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Comment on Mootha et al.: Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre
J Orthop Sci (2011) 16:836–837 DOI 10.1007/s00776-011-0161-0
LETTER TO THE EDITOR
Comment on Mootha et al.: Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre Siddhartha Sharma • Mohmmad Farooq Butt Bias Dev
•
Received: 14 May 2011 / Accepted: 30 August 2011 / Published online: 14 October 2011 Ó The Japanese Orthopaedic Association 2011
Dear Editor, We read with great interest the article by Mootha et al. [1] entitled ‘Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre’ in the online version of the Journal of Orthopaedic Science. We would like to congratulate the authors on an excellent article, and we fully agree with the authors’ recommendations of strict compliance with splintage and the need for awareness amongst people of low socio-economic status in order to minimise recurrences. However, we would like to bring forth an extremely important aspect of Ponseti management, i.e. the manipulative correction of atypical clubfeet. Atypical clubfeet, also termed as ‘complex’ or ‘stiff-stiff’ by different authors, represent a small proportion of idiopathic clubfeet [2, 3]. As described by Ponseti, these are characterized by deep creases above the heel, a transverse crease in the sole of the foot, rigid equinus, severe plantar flexion of all metatarsals, a short hyper-extended first toe and a tight Achilles tendon, which is fibrotic up to the mid calf. These feet respond poorly to the conventional techniques of manipulation and are associated with poor surgical outcomes [2, 4]. The feet tend to slip in casts owing to severe plantar flexion of the metatarsals, and this leads to oedema of the foot and formation of an oedematous fold on the dorsum of foot. Also, hyper-abduction of the forefoot in an attempt to correct the hindfoot varus leads to further increase in the plantar flexion An answer to this letter to the editor is available at doi:10.1007/s00776-011-0162-z. S. Sharma (&) M. F. Butt B. Dev Department of Orthopaedic Surgery, Government Medical College and Associated Hospitals, 180015 Jammu, India e-mail: [email protected]
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of the metatarsals and pushes the toes in abduction, resulting in a grotesque deformity. Ponseti [2] has described a modification of his original technique for manipulative correction of atypical clubfeet. The essence of this technique lies in correct identification of the talar head, which should be palpated carefully with two fingers. Adduction is corrected by gentle abduction of the forefoot around the talus; however, the foot is never abducted beyond 40°. It is important to maintain a counterpressure not only on the talar head, but also on the lateral malleolus in order to correct the hindfoot varus. Subsequently, cavus is corrected by placing thumbs of both hands on the foot and dorsiflexing all the metatarsals. At the same time, the foot is dorsiflexed and slightly abducted, and the heel is also brought into abduction. When the cavus has been corrected, a percutaneous tenotomy of Achilles tendon is done to correct the dorsiflexion. Relapses are common with the use of conventional abduction braces because the short and chubby feet tend to slip inside the brace. To overcome this problem, Ponseti used a custommade, pre-moulded ankle foot abduction brace. This consists of open-toed sandals with three straps to firmly hold the foot in place and two openings at the heel to allow the parents to ensure proper placement of the foot in the sandals. Most relapses can be managed satisfactorily with repeat manipulations and a second tenotomy. The authors reported eight atypical clubfeet in their study; all such feet were resistant to manipulation, and relapses occurred in two of the eight cases. Soft tissue release was required in 6 of the total 146 cases, although it is not clear how many of the atypical clubfeet needed soft tissue release. We believe that the results in these eight atypical feet could have been much better with the use of the modified Ponseti technique. We have been using this modified technique in our institution for the last 4 years
Comment on Mootha et al.
and have had predictably good results, which we will be reporting in due course of time. To conclude, we would like to strongly emphasize the need for identification of atypical clubfeet for several reasons. The ‘standard’ Ponseti technique is not only largely unsuccessful in correcting these feet, but can even result in grotesque deformities [2]. Most such feet end up being operated upon; even so, the results of surgical correction are poor [4]. The ‘modified’ Ponseti technique seems to be an attractive alternative for manipulative correction of such feet. However, more studies with a longer duration of follow-up are needed to validate the results of this technique.
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References 1. Mootha AK, Saini R, Krishnan V, Bali K, Kumar V, Dhillon MS. Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre. J Orthop Sci. 2011;16(2): 184–9 (Epub 2011 Feb 5. PubMed PMID: 21298304). 2. Ponseti IV, Zhivkov M, Davis N, Sinclair M, Dobbs MB, Morcuende JA. Treatment of the complex idiopathic clubfoot. Clin Orthop Relat Res. 2006;451:171–6. 3. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop B. 1995;4(2):129–36. 4. Turco V. Recognition and management of the atypical idiopathic clubfoot. In: Simons GW, editor. The clubfoot: the present and a view of the future. New York: Springer; 1994. p. 76–7.
