Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre

Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre

J Orthop Sci (2011) 16:184–189 DOI 10.1007/s00776-011-0027-5 ORIGINAL ARTICLE Management of idiopathic clubfoot by the Ponseti technique: our experi...

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J Orthop Sci (2011) 16:184–189 DOI 10.1007/s00776-011-0027-5

ORIGINAL ARTICLE

Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre Aditya Krishna Mootha • Raghav Saini • Vibhu Krishnan • Kamal Bali • Vishal Kumar Mandeep Singh Dhillon



Received: 21 July 2010 / Accepted: 8 November 2010 / Published online: 5 February 2011 Ó The Japanese Orthopaedic Association 2011

Abstract Background Clubfoot or congenital talipes equinovarus is a common congenital abnormality of uncertain etiology. The purpose of this study was to assess the results of the Ponseti method in India and to investigate the demography of relapse and resistant cases. Methods A total of 86 children (146 feet) below 1 year of age who had presented to the paediatric orthopedic outpatient department of our institution between June 2003 and January 2007 with unilateral or bilateral idiopathic clubfoot deformity were included in our study and treated conservatively by use of the Ponseti technique. Results 128 feet responded to the Ponseti casting technique initially and 18 feet were resistant to the conservative treatment. Of the responsive feet, for 20 feet there was a relapse of the deformity. Evaluation of the results showed that poor compliance with splintage was the most common cause of relapse; delayed presentation and atypical clubfeet resulted in high resistance to this technique. Correction achieved at our centre was 82.18%. This is less than in many recent studies and could be attributed to increased incidence of delayed presentation, poorer compliance, and atypical feet in our population. Conclusion We conclude that the Ponseti technique is recommended for management of clubfoot and strict compliance with splintage is essential to prevent relapses. People of lower socioeconomic status are at high risk of A. K. Mootha  R. Saini  V. Krishnan  K. Bali  V. Kumar  M. S. Dhillon Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India K. Bali (&) 42, Sec 16, Panchkula, Haryana, India e-mail: [email protected]

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relapse and must be targeted to create awareness among them about the importance of compliance with splintage.

Introduction Congenital talipes equinovarus (CTEV) is one of the oldest and one of the most common congenital anomalies of mankind, with reported incidence of one to two per thousand live births [1]. The four important components of the deformity are ankle equinus, heel varus, forefoot adduction, and cavus [2, 3]. Non-operative treatment of clubfoot has been widely accepted as the initial standard of care and is started as soon as possible after birth. Earliest non-operative treatment dates back to 400 BC when Hippocrates recommended gentle manipulation of feet followed by splinting. In 1836, Guerin introduced the plaster-of-Paris cast. Around the turn of the century, devices such as the Thomas wrench, in which rapid correction using forceful manipulation was practised, were introduced [4]. In 1930, Dr Hiram Kite introduced the technique of gentle manipulation and casting. In 1948, Dr Ignacio V. Ponseti introduced the most widely followed system of manipulation and serial casting. The Ponseti technique has been the most popularly accepted method and a few studies have established the short and long-term success of the technique at different centres [5, 6]. The purpose of this study was to review initial experience of treating club foot by the Ponseti technique at our institution and to evaluate the importance of age at presentation, sex, family history, and socioeconomic status of Indian patients in the prognosis of clubfoot correction, incidence of resistance, relapse among these feet after the Ponseti method, and complications during the course of treatment.

