti treated children (160 clubfeet) (Ponseti group). The previous treatment consisted of casting and surgery if needed. At 8–11 years of age, all children were examined by the same orthopaedic surgeon, the parents answered a questionnaire, all feet were X-rayed and information about surgical procedures was obtained from the patient records.

Results

The number of surgeries was higher in the pre-Ponseti group, and the number of extensive surgeries was 119 in the pre-Ponseti group compared to 19 in the Ponseti group. The range of motion in the ankle joint was better in the Ponseti group. Children in this group had better function, higher satisfaction and less pain according to patient and parent reported outcome measures. The incidence of moderate or severe talar flattening was higher in the pre-Ponseti group.

Conclusion

Ponseti treatment seems to be superior to the previous treatment in Norway, with regards to number and severity of operations, flexibility of the foot and ankle, parent/patient reported outcome and the presence of talar flattening on X-ray.

     

A comprehensive outcome comparison of surgical and Ponseti clubfoot treatments with reference to pediatric norms

Purpose

Isolated congenital clubfoot can be treated either operatively (posteromedial release) or conservatively (Ponseti method). This study retrospectively compared mid-term outcomes after surgical and Ponseti treatments to a normal sample and used multiple evaluation techniques, such as detailed gait analysis and foot kinematics.

Methods

Twenty-six children with clubfoot treated surgically and 22 children with clubfoot treated with the Ponseti technique were evaluated retrospectively and compared to 34 children with normal feet. Comprehensive evaluation included a full gait analysis with multi-segment and single-segment foot kinematics, pedobarograph, physical examination, validated outcome questionnaires, and radiographic measurements.

Results

The Ponseti group had significantly better plantarflexion and dorsiflexion range of motion during gait and had greater push-off power. Residual varus was present in both treatment groups, but more so in the operative group. Gait analysis also showed that the operative group had residual in-toeing, which appeared well corrected in the Ponseti group. Pedobarograph results showed that the operative group had significantly increased varus and significantly decreased medial foot pressure. The physical examination demonstrated significantly greater stiffness in the operative group in dorsiflexion, plantarflexion, ankle inversion, and midfoot abduction and adduction. Surveys showed that the Ponseti group had significantly more normal pediatric outcome data collection instrument results, disease-specific indices, and Dimeglio scores. The radiographic results suggested greater equinus and cavus and increased foot internal rotation profile in the operative group compared with the Ponseti group.

Conclusions

Ponseti treatment provides superior outcome to posteromedial release surgery, but residual deformity still persists.     

The ultrasonography evaluation of talar dysplasia as a potential prognostic factor for predicting the course and outcomes of clubfoot deformity treatment using Ponseti technique

Objective

The aim of this study was to assess the role of sonographic evaluation of Talar dysplasia in predicting the outcome of standard Ponseti method in the treatment of clubfoot deformity.

Surgical Treatment of Congenital Hallux Varus

Background

The purpose of this study was to report outcomes of congenital hallux varus deformity after surgical treatment.

Methods

We evaluated ten feet of eight patients with a congenital hallux varus deformity, including four feet combined with a longitudinal epiphyseal bracket (LEB). There were seven male patients and one female patient with a mean age of 33 months (range, 7 to 103 months) at the time of surgery. Two patients were bilaterally involved. The mean duration of follow-up was 5.9 years (range, 2.3 to 13.8 years). Clinical outcomes were assessed according to the criteria of Phelps and Grogan. Surgical procedures included the Farmer procedure, the McElvenny procedure or an osteotomy at the first metatarsal or proximal phalanx.

Results

The clinical results were excellent in two feet, good in six and poor in two feet. The LEB was associated with hallux varus in four feet and were treated by osteotomy alone or in conjunction with soft tissue procedure.

Conclusions

Congenital hallux varus was successfully corrected by surgery with overall favorable outcome. Preoperatively, a LEB should be considered as a possible cause of the deformity in order to prevent recurrent or residual varus after surgery.     

Pes planovalgus deformity surgical correction in ambulatory children with cerebral palsy

Purpose

Planovalgus foot deformity is common in diplegic and quadriplegic patients. Surgery is the definitive treatment to restore the alignment of the talus, calcaneus, and navicular bones. We aimed, in the current study, to compare the effectiveness of subtalar fusion and calcaneal lengthening, and to assess the recurrence in ambulatory children with cerebral palsy.

Methods

This is a retrospective study of 78 patients (138 feet diagnosed with planovalgus deformity) who underwent surgical correction using subtalar fusion or calcaneal lengthening. Range of motion, radiographic indices, kinematic, and pedobarographic data were used to examine the deformity and the outcome of surgery. A repeated measures analysis of variance (ANOVA) was used to test the study hypothesis.

Results

Most of the patients were diplegic (87.2 %) and the mean age at surgery was 11.9 ± 2.9 years (range from 4.7 to 18.3 years), with a mean follow-up of 5 ± 4.4 years (range from 1 to 15.4 years). Sixty-three feet were treated with calcaneal lengthening, while 75 were treated with subtalar fusion. The feet treated with subtalar fusion were more severe preoperatively. However, both surgery groups showed improvement postoperatively. Among 12 cases of recurrence, medial column fusion was the main surgery performed to correct the deformity.

