Ponseti Method for clubfoot

NewsBot · Jul 28, 2010

From the latest Podiatry Today:

Current Concepts With The Ponseti Technique

Sharing insights from the literature as well as clinical experience, this author discusses key casting principles of the Ponseti technique, the notion of age restrictions with this treatment option, its effectiveness in children with neuromuscular disorders and whether the Ponseti technique can be beneficial for other orthopedic conditions in infants.
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Full article

NewsBot · Aug 30, 2010

Treatment of Clubfoot with the Ponseti Method: Should We Begin Casting in the Newborn Period or Later?
Iltar S, Uysal M, Alemdaroğlu KB, Aydoğan NH, Kara T, Atlıhan D.
J Foot Ankle Surg. 2010 September - October;49(5):426-431.

The Ponseti method has become accepted worldwide as the treatment of choice for nonoperative management of clubfoot. However, there has been no research on whether casting should begin in the newborn period (</= 30 days old) or later (> 30 days but < 1 year old) or on whether the length of the foot at the beginning of casting is predictive of the outcome of therapy. Therefore, we conducted an investigation to compare outcomes in patients started on casting therapy in the newborn period or later. Outcomes were based on Pirani and Diméglio scores. The study population was comprised of 40 clubfeet in 29 consecutive infants with no associated neuromuscular disease, who underwent Ponseti treatment. The median follow-up was 34 months (range, 20-47 months). Casting began in the newborn period on 26 feet of 18 patients (newborn group), and after 1 month of age on 14 feet of 11 patients (older infant group). Final Diméglio scores were significantly worse for the patients whose casts were applied in the newborn period, compared with those who had the first cast applied at a time >30 days postpartum (P = .04). Infants with feet >/=8 cm in length at the start of cast treatment had better final Diméglio scores than those with feet <8 cm. Our findings suggest that casting according to the Ponseti method should begin in infants older than 1 month of age, or with an involved foot >/=8 cm in length.
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NewsBot · Sep 15, 2010

Short Term Results of Intensive Physiotherapy in Clubfoot Deformity Treated with Ponseti Method.
Nilgün B, Suat E, Engin SI, Fatma U, Yakut Y.
Pediatr Int. 2010 Sep 11.

Purpose: We aimed to determine the efficacy of the physical therapy program as an adjunct to the Ponseti technique in the treatment of idiopathic clubfoot. This study with the presumption of a difference in results between the study group who were included in the physiotherapy program and the control group who performed home exercises.

Patients and Method: Forty affected feet of 29 patients were included in the study. Average age of the control and study groups were15.00 ± 21.33 and 20.30 ± 15.78 months respectively. Passive range of motion of dorsiflexion, plantar flexion, inversion, eversion, rear foot varus angle and forefoot adduction angle were measured and the Dimeglio classification system was utilized in order to determine the severity of clubfoot deformity. Reassessments were carried out for the study group at the end of 1 month's therapy and for the control group during the 1st month follow-up.

Results: Comparison of pre and post treatment assessment results revealed a difference in terms of recovery, concerning all parameters except passive inversion values in the study group and for all parameters in the control group (p < 0.05). For study and control group comparisons, since deformity severity was higher in the study group an effect size analysis was carried out. The effect size analysis showed that the change in range of motion of dorsiflexion and Dimeglio and decrease of rear foot varus angle was higher in the study group

Conclusion: The results of this study imply that an intensive physiotherapy program may enhance the effectiveness of the Ponseti protocol.
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NewsBot · Oct 30, 2010

Unilateral foot abduction orthosis: is it a substitute for Denis Browne boots following Ponseti technique?
George HL, Unnikrishnan PN, Garg NK, Sampath J, Bruce CE.
J Pediatr Orthop B. 2010 Oct 27. [Epub ahead of print]

The use of foot abduction orthosis [Denis Browne boot (DBB)] is vital for maintaining correction after the Ponseti technique for treating idiopathic clubfoot. Lack of adherence to DBB regimen is reported to be a potent cause for recurrence. Adherence to the boots and bars programme is difficult and patients sometimes resist their use. The evaluation of alternatives that may facilitate adherence is therefore necessary and reasonable. There are less data published regarding the outcome after the use of alternative splints. In patients who showed poor adherence to DBB, we introduced a novel unilateral foot abduction orthosis (UFAO) as an alternative. The aim of this study was to determine whether the recurrence rates were increased by exchanging DBB with UFAO in nonadherent patients and to find out whether UFAO was more acceptable to families who had refused to use DBB. We reviewed 27 children with 35 idiopathic clubfeet. Twenty-three patients used the boots and bars programme for the first 3 months after completion of serial casting, before UFAO was introduced into the treatment plan for resistance to DBB usage. In four cases, UFAO was commenced immediately after the serial casting. The mean follow-up was 25 months (16-36 months). Most families reported that UFAO was easier for their child to use and facilitated adherence was observed. Recurrence (the need for further casting or operation) was observed in 11 feet. Six of these 11 recurrences responded favourably to a further period of serial casting with or without repeated tendoachilles tenotomy. Three of these 11 patients responded favourably to tibialis anterior transfer and two required a traditional posteromedial release. The recurrence rates in patients using UFAO were higher compared with those reported by others using DBB after Ponseti serial casting. Our results indicated that although a unilateral orthosis is preferred and accepted by families who do not adhere to a DBB regimen, recurrence with UFAO use is higher. This study therefore questions the effectiveness of UFAO as an alternative to DBB. The importance of following the original method described by Ponseti should be stressed.
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NewsBot · Nov 13, 2010

Ponseti's manipulation in neglected clubfoot in children more than 7 years of age: a prospective evaluation of 25 feet with long-term follow-up.
Khan SA, Kumar A.
J Pediatr Orthop B. 2010 Sep;19(5):385-9.

We wanted to evaluate the efficacy of Ponseti's technique in neglected clubfoot in children more than 7 years of age. The results of Ponseti's method were evaluated in 21 children (25 feet) with neglected club feet. Patients were evaluated using the Dimeglio scoring system. All patients underwent percutaneous tenotomy of the Achilles tendon. The mean age at the time of treatment was 8.9 years. The mean follow-up period was 4.7 years. The average Dimeglio score at the start of the treatment was 14.2 compared with an average score of 0.95 at the end of the treatment at 1-year follow-up. Eighteen feet (85.7%) had full correction. Recurrence was seen in six feet (24%). At 4-year follow-up, the average Dimeglio score for 19 feet was 0.18. We recommend that Ponseti's method should be the preferred initial treatment modality for neglected clubfeet.
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NewsBot · Nov 13, 2010

The effect of neuromuscular electrical stimulation on congenital talipes equinovarus following correction with the Ponseti method: a pilot study.
Gelfer Y, Durham S, Daly K, ****rit R, Smorgick Y, Ewins D.
J Pediatr Orthop B. 2010 Sep;19(5):390-5.

