The Ponseti method of treatment for neuromuscular and syndromic (non-idiopathic) clubfeet: evaluation of a programme-based approach at a mean follow-up of 5.8 years

Association of Polymorphism in Locus of rs274503 (ZBED5/GALNT18) with the Risk of Idiopathic Clubfoot in Chinese Children: An 11-Center Case-Control Study

Background: Idiopathic clubfoot (IC) can be corrected initially using the Ponseti method, but still there is a high recurrence rate. The etiology of IC may include many undetermined genetic and environmental factors. Single nucleotide polymorphism of rs274503 in ZBED5/GALNT18 has been found to be associated with IC in Caucasian children. Therefore, we decided to investigate the association between this polymorphism and the risk of IC in the Chinese population. Methods: We conducted an 11-center case-control study of 516 patients with IC and 661 IC-free children. The rs274503 (A>G) polymorphism was genotyped using TaqMan. Odds ratios (ORs) and adjusted ORs, as well as 95% confidence intervals (CIs) and adjusted 95% CIs, were calculated to explore the association between rs274503 polymorphism and IC risk. Results: G of rs274503 was found to be associated with increased IC risk (AG vs. AA: adjusted OR = 1.40, 95% CI = 1.03-1.92, p = 0.0327; and GG/AG vs. AA: adjusted OR = 1.38, 95% CI = 1.02-1.87, p = 0.0357) after adjusting for age and sex. Furthermore, the risk effect of rs274503 GG/AG with IC was observed in patients with bilateral feet (adjusted OR = 1.68, 95% CI = 1.12-2.54, p = 0.0133), while AA in nonrelapsed groups (OR = 0.70, 95% CI = 0.53-0.92, p = 0.0095) in the stratified analysis. However, the association was not significant in the recessive model of G (GG vs. AA/AG: adjusted OR = 1.06, 95% CI = 0.44-2.58, p = 0.8906). Conclusions: The rs274503 polymorphism is associated with the risk of clubfoot occurrence. G of rs274503 appeared to be a risk factor of IC as it may increase the bilateral case rate. However, further studies are required to confirm these findings.

Outcomes of Ponseti Method for the Treatment of Clubfeet in Children With Spina Bifida

INTRODUCTION

While the Ponseti method is the primary treatment for idiopathic clubfoot, its application in treating myelodysplastic clubfeet is less certain. Myelodysplastic clubfoot tends to be more severe and difficult to treat. Although the Ponseti method can initially correct these cases, there is conflicting evidence about recurrence rates and the need for additional treatment. This study aims to assess the effectiveness of the Ponseti method in treating myelodysplastic clubfeet compared with idiopathic clubfeet over a 20-year period.

METHODS

The study conducted a retrospective review of medical records from patients treated for clubfoot at a single institution (2002 to 2021), comparing children with myelodysplastic and idiopathic clubfoot. Included patients were under 18, initially treated with Ponseti-casting, and had a minimum 2-year follow-up. Data on demographics, treatment details, recurrence, and Patient-reported Outcomes Measurement Information System (PROMIS) scores were analyzed.

RESULTS

Forty-nine myelodysplastic and 512 idiopathic clubfeet in 366 patients met the inclusion criteria. Myelodysplastic cases had a median age of 5 months at presentation versus 2 months for idiopathic cases ( P =0.002). Initial correction was achieved in 95% of idiopathic and 87.8% of myelodysplastic feet ( P =0.185). Recurrence rates were higher in the myelodysplastic cohort, 65.3% versus 44.1% ( P =0.005). Surgery was necessary to treat recurrence in 59.2% of myelodysplastic and 37.7% of idiopathic cases, P =0.003. Follow-up was 3.9±1.8 years for myelodysplastic and 3.3±1.5 years for idiopathic feet, P =0.030. Myelodysplastic feet had lower PROMIS mobility scores; 31.94±7.56 versus 49.21±8.64, P <0.001.

CONCLUSIONS

To the best of our knowledge, we report the largest series of myelodysplastic clubfeet treated by Ponseti casting and the first to assess PROMIS data. Overall, the Ponseti method is as effective in obtaining initial correction in myelodysplastic clubfoot as it is in idiopathic clubfoot. However, myelodysplastic clubfeet has a higher risk of relapse and increased need for surgical interventions. Children with spina bifida may need closer follow-ups and more stringent adherence to bracing.

