Evaluation of Ponsti Technique in Management of Club-Foot ...medicaljournalofcairouniversity.net/Home/images/pdf/2012/march/56.pdf · treated with Ponseti method and evaluated by

Med. J. Cairo Univ., Vol. 80, No. 2, March: 205-217, 2012 www.medicaljournalofcairouniversity.com

Evaluation of Ponsti Technique in Management of Club-Foot in

Older Children

EMAD G.K. EL-BANNA, M.D. and AMR M.S. ABDEL MEGUID, M.D.

The Department of Orthopaedics, Faculty of Medicine, Bani Suef University

Abstract

The Ponseti technique is rapidly becoming the most widely practiced method for treatment of congenital clubfeet in infants. It is an easy technique to learn and, when applied accurately, yields excellent results. It consists of gentle

manipulation and casting of the feet at weekly intervals. The

first cast is applied with the foot supinated and attention

directed to elevating the first ray. Subsequent casts are applied to abduct the foot around the head of the talus, taking care

never to directly manipulate the calcaneus. At the time of the

final cast, the overwhelming majority of infants require a

percutaneous Achilles tenotomy to allow sufficient dorsiflex-ion. The final cast remains in place for three weeks, at which

time the infant is placed into a foot abduction orthosis. The orthosis is worn 23h per day for 3 months and then at night

for several years. Good results have been demonstrated at

multiple centers and long-term results indicate that foot

function is comparable with that of normal feet. Our study

included 25 children (38 feet) with average age 16.3 months

and average of duration of follow-up 13.5 months that was

treated with Ponseti method and evaluated by Pirani score.

Despite the late presentation of treatment, the Ponseti method

was applied with good success and excellent results.

Key Words: Clubfoot – Ponseti method – Pirani score.

Introduction

IDIOPATHIC clubfoot, one of the most common

problems in pediatric orthopedics, is characterized

by a complex three-dimensional deformity of the

foot. The treatment of clubfoot is controversial and continues to be one of the biggest challenges

in pediatric orthopaedics [1] .

This controversy is due in part to the difficulty in measuring and evaluating the effectiveness of

different treatment methods. We believe the heart

of the debate is a lack of understanding of the functional anatomy of the deformity, the biological response of young connective tissue to injury and

Correspondence to: Dr. Emad G.K. El-Banna, The Department of Orthopaedics, Faculty of Medicine, Bani Suef University

repair, and their combined effect on the long-term

treatment outcomes [2] .

When clubfoot is analyzed from a historical

perspective, it is difficult to ascertain if other types

of foot deformity, for example equinovarus or

metatarsus adductus, were included in the defini-tion. However, we believe most experienced authors

were able to differentiate it from the other foot

deformities when they referred to a clubfoot, given

the natural history of no improvement without treatment [3-5] .

Clubfoot was first depicted in ancient Egyptian

tomb paintings, and treatment was described in

India as early as 1000 years B.C. The first written

description of clubfoot was given to us by Hippo-crates (circa 400 B.C.), who believed the causative

factor to be mechanical pressure. He described

methods for manipulative correction remarkably

similar to current non-operative methods [4] .

Hippocrates explained that the vast majority of cases can be successfully treated with serial ma-nipulations, and that treatment should begin as early as possible before the deformity of the bones is well established. He also understood the inade-quacy of restoring the foot to its normal position, but that it must be overcorrected and then held in

this position afterwards to prevent recurrence. His technique involved repeated manipulations of the

involved foot, followed by the application of strong bandages to maintain correction as soon after birth

as possible [6] .

There is no written account of the specifics of

the actual manipulations, but there is mention of

the importance of gentleness in correcting the deformity. When correction had been obtained by

this method, special shoes were worn to maintain the correction and prevent recurrent deformity [7] .

205

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206 Evaluation of Ponsti Technique in Management of Club-Foot

These techniques were apparently forgotten by

subsequent generations. In the middle ages, the management of clubfoot and other deformities was

the province of barber-surgeons, charlatans, and

bonesetters, and minimal information is available

concerning their practice.

