Abstract
Introduction
Serial Ponseti casting achieves deformity correction in early presenting idiopathic clubfoot cases normally in around 7 casts. However, there are resistant patients where correction requires more casts than usual. In such patients a modification in standard technique might be required right from the beginning. Such patients were collectively called as difficult clubfoot. The aim of this study was to assess the outcome of our modification to Ponseti technique in difficult clubfoot.
Methods
All idiopathic clubfoot cases who were 75th percentile or more in WHO age for weight chart (chubby infants) or untreated clubfoot patients presenting for first time to our clinic at more than 5 months age (late presenters and neglected cases) were included in the study. Patients who had been previously surgically intervened elsewhere, patients over 7 years of age, patients with syndromic clubfoot or clubfoot associated with neurological conditions were excluded from the study. The patients were treated by early tenotomy of tendoachillis and a plantar fascia release before starting serial casting by Ponseti technique. Post correction, strict bracing protocol was followed with regular follow up. Pirani scoring was done at each stage. Measurement of Talocalcaneal angle on AP radiograph, maximum degree of abduction and dorsiflexion was noted once every year.
Results
There were total 28 patients in our study. In all, 47 feet were subjected to modified Ponseti protocol. There were 21 male patients. Median age at presentation was 4 months. Mean centile of weight for age as per WHO growth chart was 64. Mean Pirani score at presentation was 5.86 (S.D. ± 0.34). Mean number of casts required for correction was 3.75 ± 1.10. Maximum followup period was 25 months.
Conclusion
This modification of Ponseti casting for difficult clubfoot patients achieves correction in shorter duration with less number of casts.
Keywords: Difficult clubfoot, Modified ponseti technique, Chubby infants, Late presenters, Neglected clubfoot
1. Introduction
Clubfoot is one of the most common congenital anomalies of the lower limb. Global incidence spectrum varies from 0.76 (Philippines), to 1.2 (most Caucasians), to 3.49 (Australian aborigines) and to 6.8 (Hawaiian population) per 1000 live births.1 Ponseti method of serial casting has over time proved to be of value in treating clubfoot with good outcomes and is now the most popular technique of non-operative clubfoot deformity correction worldwide.2
An average number of five to seven casts are required for correction of deformity in early presenting idiopathic clubfeet cases.3, 4, 5 However, resistant cases i.e. late presenters, neglected, relapsed, complex (atypical) cases, chubby infants, and syndromic patients (those with AMC and neurological conditions) usually require more number of casts than usual for complete correction despite correct casting technique. Many a times, such resistant cases fail to respond to standard methods of conservative treatment.6 Various modifications in the original technique have been suggested to achieve correction in such type of cases.2 We collectively labelled such cases as having difficult clubfoot.
We modified the Ponseti protocol by doing an early tenotomy of tendoachillis and a plantar fascia release before starting serial weekly casting. The aim of this study was to assess the outcome of our modification in difficult clubfoot patients.
2. Methods
This study was carried out in the Department of Orthopaedics of a tertiary level pediatric centre in urban India. All idiopathic clubfoot cases who were 75th percentile in WHO age for weight chart or more (chubby infants/children) or untreated clubfoot patients presenting for first time to our clinic at more than 5 months age were included in the study. Of the seventy-three clubfoot patients presenting between March 2016 and December 2017, twenty-eight patients (forty seven feet) were included in our study. These were treated with modified Ponseti technique as described below. Patients who had been previously surgically intervened elsewhere or patients over 7 years of age were excluded from the study. Also, patients with syndromic clubfoot or clubfoot associated with neurological conditions were excluded from the study.
Technique: Steindler's release and percutaneous tenotomy of tendoachillis of the affected foot was performed under general anaesthesia and tourniquet control. The first cast was applied with correction of cavus by forefoot supination, maximal abduction of the foot over the talar head and simultaneous correction of equinus [Fig. 1]. This first cast was retained for 3 weeks. Special care was taken to mould the cast just above the heel as slipping within the cast starts with proximal shift of the heel.7 All casts were above knee, with knee in 100° of flexion. After first cast of 3 week duration, serial weekly casts were applied as in Ponseti technique. Pirani scoring was done before each change of cast and the endpoint of treatment was when Pirani score was zero.8 Strict compliance to bracing protocol was instructed.
