The Ponseti Method in Low and Middle Income Countries: Challenges and Lessons Learned

Diffusing a health care innovation like the Ponseti method in low and middle income countries requires more than the application of the traditional continuing medical education approach of providing lectures on the topic. Challenges include limited personnel, competing priorities, inadequate medical supplies, and limited resources. Experience has indicated that the best chances of success in establishing such a program include identifying and advising in-country "champions" to provide the leadership, energy, and direction to build the program.

Ponseti Casting and Achilles Release Versus Classic Casting and Soft Tissue Releases for the Initial Treatment of Arthrogrypotic Clubfeet

BACKGROUND

Wide soft tissue releases (STRs) are considered the classic operative approach to the arthrogrypotic clubfoot, but recently the Ponseti method with Achilles tenotomy has been proposed as the initial treatment for those deformities.

METHODS

A retrospective comparison of clinical results and treatment course after 5 to 10 years of follow-up (FU) in arthrogrypotic clubfeet treated initially with STRs or the Ponseti method was performed. Mann-Whitney and χ(2) tests were used to assess significant differences between variables.

RESULTS

Twenty-nine children with 57 arthrogrypotic clubfeet were divided into 2 subgroups: the Ponseti subgroup (9 children, 18 clubfeet, mean FU: 7.3 years), which achieved 14 good and 4 satisfactory final results. The complication rate was 5.5%. Reoperation rate was 1.2 per foot, with 90.9% being STRs and 9.1% wedge osteotomies. The mean total anesthesia and surgery time equaled 116.6 and 77.4 minutes, respectively. The interval between primary and redo surgery was 27.3 months on average. The STR subgroup (20 children, 39 clubfeet, FU: 9.0 years on average) scored 20 good, 8 satisfactory, and 11 unsatisfactory results. Rate of complications was 23%. The mean total anesthesia and surgery times were 161.4 minutes and 102.8 minutes, respectively. The interval between the initial and secondary operations was 62.8 months on average. The revision rate was 1.0 per foot with 32.5% repeated STRs, while 67.5% were talectomies, osteotomies, or salvage procedures.

CONCLUSIONS

The use of the Ponseti method as the initial treatment in arthrogrypotic clubfeet improved clinical outcomes, reduced invasiveness of revisions, and shortened overall time of anesthesia and surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Clubfoot associated with congenital constriction band: the Ponseti method perspective

BACKGROUND

The clubfoot and congenital constriction band is a known association in which the clubfoot is considered as being rigid, responding poorly to casting, and requiring surgical interventions.

OBJECTIVE AND METHODS

The series describes 3 cases of clubfoot with deep ipsilateral congenital constriction bands managed with Ponseti method and immediate outcomes achieved.

RESULTS AND CONCLUSIONS

The feet responded favorably to casting although equinus correction required more extensive surgical interventions. The preexisting edema in distal limb often precluded a snuggly fitting cast increasing the cast numbers. Careful monitoring of vascularity is essential. Simultaneous procedures of release of constriction bands, correction of hand anomalies and equinus can be combined to the advantage of the patient.

LEVELS OF EVIDENCE

Case report, Level IV.

Summary of the 2nd International Symposium on Arthrogryposis, St. Petersburg, Russia, September 17-19, 2014

Enormous progress has been made in understanding the etiology and therapies for arthrogryposis (multiple congenital contractures). A 2nd International Symposium on Arthrogryposis was sponsored by the Turner Institute in St. Petersburg, Russia. Olga Agranovich, Head of the Arthrogryposis Department of the Turner Institute, organized this special meeting. Care providers from multiple disciplines from all over the world representing 18 nations attended. Participants included: Pediatric orthopedic specialists, rehabilitation physicians, occupational therapists, physical therapists, medical geneticists, neurologists, craniofacial physicians, psychologists, developmental biologists, as well as representatives from parent support groups. The 1st symposium established the need for a collaborative and interdisciplinary approach to the treatment of arthrogryposis, engagement of parent support organizations, and the aim for more research. The Second Symposium highlighted the continuing need for more research on various therapies, identification of different types of arthrogryposis, standardized descriptions of severity, development of new orthotics, improved prenatal diagnosis, and studying adult outcome. Major progress has been made on both upper and lower limb treatments.

Relapse of clubfoot after treatment with the Ponseti method and the function of the foot abduction orthosis

Ponseti clubfoot treatment has become more popular during the last decade because of its high initial correction rate. But the most common problem affecting the long-term successful outcome is relapse of the deformity. Non-compliance with Ponseti brace protocol is a major problem associated with relapse. Although more comfortable braces have been reported to improve the compliance, they all have the same design and no significant changes have been made to the protocols. After refinement in the Ponseti method and emphasizing the importance of brace to parents, the relapse rate has been markedly decreased. Nevertheless, there are patients who do not have any recurrence although they are not completely compliant with the brace treatment, whereas other patients have a recurrence even though they are strictly compliant with the brace treatment. The aim of this article is to review the relapse of clubfoot and the function of the brace and to develop an individualized brace protocol for each patient by analyzing the mechanism of the brace and the biomechanical properties of muscles, tendons, and ligaments.