The current trends contend that clubfoot is a

surgical deformity where only mild cases can be

corrected by manipulation and immobilization.

This view is supported by the disappointing results

obtained after prolonged manipulations and casting

in the more severe cases. Interestingly, most pub-lications on the surgical treatment of clubfoot

emphasize that early alignment of the displaced

skeletal elements results in normal anatomy of

bones, joints, ligaments and muscles [8] .

However, there is still no unanimity about when surgery should be performed, how extensive it should be, or how to evaluate the results. Adding

to the uncertainty is the lack of long-term follow-up of surgically treated cases [9] .

We believe this lack of understanding has re-sulted in poor correction of the initial deformity

accompanied by severe iatrogenic deformities. An

immediate correction of the anatomic position of

the displaced bones is, in fact, impossible. Any attempt to roughly realign the talonavicular, talo-calcaneal, and calcaneocuboid joints requires wire

fixation through the joint cartilage. Inevitably, the

joint cartilage, as well as the joint capsules, is

damaged and joint stiffness sets in. A few reports

indicate that surgery is almost invariably followed by deep scarring, which appears to be particularly

severe in infants. In addition, the average failure

rate of clubfoot surgery is 25% (range 13% to

50%) and many complications can occur including

wound problems, persistent forefoot supination,

loss of reduction and recurrence, overcorrection

of the hindfoot, dorsal subluxation of the navicular,

and loss of normal motion of the ankle and subtalar

joints [10] .

Based on these concepts, Ponseti developed his treatment guidelines:

All the components of the clubfoot deformity have to be corrected simultaneously with the ex-ception of the equinus which should be corrected

last [11] .

The cavus results from a pronation of the fore-foot in relation to the hindfoot, and is corrected as

the foot is abducted by supinating the forefoot and

thereby placing it in proper alignment with the midfoot. While the whole foot is held in supination

and in flexion, it can be gently and gradually abducted under the talus, and secured against rotation in the ankle mortise by applying counter-pressure with the thumb against the lateral aspect of the head of the talus [12] .

The heel varus and foot supination will correct when the entire foot is fully abducted in maximum external rotation under the talus. The foot should

never be everted [13] .

After the above is accomplished, the equinus can be corrected by dorsiflexing the foot. The tendo-Achilles may need to be subcutaneously sectioned to facilitate this correction [14] .

When proper treatment of clubfoot with manip-ulation and plaster casts has been started shortly

after birth, a good clinical correction can be ob-tained in the vast majority of cases. A plaster cast

is applied after each weekly session to retain the

degree of correction and soften the ligaments. After two months of manipulation and casting the foot

often appears slightly overcorrected [15] .

The percutaneous tenotomy of the Achilles

tendon is an office procedure and is done in 85%

of Ponseti’s patients to correct the equinus defor-mity. Open lengthening of the tendo Achilles is indicated for children over one year of age. This is done under general anesthesia. Excessive length-ening of the tendon must be avoided since it may

permanently weaken the gastrocsoleus [16] .

Transfer of the tibialis anterior tendon to the

third cuneiform is done after the first or second

relapse in children older than two-and-a-half years

of age, when the tibialis anterior has a strong supinatory action.

The relapsed clubfoot deformity must be well corrected with manipulations and two or three plaster casts left on for two weeks each before

transfer of the tendon. With appropriate early

manipulations and plaster casts, surgery of the

ligaments and joints should only be rarely necessary [17] .

To provide patients with a functional, pain-free, normal-looking foot, with good mobility, without calluses, and requiring no special shoes, and to obtain this in a cost-effective way, further

research will be needed to fully understand the

pathogenesis of clubfoot and the effects of treat-ment, not only in terms of foot correction, but also

of long-term results and quality of life [18] .

Emad G.K. El-Banna & Amr M.S. Abdel Meguid 207

Objective of the study:

The aim of this study is to evaluate the Ponseti method in Management of Clubfoot in older chil-dren (1-3 years old).

