modified ponseti technique of management of idiopathic clubfoot

Modified Ponseti Technique of Management of Idiopathic Clubfoot

Apollo Medicine 2011 DecemberReview Article

Volume 8, Number 4; pp. 281–286

© 2011, Indraprastha Medical Corporation Ltd

Modified Ponseti technique of management of idiopathic clubfoot

Ramani Narasimhan*, Paras Bhat***Senior Consultant, Paediatric Orthopedic Surgery, **Ex-Registrar Orthopedic Surgery, Indraprastha Apollo Hospitals, Sarita Vihar,New Delhi – 110076, India.

ABSTRACT

Ponseti technique in the nonoperative management of idiopathic clubfoot is being followed worldwide and with good results. We present our results using a modification in this management to suit our practice. Twenty-one children with idiopathic clubfoot (33 feet: 12 bilateral, 9 unilateral) were treated at this center following the modified technique, between 2005 and 2008. The cases included were of Pirani scores 4–6. The patients were prospectively followed up clinically and radiologically for a minimum follow-up of 24 months (mean 27 months). We obtained good results (Pirani score 0) in 16 children, fair (Pirani score 1–3) in 3, and poor result (Pirani score >3) in terms of loss of correc-tion in 2 of the cases. This modified technical protocol ensured good compliance of follow-up and hence mainte-nance of correction of the deformities. We conclude that as long as the basic principles of Ponseti technique are followed, any modification according to ones practice can still yield good results.

Keywords: Congenital clubfoot, Ponseti technique, Pirani score

Correspondence: Dr. Ramani Narasimhan, E-mail: [email protected]: 10.1016/S0976-0016(11)60007-0

INTRODUCTION

Ponseti technique has revolutionized the whole concept of idiopathic clubfoot management, and has a unanimous acceptance. Modifications in this management like in terms of shortening the time of treatment have been described in order to ensure compliance of the family with treatment.1 Strongly supporting the Ponseti technique for idiopathic clubfoot treatment, we present the results of our series of cases with congenital clubfeet treated by our modification of the original management protocol of Ponseti to suit our practice.

MATERIALS AND METHODS

We treated 21 children with congenital clubfoot (33 feet: 12 bilateral, 9 unilateral) with the Ponseti technique using a modified protocol of management at Indraprastha Apollo Hospitals over a period of 3 years (2005–2008). The cases included were of Pirani score 4–6 (Figure 1). Of the 21 chil-dren, 16 were 3 months of age or less (12 newborns, 3 eight weeks of age and 1 twelve weeks of age) with a bilateral

deformity in 10 and unilateral in 6. Five children (2 bilateral; 3 unilateral) were between 12 and 18 months of age.

In the newborn, we did manipulation and casting weekly for the first month and thereafter, we were flexible to increase the interval between the serial castings (between 7–14 days). In all cases, the previous cast was removed roughly an hour prior to the application of the next one. In children presenting >1 month of age, we kept the interval flexibility (7–14 days) right from the start ensuring better compliance. Syrup tri-clofos (pedicloryl) was used in all children as advised by the paediatric intensivist 15–30 min prior to each manipulation and casting. An average of 6 casts was required until the foot adduction was sufficiently over-corrected before a per-cutaneous tendo-achilles release was done. In five (bilateral 1, unilateral 4) feet, we did not achieve > 50° of abduction (no change after 2 consecutive casts) and we proceeded to perform the tendo-achilles release. Under local/dissociative anesthesia and under the supervision of a paediatric intensiv-ist in the minor procedure room, we did step-cuts (distal cut is medial at the insertion, middle cut is lateral and 1–2 cm above the distal cut, and the proximal one medial just distal to the musculo-tendinous junction) of the tendo-achilles tendon to achieve a dorsiflexion of at least 15°. We performed a per-cutaneous tendo-achilles release in all the patients (Figure 2).

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282 Apollo Medicine 2011 December; Vol. 8, No. 4 Narasimhan and Bhat


We applied a thigh length plaster of Paris cast in ≥ 10° of dorsiflexion and kept it for 2 weeks. The modified con-genital talipes equinovarus (CTEV) splint was applied imme-diately after the last cast was removed 2 weeks after the

tendo-achilles release (Figure 3). The modification of the CTEV splint was that the angle of splint was fixed at 10° dorsiflexion. Use of the splint for a minimum of 22 h was encouraged till the child was weight bearing, after which the use was limited to night and nap times. Thereafter, bare-foot walking was encouraged and a CTEV shoe was added to be used 3–4 h a day till the age of 3–5 years. The splints continued till the child was 5 years after which it was planned to be weaned off. The patients were followed up clinically and radiologically for a mean of 27 months.