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Materials and methods A total of 86 children below 1 year of age who had presented to the paediatric orthopedic out-patient department of our institution between June 2003 and January 2007 with unilateral or bilateral idiopathic clubfoot deformity were included in our study. Children with any other significant anomaly or clubfoot occurring as a component of any known syndromic presentation or neuromuscular or spinal disorder were excluded from the study. Children presenting beyond 1 year of age in whom conservative management has been proved to be of less benefit were also excluded from the study. Written informed consent to participation was obtained from the parents of all the children enrolled in the study. The parents were asked about socioeconomic status, monthly income, education level, and any other similar deformity among close relatives. One of the children had a sibling with unilateral clubfoot. There was no other family incidence. There is a practice of issuance of Below Poverty Line cards in our population. This was used as the criterion for classification of our patients in the low socioeconomic status group. All the children underwent a complete head to toe examination at initial presentation to rule out any significant osseous, neurological, or muscular etiology or any other syndromic presentation. All the feet were assessed by Pirani score at presentation (Table 1). The Pirani score is entirely clinical and commonly used for its simplicity. The feet were also classified as typical and atypical feet by clinical examination. Atypical clubfeet were defined by following the features described by Ponseti [5, 6]. The procedure described by Ponseti was followed. Correction of the deformity in the Ponseti technique is accomplished by abducting the foot in supination while counter pressure is applied over the lateral aspect of the Table 1 Pirani scoring system for assessment of the severity of clubfoot

Look

Feel

Move a

The foot should be moved to the position of maximum correction when assessing the medial crease

head of the talus to prevent rotation of the talus in the ankle. A well-moulded plaster cast is applied to maintain the foot in an improved position. The ligaments should never be stretched beyond their natural amount of give. After 5 days, the ligaments can be stretched again to further improve the extent of correction of the deformity. Usually, a total of 5–6 casts is required. The tendo Achilles tenotomy was performed to correct the equinus deformity in our patients in whom we had achieved adequate abduction of 70° at the time of application of the last cast. The last cast was, further, maintained for 3 weeks. The correction was, then, maintained by use of the Denis Browne splint applied for at least for 16 h a day until 1 year of age; followed by night time splint for the first 3 years of age. The orthosis used includes a wellfitted, open-toed, high-top straight-last shoe attached to a Denis Browne bar of approximately the length between the child’s shoulders. The splint maintains the corrected foot in 70° of external rotation to prevent recurrence of the varus deformity of the heel, adduction of the foot, and toeing-in [5, 6]. The ankle should be in dorsiflexion, in an attempt to prevent equinus, and this is accomplished by bending the bar with the convexity of the bar distally directed. If the deformity is unilateral, the normal foot is placed in 30° of external rotation. The children were followed in accordance with the procedure suggested by Ponseti: once at 2 weeks after the bracing started; then at 3 months; once every 4 months until 3 years of age; every 6 months until 4 years; every 1–2 years until skeletal maturity. The parents were asked about the number of hours of use of the splint and non-compliant patients were further encouraged to use the splint. The child’s foot and the splint were evaluated at each visit. Compliance with the abduction-bar brace was defined as use of the splint for at least 16 h a day. Any deviation from this time limit was regarded as non-compliance.

Hind foot score

Mid foot score

Posterior crease

Lateral border of foot

0: No heel crease

0: No deviation from straight line

0.5: Mild heel crease

0.5: Medial deviation distally

1: Deep heel crease Empty heel sign

1: Severe deviation proximally Talar head

0: Hard heel (calcaneum in normal position)

0: Reduced talo-navicular joint

0.5: Mild softness

0.5: Subluxed but reducible talo-navicular joint

1: Very soft heel (calcaneum not palpable)

1: Irreducible talo-navicular joint

Rigidity of equinus

Medial creasea

0: Normal dorsiflexion

0: No medial crease

0.5: Foot reaches plantigrade with knee extended

0.5: Mild medial crease

1: Fixed equinus

1: Deep crease altering contour of foot

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Pirani scoring was also conducted at each visit. Followup X-rays were also taken every year during these subsequent visits. Standardized weight-bearing plain X-rays in the anteroposterior and lateral views were used for radiological assessment. The talocalcaneal angles and talar–first metatarsal angles in the AP and lateral views were measured for all patients. The need to perform posteromedial soft tissue release or other major surgical procedure was regarded as failure of treatment. The need to perform a tendo Achilles tenotomy for equines correction was not regarded as a treatment failure in our patients. The need for a repeat tendo Achilles tenotomy for an equinus relapse or tibialis anterior transfer for dynamic supination were also not regarded as failure of treatment. All statistical analysis was done using SPSS 12.0 software. The chi-squared test was applied for comparison of categorical data and the unpaired t test was used to compare numerical data where needed.

