Ponseti Method for clubfoot

NewsBot · Oct 1, 2014

Congenital idiopathic talipes equinovarus: an evaluation in infants treated by the Ponseti method
V. PAVONE, G. TESTA, L. COSTARELLA, P. PAVONE, G. SESSA
European Review for Medical and Pharmacological Sciences 2013; 17: 2675-2679

BACKGROUND: Congenital talipes
equinovarus (CTEV) is a common but still
not fully understood disorder of the lower limb. It
is usually defined as a fixation of the foot in adduction,
supination, and varus. Different treatment
options exist including the Ponseti method.
AIM:We report here the results obtained in infants
with CTEV treated by the Ponseti method.
PATIENTS AND METHODS: Eighty two patients
(114 clubfeet) were enrolled at the Orthopaedic
Clinic of Catania University during the
period of March 2004 to January 2010 and followed
prospectively up to February 2011: 56 patients
(68.29%) were male, the anomaly was bilateral
in 32 (39%) cases, unilateral in 50 (60.9%)
in the right side in 28 (56%). The mean age at initiation
of treatment was 14 days (range 3-81
days), severity of the club foot deformity by the
Pirani Severity score was 5.56 points (range 4.3-
6 points). Total numbers of Ponseti casts before
tenotomy, details of tenotomy, and compliance
with CTEV brace were recorded. Clinical evaluation
was performed using the functional Ponseti
Scoring System. Mean follow up was 4 years:
range 13-83 months.
RESULTS: An average of 6.6 casts was necessary
before performing the tenotomy. Tenotomy
was performed by a single surgeon (V.P.)
in a total of 68 patients (82.93%) always in an
operating room under general anaesthesia by
a percutaneous approach at a mean age of 106
days (range 45-213 days). Compliance with
CTEV brace was satisfactory in 79 patients
(96.3%). Functional Ponseti Scores were
good/excellent in 79 (96.34%) patients (109
clubfeet; 95.61%). Only 3 patients; 3.7% (5
clubfeet; 4.4%) suffered relapse. Poor compliance
with the Denis Browne splint was thought
to be the main cause of failure.
CONCLUSIONS: The Ponseti method provides
an excellent outcome at follow up in the treatment
of congenital idiopathic clubfoot.
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NewsBot · Oct 22, 2013

Congenital idiopathic talipes equinovarus: an evaluation in infants treated by the Ponseti method.
Pavone V, Testa G, Costarella L, Pavone P, Sessa G.
Eur Rev Med Pharmacol Sci. 2013 Oct;17(19):2675-2679.

BACKGROUND:
Congenital talipes equinovarus (CTEV) is a common but still not fully understood disorder of the lower limb. It is usually defined as a fixation of the foot in adduction, supination, and varus. Different treatment options exist including the Ponseti method.
AIM:
We report here the results obtained in infants with CTEV treated by the Ponseti method.
PATIENTS AND METHODS:
Eighty two patients (114 clubfeet) were enrolled at the Orthopaedic Clinic of Catania University during the period of March 2004 to January 2010 and followed prospectively up to February 2011: 56 patients (68.29%) were male, the anomaly was bilateral in 32 (39%) cases, unilateral in 50 (60.9%) in the right side in 28 (56%). The mean age at initiation of treatment was 14 days (range 3-81 days), severity of the club foot deformity by the Pirani Severity score was 5.56 points (range 4.3-6 points). Total numbers of Ponseti casts before tenotomy, details of tenotomy, and compliance with CTEV brace were recorded. Clinical evaluation was performed using the functional Ponseti Scoring System. Mean follow up was 4 years: range 13-83 months.
RESULTS:
An average of 6.6 casts was necessary before performing the tenotomy. Tenotomy was performed by a single surgeon (V.P.) in a total of 68 patients (82.93%) always in an operating room under general anaesthesia by a percutaneous approach at a mean age of 106 days (range 45-213 days). Compliance with CTEV brace was satisfactory in 79 patients (96.3%). Functional Ponseti Scores were good/excellent in 79 (96.34%) patients (109 clubfeet; 95.61%). Only 3 patients; 3.7% (5 clubfeet; 4.4%) suffered relapse. Poor compliance with the Denis Browne splint was thought to be the main cause of failure.
CONCLUSIONS:
The Ponseti method provides an excellent outcome at follow up in the treatment of congenital idiopathic clubfoot.
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NewsBot · Oct 24, 2013

Ponseti casting for club foot - above- or below-knee?: A prospective randomised clinical trial.
Maripuri SN, Gallacher PD, Bridgens J, Kuiper JH, Kiely NT.
Bone Joint J. 2013 Nov 1;95-B(11):1570-4.