The Ponseti method for clubfoot treatment offers satisfactory initial correction, but success correlates with abduction brace compliance, which is variable. Electrical stimulation as a dynamic intervention to prevent relapses was investigated. Data were compared to a control group. There was a significant improvement in ankle range of motion only in the study group after short-term intervention, and a trend toward greater increase in calf circumference in this group. Parental perception was positive with no compliance issues. This study suggests stimulation is feasible with potential to increase ankle range of motion and facilitate muscle activity. It could be an important adjunct in preventing relapses, however, further studies with larger groups and longer intervention and follow-up duration are necessary.
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NewsBot · Dec 25, 2010

Treatment of clubfoot with the Ponseti method: should we begin casting in the newborn period or later?
Iltar S, Uysal M, Alemdaroğlu KB, Aydoğan NH, Kara T, Atlihan D.
J Foot Ankle Surg. 2010 Sep-Oct;49(5):426-31.

The Ponseti method has become accepted worldwide as the treatment of choice for nonoperative management of clubfoot. However, there has been no research on whether casting should begin in the newborn period (< or = 30 days old) or later (> 30 days but < 1 year old) or on whether the length of the foot at the beginning of casting is predictive of the outcome of therapy. Therefore, we conducted an investigation to compare outcomes in patients started on casting therapy in the newborn period or later. Outcomes were based on Pirani and Diméglio scores. The study population was comprised of 40 clubfeet in 29 consecutive infants with no associated neuromuscular disease, who underwent Ponseti treatment. The median follow-up was 34 months (range, 20-47 months). Casting began in the newborn period on 26 feet of 18 patients (newborn group), and after 1 month of age on 14 feet of 11 patients (older infant group). Final Diméglio scores were significantly worse for the patients whose casts were applied in the newborn period, compared with those who had the first cast applied at a time >30 days postpartum (P = .04). Infants with feet > or =8 cm in length at the start of cast treatment had better final Diméglio scores than those with feet <8 cm. Our findings suggest that casting according to the Ponseti method should begin in infants older than 1 month of age, or with an involved foot > or =8 cm in length.
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carolethecatlover · Dec 28, 2010

Where can one get training in the ponsetti method in Australia?

Bug · Dec 28, 2010

Ponsetti conferences and also tertiary hospitals as this is where the treatment is provided.

It needs to be done with Paed Ortho's on staff so at the moment is generally done by physiotherapists.

Happy to be corrected but I only know of 2 ponsetti trained pod's in Australia and only one that is practicing.

NewsBot · Jan 15, 2011

Mid-term Results of Ponseti Method for the treatment of Congenital Idiopathic Clubfoot - (A Study of 67 Clubfeet with Mean Five Year Follow-Up).
Porecha MM, Parmar DS, Chavda HR.
J Orthop Surg Res. 2011 Jan 12;6(1):3. [Epub ahead of print]

BACKGROUND: Long-term success reports by Dr. Ponseti with the Ponseti method in the treatment of congenital idiopathic clubfoot have led to a renewed interest in this method among pediatric orthopedists. The purpose of this study is to evaluate mid-term effectiveness of Ponseti method for the treatment of congenital idiopathic clubfoot. Material and Methods: A total of 49 patients (67 clubfeet) were treated by Ponseti method by single orthopedic surgeon during the period of October 03 to July 07 and were studied prospectively up to July 10 (mean follow up period 5 years, minimum follow-up period of 3 years). Age at the initiation of the treatment, gender, bilaterality, severity of the initial clubfoot deformity measured by Pirani Severity Score System, total numbers of Ponseti casts before the tenotomy, details of tenotomy, compliance with brace and CTEV shoes were examined. Passive range of movements and look of club foot are evaluated with mean 5 years follow-up.

RESULTS: We followed the functional Ponseti Scoring System and got good to excellent results in 44 patients - 89.79% (58 clubfeet - 86.56%) at mean five year of follow up. Parents of 32 patients (65.30%) accept the look of the clubfoot nearly normal and parents of 12 patients (24.49%) accept the look of clubfoot as normal. Of the 49 patients who responded to initial Ponseti casting, 14 patients - 28.57% (19 clubfeet - 28.35%) had relapse at varying age; out of which 9 patients - 64.29% (10 clubfeet - 52.63%) were corrected by Ponseti casting method, while 5 patients - 35.71% (9 clubfeet - 47.37%) were resistant to Ponseti method. Poor compliance with the Denis Browne splint was thought to be the main cause of failure in these patients.

CONCLUSION: Ponseti method is a safe and satisfactory treatment for congenital idiopathic clubfoot with mid- term effectiveness.
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NewsBot · Mar 1, 2011

An accelerated Ponseti versus the standard Ponseti method
A PROSPECTIVE RANDOMISED CONTROLLED TRIAL
Journal of Bone and Joint Surgery - British Volume, Vol 93-B, Issue 3, 404-408

We conducted a prospective randomised controlled trial to compare the standard Ponseti plaster method with an accelerated method for the treatment of idiopathic congenital talipes equinovarus. The standard weekly plaster-change method was accelerated to three times per week. We hypothesised that both methods would be equally effective in achieving correction. A total of 40 consecutive patients (61 feet) were entered into the trial. The initial median Pirani score was 5.5 (95% confidence interval 4.5 to 6.0) in the accelerated group and 5.0 (95% confidence interval 4.0 to 5.0) in the standard control group. The scores decreased by an average 4.5 in the accelerated group and 4.0 in the control group. There was no significant difference in the final Pirani score between the two groups (chi-squared test, p = 0.308). The median number of treatment days in plaster was 16 in the accelerated group and 42 in the control group (p < 0.001). Of the 19 patients in the accelerated group, three required plaster treatment for more than 21 days and were then assigned to the standard control method. Of the 40 patients, 36 were followed for a minimum of six months.

These results suggest that comparable outcomes can be achieved with an accelerated Ponseti method. The ability to complete all necessary manipulations within a three-week period facilitates treatment where patients have to travel long distances.
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NewsBot · Mar 18, 2011

A Modified Ponseti Method for the Treatment of Idiopathic Clubfoot: A Preliminary Report
Xu, Rui Jiang
Journal of Pediatric Orthopaedics: April/May 2011 - Volume 31 - Issue 3 - p 317–319

Background: The regular Ponseti method for the treatment of idiopathic clubfoot requires a series of manipulations and castings at weekly intervals. It is not known whether the correction could be achieved in a shorter period of time with multiple manipulations and castings per week. This study was designed to evaluate the outcome of a modified treatment program with manipulation and casting offered twice a week.

Methods: The study included the modified group (26 patients with 40 idiopathic clubfeet treated with the Ponseti method twice a week) and the regular group (20 patients with 32 idiopathic clubfeet treated once a week). The average age of the patients at the time of treatment was 63.05 days in the regular group and 92.7 days in the modified group.

