SLR - January 2022 - Saul Rodriguez

A Prospective, Median 15-Year Comparison of Ponseti Casting and Surgical Treatment of Clubfoot

Reference: Recordon JAF, Halanski MA, Boocock MG, McNair PJ, Stott NS, Crawford HA. A Prospective, Median 15-Year Comparison of Ponseti Casting and Surgical Treatment of Clubfoot. J Bone Joint Surg Am. 2021 Nov 3;103(21):1986-1995. doi: 10.2106/JBJS.20.02014. PMID: 34547011.

Level of Evidence: Level II

Scientific Literature Review

Reviewed By: Saul Rodriguez, DPM
Residency Program: University Hospital – Newark, NJ

Podiatric Relevance: Congenital talipes equinovarus or clubfoot is a complex three dimensional skeletal deformity that affects one to two infants per live births and is characterized by four traits; equinus, varus, adductus and cavus deformity. Historically, this condition has been treated by a variety of approaches ranging from manipulations and casting to extensive tendon transfers and osteotomies. The PMR (Posteromedial Release), first introduced by Turco in 1971, was found to supersede Kite’s method but long term outcomes show it yielded high rates of relapse, residual deformities and abnormal pedobarography. Ponseti’s method, although more conservative yielded better outcomes as shown in this 15 year comparison study.

Methods: This is a Level II, prospective cohort study looking at 51 patients, 25 in the Ponseti group and 26 under the PMR group. After 15 years from treatment, 33 patient’s participated in the clinical review which reported on;  comprising-reported outcomes, clinical examination, 3-D gait analysis and plantar pressures. The MRC (Medical Research Council) recorded; Dimeglio score, standing foot alignment, passive range of motion and strength. Single heel rise and six-minute walk tests were recorded for both groups. Clinical outcome measures consisted of: Pediatric Outcomes Data Collection Instrument (PODCI), Functional Disability Inventory, Disease Specific Instrument (DSI) and American Academy of Orthopaedic Surgeons (AAO) Foot and Ankle Outcomes Questionnaire. Using the Numerical Rating Scale of 0 to 100 (0 indicating no pain), pain was assessed.

Results: Approximately 42 percent (16 out 38) of the Ponseti group and 48 percent (20 out of 42) of the PMR group required an additional surgical procedure. Relapse of deformity occurred in both groups and peaked at the age of four years for the Ponseti group and twice for the PMR group at the ages of 1-2 years and at 10 years of age. Residual forefoot varus was noted, using only a visual assessment, in 16 feet within the PMR group versus three feet in the Ponseti group, but no statistically significant difference in the rates of residual cavus or hindfoot varus between both groups. Dimeglio scores were calculated on average to be 5.8 pts for the Ponseti vs 7.0 points in the PMR group. No difference noted in the 6-minute walk test. Ponseti group fared better with DSI (80.7 vs 65.6 points) and AAOS Foot and Ankle Outcomes (52.2 vs 46.6 points.) The Ponseti group reported scores on Functional Disability Inventory (1.1 vs 5.1 in the PMR group.) Both groups had similar outcomes in 3D gait analysis when observing ankle range of motion or muscle strength with plantarflexion. Plantar pressure studies concluded; PMR feet were (15 percent) smaller and exhibited higher varus deformity.

Conclusions: The findings of this study remain consistent with similar studies proving the superiority of Ponseti casting over PMR treated patients. Complications were observed in both groups but the severity and frequency of these outcomes were less in the Ponseti group. Given the extensive follow up nature of this study, it would be safe to say that idiopathic clubfeet should be treated primarily with the Ponseti method. 

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