Outcomes of the Ponseti Method for Untreated Clubfeet in Nepalese Patients Seen Between the Ages of One and Five Years and Followed for at Least 10 Years

Clubfoot: Emphasis on the Complex and Atypical Subsets

The Ponseti method has proven to be successful in the treatment of both isolated and non-isolated clubfoot. The method should be executed prior to any pediatric invasive procedures and likewise should be attempted with any pediatric recurrence. A thorough neurologic examination and attention to clinical signs will help distinguish the atypical clubfoot. Despite this approach some children do require return to serial casting, physical therapy, and or surgery to achieve a plantigrade functional foot. Bracing strategies at a time of growth remain key.

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.

Evaluation of a surgical treatment algorithm for neglected clubfoot in low-resource settings

Purpose

Idiopathic clubfoot affects approximately 1/1000 alive-born infants, of whom 80–91% are born in low- or middle-income countries (LMICs). This retrospective study aimed to evaluate the morphological, functional, and social outcomes in patients with neglected clubfoot in rural Bangladesh, after receiving surgical treatment.

Methods

Patients received a posteromedial release (PMR) with or without an additional soft tissue intervention (group 1), a PMR with an additional bony intervention (group 2), or a triple arthrodesis (group 3) according to our surgical algorithm. Patients were followed until two year post-intervention. Evaluation was done using a modified International Clubfoot Study Group Outcome evaluation score and the Laaveg-Ponseti score.

Results

Twenty-two patients with 32 neglected clubfeet (ages 2–24 years) received surgical treatment. Nineteen patients with 29 clubfeet attended follow-up. At two year follow-up an excellent, good, or fair Laaveg-Ponseti score was obtained in 81% (group 1), 80% (group 2), and 0% (group 3) of the patients (p value 0.0038). Age at intervention is inversely correlated with the Laaveg-Ponseti score at two year follow-up (p < 0.0001). All patients attended school or work and were able to wear normal shoes.

Conclusion

Our treatment algorithm is in line with other surgical algorithms used in LMICs. Our data reconfirms that excellent results can be obtained with a PMR regardless of age. Our algorithm follows a pragmatic approach that takes into account the reality on the ground in many LMICs. Good functional outcomes can be achieved with PMR for neglected clubfoot. Further research is needed to investigate the possible role of triple arthrodesis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00264-021-05058-6.

Outcomes of Clubfoot Treated With Casting in Ghana

OBJECTIVE

Idiopathic clubfoot deformity is a condition in pediatric orthopedics with a prevalence of 1 in 1000. This study reports the outcomes of clubfoot treatment in Ghana.

METHODS

The study was Institutional Review Board (IRB) approved. Patients with clubfoot were treated by the Ponseti method including weekly casting, Achilles tendon lengthening (TAL), and prolonged bracing. Data points collected included: extent of clubfoot, age, relapse, tenotomy prevalence, and number of casts.

RESULTS

Out of 1,634 patients, 72.4% were less than a year of age at the time of the first cast, 82.6% had more than eight casts prior to bracing, and 74.0% had a percutaneous Achilles tenotomy prior to the final cast placement. Only 1.2% of patients suffered a relapse.

CONCLUSION

 In Ghana, delays in seeking in treatment are common. Optimal results for the Ponseti treatment occur in children who present prior to the age of one. In the current study, 27.6% of children delayed treatment until after one. We recommend a community advocacy program to educate leaders and medical personnel about the Ponseti method. Despite a delay of treatment in 25% of the patients, there was only a 1.2% relapse rate. We recommend the Ponseti method in Ghana for children of all ages.

Use of PROMIS in Assessment of Children With Ponseti-treated Idiopathic Clubfoot: Better Scores With Greater Than 3 Years of Brace Use

BACKGROUND

Patient-Reported Outcomes Measurement Information System (PROMIS) is a well-validated tool used to measure health-related quality of life for children and adolescents with chronic medical conditions. The current study evaluates PROMIS scores in 3 domains for children with Ponseti-treated idiopathic clubfoot.