We undertook a randomised clinical trial to compare treatment times and failure rates between above- and below-knee Ponseti casting groups. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below- or above-knee plaster of Paris casting. Outcome measures were total treatment time and the occurrence of failure, defined as two slippages or a treatment time above eight weeks. A total of 26 children (33 feet) were entered into the trial. The above-knee group comprised 17 feet in 13 children (ten boys and three girls, median age 13 days (1 to 40)) and the below-knee group comprised 16 feet in 13 children (ten boys and three girls, median age 13 days (5 to 20)). Because of six failures (37.5%) in the below-knee group, the trial was stopped early for ethical reasons. The rate of failure was significantly higher in the below-knee group (p = 0.039). The median treatment times of six weeks in the below-knee and four weeks in the above-knee group differed significantly (p = 0.01). This study demonstrates that the use of a below-knee plaster of Paris cast in conjunction with the Ponseti technique leads to unacceptably high failure rates and significantly longer treatment times. Therefore, this technique is not recommended.
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NewsBot · Oct 31, 2013

Does initial Pirani score and age influence number of Ponseti casts in children?
Agarwal A, Gupta N.
Int Orthop. 2013 Oct 30.

PURPOSE:
The prediction of number of casts in the Ponseti method has always remained a subject of interest. We investigated the correlation of the number of casts before tenotomy with the age and initial Pirani score in Ponseti treatment of club foot.
METHODS:
Inclusion criteria were idiopathic clubfeet corrected by Ponseti method requiring tenotomy for equinus correction in children up to ten years of age. Defaulters (noncompliance with serial casting schedule), children with postural, non idiopathic, previously surgically treated, recurrent clubfoot and clubfoot not requiring tenotomy were not included in this study. Further, children who did not require tenotomy were also excluded. ANOVA regression analysis was used for finding correlation between initial Pirani score, age in months and number of corrective casts prior to tenotomy.
RESULTS:
There were a total of 297 children (442 feet) in the study. The average age of the child at presentation was 10.3 months and the average initial Pirani score was 4.8. The average number of corrective casts was seven per child (range, two to18). The regression analysis showed both Pirani and age had positive correlation with number of casts, although weak (r2 = 0.05-0.20). The initial Pirani scoring correlated ten times more than age (in months) to the number of casts.
CONCLUSION:
The number of casts for correction in idiopathic clubfoot, although variable, is influenced by both initial Pirani score and age.
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NewsBot · Nov 20, 2013

Long-term Results of Comprehensive Clubfoot Release Versus the Ponseti Method: Which Is Better?
Smith PA, Kuo KN, Graf AN, Krzak J, Flanagan A, Hassani S, Caudill AK, Dietz FR, Morcuende J, Harris GF.
Clin Orthop Relat Res. 2013 Nov 19.

BACKGROUND:
Clubfoot can be treated nonoperatively, most commonly using a Ponseti approach, or surgically, most often with a comprehensive clubfoot release. Little is known about how these approaches compare with one another at longer term, or how patients treated with these approaches differ in terms of foot function, foot biomechanics, or quality-of-life from individuals who did not have clubfoot as a child.
QUESTIONS/PURPOSES:
We compared (1) focused physical and radiographic examinations, (2) gait analysis, and (3) quality-of-life measures at long-term followup between groups of adult patients with clubfoot treated either with the Ponseti method of nonsurgical management or a comprehensive surgical release through a Cincinnati incision, and compared these two groups with a control group without clubfoot.
METHODS:
This was a case control study of individuals treated for clubfoot at two separate institutions with different methods of treatment between 1983 to 1987. One hospital used only the Ponseti method and the other mainly used a comprehensive clubfoot release. There were 42 adults (24 treated surgically, 18 treated with Ponseti method) with isolated clubfoot along with 48 healthy control subjects who agreed to participate in a detailed analysis of physical function, foot biomechanics, and quality-of-life metrics.
RESULTS:
Both treatment groups had diminished strength and motion compared with the control subjects on physical examination measures; however, the Ponseti group had significantly greater ankle plantar flexion ROM (p < 0.001), greater ankle plantar flexor (p = 0.031) and evertor (p = 0.012) strength, and a decreased incidence of osteoarthritis in the ankle and foot compared with the surgical group. During gait the surgical group had reduced peak ankle plantar flexion (p = 0.002), and reduced sagittal plane hindfoot (p = 0.009) and forefoot (p = 0.008) ROM during the preswing phase compared with the Ponseti group. The surgical group had the lowest overall ankle power generation during push off compared with the control subjects (p = 0.002). Outcome tools revealed elevated pain levels in the surgical group compared with the Ponseti group (p = 0.008) and lower scores for physical function and quality-of-life for both clubfoot groups compared with age-range matched control subjects (p = 0.01).
CONCLUSIONS:
Although individuals in each treatment group experienced pain, weakness, and reduced ROM, they were highly functional into early adulthood. As adults the Ponseti group fared better than the surgically treated group because of advantages including increased ROM observed at the physical examination and during gait, greater strength, and less arthritis. This study supports efforts to correct clubfoot with Ponseti casting and minimizing surgery to the joints, and highlights the need to improve methods that promote ROM and strength which are important for adult function.
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NewsBot · Dec 3, 2013

