Treatment of syndrome-associated congenital talipes equinovarus using the Ponseti method: 4-12 years of follow-up

Outcomes of the Ponseti Technique in Different Types of Clubfoot-A Single Center Retrospective Analysis

Background: Clubfoot is a congenital deformity that can affect one or both of a newborn's lower extremities. The main objective of the study is to evaluate and compare the outcomes of the Ponseti method for the management of different types of clubfoot. Methods: A retrospective analysis of 151 children with 253 clubfeet (idiopathic untreated, idiopathic recurrent, and syndromic) with at least one year of follow-up was conducted in four months after ethical approval. Data were collected with a structured proforma after the consent of the parents. An independent sample t-test was applied to show the comparison between the groups, and a p-value of 0.05 was considered significant. Results: Out of 151 patients, 76% were male and 24% were female. Out of a total of 235 feet, 96 (63%) were idiopathic untreated, 40 (26.5%) were idiopathic recurrent, and 15 (9.5%) were syndromic clubfoot. The average number of casts was higher in syndromic clubfoot (9 casts per foot). There was no significant difference in the baseline Pirani score of the three groups (p-value > 0.05); but after one year of follow-up, there was a significant difference in the Pirani score of idiopathic and syndromic clubfoot (p-value ≤ 0.05) and between recurrent clubfoot and syndromic clubfoot (p-value = 0.01). Conclusions: The aetiology of syndromic clubfoot affects the outcomes of the Ponseti method and leads to relapse. In idiopathic (untreated and recurrent) clubfoot, the Ponseti method does not produce a significant difference in outcome. Poor brace compliance and a lack of tenotomy lead to orthotic (ankle foot orthosis AFO and foot orthosis FO) use in the day time and the recurrence of clubfoot deformity in these three types of clubfoot.

Common Errors in the Management of Idiopathic Clubfeet Using the Ponseti Method: A Review of the Literature

Congenital talipes equinovarus is one of the most prevalent birth defects, affecting approximately 0.6 to 1.5 children per 1000 live births. Currently, the Ponseti method is the gold-standard treatment for idiopathic clubfeet, with good results reported globally. This literature review focuses on common errors encountered during different stages of the management of idiopathic clubfeet, namely diagnosis, manipulation, serial casting, Achilles tenotomy, and bracing. The purpose is to update clinicians and provide broad guidelines that can be followed to avoid and manage these errors to optimize short- and long-term outcomes of treatment of idiopathic clubfeet using the Ponseti method. A literature search was performed using the following keywords: "Idiopathic Clubfoot" (All Fields) AND "Management" OR "Outcomes" (All Fields). Databases searched included PubMed, EMBASE, Cochrane Library, Google Scholar, and SCOPUS (age range: 0-12 months). A full-text review of these articles was then performed looking for "complications" or "errors" reported during the treatment process. A total of 61 articles were included in the final review: 28 from PubMed, 8 from EMBASE, 17 from Google Scholar, 2 from Cochrane Library, and 6 from SCOPUS. We then grouped the errors encountered during the treatment process under the different stages of the treatment protocol (diagnosis, manipulation and casting, tenotomy, and bracing) to facilitate discussion and highlight solutions. While the Ponseti method is currently the gold standard in clubfoot treatment, its precise and intensive nature can present clinicians, health care providers, and patients with potential problems if proper diligence and attention to detail is lacking. The purpose of this paper is to highlight common mistakes made throughout the Ponseti treatment protocol from diagnosis to bracing to optimize care for these patients.

An Approach to the Management of Severe Clubfoot Deformities on Global Humanitarian Programs: The Role of Talectomy

The approach to treatment of severe untreated or recurrent congenital talipes equinovarus deformities is very different in the world where patients are mobile, have access to repeated return visits for follow-up treatment, and where more sophisticated options for gradual correction with external fixation are available. For treatment, talectomy may be the only option to treat certain neglected clubfoot deformities during humanitarian programs and it may still have to be used as a salvage procedure used in modern foot surgery. Our extensive experience with these deformities has been on global humanitarian programs.

Syndromic clubfoot beyond arthrogryposis and myelomeningocele: orthopedic treatment with Ponseti method

INTRODUCTION

Talipes equinovarus or clubfoot is a congenital deformity of the foot with bone, muscle, and tendon involvement. It's one of the most frequent foot malformations in pediatric orthopedics. Although generally idiopathic, it may have a syndromic cause and be associated with musculoskeletal, neurological, or connective tissue conditions. The treatment of choice in idiopathic clubfoot is the Ponseti method based on manipulation and fixation with serial casts that seek progressive correction of the deformity. The Ponseti method effectiveness has been demonstrated in arthrogryposis and myelomeningocele clubfoot. There are few clinical studies demonstrating the efficacy of this therapeutic option in patients with syndromic clubfoot.

MATERIAL AND METHODS

Retrospective study with 6 patients (9 feet) with syndromic clubfoot treated in a tertiary center with the Ponseti method with a minimum follow up of two years (2-18). The results were evaluated with the Pirani classification, assessing clubfoot severity before and after treatment.

RESULTS

Of the six patients treated were used an average of 6.5 casts. The Pirani scale obtained a mean score of 5.2 before treatment, with a decrease to 1.27 after treatment, with a mean improvement of 3.93 points. In more than half of the cases it was necessary to lengthen the Achilles tendon to correct the equine deformity. In addition, an ankle-foot orthosis was used to reduce recurrences in patients with dysmetria or psychomotor retardation. The most frequently observed residual deformity was the adduct. A patient relapsed twice.

CONCLUSIONS

The Ponseti method obtains effective results in the correction of syndromic clubfoot, although it requires a greater number of corrective casts than other pediatric foot pathologies.

Correction of the Neglected Clubfoot in the Adolescent and Adult Patient

Clubfoot is a complex 4-dimensional deformity involving the hindfoot, midfoot, and forefoot. The fourth dimension is time. Treatment aims at achieving a pain-free, plantigrade, and mobile foot but, over time, flexible deformities become fixed and more difficult to manage. The Ponseti method of serial manipulation and casting can be used successfully in older children and may reduce the need for extensive open surgery. Alternatively, gradual correction of by an external device enables simultaneous correction of all components of the deformity without shortening the foot. Combining gradual soft tissue distraction with open releases and/or bony procedures may achieve a pain-free and plantigrade foot.