Early results of treatment for congenital clubfoot using the Ponseti method
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- Matuszewski, Ł., Gil, L. & Karski, J. Eur J Orthop Surg Traumatol (2012) 22: 403. doi:10.1007/s00590-011-0860-4
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The purpose of this study was to evaluate the early results of the Ponseti method in reducing extensive corrective surgery rates for congenital idiopathic clubfoot in patients treated in Children’s Orthopaedic Clinic and Rehabilitation Department Medical University of Lublin between the years 2007–2011. Thirty-five patients with 47 idiopathic clubfeet were followed prospectively while being managed with the Ponseti method. Clubfoot severity was graded with use of the Dimeglio system. The initial correction was achieved, and early results were measured by using Pirani scoring method.
KeywordsCongenital clubfoot Ponseti method Pediatric orthopedics
Feet provide the foundation for static support for body and dynamic support during walking or running. They also fulfill an important esthetic function . Congenital clubfoot has been a recognized condition since ancient Egypt. Pharaohs Siptah and Tutankhamun had clubfoot. This condition was described by Hippocrates and the Aztecs .
Clubfoot is a congenital deformity that occurs in 1/10,000 birth. It is more common in boys. The deformity includes four components: metatarsus adductus, cavus, hindfoot varus and equinus. Congenital clubfoot is a three-dimensional malformation with its center in talocalcaneonavicular articulation. The axis of deformation is interosseous talocalcaneal ligament .
The cause of clubfoot has long been debated by the medical community. According to the Journal of Children’s Orthopaedics, this condition has been studied since the 1800s. Some scientific investigators concluded that the condition was caused by malformed bones, abnormalities of muscle, joint or vascular lesions and/or abnormal ligaments and tendons. Another opinion is that congenital clubfoot results when external forces put the foot or the feet in a faulty position while the fetus is developing . Nowadays, there are two main hypotheses that say that congenital clubfoot is caused by neurogenic disorders in neuromuscle balance or gene variations .
Medial side incision (Evans, Dega, Turco)
Two skin incisions—medial and lateral side (Carroll, Sotirow, Uglov)
Circumferential (Cincinnati) (McKay, Crawford)
Ponseti described his method in late 1950s. His method is an innovative, conservative treatment for clubfoot involving a gentle manipulation of the child’s foot and the application of toe-to-groin plaster casts that is followed by bracing and tenotomy. The procedure consists of manual redresions, started as early as possible, which corrects a longitudinal arc of the foot and an abduction of a forefoot. With this treatment, soft structures are stretched with weekly, gentle manipulations. A plaster cast is applied after each weekly session to retain the degree of correction obtained and to soften the ligaments. After 4–6 weeks of the treatment, when adduction and supination of the calcaneum bone is corrected, the tight Achilles tendon is cut in a minor procedure (tenotomy) to perform correction of the equinal deformation. The corrected foot is put in a holding cast for 3 weeks to allow the tendon to regenerate. Then, when the final cast is removed, a “foot abduction brace” a.k.a. the Denis–Brown’s device is fitted. This device consists of a pair of shoes attached to an adjustable bar at a specific width and angle. Ponseti achieved successful results in more than 95% of cases .
Aim of the paper
The main objective of this paper is to present the early results of treatment congenital clubfoot by Ponseti method.
Materials and methods
The paper is based on data for 35 children—25 boys and 10 girls with 47 clubfeet treated during the period of 2007–2011. We monitored the deformation before each redresion and casting, and before and after the tenotomy. To evaluate the effects of treatment, we used Pirani’s scale with its six main features concerning external edge, medial crease and “covering” of the head of the talus bone in the midfoot region and posterior crease, incorrective equinal deformation and empty heel in hindfoot region. According to Pirani’s scale, a total score of 6 points represents a severe clubfoot with a score of 0 points representing a normal foot.
