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Loose O, Fernandez Fernandez F, Langendoerfer M, Wirth T, Eberhardt O. Complex, atypical clubfoot: follow-up after up to 16 years reveals a high risk of relapse but good functional and radiological outcomes. Arch Orthop Trauma Surg 2023; 143:6097-6104. [PMID: 37195434 DOI: 10.1007/s00402-023-04840-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/01/2023] [Indexed: 05/18/2023]
Abstract
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.
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Affiliation(s)
- Oliver Loose
- Orthopaedic Department, Klinikum Stuttgart Olgahospital, Kriegsbergstrasse 62, 70174, Stuttgart, Germany
| | | | - Micha Langendoerfer
- Orthopaedic Department, Klinikum Stuttgart Olgahospital, Kriegsbergstrasse 62, 70174, Stuttgart, Germany
| | - Thomas Wirth
- Orthopaedic Department, Klinikum Stuttgart Olgahospital, Kriegsbergstrasse 62, 70174, Stuttgart, Germany
| | - Oliver Eberhardt
- Orthopaedic Department, Klinikum Stuttgart Olgahospital, Kriegsbergstrasse 62, 70174, Stuttgart, Germany.
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Sinha SK, Garg V, Singh V. The Tug Test and Modified Ponseti Casting: A Simple and Reliable Method to Improve the Efficacy of Casting in Complex Clubfoot. Indian J Orthop 2023; 57:1147-1152. [PMID: 37384013 PMCID: PMC10293533 DOI: 10.1007/s43465-023-00910-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/12/2023] [Indexed: 06/30/2023]
Abstract
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.
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Affiliation(s)
- Sourabh Kumar Sinha
- Department of Orthopedic Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203 India
| | - Varun Garg
- Department of Orthopedic Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203 India
| | - Vivek Singh
- Department of Orthopedic Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203 India
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Patel A, Mongia AK, Sharma RK, Saini R, Chaudhary C, Singh S. Outcome of Atypical & Complex Clubfoot Managed by Modified Ponseti Method-A Prospective Study. J Foot Ankle Surg 2022; 61:1081-1085. [PMID: 35184957 DOI: 10.1053/j.jfas.2022.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/11/2022] [Accepted: 01/14/2022] [Indexed: 02/03/2023]
Abstract
Atypical or complex clubfoot constitutes a small number of cases. Due to the difference in complexity of anatomy, standard deformity correction by Ponseti is not effective. Hence a modified Ponseti method was advised which focuses on deformity differences for treatment. We conducted a prospective study to analyze the outcome in atypical or complex clubfoot treated with the modified Ponseti method. All the children of age less than 1 year were included in the study with atypical or complex clubfoot. Every case was treated according to the modified Ponseti method and tenotomy. Pirani scores were measured at pretreatment, each visit, before application of a brace, and at the latest follow-up. Statistical analysis of all continuous and categorical variables was done. A total of 30 patients (47 feet) were included in the study. Mean Pirani score improved from 5.69 at presentation to 0.45 at time of brace application and latest follow-up 0.34 (p < .001). Six patients (9 feet) had a relapse which was managed with recasting. The mean Pirani score of relapse was 0.72, which after correction reduced to 0.11 (p = .008). Six patients had cast-related complications which were managed with conservative treatment. With an increase in popularity of the Ponseti method, a greater number of complex clubfoot cases are seen due to inadequate reduction or slippage of cast or improper cast application techniques. All these need to be identified at an early age. This helps in proper treatment and improves the quality of life as well as foot appearance.
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Affiliation(s)
- Ankur Patel
- Senior Resident, Department of Orthopedics, Deen Dayal Upadhyay Hospital, New Delhi, India
| | - Aaditya Keerti Mongia
- Assistant Professor, Department of Orthopedics, Gautam Buddha Chikitsa Mahavidyalaya, Jhajhra, Dehradun, Uttarakhand, India
| | - Raj Kumar Sharma
- Senior Resident, Department of Orthopedics, Deen Dayal Upadhyay Hospital, New Delhi, India
| | - Rochak Saini
- Senior Resident, Department of Orthopedics, Deen Dayal Upadhyay Hospital, New Delhi, India
| | - Chetan Chaudhary
- Senior Resident, Department of Orthopedics, Central Institute of Orthopedics, VMMC & Safdarjung Hospital, New Delhi, India
| | - Sukhmin Singh
- Senior Resident, Department of Orthopedics, Gautam Buddha Chikitsa Mahavidyalaya, Jhajhra, Dehradun, Uttarakhand, India.