Fig. 1.
Modified technique prior to Ponseti Style Casting.
Follow Up: Pirani scoring was done at each follow up. Post correction, parents were asked to visit weekly to our clinic for first month, monthly for next 3 months, and quarterly till the age of 12 years. Measurement of Talocalcaneal angle on AP radiographic view and maximum degree of abduction and dorsiflexion was noted once every year. The Talocalcaneal angle on radiography correlates well with Foot Bimalleolar angle on podography and also clinical foot abduction.9
Data was collected using a pre-designed data entry sheet. Analysis was done using statistical software ‘SPSS version 16.0' (SPSS Inc., Chicago, IL, USA). For continuous variables, normality of distribution was assessed by Shapiro Wilk test. Normally distributed variables were summarized as mean with standard deviation. Other continuous variables were described as median with range. Qualitative data is expressed in percentage.
3. Results
There were total 28 patients in our study with 19 bilateral affection, 8 right sided affection and 1 left sided affection. Sixteen patients (26 feet) were chubby infants, while 12 patients (21 feet) were late presenters. In all 47 feet were subjected to modified Ponseti protocol. Bursal excision was done in 3 patients (4 feet). There were 21 male patients and 7 female patients [Table 1]. Median age at presentation was 4 months (Median IQR = 10.9) Mean Pirani score at presentation was 5.86 (S.D. ± 0.34). Median weight at presentation was 7.8 kgs (Range- 4.0–26.1 kgs). Mean centile of weight for age as per WHO growth chart was 64.64 (S.D. ± 22.19). Mean number of casts for correction was 3.75 (S.D. ± 1.10) (Range 2 to 6 casts). Mean duration of follow up was 18.64 months (S.D. ± 3.77). Minimum followup period was 12 months and maximum was 25 months. Average Kite's angle (talocalcaneal angle) at the end of first year of follow up was 35° (S.D. ± 4.42°). Mean maximum dorsiflexion achieved at the end of 1st year of follow up was 33.28° (S.D. ± 7.24°). Mean maximum foot abduction achieved at the end of 1st year of follow up was 57.44° (S.D. ± 5.09°). None of the child had lost the ability of active plantar flexion of foot when checked at end of 1st year of follow up. Relapse was not seen in any case until last follow up. The yearly follow up results are summarized in Table 2. Five of 28 patients (7 feet) had completed 2 years of follow up by the time of close of the study period. Category-wise results are depicted in Table 3 and representative cases are depicted in Fig. 2, Fig. 3, Fig. 4, Fig. 5, Fig. 6.
Table 1.
Early outcome.
| S.No. | Patient Name | Age at Presentation | Weight at Presentation (kgs) (Centile of WHO Growth Chart) | Sex | Category | No. of casts for correction | Side (Rt/Lt/Both) | Pirani Score before CCA |