RESULTS

We had good results in 16 children with 28 feet (Pirani score 0) (Figures 4–7 Case 1, Figures 8–10 Case 2, and

0 .5 1

CLB

0 .5 1

MC

Talar headNone 0Partial .5Full 1

LHT

0 .5

1

RE

Empty heelEasily palpable 0Palpable deep .5Not palpable 1

EH

0 .5 1

PC

Figure 1 Pirani’s 6 criteria of scoring for grading clubfoot.CLB: curvature of the lateral border; MC: medial crease; LHT: lateral head of the talus; PC: posterior crease; RE: rigidity of equinus; EH: emptiness of the heel.(Courtesy: Staheli L. Clubfoot: Ponseti Management 3rd ed. Global Help).

Figure 2 Healed scars of the step-cutting of tendo-achilles tendon.

Figure 3 Feet with modified congenital talipes equinovarus splints.

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Modified Ponseti technique of management of idiopathic clubfoot Review Article 283


Figure 4 Case 1: A 15-month-old child with a unilateral deform-ity (Pirani score 5).

Figure 5 Case 1: Normal lateral talo-calcaneal angle 3 months after full correction.

Figure 6 Case 1: Child at 18 months of age.

Figure 7 Case 1: Child at 24 months of age.

Figure 8 Case 2: Bilateral clubfeet, 1 month age.

Figure 9 Case 2: With congenital talipes equinovarus splints after full correction. Child is seen weight bearing with splints with rubber soles during the transitional period before congeni-tal talipes equinovarus shoes were delivered.

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Figures 11–13 Case 3), fair results in 2 children with 3 feet (Pirani score 1–3) and poor results in 1 child with a bilateral deformity (Pirani score >3).

One child with bilateral clubfeet developed an allergy to the splints and was out of them without information and ended up with a fair result (Figure 14). The child needed to be subjected to manipulations and castings again, till correction was achieved and that was maintained by splints made of a different material. The other child with a unilateral clubfoot with a fair result was from a family background where the grandfather firmly believed that the cast was the cause of thin calf. The corrective process ended up to be very erratic and required a prolonged treatment time. One child with a bilateral clubfeet had a poor result due to a practical difficulty of maintaining the casts. The shape of the limb was conical allowing the casts to slip off time and again. The correction suffered and hence both feet had to be operated.

Figure 10 Case 2: At 2 years of age.

Figure 11 Case 3: Newborn with bilateral clubfeet.

Figure 12 Case 3: Second manipulation and casting of right side shown.

Figure 13 Case 3: At 3 years of age.

Figure 14 Allergy to splints—fair result.

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Modified Ponseti technique of management of idiopathic clubfoot Review Article 285


The differences between our management protocol and the conventional Ponseti treatment protocol were mainly in• the frequency of manipulations and castings,• the number of castings before tendo-achilles release,• the procedure of percutaneous release of tendo-achilles

(under monitoring and supervision of a paediatric intensivist),

• the orthosis for maintenance of correction, and• the follow-up protocol during the maintenance of

correction.

DISCUSSION

Clubfoot is a developmental deformation like developmental dysplasia of the hip (DDH) or idiopathic scoliosis.2 Ponseti’s nonoperative technique has revolutionalized the treatment of idiopathic clubfoot. Principles of its correction as laid down by Ponseti are time-tested, widely accepted and show excellent results.3–10

Modifications in the protocol of Ponseti technique have been described in the past.1,11,12 In clinical set-ups across the world, especially in the developing countries, the treat-ing orthopedic surgeon needs to be acutely aware of gaining confidence and trust of the family in the long treatment of their child’s clubfoot and take it to a successful completion. One does not have an extra help from any allied medical personnel to educate and counsel families on a regular short-term basis like one does in the developed countries of in the west.