Ponseti method compared with soft-tissue release for the management of clubfoot: A meta-analysis study

AIM

To compare the functional outcomes of patients who underwent open surgery vs Ponseti method for the management of idiopathic clubfoot and to determine whether correlations exist between functional outcome and radiographic measurements.

METHODS

A meta-analysis of the literature was conducted for studies concerning primary treatment of patients with idiopathic clubfoot. We searched PubMed Medline, EMBASE, and the Cochrane Library databases from January 1950 to October 2011. Meta-analyses were performed on outcomes from 12 studies. Pooled means, SDs, and sample sizes were either identified in the results or calculated based on the results of each study.

RESULTS

Overall, 835 treated idiopathic clubfeet in 516 patients were reviewed. The average follow-up was 15.7 years. Patients managed with Ponseti method did have a higher rate of excellent or good outcome than patients treated with open surgery (0.76 and 0.62, respectively), but not quite to the point of statistical significance (Q = 3.73, P = 0.053). Age at surgery was not correlated with the functional outcome for the surgically treated patients (r = -0.32, P = 0.68). A larger anteroposterior talocalcaneal angle was correlated with a higher rate of excellent or good outcomes (r = 0.80, P = 0.006). There were no other significant correlations between the functional and radiographic outcomes.

CONCLUSION

The Ponseti method should be considered the initial treatment of idiopathic clubfeet, and open surgery should be reserved for clubfeet that cannot be completely corrected.

Evaluation of cast creep occurring during simulated clubfoot correction

The Ponseti method is a widely accepted and highly successful conservative treatment of pediatric clubfoot involving weekly manipulations and cast applications. Qualitative assessments have indicated the potential success of the technique with cast materials other than standard plaster of Paris. However, guidelines for clubfoot correction based on the mechanical response of these materials have yet to be investigated. The current study sought to characterize and compare the ability of three standard cast materials to maintain the Ponseti-corrected foot position by evaluating cast creep response. A dynamic cast testing device, built to model clubfoot correction, was wrapped in plaster of Paris, semi-rigid fiberglass, and rigid fiberglass. Three-dimensional motion responses to two joint stiffnesses were recorded. Rotational creep displacement and linearity of the limb-cast composite were analyzed. Minimal change in position over time was found for all materials. Among cast materials, the rotational creep displacement was significantly different (p < 0.0001). The most creep displacement occurred in the plaster of Paris (2.0°), then the semi-rigid fiberglass (1.0°), and then the rigid fiberglass (0.4°). Torque magnitude did not affect creep displacement response. Analysis of normalized rotation showed quasi-linear viscoelastic behavior. This study provided a mechanical evaluation of cast material performance as used for clubfoot correction. Creep displacement dependence on cast material and insensitivity to torque were discovered. This information may provide a quantitative and mechanical basis for future innovations for clubfoot care.

Use of the Ponseti method for recurrent clubfoot following posteromedial release

BACKGROUND

A child with recurrent or incompletely corrected clubfoot after previous extensive soft tissue release is treated frequently with revision surgery. This leads to further scarring, pain and limitations in range of motion. We have utilized the Ponseti method of manipulation and casting and when indicated, tibialis anterior tendon transfer, instead of revision surgery for these cases.

MATERIALS AND METHODS

A retrospective review of all children treated since 2002 (n = 11) at our institution for recurrent or incompletely corrected clubfoot after previous extensive soft tissue release was done. Clinical and operative records were reviewed to determine procedure performed. Ponseti manipulation and casting were done until the clubfoot deformity was passively corrected. Based on the residual equinus and dynamic deformity, heel cord lengthening or tenotomy and tibialis anterior transfer were then done. Clinical outcomes regarding pain, function and activity were reviewed.

RESULTS

Eleven children (17 feet) with ages ranging from 1.1 to 8.4 years were treated with this protocol. All were correctable with the Ponseti method with one to eight casts. Casts were applied until the only deformities remaining were either or both hindfoot equinus and dynamic supination. Nine feet required a heel cord procedure for equinus and 15 required tibialis anterior transfer for dynamic supination. Seven children have follow-up greater than one year (average 27.1 months) and have had excellent results. Two patients had persistent hindfoot valgus which required hemiepiphyseodesis of the distal medial tibia.

CONCLUSION

The Ponseti method, followed by tibialis anterior transfer and/or heel cord procedure when indicated, can be successfully used to correct recurrent clubfoot deformity in children treated with previous extensive soft tissue release. Early follow-up has shown correction without revision surgery. This treatment protocol prevents complications of stiffness, pain and difficulty in ambulating associated with multiple soft tissue releases for clubfeet.