Conclusions

Surgery is effective in the treatment of planovalgus deformity in ambulatory children with cerebral palsy. Severe and rigid planovalgus feet can be treated effectively with subtalar fusion. Feet with milder deformity show good results, with calcaneal lengthening. Surgery provides good correction in young patients, but there is a higher recurrence rate.

Electronic supplementary material

The online version of this article (doi:10.1007/s11832-012-0413-3) contains supplementary material, which is available to authorized users.     

Congenital idiopathic talipes equinovarus before and after walking age: observations and strategy of treatment from a series of 88 cases

Background

We reviewed a series of newborns, toddlers and ambulating children affected by idiopathic congenital talipes equinovarus (clubfoot). Taking into account the time of diagnosis, stiffness of the deformity and walking age, nonsurgical or surgical treatment was considered. This study reports clinical outcomes, early complications and relapse at mid-term follow-up.

Materials and methods

Fifty-two clubfeet were diagnosed at birth, 12 in non-ambulating children aged between 4 and 12 months and 24 in ambulating children. Feet were classified using the Pirani score. Newborns and toddlers were treated with serial casting (Ponseti); however, toddlers also underwent open Achilles tendon lengthening (2 feet) and posteromedial release (3 feet). In all ambulating children, surgical treatment was always performed: selective medial release combined with cuboid subtraction osteotomy (1 foot), posteromedial release (6 feet), and posteromedial release combined with cuboid subtraction osteotomy (17 feet).

Results

The average follow-up was 5 years (1–6 years). In newborns treated with Ponseti, the results were excellent in 42 feet, good in 6, and poor in 4. In non-ambulating children, the results were excellent in 9 feet, and good in 3. In ambulating children, the results were excellent in 5 feet, good in 16, and poor in 3. No major complications were reported. No overcorrections were observed. The need for open surgery was higher in cases of delayed treatment. In cases of relapse, re-casting and/or more extensive surgery was considered.

Conclusions

Early treatment enables a high rate of good correction to be obtained with serial casting and limited surgery. Conversely, if the deformity is observed after walking age surgery should be considered. Serial casting in cases of late observation and relapse have demonstrated encouraging results.

Level of evidence

IV.

     

Ultrasonographic findings after Achilles tenotomy during Ponseti treatment for clubfeet: Is ultrasound a reliable tool to assess tendon healing?

Introduction

Several studies have claimed ultrasound to be useful and accurate in assessing the healing phase of Achilles tendons after tenotomy during Ponseti treatment for clubfoot deformity. The purpose of our study was to assess the healing process of Achilles tendons ultrasonographically after tenotomy as part of Ponseti clubfoot management and to assess the effects of previously not considered ultrasound properties (anisotropy, partial volume effect), and whether these practical considerations affect accurate measurements which have been claimed possible in previous studies.

Materials and methods

We monitored the post-tenotomy healing process in 15 patients (22 tendons) using high frequency ultrasound for a minimum of six months (range 6–14 months). The scanning was discontinued once a tendon looked normal or when the appearance remained unchanged between scans. We also studied nine patients (11 tendons) who had undergone Achilles tenotomies up to seven years previously (range 34–83 months).

Results

In the immediate postoperative period, ultrasound showed large variations in the distance of the tenotomy from the calcaneum as well as the obliquity and completeness of the surgical division. We encountered pitfalls in the use of ultrasound to define healing stages that were not described previously. Sonography was inaccurate and subjective in assessing both completeness of the surgical division and tendon measurements. Despite ultrasonographically proven incomplete tendon division in 63 % of cases, the clinical effect of an immediate increase of passive foot dorsiflexion from the pretenotomy position with an obvious palpable tendon gap was achieved in all patients. At the end of the study, 65 % of tendons did not achieve a normal appearance.

Conclusions

We do not think that routine ultrasound studies are of any value as an adjunct to clinical assessment intra- and post-operatively. It can give misleading information regarding the need to complete the tenotomy, which may increase risks associated with a further pass of the scalpel blade.     

Radiography and sonography of clubfoot: A comparative study

Background:

Congenital talipes equinovarus is a common foot deformity afflicting children with reported incidence varying from 0.9/1000 to 7/1000 in various populations. The success reported with Ponseti method when started at an early age requires an imaging modality to quantitate the deformity. Sonography being a radiation free, easily available non-invasive imaging has been investigated for this purpose. Various studies have described the sonographic anatomy of normal neonatal foot and clubfoot and correlated the degree of severity with trends in sonographic measurements. However, none of these studies have correlated clinical, radiographic and sonographic parameters of all the component deformities in clubfoot. The present study aims to compare the radiographic and sonographic parameters in various grades of clubfoot.