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Correction results of atypical clubfeet managed with modified Ponseti technique: A meta-analysis of 354 feet. J Clin Orthop Trauma 2022; 31:101939. [PMID: 35818375 PMCID: PMC9270237 DOI: 10.1016/j.jcot.2022.101939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 10/17/2022] Open
Abstract
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.
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Al-Mohrej OA, Alshaalan FN, Alhussainan TS. Is the modified Ponseti method effective in treating atypical and complex clubfoot? A systematic review. INTERNATIONAL ORTHOPAEDICS 2021; 45:2589-2597. [PMID: 34114108 DOI: 10.1007/s00264-021-05092-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Omar A Al-Mohrej
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON, Canada. .,Section of Orthopedic Surgery, Department of Surgery, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia.
| | - Fawaz N Alshaalan
- Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Thamer S Alhussainan
- Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Using the modified Ponseti method to treat complex clubfoot: Early results. Jt Dis Relat Surg 2021; 32:170-176. [PMID: 33463433 PMCID: PMC8073454 DOI: 10.5606/ehc.2021.77135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/13/2020] [Indexed: 12/12/2022] Open
Abstract
Objectives
This study aims to present the results of complex clubfoot patients treated with modified Ponseti method and put forth the warning clinical signs of complex deformities. Patients and methods
A total of 11 patients (10 males, 1 female; mean age 60.1±49.7; range, 2 to 180 days) with 16 complex clubfeet treated with modified Ponseti method were included in this study conducted between January 2016 and June 2019. All the data of the patients were collected prospectively and reviewed retrospectively. Demographic features, clubfoot severity, number of casts, position of each foot before cast removal, ankle dorsiflexion (DF), complications, and additional procedures were noted at all clinical visits. Results
Eleven (11.2%) of 98 patients had complex clubfoot deformity. Six (7.7%) of 78 newly diagnosed patients and five (25%) of 20 referred patients had complex clubfeet. We treated 16 complex clubfeet of 11 patients. The mean follow-up period was 13.3 (range, 10 to 16) months. All deformities were initially corrected using a mean of seven (range, 5 to 8) casts and Achilles tenotomy. Relapses occurred in three (18.75%) patients, but all recovered after recasting. The creases above the heels disappeared in all of the patients, whereas plantar creases persisted on two (12.5%) feet. Pirani scores and DF improved statistically significantly after treatment, and DF improved significantly between tenotomy and the final visit. Conclusion
The modified Ponseti method is an effective treatment for complex clubfoot. Classical clinical appearance, treatment-resistant deformities and referred patients should be warning signs for complex clubfoot.
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Duman S, Camurcu Y, Cobden A, Ucpunar H, Karahan N, Bursali A. Clinical outcomes of iatrogenic complex clubfoot treated with modified Ponseti method. INTERNATIONAL ORTHOPAEDICS 2020; 44:1833-1840. [PMID: 32377781 DOI: 10.1007/s00264-020-04529-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/04/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There are not enough studies demonstrating the results of the modified Ponseti method on iatrogenic complex clubfoot that occurs due to errors during the application of the method for treating idiopathic clubfoot. The present study aimed to present the treatment results of the modified method reported by Ponseti for treating feet that became complex solely due to errors during casting. METHODS Patients with the confirmed diagnosis of iatrogenic complex clubfoot were according to initial physicians' report and photographs were included in this retrospective case series study. Patients with congenital atypical feet, incomplete medical records, and accompanying pathologies were excluded from the study. Patients' clinical data and clinical scores were recorded at the initial visit and at the latest follow-up. RESULTS There were 21 children (15 boys and 8 girls) with 32 complex clubfeet. Initial correction was achieved in all children, with an average of five serial casts (range 3 to 6 casts). At the last follow-up, ISGCF score of 25 feet (78.1%) was excellent and seven feet (21.9) was good. CONCLUSION According to the results acquired from this study, an iatrogenic complex clubfoot can be successfully treated using the modified Ponseti method.
