SLR - December 2016 - Cailin Makar
Reference: Dragoni M, Farsetti P, Vena G, Bellini D, Maglione P, Ippolito E. Ponseti Treatment of Rigid Residual Deformity in Congenital Clubfoot After Walking Age. J Bone Joint Surg Am. 2016 Oct 19; 98(20):1706–12.Scientific Literature Review
Reviewed By: Cailin Makar, DPM
Residency Program: Montefiore Medical Center, Bronx, New York
Podiatric Relevance: The Ponseti method is a manipulative technique to correct congenital clubfoot without surgery. It has dramatically improved the results for clubfoot correction in infants with success rates reported from 93 to 100 percent. Nevertheless, rigid residual deformity can be observed after walking age regardless of treatment, and its management is challenging. Soft-tissue surgical techniques, osseous surgical techniques and external fixation techniques have been described with unpredictable results. While there is currently no consensus regarding the best treatment protocol, the Ponseti method is rarely recommended for rigid residual deformity. This study applied the Ponseti method to patients with rigid residual deformity of congenital clubfoot after walking age to improve outcomes of treatment.
Methods: The authors retrospectively reviewed the cases of 68 feet in 44 patients with congenital clubfoot whose mean age of treatment was 4.8 ± 1.6 years. All patients had rigid residual deformity that was resistant to prior treatment. The patients were divided into three groups based on their original treatment. Manipulations were performed under sedation for all patients, and all casts were worn for four weeks. Percutaneous plantar fasciotomies were performed in patients when fascia was still under tension after the first cast. In feet with equinus, an Achilles tenotomy or posterior release was performed. Patients more than 2.5 years of age also had a tibialis anterior tendon transfer. Patients were clinically and radiographically evaluated using the International Clubfoot Study Group Score.
Results: In this study, 33 patients were female and 11 were male at a mean age of 4.8 ±1.6 at time of treatment. Before treatment, all deformities were stiff, 12 rated as fair and 56 rated as poor. All patients had abnormal gait and difficulty in shoe gear. The residual deformities were noted to be adduction in 66 feet, cavus in 57 feet, varus in 53 feet, equinus in 33 feet and supination in 10. Patients who underwent extensive soft-tissue release or were more than six years old required a mean of 3.4 ± 0.6 casts while patients treated with conservative methods or who were less than six years old had a mean of 2.1 ± 0.4 casts, which was statistically significant. After cast treatment, six feet in patients under four years old had heel cord tenotomy, 22 had percutaneous lengthening and five had an open posterior release. Percutaneous plantar fasciotomies were performed in 30 cavus feet, and 60 feet underwent tibialis anterior tendon transfer. Six children under age three were managed with a brace for a mean of 16 months. The mean length of follow-up was 4.9 ± 1.8, and mean age at follow-up was 9.8 ± 1.8 years. Eight feet had an excellent result, 49 had a good result and 11 had a fair result. Results were noted to be significant. All children had plantigrade and flexible feet, had a normal gait and could tolerate shoes.
Conclusions: The limitations of the study are that it was retrospective in nature, the sample size was relatively small, the follow-up was relatively short and records were missing for some patients. The authors concluded that Ponseti casting plus tibialis anterior tendon transfer, which was performed in 88 percent of feet, was effective, and satisfactory results were achieved in 84 percent of the feet. Results are better than those reported for other surgical procedures, and it is an effective treatment of rigid residual congenital clubfoot deformity in children from two to eight years of age.