Posteromedial Release versus Ponseti Treatment of Congenital Idiopathic Clubfoot: A Long-Term Retrospective Follow-Up Study into Adolescence

Flat-top talus after clubfoot treatment: a literature review

Flat-top talus (FTT) is a complication well-known to those treating clubfoot. Despite this, it receives little attention in textbooks, so our knowledge and understanding can be limited to anecdote and hearsay. In particular, its association with different treatments, especially the Ponseti method, is not well understood. This review provides some clarity on the possible pathoanatomical, radiological and iatrogenic causes of FTT. It summarises its prevalence following different treatments. It is seen after surgery, 'pre-Ponseti' casting and the Ponseti method, and seems least common following Ponseti. Potential surgical management strategies are also discussed.

Factors associated with the relapse in Ponseti treated congenital clubfoot

Objectives

We retrospectively investigated the clinical materials to seek the factors that lead to relapse after using the Ponseti method.

Methods

We retrospectively reviewed all children with congenital clubfoot treated with the Ponseti method in our hospital from June 2008 to June 2013. The data included the following factors: age, gender, initial Pinari score, number of casts, number of feet (unilateral or bilateral), age at the first casting, age of mother, tenotomy, walking age, and compliance with using bracing. All investigations were conducted in conformity with ethical standards. This study was approved by Guilin Peoples’ Hospital Ethics Committee.

Results

In this study, there were 148 cases (164 ft) in total that underwent the Ponseti method, with the follow–up period at least 5 years. Of them, 64 children presented with left side, 58 with right side, and 26 with bilateral cases. This study included 75 males and 73 females; sex did not affect the outcomes. The mean age of the first casting was 2.50 ± 2.15 months. The average initial Pirani score was 4.98 ± 1.33, and the average number of casts was 5.71 ± 2.28 times. The mean age of mothers at birth was 25.81 ± 2.38 years old. The walking age of children was at a mean of 14.83 ± 1.18 months. Forty-nine cases could not tolerate using braces, namely the rate of noncompliance in this study was 33.1%. Tenotomy was performed on 113 ft (76.4%). The average follow–up period was 7.27 ± 1.29 years (from 5 to 10 years). The rate of relapse was 21.6% (32 cases) at the end of the follow-up. The rate of relapse in the noncompliance with using bracing group was significantly higher compared to the compliance group .

Conclusion

The initial Pirani score, compliance with the foot abduction brace and the age at the first casting are three independent factors for relapse in clubfoot.

Long-term outcomes of the Ponseti method for treatment of clubfoot: a systematic review

PURPOSE

The Ponseti method has revolutionized the clubfoot treatment and has been adopted globally in the past couple of decades. However, most reported results of the Ponseti method are either short or midterm. Studies reporting long-term outcomes of the Ponseti method are limited. The following systematic review aimed to provide a comprehensive overview of the published articles on long-term outcomes of the Ponseti method.

MATERIAL AND METHODS

A literature search was performed for articles published in electronic database PubMed (includes Medline) and Cochrane for broad keywords: "Clubfoot"; "Ponseti method/technique"; "long term outcomes/results." Studies selected included full-text articles in English language on children less than one year with primary idiopathic clubfoot treated by the Ponseti method with mean ten year follow-up. Non-idiopathic causes or syndromic clubfoot and case reports/review articles/meta-analyses were excluded. The following parameters were included for analysis: number of patients/clubfeet, male/female, mean age at treatment, mean/range of follow-up, relapses, additional surgery, range of motion, various outcome scores, and radiological variables.

RESULTS

Fourteen studies with 774 patients/1122 feet were included. The male:female ratio was 2.4:1. Mean follow-up recorded in studies was 14.5 years. Relapses occurred in 47% patients with additional surgery being required in 79% patients with relapses. Of these, 86% of surgery were extra-articular while 14% were intra-articular. Plantigrade foot was achieved in majority patients with mean ankle dorsiflexion of 11 degrees. The outcome scores were in general good in contrast to radiological angles which were mostly outside normal range with talar flattening/navicular wedging/degenerative osteoarthritis changes occurring in 60%, 76%, and 30%, respectively.

