SLR - May 2014 - Joseph Genualdi

Long-term Results of Comprehensive Clubfoot Release Versus the Ponseti Method: Which is Better?

Reference: Smith PA, Kuo KN, Graf AN, Krzak J, Flanagan A, Hassani S, Caudill AK, Dietz FR, Morcuende J, Harris GF. Clin Orthop Relat Res. 2014 Apr; 472(4): 1281-90.

Scientific Literature Review

Reviewed By: Joseph Genualdi, DPM
Residency Program: University Hospital- Newark, NJ

Podiatric Relevance: The incidence of congenital talipes equinovarus is approximately 3/1000 live births. Clubfoot is a complex triplane deformity most commonly treated by the Ponseti method of serial manipulation and casting. The purpose of this level III prognostic study was to compare the long term functional and quality of life outcomes of pediatric clubfoot treated by Ponseti method versus comprehensive surgical release.

Methods: The authors enrolled 24 adult patients who were treated with comprehensive surgical release by the age of 18 months at Shriners Hospital for Children after a failed course of conservative treatment which did not include the Ponseti method, 18 adult patients treated by the Ponseti method at University of Iowa as infants, and 48 adult control subjects without history of clubfoot from Marquette University. The authors analyzed various physical measures, radiographic signs of osteoarthritis, gait abnormalities, as well as quality of life outcomes by means of AOFAS, SF-36, and International Clubfoot Study Group Score.

Results: Both treatment groups had significantly decreased range of motion and strength compared to the control group, however, the surgical group was found to have significantly reduced passive plantarflexion, inversion and heel rise strength compared to the Ponseti treated group. The surgical and Ponseti treatment groups had a relatively low incidence of moderate-to-severe osteoarthritis, 4 percent and 3 percent respectively. During gait, the surgically treated group was found to have significantly reduced speed, stride length and peak plantar pressure during pre-swing phase compared to the Ponseti and control groups. The treatment groups scored significantly lower than controls using the outcome measures of AOFAS and SF-36; while 80 percent of the Ponseti group and 60 percent of the surgical group scored good to excellent outcomes using the International Clubfoot Study Group Score.

Conclusions: Despite being highly functional adults, both treatment groups scored significantly lower than the control group on the quality of life surveys. In addition, both treatment groups at long term follow-up were found to have increased pain, decreased ROM and strength compared to the control subjects. The statistical differences in long term ROM, strength and gait between the two treatment groups supports serial manipulation and casting by the Ponseti method as the first line of treatment for congenital clubfoot. With the evidence presented practitioners treating pediatric clubfoot should be well trained in the Ponseti method and those with little experience should refer out as early as possible.

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