|||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1st | 2nd | 3rd | 4th | 5th | 6th | ||||||||
| 1 | Patient 1 | 2.5 mo | 6.7 (85) | M | A | 4 | Rt | 5 | 3.5 | 2 | 1 | - | - |
| 2 | Patient 2 | 2 mo | 5.7 (75) | F | A | 4 | Both | 5;5.5 | 3;3.5 | 2;2.5 | 0.5;1 | - | - |
| 3 | Patient 3 | 24 days | 4.8 (85) | M | A | 5 | Rt | 6 | 3 | 2 | 1 | 0.5 | - |
| 4 | Patient 4 | 1 yr | 9.5 (50) | M | B | 2 | Both | 6;6 | 2;1.5 | - | - | - | - |
| 5 | Patient 5 | 2 yrs | 12.5 (50) | M | B | 3 | Rt | 6 | 2.5 | 1 | - | - | - |
| 6 | Patient 6 | 1 mo | 5.0 (85) | M | A | 4 | Both | 6;6 | 4;3 | 2.5;2 | 1.5;1 | - | - |
| 7 | Patient 7 | 1.5 mo | 5.2 (75) | F | A | 4 | Rt | 6 | 3.5 | 2.5 | 1 | - | - |
| 8 | Patient 8 | 7 mo | 9.0 (75) | M | A | 4 | Both | 6;6 | 3.5;4 | 2;2.5 | 1;1.5 | 0.5;0.5 | - |
| 9 | Patient 9 | 5 mo | 8.9 (95) | M | A | 5a | Rt | 6 | 3 | 2 | 1.5 | 1 | - |
| 10 | Patient 10ˆ | 29 days | 5.2 (85) | F | A | 3 | Both | 5;5 | 2.5;2 | 1;0.5 | - | - | - |
| 11 | Patient 11 | 26 days | 5.0 (85) | M | A | 5 | Both | 6;5.5 | 4;3.5 | 3;2.5 | 1.5;2 | 0.5;1 | - |
| 12 | Patient 12 | 3 mo | 6.8 (85) | F | A | 4 | Both | 6;6 | 3.5;2.5 | 2.5;1 | 1;0 | - | - |
| 13 | Patient 13c | 6 yrs | 19.2 (50) | F | B | 4 | Both | 6;6 | 2.5;3 | 1.5;2 | 1;1 | - | - |
| 14 | Patient 14 | 2 mo | 6.2 (75) | M | A | 4 | Rt | 6 | 3.5 | 2 | 1 | - | - |
| 15 | Patient 15b | 7 yrs | 26.1 (85) | M | A | 6 | Lt | 6 | 4 | 2.5 | 2 | 1 | 0.5 |
| 16 | Patient 16 | 5 mo | 7.6 (50) | M | B | 2 | Both | 5.5;6 | 2;1.5 | - | - | - | - |
| 17 | Patient 17 | 1 yr | 8.4 (25) | F | B | 3 | Both | 6;6 | 2;2.5 | 0.5;1 | - | - | - |
| 18 | Patient 18 | 3 mo | 7.4 (85) | M | A | 6 | Both | 6;6 | 4;3.5 | 3;3 | 2.5;2 | 1.5;1 | 0.5;0.5 |
| 19 | Patient 19 | 2 yrs | 12 (25) | M | B | 3 | Both | 6;6 | 2.5;1.5 | 1;0.5 | - | - | - |
| 20 | Patient 20 | 3 yrs | 14.6 (50) | M | B | 3 | Both | 6;6 | 3;2.5 | 1.5;1 | - | - | - |
| 21 | Patient 21 | 22 days | 4.5 (75) | M | A | 5 | Both | 6;6 | 3.5;4 | 2;3 | 1;2 | 0.5;0.5 | - |
| 22 | Patient 22 | 8 mo | 8.5 (50) | M | B | 4 | Rt | 6 | 3.5 | 2 | 1 | - | - |
| 23 | Patient 23 | 18 days | 4.0 (75) | M | A | 4 | Both | 6;6 | 2;3 | 1.5;2 | 0.5;1 | - | - |
| 24 | Patient 24 | 18 days | 4.2 (75) | M | A | 4 | Both | 6;6 | 3;2.5 | 2;1.5 | 1;0.5 | - | - |
| 25 | Patient 25 | 2 yrs | 11.5 (25) | M | B | 2 | Rt | 6 | 2 | - | - | - | - |
| 26 | Patient 26b | 5 yrs | 18.5 (50) | M | B | 3 | Both | 6;6 | 2.5;2.5 | 1.5;1 | 1;0.5 | - | - |
| 27 | Patient 27 | 1 yr | 9.0 (50) | F | B | 2 | Both | 6;6 | 1.5;2 | - | - | - | - |
| 28 | Patient 28 | 7 mo. | 8.0 (50) | M | B | 3 | Both | 6;6 | 3;3 | 1;0.5 | - | - | - |
CCA Corrective Cast application.
2nd Plaster reapplied on 3rd day of the week due to accidental soiling in urine.
Unilateral bursal excision done.
Bilateral bursal excision done.
Table 2.
