Ponseti Method for clubfoot

NewsBot · Jan 24, 2023

The Ponseti Method for the Treatment of Clubfeet Associated With Down Syndrome: A Single-institution 18-year Experience
Portalatin Perez, Edwin MD et al
Journal of Pediatric Orthopaedics 43(2) e106-e110, February 2023. | DOI: 10.1097/BPO.0000000000002293

Background:
Although the Ponseti method has been used with great success in a variety of nonidiopathic clubfoot deformities, the efficacy of this treatment in clubfeet associated with Down syndrome remains unreported. The purpose of this study is, therefore, to compare treatment characteristics and outcomes of clubfoot patients with Down syndrome to those with idiopathic clubfoot treated with the Ponseti method.

Methods:
An Institutional Review Board–approved, retrospective review of prospectively gathered data were performed at a single pediatric hospital over an 18-year period. Patients with either idiopathic clubfeet or clubfeet associated with Down syndrome who were less than 1 year of age at the outset of treatment were treated by the Ponseti method, and had a minimum of 2 year’s follow-up were included. Initial Dimeglio score, number of casts, need for heel cord tenotomy, recurrence, and need for further surgery were recorded. Outcomes were classified using the Richards classification system: “good” (plantigrade foot +/− heel cord tenotomy), “fair” (need for a limited procedure), or “poor” (need for a full posteromedial release).

Results:
Twenty clubfeet in 13 patients with Down syndrome and 320 idiopathic clubfeet in 215 patients were identified. Average follow-up was 73 months for the Down syndrome cohort and 62 months for the idiopathic cohort. Down syndrome patients presented for treatment at a significantly older age (61 vs. 16 d, P=0.00) and with significantly lower average initial Dimeglio scores than the idiopathic cohort (11.3 vs. 13.4, P=0.02). Heel cord tenotomy was performed in 80% of the Down syndrome cohort and 79% of the idiopathic cohort (P=1.00). Recurrence rates were higher in the Down syndrome cohort (60%) compared with the idiopathic group (37%), but this difference was not statistically significant (P=0.06). Need for later surgical procedures was similar between the 2 cohorts, though recurrences in the Down syndrome group were significantly less likely to require intra-articular surgery (8.3% vs. 65.5%, P=0.00). Clinical outcomes were 95% “good,” 0% “fair,” and 5% “poor” in the Down syndrome cohort and 69% “good,” 27% “fair,” and 4% “poor” in the idiopathic cohort (P=0.01).

Conclusions:
Despite the milder deformity and an older age at presentation, clubfeet associated with Down syndrome have similar rates of recurrence and may have better clinical outcomes when compared with their idiopathic counterparts. When deformities do relapse in Down syndrome patients, significantly less intra-articular surgery is required than for idiopathic clubfeet.
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NewsBot · Jan 24, 2023

Efficacy of 2 Nonpharmaceutical (Non-nutritive Sucking and Human Care Contact) Pain Relief Measures for Idiopathic Clubfoot Casted Using Ponseti Technique
Upadhyay, Ankur et al
Journal of Pediatric Orthopaedics 43(2) e100-e105, February 2023. | DOI: 10.1097/BPO.0000000000002299

Purpose:
This study aimed at exploring the pain and physiological responses exhibited during Ponseti manipulation and casting in clubfoot infants. In addition, we compared the efficacy of 2 nonpharmaceutical techniques (non-nutritive sucking and human care contact) for tackling these responses.

Methods:
The study included children with unilateral and bilateral idiopathic clubfeet between 15 days to 6 months of age. For comparisons, children were divided into control group without any intervention (group A), non-nutritive sucking group (group B), and human care contact group (group C). Pain score (Neonatal Infant Pain Score), heart rate (HR), and oxygen saturation (SpO2) was assessed before, during and 1 minute after casting. These measurements were compared using statistical methods.

Results:
There were 16 children (11 bilateral) in group A, 17 (10 bilateral) in group B, and 18 (8 bilateral) in group C. Before casting, the baseline parameters (Neonatal Infant Pain Score, HR, and SpO2) of the 3 groups were comparable. Groups B and C had a significant reduction in pain score at casting and in postcasting period when compared with group A (P<0.05). Group B (at casting—mean: 174.1/min, postcasting—mean: 168.2/min) had the lowest HR both during and after cast application. Group B had the highest SpO2 among all the 3 groups, both during casting (mean: 95.7%) and after casting (mean: 97.4%) (P<0.05).