Results: All aspects of the deformity with the exception of the equinus were corrected in 20.61 days in the modified group and in 35.35 days in the regular group (P=0.0001). There were no differences between the 2 groups in the average number of casts (P=0.61). Percutaneous Achilles tenotomy was performed in 87.5% (35 of 40) of those in the modified group and 87.5% (28 of 32) of those in the regular group (P=0.47). A corrective surgery for a complete correction of the deformity was performed in 4 feet in the modified group (10%; 2 posteromedial releases; 2 posterior releases) and 3 feet in the regular group (10%; 2 posteromedial releases; 1 posterior release).

Conclusions: The modified Ponseti method with the treatment program twice a week is safe and effective. It significantly shortens the timeframe for the treatment.
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NewsBot · Mar 20, 2011

Comparative study: ponseti method versus French physiotherapy for initial treatment of idiopathic clubfoot deformity.
Chotel F, Parot R, Seringe R, Berard J, Wicart P.
J Pediatr Orthop. 2011 Apr-May;31(3):320-5.

BACKGROUND: Nonoperative treatment avoids the complications after extensive surgery for idiopathic clubfeet. The purpose of this study was to compare retrospectively French physiotherapy and Ponseti method used to treat idiopathic clubfoot in 2 institutions.

METHODS: Two hundred nineteen idiopathic clubfeet (146 patients) managed during a 3-year period (2000 to 2003) were included in this study: 116 clubfeet in group FM were treated according to modified French physiotherapy (with percutaneous heel-cord tenotomy in 17%) and 103 clubfeet in group PM were treated according to the Ponseti method. The use of further surgery was considered as failure of the nonoperative management: complete posteromedial release were noted poor, limited posterior release were noted fair, and nonrelease surgery or nonoperated feet were scored with the modified Ghanem score.

RESULTS: After a mean follow-up of 5.5 years (range, 2.5 to 7.4 y), similar rate of surgery was performed in both groups (21% in group FM and 16% in group PM) but complete posteromedial release was mainly done in group FM (19% of feet), and limited surgery was done in group PM. Results were noted excellent, good, fair, and poor in respectively 55%, 20%, 6%, and 19% of patients in group FM and 79%, 15%, 4%, and 2% of patients in group PM. Results for Dimeglio grade II clubfeet were not different, but results for grade III and grade IV clubfeet were better in PM group.

CONCLUSIONS: Ponseti method enables reduction of extensive surgery compared with French physiotherapy mainly for severe deformities.
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NewsBot · Mar 23, 2011

Unilateral foot abduction orthosis: is it a substitute for Denis Browne boots following Ponseti technique?
George HL, Unnikrishnan PN, Garg NK, Sampath J, Bruce CE.
J Pediatr Orthop B. 2011 Jan;20(1):22-5.

The use of foot abduction orthosis [Denis Browne boot (DBB)] is vital for maintaining correction after the Ponseti technique for treating idiopathic clubfoot. Lack of adherence to DBB regimen is reported to be a potent cause for recurrence. Adherence to the boots and bars programme is difficult and patients sometimes resist their use. The evaluation of alternatives that may facilitate adherence is therefore necessary and reasonable. There are less data published regarding the outcome after the use of alternative splints. In patients who showed poor adherence to DBB, we introduced a novel unilateral foot abduction orthosis (UFAO) as an alternative. The aim of this study was to determine whether the recurrence rates were increased by exchanging DBB with UFAO in nonadherent patients and to find out whether UFAO was more acceptable to families who had refused to use DBB. We reviewed 27 children with 35 idiopathic clubfeet. Twenty-three patients used the boots and bars programme for the first 3 months after completion of serial casting, before UFAO was introduced into the treatment plan for resistance to DBB usage. In four cases, UFAO was commenced immediately after the serial casting. The mean follow-up was 25 months (16-36 months). Most families reported that UFAO was easier for their child to use and facilitated adherence was observed. Recurrence (the need for further casting or operation) was observed in 11 feet. Six of these 11 recurrences responded favourably to a further period of serial casting with or without repeated tendoachilles tenotomy. Three of these 11 patients responded favourably to tibialis anterior transfer and two required a traditional posteromedial release. The recurrence rates in patients using UFAO were higher compared with those reported by others using DBB after Ponseti serial casting. Our results indicated that although a unilateral orthosis is preferred and accepted by families who do not adhere to a DBB regimen, recurrence with UFAO use is higher. This study therefore questions the effectiveness of UFAO as an alternative to DBB. The importance of following the original method described by Ponseti should be stressed.
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NewsBot · Apr 24, 2011

A comparison of ankle foot orthoses with foot abduction orthoses to prevent recurrence following correction of idiopathic clubfoot by the Ponseti method.
Janicki JA, Wright JG, Weir S, Narayanan UG.
J Bone Joint Surg Br. 2011 May;93-B(5):700-704.

The Ponseti method of clubfoot management requires a period of bracing in order to maintain correction. This study compared the effectiveness of ankle foot orthoses and Denis Browne boots and bar in the prevention of recurrence following successful initial management. Between 2001 and 2003, 45 children (69 feet) with idiopathic clubfeet achieved full correction following Ponseti casting with or without a tenotomy, of whom 17 (30 clubfeet) were braced with an ankle foot orthosis while 28 (39 clubfeet) were prescribed with Denis Browne boots and bar. The groups were similar in age, gender, number of casts and tenotomy rates. The mean follow-up was 60 months (50 to 72) in the ankle foot orthosis group and 47 months (36 to 60) in the group with boots and bars. Recurrence requiring additional treatment occurred in 25 of 30 (83%) of the ankle foot orthosis group and 12 of 39 (31%) of the group with boots and bars (p < 0.001). Additional procedures included repeat tenotomy (four in the ankle foot orthosis group and five in the group treated with boot and bars), limited posterior release with or without tendon transfers (seven in the ankle foot orthosis group and two in the group treated with boots and bars), posteromedial releases (nine in the orthosis group) and midfoot osteotomies (five in the orthosis group, p < 0.001). Following initial correction by the Ponseti method, children managed with boots and bars had far fewer recurrences than those managed with ankle foot orthoses. Foot abduction appears to be important to maintain correction of clubfeet treated by the Ponseti method, and this cannot be achieved with an ankle foot orthosis.
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NewsBot · Apr 30, 2011

Progression of idiopathic clubfoot correction using the Ponseti method.
Chaudhry S, Chu A, Labar AS, Sala DA, van Bosse HJ, Lehman WB.
J Pediatr Orthop B. 2011 Apr 27. [Epub ahead of print]

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.
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NewsBot · Jun 15, 2011

Management of idiopathic clubfoot in toddlers by Ponseti's method.
Verma A, Mehtani A, Sural S, Maini L, Gautam VK, Basran SS, Arora S.
J Pediatr Orthop B. 2011 Jun 9. [Epub ahead of print]