LEVEL OF EVIDENCE

Level III-therapeutic studies-investigating the results of treatment.

Outcomes of Ponseti Method for the Treatment of Clubfeet in Children With Arthrogryposis

INTRODUCTION

The Ponseti serial casting method is the method of choice in treating children with congenital clubfeet. The arthrogrypotic clubfoot has traditionally been considered challenging to treat, with higher rates of recurrence and the need for more corrective surgeries. However, initial reports have found promising results in using the Ponseti method to treat arthrogrypotic feet. This study aims to compare the outcomes of idiopathic versus arthrogrypotic clubfeet following initial treatment with the Ponseti serial casting method.

METHODS

A retrospective review of medical records from a single institution was conducted. Data was collected from children ages 0 to 18 with idiopathic or arthrogrypotic clubfoot treated from 2002 to 2022 with Ponseti-style serial casting with a minimum 2-year follow-up. Recurrence was defined as the need for additional casting or subsequent surgeries following initial correction. Data was collected on relevant patient demographics, previous treatment, casting records, Achilles tenotomies, and surgical treatments.

RESULTS

A total of 352 patients (546 feet) met inclusion criteria. In all, 334 idiopathic and 18 arthrogrypotic patients were analyzed with an average follow-up duration of 3.4 and 4.2 years, respectively. Twelve patients had distal arthrogryposis, and 6 had amyoplasia. In all, 93.4% of idiopathic and 72.2% of arthrogrypotic patients successfully achieved correction with Ponseti casting and Achilles tenotomy. Recurrence rates were significantly higher in the arthrogrypotic group at 83.3% compared with 44.6% in the idiopathic group ( P =0.001). A posterior or posterior medial release was performed in 35.0% of idiopathic and 66.7% arthrogrypotic feet.

CONCLUSIONS

We report the largest series of arthrogrypotic clubfeet treated by Ponseti casting to the best of our knowledge. In contrast to earlier reports, our investigation underscores that while the Ponseti method may be able to secure initial correction in arthrogrypotic clubfeet, on average, at a 3-year follow-up, the prognosis is less favorable. These patients exhibit higher recurrence and often require operative treatment. Notably, a posterior medial release may eventually be needed in up to 6 of 10 patients.

LEVEL OF EVIDENCE

Level III-therapeutic studies-investigating the results of treatment.

Comparing patient-reported outcomes of the Oxford Ankle and Foot Questionnaire in children with clubfoot from two different geographic and cultural environments: a cohort study in India and Canada

PURPOSE

The purpose of this study is to compare the results of the Oxford Ankle and Foot Questionnaire (OxAFQ) in children with clubfoot in Canada and India to assess its ability to predict outcomes and capture patient experiences in different cultural contexts.

METHODS

This is a retrospective study of children with clubfoot in India and Canada who completed the OxAFQ. Statistical analyses were implemented on registry-collected data to test for independent predictors of poor outcomes and compare scores between countries, among children and their parents, and in Canada where relapse data was collected and the effect of a relapse on scores.

RESULTS

A total of 361 children were included. The mean Indian OxAFQ scores were higher (p < 0.001) in all domains. Pirani score, tenotomy, laterality, and age at presentation were found to be predictive of outcomes between the sites (p < 0.05). OxAFQ scores decreased after relapse for children in Canada (p < 0.05). Canadian children were found to generally have lower OxAFQ scores in all domains compared to their parents (n = 95; Z = -3.178, -3.493, -3.353, and -3.635 for physical, school and play, emotion, and footwear, respectively; p < 0.001). Indian parents and children showed no significant differences in their scores.

CONCLUSIONS

A difference was observed in scores between both sites, suggesting there may be differences in how these populations assess personal health outcomes. These findings support the need for cultural validity of patient-reported outcome measures.

