- Email: [email protected]
Assessment of Ponseti technique for clubfoot
APME-409; No. of Pages 3 apollo medicine xxx (2017) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Original Article
Assessment of Ponseti technique for clubfoot Vikram Khanna a,*, Raju Vaishya b a b
Department of Orthopaedics, Ranjana Hospital, Allahabad, India Department of Orthopaedics, Indraprastha Apollo Hospital, Delhi, India
article info
abstract
Article history:
Introduction: Clubfoot is a really complicated deformity of the foot. There are 4 components
Received 16 January 2017
to this deformity which are forefoot varus, adduction, cavus and equinus. The main goal of
Accepted 14 February 2017
the treatment is the attainment of a supple plantigrade foot which is cosmetically and
Available online xxx
functionally acceptable. This study has been done with the aim to present with the authors
Keywords:
Material & Methods: This prospective study included 100 children with 137 club feet from
experience of managing clubfoot using ponseti. Clubfoot
January 2015 to December 2016. All children below the age of 2 years with congenital talipes
Ponseti
equino-varus (CTEV) were included in this study. The severity of the deformity was assessed
Pirani's score
with the help of the Pirani's score and clinical evaluation of the foot was taken and noted. In all the cases the Ponseti method was used for the management. After cast removal the foot was kept in a foot abduction brace with the corrected foot kept in a foot abduction brace for 23 hours in a day and this was decreased to night time wearing after 3 months and the parents were advised to continue wearing it till the age of 5 years. All the observations were done by a single observer to prevent any inter-observer variation. Results: Out of 100 patients 63 were unilateral clubfoot and 37 were bilateral cases of clubfoot. The mean number of casts was found to be 7.56 (4–9). There was recurrence seen in 7 feet which had to be managed with 2–3 serial manipulations and casting and these resolved. Conclusion: Ponseti technique is a very useful method of management of CTEV. © 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
1.
Introduction
Clubfoot is a really complicated deformity of the foot.1 The idiopathic variety is the most common deformity encountered of the foot.2 The incidence is close to 1–2 cases in 1000 live births. It occurs bilaterally in 40% of cases3 and it is more common in males than in females with a ratio of 3:1.2.4 There are four components to this deformity which are forefoot varus, adduction, cavus, and equinus.1,4,5 The main
goal of the treatment is the attainment of a supple plantigrade foot which is cosmetically and functionally acceptable.1,5,6 The treatment of clubfoot ranges from nonoperative to operative. The nonoperative treatment includes serial manipulations with casting, strapping or splinting to maintain the correction.2 Two manipulation techniques have been described in the literature for the management of clubfoot.2,7 One was described by Kite (1939) with success rates ranging from 11% to 58%.2,8 This was later attributed to the fact that Kite thought
* Corresponding author at: Department of Orthopaedics, Ranjana Hospital, 13, D-Road, Allahabad 211003, India. Tel.: +91 7073647974. E-mail address: [email protected] http://dx.doi.org/10.1016/j.apme.2017.02.006 0976-0016/© 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
Please cite this article in press as: Khanna V, Vaishya R. Assessment of Ponseti technique for clubfoot, Apollo Med. (2017), http://dx.doi.org/ 10.1016/j.apme.2017.02.006
APME-409; No. of Pages 3
2
apollo medicine xxx (2017) xxx–xxx
that the axis of the deformity was the calcaneocuboid joint and he tried to forcefully correct the deformity while holding the calcaneum in its place leading to a mid-tarsal break which caused rocker bottom foot. The other method was described by Dr. Ignati Ponseti (1963) also known as the Iowa method which involved serial manipulation and casting every week followed by percutaneous tendoachilles (TA) tenotomy and a foot abduction brace. This technique was associated with better correction rates (up to 98% in experienced hands) and lower complication rates.2,9 This study has been done with the aim to present with the authors experience of managing clubfoot using Ponseti. The assessment has been done using the Pirani's score10 along with clinical evaluation.
2.