The Ponseti method has been reported to have successful results in clubfoot patients less than 6 months of age but the literature on its efficacy in older clubfoot patients still remains sparse. In our study, we prospectively evaluated 55 clubfeet (37 patients) to determine clinically whether the Ponseti method is effective in the management of clubfoot in older children between the age of 12 and 36 months (mean: 24.8 months). All the patients belonged to moderate or severe grades of deformity as per the Pirani scoring. Painless, supple, plantigrade and cosmetically acceptable feet were achieved in 49 clubfeet. Seven patients (seven feet) developed recurrence of adduction, varus and equinus deformity whereas three patients (five feet) developed isolated recurrence of equinus deformity. These seven patients responded to repeat treatment and obtained satisfactory outcome. Four of these seven patients underwent tibialis anterior transfer to third cuneiform for dynamic supination. Three patients, those developed isolated recurrence of equinus deformity, underwent repeat tenotomy. One foot achieved satisfactory amount of dorsiflexion, three feet underwent tendoachilles lengthening whereas another foot underwent posterior release to obtain satisfactory dorsiflexion. Six to 12 numbers of casts (mean: 10) were required to obtain correction of clubfoot deformities. Mean period of immobilization in a cast was 13.9 weeks (10-15 weeks). We found that the Ponseti method is effective in children between the age of 12 and 36 months.
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NewsBot · Jun 17, 2011

Comparison of Ponseti Versus Surgical Treatment in Congenital Talipes Equinovarus
Nicholas M.P. Clarke, Michael G. Uglow, Katy M. Valentine
Journal of Foot and Ankle Surgery published online 16 June 2011.

In the present study we compared the rate of relapse after conservative Ponseti treatment method with that of a historical cohort who underwent conventional operative treatment. From June 2002 to December 2004, 70 patients presented with 107 clubfeet and started Ponseti treatment. Of these 70 patients, 9 (15 feet) were excluded because of a teratologic deformity. Thus, 50 patients with 75 clubfeet were studied (41 [82%] boys and 9 [18%] girls). Data were compiled from the clinic assessment forms and patient notes. All cases resulting in recasting or additional operative procedures were regarded as failure of conservative treatment. The minimum follow-up period was 2 years or failure of the Ponseti method within this period. These data were then compared with the published data from the same center, regarding relapse after the 2-stage operative method. From 1988 to 1995, 86 patients had presented with 120 clubfeet and undergone operative treatment. Of the 86 patients, 68 (91 clubfeet; 48 boys and 20 girls) underwent the 2-stage operative procedure and were followed up to a mean age of 5.7 (range, 2.2 to 9.6) years. The mean age at operative treatment was 8.9 months. The relapse rate of both treatment methods was compared for all feet in all Dimeglio grades. The relapse rate for Ponseti versus surgery was 18.2% versus 0% for grade 2, 36.2% versus 20.4% for grade 3, and 35.3% versus 65.4% for grade 4, respectively. No statistically significant difference was found. The Ponseti method is as valid as the 2-stage operative method for the treatment of clubfoot. The functional outcomes of the 2 treatment methods need to be compared.
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NewsBot · Jul 3, 2011

A comparison of ankle foot orthoses with foot abduction orthoses to prevent recurrence following correction of idiopathic clubfoot by the Ponseti method.
Janicki JA, Wright JG, Weir S, Narayanan UG.
J Bone Joint Surg Br. 2011 May;93(5):700-4.

The Ponseti method of clubfoot management requires a period of bracing in order to maintain correction. This study compared the effectiveness of ankle foot orthoses and Denis Browne boots and bar in the prevention of recurrence following successful initial management. Between 2001 and 2003, 45 children (69 feet) with idiopathic clubfeet achieved full correction following Ponseti casting with or without a tenotomy, of whom 17 (30 clubfeet) were braced with an ankle foot orthosis while 28 (39 clubfeet) were prescribed with Denis Browne boots and bar. The groups were similar in age, gender, number of casts and tenotomy rates. The mean follow-up was 60 months (50 to 72) in the ankle foot orthosis group and 47 months (36 to 60) in the group with boots and bars. Recurrence requiring additional treatment occurred in 25 of 30 (83%) of the ankle foot orthosis group and 12 of 39 (31%) of the group with boots and bars (p < 0.001). Additional procedures included repeat tenotomy (four in the ankle foot orthosis group and five in the group treated with boot and bars), limited posterior release with or without tendon transfers (seven in the ankle foot orthosis group and two in the group treated with boots and bars), posteromedial releases (nine in the orthosis group) and midfoot osteotomies (five in the orthosis group, p < 0.001). Following initial correction by the Ponseti method, children managed with boots and bars had far fewer recurrences than those managed with ankle foot orthoses. Foot abduction appears to be important to maintain correction of clubfeet treated by the Ponseti method, and this cannot be achieved with an ankle foot orthosis.
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NewsBot · Aug 16, 2011

Orthosis noncompliance after the ponseti method for the treatment of idiopathic clubfeet: a relevant problem that needs reevaluation.
Ramírez N, Flynn JM, Fernández S, Seda W, Macchiavelli RE.
J Pediatr Orthop. 2011 Sep;31(6):710-5.

INTRODUCTION:
Idiopathic talipes equinovarus is the most common congenital defect characterized by the presence of a congenital dysplasia of all musculoskeletal tissues distal to the knee. For many years, the treatment has been based on extensive surgery after manipulation and cast trial. Owing to poor surgical results, Ponseti developed a new treatment protocol consisting of manipulation with cast and an Achilles tenotomy. The new technique requires 4 years of orthotic management to guarantee good results. The most recent studies have emphasized how difficult it is to comply with the orthotic posttreatment protocol. Poor compliance has been attributed to parent's low educational and low income level. The purpose of the study is to evaluate if poor compliance is due to the complexity of the orthotic use or if it is related to family education, cultural, or income factors.

METHOD:
Fifty-three patients with 73 idiopathic talipes equinovarus feet were treated with the Ponseti technique and followed for 48 months after completing the cast treatment. There was a male predominance (72%). The mean age at presentation was 1 month (range: 1 wk to 7 mo). Twenty patients (38%) had bilateral involvement, 17 patients (32%) had right side affected, and 16 patients (30%) had the left side involved. The mean time of manipulation and casting treatment was 6 weeks (range: 4 to 10 wk). Thirty-eight patients (72%) required Achilles tenotomy as stipulated by the protocol. Recurrence was considered if there was a deterioration of the Dimeglio severity score requiring remanipulation and casting.

RESULTS:
Twenty-four out of 73 feet treated by our service showed the evidence of recurrence (33%). Sex, age at presentation, cast treatment duration, unilateral or bilateral, severity score, the necessity of Achilles tenotomy, family educational, or income level did not reveal any significant correlation with the recurrence risk. Noncompliance with the orthotic use showed a significant correlation with the recurrence rate. The noncompliance rate did not show any correlation with the patient demographic data or parent's education level, insurance, or cultural factors as proposed previously.