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LETTER TO THE EDITOR
Comment on Mootha et al.: Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre Siddhartha Sharma • Mohmmad Farooq Butt Bias Dev
•
Received: 14 May 2011 / Accepted: 30 August 2011 / Published online: 14 October 2011 Ó The Japanese Orthopaedic Association 2011
Dear Editor, We read with great interest the article by Mootha et al. [1] entitled ‘Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre’ in the online version of the Journal of Orthopaedic Science. We would like to congratulate the authors on an excellent article, and we fully agree with the authors’ recommendations of strict compliance with splintage and the need for awareness amongst people of low socio-economic status in order to minimise recurrences. However, we would like to bring forth an extremely important aspect of Ponseti management, i.e. the manipulative correction of atypical clubfeet. Atypical clubfeet, also termed as ‘complex’ or ‘stiff-stiff’ by different authors, represent a small proportion of idiopathic clubfeet [2, 3]. As described by Ponseti, these are characterized by deep creases above the heel, a transverse crease in the sole of the foot, rigid equinus, severe plantar flexion of all metatarsals, a short hyper-extended first toe and a tight Achilles tendon, which is fibrotic up to the mid calf. These feet respond poorly to the conventional techniques of manipulation and are associated with poor surgical outcomes [2, 4]. The feet tend to slip in casts owing to severe plantar flexion of the metatarsals, and this leads to oedema of the foot and formation of an oedematous fold on the dorsum of foot. Also, hyper-abduction of the forefoot in an attempt to correct the hindfoot varus leads to further increase in the plantar flexion An answer to this letter to the editor is available at doi:10.1007/s00776-011-0162-z. S. Sharma (&) M. F. Butt B. Dev Department of Orthopaedic Surgery, Government Medical College and Associated Hospitals, 180015 Jammu, India e-mail: [email protected]
123
of the metatarsals and pushes the toes in abduction, resulting in a grotesque deformity. Ponseti [2] has described a modification of his original technique for manipulative correction of atypical clubfeet. The essence of this technique lies in correct identification of the talar head, which should be palpated carefully with two fingers. Adduction is corrected by gentle abduction of the forefoot around the talus; however, the foot is never abducted beyond 40°. It is important to maintain a counterpressure not only on the talar head, but also on the lateral malleolus in order to correct the hindfoot varus. Subsequently, cavus is corrected by placing thumbs of both hands on the foot and dorsiflexing all the metatarsals. At the same time, the foot is dorsiflexed and slightly abducted, and the heel is also brought into abduction. When the cavus has been corrected, a percutaneous tenotomy of Achilles tendon is done to correct the dorsiflexion. Relapses are common with the use of conventional abduction braces because the short and chubby feet tend to slip inside the brace. To overcome this problem, Ponseti used a custommade, pre-moulded ankle foot abduction brace. This consists of open-toed sandals with three straps to firmly hold the foot in place and two openings at the heel to allow the parents to ensure proper placement of the foot in the sandals. Most relapses can be managed satisfactorily with repeat manipulations and a second tenotomy. The authors reported eight atypical clubfeet in their study; all such feet were resistant to manipulation, and relapses occurred in two of the eight cases. Soft tissue release was required in 6 of the total 146 cases, although it is not clear how many of the atypical clubfeet needed soft tissue release. We believe that the results in these eight atypical feet could have been much better with the use of the modified Ponseti technique. We have been using this modified technique in our institution for the last 4 years
Comment on Mootha et al.
and have had predictably good results, which we will be reporting in due course of time. To conclude, we would like to strongly emphasize the need for identification of atypical clubfeet for several reasons. The ‘standard’ Ponseti technique is not only largely unsuccessful in correcting these feet, but can even result in grotesque deformities [2]. Most such feet end up being operated upon; even so, the results of surgical correction are poor [4]. The ‘modified’ Ponseti technique seems to be an attractive alternative for manipulative correction of such feet. However, more studies with a longer duration of follow-up are needed to validate the results of this technique.
837
References 1. Mootha AK, Saini R, Krishnan V, Bali K, Kumar V, Dhillon MS. Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre. J Orthop Sci. 2011;16(2): 184–9 (Epub 2011 Feb 5. PubMed PMID: 21298304). 2. Ponseti IV, Zhivkov M, Davis N, Sinclair M, Dobbs MB, Morcuende JA. Treatment of the complex idiopathic clubfoot. Clin Orthop Relat Res. 2006;451:171–6. 3. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop B. 1995;4(2):129–36. 4. Turco V. Recognition and management of the atypical idiopathic clubfoot. In: Simons GW, editor. The clubfoot: the present and a view of the future. New York: Springer; 1994. p. 76–7.
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