| Abstract|| |
Background : Though described long back, there has been a renewed interest towards Ponseti method of conservative treatment of clubfoot recently.
Methods : Forty children with idiopathic clubfeet were treated by Ponseti technique. The median age at presentation was 9 days. Twenty-six children with bilateral and 12 children with unilateral clubfeet were graded by the Pirani method at the commencement of treatment and then at the final follow-up. Feet were graded as excellent if the Pirani score was zero, fair, if the sum of mid-foot and hind-foot score was one or less and poor, if the score was more than one. Thirty four children need a heel cord tenotomy and all children received conventional ankle-foot orthosis (AFO) and foot-abduction orthosis (FAO) to maintain correction.
Results : Twenty-eight children had excellent correction, four had a fair outcome and eight cases had relapse in their deformity. Poor splint compliance and fitting along with incomplete correction of the deformity were identified as the chief causes leading to a poor result.
Conclusion : A strict protocol and parent education can improve the outcome for all cases with the Ponseti technique. Key-words: Clubfoot; Congenital talipes equinovarus; Ponseti technique.
|How to cite this article:|
Bhaskar A, Rasal S. Results of treatment of clubfoot by Ponseti's technique in 40 cases : Pitfalls and problems in the Indian scenario. Indian J Orthop 2006;40:196-9
|How to cite this URL:|
Bhaskar A, Rasal S. Results of treatment of clubfoot by Ponseti's technique in 40 cases : Pitfalls and problems in the Indian scenario. Indian J Orthop [serial online] 2006 [cited 2020 Jan 26];40:196-9. Available from: http://www.ijoonline.com/text.asp?2006/40/3/196/34493
| Introduction|| |
Conservative treatment of clubfoot has enjoyed periods of varying popularity and success since decades ,, . Surgery for clubfoot deformity is usually reserved for cases which don't respond to conservative treatment, in relapse cases or when children present late with rigid deformity  . In the recent years, there has been a renewed interest towards conservative treatment of clubfoot, mainly by the proponents of Ponseti and the French technique ,, .
The Ponseti technique was described in the early 1960's, but it is only in the last decade that its benefits in the early treatment of clubfoot deformity have been highlighted ,, .
Although newer imaging modalities that have improved our understanding of the patho-anatomy of clubfoot, a reliable classification system still remains elusive. Of the several classification systems, only the Dimeglio system  and Pirani score are in vogue for their simplicity and satisfactory reliability. The Pirani score is more objective, user-friendly and hence easy to apply for this difficult deformity  .
This study was undertaken to determine the early results following the Ponseti technique in a consecutive series of patients following in the clubfoot clinic. The aim is to highlight the pitfalls and problems which can compromise a satisfactory clinical outcome.
| Patients and Methods|| |
Fifty children referred to the 'Children Orthopaedic Clinic' with a diagnosis of foot deformity were prospectively analysed. Six children had postural clubfeet and four discontinued treatment after the initial casting and hence there were 40 children available for the study. Twenty-six had bilateral clubfeet [Figure - 1] and 14 were unilateral clubfoot. There were 30 boys and 10 girls in the study. The median age at presentation was 9.5 days (2 days - 180 days). Patient and examination data was recorded in a 'Clubfoot proforma'. This database included a detailed birth history, birth weight, and family history. Examination findings included side involved, grading of severity of clubfoot using the Pirani score, other skeletal examination and the neuromuscular assessment.
Treatment comprised of serial casting as advocated by the Ponseti technique. Casts were changed at 10 day intervals. The first cast was directed to improve the cavus component by lifting the first ray. This exaggerates the deformity but is an essential step to unlock the mid-foot. The feet were then gradually abducted using counter-pressure on the head of the talus.
Because of the coupling between the hindfoot joints (subtalar, talo-navicular and calcaneo-navicular) the abduction manoeuvre also led to correction of hindfoot varus. At the end of the fourth cast the dorsiflexion of the hind-foot was assessed. Equinus was judged by the limitation of ankle motion and by Pirani score. Heel cord tenotomy was performed under general anaesthesia when the midfoot score was zero and only hindfoot equinus persisted. A hind-foot score greater than 2 and ankle dorsiflexion less than 15 degrees was indication for tenotomy.
