SLR - September 2018 - Curt J. Martini
Reference: van Praag VM, Lysenko M, Harvey B, Yankanah R, Wright JG. Casting Is Effective for Recurrence Following Ponseti Treatment of Clubfoot. J Bone Joint Surg Am. 2018 Jun 20; 100(12): 1001–1008.Scientific Literature Review
Reviewed By: Curt J. Martini, DPM
Residency Program: Mercy Hospital and Medical Center, Chicago, Illinois
Podiatric Relevance: Utilization of the Ponseti technique for idiopathic clubfoot is considered the gold standard of treatment for correction of deformities. However, approximately 40 percent of patients experience recurrence of the deformity after initial casting. Typically, firstline treatment for recurrence has consisted of surgical intervention. Surgery has an increased risk of overcorrection, worse functional outcomes and worse results for deformity correction when compared with Ponseti technique. This study evaluates the ability of the Ponseti technique on recurrent deformities to correct the deformity and to prevent surgery and associated surgical risks.
Methods: A level III therapeutic study was performed on patients who had initially undergone the Ponseti technique for idiopathic clubfoot and had experienced recurrence of the deformity. Of the eligible patients, 35 participated in the recurrence group who underwent further use of Ponseti technique. Of patients who had not had recurrence of idiopathic clubfoot, 42 patients were chosen at random for comparison. Patients were then evaluated utilizing the Disease-Specific Instrument (DSI) questionnaire, dorsiflexion at ankle, plantigrade foot, alignment of hindfoot, nature of lateral border and ability to squat. Secondary outcomes included the percentage of patients who had plantigrade foot, straight lateral border, hindfoot alignment and degrees of dorsiflexion.
Results: There was no difference in the groups in terms of sex, age at presentation, follow-up, age at initial presentation, complexity or laterality. Eighty-three percent of the control group had successful results at the time of follow-up compared to 74 percent of the recurrence group. The control group had significantly better dorsiflexion, valgus hindfoot position and straight lateral border. The control group also had significantly more patients with ability to squat, 76 percent versus 43 percent in the recurrent group. In terms of the DSI questionnaire, there was no difference between the two groups for function or satisfaction scores, with both groups reporting excellent to good outcomes.
Conclusion: There were no statistically different measurements with the DSI questionnaire between the two groups for function and satisfaction; however, patients who did not need recurrent casting had overall better objective outcomes. There is diminishing return of results that correlates to the number of recurrences of deformity that a patient may experience. However, patients can undergo multiple uses of the Ponseti technique to achieve good clinical outcomes and prevent possible surgery. Patients initially were only followed for two years; this study and future studies would benefit from longer follow-up to determine true amount of recurrence with idiopathic clubfoot.