Material and methods
This prospective study included 100 children with 137 clubfeet from January 2015 to December 2016 in Ranjana Hospital, Allahabad and NIMS Medical College, Jaipur. All children below the age of 2 years with congenital talipes equino-varus (CTEV) were included in this study. All cases of secondary CTEV were excluded from this study. After discussing the treatment plan with the patients' guardians and getting their informed consent the severity of the deformity was assessed with the help of the Pirani's score and clinical evaluation of the foot was taken and noted. A detailed birth history was also taken to look for any significant findings. In all the cases the Ponseti method was used for the management and the number of casts used in each case was noted. The deformity was assessed every time the cast was changed and noted. In all the cases the TA tenotomy was done and this was followed by the final cast for a period of 15 days. After cast removal the foot was kept in a foot abduction brace with the corrected foot kept in a foot abduction brace for 23 h in a day and this was decreased to night time wearing after 3 months and the parents were advised to continue wearing it till the age of 5 years. Children who can walk were advised CTEV shoes to wear and this was also advised till the age of 5 years. All the children were followed up every month for a period of 6 months to check for compliance in the brace and to look for any relapse case. All the manipulations were done by the first author and the measurements were done by another observer. All the observations were done by a single observer to prevent any inter-observer variation. After the Pirani score was calculated in all the patients. The medial and lateral border of the foot was measured and their ratio was calculated and documented. The equinus, adduction, and varus were all measured from the neutral position and documented and the Cavus deformity was documented as either present or not.
3.
Results
Out of 100 patients 63 were unilateral clubfoot and 37 were bilateral cases of clubfoot. Among the unilateral 26 (41.2%)
Table 1 – Pre and post treatment evaluation. Premanipulation assessment
Postmanipulation assessment
5.4 (4–6)
0.015 (0–0.5)
65%
45%
Equinus <08 0–208 20–508
0% 1% 64%
96% 4% 0%
Varus >508 <08 <58 5–208 >208
35% 0% 5% 65% 30%
0% 97% 3% 0% 0%
Cavus
95%
0%
Mean Pirani's score (range) Mediolateral border ratio <1
were of the right side and the remaining 37 (58.8%) were of the left side. The mean age of the patients was 25.3 weeks. 85% of the children were born full term and the remaining were preterm. Normal delivery was done in 65% of the case and LSCS was done in the remaining cases. There were 66 male children and 34 female children in this study. The mean number of casts was found to be 7.56 (4–9). TA tenotomy was done in all the cases with similar follow-up instructions followed in all the patients. The results are summarized in Table 1. There was recurrence seen in 7 ft which had to be managed with 2–3 serial manipulations and casting and these resolved.
4.
Discussion
Although, the management of CTEV has been under controversies on which path to follow but in recent times there has been wide acceptance of the Ponseti method as the first line of management of CTEV.1,3,4,11 This treatment should be started as soon as possible after birth. 1,5 This helps in fulfilling the main goal of the outcome of the management which is to obtain a plantigrade supple foot with good mobility. 1,4–6 The treatment does not only involve serial manipulation and casting but it involves the counseling of the family by the doctor about the treatment and the importance of the brace treatment in the followup period. This maybe done with the help of illustrated booklets which are easy to understand and to follow. In cases when it was difficult for the family to understand the treatment and the posttreatment management then the child was regular monitored in the followup period with special care of the bracing protocol. Idiopathic clubfoot or primary clubfoot has been defined as clubfoot having no definitive etiology, whereas neurological clubfoot has been defined as clubfoot with a central, spinal or peripheral disease. In this study all cases with an associated
Please cite this article in press as: Khanna V, Vaishya R. Assessment of Ponseti technique for clubfoot, Apollo Med. (2017), http://dx.doi.org/ 10.1016/j.apme.2017.02.006
APME-409; No. of Pages 3 apollo medicine xxx (2017) xxx–xxx
condition were excluded and only idiopathic clubfoot were included. The manipulation and casting was done by a single surgeon to avoid any change in the skill or management technique of the patient. All the observations were done by the second author to avoid any bias in the estimation of the outcome of the treatment. In this study males were more affected than females which is also seen in other studies seen in the literature. 1,4 Premanipulation mean Pirani's score was found to be 5.4 (4.5–6) which was consistent with other studies as well. 1,4,12 Mean number of casts given were 7.56 (5–9) which was comparable to other studies. 4 In this study TA tenotomy was done in all the patients as described by Ponseti. Advising and compliance of the bracing protocol is the most difficult and the important part of the treatment.12 This not only requires adequate counseling and regular checking of the brace but also parents education and cooperation is required to maintain proper bracing protocol. There was recurrence of the deformity seen in 7 cases all of whom were diagnosed within 6 months of completion of the treatment. These children were again managed with the Ponseti technique. All patients were managed with casting and in none of the patients any surgical intervention was required.
5.
Conclusion
Ponseti technique is a very useful method of management of CTEV. This has led to the successful management of an otherwise crippling deformity of clubfoot.