Conclusions:
Infants exhibit moderate pain response and altered physiological responses during and after Ponseti casting. Non-nutritive sucking emerged as a better method to lessen these parameters when compared with the conventional technique and human care contact.
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NewsBot · Feb 23, 2023

Effectiveness of the Ponseti Method in the Treatment of Clubfoot: A Systematic Review
Elena López-Carrero et al
Int. J. Environ. Res. Public Health 2023, 20(4), 3714; https://doi.org/10.3390/ijerph20043714

Clubfoot is a common congenital deformity of the lower limbs. It should be treated as soon as possible so that its correction is more easily achieved. The objective of this systematic review was to assess the effectiveness of the Ponseti method in the treatment of clubfoot. A bibliographic search was carried out in different databases, including PubMed and SciELO. Filters such as full text and randomized controlled trial were selected to find those articles that best matched our search. Among the results, we selected the ones that interested us, and the rest were discarded, either because they did not meet the requirements for our work or because they were repeated. In total, we collected 19 articles, but after using the critical evaluation instrument CASPe, 7 of them were eliminated, leaving us with a total of 12 articles for our systematic review. After analyzing the results obtained in the selected articles, we concluded that the Ponseti method is effective in the treatment of clubfoot, presenting a high success rate.
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NewsBot · Mar 30, 2023

Experience with accelerated ponseti technique for treatment of idiopathic clubfoot in a regional orthopaedic hospital in Nigeria
Omolade Ayoola Lasebikan et al
Afr J Paediatr Surg. 2023 Apr-Jun;20(2):106-108.

Introduction: Idiopathic talipes equinovarus (ITEV) 'aka clubfoot' is the most common foot deformity in children. Ponseti technique had been accepted as a standard method for correction. The traditional Ponseti technique for correction is well known. Accelerated Ponseti technique is said to offer some advantages over the standard technique. The aim of this study was to determine and document the efficiency and success rate of accelerated Ponseti technique.

Methods: This was a prospective interventional study which lasted 26 months from February 2017 to April 2019. Twenty-eight patients with 42 feets who met the inclusion criteria were recruited. They had serial manipulation and casting twice every week till percutaneous tenotomy was done as indicated. Final cast usually applied after tenotomy and left for 3weeks. Each patient was followed up for a year corresponding to 9 months after the commencement of night bracing. Data were analysed using SPSS version 20.

Results: The mean age was 8.1 months with a range of 1-36 months. The mean Pirani score recorded was 4.4, while the mean number of casting sessions was 3.6 and the mean duration of treatment was 12.4 days. The tenotomy rate recorded was 42.9%. Pre-bracing assessment of Pirani score, passive ankle dorsiflexion and foot abduction done and repeated after a year revealed optimal correction. The relapsed rate at 1 year was 4.8%. The only complication observed was pressure sore in a patient.

Conclusion: The accelerated Ponseti technique is an efficient method of treatment of ITEV in a much shorter time with a higher success rate. It facilitates compliance with treatment.
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NewsBot · Apr 9, 2023

Anterior Distal Tibial Guided Growth for recurrent equinus deformity in idiopathic Congenital Talipes Equinovarus treated with the Ponseti method
Arya Suman Mishra et al
Foot Ankle Surg. 2023 Mar 29

Introduction: Distal Anterior Tibial Guided Growth has been shown to be useful to correct recurrent equinus deformity after open surgical release for Congenital Talipes Equinovarus. This has not been evaluated in a recurrence after use of the Ponseti method, where soft tissue releases are currently understood as the mainstay of treatment.

Methods: Patients with recurrence of equinus component of CTEV, who underwent DATGG with at least 6-month follow-up were identified retrospectively. The criteria for performing this procedure were (1) equinus not correctable to neutral passively (2) the feeling of a bony block to dorsiflexion clinically as evidenced by a supple Achilles' tendon at maximum dorsiflexion and (3)a finding of a flat-top talus radiologically. Successful treatment was defined by the achievement of heel strike on observation of gait. Details of the index procedure including concurrent procedures, any complications and their treatment, past and subsequent treatment episodes were retrieved from electronic patient records. Pre-op and last available post-op X-rays were evaluated for change in the anterior distal tibial angle and for flat-top talus deformity.

