The use of the Ponseti method to treat clubfeet associated with congenital annular band syndrome

The Ponseti Method for the Treatment of Clubfeet Associated With Down Syndrome: A Single-institution 18-year Experience

BACKGROUND

Although the Ponseti method has been used with great success in a variety of nonidiopathic clubfoot deformities, the efficacy of this treatment in clubfeet associated with Down syndrome remains unreported. The purpose of this study is, therefore, to compare treatment characteristics and outcomes of clubfoot patients with Down syndrome to those with idiopathic clubfoot treated with the Ponseti method.

METHODS

An Institutional Review Board-approved, retrospective review of prospectively gathered data were performed at a single pediatric hospital over an 18-year period. Patients with either idiopathic clubfeet or clubfeet associated with Down syndrome who were less than 1 year of age at the outset of treatment were treated by the Ponseti method, and had a minimum of 2 year's follow-up were included. Initial Dimeglio score, number of casts, need for heel cord tenotomy, recurrence, and need for further surgery were recorded. Outcomes were classified using the Richards classification system: "good" (plantigrade foot +/- heel cord tenotomy), "fair" (need for a limited procedure), or "poor" (need for a full posteromedial release).

RESULTS

Twenty clubfeet in 13 patients with Down syndrome and 320 idiopathic clubfeet in 215 patients were identified. Average follow-up was 73 months for the Down syndrome cohort and 62 months for the idiopathic cohort. Down syndrome patients presented for treatment at a significantly older age (61 vs. 16 d, P =0.00) and with significantly lower average initial Dimeglio scores than the idiopathic cohort (11.3 vs. 13.4, P =0.02). Heel cord tenotomy was performed in 80% of the Down syndrome cohort and 79% of the idiopathic cohort ( P =1.00). Recurrence rates were higher in the Down syndrome cohort (60%) compared with the idiopathic group (37%), but this difference was not statistically significant ( P =0.06). Need for later surgical procedures was similar between the 2 cohorts, though recurrences in the Down syndrome group were significantly less likely to require intra-articular surgery (8.3% vs. 65.5%, P =0.00). Clinical outcomes were 95% "good," 0% "fair," and 5% "poor" in the Down syndrome cohort and 69% "good," 27% "fair," and 4% "poor" in the idiopathic cohort ( P =0.01).

CONCLUSIONS

Despite the milder deformity and an older age at presentation, clubfeet associated with Down syndrome have similar rates of recurrence and may have better clinical outcomes when compared with their idiopathic counterparts. When deformities do relapse in Down syndrome patients, significantly less intra-articular surgery is required than for idiopathic clubfeet.

LEVEL OF EVIDENCE

Level III.

Management issues of congenital talipes equinovarus in the neonatal intensive care unit: A systematic review

BACKGROUND

The Ponseti method is the standard of care for managing idiopathic congenital talipes equinovarus (clubfoot) in the outpatient setting, but there are no clinical guidelines for inpatient treatment. Children in the neonatal intensive care unit (NICU) with clubfoot often delay treatment initiation due to medical reasons.

METHODS

We systematically reviewed literature related to the treatment of clubfoot in the NICU, non-idiopathic clubfoot, and older infants, as well as barriers to care.

RESULTS

In a mixed NICU population of syndromic and idiopathic clubfoot, the Ponseti method has good functional outcomes with minimal interference with medical management. The Ponseti method has good functional outcomes with reduced need for extensive surgical procedures in non-idiopathic clubfoot and idiopathic clubfoot with delayed presentation (under one year of age).

CONCLUSIONS

It is possible to begin Ponseti treatment in the NICU without compromising medical management. It is not clear if this confers an advantage over waiting for outpatient casting.

The Ponseti Method for the Treatment of Clubfeet Associated With Amniotic Band Syndrome: A Single Institution 20-Year Experience

BACKGROUND

Amniotic band syndrome (ABS) is a congenital disorder resulting in fibrous bands that can cause limb anomalies, amputations, and deformities. Clubfoot has been reported in up to 50% of patients with ABS. The purpose of this study is to compare treatment characteristics and outcomes of clubfoot patients with ABS to those with idiopathic clubfoot treated with the Ponseti method.

METHODS

An Institution Review Board (IRB) approved retrospective review of prospectively gathered data was performed at a single pediatric hospital over a 20-year period. Patients with either idiopathic clubfeet or clubfeet associated with concomitant ABS who were <1 year of age and treated by the Ponseti method were included. Initial Dimeglio score, number of casts, need for heel cord tenotomy, recurrence, and need for further surgery were recorded. Outcomes were classified as "good" (plantigrade foot±heel cord tenotomy), "fair" (need for a limited procedure), or "poor" (need for a full posteromedial release).