Results All patients were treated by the Ponseti technique and have been followed up at the out-patient pediatric orthopedic department of our hospital up to this date. The average period of follow-up of the patients has been 4 years (range 2–7 years). The total number of patients included in the study was 86 (a total of 146 feet were studied). There were 54

Table 2 Demography of the study sample Total no. of patients in the study 86 Total no. of feet studied Age at presentation

146 22 (\3 months): (25.6%) (38 feet) 64 ([3 months): (74.4%) (108 feet)

Sex

Males: 54 Females: 32

Bilateralism

Bilateral: 60 Unilateral: 26

At presentation

Initially treated elsewhere: 48 feet First presentation: 98 feet

Atypical feet

8

BPL card holders

40 feet

males and 32 females. There was a much higher incidence of patients with bilateral involvement. For 38 feet (22 patients) presentation at our hospital was before 3 months, with more delayed presentation for the remaining 108 feet. 48 feet had been partially treated elsewhere and the remaining 98 feet were presented to us first (Table 2). The mean age at presentation of the patients was 15.67 ± 6.57 weeks. Of the 146 feet, 128 feet (87.7%) responded to the treatment initially whereas 18 feet (12.3%) did not respond to casting and needed posteromedial medial soft tissue release by the Turco procedure or another major surgical procedure. 8 of our feet were atypical feet at presentation (as per Ponseti’s description) and 5 were resistant to our initial treatment. The mean initial Pirani score for the responsive patients was 4.5 (mean hind foot score 2.5 and mid foot score of 2) whereas the mean Pirani score at follow-up for these patients was 0.5 (0–1.0) (mean hind foot score 0.5 and mid foot score of 0). Among the patients who had not responded, the mean Pirani score was 5.5 (mean hind foot score 3 and mid foot score of 2.5). The mean Pirani score for these patients at follow-up was 1.5 (mean hind foot score 1.0 and mid foot score of 0.5). The responsive and resistant feet are compared in Table 3. The mean age at presentation for the resistant feet was, thus, significantly higher than that for the non-responsive feet. Also, a relatively higher number of patients had been partially treated elsewhere among the resistant population group. The atypical feet were also more resistant to conservative treatment, as expected. However, socioeconomic status (Below Poverty Line card holders) was not important in increased resistance to treatment. Percutaneous tenotomy was performed for 90% of the feet. Of the total 128 feet that initially responded successfully to treatment, 20 (15.6%) feet relapsed after initial success. Of these, 12 feet (60%) responded to repeat casting and repeat percutaneous tenotomy. The remaining eight (40%) relapsed feet required surgical intervention. 2 (25%) of these feet had presented with dynamic supination that required tibialis anterior transfer. However, the remaining 6 (75%) patients required extensive soft tissue release surgery. Socioeconomic status, family history, age, sex, bilateralism and other general features of the population with

Table 3 Comparison of responsive and resistant feet

* Significant

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Responsive feet (128)

Resistant feet (18)

P value 0.00*

Mean age at presentation

14.54 ± 5.54 weeks

23.72 ± 7.72 weeks

Partially treated before presenting to us

34 (26.6%)

14 (77.8%)

0.01*

Atypical clubfeet

2 (1.6%)

6 (33.3%)

0.00*

Socio economic status

34 (26.6%)

6 (33.3%)

0.66

CTEV management by Ponseti technique Table 4 Comparison of nonrelapsed and relapsed feet in the responsive group

* Significant

Table 5 Comparison of feet presented before or after 12 weeks

* Significant

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Non-relapsed feet (108)

Relapsed feet (20)

P value 0.35

Mean age at presentation

14.64 ± 5.61 weeks

15.90 ± 4.61 weeks

Partially treated before presenting to us

28 (25.9%)

