The Problems Encountered in a CTEV Clinic: Can Better Casting and Bracing Be Accomplished?

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 analysis of treatment outcome following classical Ponseti technique in older children with clubfoot - A concept stretched too far?

We questioned whether indications of Achilles tenotomy and standards of equinus correction as used for infants/young children hold true for use of the classical Ponseti technique in older children as well. Children aged 2-12 years with previously untreated unilateral/bilateral idiopathic clubfeet were included. For the purpose of this study, the subjects were treated by the classic Ponseti technique and underwent percutaneous tenotomy when talar head was reduced. A successful outcome and braceable feet were considered to be achieved when there was at least 10 degrees of ankle dorsiflexion post-tenotomy. The feet were classified into success and failure groups based on the above outcome and compared statistically. Furthermore, we documented the overall foot abduction and ankle dorsiflexion achieved post-tenotomy in older children. Final evaluations were done in 27 patients (39 feet; bilateral 12). Post-tenotomy, 16 feet (41%) constituted the success group. The average age (3.3 versus 5.8 years), foot abduction (39.4 versus 28.7 degrees) and ankle dorsiflexion (14.7 versus 4.1 degrees) for the success group were statistically different from the failure group. There were several residual foot deformities post-tenotomy, chiefly empty heel, varus, equinus and rotation. The reduction of lateral head of talus was not a reliable indicator for planning Achilles tenotomy in the older child. A 10-degree ankle dorsiflexion postclassical Ponseti method was achievable in only 41% feet for older children. Further, several residual deformities were present in treated feet post-tenotomy.

Semirigid Fiberglass Casting for the Early Management of Clubfoot: A Single-Center Experience

Background

Semirigid fiberglass (SRF) is an alternative material to plaster of Paris (POP) for idiopathic clubfoot casting in the Ponseti method. The purpose of this study was to evaluate early clinical outcomes in a series of idiopathic clubfoot patients treated with SRF at a single institution and to compare these findings to historical norms with POP casting present in the literature.

Methods

A series of idiopathic clubfoot patients managed exclusively with SRF in the Ponseti method was identified. Treatment efficacy was evaluated by number of casts, change in Pirani score, frequency of treatment-related complications, and frequency of surgery other than tenotomy. A comprehensive literature review was used for comparative historical norms.

Results

The study included 34 feet in 26 patients. Pirani score was 4.7±1.3 at presentation and 1.9±1.4 at the end of casting, representing a score change of 2.8±1.3 with SRF. Initial correction was obtained with 6.9±1.4 casts. Treatment-related complications occurred in six treated feet (17.6%) including 13 cast slippages in five feet and one cast-related thigh abrasion. A total of 25 (73.5%) feet underwent tenotomy. Two feet required an additional surgical procedure.

Conclusion

Clubfoot patients treated with SRF demonstrated acceptable deformity correction following Ponseti-style casting. The quantitative clinical outcomes evaluated appeared similar to norms using POP present in the literature. The findings of this study support SRF as a viable alternative to plaster casting for clubfoot correction utilizing the Ponseti method. As such, further investigation for rigorous comparative assessment is warranted.

Alternatives to Traditional Cast Immobilization in Pediatric Patients

Casts are commonly used for fracture management and postoperative immobilization in pediatric patients. However, cast immobilization is not without complications (eg, thermal injuries, pressure sores, infection, and neurovascular injury) and may be associated with additional costs and increased loss of school/work days for cast removal or other complications. The disadvantages of traditional casting can be minimized by alternative management strategies: waterproof casts to facilitate bathing and swimming; a Pavlik harness in infants, a single-leg spica cast, or flexible intramedullary nails to avoid complications with double-leg spica casts for femur fractures; and braces or splints to manage buckle and minimally displaced distal radius fractures, toddler's fractures, and stable foot/ankle fractures.