| Abstract|| |
Introduction: Idiopathic congenital talipes equinovarus (Club Foot) is a complex deformity that is difficult to correct. The goal of treatment is to reduce or eliminate its four components so that the patient has a functional, pain free, plantigrade foot, with good mobility and without calluses, and does not need to wear modified shoes.
Material and Methods: We have treated 41 patients with 60 idiopathic clubfoot deformity using Ponseti method of management. The severity of foot deformity was assessed according to the grading system of Dimeglio et al.
Results: The mean number of casts that were applied to obtain correction was six (range four to nine casts). Tenotomy was done in 58 feet. Fifty eight feet had good results.Two patients developed recurrence of the deformity due to non-compliance of the use of orthrotics.
Conclusion: The Ponseti method is a safe and effective treatment for congenital idiopathic clubfoot and radically decreases the need for extensive corrective surgery. Non compliance with orthotics has been widely reported to be the main factor causing failure of the technique.
Keywords: Idiopathic clubfoot; Ponseti technique; Manipulation and cast application.
|How to cite this article:|
Agrawal R A, Suresh M S, Agrawal R. Treatment of congenital club foot with Ponseti method. Indian J Orthop 2005;39:244-7
| Introduction|| |
Idiopathic congenital talipes equinovarus is a complex deformity that is difficult to correct  . It is one of the most common congenital deformities. The ratio of male to female is 3:1, and 40% of cases are bilateral  .
The prevalence of both immediate and long-term complications in surgically treated clubfoot has cultivated a renewed interest in nonsurgical treatment  . The Ponseti method involves serial manipulation, a specific technique of cast application, and a possible percutaneous tendo achilles tenotomy. It is reported to provide a lower complication rate, less pain and better function as the patient ages as compared to operative treatment  .
The method has been reported to have short-term success rates approaching 90% and the long-term results have been equally impressive  . Complications occurring as a result of this technique have not been reported  . The aim of this study is to present the author's experience with the Ponseti technique in correcting clubfoot and to stress the importance of percutaneous tenotomy in management.
| Materials and methods|| |
We have treated 41 patients with sixty idiopathic clubfoot deformities using Ponseti method of management. All patients with secondary congenital talipes equino varus were excluded from this study. The severity of foot deformity was assessed according to the grading system of Dimeglio et al . In this system, four parameters are assessed on the basis of their reducibility with gentle manipulation as measured with a handheld goniometer: (1) equinus deviation in the saggital plane, (2) varus deviation in the frontal plane, (3) deviation around the talus-calcaneo-forefoot in the horizontal plane, and (4) adduction of the forefoot relative to the hind foot in the horizontal plane. A score is assigned to each one of the four parameters on a 4 point scale, with 4 points indicating reducibility from 90° to 45°; 3 points, reducibility from 45° to 20°; 2 points, reducibility from 20° to 0°; 1 point, reducibility from 0° to 20°; and 0 point reducibility of less than -20°. The sum of these parameters constitutes a 16-point scale. Four additional points are awarded, one point each for a marked posterior crease, medial crease, cavus deformity and poor muscle condition. Poor muscle conditions constitute fibrous, hypertonic or contracted tendo-achilles, tibial or peroneal muscles. These add up to a total of 20 points.
The feet were graded according to the severity of the deformity. Grade - - I feet had a mild deformity, were >90% reducible and had a score of 0 to 5 points. Grade - - II feet had a moderate deformity, were partially reducible and had a score of 5 - - 10 points. Grade - - III feet had a severe deformity, were more resistant than reducible and had a score of 10 - - 15 points. Grade - IV feet had a very severe deformity, were irreducible and had a score of 15 - - 20 points  .
All clubfoot deformities were graded according to Dimeglio et al  system before and after treatment. Any residual deformities or complications during treatment were recorded. The number of casts required to obtain correction and the need for tenotomy was also recorded. Demographic data including age, sex and bilateral deformity were noted.
Treatment regimen: The Ponseti method of management was used according to the following regimen:
All patients of less than 2 years age were treated by Ponseti technique as soon as possible after referral. Treatment consists of gentle manipulation of the foot and serial application of long leg plaster cast without the use of anesthesia, as described by Ponseti  . In all patients, cavus was corrected first by supinating the forefoot and dorsiflexing the first metatarsal. Failure to supinate the forefoot as the first step ultimately leads to incomplete correction of the clubfoot. To correct the varus and adduction, the foot in supination was abducted while counterpresure was applied with the thumb against the head of the talus. Casts were changed weekly after proper manipulation of the foot until good correction is obtained [Figure - 1]. In the last cast, the foot should be markedly abducted (70°) without pronation. This position was essential in obtaining complete correction and it prevents recurrence. If residual equinus is observed after the adduction of the foot and the varus deformity of the heel has been corrected, a simple percutaneous tenotomy of the Achilles tendon was performed under local anesthesia. After tenotomy, a cast was applied and left in place for three weeks to allow for healing of the tendon.