The Ponseti method in the treatment of children with idiopathic clubfoot presenting between five and ten years of age
B. Banskota, et al
Bone Joint J December 2013 vol. 95-B no. 12 1721-1725

Our goal was to evaluate the use of Ponseti’s method, with minor adaptations, in the treatment of idiopathic clubfeet presenting in children between five and ten years of age. A retrospective review was performed in 36 children (55 feet) with a mean age of 7.4 years (5 to 10), supplemented by digital images and video recordings of gait. There were 19 males and 17 females. The mean follow-up was 31.5 months (24 to 40). The mean number of casts was 9.5 (6 to 11), and all children required surgery, including a percutaneous tenotomy or open tendo Achillis lengthening (49%), posterior release (34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue release combined with an osteotomy (2%). The mean dorsiflexion of the ankle was 9° (0° to 15°). Forefoot alignment was neutral in 28 feet (51%) or adducted (< 10°) in 20 feet (36%), > 10° in seven feet (13%). Hindfoot alignment was neutral or mild valgus in 26 feet (47%), mild varus (< 10°) in 19 feet (35%), and varus (> 10°) in ten feet (18%). Heel–toe gait was present in 38 feet (86%), and 12 (28%) exhibited weight-bearing on the lateral border (out of a total of 44 feet with gait videos available for analysis). Overt relapse was identified in nine feet (16%, six children). The parents of 27 children (75%) were completely satisfied.

A plantigrade foot was achieved in 46 feet (84%) without an extensive soft-tissue release or bony procedure, although under-correction was common, and longer-term follow-up will be required to assess the outcome.
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NewsBot · Dec 17, 2013

The effect of two different plastering techniques on the rate of major surgery in idiopathic clubfoot
A Horn; SI Dix-Peek; EB Hoffman
SA orthop. j. vol.12 no.4 Pretoria Dec. 2013

BACKGROUND: The Ponseti technique of clubfoot manipulation and casting is reported to have almost eliminated the need for extensive surgery (posterior and posteromedial release) and surgical decision-making is now largely based on clinical assessment, as opposed to pre-operative radiographs. The Ponseti method of manipulation and casting was introduced at our institution in 2002, prior to which we used the Kite method. Both prior to, and following the introduction of Ponseti casting, surgical decision-making was based on pre-operative radiology, and intra-operative clinical assessment.
METHODS: A retrospective comparative study was performed to compare the incidence of radical surgery following the use of the Kite method versus the Ponseti method. In addition, the accuracy of measured radiographic parameters in predicting which surgery was to be performed was investigated.
RESULTS: The incidence of radical surgery decreased from 40% with the Kite method to zero with the Ponseti method. Of the four routinely measured radiographic angles, only the tibiocalcaneal angle and the talometatarsal angle significantly correlated with the extent of surgery performed.
CONCLUSIONS: Using the Ponseti method greatly decreases the need for radical surgery in idiopathic clubfoot. Radiographic measurements do not influence surgical decision-making significantly.
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NewsBot · Jan 15, 2014

Osteopathic manipulative treatment of congenital talipes equinovarus: A case report.
Andreoli E, Troiani A, Tucci V, Barlafante G, Cerritelli F, Pizzolorusso G, Renzetti C, Vanni D, Pantalone A, Salini V.
J Bodyw Mov Ther. 2014 Jan;18(1):4-10.