6 (30%)

0.77

Atypical clubfeet

2 (1.8%)

1 (5%)

0.15

Socio economic status

17 (15.8%)

17 (85%)

0.00*

Poor compliance with splint

8 (7.4%)

20 (100%)

0.00*

\3 months (38 feet)

[3 months (108 feet)

P value

Mean Pirani score

4.94 ± 0.57

5.07 ± 0.55

0.24

No. of casts

4.47 ± 0.73

7.12 ± 1.67

0.00*

Relapses

5 (13.1%)

15 (13.9%)

0.92

Resistance

2 (5.3%)

16 (14.8%)

0.27

Partially treated before presenting to us

4 (10.5%)

44 (40.8%)

0.01*

Socio economic status Atypical feet

9 (23.7%) 3 (7.9%)

31 (28.7%) 5 (4.6%)

0.64 0.76

deformity relapse were analysed. Of the 20 feet that had relapsed, 17 (85%) were of the poorer socioeconomic group (Below Poverty Line card holders). This was a significant difference. All had poor compliance with the Dennis Browne splint which was noted on further questioning (Table 4). 64 (74.4%) of our patients presented after 3 months whereas 22 (25.6%) presented earlier than 3 months. For patients with early presentation (\3 months) at our hospital a significantly lower number of casts was required for correction than for those who had later ([3 months) presentation. There was also a significantly lower incidence of resistant cases among the population that presented earlier than 3 months for conservative treatment (Table 5). The mean number of casts required for correction of the responsive feet was 5.7 (4–13). Tendo Achilles tenotomy was required for 90% of our patients. Early correction at our centre was, thus, 82.18%. A total of 17.8% feet underwent extensive surgery either for a resistant or a relapsed deformity. The mean initial anteroposterior and lateral talocalcaneal angles were 13° (range 24°–0°, standard deviation 9°) and 18° (range 26°–10°, standard deviation 7°), respectively. The mean initial anteroposterior and lateral talar– first metatarsal angles were 38.6° (range 71°–8°, standard deviation 20°) and 3.2° (range 8°–0°, standard deviation 2.8°), respectively. The mean anteroposterior and lateral talocalcaneal angles at last follow-up for the responsive feet were 24.8° (range 39°–16°, standard deviation 6°) and 27.3° (range 45°–16°, standard deviation 10.8°), respectively. The mean anteroposterior and lateral talar–first metatarsal angles at the last follow-up were 0° (range 47°

to -32°, standard deviation 28) and 26.4° (range 80°–1°, standard deviation 30.6°), respectively.

Discussion The objective of treatment of clubfoot is to achieve a painless, plantigrade foot with good mobility, without any need for special orthosis or modified shoes. Current literature supports the use of primary non-operative techniques to achieve this. Newer methods of non-operative management include manipulation of the foot by a physical therapist [7], continuous passive motion by machine [8], the French method [9], and Botulinum toxin type A injection into the gastrosoleus and tibialis posterior muscles [10]. The most popular technique followed today is the serial casting method devised by Ponseti. All the feet in our study were assessed by use of Pirani scoring [11]. Several scoring systems are in use, for example, the Dimeglio score [12], the Carroll severity scale [13], and the Pirani score [11]. All of these systems have been independently validated; inter and intra-observer reliability is very good and they correlate well with patientbased assessments of outcome [14]. The incidence of neglected cases of CTEV in our institution is high. The older patients respond relatively poorly to the Ponseti technique and also present with a multitude of soft tissue and skin problems. The socioeconomic status and the education level of the parents in our country are also poor. These factors may affect the results of a technique like that of Ponseti in which the parents play an important role during the treatment and in the

