The Ponseti Method in the Treatment of Children with Idiopathic Clubfoot Presenting Between Five and Ten Years of Age.

SLR- February 2014- David Harrison

Reference: Banskota B; Banskota AK; Regmi R; Rajbhandary T; Shrestha OP; Spiegel DA.  Bone Joint J. 2013 Dec 1; 95-B(12):1721-5.

Podiatric Relevance: The minimally invasive Ponseti method has become widely recognized as the initial treatment of choice for infants with clubfoot in many centers throughout the world. Long-term studies have shown that a supple, plantigrade foot is maintained in most infants and children with this condition treated in this way, with similar findings also reported in the short-term. However, only two studies have focused on children aged > five years, and although a plantigrade foot was achieved in all 49 children at early to mid-term follow-up, 25 (50 percent) required further surgery. The upper age limit for this form of treatment is not known. Even if complete correction cannot be achieved in older children, reducing the extent of the surgery required, and/or the complications of surgery such as infection or wound dehiscence, would be desirable. The goal of the authors with this investigation was to evaluate the use of Ponseti’s method, with minor adaptations, in the treatment of idiopathic clubfeet presenting in children between five and ten years of age. 

Methods: A retrospective review was performed in 36 children (55 feet) with a mean age of 7.4 years (5 to 10), supplemented by digital images and video recordings of gait. There were 19 males and 17 females. The mean follow-up was 31.5 months (24 to 40). The mean number of casts was 9.5 (6 to 11), and all children required surgery, including a percutaneous tenotomy or open tendo Achillis lengthening (49 percent), posterior release (34.5 percent), posterior medial soft-tissue release (14.5 percent), or soft-tissue release combined with anosteotomy (2 percent). The mean dorsiflexion of the ankle was 9° (0° to 15°). Forefoot alignment was neutral in 28 feet (51 percent)or adducted (< 10°) in 20 feet (36 percent), > 10° in seven feet (13 percent). Hindfoot alignment was neutral or mild valgus in 26 feet (47 percent), mild varus (< 10°) in 19 feet (35 percent), and varus (> 10°) in ten feet (18 percent). Heel–toe gait was present in 38 feet (86 percent), and 12 (28 percent) exhibited weight-bearing on the lateral border (out of a total of 44 feet with gait videos available for analysis). Overt relapse was identified in nine feet (16 percent, six children). The parents of 27 children (75 percent) were completely satisfied.

Conclusions: The authors found that a significant number of untreated idiopathic clubfeet in children aged between five and ten years achieved adequate correction of the deformity and reasonable function at early follow-up after treatment using the Ponseti method. Although limitations in soft tissue elasticity and remodeling potential may reduce the success in this group compared with those who are treated between birth and age two years, in the age group between five and 10 years preliminary casting using the Ponseti method limits the amount of surgery required even when adequate correction cannot be achieved.