Common Errors in the Management of Idiopathic Clubfeet Using the Ponseti Method: A Review of the Literature

Congenital talipes equinovarus is one of the most prevalent birth defects, affecting approximately 0.6 to 1.5 children per 1000 live births. Currently, the Ponseti method is the gold-standard treatment for idiopathic clubfeet, with good results reported globally. This literature review focuses on common errors encountered during different stages of the management of idiopathic clubfeet, namely diagnosis, manipulation, serial casting, Achilles tenotomy, and bracing. The purpose is to update clinicians and provide broad guidelines that can be followed to avoid and manage these errors to optimize short- and long-term outcomes of treatment of idiopathic clubfeet using the Ponseti method. A literature search was performed using the following keywords: "Idiopathic Clubfoot" (All Fields) AND "Management" OR "Outcomes" (All Fields). Databases searched included PubMed, EMBASE, Cochrane Library, Google Scholar, and SCOPUS (age range: 0-12 months). A full-text review of these articles was then performed looking for "complications" or "errors" reported during the treatment process. A total of 61 articles were included in the final review: 28 from PubMed, 8 from EMBASE, 17 from Google Scholar, 2 from Cochrane Library, and 6 from SCOPUS. We then grouped the errors encountered during the treatment process under the different stages of the treatment protocol (diagnosis, manipulation and casting, tenotomy, and bracing) to facilitate discussion and highlight solutions. While the Ponseti method is currently the gold standard in clubfoot treatment, its precise and intensive nature can present clinicians, health care providers, and patients with potential problems if proper diligence and attention to detail is lacking. The purpose of this paper is to highlight common mistakes made throughout the Ponseti treatment protocol from diagnosis to bracing to optimize care for these patients.

An investigation of maternal psychological status of children with congenital talipes equinovarus treated with the Ponseti method

Objectives:

To investigate maternal psychological status of children with congenital talipes equinovarus in different periods, and to clarify the influence on maternal psychological status of congenital talipes equinovarus treated with the Ponseti method.

Methods:

Sixty-seven mothers of children with congenital talipes equinovarus were investigated. Self-rating Depression Scale and Self-rating Anxiety Scale were used to evaluate the psychological stress of the mothers at different periods. Paired-samples t-test was used to analyze the results.

Results:

The mothers of 67 children with congenital talipes equinovarus ranged from 25 to 38 years old, with an average of 33.5 years old. Before prenatal diagnosis of congenital talipes equinovarus, the average score of Self-rating Anxiety Scale was 42.537 ± 10.476, and the average score of Self-rating Depression Scale was 47.254 ± 12.846; after prenatal diagnosis of congenital talipes equinovarus, the average score of Self-rating Anxiety Scale was 54.224 ± 13.050, and the average score of Self-rating Depression Scale was 57.403 ± 13.649 points. Before the postpartum treatment of congenital talipes equinovarus, the average score of Self-rating Anxiety Scale was 53.388 ± 12.716, the average score of Self-rating Depression Scale was 56.284 ± 13.617; after the treatment of congenital talipes equinovarus with the Ponseti method, the average score of Self-rating Anxiety Scale was 47.731 ± 12.259, and the average score of Self-rating Depression Scale was 51.910 ± 13.878 points. The above differences were statistically significant (P < 0.001).

Conclusion:

The prenatal diagnosis of congenital talipes equinovarus will increase the maternal psychological stress, and the maternal psychological status will be significantly improved after the deformity of congenital talipes equinovarus is corrected effectively by the Ponseti method.

Level of evidence:

level III, retrospective study.

The demographics of talipes equinovarus in Indiana, with a particular emphasis on comparisons between clubfoot types

Talipes equinovarus (TEV) can be an isolated idiopathic deformity or associated with various syndromes. The purpose of our study was to examine the demographics of TEV in Indiana. All TEV patients from 2010 to 2019 from our institution were reviewed, recording standard demographic variables. The socioeconomic level of the family was determined using the 2018 Area Deprivation Index (ADI). There were 568 patients; 456 had idiopathic TEV and 112 syndromic. Within the idiopathic group, 69.1% were male, 92.1% were typical and 7.9% were atypical. Medical issues during the pregnancy occurred in 19.5%, maternal smoking in 2.9%, hypertension in 3.9% and diabetes in 5.3%. The most common syndromic patients were myelomeningocele (29%) and arthrogryposis (17%). Patients with syndromic TEV had more bilateral involvement (68.2% vs. 45.2%) and other associated congenital deformities (67.0% vs. 11.4%). TEV was less common in Hispanics and Asians but more common in Whites and Blacks ( P  = 0.003). Complex TEVs were less frequent in White (6.9%) and Black (5.0%) and more common in Hispanic (30%) children ( P  = 0.0002). The ADI demonstrated no difference in prevalence across socioeconomic levels. There were no differences by state ADI levels for TEV type (syndromic/idiopathic), sex, maternal smoking or illicit drug use, or typical/complex TEV. This study is the first to describe the demographics of TEV in Indiana, demographic differences between typical and complex types of clubfeet, and TEV patients using the ADI. TEV did not show any difference in prevalence by socioeconomic level.