Patients and Methods

We have managed 25 children (38 feet) with

congenital idiopathic clubfoot in the Beni Suef University and the Insurance hospitals from June

2008 to June 2011. Of these 25 patients 15 were males (60% of patients) and 10 were females (40% of patients). The age ranged from 12 to 31 months

(mean 16.3 months). 13 patients had bilateral club feet, 6 patients had right clubfoot and 6 patients had left clubfoot. No family history of drug intake during pregnancy. No other congenital anomalies

were present.

All patients had been treated previously for club feet, by plaster-cast treatment (we do not

know the precise techniques of manipulation or casting) elsewhere before their initial visit. 2 pa-tients (8%) had been treated previously by posterior

and posteromedial release.

We excluded patients with arthrogryposis and neuromuscular disorders. No patients were lost to follow-up. The average duration of follow-up ranged from 10 to 24 months (mean 13.5).

The patients initially treated by other orthope-dists had many plaster casts before referral, some

below the knee, others a combination of below and

above the knee. Many of the casts had slipped down completely or partially to the middle or tip of the crowded toes, causing edema, wrinkles, and

sores on the dorsal skin of the foot. The big toe,

often in hammertoe position, was short; the other toes were in some flexion and the whole foot was

grotesquely stunted (Fig. 1). In unilateral cases,

the involved foot usually was shorter (estimated

1.5-2cm) than the normal foot.

Radiographs were not routinely obtained. How-ever, some parents brought radiographs performed

at their local institutions. The calcaneus and the

talus were in severe plantar flexion (Fig. 2). In most cases, the talus and calcaneous were parallel

in the AP and lateral views, the cuboid was dis-placed medially and all the metatarsals were in

severe plantar flexion, more so the first metatarsal.

We obtained AP and lateral radiographs at the

initial treatment and at the latest follow-up.

In order to achieve correction of the clubfoot,

the calcaneum should be allowed to rotate freely

under the talus. The correction takes place through

the normal arc of the subtalar joint. This is achieved

by placing the index finger of the operator on the

medial malleolus to stabilize the leg and levering

on the thumb placed on the lateral aspect head of the talus while abducting the forefoot in supination

(Fig. 3). Manipulation was done under general anesthesia (slight sedation) in patients above 2 years.

The cast was applied after the manipulation to immobilize the foot in order to stretch the tight ligaments.

Foot cavus increases when the forefoot is pr-onated. The first step in the manipulation process

is to supinate the forefoot by gently lifting the

dropped first metatarsal to correct the cavus. Once

the cavus is corrected, the forefoot can be abducted

(Fig. 4).

After the foot is manipulated, a long leg cast is applied to hold the correction. Initially, the short

leg component is applied. The cast should be snug with minimal but adequate padding (Fig. 5). Each cast aims for more abduction of the supinated foot

to be 70° at the end.

Percutaneous tentomy of the achillis tendon

was required for all of our clubfoot children to correct the rigid ankle equinous (Fig. 6).

A cast will be applied right after the tenotomy

had been done and has to stay on for 3 weeks: 70 ° abduction, 10-15 ° dorsiflexion (Fig. 7).

After the clubfoot is corrected it has to be held

in a corrected position to prevent recurrence. The

brace needs to be put on immediately after the last

casts are removed. Bracing time for small children

(who haven't walked before the treatment is started):

- Full-time (except bathing = 23 hours a day) for

3 months.

- Sleeping time (night and during day sleeps) for

4 years.

• Bracing time for older children of walking age

(about 2-4 years):

- 18 hours a day for 3 months (6 hours out of the

brace during the day time for playing, moving,

walking, bathing, etc.).

- Sleeping time (= 14-16 hours a day) until the age of 5.

The brace needs to have both shoes attached

to a bar in order to prevent a recurrence. (Fig. 8):

A- Bilateral clubfoot:

• Both feet in 70 ° abduction (or external rotation)

+ 10-15 ° dorsiflexion.


B- Unilateral clubfoot:

• Clubfoot in 70° abduction (or external rotation)

+ 10-15 ° dorsiflexion.

• Normal foot in about 45 ° abduction (or ex-ternal rotation) + 10-15 ° dorsiflexion.