Conflicts of interest The authors have none to declare.
references
1. Ramakrishnan A, Gopakumar TS, Mohan R. Ponseti technique in the management of idiopathic club foot. Kerala J Orthop. 2014;15–17. 2. Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Jt Surg Am. 2004;86:22–27. 3. Ponseti IV. Congenital Clubfoot Fundamentals of Treatment. 1st ed. New York: Oxford University Press Inc.; 1996. 1–2, 448–54. 4. Matuszewski L, Gil L, Karski J. Early results of treatment for congenital clubfoot using the Ponseti method. Eur J Orthop Surg Traumatol. 2012;22:403–406. 5. Bridgens J, Kiely N. Current management of club foot (congenital talipes equinovarus). BMJ. 2010;340:c355. 6. Noh H, Park SS. Predictive factors for residual equinovarus deformity following Ponseti treatment and percutaneous Achilles tenotomy for idiopathic clubfoot: a retrospective review of 50 cases followed for median 2 years. Acta Orthop. 2013;84(April (2)):213–217. 7. Colburn M, Williams M. Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method. J Foot Ankle Surg. 2003;42(5):259–267. 8. Diméglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop. 1995;4:129–136. 9. Lehman WB, Mohaideen A, Madan S, et al. A method for the early evaluation of the Ponseti (Iowa) technique for the treatment of idiopathic clubfoot. J Pediatr Orthop. 2003;12 (2):133–140. 10. Pirani S, Outerbridge HK, Sawatzky B, Stothers K. A reliable method of clinically evaluating a virgin clubfoot evaluation. In: 21st SICOT Congress. 1999. 11. Chotel F, Parot R, Seringe R, Berard J, Wicart P. Comparative study: Ponseti method versus French physiotherapy for initial treatment of idiopathic clubfoot deformity. J Pediatr Orthop. 2011;31(April–May (3)):320–325. 12. Saif Ullah M, Md Noor-Ul Ferdous K, Shahjahan M, Abu Sayed S. Management of congenital talipes equino varus (CTEV) by Ponseti casting technique in neonates: our experience. J Neonatal Surg. 2013;2(April (2)):17.
Please cite this article in press as: Khanna V, Vaishya R. Assessment of Ponseti technique for clubfoot, Apollo Med. (2017), http://dx.doi.org/ 10.1016/j.apme.2017.02.006
3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Original Article
Assessment of Ponseti technique for clubfoot Vikram Khanna a,*, Raju Vaishya b a b
Department of Orthopaedics, Ranjana Hospital, Allahabad, India Department of Orthopaedics, Indraprastha Apollo Hospital, Delhi, India
article info
abstract
Article history:
Introduction: Clubfoot is a really complicated deformity of the foot. There are 4 components
Received 16 January 2017
to this deformity which are forefoot varus, adduction, cavus and equinus. The main goal of
Accepted 14 February 2017
the treatment is the attainment of a supple plantigrade foot which is cosmetically and
Available online xxx
functionally acceptable. This study has been done with the aim to present with the authors
Keywords:
Material & Methods: This prospective study included 100 children with 137 club feet from
experience of managing clubfoot using ponseti. Clubfoot
January 2015 to December 2016. All children below the age of 2 years with congenital talipes
Ponseti
equino-varus (CTEV) were included in this study. The severity of the deformity was assessed
Pirani's score
with the help of the Pirani's score and clinical evaluation of the foot was taken and noted. In all the cases the Ponseti method was used for the management. After cast removal the foot was kept in a foot abduction brace with the corrected foot kept in a foot abduction brace for 23 hours in a day and this was decreased to night time wearing after 3 months and the parents were advised to continue wearing it till the age of 5 years. All the observations were done by a single observer to prevent any inter-observer variation. Results: Out of 100 patients 63 were unilateral clubfoot and 37 were bilateral cases of clubfoot. The mean number of casts was found to be 7.56 (4–9). There was recurrence seen in 7 feet which had to be managed with 2–3 serial manipulations and casting and these resolved. Conclusion: Ponseti technique is a very useful method of management of CTEV. © 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
1.