An orthosis was used to prevent relapse of the deformity. The brace was fitted on the same day as the last POP cast was removed, to prevent relapse/recurrence of the deformity. The real length of the foot sole of the baby was measured in centimeters. An extra centimeter as allowance for growth was not added as the pattern of the shoe already has an allowance for this.
We used well-fitted, open-toed, high-top, straight-last shoes attached to a Denis Browne bar of length equal to the distance between the child's shoulders [Figure - 2]. The corrected foot was maintained in 70° of external rotation with ankle in dorsiflexion. This prevented recurrence of varus deformity of the heel, adduction of the foot, toeing-in and equinus deformity. The normal foot in a unilateral deformity, was placed in 45° of external rotation. The orthosis was worn for twenty three hours a day for the first three months and then at night for twelve hours for three years.
The parents were instructed to perform range of motion exercises for the ankle and foot when it was out of the brace. Two exercises were taught to the parents. In the first exercise the infant was made to squat on level ground while being supported by the parent. This brought the ankle in dorsiflexion and prevents equinus deformity. In the second exercise the parent stabilized the leg with one hand while using the other hand to grasp the foot. The lateral border of the foot was then approximated towards the shin of the foot. These exercises were repeated twenty times at each sitting.
The exercises were performed twice a day for the first three months (when the brace was applied for twenty three hours a day) and five times daily for the next three years (when the brace was applied for twelve hours at night).
The patients were followed up on a weekly basis during the initial stages of treatment. After orthosis was applied, the patient was seen on a monthly basis for three months and then once every three months till the patient was three years of age. The patient was also followed up every six months to one year till skeletal maturity is achieved.
| Results|| |
The average age of the patients was three months (range, 1 day to 22 months of age). Of the 41 infants, 22 had unilateral and 19 had bilateral involvement (60 feet). None of these patients had received any surgical treatment before referral.
The deformity was classified according to the system of Dimeglio et al as grade II (moderate) in 3 feet, grade III (severe) in 17 feet and grade IV (very severe) in 40 feet. The mean number of cast that were applied to obtain correction was six (range four to nine casts). More number of casts was required to obtain correction in very severe deformity. Fifty eight of the 60 clubfeet required percutaneous tendo achilles tenotomy to correct the residual equinus deformity [Figure - 3]. The average follow-up was for three years (range two to four years).
Fifty eight feet were treated successfully using the Ponseti method [Figure - 4]. These patients obtained complete correction of the deformity with dorsiflexion of >20° and plantar flexion of >40°. In the two patients with poor result, correction was obtained after tenotomy but the deformity relapsed. The families of both these patients had not complied with the use of orthosis. The reason given for non-compliance was inconvenience.
| Discussion|| |
In 1948, Ponseti proposed reducing the deformity with successive casts. Although treatment with cast is a very old method, Ponseti's method is based on strict rules established from anatomic evidence. The goal is not to correct the apparent deformation, but on the contrary, to impose a simultaneous supination and abduction of the foot. Once the calcaneopedal block has been derotated, percutaneous tenotomy of the achilles tendon is performed . Extensive open surgery like postero-medial release is commonly associated with long term stiffness and weakness which is avoided by the Ponseti technique  . Comparative studies have shown advantages of Ponseti technique of management over traditional methods of casting. Correction of the heel varus and the increased declination angle of the neck of the talus are better in the club feet treated with Ponseti method of management as compared to traditional casting methods. Three dimensional CT reconstruction of the whole foot also showed that cavus, supination and adduction are corrected much better with Ponseti technique .
Ponseti technique has been reported with 92 to 98 % successful results for the treatment of idiopathic clubfoot ,,, . We have successfully corrected fifty eight (96.7%) of the sixty clubfoot deformities using Ponseti method. The two patients who developed recurrence of the deformity were due to non-compliance with the use of orthrotics. This reason has been widely reported to be the main factor causing failure of the technique ,,,,. Serious bleeding complications have been reported following percutaneous tendo-achilles tenotomy  . However, we did not encounter any of the complications and found it very helpful in obtaining full correction.
The Ponseti method is a safe and effective treatment for congenital idiopathic clubfoot and radically decreases the need for extensive corrective surgery. This technique can be used in children up to 2 years of age. Longer follow-up will decide whether we can continue to match Ponseti's results.
| References|| |
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R A Agrawal
Agrawal Orthopaedic Hospital, Jubilee Road, Gorakhpur - 273013
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]