C- Overcorrected clubfoot (e.g. hypermobil, low

muscle tone child or atypical clubfoot) and corrected clubfoot that develop excessive heel

valgus and external tibial torsion:

• Both feet in about 45 ° abduction (or external rotation) + 10-15 ° dorsiflexion.

• Length of the bar:

Length of the bar should be about the width of the child's shoulders.

In 10-30% of cases, a tibialis anterior tendon transfer to the lateral cuneiform is performed when

the child is aged approximately 3-4 years, and there is over action of the tibialis anterior tendon to correct the dynamic supination of the foot. This gives lasting correction of the forefoot, preventing

metatarsus adductus and foot inversion. (Fig. 9A,

B). Prior to surgery, cast the foot in a long leg cast

for a few weeks to regain the correction.

Assessment: Clinically by Pirani severity scoring system:

Dr. Pirani has developed a rationale and valid

method of clinically assessing the amount of de-formity present in an unoperated congenital club-foot. It is useful because there is no science without reliable and valid measurement.

The Pirani scheme scores six clinical signs either 0 (normal), 0.5 (moderately abnormal), or 1 (severely abnormal) (Fig. 10).

Midfoot score: Three signs comprise the Midfoot score (MS),

grading the amount of deformity between 0 and 1.

• Curved lateral border (A).

• Medial crease (B).

• Talar head coverage ©.

Hindfoot score: Three signs comprise the Hindfoot score (HS),

grading the amount of deformity between 0 and 1.

• Posterior crease (D).

• Rigid equinus (E).

• Empty heal (F).

Use of pirani score:

• Every clubfoot under Ponseti management is

scored each week for HS, MS and total score (G).

• Plotting scores on a graph shows where the foot

is on the roadmap of treatment, visually and easily reassuring parents of satisfactory progress.

• Tenotomy is indicated when HS>1, MS<1, and the head of talus is covered (5).

Radiological assesment: To be done at presentation, the end of manipu-

lation and every 6 month by measuring the follow-ing angels.

AP view: Anteroposterior talocalcaneal angle,

calcaneus-second metatarsal angle, anteroposterior

talus-first metatarsal angle.

Lateral view: lateral talocalcaneal angle, calca-neus-first metatarsal angle, tibiocalcaneal angle, tibiotalar angle, lateral talus-first metatarsal angle.

Fig. (1): Club foot in left lower limb.


Fig. (2): X-ray examination of the ankle and foot.

Fig. (3): Manipulation of the foot.

Fig. (4): Correction of the cavus.

Fig. (9-A): The foot before tibialis tendon transfer. Fig. (9-B): The foot after 6 weeks of tibialis tendon transfer.

Fig. (5): Correction of the midfoot inversion and heal varus.

Fig. (6): Percutaneous tenomy of achillis tendon.

Fig. (7): Casting after tenotomy. Fig. (8): Dennis brown bracing.


CLB PC

MC RE

LHT EH

No

Sex

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

F

F

M

M

M

M

M

M

F

F

M

M

M

M

M

M

M

M

F

F

M

F

F

F

F

'1 '

1 '

1 '

1 4 '1

'

1 4 4

4 4

4 4

4 4

'1 '

1 4 4

4 4

4 4

'1 '1

Emad G.K. El-Banna & A mr M.S. Abdel Meguid 211

Fig. (10): Pirani score system.

Results

We have managed 25 children (38 feet) with

congenital idiopathic clubfoot, our findings included:

• Number of serial casting: From 5 to 14 (mean 8). • Duration of follow-up (months): 10 to 24 (mean

13.5). • Pirani score at the beginning of casting: 4 to 6

(mean 5.6 ).

Table (1): General collecting data for the patients.

• Pirani score at the end of manipulation: 0.5 to 5

(mean 0.9).

• All patients needed tendo achilis tentomy.

• 6 patients (24%) needed tibialis anterior tendon transfer.

• 2 patients (16%) needed extensive surgical release

(posterior and medial release), they were above

2 years.