CONCLUSION:
The use of the brace is extremely relevant with the Ponseti technique outcome (recurrence) in the treatment of idiopathic talipes equinovarus. Noncompliance is not related to family education, cultural, or income level. The Ponseti postcasting orthotic protocol needs to be reevaluated to a less demanding option to improve outcome and brace compliance.
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NewsBot · Aug 19, 2011

NewsBot said: ↑

Comparative study: ponseti method versus French physiotherapy for initial treatment of idiopathic clubfoot deformity.
Chotel F, Parot R, Seringe R, Berard J, Wicart P.
J Pediatr Orthop. 2011 Apr-May;31(3):320-5.

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Comments on this study in the latest Lower Extremity Review:
French study favors Ponseti over compatriots’ technique

NewsBot · Aug 24, 2011

Application of Ponseti method in case of neglected talipes equinovarus in 4 years and 9 months old boy with DiGeorge syndrome--case report
Golański G, Niedzielski KR.
Chir Narzadow Ruchu Ortop Pol. 2011 Mar-Apr;76(2):115-7.

Case report of application of Ponseti method in treatment of neglected congenital talipes equinovarus in boy with DiGeorge syndrome who was 4 years and 9 months of age at the beginning of the treatment. Foot was classified as very severe, scored 4.5 points according to Pirani and 15 points according to DiMeglio classification. After 9 casts set according to Ponseti protocol good correction of all components was achieved accept for the equinus deformity. Achilles lengthening procedure was done, but there was necessity to perform posterior release to achieve good dorsiflexion. Finally, goals of treatment were achieved: the foot is flexible, well shaped, pain free, ready for weight-bearing and use of commercial shoes. At current stage of treatment the foot scores 0.5 points according Pirani and 4 points according to DiMeglio classifications.
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NewsBot · Sep 12, 2011

Management of congenital talipes equinovarus using the Ponseti method
A SYSTEMATIC REVIEW
C. R. Jowett et al
Journal of Bone and Joint Surgery - British Volume, Vol 93-B, Issue 9, 1160-1164

We present a systematic review of the results of the Ponseti method of management for congenital talipes equinovarus (CTEV). Our aims were to assess the method, the effects of modifications to the original method, and compare it with other similar methods of treatment. We found 308 relevant citations in the English literature up to 31 May 2010, of which 74 full-text articles met our inclusion criteria. Our results showed that the Ponseti method provides excellent results with an initial correction rate of around 90% in idiopathic feet. Non-compliance with bracing is the most common cause of relapse. The current best practice for the treatment of CTEV is the original Ponseti method, with minimal adjustments being hyperabduction of the foot in the final cast and the need for longer-term bracing up to four years. Larger comparative studies will be required if other methods are to be recommended.
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NewsBot · Sep 21, 2011

Early results of treatment for congenital clubfoot using the Ponseti method
Łukasz Matuszewski, Leszek Gil and Jacek Karski
European Journal of Orthopaedic Surgery & Traumatology; DOI: 10.1007/s00590-011-0860-4

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.
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Simon Spooner · Sep 26, 2011

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NewsBot · Oct 10, 2011

A 14-year longitudinal comparison study of two treatment methods in clubfoot : Ponseti versus traditional
ACTA ORTHOPÆDICA BELGICA 2011, N° 4 (Vol. 77/4) p.522-528
Richard A. Boden, Graham H. Nuttall, Robin W. Paton

The optimal management of idiopathic clubfoot has changed over three decades. Recently there has been an enthusiastic embracing of the Ponseti technique with a move away from the traditional stretch and strap technique. The purpose of this 14-year comparative prospective longitudinal study was to directly assess the differences in results between these two treatment methods. Over the period of this study there were 52,514 births in the local population and all newborns with clubfoot were referred directly to the paediatric orthopaedic surgeon. Patient demographics, the Harrold & Walker Classification, and associated risk factors for clubfoot were collected prospectively and analyzed. If conservative treatment failed to correct the deformity adequately, a radical subtalar release (RSR) was undertaken (the primary outcome measure of the study). There were 114 feet (80 patients) : 64 feet treated ‘traditionally’ and 50 feet with the Ponseti technique. Idiopathic clubfoot was present in 76.25% of patients. Mean time to RSR was 33.3 and 44.1 weeks for the traditional and Ponseti groups respectively. In the traditional group 65.6% (CI : 53.4 to 76.1%) of feet underwent RSR surgery compared to 25.5% (CI : 15.8 to 38.3%) in the Ponseti group. When idiopathic clubfoot alone was analysed, these rates reduce to 56.5% (CI : 42.3 to 69.8%) and 15.8% (CI : 7.4 to 30.4%) respectively. The Relative Risk of requiring RSR in traditional compared to Ponseti groups was 2.58 (CI : 1.59 to 4.19) for all patients and 3.58 (CI : 1.65 to 7.78) for idiopathic clubfoot. Introduction of the Ponseti technique into our institution significantly reduced the need for RSR in fixed clubfoot.
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NewsBot · Oct 27, 2011

Tibiofibular torsion in congenital clubfoot.
Farsetti P, Dragoni M, Ippolito E.
J Pediatr Orthop B. 2011 Oct 24.

Tibiofibular torsion was measured by computed tomography in three series of patients affected by congenital clubfoot who were treated with different protocols. The normal leg of unilateral deformities served as the control. For the bilateral cases, only the right side was included in the study. The angle between the bicondylar axis of the tibia and the bimalleolar axis was the index of tibiofibular torsion. There were 34 clubfeet in the first series, treated with a posteromedial release, and 40 clubfeet in the second series, treated with a modified Ponseti method, whereas the third series included 16 clubfeet, treated with the original Ponseti method. All 90 clubfeet were graded at birth as group 3 according to the Manes classification. No patient had previous treatment. The patients of the first and the second series were followed up to maturity, whereas the patients of the third series were followed up to a maximum of 11 years of age. In the congenital clubfoot, the tibia and the fibula were externally rotated, in comparison with the normal leg; in fact, the average value of the angle of tibiofibular torsion was 32.2° in the first series, 23.9° in the second series, and 21.1° in the third series. In the normal tibiae, the average value of the angle of tibiofibular torsion was 21.4°. The difference between the first series and the normal controls was statistically significant, as was the difference between the first one and the other two series. The value of the tibiofibular torsion angle seems to be related to the manipulation technique used to treat clubfoot: when the manipulation does not allow a progressive eversion of the talus underneath the calcaneus, the external tibial torsion increases. At follow-up, an intoeing gait was present in seven treated clubfeet of the first series. In all of them except one, the highest value of the external tibial torsion angle was observed, with a low value of the Kite's angle and/or residual forefoot adduction. In the treated congenital clubfoot, persistent intoeing is not related to the angle of tibial torsion but rather to the amount of correction of calcaneal inversion and residual forefoot adduction.
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NewsBot · Nov 9, 2011

Management of congenital talipes equinovarus using the Ponseti method: a systematic review.
Jowett CR, Morcuende JA, Ramachandran M.
J Bone Joint Surg Br. 2011 Sep;93(9):1160-4.

