Management of clubfoot by Ponseti technique our experience

We report our experience of using the Ponseti method for the treatment of congenital idiopathic clubfoot. From August 2007 to July 2010 we treated 107 feet in 79 patients by this method with the mean follow-up time of 15 months (6 to 24). The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo-achillis were performed under general anaesthesia in the operation theatre and change of plaster fortnightly. The Pirani score was used for assessment. The objectives of the study were to access the results in terms of the number of casts applied, the need for tenotomy of tendo achillis and recurrence of the deformity. Tenotomy was required in 87 of the 107 feet. Ten feet failed to respond to the initial treatment regimen and required extensive soft-tissue release. Of the 97 feet which responded to initial casting, 35 (32.71%) had a recurrence, 19 of which were successfully treated by repeat casting and/or tenotomy and casting. The remaining 16 required extensive soft-tissue release and external fixator application. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients. key words : Clubfoot, Ponseti technique, pirani scoring, percutaneous tenotomy. Author's affiliations *MBBS, DNB (PMR), Senior Resident, JNIMS, Imphal. **MBBS, MS (Ortho.), DNB (PMR), Assist. Prof.(Ortho), NIOH, Kolkata. ***MBBS, DNB (PMR), RMO-CT, Dr B.C. Roy Postgraduate Institute of Pediatric Sciences, Kolkata. ****MBBS, MS (Ortho.), DNB (PMR), Director, NIOH, Kolkata. Account of contributions Dr Ningthoujam Jungindro Singh, the main author of this article took keen interest during the whole process of the study. The study was conducted during his tenure of DNB training at the National Institute for the Orthopaedically Handicapped, Kolkata. He was one of the interobserver of the study. The manuscript is solely written by him. Dr Sanjay Keshkar, initiated the idea of the study. He gave the theoretical and practical knowledge of the study. He was also one of the interobserver and also done proof readings of the manuscript. Dr Pampa De, was also involved in the study as an interobserver. She took part in the study while she was working as Junior Resident at NIOH, Kolkata. Dr Ratnesh Kumar, as the head of the institute always motivated the study works and gave valuable advice during the study especially in orthotic designing and fitment. He also did proof reading of the manuscript. Received on 30/04/2011, Accepted on 10/08/2011 as the aetiological factor of the idiopathic club foot4. Chromosomal deletion [on chromosome 2 (2q31-33) (related to the CASP10 gene)] has been found associated with clubfoot in one of the study10. Assessments of the severity of the deformity include imaging like radiograph, ultrasound, and MRI. The latter two used to visualise the non-ossified parts of the skeleton. Radiographs of the infant foot are difficult to interpret and hence, clinical examination remains the optimum means of assessment (Ponseti and Smoley system, Harrold and Walker system, Catterall system and Diméglio et al)11. Pirani and Diméglio scoring systems are commonly used classification systems for clinical practice with both systems having very good interobserver reliability and reproducibility8,12. Podograms may also be taken for documentation13. It has become a general rule to start treatment as soon as possible after birth with the initial treatment being non-surgical1,5. Many methods have been described in the literature (Kite technique, Ponseti method, French method, Ponseti modification etc.)5-8,14-16 which are mostly serial manipulation and casting. Ponseti method has become famous after the author reported successful correction in 85% 90% cases without need for posteromedial release. The correction achieved has been reported as being long lasting with some patients followed up to their fourth or fifth decade.1,17 Material and Methods In our study we have included 107 idiopathic club feet, 79 patients (28 bilateral), 56 males and 23 females of 15 days to 1 year age group using Ponseti method of management. The study was conducted from August 2007 to July 2010 with maximum follow-up of two years. Secondary causes of talipes equinovarus and clubfoot associated with other deformities were excluded from this study. The patient and examination data were recorded in a ‘Clubfoot Proforma’. This database included a detailed birth history and family history. Examination findings included side involved, grading of severity using Pirani score, other skeletal examination and the neuromuscular assessment. Comment: Inclusion criteria needs to be more specified. Upper age limit of inclusion is preferably 9 months; though 1 year also can be accepted. The results were evaluated for correction of deformity, the number of casts required, the need for tenotomy of tendo-achillis, relapse of the deformity and surgery required. We use the protocol as described by Dr. Ignacio Vives Ponseti5 with little modification that instead of the weekly change of plaster we did fortnightly and tenotomy of tendo-achillis [Fig.1], when required, was done under general anaesthesia in Operation Theatre under proper aseptic and antiseptic precaution which Ponseti does under local anaesthesia. Tenotomy was indicated when hindfoot score >1 and midfoot score <1in Pirani scoring. After the last cast, the feet were kept with the foot abduction orthosis (Denis Browne splint). The orthosis consists of an open toe high-top straight last leather shoes attached to a bar with adjustable plastic screw [Fig.2]. The parents were advised to let the child use the orthosis for full time basis (23 hrs a day) for three months and thereafter at night time up to 3-4 years. The orthosis was kept at 70° external rotation on both sides for bilateral cases or 30-40° of external rotation on the normal side in unilateral cases. The verbal report given by the parents at follow-up was used to assess the compliance of the use of the splint. Follow–ups were done every 3 weekly after the splint is given for the first 2 months and every 12-16 weeks thereafter. The result was designated as good (<0.5), fair (0.5-2) and poor (>2) using Pirani scoring system.