Age (months)

Number of serial casting

Previous casting

Previous operation

Other Family congenital history anomalies

Tendo achilles

tenotomy

Tibialis anterior tendon transfer

Duration of follow up (months)

Need surgical release

Score at begning of

casting

Unilateral or bilateral

Score at end of

manipulation

20 8 Yes No Negative No Yes No 12 No 6 Right 1 21 9 Yes No Negative No Yes No 13 No 6 Right 1 18 8 Yes No Negative No Yes No 14 No 6 Bilateral 1 19 7 Yes No Negative No Yes No 15 No 6 Bilateral 1 15 6 Yes Yes Negative No Yes Yes 20 No 6 Left 0.5 16 6 Yes NO Negative No Yes Yes 21 No 6 Left 1 13 6 Yes Yes Negative No Yes No 13 No 6 Bilateral 0.5 14 6 Yes Yes Negative No Yes No 14 No 6 Bilateral 1 24 14 Yes No Negative No Yes No 24 Yes 6 Bilateral 5 25 14 Yes No Negative No Yes No 22 Yes 6 Bilateral 5 13 8 Yes No Negative No Yes No 12 No 5 Bilateral 0.5 14 9 Yes No Negative No Yes No 10 No 5 Bilateral 0.5 31 14 Yes YES Negative No Yes Yes 18 Yes 6 Right 4 30 12 Yes No Negative No Yes No 19 Yes 6 Right 4 19 8 Yes No Negative No Yes No 12 No 6 Right 0.5 18 7 Yes No Negative No Yes No 11 No 6 Bilateral 0.5 12 5 Yes No Negative No Yes No 14 No 6 Right 0.5 13 5 Yes No Negative No Yes No 11 No 6 Bilateral 0.5 24 10 Yes No Negative No Yes Yes 12 No 5.5 Bilateral 0.5 25 9 Yes No Negative No Yes Yes 13 No 5.5 Left 0.5 19 8 Yes No Negative No Yes No 14 No 6 Left 0.5 20 8 Yes No Negative No Yes No 10 No 6 Bilateral 0.5 16 8 Yes No Negative No Yes No 15 No 6 Bilateral 0.5 17 9 Yes No Negative No Yes Yes 13 No 6 Left 0.5 14 9 Yes No Negative No Yes No 13 No 6 Left 0.5

Mea

n

15

10

5

Table (2): Comparison between all patients according to the following parameters (25 patients).

Minimum

Maximum

Mean p-value

Age (months) 12 31 16.3 –

Number of serial casting

5 114 8 –

Duration of follow-up (months)

10 24 13.5 –

Score at begining of casting

4 6 5.6

0.0001** Score at end of

manipulation 0.5 5 0.9

p-value<0.001. Sig.: Significance. NS: Non-significant (p-value>0.05).

0 Age

(months) Number of serial casting

Duration of follow-up (months)

Score begining of casting

Score at end of Man ipulation

20

Value p-value

0.307 Chi-square 1.0

Table (3): Correlation between sex and the need for surgical

release.

No Yes Needed surgical release

No.

20

15

10

Male Famale

5

0

Needed surgical release

No Yes

Sex: Male

Female

Total

No. % within sex

No. % within sex

14 93.3

9

1 6.7

1

15 100

10 90 10 100

No. % within sex

23 92

2 8

25 100

Total

Right Left Bilateral

9 4 21

2 33.3

19 100

6 100

No. % within sex

No. % within sex

47.5

4 0 0

6 31.5

66.7

25 6 6 13 100 24 24 52

Value p-value

0.086 Chi-square 4.906

Table (6): Correlation between sex and unilateral or bilateral deformity.

Unilateral or bilateral

Sex: Male

Female

Total No. % within sex

Total


Fig. (11): Comparison between all patients (25 patients).

Fig. (12): Cross tabulation between the sex and the need for

surgical release.

Table (4): Cross tabulation between the sex and the need for

surgical release.

Table (5): Cross tabulation between the sex and unilateral or

bilateral deformity.

Table (7): Cross tabulation between the sex and tibialis anterior

tendon transfer.