METHODS

This is a retrospective cohort study of 77 children, ages 5 to 16 years, treated by Ponseti protocol for idiopathic clubfoot. Three pediatric PROMIS domains (Mobility, Pain Interference, and Peer Relationships) were administered between April 2017 and June 2018. One-way analysis of variance with Bonferroni post hoc and independent sample t tests were performed to explore differences across PROMIS domain scores by sex, age, initial Dimeglio score, laterality, bracing duration, and whether the child underwent tibialis anterior transfer.

RESULTS

In the self-reported group (ages 8 to 16), mean T-scores for all 3 domains in both unilaterally and bilaterally affected groups were within the normal range, with respect to the general reference pediatric population. However, children with unilateral clubfoot had a significantly higher mean Mobility T-score (54.77) than children with bilateral clubfoot (47.81, P=0.005). Children with unilateral clubfoot also had significantly lower mean pain scores (39.16) than their bilateral counterparts (46.56, P=0.005). Children who had braced >36 months had a significantly higher mean Mobility T-score (53.68) than children who braced ≤36 months (46.28, P=0.004).In the proxy group (ages 5 to 7), mean T-scores for all 3 domains in both laterality groups were within the normal range, with respect to the reference population. Children who had braced >36 months had a significantly higher mean Mobility T-score (52.75 vs. 49.15, P=0.014) and lower Pain Interference score (43.04 vs. 49.15, P=0.020) than children who braced ≤36 months.

CONCLUSIONS

Children treated by Ponseti protocol for idiopathic clubfoot yielded PROMIS scores for Mobility, Pain Interference, and Peer Relationships domains similar to the reference population. Bracing duration >36 months and unilaterality were associated with less mobility impairment than their counterparts. These findings may help guide parent recommendations.

LEVEL OF EVIDENCE

Level III.

Impact of North American Institutions on Orthopedic Research in Low- and Middle-Income Countries

There exists an unmet need for locally relevant and sustainable orthopedic research in low- and middle-income countries. Partnerships between high-income countries and low- and middle-income countries can bridge gaps in resources, knowledge, infrastructure, and skill. This article presents a select list of models for high-income countries/low- and middle-income countries research partnerships including academic partnerships, international research consortia, professional society-associated working groups, and nongovernmental organization partnerships. Models that produce research with lasting legacy are those that promote mutually beneficial partnerships over individual gains.

The PBS Score - a clinical assessment tool for the ambulatory and recurrent clubfoot

PURPOSE

The signs for clubfoot relapse are poorly defined in the literature and there is a lack of a scoring system that allows assessment of clubfeet in ambulatory children. The aim of this study is to develop an easy to use, reliable and validated evaluation tool for ambulatory children with a history of clubfoot.

METHODS

A total of 52 feet (26 children, 41 clubfeet, 11 unaffected feet) were assessed. Three surgeons used the seven-item PBS Score to rate hindfoot varus, standing and walking supination, early heel rise, active/passive ankle dorsiflexion and subtalar abduction blinded to the other examiners. All parents answered the modified Roye score questionnaire prior to the clinical assessment. Correlation between the mean PBS Score and the Roye score was evaluated using Spearman's rank correlation coefficient. Interobserver reliability was tested using weighted and unweighted Cohen's Kappa coefficients.

RESULTS

The Spearman's rank correlation coefficient for correlation between mean PBS Score and Roye score was 0.73 (moderate to good correlation).The interobserver agreement for the total PBS Score resulted in an intraclass correlation coefficient of 0.93 (almost perfect agreement).

CONCLUSION

The PBS score is an easy to use, clinical assessment tool for walking age children with clubfoot deformity. It includes passive and active criteria with a very good interobserver reliability and moderate to good validity.

LEVEL OF EVIDENCE

Level I - Diagnostic study.