Introduction
Clubfoot is a really complicated deformity of the foot.1 The idiopathic variety is the most common deformity encountered of the foot.2 The incidence is close to 1–2 cases in 1000 live births. It occurs bilaterally in 40% of cases3 and it is more common in males than in females with a ratio of 3:1.2.4 There are four components to this deformity which are forefoot varus, adduction, cavus, and equinus.1,4,5 The main
goal of the treatment is the attainment of a supple plantigrade foot which is cosmetically and functionally acceptable.1,5,6 The treatment of clubfoot ranges from nonoperative to operative. The nonoperative treatment includes serial manipulations with casting, strapping or splinting to maintain the correction.2 Two manipulation techniques have been described in the literature for the management of clubfoot.2,7 One was described by Kite (1939) with success rates ranging from 11% to 58%.2,8 This was later attributed to the fact that Kite thought
* Corresponding author at: Department of Orthopaedics, Ranjana Hospital, 13, D-Road, Allahabad 211003, India. Tel.: +91 7073647974. E-mail address: [email protected] http://dx.doi.org/10.1016/j.apme.2017.02.006 0976-0016/© 2017 Indraprastha Medical Corporation Ltd. All rights reserved.
Please cite this article in press as: Khanna V, Vaishya R. Assessment of Ponseti technique for clubfoot, Apollo Med. (2017), http://dx.doi.org/ 10.1016/j.apme.2017.02.006
APME-409; No. of Pages 3
2
apollo medicine xxx (2017) xxx–xxx
that the axis of the deformity was the calcaneocuboid joint and he tried to forcefully correct the deformity while holding the calcaneum in its place leading to a mid-tarsal break which caused rocker bottom foot. The other method was described by Dr. Ignati Ponseti (1963) also known as the Iowa method which involved serial manipulation and casting every week followed by percutaneous tendoachilles (TA) tenotomy and a foot abduction brace. This technique was associated with better correction rates (up to 98% in experienced hands) and lower complication rates.2,9 This study has been done with the aim to present with the authors experience of managing clubfoot using Ponseti. The assessment has been done using the Pirani's score10 along with clinical evaluation.
2.
Material and methods
This prospective study included 100 children with 137 clubfeet from January 2015 to December 2016 in Ranjana Hospital, Allahabad and NIMS Medical College, Jaipur. All children below the age of 2 years with congenital talipes equino-varus (CTEV) were included in this study. All cases of secondary CTEV were excluded from this study. After discussing the treatment plan with the patients' guardians and getting their informed consent the severity of the deformity was assessed with the help of the Pirani's score and clinical evaluation of the foot was taken and noted. A detailed birth history was also taken to look for any significant findings. In all the cases the Ponseti method was used for the management and the number of casts used in each case was noted. The deformity was assessed every time the cast was changed and noted. In all the cases the TA tenotomy was done and this was followed by the final cast for a period of 15 days. After cast removal the foot was kept in a foot abduction brace with the corrected foot kept in a foot abduction brace for 23 h in a day and this was decreased to night time wearing after 3 months and the parents were advised to continue wearing it till the age of 5 years. Children who can walk were advised CTEV shoes to wear and this was also advised till the age of 5 years. All the children were followed up every month for a period of 6 months to check for compliance in the brace and to look for any relapse case. All the manipulations were done by the first author and the measurements were done by another observer. All the observations were done by a single observer to prevent any inter-observer variation. After the Pirani score was calculated in all the patients. The medial and lateral border of the foot was measured and their ratio was calculated and documented. The equinus, adduction, and varus were all measured from the neutral position and documented and the Cavus deformity was documented as either present or not.
3.
Results
Out of 100 patients 63 were unilateral clubfoot and 37 were bilateral cases of clubfoot. Among the unilateral 26 (41.2%)
Table 1 – Pre and post treatment evaluation. Premanipulation assessment
Postmanipulation assessment
5.4 (4–6)
0.015 (0–0.5)
65%
45%
Equinus <08 0–208 20–508
0% 1% 64%
96% 4% 0%
Varus >508 <08 <58 5–208 >208
35% 0% 5% 65% 30%
0% 97% 3% 0% 0%
Cavus
95%
0%
Mean Pirani's score (range) Mediolateral border ratio <1
were of the right side and the remaining 37 (58.8%) were of the left side. The mean age of the patients was 25.3 weeks. 85% of the children were born full term and the remaining were preterm. Normal delivery was done in 65% of the case and LSCS was done in the remaining cases. There were 66 male children and 34 female children in this study. The mean number of casts was found to be 7.56 (4–9). TA tenotomy was done in all the cases with similar follow-up instructions followed in all the patients. The results are summarized in Table 1. There was recurrence seen in 7 ft which had to be managed with 2–3 serial manipulations and casting and these resolved.
4.