Results: We identified 22 feet in 16 patients, with an average follow-up was 25 (8.8-47.3) months. The mean aDTA changed from 88.9 (82.3-94.5) to 77.0 (65.0-83.9) degrees, which was statistically significant (p < 0.0001) using the Paired t-test. Clinically, 17 feet (77 %) obtained a plantigrade foot with a normal heel strike. Complications were identified in 5 feet and include staple migration, oversized staple, superficial infection, iatrogenic varus deformity. Recurrence after completed treatment was noted in one foot.

Conclusion: This procedure should form a part of the armamentarium of procedures for treating equinus component of CTEV recurrences even in feet not treated previously by open procedures. When used in patients without significant surgical scarring it helps to address bony and soft-tissue factors, leading to effective treatment.
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NewsBot · Apr 14, 2023

Pain behavior of children with bilateral idiopathic clubfoot undergoing Ponseti casting and the effect of non-pharmaceutical pain-relieving agents
Anil Agarwal et al
Arch Orthop Trauma Surg. 2023 Apr 13

Introduction: This study prospectively investigated the pain response and physiological parameters [heart rate (HR) and oxygen saturation (SpO2)] during sequential casting in bilateral clubfoot. Additionally, it explored the role of non-nutritive sucking and human care contact on the observed responses during casting.

Methods: Subjects were allotted to control group (Group A with no intervention) and two intervention groups (Group B: non-nutritive sucking intervention, Group C: human care contact intervention). Neonatal Infant Pain Score (NIPS), heart rate (HR), and oxygen saturation (SpO2) were used to assess the response.

Results: The three groups matched in age and gender characteristics of the participants. Pain response was noted across all groups. The left foot demonstrated a statistically significant preexisting tachycardia which rose further during casting (p < 0.01). Intergroup comparisons revealed that the alteration for NIPS during casting was in following sequence (Group A > C > B, p < 0.00001). The effect of interventions offered in Group B and C lasted in the post-cast period as well (B > C).

Conclusion: The clubfoot child exhibited moderate pain response during casting of both feet. A tachycardia was noted prior to initiation of second cast which further exaggerated with subsequent cast. Pacifier (non-nutritive sucking) intervention produced better control of pain response than human care contact during casting for both feet.
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NewsBot · May 9, 2023

EVALUATION OF EARLY TREATMENT OF IDIOPATHIC CLUBFOOT USING THE PONSETI METHOD
Caio Luiz DE Toledo Oliveira, Geraldo Mota Gonçalves, José Batista Volpon
Acta Ortop Bras. 2023 May 1;31(2)

Congenital clubfoot is one of the most common congenital deformities of the lower limbs, with an estimated incidence of 1 for every 1,000 live births. Its treatment is controversial, and currently the Ponseti method has been widespread, showing promising results and decreasing the need for extensive surgical releases, as was usually done until the introduction of the technique. Currently used in approximately 55 countries, the method has changes and scopes that vary according to the society in which it is applied, with the results and peculiarities of the method molded according to the sample studied.

Objective: To evaluate the clinical outcome of clubfoot treatment using the Ponseti method under local conditions.

Methods: The clinical evaluation will include a descriptive analysis of the sample, as well as radiographic evaluation and family satisfaction with the treatment.

Results: In total, 46% of the patients had good results and no family was dissatisfied with the treatment results. No statistically relevant relationships were found between the studied variables.

Conclusion: The results are good and generally similar to those in the literature. Our epidemiological data generally agree with those reported by other authors
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NewsBot · May 23, 2023

Effectiveness of Ponseti technique in management of arthrogrypotic clubfeet - a prospective study
Noor Alam et al
Int J Burns Trauma. 2023 Apr 15;13(2):33-43. eCollection 2023.

Background: Clubfoot constitutes roughly 70 percent of all foot deformities in arthrogryposis syndrome and 98% of those in classic arthrogryposis. Treatment of arthrogrypotic clubfoot is difficult and challenging due to a combination of factors like stiffness of ankle-foot complex, severe deformities and resistance to conventional treatment, frequent relapses and the challenge is further compounded by presence of associated hip and knee contractures.

Method: A prospective clinical study was conducted using a sample of nineteen clubfeet in twelve arthrogrypotic children. During weekly visits Pirani and Dimeglio scores were assigned to each foot followed by manipulation and serial cast application according to the classical Ponseti technique. Mean initial Pirani score and Dimeglio score were 5.23 ± 0.5 and 15.79 ± 2.4 respectively. Mean Pirani and Dimeglio score at last follow up were 2.37 ± 1.9 and 8.26 ± 4.93 respectively. An average of 11.3 casts was required to achieve correction. Tendoachilles tenotomy was required in all 19 AMC clubfeet.