Comparative evaluation and analysis of outcomes in non-idiopathic and idiopathic clubfeet with Ponseti method at a tertiary care centre of a developing country

BACKGROUND

Idiopathic clubfoot (congenital talipes equinovarus, CTEV) is being managed worldwide by Ponseti method with high success rates, while for non-idiopathic clubfoot surgical interventions is being widely used with variable results. This study evaluated the effectiveness of Ponseti method in non-idiopathic clubfoot and compared the results with idiopathic clubfoot.

METHODS

The paper evaluated the epidemiological incidence and demographic profile of non-idiopathic clubfoot in a tertiary centre of developing country. A total of 108 subjects with 85 having idiopathic (group I;125 feet) and 23 having non-idiopathic variety (group II;34 feet) were managed with Ponseti method and were followed for a mean duration of 38.33 (12-62) and 36.27 months (12-58) in group I and II respectively. The most common associations were meningomyelocele (MMC/spina bifida,5), arthrogryposis multiplex congenita (AMC,4), developmental dysplasia of hip (DDH,3) and Down's syndrome and amniotic band syndrome (2 each).

RESULTS

Primary correction was achieved in both the groups in 98% and 87% in group I and II respectively, while recurrences of at least one deformity was observed in 11 (9%) and 12 (40%) feet in group I and II respectively. Favourable outcomes were noticed in 22 (65%) feet in non-idiopathic group and 12 feet (35%) underwent extensive soft tissue release as compared to 3 feet (2.4%) in idiopathic variety.

CONCLUSION

Deformities improved significantly in non-idiopathic clubfeet with Ponseti methods although complete correction was not possible. Extensive surgical interventions were reduced in up to 35% feet in non-idiopathic variety and hence, it is recommended as primary treatment for all variety of clubfeet, irrespective of their etiology.

Ponseti Casting vs. Soft Tissue Release for the Initial Treatment of Non-idiopathic Clubfoot

Purpose: Ponseti casting has universally been accepted as the gold standard for treatment of idiopathic clubfoot. Conversely, primary treatment for non-idiopathic clubfoot has not been established. The purpose of this study is to compare treatment outcomes following primary soft tissue release (STR) and Ponseti casting of non-idiopathic clubfoot.

Methods: An IRB-approved retrospective study of patients treated for non-idiopathic clubfoot between 2005 and 2020 was conducted. Patients were included if they began treatment before the age of 2 and had at least 1 year of follow up. Patients were placed into either the STR group or Ponseti group and variables of interest were documented including reoccurrence of deformity, number of surgeries performed, type of surgeries performed, anesthesia time, and surgery time. Data was analyzed using Mann-Whitney U test for continuous variables.

Results: A total of 33 children with 57 neuromuscular/syndromic clubfoot were identified of which 9 (15 feet) were treated with STR and 24 (42 feet) were treated with Ponseti casting. Average anesthesia and surgery time were found to be 291 and 179 min, respectively, for the STR group, and 113 and 67 min for the Ponseti group. The difference in operating time was determined to be significant (p = 0.02, p = 0.01). Patients treated with STR were found to have significantly more surgeries performed over the course of treatment than those treated with Ponseti casting (p = 0.001) with an average of 4.2 surgeries in the STR group and 1.5 surgeries in the Ponseti group. Extracapsular procedures were performed in 100% of the STR group and 97.6% of the Ponseti group (p = 0.55). Intracapsular procedures were performed in 100% of the STR group and 50% of the Ponseti group (p = 0.001).

Conclusion: The Ponseti method should serve as the primary approach in the initial treatment of non-idiopathic clubfoot as it can reduce the risk of future invasive intracapsular surgery and shorten anesthesia and surgery times when surgical treatment is necessary.

Level of Evidence: Level III retrospective case control study.