THE PONSETI TREATMENT FOR CLUBFEET: THE AFULA EXPERIENCE WITH A MINIMUM OF 5 YEARS FOLLOW-UP

Abstract

Introduction: Idiopathic congenital talipes equinovarus (clubfoot) is a common complex deformity that occurs in approximately one or two per 1000 newborns. For many years, most surgeons considered it as a “surgical disease”. The long term results of the surgical release are disappointing, with increased foot pain, joints stiffness and muscle weakness.

It would appear that the most successful conservative treatment for clubfoot is the method developed in the late 1940s by Ponseti.

We recently reviewed the outcomes of treatment in Afula with the Ponseti method in our first 28 patients with minimum of five years follow-up.

Materials and Methods: In our study are included 28 patients (38 feet). 22 males and six females, 18 unilateral and ten bilateral cases, with idiopathic clubfoot. The average follow-up duration is of 6.5 years (range 5–8.5). The cases were evaluated using the 6-point clssfication system described by Pirani. Each foot was assigned a total score of 6 points or less, with higher scores indicating more severe deformity, 0 points indicate a normal foot.

Results: The average Pirani score at initial presentation was 5.5 (range 3–6). Only two feet out of 38 (7%), required complete surgical release, using the Turco method. The average number of casts applied was 7.5 (range, 5–13), and 35 of 38 (92%) feet required percutaneous Achilles tenotomy.

We used the Garceau classification to assess residual deformity. The average scoring was 3.6 points (range 2–4). Twelve feet out of 36 (33%) (excluding the 2 feet who underwent PMR), ended up with some residual supination, according to the Garceau classification, 11 feet rated 3 points each, and only one foot 2 points.

Only12 patients were defined as compliant with the use of the foot abduction brace. In seven out of 36 feet (18% of the feet, six patients) tibialis anterior transfer for residual supination was performed, only one of these patients was compliant with the use of the foot abduction brace. However, despite bad compliance with the use of the orthosis, eight out of 16 patients obtained good results.

An average of 13 degrees (range. 0–25) of dorsiflexion and 50 degrees (40–70) of plantarflexion was noticed in all 36 feet (again excluded the 2 post PMR feet), and very supple subtalar joints.

Conclusion: thirty-seven out of the 38 feet, at the latest follow-up, had an almost normal foot appearance.

Discussion: During the last nine years, the Ponseti technique has become the gold standard of treatment for clubfoot, with countless surgeons abandoning the surgical technique in favor of the Ponseti method.

Proper use of the foot abduction brace is essential. Those patients who underwent tibials anterior transfer, were non-compliant with the use of the brace. One of our patients whose parents refused to use the orthosis at all required complete open release with the Turco method.

Few patients may end up with good result despite bad comliance with the use of the brace. Since this is unpredictable, parents should be recommended to be fully commited as to the use of the brace.