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Affiliation(s)
- Serda Duman
- Department of Orthopaedics and Traumatology, Selahaddin Eyyubi State Hospital, Yenisehir Mahallesi, 21100, Diyarbakir, Turkey.
| | - Yalkin Camurcu
- Department of Orthopaedics and Traumatology, Erzincan University Faculty of Medicine, Basbaglar Mahallesi, 24030, Erzincan, Turkey
| | - Adem Cobden
- Department of Orthopaedics and Traumatology, Kayseri City Hospital, Şeker Mahallesi, Kocasinan, 38080, Kayseri, Turkey
| | - Hanifi Ucpunar
- Department of Orthopaedics and Traumatology, Erzincan University Faculty of Medicine, Basbaglar Mahallesi, 24030, Erzincan, Turkey
| | - Nazim Karahan
- Department of Orthopaedics and Traumatology, Selahaddin Eyyubi State Hospital, Yenisehir Mahallesi, 21100, Diyarbakir, Turkey
| | - Aysegul Bursali
- Private Office Pediatric Orthopaedics, Yıldızposta Cad. Emekli Subayevleri, 34. Blok, Daire: 1, İstanbul, Turkey
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Agarwal A, Gupta S, Sud A, Agarwal S. Results of Modified Ponseti Technique in Difficult Clubfoot and a review of literature. J Clin Orthop Trauma 2020; 11:222-231. [PMID: 32099284 PMCID: PMC7026550 DOI: 10.1016/j.jcot.2019.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/01/2019] [Accepted: 05/06/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Serial Ponseti casting achieves deformity correction in early presenting idiopathic clubfoot cases normally in around 7 casts. However, there are resistant patients where correction requires more casts than usual. In such patients a modification in standard technique might be required right from the beginning. Such patients were collectively called as difficult clubfoot. The aim of this study was to assess the outcome of our modification to Ponseti technique in difficult clubfoot. METHODS All idiopathic clubfoot cases who were 75th percentile or more in WHO age for weight chart (chubby infants) or untreated clubfoot patients presenting for first time to our clinic at more than 5 months age (late presenters and neglected cases) were included in the study. Patients who had been previously surgically intervened elsewhere, patients over 7 years of age, patients with syndromic clubfoot or clubfoot associated with neurological conditions were excluded from the study. The patients were treated by early tenotomy of tendoachillis and a plantar fascia release before starting serial casting by Ponseti technique. Post correction, strict bracing protocol was followed with regular follow up. Pirani scoring was done at each stage. Measurement of Talocalcaneal angle on AP radiograph, maximum degree of abduction and dorsiflexion was noted once every year. RESULTS There were total 28 patients in our study. In all, 47 feet were subjected to modified Ponseti protocol. There were 21 male patients. Median age at presentation was 4 months. Mean centile of weight for age as per WHO growth chart was 64. Mean Pirani score at presentation was 5.86 (S.D. ± 0.34). Mean number of casts required for correction was 3.75 ± 1.10. Maximum followup period was 25 months. CONCLUSION This modification of Ponseti casting for difficult clubfoot patients achieves correction in shorter duration with less number of casts.
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Affiliation(s)
- Ankur Agarwal
- Department of Orthopaedics, Superspecialty Pediatric Hospital & Postgraduate Teaching Institute, Noida, India,Corresponding author. Department of Orthopaedics, Superspecialty Pediatric Hospital and Postgraduate Teaching Institute, Noida, 201303, India.
| | - Sumit Gupta
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Alok Sud
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - Sheetal Agarwal
- Department of Pediatrics, PGIMER & RML Hospital, New Delhi, India
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