BACKGROUND:
Treatment recommendations for congenital talipes equinovarus are focused on conservative treatments.
OBJECTIVES:
The aim of this paper is to present a case report of bilateral congenital talipes equinovarus treated with two short-leg serial casting in combination with osteopathic manipulative treatment.
METHODS:
A newborn, 12 days old, with severe bilateral congenital talipes equinovarus entered to the Department of Orthopedics at the University of Chieti, Italy. The pediatric orthopedic surgeon applied two single series of short-leg casts, at 12 and 20 days of age. The osteopath scheduled 4 indirect myofascial release techniques sessions.
RESULTS:
At day 33 the newborn achieved a complete correction of the congenital talipes equinovarus deformity and there was no need to apply a third series of casts.
CONCLUSIONS:
Results from this single case study create an interesting and clear precedent for considering OMT in future clinical trials.
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NewsBot · Jan 21, 2014

Results of Clubfoot Management Using the Ponseti Method: Do the Details Matter? A Systematic Review
Dahang Zhao MD, Hai Li MD, PhD, Li Zhao MD, PhD, Jianlin Liu MD, Zhenkai Wu MD, Fangchun Jin MD, PhD
Clinical Orthopaedics and Related Research® January 2014

Background
Although the Ponseti method is accepted as the best choice for treatment of clubfoot, the treatment protocol is labor intensive and requires strict attention to details. Deviations in strict use of this method are likely responsible for the variations among centers in reported success rates.
Questions/purposes
We wished to determine (1) to what degree the Ponseti method was followed in terms of manipulation, casting, and percutaneous Achilles tenotomy, (2) whether there was variation in the bracing type and protocol used for relapse prevention, and (3) if the same criteria were used to diagnose and manage clubfoot relapse.
Methods
We conducted a systematic review of MEDLINE, EMBASETM, and the Cochrane Library. Studies were summarized according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement. Five hundred ninety-one records were identified with 409 remaining after deduplication, in which 278 irrelevant studies and 22 review articles were excluded. Of the remaining 109 papers, 19 met our inclusion criteria. All 19 articles were therapeutic studies of the Ponseti method.
Results
The details of manipulation, casting, or percutaneous Achilles tenotomy of the Ponseti method were poorly described in 11 studies, whereas the main principles were not followed in three studies. In three studies, the brace type deviated significantly from that recommended, whereas in another three studies the bracing protocol in terms of hours of recommended use was not followed. Furthermore no unified criteria were used for judgment of compliance with brace use. The indication for recognition and management of relapse varied among studies and was different from the original description of the Ponseti method.
Conclusions
We found that the observed clinically important variation may have been the result of deviations from the details regarding manipulation, casting, percutaneous Achilles tenotomy, use of the bar-connected brace, and indication for relapse recognition and management recommended for the classic Ponseti approach to clubfoot management. We strongly recommend that clinicians follow the Ponseti method as it initially was described without deviation to optimize treatment outcomes.
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NewsBot · Mar 4, 2014

Ponseti method surpasses surgery for long-term clubfoot outcomes

NewsBot · Mar 29, 2014

Influence of Age, Weight, and Pirani Score on the Number of Castings in the Early Phase of Clubfoot Treatment using Ponseti Method.
AWANG, Mazlina; SULAIMAN, Abdul Razak; MUNAJAT, Ismail; FAZLIQ, Mohd Emil
Malaysian Journal of Medical Sciences . Mar/Apr2014, Vol. 21 Issue 2, p40-43. 4p.

Background: The objectives of this study were to investigate whether severity of clubfoot, age, and weight of the patients at initial manipulation and casting influence the total number of castings required.

Methods: This prospective study was conducted on 38 idiopathic clubfoot patients undergoing weekly manipulation and casting using the method recommended by Ponseti. The patients' age, weight, and foot Pirani score at the start of manipulation and casting were analysed against the total number of castings required to achieve correction to 60° abduction.

Results: Simple linear regression analysis on the influence of weight, age, and Pirani score at the time of cast initiation showed that the Pirani score was the only significant predictor for the total number of castings required.