Long term followup.
| S.No. | Patient Name | Agea | Side (Rt/Lt/Both) | Category | Followup (months) | Pirani Score (Rt;Lt) |
TC Kite's Angle (°) (AP) |
Maximum Abduction (°) |
Maximum Dorsiflexion (°) |
Ability to Tiptoe |
||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Yr 1 end | Yr 2 end | Yr 1 end | Yr 2 end | Yr 1 end | Yr 2 end | Yr 1 end | Yr 2 end | Yr 1 end | ||||||
| 1 | Patient 1 | 2.5 m | Rt | A | 25 | 0 | 0 | 30 | 40 | 60 | 60 | 35 | 30 | Yes |
| 2 | Patient 2 | 2 m | Both | A | 25 | 0;0 | 0;0 | 30;40 | 35;40 | 60;60 | 60;60 | 40;40 | 30;30 | Yes |
| 3 | Patient 3 | 24 d | Rt | A | 24 | 0 | 0 | 30 | 40 | 60 | 60 | 40 | 40 | Yes |
| 4 | Patient 4 | 1 y | Both | B | 24 | 0;0 | 0;0 | 40;40 | 40;40 | 60;60 | 60;60 | 30;30 | 30;30 | Yes |
| 5 | Patient 5 | 2 y | Rt | B | 24 | 0 | 0 | 40 | 40 | 50 | 50 | 30 | 30 | Yes |
| 6 | Patient 6 | 1 m | Both | A | 21 | 0;0 | - | 30;35 | - | 60;60 | - | 40;40 | - | Yes |
| 7 | Patient 7 | 1.5 m | Rt | A | 21 | 0 | - | 30 | - | 60 | - | 40 | - | Yes |
| 8 | Patient 8 | 7 m | Both | A | 21 | 0;0 | - | 30;30 | - | 60;60 | - | 35;35 | - | Yes |
| 9 | Patient 9 | 5 m | Rt | A | 21 | 0 | - | 35 | - | 60 | - | 35 | - | Yes |
| 10 | Patient 10 | 16 d | Both | A | 21 | 0;0 | - | 30;30 | - | 60;60 | - | 40;40 | - | Yes |
| 11 | Patient 11 | 6 d | Both | A | 21 | 0;0 | - | 30;30 | - | 60;60 | - | 40;40 | - | Yes |
| 12 | Patient 12 | 3 m | Both | A | 21 | 0;0 | - | 35;30 | - | 60;60 | - | 35;35 | - | Yes |
| 13 | Patient 13 | 6 y | Both | B | 18 | 0;0.5 | - | 40;40 | - | 45;50 | - | 25;20 | - | Yes |
| 14 | Patient 14 | 2 m | Rt | A | 18 | 0 | - | 30 | - | 60 | - | 40 | - | Yes |
| 15 | Patient 15 | 7 y | Lt | A | 18 | 0 | - | 30 | - | 45 | - | 20 | - | Yes |
| 16 | Patient 16 | 5 m | Both | B | 18 | 0;0 | - | 30;35 | - | 60;60 | - | 30;30 | - | Yes |
| 17 | Patient 17 | 1 y | Both | B | 18 | 0;0 | - | 40;40 | - | 60;60 | - | 25;25 | - | Yes |
| 18 | Patient 18 | 3 m | Both | A | 18 | 0;0 | - | 40;35 | - | 60;60 | - | 35;35 | - | Yes |
| 19 | Patient 19 | 23 d | Both | B | 18 | 0;0 | - | 35;30 | - | 50;50 | - | 35;35 | - | Yes |
| 20 | Patient 20 | 3 y | Both | B | 18 | 0;0 | - | 40;40 | - | 50;50 | - | 25;25 | - | Yes |
| 21 | Patient 21 | 22 d | Both | A | 15 | 0;0 | - | 30;35 | - | 60;60 | - | 40;40 | - | Yes |
| 22 | Patient 22 | 8 m | Rt | B | 15 | 0 | - | 35 | - | 60 | - | 30 | - | Yes |
| 23 | Patient 23 | 8 d | Both | A | 15 | 0;0 | - | 35;30 | - | 60;60 | - | 40;40 | - | Yes |
| 24 | Patient 24 | 18 d | Both | A | 15 | 0;0 | - | 30;35 | - | 60;60 | - | 40;40 | - | Yes |
| 25 | Patient 25 | 2 y | Rt | B | 15 | 0 | - | 40 | - | 60 | - | 25 | - | Yes |
| 26 | Patient 26 | 5 y | Both | B | 13 | 0;0 | - | 40;40 | - | 45;45 | - | 25;25 | - | Yes |
| 27 | Patient 27 | 1 y | Both | B | 13 | 0;0 | - | 40;40 | - | 60;60 | - | 30;30 | - | Yes |
| 28 | Patient 28 | 7 mo. | Both | B | 12 | 0;0 | - | 35;40 | - | 60;60 | - | 35;40 | - | Yes |
At presentation.