The final cast after tenotomy was kept for four weeks [Figure - 2]. All casts were applied using plaster of paris cast. Only for the last cast which was kept for 4 weeks, a synthetic fibreglass material was used. After final cast removal patients were referred to an orthotist for splints. Two types of splints were used in the post-corrective phase. The conventional ankle-foot-orthosis (AFO) and a Foot Abduction Orthosis (FAO). The AFO [Figure - 3] had a straight medial border and velcro fasteners to hold the foot and leg. The FAO [Figure - 4] consisted of a metal bar with two fitted straight-last shoes attached to its ends. The feet were rotated externally by 50 degrees and a ten degrees dorsiflexion was built into the orthosis.
At three months, supervised radiographs were taken in two planes to assess radiological correction. The talocalcaneal angles were measured in frontal and lateral radiographs and the relationship between talus and calcaneum ossific nucleus was also noted.
Parents were advised to ensure splint compliance for at
least 23 hours a day. The FAO was to be maintained for 16 hours and for the remaining time the AFO could be used. Non-compliance was defined as the inability to adhere to the above mentioned criteria and also delay in changing the splint as the foot size changed.
The mean duration of follow up was 12 months (9 - 15 months). Patients were assessed at one month intervals following complete correction of deformity. At each visit the foot was assessed for any loss of correction, i.e., limitation of ankle motion, empty heel sign and, curving of lateral border of foot. The earliest sign of relapse was the loss of ankle dorsiflexion. The splint fitting and compliance was recorded and any modifications required were discussed with the family.
Results were graded as excellent, if the Pirani score remained zero; fair, if the total score was one (Hind foot score and mid foot score) or less and poor if the total score exceeded one. We used this simple assessment for grading the outcome as the follow-up period was short and as also this would help us to detect the early relapses. A more comprehensive assessment is planned at 7 years.
| Results|| |
At the commencement of treatment, of the 26 bilateral clubfeet (52 feet), 24 children (48 feet) had a Pirani score of six, and two children (four feet) had a Pirani score of five. In the unilateral group the mean Pirani score was 5.07 (range 5 - 6).
The mean MFS and HFS for the entire group was 2.9 (range 2.5-3) and 2.71 (range 2-3) respectively. Thirty four children needed the heel cord tenotomy, 22 in the bilateral group and 12 in the unilateral group. The mean midfoot score and hindfoot score for the entire group at the time of tenotomy was 0.56 and 2.55 respectively. After cast removal, the feet were measured for splints. The mean delay between final cast removal and fitting of splints was 4.5 days (3 - 12 days).
The results were graded for all feet. All feet with relapse were graded as a poor on using the Pirani score. In the bilateral group 16 children had complete correction of their deformity, and four had a fair outcome. In the unilateral group 12 children had an excellent outcome.
Eight children had a relapse of their deformity. Six were in the bilateral group and 2 were in the unilateral group. Of the six children (12 feet) in the bilateral group, two children (four feet) had complete relapse, three children had relapse on the left foot (3 feet) and one child had relapse on the right foot. In the unilateral group both the relapses was on the left side. All eight relapses were seen at a mean duration of five months (3 - 8 months) after achieving complete correction.
The splint compliance was compromised in the relapsed cases. In three children the FAO was used infrequently and it was almost never used in 2 children. In three children a poor fitting orthosis was used and this could have lead to a recurrence. In two children the equnius was corrected only up to 90 degrees neutral alignment and not 15 degrees dorsiflexion as recommended. The heel cord tenotomy was deferred in these two cases and subsequent correction was lost as the foot relapsed into equinus and varus. Of the eight relapses, two underwent a complete sub-talar release, two had posterior release and the remaining were treated with subsequent casting.
Few complications were encountered. One child had a plaster sore on the lateral aspect of the skin overlying the talar head. This healed with local dressing only.