RESULTS

Forty-three clubfeet in 32 patients with ABS, and 320 idiopathic clubfeet in 215 patients were identified. Average age at last follow up was not different between ABS and idiopathic cohorts (7.4 vs. 5.2 y, P=0.233). Average Dimeglio score was lower in the ABS cohort (12.3 vs. 13.7, P=0.006). Recurrence rate was significantly higher in the ABS (62.8%) compared with idiopathic cohort (37.2%) (P=0.001). Clinical outcomes were significantly better in the idiopathic cohort (69.4% "good", 26.9% "fair", 3.8% "poor") compared with the ABS cohort (41.9% "good", 34.9% "fair", and 23.3% "poor") (P<0.001). Within the ABS cohort, no significant differences in clinical outcomes were found based upon location, severity, or presence of an ipsilateral lower extremity band.

CONCLUSION

Clubfeet associated with ABS have higher rates of recurrence, a greater need for later surgery, and worse clinical outcomes than idiopathic clubfeet. This information may prove helpful in counseling parents of infants with ABS associated clubfeet.

LEVEL OF EVIDENCE

Level III.

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.

Clubfeet and congenital constriction band syndrome

BACKGROUND

Clubfeet and constriction band syndrome is a very rare non-idiopathic condition. Treatment is often difficult and the recurrence deformity rate is high. The purpose of this study was to assess the effectiveness of Ponseti method in the treatment of congenital constriction band syndrome accompanied by clubfoot deformity and lymphedema.

CASE PRESENTATION

We are presenting an interesting case of bilateral clubfeet and congenital circumferential constriction band syndrome in the lower limb. Ponseti method of correcting the congenital clubfoot deformity was applied. Constriction band release is accomplished by two stages completely excising the fibrous band and multiple two-stage Z-plasties on the right calf.

CONCLUSION

The results of this study indicate that the Ponseti method of gentle, systematic manipulation and weekly cast changes is an effective treatment of non-idiopathic clubfoot distal to congenital amniotic constriction band.

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

to evaluate the effectiveness of the Ponseti method in treating syndrome-associated (nonidiopathic) congenital talipes equinovarus. This was a retrospective consecutive review over a 12-year period in a tertiary centre of all patients with syndrome-associated talipes equinovarus treated with the Ponseti method. The primary outcome measure at the final follow-up was the functional correction of the deformity. There were 16 (28 feet) children, with an average follow-up of 7 years (range: 4-12). The average age at presentation was 6.1 (range: 2-17) weeks. Deformities were severe, with an average Pirani score of 5.0 (range: 3.0-6.0). Initial correction was achieved in all children, with an average of 6 (range: 4-9) Ponseti casts and a tendo-Achilles tenotomy performed in 21/28 (75%) feet. Satisfactory outcome at the final follow-up was achieved in 23/28 (82%) feet. The Ponseti method is an effective first-line treatment for syndrome-associated talipes equinovarus to achieve functional painless feet; children will often require more casts and have a higher risk of relapse.

The Effectiveness of the Ponseti Method for Treating Clubfoot Associated With Amniotic Band Syndrome

BACKGROUND

Amniotic band syndrome (ABS) is a congenital disorder with an associated incidence of clubfoot deformity in over 50% of patients. Although early reports in the literature demonstrated a poor response to casting treatments, recent application of the Ponseti technique in ABS patients have been more promising.

METHODS

A retrospective review of all patients with clubfoot and a concurrent diagnosis of ABS were reviewed at a single institution. Patients not managed initially with the Ponseti method were excluded. Data collected included patient age at presentation, sex, unilateral or bilateral, amniotic band location and associated findings, and response to treatment-number of casts and requirement of Achilles tenotomy, tibialis anterior tendon transfer, or other surgical procedures. Duration of treatment at latest follow-up visit was noted and outcome was based on clinical foot appearance and plan for any further procedures.

RESULTS

Twelve patients (7 female and 5 male) with a total of 21 feet (9 bilateral and 3 unilateral) were identified. The average age at presentation was 3 weeks (range, 1 to 9 wk). The average number of casts was 6 (range, 3 to 11). Seventeen of 21 feet (81.0%) underwent percutaneous Achilles tenotomy. The initial correction rate for all patients with the Ponseti technique was 20/21 feet (95.2%) and recurrence was noted in 7/21 feet (33.3%). One patient underwent primary posteromedial release and 2 patients had associated neurological deficits. The average follow-up was 3.9 years (range, 9 mo to 10 y) and all but one patient had supple, plantigrade feet.

CONCLUSION

The Ponseti technique is an effective first-line treatment in patients who have clubfeet associated with ABS, including those with a neurological deficit.

LEVEL OF EVIDENCE

Level IV.