Table 3.
Category wise Results.
| Category of Clubfoot Patients | No. of Patients | No. of Feet | Age in monthsa [Median (IQR)] | Pirani Scorea (Mean) | Weight in kgsa [Median (IQR)] | Centile of weighta for age (Mean ± S.D) | No. of casts for correction (Mean ± S.D) | Follow up in months (Mean ± S.D.) | TC Angle (AP) (Mean ± S.D.) |
Degrees of Dorsiflexion (Mean ± S.D.) |
Abduction (Mean ± S.D.) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1st Yr End | 1st Yr End | 1st Yr End | |||||||||
| Chubby Infants (A) | 16 | 26 | 1.5 (2.2) | 5.77 ± 0.41 | 5.2 (2.0) | 82.33 ± 5.93 | 4.46 ± 0.83 | 19.8 ± 3.16 | 32.70 ± 3.60 | 37.50 ± 4.66 | 59.37 ± 3.06 |
| Late Presenting & Neglected (B) | 12 | 21 | 12 (23) | 5.96 ± 0.20 | 9.5 (5.1) | 44.23 ± 14.97 | 2.92 ± 0.75 | 17.30 ± 4.09 | 37.39 ± 3.95 | 29.78 ± 5.32 | 55.43 ± 6.01 |
| Overall | 28 | 47 | 4.0 (10.9) | 5.86 ± 0.34 | 7.8 (5.3) | 64.64 ± 22.19 | 3.75 ± 1.10 | 18.64 ± 3.77 | 35.0 ± 4.42 | 33.28 ± 7.24 | 57.44 ± 5.09 |
TC Angle- Talocalcaneal Angle.
At presentation.
Fig. 2.
Representative case (Chubby Infants).
Fig. 3.
Representative case of Chubby Infant.
Fig. 4.
Representative case (Late Presenting Clubfoot).
Fig. 5.
Representative case of Late Presenting Clubfoot.
Fig. 6.
Representative case (Neglected Clubfoot).
4. Discussion
Several researchers have proposed various modifications in classical Ponseti protocol in different subset of clubfoot patients which is summarized in Table 4. A technique called minimally invasive cast correction (MICC) has been described in literature where percutaneous tendoachillis tenotomy and plantar fascia release is done prior to serial Ponseti casting.10 This has been advocated in late presenting infants (upto 1 year of age) and early cases of neglected clubfoot (less than 3 years of age). On the other hand, we have used our technique in resistant cases of clubfoot upto 7 years of age. Percutaneous tendoachillis tenotomy only prior to weekly Ponseti casting has been tried in a series of 50 neonates (82 feet) with idiopathic clubfoot within 4 weeks of birth. Here, only 1 cast was required to correct the deformity in 85% cases.11 Percutaneous heel chord tenotomy prior to weekly Ponseti style casting has also been suggested for cases of AMC with Clubfoot. In a series of 10 cases (19 feet) mean casts for correction was 7.712
Table 4.