We present a systematic review of the results of the Ponseti method of management for congenital talipes equinovarus (CTEV). Our aims were to assess the method, the effects of modifications to the original method, and compare it with other similar methods of treatment. We found 308 relevant citations in the English literature up to 31 May 2010, of which 74 full-text articles met our inclusion criteria. Our results showed that the Ponseti method provides excellent results with an initial correction rate of around 90% in idiopathic feet. Non-compliance with bracing is the most common cause of relapse. The current best practice for the treatment of CTEV is the original Ponseti method, with minimal adjustments being hyperabduction of the foot in the final cast and the need for longer-term bracing up to four years. Larger comparative studies will be required if other methods are to be recommended.
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NewsBot · Nov 24, 2011

Multiple Tenotomies after Ponseti Method for Management of Severe Rigid Clubfoot
Hazem M. ElTayeby
Journal of Foot and Ankle Surgery (in press)

The purpose of the present study was to evaluate the efficacy of multiple tenotomies performed after application of the Ponseti method in reducing the tendency for recurrence in the severe rigid idiopathic clubfoot and limiting the need for application of the hyperabduction brace in the prewalking age. From November 2002 to December 2004, 30 severe (Pirani >5), rigid (nonresilient), idiopathic clubfeet in newly born infants aged 2 to 24 days were treated by the Ponseti method of weekly manipulations and castings until achieving full correction, apart from equinus. With the patient under general anesthesia, through 2 small incisions (2 cm), tenotomy of the Achilles tendon, tibialis posterior, and flexor digitorum longus was performed, together with posterior capsulotomy of the ankle to achieve >30° dorsiflexion in 26 feet. An above the knee plaster cast in extreme dorsiflexion and 70° hyperabduction was applied for 6 to 8 weeks. This was followed by a hyperabduction brace on a full-time basis (23 hours daily) for an additional 6 months. A satisfactory result was achieved after a follow-up period of 2 to 5 (mean 3.8) years. The Pirani score on initial presentation was 5 to 6 and on the final visit was 0 to 0.25, with 10° to 20° passive dorsiflexion of the ankle in those who underwent posterior capsulotomy compared with 5° to 10° in the 4 patients who had not. The number of manipulations needed before tenotomy was 5 to 7 (mean 5.9), reflecting the rigidity of the studied feet. Active plantarflexion to almost normal power was regained at 18 to 30 months of age. A relapse developed in only 1 foot that failed to respond to manipulation and casting. It required posteromedial release and tibialis anterior transfer at 2 years of age. The proposed minimally invasive procedure of open multiple tenotomies and posterior capsulotomy of the ankle is safe and effective. If performed in newly born infants with severe rigid clubfeet followed by strict application of the hyperabduction brace on a full time basis for 6 months, it will ensure full correction of the deformity. Thus, the brace can be discarded before the infant reaches walking age, with no tendency for relapse.
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NewsBot · Dec 3, 2011

The French functional physical therapy method for the treatment of congenital clubfoot.
J Pediatr Orthop B. 2012 Jan;21(1):28-39.

The French method, also called the functional physical therapy method, is a combination of physiotherapy, splinting and surgery à la carte. The French functional physical therapy method consists of daily manipulations of the newborn's clubfoot by a specialized physical therapist, stimulation of the muscles around the foot and temporary immobilization of the foot with elastic and nonelastic adhesive taping. Physiotherapy is optimized by early triceps surae lengthening. Sequences of plaster can also be used. If conservative treatment is no longer effective, surgery should be considered. Mini-invasive surgery is a complementary procedure to nonoperative treatment (surgery 'à la carte'). The French method reduces but does not eliminate the need for mini-invasive surgical procedures. Equinus is the most difficult deformity to treat; posterior release is sometimes necessary in a severe foot. Very severe feet (stiff-stiff; score, 16-20) are still a challenge. However, regular manipulations and splinting improve foot morphology and stiffness, and, ultimately, make surgery easier and less extensive. From the French method to the Ponseti method, the Hybrid method or the 'the third way', combining the advantages of both methods, is the future. The primary reason for relapses is the inability of families to maintain the correction initially achieved. The aim of this work is to provide an overview of the French functional physical therapy method and to help understand how it has evolved over time.
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NewsBot · Dec 18, 2011

Relapse after tibialis anterior tendon transfer in idiopathic clubfoot treated by the ponseti method.
Masrouha KZ, Morcuende JA.
J Pediatr Orthop. 2012 Jan;32(1):81-4.

BACKGROUND:
The Ponseti method for clubfoot correction has demonstrated excellent results. However, relapses are common and continue to be the most important problem facing clubfoot practitioners. Relapses usually require repeated casting and/or surgical intervention with tibialis anterior tendon transfer (TATT). However, recent data on relapses suggest that performing a successful TATT may not be a definitive cure as there may be other processes, such as neuromuscular deficits, that may result in subsequent relapses.

METHODS:
The authors reviewed 66 patients (102 clubfeet) treated by TATT for clubfoot relapses after successful initial treatment by the Ponseti method. Ten patients (15 clubfeet) experienced a subsequent relapse. Demographic, clinical, and treatment data was recorded.

RESULTS:
These patients had a tendency toward a greater number of casts at initial treatment (P=0.14) and they underwent relapse surgery earlier than those who did not relapse after TATT (P=0.05). Two of these patients had a neuromyopathy, diagnosed by muscle biopsy. The treatment of post-TATT relapse included casting (6 patients), ankle foot orthotic (4 patients), physical therapy (2 patients), or bracing (1 patient). One patient was treated by osteotomies of the cuboid and medial cuneiform and 1 patient had a peroneus longus to peroneus brevis tendon transfer.

CONCLUSIONS:
Performing a TATT may not be the definitive treatment for clubfoot relapses as neuromuscular deficits may be involved. In addition, these patients may be at an increased risk of relapse due to the earlier age at which TATT was performed. When there is a high index of suspicion, prompt diagnosis with muscle biopsy is warranted.
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NewsBot · Mar 2, 2012

Mid-term results of Ponseti method for the treatment of congenital idiopathic clubfoot--(a study of 67 clubfeet with mean five year follow-up).
Porecha MM, Parmar DS, Chavda HR.
J Orthop Surg Res. 2011 Jan 12;6:3.

BACKGROUND:
Long-term success reports by Dr. Ponseti with the Ponseti method in the treatment of congenital idiopathic clubfoot have led to a renewed interest in this method among pediatric orthopedists. The purpose of this study is to evaluate mid-term effectiveness of Ponseti method for the treatment of congenital idiopathic clubfoot.

MATERIAL AND METHODS:
A total of 49 patients (67 clubfeet) were treated by Ponseti method by single orthopedic surgeon during the period of October 03 to July 07 and were studied prospectively up to July 10 (mean follow up period 5 years, minimum follow-up period of 3 years). Age at the initiation of the treatment, gender, bilaterality, severity of the initial clubfoot deformity measured by Pirani Severity Score System, total numbers of Ponseti casts before the tenotomy, details of tenotomy, compliance with brace and CTEV shoes were examined. Passive range of movements and look of club foot are evaluated with mean 5 years follow-up.