Result: The primary outcome measure was to evaluate the role of Ponseti technique in management of arthrogrypotic clubfeet. The secondary outcome measure was to study the possible causes of relapses and complications with additional procedures required to manage clubfeet in AMC an initial correction was achieved in 13 out of 19 arthrogrypotic clubfeet (68.4%). Relapse occurred in 8 out of 19 clubfeet. Five of those relapsed feet were corrected by re-casting ± tenotomy. 52.6% of arthrogrypotic clubfeet were successfully treated by the Ponseti technique in our study. Three patients failed to respond to Ponseti technique required some form of soft tissue surgery.

Conclusion: Based on our results, we recommend the Ponseti technique as the first line initial treatment for arthrogrypotic clubfeet. Although such feet require a higher number of plaster casts with a higher rate of tendo-achilles tenotomy but the eventual outcome is satisfactory. Although, relapses are higher than classical idiopathic clubfeet, most of them respond to re-manipulation and serial casting ± re-tenotomy.
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NewsBot · May 29, 2023

Exploring the distribution of risk factors for drop-out from Ponseti treatment for clubfoot across Bangladesh using geospatial cluster analysis
Manon Pigeolet et al
Geospat Health. 2023 May 25;18(1)

Clubfoot is a congenital anomaly affecting 1/1,000 live births. Ponseti casting is an effective and affordable treatment. About 75% of affected children have access to Ponseti treatment in Bangladesh, but 20% are at risk of drop-out. We aimed to identify the areas in Bangladesh where patients are at high or low risk for drop-out. This study used a cross-sectional design based on publicly available data. The nationwide clubfoot program: 'Walk for Life' identified five risk factors for drop-out from the Ponseti treatment, specific to the Bangladeshi setting: household poverty, household size, population working in agriculture, educational attainment and travel time to the clinic. We explored the spatial distribution and clustering of these five risk factors. The spatial distribution of children <5 years with clubfoot and the population density differ widely across the different sub-districts of Bangladesh. Analysis of risk factor distribution and cluster analysis showed areas at high risk for dropout in the Northeast and the Southwest, with poverty, educational attainment and working in agriculture as the most prevalent driving risk factor. Across the entire country, twenty-one multivariate high-risk clusters were identified. As the risk factors for drop-out from clubfoot care are not equally distributed across Bangladesh, there is a need in regional prioritization and diversification of treatment and enrolment policies. Local stakeholders and policy makers can identify high-risk areas and allocate resources effectively.
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NewsBot · Jun 6, 2023

The Tug Test and Modified Ponseti Casting: A Simple and Reliable Method to Improve the Efficacy of Casting in Complex Clubfoot
Sourabh Kumar Sinha, Varun Garg & Vivek Singh
Indian Journal of Orthopaedics (2023)

Background
The clinical entity of complex clubfoot poses a significant challenge to correction by slippage of casts which further complicates the deformity and prolongs the treatment. A static and dynamic component associated with this deformity causing cast slippage was recognized. The purpose of this study was to evaluate the clinical outcomes at the end of the casting period while addressing these issues.

Methods
A retrospective study of 17 patients with 25 complex clubfeet over a period of 2 years was conducted. Tug test was used to ascertain the snugness of the cast. To address the dynamic component, distal extent of the cast was limited to metatarsal heads.

Results
The mean age of patients at diagnosis was 4.41 months (2–7 months). The mean pre-casting Pirani score was 4.8 (4–6) and post casting Pirani score was 0.4 (0–1). A total of 128 casts were applied to correct 25 complex clubfeet. The average number of casts required to achieve correction by the modified Ponseti technique was 5.12 (4–7). Overall, four incidences of cast slippage occurred.

Conclusion
The modified Ponseti technique is effective in the correction of complex clubfoot. Tug test can detect casts which are prone to slippage. Limiting the distal extent of the cast to the metatarsal heads can reduce cast slippage by reducing the repeated downward pressure by the toes on the cast.
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NewsBot · Jul 19, 2023

Achilles tenotomy during Ponseti’s clubfoot treatment: better early than late
Ghanem, Ismata; Ghanem, Dianeb; Rassi, Joea; Saliba, Ibrahima
Journal of Pediatric Orthopaedics B ():10.1097/BPB.0000000000001106, July 03, 2023.