Two children developed an allergic reaction to the softroll. One child developed transitory discolouration of the toes following heel cord tenotomy and correction of equinus. This was probably due to vascular spasm, and resolved uneventfully. No wound problems were seen related to the percutaneous incision.
| Discussion|| |
Correction of clubfeet by non-operative means entails a thorough understanding of the patho-anatomy of this complex deformity 8 . The indications, pitfalls and results of the Ponseti technique have been well described and several studies have attested to its efficacy. The French technique is time-consuming and requires dedicated physiotherapists to perform the correction , .
The conservative treatment of clubfoot has three phases: the corrective phase involves application of casts, the maintenance phase where splint fitting is emphasized and the transition phase where the splints are discontinued and regular foot wear allowed. Problems can occur in any phase due to many causes: incorrect casting technique, improper tenotomy, under-corrected deformity, ill - fitting splints, lack of understanding and poor compliance can all affect a successful outcome.
This study showed good results with the Ponseti technique in 80 % of cases. There was no difference in the mean Pirani grade between successful and relapse cases (5.07 and 5.12 respectively)
The relapse rate in eight cases highlights the learning curve with this technique and also the need to adhere to the correct technique. There were more relapse on the left side (6 out of 8 feet) and this perhaps may reflect right hand dominance of the treating surgeon. Thus, a more abduction force may be required to correct the left foot when left hand is the abduction side.
There were three main issues which lead to inferior results in this study: splint compliance, splint fitting and undercorrection.
Poor splint compliance was a major issue especially in children coming form low socio-economic strata and where the parents education level was poor. In addition, referral to different orthotists led to fabrication of ill-fitting splints in three children. This compounded the problem and led to loss of correction in all three cases.
We now advocate tenotomy in every case to achieve at least 15 degrees of ankle dorsiflexion. This is a critical step as frequently equinus is the first sign of recurrence. In this study casts were changed at 10 days intervals and not at 7 days as recommended. We do not feel this would have led to more relapse. The 10 day interval was mainly to fit in as many patients in a single session for subsequent cast changes
We also currently recommend use of a commercially available FAO to offset any problems with fabrication by various orthotists. Thus, in conclusion, although the foot morphology improves with rigid adherence to the casting technique it is in the post-correction phase which needs careful attention and close follow up to ensure a successful outcome.
| References|| |
|1.||Bensahel H, Guillaume A, Czukonyi Z et al. Results of physical therapy for idiopathic clubfoot: a long term follow-up study. J Pediatr Orthop. 1990; 10:189-192. |
|2.|| Carroll NC. Clubfoot: what have we learned in the last quarter century? J Pediatr Orthop. 1997; 17:1-2 |
|3.||Kite JH. Principles involved in the treatment of congenital clubfoot. J Bone Joint Surg. 1939; 21: 595-606 |
|4.||Aronson J, Puskarich CL. Deformity and disability from clubfoot. J Pediatr Orthop. 1990; 10:109-19 |
|5.||Richards BS, Johnston CE, Wilson H. Nonoperative clubfoot treatment using the French physical therapy method. J Pediatr Orthop. 2005; 25(1): 98-102 . |
|6.||Thacker MM, Scher DM, Sala DA et al. Use of foot abduction orthosis following Ponseti casts - is it essential. J Pediatr Orthop. 2005;25(2): 225-28 |
|7.||Ponseti IV, Smoley EN. Congenital clubfoot: results of treatment. J Bone Joint Surg. 1963; 45: 261-75 |
|8.||Ponseti IV, Campos J. Observations on the pathogenesis and treatment of congenital clubfoot. Clin Orthop 1972; 84: 50-60. [PUBMED] |
|9.||Dimeglio A, Bensahel H, Souchet P et al. Classification of clubfoot. J pediatr Orthop (B). 2005; 22: 517-21. |
|10.||Lehmann WB, Mohaideen A, Madan S, et al. A method for the early evaluation of the Ponseti (Iowa) technique for the treatment of idiopathic clubfoot. J Pediatr Orthop (B). 2003; 12: 133-140. |
Apt 403, Bldg No 18, MHADA complex, Oshiwara, Andheri, Mumbai 4000 053
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]