Influence of Beginning Time of Casting for Clubfoot Treatment by Ponseti Method in Different Age Group Infants: A Retrospective Study

Abstract

Background

The clubfoot is one of the commonly found congenital deformities in newborn. The Ponseti method is the most effective nonoperative clubfoot management method. It is based on understanding of pathoanatomy of clubfoot. For classifying severity of clubfoot, Pirani score is used. The number of cast required for clubfoot correction is dependent on its initial Pirani score. This study aimed on how the number of cast for correction of clubfoot deformity depends on starting time of casting and pretreatment Pirani score.

Materials and Methods

This study comprises of 200 patients with 297 affected foot nonoperatively managed with Ponseti technique of casting. We measured initial and final Pirani scores of patients with different age groups.

Results

We found that initial severity was less in 0–1 month age group children but mean casting number was more while initial severity was more in 1–2 month age group, the mean number of casting was less. Tenotomy requirement was also less in 1–2 month age group.

Conclusion

We concluded that casting according to the Ponseti method should be started in 1–2 months age group which shows better results than the other age groups in clubfoot.

Introduction

Worldwide, the Clubfoot is one of the commonly found congenital deformities in newborn. It is incident in around 1 in 1000 newborns which is more common in male child and mostly bilateral. In nonoperative management of clubfoot, Ponseti method has proven more effective than kite’s method and accepted as the treatment of choice in majority of centers worldwide [1]. The Ponseti method is based on understanding of the pathoanatomy of the clubfoot [2, 3]. This method is divided into two phases: (1) correction phase in which the deformity is corrected by serial manipulation and casting; (2) maintenance phase in which the obtained correction is maintained by brace.

The Pirani score is used as one of the popular systems for classification of the severity in clubfoot deformity. The number of cast required for clubfoot correction is dependent on its initial Pirani score [4–8].

It is believed that for clubfoot correction, manipulation and casting should begin as soon as possible [9–13]. However, according to some authors, clubfoot presenting in hospital after the first few months of life can also be successfully managed by Ponseti method [14–16]. There is lack of studies which shows association between beginning of casting time and functional outcome of clubfoot, therefore, our studies focus on how the number of cast for correction of clubfoot deformity depends on beginning time of casting and pretreatment Pirani score.

Materials and Methods

In this retrospective study, we analyzed the records of enrolled children with primary idiopathic clubfoot, managed in our clubfoot Ponseti clinic in association with CURE international India during the period January 2013–December 2018. We followed the protocol based on Ponseti method. A datasheet was used to follow each patient in clinic which indicated the demographic data of the patient, the type and side of clubfoot, Pirani score at presentation and during follow-ups, number of corrective cast for each patient, timing of tenotomy and follow-up after giving abduction brace [17].

A total 230 patients of age group up to 12 months included in our study in which 30 patients discontinued the treatment. According to the age group, patients divided in seven groups which were group A (0–1 month), group B (1–2 month), group C (2–3 month), group D (3–4 month), group E (4–5 month), group F (5–6 month) and group G (6–12 months). Management of these 200 patients with 297 affected foot done with Ponseti technique of casting. All casts were applied by experienced orthopedicians of similar experience. Still all doctors were sensitized periodically by Senior Professor to follow the standard guidelines for cast application.

Inclusion criteria: all cases were selected on the basis of

1. Cavus, adduction, varus and equinus deformity of the foot with or without wasting of calf muscles.

2. Age less than 1 year (age range, 1 day to 12 months).

3. Fresh clubfoot.

Exclusion criteria:

1. Postural, syndromic, neglected and relapsed club foot.

2. Patients above the age of 1 year.

3. Patients who are unfit and non-compliant to the Ponseti technique.

Results

In our study, a total of 230 patients were completed the inclusion criteria. Out of these, 30 patients discontinued the treatment. Therefore, only 200 patients with 297 affected foot were included. The male and female ratio was 2.9:1 with 149 males and 51 females (Table 1). Among these 200 patients, unilateral and bilateral cases were 103 (51.5%) and 97 (48.5%), respectively. In unilateral cases there were 49 (24.5%) right-sided and 54 (27%) left-sided cases (Table 2).

Table 1.

Demographic distribution of clubfoot children

Group of children	Number of children	Male	Female	Male:female
Group A	38	27	11	2.4
Group B	36	27	9	3
Group C	32	26	6	4.3
Group D	23	17	6	2.8
Group E	9	7	2	3.5
Group F	29	19	10	1.9
Group G	33	26	7	3.7
Total	200	149	51	2.9

Table 2.

Side distribution of clubfoot

Group of children	Number of children	Number of feet
		Unilateral		Bilateral	Total
		Left	Right
Group A	38	11	10	17	55
Group B	36	4	11	21	57
Group C	32	5	6	21	53
Group D	23	10	5	8	31
Group E	9	2	4	3	12
Group F	29	9	5	15	44
Group G	33	13	8	12	45
Total	200	54	49	97	297

Mean Number of Cast

In present study, the mean of total number of cast applied for 297 feet for full correction of clubfoot was 7.59 (Table 3). The Graph 1 shows that the mean number of casting was decreased from group A (7.92) to group B (7.11) after that number of casting increased gradually in later age groups. This difference was found statistically significant at p value < 0.05.