Tibialis anterior tendon transfer

Total No Yes

Sex: Male

Female

Total

No. % within sex

No. % within sex

11 73.3

8 80

4 26.7

2 20

15 100

10 100

No. % within sex

19 76

6 24

25 100

Table (8): Correlation between sex and tibialis anterior tendon

transfer.

Value p-value

Chi-square 0.22 0.636


Table (9): Cross tabulation between the sex and previous

operations.

Previous operation

No Yes

Sex: Male

Female

Total

No. % within sex

No. % within sex

13 86.7

10 100

2 13.3

0 0

15 100

10 100

No. % within sex

23 92

2 8

25 100

Table (10): Correlation between sex and previous operations.

Value p-value

Chi-square 1.69 0.193

Discussion

There is a geographical variation in the preva-lence of idiopathic club foot, but most cases occur in developing nations. As a result, many children born with this deformity do not receive treatment and grow up with neglected club feet. This can cause considerable physical, social, psychological

and financial burdens on the patient and their

families [19] .

Adults with untreated club feet can experience

pain and disability, and have difficulty in finding

a job which accommodates their limitations.

Treatment for neglected feet ranges from ex-tensive soft tissue release to complex correction

using different types of external fixator, corrective

osteotomy and triple arthrodesis. However, these

techniques are long and costly and have a signifi-cant rate of complications [20-22] .

Open surgical release often leads to scarring

and stiffening of the ankle and foot, resulting in

limitation of motion and strength [25-28] .

Comparison between groups of patients who

had casting only or casting with additional heel cord lengthening and patients who had posterome-dial release shows that the latter group had reduced

ankle plantar flexion motion and diminished push-off strength. Some authors think that successful

results are expected only when more extensive

surgical approaches are used, particularly for a

more resistant foot that had a circumferential skin

incision [28-35] .

Different methods of nonoperative treatment

have been described. Kite [36] recommended ma-

nipulating the feet by abducting the forefoot against

pressure at the calcaneocuboid joint. Ponseti [37] called this maneuver “Kite’s error” because it blocks correction of the hindfoot varus and internal rotation. Zimbler [38] treated patients using Kite’s

method of manipulation and casting, but only 10% of the patients achieved successful results.

The method of serial manipulations that was created by physiothera-pists and adopted by Ben-sahel et al. [39] involves a lengthy procedure and a long casting time. The method also has a lower success rate compared with that of Ponseti man-agement.

Ponseti developed his method of clubfoot ma-nipulation based on his understanding of the normal

anatomy of the subtalar joint. He views the clubfoot

deformity as an exaggerated position of the ankle

and subtalar joint forefoot in maximum varus, equinus, and inversion. Undoing the positions

means reversing the direction of the subtalar and

ankle joints into maximum valgus, dorsiflexion, and eversion. All Ponseti's maneuvers are based

on taking advantage of the natural movements of the subtalar and ankle joints.

The Ponseti method includes the following steps:

• Correction of the cavus to bring the forefoot in

line with the hindfoot.

• External rotation of the foot accompaying by stabilizing the head of the talus

• Correction of the equinous by percautaneous

tentomy of the tendo achilis

• Tibialis anterior tendon transfer if there is dynamic

supination of the foot at approximately the age

of 3-4 years [40] .

Our study included 25 children (38 feet) pre-sented with congenital talipes equino varus, the

period of this study starting from June 2008 to

June 2011, the children were treated with Ponseti method in the Beni Suef University and the Insur-ance Hospitals of Beni Suef.

The criteria of the patients were:

• The age range from 12 to 31 months (mean 16.3

months).

• Male to female ratio was 60% (15 male) to 40% (10 female).

• Number of serial casting range from 5 to 14

(mean 8).

• The older infants we treated had been treated

previously for resistant club feet, by serial casting

Total


in all patients and by posterior and medial release in 2 patients (8%) of our patients.

• Duration of follow up range from 10 to 24 months

(mean 13.5).

• Pirani score at the begining of casting was 4 to 6 (mean 5.6 ).

