The Ponseti technique and improved ankle dorsiflexion in children with relapsed clubfoot: a retrospective data analysis

Use of Ankle Dorsiflexion and the Dimeglio and Pirani Scores in Predicting Relapse of Clubfoot Treated With the Ponseti Method

Although Dimeglio and Pirani scores are frequently employed to rate the severities of clubfoot and to evaluate treatment outcomes, it is unclear if these scores predict relapse after treatment. Ankle dorsiflexion has been suggested in recent years to be a promising predictor of relapse. The aim of this study was to investigate ankle dorsiflexion and Dimeglio and Pirani scores in predicting the relapse of clubfoot after treatment with the Ponseti method. We included patients with clubfoot previously treated by the Ponseti method, and retrospectively analyzed their initial ankle dorsiflexion, Pirani and Dimeglio scores, number of castings, and the occurrence of relapse. We analyzed 218 feet of 176 infants with clubfoot who showed an incidence of relapse of 17.0% (30/176). The mean initial Pirani and Dimeglio scores of the feet showing recurrence were significantly higher than individuals with non-recurrence (p < .001 each). We observed a robust association between Pirani and Dimeglio scores and the recurrence of clubfoot at the last follow-up (γ = 0.53, p = .001). In contrast, ankle dorsiflexion was negatively correlated with recurrence of clubfoot (γ = -0.21, p = .001). Dimeglio scores significantly predicted the recurrence of clubfoot (p = .014). Receiver operating characteristic curve analysis exhibited slightly better performance regarding the Dimeglio score relative to the Pirani score and ankle dorsiflexion in predicting recurrence. Ankle dorsiflexion and Pirani and Dimeglio scores were related to recurrence in patients with clubfoot. However, the Dimeglio score reflected superior accuracy in predicting the prognosis of clubfoot treated with the Ponseti method.

What is New in Pediatric Orthopaedic Foot and Ankle

BACKGROUND

This paper aims to report on the last 5 years of relevant research on pediatric foot and ankle pathology with specific focus on clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans.

METHODS

The Browzine platform was used to review the table of contents for all papers published in the following target journals related to the treatment of pediatric foot and ankle conditions. Search results were further refined to include clinical trials and randomized controlled trials published from March 1, 2015 to November 15, 2021.

RESULTS

A total of 73 papers were selected for review based on new findings and significant contributions in treatment of clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans. Also included were several papers that did not fit into any of these categories but provided new insight into specific foot and ankle pathologies.

CONCLUSIONS

Treatment strategies for children with foot and ankle pathology are continually evolving. We review many of the most recent publications with the goal of improving understanding of these pathologies and highlighting current best practices.

LEVEL OF EVIDENCE

Level III.

Interventions for congenital talipes equinovarus (clubfoot)

BACKGROUND

Congenital talipes equinovarus (CTEV), also known as clubfoot, is a common congenital orthopaedic condition characterised by an excessively turned-in foot (equinovarus) and high medial longitudinal arch (cavus). If left untreated it can result in long-term disability, deformity and pain. Interventions can be conservative (such as splinting or stretching) or surgical. Different treatments might be effective at different stages: at birth (initial presentation); when initial treatment does not work (resistant presentation); when the initial treatment works but the clubfoot returns (relapse/recurrent presentation); and when there has been no early treatment (neglected presentation). This is an update of a review first published in 2010 and last updated in 2014.

OBJECTIVES

To assess the effects of any intervention for any type of CTEV in people of any age.