Table 3.

Relation between clubfoot severity and average casting

Group of children	Pre-Pirani average score	Post-Pirani average score	Average casting
Group A	4.92	0.08	7.92 1.5
Group B	4.97	0.02	7.11 1.6
Group C	5.28	0.03	7.21
Group D	5.30	0.06	7.52
Group E	5.37	0.19	7.55
Group F	5.38	0.19	7.89
Group G	5.48	0.21	7.93
Total	5.24	0.12	7.59

Graph 1.

Average casting in different age groups

Relationship Between Initial and Final Severity of the Clubfoot

According to Table 3, the mean of the initial Pirani score before casting in group A and group B was 4.92 and 4.97, respectively. Although these data show that initial severity was less in group A children but mean casting number was more. In spite of initial severity being more in group B, the mean number of casting was less. Graphs 2 and 3 show the relation between the severity in clubfoot with different age groups.

Graph 2.

Pre-Pirani average score

Graph 3.

Post-Pirani average score

Tenotomy and Age Distribution

The Graph 4 shows the relationship between number of tenotomies with different age groups (Table 4). The line of the graph is the lowest in the area of group B in which tenotomy percent was 75.43 which was very less than group A and other adjacent age groups. It signifies that the group B patients need less number of tenotomies as well as difficulties in treatment is also decreased after the neonatal period which is on power analysis, the power to detect this difference was > 80% and also the number of patients in group A and group B were adequate to detect this difference.

Graph 4.

Tenotomy after casting

Table 4.

Requirement of tenotomy in different age groups

Group of children	Tenotomy/total feet	Tenotomy percent
Group A	50/55	90.91
Group B	43/57	75.44
Group C	49/53	92.45
Group D	29/31	93.55
Group E	11/12	91.67
Group F	43/44	97.73
Group G	43/45	95.56
Total	268/297	90.24

Discussion

According to Ponseti, treatment should begin in the first days of life so we can take advantage of the favorable fibroelastic properties of the connective tissue which forms the ligaments, joint capsules and tendons. If early surgical interventions are performed for Clubfoot correction, it induces fibrosis, scarring and stiffness [3]. Therefore, it must be delayed until the child is at least 3 months old. These first 3 months offer the skilled and knowledgeable surgeon a golden opportunity to correct the deformity by manipulation and casting. Proper manipulative techniques followed by applications of well-moulded plaster casts by Ponseti method offer the best and safest correction of most clubfeet deformities in infants [10].

In our study the Ponseti success rate was 86.95%. Also, our study data show that initial Pirani severity in group A was less but the mean casting number was more in group A (7.92) than group B (7.11). Tenotomy requirement was also less in group B which was 75.43% when compared to average of all groups (90.45%).

These findings suggest that casting according to the Ponseti method should begin in infants of age group B (1–2 months) which shows better results than the other age groups.

Similar results were obtained in the study done by Iltar et al. in 2010 [1]. They did this study for the beginning of casting in the newborn period (0–1 month old) or later (greater than 1 month but less than 1 year of age). They concluded that Final Diméglio scores were significantly worse for the patients whose casts were applied in the newborn period, compared with those who had the first cast applied at a time more than 1 month postpartum (p = 0.04). Our study also supported by another study done by Anil Agarwal et al. in 2014 [18]. They concluded that both Pirani score and age had positive correlation with number of casts for clubfoot correction. The initial Pirani scoring correlated ten times more than age (in months) to the number of casts.

While there are some other studies which are contradictory to our results. In 2014, Mazlina et al. noticed that total number of castings required to treat clubfoot was determined by its severity when using Ponseti manipulation but not by the weight and age of patients where findings showed that age of initiation of manipulation and casting in patients younger than 120 days did not influence the total number of castings [19].

Another contradictory study done by Lebel et al. in 2017 “early application of the Ponseti casting technique for clubfoot correction in sick infants at the neonatal intensive care unit”. They concluded that in most cases, clubfoot treatment is feasible and effective within the first week of life [20].

Conclusion

Our study concluded that casting in clubfoot patients should be started in the age of 1–2 month (group B). This is because of cuboid bone which is still not well ossified in the first month of life. It may be compressed during the manipulations rather than corrected, if casting started in first month of life which leads to decrease the final outcome. And if casting starts after 2 months of age, because of increase in stiffness of fibroelastic tissue, the final outcome again decreases. Therefore, casting in clubfoot should be started in the age of 1–2 month for getting good results and also requirement of tenotomy is less in this age group.

Funding

None.

Compliance with Ethical Standards

Conflict of interest

There is no conflict of interest.

Ethical standard statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.