RESULTS:
We followed the functional Ponseti Scoring System and got good to excellent results in 44 patients--89.79% (58 clubfeet--86.56%) at mean five year of follow up. Parents of 32 patients (65.30%) accept the look of the clubfoot nearly normal and parents of 12 patients (24.49%) accept the look of clubfoot as normal. Of the 49 patients who responded to initial Ponseti casting, 14 patients--28.57% (19 clubfeet--28.35%) had relapse at varying age; out of which 9 patients--64.29% (10 clubfeet--52.63%) were corrected by Ponseti casting method, while 5 patients--35.71% (9 clubfeet--47.37%) were resistant to Ponseti method. Poor compliance with the Denis Browne splint was thought to be the main cause of failure in these patients.

CONCLUSION:
Ponseti method is a safe and satisfactory treatment for congenital idiopathic clubfoot with mid- term effectiveness.
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NewsBot · Mar 7, 2012

Assessment of talipes equinovarus treated by Ponseti technique: Three-year preliminary report.
Yapp LZ, Arnold GP, Nasir S, Wang W, Maclean JG, Abboud RJ.
Foot (Edinb). 2012 Mar 1.

BACKGROUND:
The Ponseti method has become increasingly popular in the treatment of congenital talipes equinovarus (CTEV). Current methods of assessment focus on clinical, functional and radiological outcomes which are subjective and often difficult to repeat. However, integration of biomechanical evaluation can provide objective and quantifiable analysis. This study aims to evaluate the treatment outcome of CTEV patients on the basis of long-term clinical, functional and biomechanical assessment.

METHODS:
Following treatment, five children with CTEV were reviewed annually for the period 2008-2010. Clinical and functional outcomes were graded using parental questionnaires and clinical examination. Biomechanical parameters were evaluated using digital foot pressure studies.

RESULTS:
The study group recorded good clinical and functional outcomes. However, biomechanical studies have been able to identify subtle abnormalities that would be unapparent otherwise on clinical examination.

CONCLUSIONS:
It is recommended that biomechanical assessment be integrated into the overall evaluation of the outcome of CTEV after treatment
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Admin2 · Mar 14, 2012

Use of the ponseti method in the Iranian population.
Panjavi B, Sharafatvaziri A, Zargarbashi RH, Mehrpour S.
J Pediatr Orthop. 2012 Apr;32(3):e11-4.

BACKGROUND:
The most common congenital orthopaedic condition requiring treatment is clubfoot. The Ponseti method, which has improved the recurrence rate, is at present the most attractive method of treatment in the north of America. The purpose of this study was to evaluate the outcome of this method in an Iranian population and look for characteristics that may affect the treatment process.

METHODS:
A total of 78 patients (129 feet) were treated by precisely adhering to the technique originally introduced by Ponseti. Relapse was defined as any return of each of 4 clubfoot components according to the Dimeglio-Bensahel system. The mean follow-up period was 24.7 months and relapse was analyzed with respect to severity of primary disorder, number of casts, compliance with postcorrection bracing and stretching exercise, and educational level of parents.

RESULTS:
At the end of the follow-up, 24 (18.6%) clubfeet experienced relapse as defined. The mean time to relapse was 13.7 months, 30 feet had brace noncompliance, and stretching was not done for 35 feet. Significant association was detected between recurrence and severity of clubfoot, number of casts for complete correction, and bracing and stretching exercise noncompliance.

CONCLUSIONS:
The Ponseti method is a successful treatment protocol for idiopathic clubfoot. Its success rate will increase with use of abduction orthosis after complete correction and also by performing regular stretching exercises.
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Admin2 · Mar 18, 2012

Early results of congenital clubfoot using Ponseti method
Niedzielski KR, Małecki K, Kosińska M, Lipczyk Z.
Chir Narzadow Ruchu Ortop Pol. 2011 Sep-Oct;76(5):247-51.

Congenital clubfoot is one of the most common congenital skeletal defects. Its aetiology remains unclear. Due to its high incidence and social consequences, the therapy of congenital clubfoot presents an important medical issue. Non-surgical treatment methods are preferred. Many publications confirmed the efficacy of the Ponseti method. The aim of this study was to present early results of congenital clubfoot treatment using the Ponseti method in a one-year follow-up. The therapy protocol was in accordance with guidelines presented by the inventor. The necessity of surgical treatment was a criterion for negative treatment outcome. One hundred and sixteen feet of 92 children were analysed. A Dimeglio-Bensahel classification was used for the evaluation of the defect advance. Seventy-one feet (61.2%) were assessed as grade II, 43 feet as grade III (37.1%) and 2 feet as grade IV deformation. No patients with grade I deformation were included into the study. A positive treatment outcome was observed for 96 feet (82.7%), whereas a negative result for the remaining 20 feet (17.3%). Our results are therefore not consistent with the literature data. It could have resulted from the too precipitate qualification for surgery by the physician and problems with compliance. The Ponseti method is an effective and less straining treatment modality of the congenital clubfoot. In most cases it allows for avoiding extensive surgery and associated complications. A necessity of wearing an orthosis and a risk treatment failure, if not worn systematically, should be emphasised. A longer follow-up period is required for complete result analysis.
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NewsBot · Apr 4, 2012

The influence of brace type on the success rate of the Ponseti treatment protocol for idiopathic clubfoot.
Hemo Y, Segev E, Yavor A, Ovadia D, Wientroub S, Hayek S.
J Child Orthop. 2011 Apr;5(2):115-9

PURPOSE:
The success of the Ponseti method for treating idiopathic clubfoot deformity is dependent on the casting techniques and the adherence of the patient to the foot abduction brace protocol. Newly developed brace designs claim to be more comfortable, to be easier to use and to prevent dislodgement of the foot from the brace, making them more efficient and improving patient compliance. They are, however, more costly, and, therefore, accessible to fewer patients. We compared the compliance and treatment outcome using two brace designs, the traditional simple brace of pre-walking shoes attached to a Dennis Browne (DB) bar and the new sophisticated Mitchell brace.

METHODS:
We compared the functional outcome and compliance with the post-corrective bracing protocol of 38 children with idiopathic clubfoot treated in our institution using two brace designs. Twenty-one chose the DB brace and 17 chose the Mitchell brace.

RESULTS:
There was no difference in the compliance rate or in the final clinical and radiological outcomes of the two groups after a minimum of 2 years of follow-up. A positive correlation was found between the Pirani score at the beginning of treatment and the final functional score for both groups. Both groups were satisfied with the selected brace. Both groups were equally compliant with the brace protocol.

CONCLUSION:
We conclude that new and more expensive brace designs do not necessarily provide better clinical results. Fully corrected foot and a strong family-treating team partnership are crucial to adherence with the brace protocol.
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Admin2 · Apr 5, 2012

Management of idiopathic clubfoot in toddlers by Ponseti's method.
Verma A, Mehtani A, Sural S, Maini L, Gautam VK, Basran SS, Arora S.
J Pediatr Orthop B. 2012 Jan;21(1):79-84.