Angular deformation before treatment—most of them were medium or maximal (40°–90°)
Result after tenotomy
Passive dorsal flexion
Angular deformation for varus and adduction after redresions and casting treatment—during passive correction—we reached 0°–5° in all treated patients
Grade of varus and adduction deformation
Number of feet
Correction in sagittal plane and ability of passive dorsal flexion after tenotomy—we reached good results in 85% of treated feet
Result after tenotomy
Passive dorsal flexion
Number of feet (%)
39 feet (85%)
8 feet (15%)
Pirani scale before and after treatment—we accomplished 0.5–1.5 point in all 33 treated feet
Before treatment by Ponseti method
8–42 months after Achilles tenotomy
Number of feet
Number of feet
The main objective of treatment for congenital clubfoot is to obtain pain-free, plantigrade foot, with good mobility and without calluses. In general, children who suffer from such deformation undergo some type of surgery to complete the correction. This can range from a percutaneous heelcord lengthening to a wide release of medial, posterior and lateral structures, with or without transfer of the anterior tibial tendon [7, 8].
There is general agreement that initial treatment for congenital clubfoot should be nonsurgical. This leads Ponseti to develop his method in the 1950s, repopularized in the beginning of 2000 in the USA and Europe. Currently, manipulation, redresions and casting according to Ponseti method are the “gold standard,” and this method is endorsed by the American Association of Orthopedic Surgeons. Napiontek  in 2004 introduced and widely popularized Ponseti method in Poland, and since 2007, we have been using it in our Clinic. Treatment should be initiated as soon as possible, preferably within the first week of life. The majority of clubfeet can be corrected in infancy in about 6–8 weeks with the proper gentle manipulations and plaster casts followed by tenotomy. However, the technique requires a lot of training, experience and practice .
In our study, nonoperative procedures took usually 5–8 weeks which is a similar period to Ponseti standards and that what other author report [11, 12]. For the treatment performed at our clinic, tenotomy of the Achilles tendom was crucial for the completion of a successful correction of the foot. Despite successful initial treatment, congenital clubfoot has a natural tendency to recur. Therefore, bracing is essential and necessary to prevent a recurrence of deformation. There are several types of braces. All of them consist of a bar with shoes that are attached at the ends of the bar in external rotation. The device is worn 23 h a day for 3–4 months and then at nighttime for 2–4 years. In our clinic, we used TIBAX or CLUBAX device which was similar to orthosis recommended by POSNA (Pediatric Orthopaedic Society of North America) as: the Dobbs Dynamic Abduction Brace, the Markell or Mitchell Abduction Brace. Severity of the deformity at birth is not a reliable indicator of the odds for a relapse; therefore, almost all clubfoot patients are held to the same bracing protocols in order to provide them with the best protection against regression [13, 14]. In early results, we noticed that all children who did not use the orthosis as it was prescribed experienced high recurrence rate. We have to add that in some severe cases, more invasive surgery treatment is needed to correct the position of the clubfoot despite using Ponseti method. Most often, a more invasive surgery is this is needed in cases when a child has other developmental problems as, e.g., arthrogryposis .
We also want to point out that the time when the child begins treatment by Ponseti method is an important factor. All of our patients received such treatment in first month of life. Most authors consider that a congenital clubfeet treatment has to start no more than a few months after birth. However, some resent researches showed that the Ponseti method is effective for children as old as ten, even in cases of a failed surgery [16, 17]. We agree with Ponseti’s thesis that the basic of deformity in the congenital clubfoot is fibrosis of the soft tissue. Therefore, soft tissue in infants is more responsive to redresions, casting and finally bracing.
In essence, our study supports the principles of Ponseti’s method, because in cases when these principles were strictly obeyed, all patients accomplished satisfactory results and there have been no recurrences that are known to us [5, 18]. Therefore, we strongly recommend using this method to avoid more invasive surgery in the future. This method is of the particular value for the initial treatment of congenital clubfoot deformity.
Conflict of interest
The authors of this manuscript have chosen not to furnish Ejost and its readers with information regarding any relationship that might exist between a commercial party and material contained in this manuscript that might represent a potential conflict of interest. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.
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