Review of literature.
| S.No. | Researcher (Year) | Category of Patients | Modification of Ponseti Technique | No. of Children (No. of Feet) assessed | Avg. age and Pirani Score at presentation | Outcome (No. of casts) | Period of Followup (mnths/yrs) | Study Type | Comments |
|---|---|---|---|---|---|---|---|---|---|
| 1 | Morcuende et al.19 (2005) | All clubfoot patients including patients who received casting elsewhere | Serial Ponseti casting done every 5 days (compared with every 7 day casting) | 230 (319) | 3 months | 4 (1–7) | Not mentioned | Retrospective Cohort study | 1.Relapses (36) 2.Corrective Surgery(3) |
| Not applicableˆ | |||||||||
| 2 | Ponseti et al.7 (2006) | Complex Clubfeet (excluded patients with AMC or neuromuscular clubfeet) | 1. Avoid hyperabduction of metatarsals and hindfoot 2. Hyperflexion of metatarsals & rigid equinus were corrected simultaneously 3. One reinforced plaster splint was applied over the calf, heel, and sole; & other in front of the knee. |
50 (75) | 3 mnths (1 wk–9 mnths) | 5 (1–10) | 23 months (6–46 months) | Multicentre (5) study, Level-IV | 1.Relapses (7) 2.Second Tenotomy (3) 3.Persistent plantar crease (10) 4.Minimal Cavus(6) |
| Not applicableˆ | |||||||||
| 3 | Brewster et al.31 (2008) | All idiopathic clubfoot cases without prior intervention. Those with neuromuscular disorders or syndromes excluded. | 1.A small piece of Granuflex# applied over the talar head to prevent skin maceration. 2.Below-knee Softcast∗ is applied directly over a stockinette, without padding thereby obtaining a snug fit. 3.Foot is held in the corrected position until the material has set. Cast is completed with application of Elastoplast$ taping to proximal and distal ends. |
51 (80) | 4.5 wks (4 days–62 wks) | Not mentioned | 27 months (6–55) | Prospective cohort study | Relapses (6.25%); Advantage of knee movements & lesser cast related osteopenia |
| 5.5 (3–6) | |||||||||
| 4 | Bosse et al.12 (2009) | Clubfoot children with AMC | PC TA tenotomy, followed by Ponseti style weekly casts | 10 (19) | 16.2 months (3–40 months) | 7.7 (4–12) | 38.5 months (13–70 months) | Retrospective case series without comparison | 1.Repeat Tenotomy (53%) |
| 4.8 (1.5–6) | |||||||||
| 5 | Xu22 (2011) | All clubfoot patients coming between Jan 2003 to Dec 2006 | 1.Serial Ponseti casting done twice a week (compared with once a week casting) 2.Manipulation for 2 min before cast application |
26 (40) | 92.7 days (7–548 days) | 5.04 (4–8) | 4 yrs (2–6 yrs) | Prospective non randomized Control study; Level II | 1.Relapse (2 cases) 2.Corrective surgery (4 feet) |
| 1.5 to 6 | |||||||||
| 6 | Harnett et al.24 (2011) | Children with idiopathic clubfoot less than 90 days age & local residency | Serial Ponseti casting done thrice a week (compared with weekly casting) | 19 (29) | 21 days (7–48 days) | 7 (6–9) | Minimum 6 months | Prospective randomized Control study | 1.Two failures 2.One required additional surgery |
| 5.5 (4.5–6) | |||||||||
| 7 | Ullah et al.23 (2011) | All clubfoot patients coming to clinic between Dec 13 to July 14 except with additional congenital anomalies or those treated elsewhere | Serial Ponseti casting done twice a week | 28 (40) | 18 weeks | 7 | Not mentioned | Prospective study | 1.15% cases partial correction |
| 5.2 | |||||||||
| 8 | Narsimhan et al.30 (2011) | All patients with Congenital Clubfoot between 2005 and 2008 | In newborn weekly Ponseti casts for 1 month, followed by casts at flexible 7–14 days interval till correction. In patients with age >1 month flexible interval right from the beginning | 21 (33) | Newborns to 18 mnths of age | Avg. 6 casts + 1 post tenotomy cast | 27 mnths (24 to mnths) | Prospective cohort study | Fair result in 2 cases (3 feet), Poor result in 1 case (2 feet) |
| (4–6) | |||||||||
| 9 | Kumar et al.11 (2012) | Neonates with idiopathic clubfoot within 4 weeks of birth | PC TA tenotomy, followed single Ponseti cast for 3 weeks | 50 (82) | <4 weeks of age | 1 (85% cases) | 28 months (24–32 months) | Prospective non randomized | Failure rate (14.7%), further 2 to 3 weekly casts |
| 3.5 (2–5) | |||||||||