We felt that a minimum period of 7 days/1 week is nec-essary for the re-formation of the ‘crimp’ as described by Ponseti,2 in order to achieve further correction. We changed plasters between 7 and 14 days (average 10) which helped the family to plan their arrival in advance. An average of 6 cast changes was found to be needed before the tendo-Achilles release. Once the complete management protocol was dis-cussed in detail on their first visit, no family had any problem with the time required to achieve full correction.

We feel that it is impossible to achieve the recommended single incision full tenotomy of tendo-achilles percutane-ously, ensuring that the sheath is intact, as an outpatient department (OPD) procedure using local anesthesia. Hence, the step correction of tendo-achilles under the supervision of a paediatric intensivist and proper monitoring (not as an OPD procedure),11,12 is just playing safe in this day and age of multiple lawsuits.

Although the efficacy of foot-abduction brace as a dynamic orthosis for the maintenance of correction is well established, it is only based on the assumption that all families

are comfortable using it and are thoroughly compliant, espe-cially immediately after full correction. Sadly, compliance was a huge issue with foot abduction orthosis (FAO) in most families coming to us.11,13 There is a lack of social workers and other allied medical personnel (as mentioned earlier) in our set-up to constantly counsel families, espe-cially to convince them regarding the importance of using the FAO. In fact, it was more difficult to convince them that an FAO will not be an obstacle in the motor develop-ment of their child. Although not an orthosis preferred for correction maintenance and not considered by majority as ‘effective’, we feel that a CTEV splint with a small modifica-tion of 10° in dorsiflexion maintained our corrections rea-sonably well. No family had problems in using this orthosis even for a longer period of time. We preferred a less accept-able but more compliant orthosis to the more acceptable and more effective but much less compliant one and achieved good results.

Barefoot walking mainly, along with the usage of CTEV shoe in the initial years, helped us to maintain correction dynamically. We feel that it is imperative to keep a regular follow-up during the period of growth, even after the best of achieved corrections.

Finally, as long as one strongly adheres to the principles of Ponseti2,4–6,8 to achieve full correction of clubfoot and are conscious of maintaining the same, any modification of the management protocol in one’s practice especially in terms of correction maintenance, can still yield good results.

REFERENCES

1. Xu RJ. A modified Ponseti method for the treatment of idio-pathic clubfoot: a preliminary report. J Pediatr Orthop 2011;31:317–19.

2. Staheli L. Clubfoot: Ponseti Management 3rd ed. Global Help.

3. Abdelgawad AA, Lehman WB, van Bosse HJ, Scher DM, Sala DA. Treatment of idiopathic clubfoot using the Ponseti method: minimum 2-year follow-up. J Pediatr Orthop B 2007;16:98–105.

4. Herzenberg JE, Radler C, Bor N. Ponseti versus traditional methods of casting for idiopathic clubfoot. J Pediatr Orthop 2002;22:517–21.

5. Morcuende JA, Weinstein SL, Dietz FR, Ponseti IV. Plaster cast treatment of clubfoot: the Ponseti method of manipula-tion and casting. J Pediatr Orthop (Part B) 1994;3:161–7.

6. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduc-tion in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics 2004;113:376–80.

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7. Lehman 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;12:133–40.

8. Ponseti IV, Smoley EN. Congenital Clubfoot: the results of Treatment. Bone Joint Surg 1963;45-A:261–75.

9. Richards BS, Faulks S, Rathjen KE, Karol LA, Johnston CE, Jones SA. A comparison of two nonoperative methods of idiopathic clubfoot correction: the Ponseti method and the French functional (physiotherapy) method. J Bone Joint Surg Am 2008;90:2313–21.

10. Tindall AJ, Steinlechner CW, Lavy CB, Mannion S, Mkandawire N. Results of manipulation of idiopathic clubfoot deformity in Malawi by orthopaedic clinical officers using the Ponseti

method: a realistic alternative for the developing world? J Pediatr Orthop 2005;25:627–9.

11. Changulani M, Garg NK, Rajagopal TS, et al. Treatment of idiopathic club foot using the Ponseti method. Initial experience. J Bone Joint Surg Br 2006;88:1385–7.

12. Parada SA, Baird GO, Auffant RA, Tompkins BJ, Caskey PM. Safety of percutaneous tendoachilles tenotomy performed under general anaesthesia on infants with idiopathic clubfoot. J Pediatr Orthop 2009;29:916–19.

13. Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg Am 2004;86-A:22–7.

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modified ponseti technique of management of idiopathic clubfoot

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