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.     

Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method

The initial treatment of congenital idiopathic talipes equinovarus (clubfoot) is most often nonsurgical. However, surgical treatment in the form of posteromedial release is often undertaken after failure of conservative measures. The prevalence of both immediate and long-term complications in surgically treated clubfeet has cultivated a renewed interest in nonsurgical treatment. The Ponseti method for treating clubfoot has seen a revived interest among those caring for infantile clubfeet. We report on our first 34 infants (57 clubfeet) treated by using the techniques and principles described by Ponseti. Using a standard scoring system, 54 of 57 clubfeet were successfully corrected without requiring posteromedial release. Only 2 patients (3 clubfeet) required extensive surgical correction. There were 6 relapses. In all recurrent cases, there was a lack of compliance with the straight-last shoe and foot abduction bar regimen. Based on this level of initial success, we believe that posteromedial release is no longer necessary for the majority of cases of congenital clubfeet.     

Progression of idiopathic clubfoot correction using the Ponseti method

The Ponseti technique involves sequential clubfoot correction by abduction, supination, and finally dorsiflexion. Although shown to be effective, correction progression has not been examined. The Dimeglio/Bensahel classification system was used to analyze heel equinus, varus, midfoot rotation, adduction, posterior crease, medial crease, and cavus initially and after each casting. From 2000 to 2008, 123 patients (185 feet) with idiopathic clubfeet, aged below 60 days, without prior treatment were grouped by number of casts required. Successive castings achieved goals of reducing cavus and medial crease first, then gradually correcting midfoot rotation, adduction, and heel varus. Unexpectedly, heel equinus improved simultaneously with midfoot variables, as well as with final casting.     

Ponseti versus traditional methods of casting for idiopathic clubfoot

Serial casting is successful in avoiding extensive posteromedial release (PMR) in only 11% to 58% of patients with idiopathic congenital clubfoot. Extensive open surgery is commonly associated with long-term stiffness and weakness. Ponseti claims to avoid PMR in 89% of cases by using his specific technique of manipulation, casting, and limited surgery. The authors report their first 27 patients undergoing the Ponseti technique (34 feet) with a group of 27 matched control patients (34 feet). All patients underwent serial casting, begun within the first 3 months of life. The parameter studied was the need to perform PMR within the first year of life. In the Ponseti group, only 1 (3%) of 34 feet required PMR. In 31 (91%) of 34 feet, percutaneous Achilles tenotomy was performed at age 2 to 3 months. The average duration of casting was 2 months. In the control group, 32 (94%) of 34 feet required PMR within the first year of life, despite a longer casting period. Based on the authors' initial success with the Ponseti method, they no longer believe that PMR is required for most cases of idiopathic clubfoot. Foot abduction splints are crucial to avoid recurrence. Longer follow-up will determine whether the authors can continue to match Ponseti's reported outcomes.     

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.     

Ponseti法治疗先天性马蹄内翻足疗效分析

[目的]评价采用Ponseti法治疗1岁以内先天性马蹄内翻足的疗效。[方法]2005年4月~2008年10月,本院骨科共收治先天性马蹄内翻足病例125例138足,男98例106足,女27例32足,年龄7 d~12个月。按年龄分为新生儿期(7~28 d)、小婴儿期(29 d~6个月)、婴儿期(6~12个月)三组,均按D im eglio评分系统进行评分,应用Ponseti法(手法矫正+石膏固定+经皮跟腱切断+足外展支具)治疗。[结果]病例随访13~42个月,平均25.3个月。按D im eglio评分系统评价疗效,120例132足矫形效果满意,5例6足残余部分畸形行手术治疗。各年龄组治疗优良率无显著差异(P0.05)。[结论]Ponseti法治疗先天性马蹄内翻足疗效确切,是一种很好的保守治疗方法。对于1岁以内先天性马蹄足均可取得优良效果。     

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.     

Persistent clubfoot deformity following treatment by the Ponseti method

The Ponseti method of clubfoot correction is now widely practiced worldwide. Initial correction rates are nearly 100%, but subsequent relapses may occur in up to one-third of patients. Very little has been written by anyone other than Dr Ponseti about the characterization and treatment of recurrent clubfoot deformity following use of the Ponseti method. This review paper is the first one which draws together the current literature on the topic.     