| 10 | Elgohary et al.20 (2015) | Idiopathic clubfoot patients with pirani score>4 (excluded patients with previous surgical intervention) | Serial Ponseti casting done twice a week | 21 (32) | 11.57 weeks (2–26 weeks) | 5.16 (±0.72) | 23.38 months (12–44 months) | Prospective randomized Control study | 1.Relapses (5) |
| 5.13 ± 0.61 | |||||||||
| 11 | Anil Gupta et al.26 (2015) | Atypical Clubfoot (excluded patients with syndromic or neuromuscular clubfeet) | Modified protocol as suggested by Ponseti et al., 2006 | 16 (16) | 3.2 months (1–5 months) | 7 (4-9) | 2 yrs (1–3 yrs) | Prospective Cohort study | None |
| Not mentioned | |||||||||
| 12 | Matar et al.25 (2016) | Complex Clubfoot (excluded patients with syndromes or neuromuscular problems) | Modified protocol as suggested by Ponseti et al., 2006 | 11 (17) | 5.2 weeks (2–11weeks) | 7 (5-10) | 7 yrs (3–11 yrs) | Retrospective, Level-IV | 1.Relapses(9) 2.Second Tenotomy (4) 3.Additional Surgical Procedure(6) |
| 5.5 (4.5-6) | |||||||||
| 13 | Bashi et al.28 (2016) | Neglected Clubfoot in older children & adolescents | 1.Manipulation before each cast for 3–5 min 2.Forefoot abduction to 30° instead of 70° 3.Short leg casts each for 3 weeks 4.Miniopen achillis tendon lengthening & tibiotalar capsulotomy 5.Additional procedure miniopen plantar fascia release ± Tibialis anterior tendon transfer |
11 (18) | 11.2 yrs (6–19 years) | 9 (6-13) | 15 months (12–36 months) | Prospective Cohort study | 1.Plantar Haematoma 2.Wound dehiscence 3.Failure (1) |
| Not mentioned | |||||||||
| 14 | Evans et al.21 (2017) | All clubfoot patients coming to clinic from Jun 2015 to Jun 2016 (6 atypical and 5 syndromic patients) | 1.Extended manipulation to 2 min before cast application 2.Ponseti cast changed every 3 days (fast cast) 3.percutaneous needle TA tenotomy |
123 (190) | 51 days (13–240 days) | 5 (2–10) | 1 yr | Prospective non randomized Cohort study | Minor- skin lesions (4), disrupted casting (3) |
| Not mentioned | |||||||||
| 15 | Mehtani et al.29 (2017) | All cases of neglected clubfoot(walking child with clubfoot over the age of 1 yr without previous intervention) | 1.Corrected cavus simultaneously with the abduction of calcaneo-pedal block 2. Reapplied the post tenotomy cast at 2 weeks in maximum achievable dorsiflexion & abduction 3.Instead of foot abduction brace for 23 h for initial 3 months, two biweekly below-knee weight-bearing casts in maximum dorsiflexion and external rotation after removal of post-tenotomy casts at 4 weeks. |
41 (62) | 3.1 yrs (1.1–12 yrs) | 6.9 (4-10) + 2 biweekly post tenotomy casts | 3 yrs (1.2–4 yrs) | Prospective non randomized | 1.Relapses (10.6%) 2. Minor Complication-plaster sores, skin redness, toe swelling. |
| 4.21 | |||||||||
| 16 | Mejabi et al. (2017)32 | Congenital idiopathic clubfoot upto 2 yrs age (excluded syndromic, recurrent and walking clubfoot) | Below knee post tenotomy final cast after serial ponseti casting | 20 (35) | 21 weeks (1–104 weeks) | 4.7 | 6 months | Prospective randomized cohort study, Level-I | None |
| 5.0 (4.1–5.9) | |||||||||
| 17 | Dragoni et al.14 (2018) | Complex Iatrogenic Clubfoot | 1.Modified protocol as suggested by Ponseti et al., 2006 2.Additional procedure in the form of TA lengthening/ percutaneous TA tenotomy |
9 | 10 weeks (6–20 weeks) | 6 (4-8) | 7.2 yrs | Prospective Cohort study | 1.Relpses (5) |
| 4.5 to 6 | |||||||||
| 18 | Mandlecha et al.27 (2018) | All patients of Complex Clubfoot less than 1 yr of age, without any prior intervention | Same as suggested by Ponseti et al., in 2006 | 16 (27) | 4.77 months | 7.44 (6-10) | 14.7 mnths (6–22 mnths) | Level IV Evidence | Relapse 11.11% (3 feet) |
| 5.57 (4.5–6) |
We have done percutaneous tendoachillis tenotomy along with plantar fascia release prior to weekly Ponseti style corrective casting in chubby infants with idiopathic clubfoot. In chubby infants there are high chances of cast slippage due to thick soft tissue between the skin and bone and even minor slippage within the cast can result in iatrogenic atypical (complex) clubfoot.13,14 The foot arches downward and often slips up inside the cast. The toes gradually disappear while the deformity worsens.3 There is a need to overcome the cavus and equinus which strongly resist correction in this variant of clubfoot.