CONCLUSIONS

Long-term follow-up of infants with primary idiopathic clubfeet treated by the Ponseti method revealed relatively high relapse and additional surgery rates. Radiologically, the various angles were inconsistent compared to normal ranges and anatomical deformations/degenerative changes were present in treated feet. Moreover, the relapse rates and requirement of additional surgery increased on long-term follow-up. Despite this, majority feet were plantigrade and demonstrated good clinical results as measured by various outcome tools. There should be emphasis on long-term follow-up of children with clubfeet in view of late relapses and secondary late changes.

Sonoelastographic Findings in Clubfeet

Purpose

One of the main features of congenital idiopathic clubfoot is the increased stiffness of soft tissues. With the growing popularity and availability of sonoelastography as a method to assess the stiffness of different tissues, we considered applying it to congenital clubfeet in order to to determine whether sonoelastography can be a useful imaging method for the evaluation of clubfeet, to assess whether there are any differences in stiffness of specific tendons between clubfeet and normal contralateral feet and to observe which treatment methods have an impact on the aspect of these structures on the elastograms.

Patients and Methods

A case-control study was performed involving 10 adolescent patients with unilateral idiopathic congenital clubfeet who were treated either with the Ponseti method or surgically with posteromedial release (PMR) during early infancy. Using compression sonoelastography, we obtained semi-quantitative data expressed as fat to tendon ratios in treated clubfeet and normal contralateral feet. The tendons of the following muscles were examined: tibialis anterior, tibialis posterior, flexor hallucis longus, peroneus longus and Achilles tendon at three levels (calcaneal insertion, lengthened zone and musculotendinous junction).

Results

The only statistically significant difference in the strain ratio (p = 0.023) between clubfeet and normal feet was at the level of the calcaneal insertion of the Achilles tendon, which was stiffer in clubfeet. Although other differences were not statistically significant, they may reflect some of the pathological modifications of clubfeet.

Conclusion

Overall, sonoelastography may be a useful examination tool in the quantitative and qualitative assessment of soft tissue stiffness in clubfeet, but further research is necessary.

Relapses in clubfoot treated with Ponseti technique and standard bracing protocol- a systematic analysis

PURPOSE

The analysis determined the relapses in clubfoot children treated with Ponseti technique and standard bracing protocol and their correlation with overall follow up duration using pooled data from various series. It also tested the prescribed timelines of 5 and 7 years for slow-down/cessation of relapses in clubfoot children.

METHODS

A systematic literature search was performed for articles published in "Pubmed (includes Medline indexed journals)" electronic databases using key words: "Clubfoot or CTEV or congenital talipes equinovarus", "Ponseti" for years 1^st January 2001 to 15^th November 2020. Included were studies that addressed treatment of idiopathic clubfoot using the standard Ponseti technique, followed a well defined brace protocol (maintenance of corrected deformity using a central bar based brace and prescribed duration mentioned), reported a minimum mean follow up of 4 years and having relapse as one of their outcome measure. Studies reporting Ponseti technique for non-idiopathic clubfoot, child's age older than 1 year at the time of primary treatment, clubfoot with previous interventions before Ponseti treatment, where relapse and residual deformities were not identified distinctly in follow up, abstract only publications, letter to the editors, case reports, technique papers and review articles were excluded. The following characteristics of clubfoot patients in the selected articles were included for analysis: Patient numbers/feet treated with Ponseti technique; follow up years (<5; 5-7 and >7 years; overall) and corresponding relapse percentages for patients.

RESULTS

There were total 2206 patients in the included 24 studies. Average follow up was 6 years. The average relapse rates for clubfoot patients in the pooled data stood at 30%. The overall relapse rates increased with a longer follow up and the curve befitted a linear regression equation with weak positive correlation (Pearson correlation coefficient = 0.08). The relapse rates in follow up categories of <5 years (26.6 ± 15.6%), 5-7 years (30.8 ± 16.3%) and >7 years (28.4 ± 6.2%) were similar statistically (Analysis of variance, ANOVA).

CONCLUSIONS

Approximately 1 in 3 clubfoot patients suffer relapse post Ponseti technique and standard bracing protocol. A weak positive correlation was observed for relapses when correlated with increasing follow up years. The relapses however tend to slow down after initial growth years. There is a need to educate the care receivers regarding the possibility of late relapses despite proper Ponseti treatment and accordingly to keep them under supervised follow up for longer periods.