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maintenance of correction after completion of treatment. A previous study conducted in India reported 95% correction after treatment for idiopathic club foot (CTEV) by the Ponseti method [15]. There was a statistically significant difference between pre and postcorrection Pirani scores and mean footprint angle (FPA) in their patients. This study was planned to follow the results of correction by the Ponseti technique in our patients, to analyse the demographic and other features of the populations of responders and non-responders and to identify the factors that resulted in relapse in these patients after initial correction. The general profile of our group of patients was quite different from the usual reported population of CTEV patients. There was a relatively higher incidence of male patients in our population (62.8%). The incidence of bilateral cases was 60 compared with 26 unilateral cases. This was much higher than the figure reported in the literature (50% bilateralism). This could be attributed to selection bias, because our institution was a referral centre and the more severe manifestations were usually received at our outpatient department. There was a 5.4% incidence of atypical clubfoot in our population. The mean age at presentation of the patients was 15.67 ± 6.57 weeks. This was a significant deviation from the population of patients who presented in the developed countries at birth. There are, still, a large number of deliveries that are conducted at home without proper trained attendants in our country. As a result, a large number of CTEV cases are missed at the neonatal period. Our sample could have also been biassed for reasons stated earlier (because most of the neglected patients are referred to our institution). The later age at presentation and the atypical clubfeet were significantly more resistant in our study. Ponseti had described incidence of 2–3% of atypical clubfeet. He stated that these feet were more resistant to the usual corrective technique, and he described a different technique to correct these feet. The pre-moulded foot–ankle brace developed to improve compliance with bracing was also recommended for these patients. We used the conventional correction technique for all our feet irrespective of the nature of the deformity. This could have been the reason for the higher incidence of resistance to Ponseti correction of these feet by our patients. The socio economic status of our patients did not significantly affect correction of their deformity. However, this factor had a significant bearing on relapse of the deformity. The parents of patients belonging to lower socio economic strata had a poor educational status and, therefore, poorer understanding of the need for continued splintage. Parents from the poorer socio economic strata also had difficulty in travelling long distances for regular follow-up for a period of 3–4 years and changing the splint as the children’s feet grew with age (most probably because of economic constraints).

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Non-compliance with regular splintage was revealed by Ponseti as the most common cause of recurrence of the deformity. Our study also confirmed this observation of Ponseti. One limitation of our study, which was also noted in a similar study reported in the literature, was the difficulty of accurately assessing compliance. Objective measures of compliance were not available; therefore, verbal reports of parents with regard to the use of the brace were used as the primary means of assessing compliance. We deviated a little from Ponseti’s procedure for splintage in that Ponseti recommended splintage for 23 h a day for 3 months or the age of 1 year whichever is earlier and then at night times till the age of 3 years. However we recommended to all the parents in our study to continue bracing for at least 16 h a day until the age of 1 year considering the delayed age of presentation and willingness of the parents. We arrived at an arbitrary value of 16 h per day from our previous survey of parents whose children had good response to the Ponseti technique without any relapse (unpublished). The incidence of poor compliance in our patients was 21.8%, which was quite high. We had a high incidence of poor compliance despite having advised the parents of the importance of regular long term splintage. Some parents had also been reluctant in attending the follow-up OPDs. With the Ponseti technique, we were able to avoid posteromedial soft tissue release surgery in 82% of our cases. The Ponseti technique has been a successful nonoperative modality of treatment for clubfoot. Many studies have proved the efficacy of this technique for this condition. However, most of these studies have been in the developed world. Our study was conducted at an apex institute in India. The age, presentation of the clubfeet, and the socioeconomic profile of our patients were quite different from those in the developed world. The technique was equally effective in Indian patients in achieving correction despite these differences. Our study showed that the Ponseti method should be the initial mode of treatment in our patients also. However, there is a great need to identify cases at a much earlier age for improved results. Our study also showed a need to identify the atypical clubfeet more effectively and use of greater care to correct these feet. The major problem in our patients was the poorer education level and socioeconomic status. These were major hurdles in maintaining the correction once it was achieved. There is a need to concentrate especially on these highrisk parents and to impress upon them the need for greater conviction and commitment. It may also be suggested that these parents need to be educated specially by the treating doctors, with possible involvement of special NGOs, health care workers, and community health personnel at the primary health care level.

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