Materials and Methods:

Thirty-one children with unilateral clubfoot were examined clinically and graded according to the Demeglio system of classification of clubfoot severity. Antero-posterior (AP) and lateral radiographs of both normal and affected feet were obtained in maximum correction and AP talo-calcaneal (T-C), AP talo-first metatarsal (TMT) and lateral T-C angles were measured. Sonographic examination was done in medial, lateral, dorsal and posterior projections of both feet in static neutral position and after Ponseti manouever in the position of maximum correctability in dynamic sonography. Normal foot was taken as control in all cases. The sonographic parameters measured were as follows : Medial malleolar- navicular distance (MMN) and medial soft tissue thickness (STT) on medial projection, calcaneo-cuboid (C-C) distance, calcaneo-cuboid (C-C) angle and maximum length of calcaneus on lateral projection, length of talus on dorsal projection; and tibiocalcaneal (T-C) distance, posterior soft tissue thickness and length of tendoachilles on posterior projection. Also, medial displacement of navicular relative to talus, mobility of talonavicular joint (medial view); reducibility of C-C mal alignment (lateral view); talonavicular relation with respect to dorsal/ ventral displacement of navicular (dorsal view) and reduction of talus within the ankle mortise (posterior view) were subjectively assessed while performing dynamic sonography. Various radiographic and sonographic parameters were correlated with clinical grades.

Results:

MMN distance and STT measured on medial view, C-C distance and C-C angle measured on lateral view and tibiocalcaneal distance measured on posterior view showed statistically significant difference between cases and controls. A significant correlation was evident between sonographic parameters and clinical grades of relevant components of clubfoot. All radiographic angles except AP T-C angle were significantly different between cases and controls. However, they did not show correlation with clinical degree of severity.

Conclusion:

All radiographic angles except AP T-C angle and sonographic parameters varied significantly between cases and controls. However, radiographic parameters did not correlate well with clubfoot severity. In contrast, sonography not only assessed all components of clubfoot comprehensively but also the sonographic parameters correlated well with the severity of these components. Thus, we conclude that sonography is a superior, radiation free imaging modality for clubfoot.     

Midterm results of the Ponseti method in the treatment of congenital clubfoot

Purpose

The Ponseti method has become the gold standard for clubfoot treatment. Although promising short-term results have been published, only a few studies report results at the end of the bracing period. We aimed to evaluate the functional midterm results, rate of recurrence and need for subsequent surgery.

Methods

Patients from our prospective database of clubfeet treated with the Ponseti method with a minimum age of three years were identified. Exclusion criteria were syndrome or neurogenic association, address in a foreign country, presentation after six weeks of age, more than three casts applied elsewhere and correction with less than three casts. A total of 125 patients met the inclusion criteria. The Pediatric Outcomes Data Collection Instrument (PODCI), the disease-specific instrument (DSI) questionnaire and an invitation for a clinical examination were sent out. For patients not presenting for evaluation, data from the last follow-up were extracted.

Results

Seventy questionnaires (56 %) of patients with a mean age of 5.7 years (3.3–8.9 years) were returned. The DSI score (n = 65) was 85.3 (± 13.01 SD) and the PODCI score (n = 59) was 95.5 (± 6.3 SD). A total of 113 of 125 patients (90.4 %) with 182 clubfeet were examined in the study or seen in follow-up. During a mean follow-up of 5.2 years (range 3–8.5 years) a repeat tenotomy was performed in 4 % of cases, a percutaneous Achilles tendon lengthening in 3 %, a tibialis anterior tendon transfer in 13 % and open joint surgery in 5 %. The mean dorsiflexion with knee extended was 15.9° (range 0–32°; SD ±5.5) with 16 feet (9 %) presenting less than 10°.

Conclusions

The functional scores indicate that the Ponseti method results in mostly pain-free feet not limiting age-appropriate activity. In this consecutive case series open joint surgery could be avoided in 95 % of cases with a good functional and anatomic outcome.     

Resistant clubfoot deformities managed by Ilizarov distraction histogenesis

Background:

Resistant clubfoot deformities of the foot and ankle remain a difficult problem even for the most experienced surgeon. We report a series of neglected resistant clubfoot deformities treated by limited surgery and Ilizarov distraction histogenesis.

Materials and Methods:

Twenty one patients with 27 feet having resistant clubfoot deformities were managed by Ilizarov distraction histogenesis from April 2005 to May 2008. The mean age was 12 years (range 8–20 years). A limited soft tissue dissection like percutaneous Achilles sheath tenotomy and plantar fasciotomy were done. Progressive correction of the deformities was achieved through the standard and simple Ilizarov frame construct setting. After removal of Ilizarov frame, a short leg walking cast was used for an additional 6 weeks, followed by an ankle foot orthrosis for 3 months.

Results:

The mean followup period was 18.7 months (range 20-36 months). The mean duration of fixator application was 3.6 months (range 3–5 months). At the time of removal of the fixator, a plantigrade foot was achieved in 25 feet and gait was improved in all patients. There was residual varus hind foot deformity in two patients. Out of 27 feet, 3 (11.11%) were rated as excellent, 17 (62.96%) as good, 5 (18.51%) as fair, and 2 (7.40%) as poor according to Reinkerand Carpenter scale. Excellent and good results (74.07%) were considered satisfactory, while fair and poor results (25.92%) were considered unsatisfactory.

Conclusion:

The short term clinical and functional results of resistant clubfoot deformities with Ilizarov''s external fixator is promising and apparently a good option.