SLR - April 2016 - Ashton J. Nelson

Title: Modified Ponseti Method of Treatment for Correction of Neglected Clubfoot in Older Children and Adolescents – A Preliminary Report

Reference: Haj Zargar Bashi R, Baghdadi T, Ramezan Shirazi M, Abdi R and Aslani H. Modified Ponseti Method of Treatment for Correction of Neglected Clubfoot in Older Children and Adolescents – A Preliminary Report. J Pediatr Orthop B. 2016 Mar;25(2): 99-103.

Scientific Literature Review

Reviewed By: Ashton J. Nelsen, DPM
Residency Program: Hennepin County Medical Center

Podiatric Relevance: Congenital talipes equinovarus is likely the most common congenital orthopedic condition requiring treatment. Ponseti introduced his technique in the early 1940s. Reports have shown successful clubfoot treatment in children up to age 9 using his technique. However, it is not known whether age at the beginning of treatment affects the rate of effective correction or relapse. This study applies the Ponseti technique with some modifications to neglected and untreated clubfoot older children and adolescents with an age range of six to 19 years in Tehran, Iran.  This treatment method is very simple and cost effective in developing countries with limited financial and social resources for health care.

Methods: Eleven patients with congenital idiopathic clubfoot (18 feet) were treated at the Referral Pediatric Center in Tehran. Ten of these patients had no previous treatment, one patient had residual clubfoot after being treated surgically in another center, and one patient had failed previous Ponseti casting. The mean age was 11.2 years, range 6-19.  Modifications of standard Ponseti technique were as follows: 1) manipulations prior to casting lasted 3-5 minutes; 2) the foot was abducted to 30o rather than 70o; 3) each cast was left on for three weeks instead of one week; and 3) short leg casts were used in lieu of long leg casts. Achilles tendon lengthening and posterior tibiotalar capsulotomies were performed in all patients to correct the equinus deformity.  Additional soft tissue procedures were performed as needed. Post-cast bracing consisted of night ankle foot orthosis with a forefoot abduction pad. Daily high top shoes with reverse last were also worn. Radiographs of the affected foot were taken pre-operatively and at the latest follow-up.

Results: Mean follow-up was 15 months (range 12-36 months) and no patients were lost to follow-up. Correction of deformity was achieved with a mean of nine casts (range 6-13). Mean time of night bracing post-casts was three months (range 1.5-5 months).One foot required a tibialis anterior tendon transfer and three feet required plantar fascial release. Complications from casting included plantar hematoma from percutaneous plantar fascia release. Skin complications included wound dehiscence in the patient who had undergone previous surgery. No infections or neurovascular compromise occurred. Seventeen feet (94.4 percent) were considered to have a good result with no need for further surgery. “Good” criteria was defined as a plantigrade foot, no pain during ambulation and at rest, able to wear normal shoes, and near normal ankle and subtalar joint range of motion. These 17 feet were also noted to have a major improvement in cosmesis. One patient failed to achieve full correction with above measures and so underwent Ilizarov external fixation.

Conclusions: This study shows that a modified Ponseti technique can be used to treat talipes equinovarus in older children and adolescents. One could argue a lesser success rate of 13/18 (72.2 percent) instead of the 17/18 (94.4 percent) reported in the article, because of the additional soft tissue procedures needed, including plantar fascial release, tibialis anterior tendon transfer. However, 17/18 patients did experience good results from the addition of soft tissue procedures only. These preliminary results are encouraging, especially for areas where access to healthcare is limited. It will be interesting to follow the authors’ long-term results.

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