The Ponseti method has been reported to have successful results in clubfoot patients less than 6 months of age but the literature on its efficacy in older clubfoot patients still remains sparse. In our study, we prospectively evaluated 55 clubfeet (37 patients) to determine clinically whether the Ponseti method is effective in the management of clubfoot in older children between the age of 12 and 36 months (mean: 24.8 months). All the patients belonged to moderate or severe grades of deformity as per the Pirani scoring. Painless, supple, plantigrade and cosmetically acceptable feet were achieved in 49 clubfeet. Seven patients (seven feet) developed recurrence of adduction, varus and equinus deformity whereas three patients (five feet) developed isolated recurrence of equinus deformity. These seven patients responded to repeat treatment and obtained satisfactory outcome. Four of these seven patients underwent tibialis anterior transfer to third cuneiform for dynamic supination. Three patients, those developed isolated recurrence of equinus deformity, underwent repeat tenotomy. One foot achieved satisfactory amount of dorsiflexion, three feet underwent tendoachilles lengthening whereas another foot underwent posterior release to obtain satisfactory dorsiflexion. Six to 12 numbers of casts (mean: 10) were required to obtain correction of clubfoot deformities. Mean period of immobilization in a cast was 13.9 weeks (10-15 weeks). We found that the Ponseti method is effective in children between the age of 12 and 36 months.
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NewsBot · May 16, 2012

Treatment Results of Late-relapsing Idiopathic Clubfoot Previously Treated With the Ponseti Method.
McKay SD, Dolan LA, Morcuende JA.
Pediatr Orthop. 2012 Jun;32(4):406-11.

BACKGROUND:
Idiopathic clubfoot has a stubborn tendency for relapse, with most relapses happening within the first few years. However, a few patients relapse later, adding to the complexity of management. This study investigates the treatment results of relapsing clubfoot deformity after age 4.

METHODS:
Thirty-nine patients (60 feet) met the inclusion criteria. Age at initial treatment, previous treatment, number of casts and tenotomies, length of bracewear, and relapse presentation were recorded. Treatment of late relapse followed 1 of the 5 courses: (1) observation only (4 feet); (2) bracing (26 feet); (3) casting followed by bracing (7 feet); (4) casting followed by tibialis anterior tendon transfer (TATT) with or without open tendo Achilles lengthening (TAL) (8 feet); or (5) primary TATT±TAL (15 feet). Of the 37 feet treated initially with observation, bracing, or casting, 33 went on to have TATT (89%). Multiple other concurrent procedures were performed according to the specific deformities. These included plantar fasciotomy (6 feet), extensor hallicus longus recession (5 feet), limited posterior release 5 feet, and others (3 feet). Five feet underwent revision surgery after TATT, 2 of which ended in triple arthrodeses.

RESULTS:
Average age at final follow-up was 23.3 years (range, 8.5 to 50.6 y). Ninety percent of patients wore regular shoes, 41% had pain with activities, but only 18% were limited in function by their feet. Average ankle dorsiflexion was 6 degrees (range, -15 to 25 degrees). Mild residual deformities were noted in 55% of feet.

CONCLUSIONS:
This challenging group of patients with apparently persistent deforming biology achieves acceptable results with individualized evaluation and treatment of their foot deformities.
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NewsBot · May 16, 2012

Achilles tenotomy as an office procedure: safety and efficacy as part of the ponseti serial casting protocol for clubfoot.
Lebel E, Karasik M, Bernstein-Weyel M, Mishukov Y, Peyser A.
J Pediatr Orthop. 2012 Jun;32(4):412-5.

BACKGROUND:
Ponseti demonstrated the correction of clubfoot in infants using manipulation followed by the application of well-molded long-leg plaster casts. Percutaneous Achilles tenotomy was recommended to correct residual equinus contracture in approximately 80% of cases. In the current study, we evaluated the safety of this practice for the treatment of clubfoot when performed as an "office procedure" without sedation or general anesthesia during the final stage of the serial casting protocol.

PATIENTS AND METHODS:
We retrospectively collected data regarding babies who underwent serial manipulation and casting according to the Ponseti protocol for the treatment of clubfoot. All babies managed in the outpatient clinic between 2006 and 2010 were included. Tenotomy was indicated when the forefoot was completely corrected and if the hind-foot showed rigid equinus. Tenotomy was performed by a single scalpel stab in the outpatient clinic, using topical and local anesthesia (without general anesthesia or sedation). The cast was then applied and kept on for 3 weeks. Babies were discharged home after 1 hour of supervision. Surgical reports regarding Achilles tenotomy were reviewed, and data were collected from postoperative notes. We specifically looked for perioperative complications, recovery unit notes, and hospital readmission.

RESULTS:
Fifty-six babies (83 feet) were included in the current study. There were 40 males and 16 females, and 27 of them had bilateral clubfoot. Three babies (0.5%) had complex (syndrome-related) clubfoot; familial risk was known in 6 (11%) babies. Forty-one (73%) babies were indicated for Achilles tenotomy. Tenotomy was performed after an average of 5 casts (range, 3 to 9). No adverse events were related to local anesthesia and/or the procedure itself, and there was no delay in discharge in any of the operated babies. One baby was evaluated in the emergency room 3 days after the procedure because of (unfounded) parental concern of swelling inside the cast. All other babies had an uneventful course. Retenotomy was performed in 7 babies (12 feet); 2 of them (4 feet) had complex clubfoot. All of these babies (ie, their parents), except 1, had moderate to poor compliance with the treatment protocol.

CONCLUSIONS:
Tenotomy as an office procedure using topical and local anesthesia is a safe procedure. It does not incur a substantial rate of readmission to the emergency room, either because of parental concern or because of actual complications. The need for retenotomy is related to a low compliance with the treatment protoco
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NewsBot · May 18, 2012

Idiopathic club foot treated with the Ponseti method. Clinical and sonographic evaluation of Achilles tendon tenotomy. A review of 221 club feet.
Marleix S, Chapuis M, Fraisse B, Tréguier C, Darnault P, Rozel C, Rayar M, Violas P.
Orthop Traumatol Surg Res. 2012 May 14.

The Ponseti method applied to treating idiopathic club foot consists in placing successive corrective casts, possibly an Achilles tendon tenotomy, then derotation braces, a method that has proven its efficacy. This study compared 221 cases of club foot treated with this method between 2002 and 2007 divided into two groups, based on whether or not Achilles tendon tenotomy was performed. Assessment was both clinical and sonographic. We observed clear improvement of the results in the group that underwent Achilles tendon tenotomy and a significant difference in the rate of secondary surgery. The sonographic evaluation also showed improvement of the morphological results. We now systematically propose Achilles tendon tenotomy however severe club foot may be.
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Ponseti Method for clubfoot

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