To evaluate the outcome of Achilles tenotomy at first cast in neonates with stiff clubfoot undergoing Ponseti’s method of treatment. One hundred forty stiff clubfeet (Dimeglio grades III and IV) scheduled for Ponseti’s method were prospectively randomized into two groups of 70 each: (1) early, tenotomy at first cast; (2) late, tenotomy at fourth to sixth casts (conventional). The procedure was performed under local lidocaine spray in an office setting using a needle. The results were assessed at an average follow-up of 12.4 years. Technical difficulties and short and long-term complications were recorded. At last follow-up, the results were rated excellent, good, fair, and poor in 70, 18, 9, and 3% of patients in the late group, respectively, and 82, 13, 4, and 1% in the early group (P = 0.048). Technical difficulties were encountered in 38% of the late group and 3% in the early group (P < 0.0001). Flattening of the talar dome of mild to moderate severity was found in 16% of the late group and 4% in the early group (P < 0.001). Early Achilles tenotomy seems to give better results than the conventional late tenotomy, with less short and long-term complications. This may be explained by the greater ease to palpate the Achilles tendon on a previously untreated foot, and the less amount of compressive forces across the tibiotalar and subtalar joints produced by early release of the posterior tether.
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NewsBot · Aug 11, 2023

A four-year clinical and sonographic longitudinal follow-up of clubfeet treated according to Ponseti with normal references
G Arne Johansson et al
J Child Orthop. 2023 May 17;17(3):212-223

Purpose: To follow children with a clubfoot by ultrasonography during the entire treatment period up to 4 years and compare with controls.

Method: Thirty clubfeet in 20 children treated using the Ponseti method and 29 controls were followed by repeated ultrasonography investigations from neonates to the age of 4 years. The previously established coronal medial and lateral, sagittal dorsal and posterior projections were used. Changes over time, correlations to the Diméglio score, and the course of treatment were studied.

Results: The medial malleolus-navicular distance was shorter, while the talar tangent-navicular distance and the talo-navicular angle were larger in clubfeet than in controls even after the initial correction. The healthy feet in unilateral cases did not differ significantly from the controls. The range of motion in the talo-navicular joint was approximately 20° less in clubfeet than in controls during the first four years of life. The medial malleolus-navicular distance (r = -0.58) and the talo-navicular angle (r = 0.66) at the first ultrasonography showed the highest correlation to the number of casts needed to correct the deformities.

Conclusion: Ultrasonography can be used to evaluate the initial degree of deformities in clubfeet and to follow the progress of the treatment and growth. Ultrasonography showed a clear difference between clubfeet and controls during the first four years of life. Although it was not possible to define specific limit values as benchmarks in the treatment, dynamic ultrasonography can provide valuable support in the decision-making process when complementary treatment may be needed.
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NewsBot · Sep 8, 2023

Outcomes of the Ponseti Technique in Different Types of Clubfoot-A Single Center Retrospective Analysis
Maryum Naseer Buttet al
Children (Basel). 2023 Aug 3;10(8):1340

Background: Clubfoot is a congenital deformity that can affect one or both of a newborn's lower extremities. The main objective of the study is to evaluate and compare the outcomes of the Ponseti method for the management of different types of clubfoot. Methods: A retrospective analysis of 151 children with 253 clubfeet (idiopathic untreated, idiopathic recurrent, and syndromic) with at least one year of follow-up was conducted in four months after ethical approval. Data were collected with a structured proforma after the consent of the parents. An independent sample t-test was applied to show the comparison between the groups, and a p-value of 0.05 was considered significant. Results: Out of 151 patients, 76% were male and 24% were female. Out of a total of 235 feet, 96 (63%) were idiopathic untreated, 40 (26.5%) were idiopathic recurrent, and 15 (9.5%) were syndromic clubfoot. The average number of casts was higher in syndromic clubfoot (9 casts per foot). There was no significant difference in the baseline Pirani score of the three groups (p-value > 0.05); but after one year of follow-up, there was a significant difference in the Pirani score of idiopathic and syndromic clubfoot (p-value ≤ 0.05) and between recurrent clubfoot and syndromic clubfoot (p-value = 0.01). Conclusions: The aetiology of syndromic clubfoot affects the outcomes of the Ponseti method and leads to relapse. In idiopathic (untreated and recurrent) clubfoot, the Ponseti method does not produce a significant difference in outcome. Poor brace compliance and a lack of tenotomy lead to orthotic (ankle foot orthosis AFO and foot orthosis FO) use in the day time and the recurrence of clubfoot deformity in these three types of clubfoot.
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Ponseti Method for clubfoot

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Ponseti Method for clubfoot

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