The Ponseti method of clubfoot treatment in walking age children: is it effective? A study of 56 children from 1 to 10 years of age

Abstract

The Ponseti method is well-established for the treatment of clubfoot in younger babies; however, its effectiveness in older children is still unclear. The aim of our study was to report our results of the ‘traditional’ Ponseti method in the management of clubfoot in children of walking age. A total of 56 (81 clubfeet) children with a mean age of 3.16±2.35 years (1–10 years) were divided into two groups: group I consisted of 12 (18 clubfeet) patients with a mean age of 3.36±2.7 years (range: 1–8.4 years) who presented with an untreated clubfoot whereas group II consisted of 44 (63 clubfeet) patients with a mean age of 3.19±2.34 years (range: 1–10 years) who presented with a recurrent clubfoot. All children underwent the standard manipulation and casting technique described by Ponseti, including a percutaneous tenotomy of the Tendo Achilles. The bracing protocol was modified appropriately. All feet corrected with a mean of 7.36 (3–17) casts in group I and 4.49 (1–12) casts in group II. All children in group I and 70.45% in group II underwent a percutaneous Tendo Achilles tenotomy. There was a statistically significant change between the pretreatment and post-treatment Pirani scores in both groups. Nineteen (30.86%) patients underwent relapse at a mean follow-up of 2.84±1.25 years (1.2–5.4 years), who were treated by re-casting, bracing and tibialis anterior tendon transfer. The Ponseti method is effective even in walking age children upto the age of 10 years with a good success rate, although approximately one-third of the clubfeet relapsed and needed further treatment. No modifications to the standard casting protocol are required. Despite a high relapse rate, a supple, plantigrade and pain-free foot is achievable without the need for extensive soft-tissue surgeries or bony procedures. The Ponseti method lends itself well to developing a nation-wide program for clubfoot treatment in countries with limited resources. Level of Evidence: Level III.

What is the optimal treatment for equinus deformity in walking-age children with clubfoot? A systematic review

“… 39 The other did not report any direct ROM metrics, but reported a ‘pain-free, plantigrade foot, without the need for extensive soft tissue release’. 40 Posterior capsulotomy improved mean ankle dorsiflexion from –6.5° pre operation to +9.7° post operation, and +8.3° at final follow-up. 38 …”

“… 39 The other study examining release of the GSC did not report radiographic outcomes. 40 Posterior capsulotomy delivered mixed radiographic results with a significant improvement in mean LAT tibiocalcaneal angle (TibCA) from 98.9° to 63.7°, but no improvement in anteroposterior (AP) or LAT talo-first metatarsal angle (TMT1). 38 …”

“…Five studies included only surgically-corrected feet 33 – 37 and three reports included only Ponseti-corrected feet. 38 – 40 Refai et al reported a mixed cohort of feet corrected by the Ponseti method and a surgical posteromedial release. 41 …”

“…tendon Achilles lengthening (TAL) or Vulpius procedure. 39 , 40 One study also performed posterior capsulotomy. 38 Two studies performed distraction via a circular frame (one with distal tibial osteotomy [DTO] but neither with hindfoot osteotomy), 33 , 41 one further study utilized DTO, 35 and three studies performed anterior distal tibial hemi-epiphysiodesis (ADTH) using either 8-plates or staples.…”

“…Protocols by Jauregui et al, Shah et al, and Refai et al, 38 , 40 , 41 state the use of serial casting as initial management of relapsed feet; other protocols do not state whether serial casting was utilized prior to the investigational intervention.…”