Conclusion: The total number of castings required to treat clubfoot was determined by the severity of clubfoot but not by the weight and age of patients.
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NewsBot · Apr 9, 2014

Correlation of Pirani and Dimeglio Scores With Number of Ponseti Casts Required for Clubfoot Correction.
Gao R, Tomlinson M, Walker C.
J Pediatr Orthop. 2014 Apr 3.

BACKGROUND::
A number of grading systems for severity of clubfoot have been reported in the literature, but none are universally accepted. The aim of this study was to find the correlation between 2 of the most widely utilized classification systems (the Pirani score and the Dimeglio score) with number of Ponseti casts required to achieve initial clubfeet correction.
METHODS::
A retrospective study of prospectively collected data was performed. All clubfeet assessed at our dedicated clubfoot clinic from January 2007 to December 2011 were included. Clubfoot severity was assessed using both the Pirani score and the Dimeglio score. The total number of casts was calculated from the first cast to the time of initiation of the foot abduction orthosis.
RESULTS::
The mean number of Ponseti casts required to achieve initial correction was 5.8 (range, 2 to 10 casts). A low correlation (rs 0.21) was identified when the total Dimeglio score was compared with the number of casts. No correlation (rs 0.12) was identified between the Pirani score and the number of casts.
CONCLUSIONS::
The Dimeglio and Pirani scores remain the most widely accepted clubfoot severity grading systems. However, their prognostic value remains questionable, at least in the early treatment stages.
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NewsBot · May 3, 2014

A Randomized Clinical Trial Comparing Reported and Measured Wear Rates in Clubfoot Bracing Using a Novel Pressure Sensor.
Morgenstein A, Davis R, Talwalkar V, Iwinski H Jr, Walker J, Milbrandt TA.
J Pediatr Orthop. 2014 Apr 29.

BACKGROUND::
The treatment of clubfoot by the Ponseti method requires the utilization of a foot abduction orthosis (FAO) after manipulation and casting. Adherence to this protocol, specifically FAO wear rates, has been postulated to improve treatment outcomes. Our hypothesis was that caregiver-reported wear rates were significantly less than actual wear rates in these braces.
METHODS::
A randomized prospective study of 67 children, aged 0 to 3 years old with idiopathic clubfoot, treated using the Ponseti technique for idiopathic clubfoot, was undertaken after IRB approval. Participants were randomized into 3 groups: a functioning pressure-based sensor (group FPS) attached to the FAO (21 patients), a nonfunctioning sensor (NFPS group) attached to the FAO (24 patients), or no sensor (NS group) (22 patients). All caregivers filled out a diary of subjective wear rates. Reported and actual wear rates were recorded as a percentage of the entire day and compared.
RESULTS::
In the FPS group, the average actual wear rate for months 1, 2, and 3 were 91.7% (15 patients; 72.7% to 97.0%), 86.8% (9 patients; 60.5% to 96.3%), and 77.1% (7 patients; 52.6% to 95.8%), respectively. The average self-reported wear rate in the FPS group in months 1, 2, and 3 were 94.9% (13 patients; 93.1% to 98.7%), 95.6% (10 patients; 92.3% to 99.4%), and 94.8% (11 patients; 82.8% to 99.6%), respectively. The most predictive factor in determining a patient's decrease in the overall wear rate was a drop in the wear rate between months 1 and 2 (P<0.001). The reported wear rates were not statistically different between any of the 3 groups (P<0.01).
CONCLUSIONS::
By using a novel method of pressure measurement, which documented FAO wear, we have shown a significant decline in wear rates from months 1 to 3. These actual FAO wear rates did not match their reported rates, thus putting into question previous assumptions about reported brace compliance. The largest drop in wear rates occurred from months 2 to 3. This study provides the first objective measurement of FAO brace wear in patients undergoing the Ponseti method of treatment.
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NewsBot · May 3, 2014

Results of clubfoot management using the Ponseti method: do the details matter? A systematic review.
Zhao D, Li H, Zhao L, Liu J, Wu Z, Jin F.
Clin Orthop Relat Res. 2014 Apr;472(4):1329-36.