Discussion
Although, the management of CTEV has been under controversies on which path to follow but in recent times there has been wide acceptance of the Ponseti method as the first line of management of CTEV.1,3,4,11 This treatment should be started as soon as possible after birth. 1,5 This helps in fulfilling the main goal of the outcome of the management which is to obtain a plantigrade supple foot with good mobility. 1,4–6 The treatment does not only involve serial manipulation and casting but it involves the counseling of the family by the doctor about the treatment and the importance of the brace treatment in the followup period. This maybe done with the help of illustrated booklets which are easy to understand and to follow. In cases when it was difficult for the family to understand the treatment and the posttreatment management then the child was regular monitored in the followup period with special care of the bracing protocol. Idiopathic clubfoot or primary clubfoot has been defined as clubfoot having no definitive etiology, whereas neurological clubfoot has been defined as clubfoot with a central, spinal or peripheral disease. In this study all cases with an associated
Please cite this article in press as: Khanna V, Vaishya R. Assessment of Ponseti technique for clubfoot, Apollo Med. (2017), http://dx.doi.org/ 10.1016/j.apme.2017.02.006
APME-409; No. of Pages 3 apollo medicine xxx (2017) xxx–xxx
condition were excluded and only idiopathic clubfoot were included. The manipulation and casting was done by a single surgeon to avoid any change in the skill or management technique of the patient. All the observations were done by the second author to avoid any bias in the estimation of the outcome of the treatment. In this study males were more affected than females which is also seen in other studies seen in the literature. 1,4 Premanipulation mean Pirani's score was found to be 5.4 (4.5–6) which was consistent with other studies as well. 1,4,12 Mean number of casts given were 7.56 (5–9) which was comparable to other studies. 4 In this study TA tenotomy was done in all the patients as described by Ponseti. Advising and compliance of the bracing protocol is the most difficult and the important part of the treatment.12 This not only requires adequate counseling and regular checking of the brace but also parents education and cooperation is required to maintain proper bracing protocol. There was recurrence of the deformity seen in 7 cases all of whom were diagnosed within 6 months of completion of the treatment. These children were again managed with the Ponseti technique. All patients were managed with casting and in none of the patients any surgical intervention was required.
5.
Conclusion
Ponseti technique is a very useful method of management of CTEV. This has led to the successful management of an otherwise crippling deformity of clubfoot.
Conflicts of interest The authors have none to declare.
references
1. Ramakrishnan A, Gopakumar TS, Mohan R. Ponseti technique in the management of idiopathic club foot. Kerala J Orthop. 2014;15–17. 2. Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Jt Surg Am. 2004;86:22–27. 3. Ponseti IV. Congenital Clubfoot Fundamentals of Treatment. 1st ed. New York: Oxford University Press Inc.; 1996. 1–2, 448–54. 4. Matuszewski L, Gil L, Karski J. Early results of treatment for congenital clubfoot using the Ponseti method. Eur J Orthop Surg Traumatol. 2012;22:403–406. 5. Bridgens J, Kiely N. Current management of club foot (congenital talipes equinovarus). BMJ. 2010;340:c355. 6. Noh H, Park SS. Predictive factors for residual equinovarus deformity following Ponseti treatment and percutaneous Achilles tenotomy for idiopathic clubfoot: a retrospective review of 50 cases followed for median 2 years. Acta Orthop. 2013;84(April (2)):213–217. 7. Colburn M, Williams M. Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method. J Foot Ankle Surg. 2003;42(5):259–267. 8. Diméglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop. 1995;4:129–136. 9. Lehman WB, Mohaideen A, Madan S, et al. A method for the early evaluation of the Ponseti (Iowa) technique for the treatment of idiopathic clubfoot. J Pediatr Orthop. 2003;12 (2):133–140. 10. Pirani S, Outerbridge HK, Sawatzky B, Stothers K. A reliable method of clinically evaluating a virgin clubfoot evaluation. In: 21st SICOT Congress. 1999. 11. Chotel F, Parot R, Seringe R, Berard J, Wicart P. Comparative study: Ponseti method versus French physiotherapy for initial treatment of idiopathic clubfoot deformity. J Pediatr Orthop. 2011;31(April–May (3)):320–325. 12. Saif Ullah M, Md Noor-Ul Ferdous K, Shahjahan M, Abu Sayed S. Management of congenital talipes equino varus (CTEV) by Ponseti casting technique in neonates: our experience. J Neonatal Surg. 2013;2(April (2)):17.
Please cite this article in press as: Khanna V, Vaishya R. Assessment of Ponseti technique for clubfoot, Apollo Med. (2017), http://dx.doi.org/ 10.1016/j.apme.2017.02.006
3