• Pirani score at the end of manipulation was 0.5 to 5 (mean 0.9).

• All patients needed tendo achilis tentomy.

• 6 patients (24%) needed tibialis anterior tendon

transfer to the third cuneiform bone to correct

the dynamic supination of the foot.

• 92% of our patients achieved full correction with a mean of 8 casts. 2 patients (8%) of our patients

required extensive surgery (posterior and medial

release), these surgeries were done after the

relapse of the deformity due to non compliance of the parents where they did not use the Dennis

Brown orthosis frequently and did not come to the regular follow-up.

Our study included 25 children (38 feet), the

age of our patients ranged from 12 to 31 months (mean 16.3 months), this age is comparable with the age group presented by Garg and Dobbs [23] , in a study including eleven children (17 feet) with

ages ranging from 1.1 to 8.4 years. It was less than

the age group presented by Lourenço & Morcuende [24] in a study including 17 children (24 feet) with congenital idiopathic club foot was treated by the

method described by Ponseti. The mean age at presentation was 3.9 years (1.2 to 9.0), and it was

comparable with the age group presented by Noguei-ra et al. [41] , who retrospectively reviewed 58

children (83 feet) treated with the Ponseti technique

for recurrences after posteromedial releases, in their

study the mean age at presentation was 5 years 2

months (range, 7 months-14 years). Our age group was comparable with the age group presented by David et al. [42] in a study that included 171 patients (260 feet), presenting between the ages of 1 and 6

years, our age group is comparable with the age group presented by Batlle et al. [43] , in a study that included 200 patients ,mean age at the beginning

of Ponseti treatment was 16 months. Our age group

is comparable with the age group treated by Thomas

et al. [44] , in a study that included 21 patients from 4 months to 15 months, it was also comparable with the age group presented by Jose et al. [45] , in a study that included 157 patients (256 clubfeet),

128 (81%) patients were younger than 6 months

and 29 (19%) were older than 6 months.

Our study included 25 children male to female ratio was 60% (15 male) to 40% (10 female). This

was comparable with the distribution presented by

Thomas, et al. [44] , where there were 6 (28.6%) females and 15 (71.4%) males. And this was also comparable with the distribution presented by

David et al. [42] where there were 30% females

and 70% males.

The number of serial casting we needed to correct the deformity ranged from 5 to 14 (mean

8), this number of serial casts is more than the

number used by Garg and Dobbs, [23] , they cor-rected all feet with the Ponseti method with one to eight casts. Our number is less than the number

used by Lourenço and Morcuende, [24] where correction was obtained with a mean of nine casts

(7 to 12). Our number of serial casts is more than the number used by Monica et al. [41] where cor-rection was obtained with a mean of 4 casts (1 to

10). Our number is comparable with the number

used by David et al. [42] where a mean of seven casts (range, 4-14) was required to correct the

deformty. Our number is less than the number used

by Batlle et al. [43] , where Clubfoot correction was obtained in all the patients by 5,8 casts, Our number

is comparable with the number used by Thomas, et al. [44] where the number of casts used was 7.24

casts (range 1-12). And our number is less than the number used by Jose A. et al. [45] where the patients required 5 casts for treatment.

In our study all the patients needed tendo achilis

tentomy, also in the study presented by Lourenço

and Morcuende, [24] a percutaneous tenotomy of tendo Achillis was performed in all patients, but

in the study presented by Garg and Dobbs, [23] 9 feet from 17 feet needed tendo achilis tentomy,

and in the study presnted by David et al. [42] where a percutaneous tendo-Achilles releaseis done in

82% of the patients, and in the study presented by

Batlle, et al. [43] , 90% of the patients needed percutaneous tenotomy.

In our study 6 patients (24%) needed tibialis anterior tendon transfer. In the study done by Garg

and Dobbs, [23] 15 feet from 17 feet needed tibialis

anterior tendon transfer. In the study done by

Lourenço and Morcuende, [24] no tibialis anterior tendon transfer was done. In the study done by

Monica et al. [41] five children (10%) from 58 patients needed tibialis anterior tendon transfer. In

the study done by Batlle et al. [43] , 9 (4,5%) patients needed anterior tibial tendon transfer. And in the study done by Jose et al. [45] , four patients (2.5%) underwent an anterior tibial tendon transfer.

