Good Results with the Ponseti Method

SLR - July 2013 - Andrew Hall

Reference: Saetersdal C, Fevang J, Fosse L, Engesaeter L.  Good Results with the Ponseti Method.  Acta Orthopaedica 2012; 83 (3): 288-293.

Scientific Literature Review
 

Reviewed by: Andrew Hall, DPM
Residency Program: Southern Arizona VA Health Care System

Podiatric Relevancy:  Due to unsatisfactory results from other interventions, the Ponseti method of treating clubfoot was introduced at several hospitals in Norway in 2002 and 2003. Traditionally in Norway, a unilateral above-the-knee dynamic brace had been used to prevent relapse, whereas the Ponseti method utilizes a bilateral foot abduction brace. With this study, the short-term and long-term results were compared to previous literature. The two bracing methods were also directly compared.
 

Methods:  One hundred thirty-four newborns with idiopathic congenital clubfoot were treated at eight hospitals in Norway from 2004 to 2006. In 2009, all children were evaluated using a standardized clinical examination by one of the authors. Fifteen patients were lost to follow-up and three children had a treatment which strayed too far from the described Ponseti method. The condition was present unilaterally in 70 patients, while 46 had a bilateral occurrence. A total of 162 clubfeet were examined. 

Sixty-two percent of children used a standard bilateral abduction brace as recommended by Ponseti, after the casting phase. Thirty-two percent of children used a unilateral above-the-knee brace, five children used a below-the-knee brace and one child used no bracing. Compliance to bracing was graded as excellent, good, fair or non-compliant. 
 

The mean age of the children at time of the follow-up was three years, 10 months. All feet were assessed according to Pirani’s scoring system, which takes six variables into consideration (posterior crease, empty heel, equinus, reduction of the navicular bone, medial crease, and lateral curvature of the foot). The Pearson chi-square test was used for comparison of the variables. 

Results: The mean Pirani score after treatment was 7.2 (versus 4.8 before treatment). The mean number of casts applied was 7.2. A higher Pirani score was achieved in the group that used the foot abduction brace, but better compliance was found with the unilateral brace.
 

At time of follow-up, 15 feet underwent a second period of casting, 18 had a second Achilles tenotomy and six had both due to relapse. Six feet underwent a more extensive surgery then a tenotomy (three had a postero-medial release, two had a posterior release and one had a tibialis anterior transfer). Those treated with a unilateral above-the-knee had more cast applications and a higher frequency of Achilles tenotomy. 

Conclusions: The authors concluded that introduction of the Ponseti method at the participating hospitals in Norway has been successful and the results were similar to previously published reports. Overall, both braces achieved good outcomes. With successful closed treatment, surgery is typically not necessary. Patients who used the bilateral abduction brace had higher Pirani scores, though there was a tendency for better compliance with the unilateral brace.