SLR - April 2020 - Du H. Jun

Results of Modified Ponseti Technique in Difficult Clubfoot and a Review of Literature  
Ankur Agarwal, Sumit Gupta, Alok Sud, Sheetal Agarwal. Results of Modified Ponseti Technique in Difficult Clubfoot and a Review of Literature. J Clin Orthop Trauma. 2020 Mar-Apr;11(2):222-231 
Scientific Literature Review 
Reviewed By: Du H. Jun, DPM  
Residency Program: North Colorado Medical Center Podiatric Medicine and Surgery – Greeley, CO 
Podiatric Relevance: Clubfoot deformities is one of the most common anomalies of the lower extremities with varying global incidences. The Ponseti method of serial casting has shown good outcomes and is now the most popular nonoperative technique. However, resistant cases particularly in neglected relapse, complex cases, and obese infants have shown to require a greater number of casts then average with some failing to respond to standard modalities. Various modifications of the technique have been suggested in the literature. This paper discusses the outcomes of one of the modified techniques that begins first with an early TAL and plantar fascia release before starting serial casting in difficult clubfoot patients. 
Methods: Twenty-eight patients were selected who fit the following criteria: those who had idiopathic clubfoot, those in the 75th percentile in the WHO age for weight chart, and those greater then five months of age with untreated clubfoot. Exclusion criteria consisted of patients who previously had surgical intervention, patients over seven years of age, and patients with syndromic clubfoot. Steidler’s release and percutaneous tenotomy of the tendoachillies was first performed, followed by the first ponsetti cast application. The first cast was then retained for three weeks after which serial weekly casts were applied with Pirani scoring and radiographs completed before each change of cast. The endpoint was achieved when the Pirani score was zero. Follow up was completed weekly for the first month, monthly for three months after and quarterly until the age of 12. 
Results: In 28 patients 19 were bilateral accounting for a total of 47 feet. Mean Pirani score of 5.86, median weight of 7.8 kilograms and mean number of casts for correction was 3.75, with mean follow up of 18.64 months. Average kite’s angle after the first year of follow up was 33.28 degrees. Maximum foot abduction was 57.44 degrees with no  children losing the ability to actively plantar flex. 

Conclusions: In cases of difficult clubfoot as described above, the group’s modification of Ponseti technique had very good results requiring only on  average, four casts to correct the deformity. In “chubby” infants there are higher chances of cast slippage due to thick soft tissue and even minor slippage within the cast can result in iatrogenic atypical (complex) clubfoot. Care must be taken when applying. A plantar aponeurosis release allows for forefoot supination and abduction along with a tendoachillis tenotomy which eases the correction of equinus and hindfoot varus. Completing these procedures prior to initiating casting can save on several weekly casts required for gradual relaxation of these structures. Future research that incorporates multi-centric trials using the same technique, longer follow-up, and application of this technique in patients greater than seven years of age are needed. 

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