Similar procedure for late presenting cases and neglected (untreated) cases has been done where the bones of the foot had not deformed owing to prolonged walking on deformed foot. Such cases would require an additional bony procedure, and hence excluded from the study.
Deformity correction in difficult clubfoot by movement of calcaneo-pedal block around the talar head as axis is not possible without the release of tight restraints of taut tendoachillis and plantar fascia. These two structures act as a limiting factor (bow string effect) for other less tight structures and the movement of foot around the talar head in these cases. Hence, when serial casting is done without prior release of tight tendoachillis and plantar fascia in resistant or difficult clubfoot, there is little improvement in Pirani score.
When plantar fascia is released, it helps in easing correction of forefoot adduction and cavus deformity. Abduction to 60° is necessary for the calcaneus to be able to swing out completely from underneath the talus which corrects subtalar malalignment. Attempts to correct the equinus, before the heel varus and foot supination are corrected will result in a rocker bottom deformity.15 If the tendoachillis tenotomy is performed before 60–70° of abduction and before correction of the subtalar alignment, the hindfoot will most likely stay uncorrected.16 Hence, it is more prudent to perform a plantar aponeurosis release to allow forefoot supination and abduction along with tendoachillis tenotomy before start of Ponseti casting in select cases, as in our series instead of performing tendoachillis tenotomy alone before start of Ponseti casting. We have also found that, in difficult clubfoot either the tendoachillis is very thick or the pull of gastrocnemius muscle is very strong. Hence, when tendoachillis is released it helps in easing the correction of equinus and hindfoot varus. Thus, releasing the two aforesaid structures by a short simple procedure, can save on several weekly casts required for gradual relaxation of these structures.
Our study had some limitations. Further study needs to be done to assess usability of the technique in patients more than 7 years age and in other subset of clubfoot patients. Multicentric trials using the same technique are also required. Ponseti stated that “regardless of the mode of treatment, the clubfoot has a stubborn tendency to relapse”.3,17 The maximum follow up period in our study is 25 months. Further follow up is required to assess long term relapse rate. However, we believe that, relapse rate is not dependent on method of casting employed, but on under correction of deformity, adherence to post cast bracing protocol and parent's compliance to follow up.18 For this we have reiterated a slogan of “twelve year war against clubfoot” to all parents attending our clubfoot clinic.
5. Conclusion
In cases of difficult clubfoot as described above, our modification of Ponseti technique has very good results requiring only on an average 4 casts to correct the deformity, hence should be used for difficult to treat clubfoot cases.
Compliance with ethical standards
Yes.
Conflicts of interest
All authors declare that they have no conflict of interest.
Funding
None.
Acknowledgements
I would like to thank Dr Poonam Motiani, Dr Vikas Gupta and Dr Atul Sharma, my colleagues without whose help the manuscript would not have taken the present form. I also thank our CURE India counseling volunteers Ms Savita Solomon and Mrs Manisha Kattal for their efforts in our clubfoot clinic.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jcot.2019.05.003.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
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