SEARCH METHODS

On 28 May 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus, AMED and Physiotherapy Evidence Database. We also searched for ongoing trials in the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (to May 2019). We checked the references of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs evaluating interventions for CTEV, including interventions compared to other interventions, sham intervention or no intervention. Participants were people of all ages with CTEV of either one or both feet.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risks of bias in included trials and extracted the data. We contacted authors of included trials for missing information. We collected adverse event information from trials when it was available. When required we attempted to obtain individual patient data (IPD) from trial authors for re-analysis. If unit-of-analysis issues were present and IPD unavailable we did not report summary data, MAIN RESULTS: We identified 21 trials with 905 participants; seven trials were newly included for this update. Fourteen trials assessed initial cases of CTEV (560 participants), four trials assessed resistant cases (181 participants) and three trials assessed cases of unknown timing (153 participants). The use of different outcome measures prevented pooling of data for meta-analysis, even when interventions and participants were comparable. All trials displayed high or unclear risks of bias in three or more domains. Twenty trials provided data. Two trials reported on the primary outcome of function using a validated scale, but the data were not suitable for inclusion because of unit-of-analysis issues, as raw data were not available for re-analysis. We were able to analyse data on foot alignment (Pirani score), a secondary outcome, from three trials in participants at initial presentation. The Pirani score is a scale ranging from zero to six, where a higher score indicates a more severe foot. At initial presentation, one trial reported that the Ponseti technique significantly improved foot alignment compared to the Kite technique. After 10 weeks of serial casting, the average total Pirani score of the Ponseti group was 1.15 points lower than that of the Kite group (mean difference (MD) -1.15, 95% confidence interval (CI) -1.32 to -0.98; 60 feet; low-certainty evidence). A second trial found the Ponseti technique to be superior to a traditional technique, with mean total Pirani scores of the Ponseti participants 1.50 points lower than after serial casting and Achilles tenotomy (MD -1.50, 95% CI -2.28 to -0.72; 28 participants; very low-certainty evidence). One trial found evidence that there may be no difference between casting materials in the Ponseti technique, with semi-rigid fibreglass producing average total Pirani scores 0.46 points higher than plaster of Paris at the end of serial casting (95% CI -0.07 to 0.99; 30 participants; low-certainty evidence). We found no trials in relapsed or neglected cases of CTEV. A trial in which the type of presentation was not reported showed no evidence of a difference between an accelerated Ponseti and a standard Ponseti treatment in foot alignment. At the end of serial casting, the average total Pirani score in the accelerated group was 0.31 points higher than the standard group (95% CI -0.40 to 1.02; 40 participants; low-certainty evidence). No trial assessed gait using a validated assessment. Health-related quality of life was reported in some trials but data were not available for re-analysis. There is a lack of evidence for the addition of botulinum toxin A during the Ponseti technique, different types of major foot surgery or continuous passive motion treatment following major foot surgery. Most trials did not report on adverse events. Two trials found that further serial casting was more likely to correct relapse after Ponseti treatment than after the Kite technique, which more often required major surgery (risk differences 25% and 50%). In trials evaluating serial casting techniques, adverse events included cast slippage (needing replacement), plaster sores (pressure areas), and skin irritation. Adverse events following surgical procedures included infection and the need for skin grafting.

AUTHORS' CONCLUSIONS

From the evidence available, the Ponseti technique may produce significantly better short-term foot alignment compared to the Kite technique. The certainty of evidence is too low for us to draw conclusions about the Ponseti technique compared to a traditional technique. An accelerated Ponseti technique may be as effective as a standard technique, but results are based on a single small comparative trial. When using the Ponseti technique semi-rigid fibreglass casting may be as effective as plaster of Paris. Relapse following the Kite technique more often led to major surgery compared to relapse following the Ponseti technique. We could draw no conclusions from other included trials because of the limited use of validated outcome measures and the unavailability of raw data. Future RCTs should address these issues.

Factors Related to Early Recurrence of Idiopathic Clubfoot Post the Ponseti Method

Introduction: Idiopathic clubfoot or congenital talipes equinovarus (CTEV) is managed by the Ponseti method worldwide; however, the recurrence of the deformity is a challenging problem. The purpose was to review the factors associated with early recurrence of CTEV post the Ponseti method. Materials and Methods: During 2011-2016, 34 infants with 52 CTEV, who underwent the Ponseti method and a minimum follow-up period of six months, were reviewed. Twenty-two infants (65%) were male, and 18 infants (53%) had bilateral CTEV. Recurrence of CTEV was defined as a reappearance of at least one of the four components of the deformity. The association between recurrence and factors, including age, gender, bilaterality, family geography, type of principal caregiver, severity at presentation, centre where the Ponseti method was initiated, compliance to foot abduction brace (FAB), practice of stretching exercise, type of FAB, and complications of casting, were evaluated using univariate logistic regression analysis. Results: The median age at initiation of the treatment was 3.4 (IQR; 2.1-12.6) weeks. A median of six (range; 3-12) casts were required. Tenotomy was performed in 32/34 (94%) of cases. Recurrence occurred in 14/52 feet (27%) at an average follow-up period of 2.3±1.1 years. Non-compliance to FAB protocol began at an average age of 11.2±6.5 months, and significantly increased the risk of recurrence during the weaning phase [OR (95%CI)=8.4 (1.2-92.4), p=0.03]. Other factors were not associated with the recurrence. Conclusion: Non-compliance to FAB occurred early during the treatment and related to a risk of recurrence of CTEV. Physicians should encourage the parents and/or guardians to follow the protocol to decrease the risk of recurrence.