BACKGROUND:
Although the Ponseti method is accepted as the best choice for treatment of clubfoot, the treatment protocol is labor intensive and requires strict attention to details. Deviations in strict use of this method are likely responsible for the variations among centers in reported success rates.
QUESTIONS/PURPOSES:
We wished to determine (1) to what degree the Ponseti method was followed in terms of manipulation, casting, and percutaneous Achilles tenotomy, (2) whether there was variation in the bracing type and protocol used for relapse prevention, and (3) if the same criteria were used to diagnose and manage clubfoot relapse.
METHODS:
We conducted a systematic review of MEDLINE, EMBASE(TM), and the Cochrane Library. Studies were summarized according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement. Five hundred ninety-one records were identified with 409 remaining after deduplication, in which 278 irrelevant studies and 22 review articles were excluded. Of the remaining 109 papers, 19 met our inclusion criteria. All 19 articles were therapeutic studies of the Ponseti method.
RESULTS:
The details of manipulation, casting, or percutaneous Achilles tenotomy of the Ponseti method were poorly described in 11 studies, whereas the main principles were not followed in three studies. In three studies, the brace type deviated significantly from that recommended, whereas in another three studies the bracing protocol in terms of hours of recommended use was not followed. Furthermore no unified criteria were used for judgment of compliance with brace use. The indication for recognition and management of relapse varied among studies and was different from the original description of the Ponseti method.
CONCLUSIONS:
We found that the observed clinically important variation may have been the result of deviations from the details regarding manipulation, casting, percutaneous Achilles tenotomy, use of the bar-connected brace, and indication for relapse recognition and management recommended for the classic Ponseti approach to clubfoot management. We strongly recommend that clinicians follow the Ponseti method as it initially was described without deviation to optimize treatment outcomes.
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NewsBot · May 9, 2014

The Ponseti method of treatment for clubfoot in Brazil: barriers to bracing compliance.
Nogueira MP1, Fox M, Miller K, Morcuende J.
Iowa Orthop J. 2013;33:161-6.

BACKGROUND:
Clubfoot is the most common extremity birth defect. It causes the feet of affected individuals to point inward and downward, preventing them from walking normally. Neglected clubfoot causes disabilities that result in a lack of social integration, creating a psychological and financial burden for the family and community. Clubfoot has been effectively treated through the Ponseti method, a treatment utilizing serial casts to correct the deformity followed by use of an abduction brace for approximately 2-4 years. sustained use of the brace is necessary to prevent relapse and ensure a successful outcome. Brace compliance in the setting of limited resources in the developing world can be challenging. The purpose of this study was to identify the barriers to bracing compliance in southeastern Brazil. In addition to socioeconomic and cultural barriers, this study also looked at improper prescribing practices by physicians as a potential cause of noncompliance. The study sought to identify the role of physician education in the use of the Ponseti method and physicians' knowledge of the bracing process.
PURPOSE OF THE STUDY:
Identify the barriers to bracing adherence that could negatively impact the treatment of children with clubfoot.
METHODS:
Forty-five orthopedists from several centers in southeastern Brazil were interviewed. Physicians were asked about their training in the Ponseti method, their protocol when prescribing the brace, their evaluation of its importance, and a series of open-ended questions designed to identify the positive and negative qualities of local braces. They were also asked what they perceived to be the biggest challenges to sustained brace use.
RESULTS:
sixteen of the physicians interviewed were orthopedic residents, and 29 had completed their residencies. Of these two groups, only 25% and 65%, respectively, appropriately prescribe the abduction brace for patients, with the majority recommending use of the brace for an inadequate period of time. The high costs and delays in acquisition of the brace and a lack of orthopedic stores able to adequately construct the orthotic, also present considerable barriers to sustained brace use.
CONCLUSIONS:
Many of the causes of noncompliance with bracing protocol stem from systemic inequities and challenges, rather than a lack of collaboration from the families themselves. Furthermore, insufficient prescription of the brace by physicians may represent a major barrier to bracing compliance in southeastern Brazil. This research indicates a need to evaluate physician training and continuing medical education in order to ensure that physicians are adequately utilizing the brace.
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NewsBot · May 9, 2014

Early effects of a 'train the trainer' approach to Ponseti method dissemination: a case study of Sri Lanka.
Jayawardena A, Wijayasinghe SR, Tennakoon D, Cook T, Morcuende JA.
Iowa Orthop J. 2013;33:153-60.

