Clinical outcomes of iatrogenic complex clubfoot treated with modified Ponseti method

Complex, atypical clubfoot: follow-up after up to 16 years reveals a high risk of relapse but good functional and radiological outcomes

INTRODUCTION

The treatment of complex atypical clubfoot poses many challenges. In this paper, we report on the course of complex clubfoot, primary correction using the modified Ponseti method and midterm outcomes. Special consideration is given to clinical and radiological changes in cases of relapse.

MATERIALS AND METHODS

Twenty-seven cases of complex, atypical, non-syndromic clubfoot were treated in 16 children between 2004 and 2012. Patient data, treatment data, functional outcomes and, in the relapse cohort, radiological findings were documented during the course of treatment. The radiological findings were correlated with the functional outcomes.

RESULTS

All atypical complex clubfeet could be corrected using a modified form of the Ponseti method. Over an average study period of 11.6 years, 66.6% (n = 18) of clubfeet relapsed. Correction after relapse showed an average dorsiflexion of 11.3° during a 5-years' follow-up period. Radiological results showed residual clubfoot pathologies such as a medialized navicular bone in four clubfeet. There were no instances of subluxation or dislocation of the talonavicular joint. Extensive release surgery was not necessary. Nevertheless, after 2.5 preoperative casts (1-5 casts), bone correction was performed in n = 3 feet in addition to Achilles tendon lengthening and tibialis anterior tendon transfer.

CONCLUSION

Good primary correction of complex clubfoot using the modified Ponseti technique results in a high recurrence rate in the medium term. Relapse treatment without peritalar arthrolysis procedures produces good functional results even though minor residual radiological pathologies did persist in a minor number of cases.

The Tug Test and Modified Ponseti Casting: A Simple and Reliable Method to Improve the Efficacy of Casting in Complex Clubfoot

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.Level of evidence Level 4.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00910-w.

A four-year clinical and sonographic longitudinal follow-up of clubfeet treated according to Ponseti with normal references

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.

Level of evidence

III.

Correction results of atypical clubfeet managed with modified Ponseti technique: A meta-analysis of 354 feet

BACKGROUND/PURPOSE

Atypical clubfeet are distinct from idiopathic clubfeet. It is resistant to correction by conventional casting methods and often requires a modification of Ponseti's casting technique. Although the initial correction rates are reasonable, relapse and complications are frequent. There is limited literature on the results of modified Ponseti casting of these feet. We conducted this meta-analysis to study a few important aspects of atypical/complex clubfeet treatment by the modified Ponseti technique.

RESEARCH QUESTION

What are the results of atypical or complex clubfeet after treatment by the modified Ponseti technique?

METHODOLOGY

Five electronic databases (PubMed, Embase, Scopus, Ovid, and Cochrane Library) were searched for articles reporting on the results of atypical/complex clubfeet treated by the modified Ponseti technique. Details of the number of casts required for correction, rate of percutaneous Achilles tenotomy (PAT), other soft tissue procedures required, complications, and relapse rates were extracted into spreadsheets, and meta-analysis was carried out using OpenMeta Analyst software.

RESULTS

Ten studies were included for analysis with a total of 240 patients with 354 clubfeet. The initial correction was achieved in all feet. A pooled analysis of the data showed that a mean of six casts was required for the initial correction. The rate of PAT was 98.3%. The overall complication rate was 16.8%. 7.2% required an additional soft tissue procedure apart from the PAT, and relapse of the deformity was observed in a mean of 19.8% cases.

CONCLUSION

Modified Ponseti technique is effective in the initial management of atypical/complex clubfeet. Although the PAT rate is slightly higher in the Modified Ponseti technique, the remaining result parameters are comparable with the results of idiopathic clubfoot managed with the Ponseti method of casting. However, these children should be kept under follow-up for a longer duration to find the exact relapse rates.

Is the modified Ponseti method effective in treating atypical and complex clubfoot? A systematic review

PURPOSE

In 2006, Ponseti modified the standard technique to treat cases of "atypical" and "complex" clubfoot. To determine the outcomes of Ponseti's modified method to treat complex idiopathic clubfoot patients, we asked the following: (1) What is the deformity correction success rate? (2) What is the relapse rate after the correction? (3) What is the incidence of complications?

MATERIALS AND METHODS

We performed a systematic review by searching the EMBASE, MEDLINE, Cochrane Library, and Web of Science databases from inception to March 1, 2021. All studies on idiopathic, complex, and atypical clubfoot that assessed Ponseti's modified technique were included. Of 699 identified articles, ten met the inclusion criteria. The mean index for non-randomized studies score for the included studies was 11.8 ± 1.7.

RESULTS

Early detection of the deformity and modifying the standard protocol, as described by Ponseti, resulted in a high rate of success. Initial correction occurred in all children, with a mean ankle dorsiflexion of 15°. Relapse occurred often ranging between 10.5 and 55%. The incidence of complications associated with the modified Ponseti method ranged from 6 to 30%.

CONCLUSIONS

Studies using the modified Ponseti technique have shown high initial correction rates and a smaller number of relapses. However, studies with prospective designs and long-term follow-up are required to conclude whether these observations are due to properly performing the modified method or if higher rates of relapse increase with further follow-up.