In our study the duration of follow-up ranged from 10 to 24 months (mean 13.5), the duration of


follow-up in the study done by Garg and and Dobbs, [23] 4 children have follow-up less than one year

and 7 children have follow-up more than one year

(average 27.1 months), the duration of follow-up

in the study done by Lourenço and Morcuende, 24

ranged from 2.1 to 5.6 years (average 3.1 years), the duration of follow up in the study done by

Monica et al. [41] ranged from 24-80 months (av-erage, 45 months), and the duration of follow-up in the study done by Thomas et al. [44] was 12 months.

In our study 92% of our patients achieved full

correction but 2 patients (8%) required extensive

surgery (posterior and medial release), these results

is more better than the results presented by Garg

and Dobbs, [23] where two patients from 11 patients

(18%) had persistent hindfoot valgus which re-quired hemiepiphyseodesis of the distal medial tibia. Also our results is more better than the results presented by Lourenço and Morcuende, [24] where five patients from 17 patients (30%) needed a

posterior release for full correction of the hindfoot,

but no medial release was necessary. Also our

results was comparable with results presented by

Monica et al. [41] , where 71 feet (86%) had good results. Our results was comparable with the results

presented by David et al. [42] , where surgical release was done in 14% of the patients. In the study done

by Batlle et al. [43] , no posteromedial release was necessary. Our results also was comparable with

the results presented by Jose et al. [45] where clubfoot correction was obtained in all but 3 patients (97.5%), only 4 (2.5%) patients required extensive corrective surgery.

As regards statistical analyses: All the children (excluding the patients that

needed surgical release) had reductions in Pirani

score, we observed a reduction of 4.7 points

(p\0.001 ) in the mean score of Pirani. We observed no correlation (p=0.739) between age of the patients

at the beginning of treatment and the number of

serial casts needed for correction. We observed no

correlation (p=0.636) between the sex and the need

for tibialis anterior tendon transfer. We observed

no correlation (p=0.086) between the sex and the presence of unilateral or bilateral club foot defor-mity. We observed no correlation ( p=0.307) be-tween the sex and the need for surgical release.

We observed no correlation (p=0.451) between the sex and the number of serial casting.

In the study presented by Monica et al. [41] All children (excluding the one that had undergone a

new posteromedial release) had reductions in Pirani

score, they observed a reduction of 3.6 points

(p\0.001) in the mean score of Pirani. They ob-served no correlation (p=0.16) between age of the patients at the beginning of treatment and changes in scores. They observed no correlation (p=0.16) between number of casts and reduction of scores

(percentage of reduction). The number of casts also did not correlate ( r=0.27; p=0.02) with the initial score.

In the study presented by David et al. [42] , the Pirani score was 5.2 ±0.92 before casting and 2.1 ± 1.03 after casting with change around 3.1 in the score.

In the the study done by Thomas et al. [44] , the mean initial Pirani score were 3.39. After full

correction by castings the final score was found

to be 0.14 and the mean change in the score was found to be 3.25.

Conclusion: On comparing our study with the previous

studies we found that:

• With increasing ages, the number of serial casts

increase and the probability of doing tibialis anterior tendon transfer increases and all patients

needed tendo achilis tentomy.

• There is no correlation between the previous

failed surgical release and the outcome of the

Ponseti method as we treated 2 patients with

Ponseti method with good results although they had been treated previously with surgical release.

• Despite the late presentation for treatment, the

Ponseti method was applied with good success.

Only 2 patients (8%) of our patients required

extensive surgery (posterior and medial release).

• Our study suggests that the use of Ponseti method

in management of club foot in older children (1- 3 years old) gives good results.

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Evaluation of Ponsti Technique in Management of Club-Foot ...medicaljournalofcairouniversity.net/Home/images/pdf/2012/march/56.pdf · treated with Ponseti method and evaluated by

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