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.     

A method for the early evaluation of the Ponseti (Iowa) technique for the treatment of idiopathic clubfoot

The Ponseti casting technique is reported to have a high success rate in the treatment of idiopathic clubfoot. Non-operative treatment of clubfoot provides a lower complication rate, less pain, and higher function as the patient ages than operative treatment. To demonstrate serial post-treatment change in clubfeet over time, three clubfoot rating systems were utilized in the current study. Patients compliant with the Ponseti technique and treated before the age of 7 months, had a 92% success rate at an early follow-up after casting was completed. It is not the purpose of this article to analyze the long-term clubfoot treatment result but to establish tools which can be used to judge initial success with the Ponseti technique. Complications are few and minor, limited to equipment used and cast technique.     

Treatment of idiopathic clubfoot using the Ponseti method: minimum 2-year follow-up

One hundred and thirty-seven idiopathic clubfeet were treated by the Ponseti technique and followed for at least 2 years. Nine feet (7%) were not corrected with initial casting and required early surgery. Recurrence after correction was related to compliance with bracing. At latest follow-up, two-thirds of those noncompliant with brace had recurrences with one-third of these recurrences requiring more extensive surgery than Achilles tenotomy and anterior tibial tendon transfer while only 14% of those compliant with brace had recurrences with none requiring more than Achilles tenotomy and anterior tibial tendon transfer. Early failures and recurrences constituted about 20% of our 137 feet by 2 years of follow-up. When the Ponseti method was fully followed, including initial casting, compliance with brace and treatment of recurrences by recasting, Achilles tenotomy and/or anterior tibial tendon transfer, our success rate was 93%.     

Worldwide spread of the Ponseti method for clubfoot

The Ponseti method has become the gold standard for the treatment of idiopathic clubfoot. Its safety and efficacy has been demonstrated extensively in the literature, leading to increased use around the world over the last two decades. This has been demonstrated by the increase in Ponseti related PubMed publications from many countries. We found evidence of Ponseti activity in 113 of 193 United Nations members. The contribution of many organizations which provide resources to healthcare practitioners in low and middle income countries, as well as Ponseti champions and modern communication technology, have helped to spread the Ponseti method around the world. Despite this, there are many countries where the Ponseti method is not being used, as well as many large countries in which the extent of activity is unknown. With its low rate of complication, low cost, and high effectiveness, this method has unlimited potential to treat clubfoot in both developed and undeveloped countries. Our listing of countries who have not yet shown presence of Ponseti activity will help non-governmental organizations to target those countries which still need the most help.     

改良Ponseti方法治疗早期先天性马蹄内翻足

先天性马蹄内翻足（congenital clubfoot,CCF）是小儿足部常见的一种先天性畸形,表现为足马蹄、后足内翻、前足内收、高弓。该病严重影响患儿的成长发育、身心健康及日后的生活,目前治疗CCF的办法很多,但复发率较高,不但增加手术次数,而且增加患者治疗费用,也带来不必要的残疾。目前国际公认的早期保守治疗的较好方法是Ponseti方法,     

Early radiographic risk factors for rigid relapse in idiopathic clubfoot treated with the Ponseti method

Background

This study aimed at identifying early risk factors for rigid relapse in idiopathic clubfoot using foot radiographs.

Foot abduction brace in the Ponseti method for idiopathic clubfoot deformity: torsional deformities and compliance

The Ponseti method has shown to be effective in treating idiopathic clubfoot deformity. Application of a foot abduction brace is crucial to long term outcome. Compliance and possible effect on femoral anteversion and tibial torsion were assessed in 20 children with an average bracing period of 33 months. Nineteen patients were compliant with the bracing protocol and highly satisfied with the treatment protocol. Ultrasound measurement of femoral anteversion (40.5 degrees) and tibial external torsion (38.4 degrees) of the affected side were within the normal range. Range of motion of the ankle joint in all clubfeet resulted in an average dorsiflexion of 27.5 degrees. Among our patient group, the method proved to be highly accepted by almost all families, with excellent functional results. Application of the foot abduction brace did not result in pathological changes of femoral anteversion or tibial torsion.