BACKGROUND:
The Ponseti method has been established as the standard of care for the treatment of clubfoot in many developed countries for its utility, cost-effectiveness, and efficiency. However, despite its being described as the gold-standard for clubfoot treatment, there are still many areas of the world bereft in formal training in the Ponseti method. This is especially important since 80% of patients with clubfoot are born in developing countries where the need is the greater for experienced providers. This study analyzes a 'Train the Trainer' approach, specifically in the island nation of Sri Lanka, as a model for future dissemination of the Ponseti method throughout the developing world.
METHODS:
A rapid ethnographic study design that included interviews, focus groups, and direct observation of 162 patients and healthcare practitioners directly involved with clubfoot care was conducted.
RESULTS:
The average age of the patients at the time of the interview was 75.4 weeks old (SD = 149.2), traveled 45.2 kilometers (SD = 49.8) to receive their care, and received 4 casts (SD = 2.2) for correction of the deformity. Since the initiation of the 'Train the Trainer' educational program, clubfoot clinics reportedly grew from 6-7 patients per week to over 60 patients per week. The majority of this patient population growth was attributed to word of mouth. Major barriers to the method included casting materials, bracing materials, and a lack of a dedicated area of the clinic to conduct tenotomies under local anesthesia. Of note, cost was not cited as a major barrier.
CONCLUSION:
Early evaluation suggests great utility of the 'Train the Trainer' method - especially regarding an increased patient demand for treatment. However, further studies are necessary to understand the long-term utility of this training methodology.
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NewsBot · May 9, 2014

Management of idiopathic clubfoot after formal training in the Ponseti method: a multi-year, international survey.
Asitha J, Zionts LE, Morcuende JA.
Iowa Orthop J. 2013;33:136-41.

BACKGROUND:
Over the past decade, the Ponseti method has become the standard of care to treat clubfoot amongst orthopaedic surgeons around the world. Since 2001, the University of Iowa, under the guidance of the late Dr. Ignacio Ponseti, has been teaching the Ponseti method through a standardized training course. This study examines the current clubfoot management practices of those who have participated in the course and the effectiveness of formal Ponseti Training Courses.
METHODS:
An online survey was administered to practitioners who participated in the University of Iowa Ponseti Training Course from 2001-2011.
RESULTS:
One hundred and thirty-one practitioners responded to the survey representing 33 different countries and 70 different orthopaedic societies. Ninety-seven percent of practitioners reported currently using the Ponseti method as the preferred treatment for clubfoot. The respondents reported the average duration of each cast was 9.21 days (SD=9.04 d) and the average cast phase of treatment lasted 7.62 weeks (SD=2.43 w). Physicians were responsible for applying the cast 79% of the time. Braces were utilized following casting by 96% of physicians. The average age of brace use was 41 months (SD=16 m). The reported relapse rate was 21% (SD=17%). Ninety-seven percent of practitioners changed their practice after completion of the course. The preferred method prior to the course was surgical release (48%). Sixty-one percent of practitioners preferred review articles as an additional educational support; 49% preferred training videos. Sixty-seven percent believed an 'on-site' visit to their hospital by an expert in the Ponseti method would be very beneficial. Seventy-three percent suggested improving the course by providing more 'hands on' experience. Ninety-five percent of practitioners were satisfied with the course.
CONCLUSION:
The Ponseti Training Course is an effective way to educate physicians on how to treat clubfoot with the Ponseti method. However, improvements should include more hands-on learning as well as an 'on-site' visit with an expert Ponseti practitioner.
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NewsBot · May 17, 2014

Ponseti technique in the management of Idiopathic club foot
T S Gopakumar, Rahul Mohan
Kerala Journal of Orthopaedics ; Vol 27, No 1 (2014)

284 feet in 182 children with clubfoot treated by Ponseti method in Government Medical College, Thiruvananthapuram during period of August 2011 to August 2013 were studied prospectively. Aim of the study was to evaluate the results and complications of Ponseti method of treatment and to assess the compliance of Foot abduction orthosis by children and parents.
The severity of initial club foot deformity, age at the initiation of manipulation, total duration of treatment and the need for tenotomy were studied. Severity of club foot was evaluated by Pirani scoring. The children were followed up for an average duration of 20 months. The outcome has no relation with the severity of deformity, but the younger the age the less the number of the casts were needed.
Parents of 62 infants were feeling discomfort with the use of the orthosis but when explained properly they co-operated. 89% patients had post treatment score of 0 compared with average pretreatment score of 5.5. 56% needed tenotomy. Total average duration of the cast treatment was 2 months and we found excellent to good functional results in 80% in 20 months follow up.
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NewsBot · May 31, 2014

Influence of Age, Weight, and Pirani Score on the Number of Castings in the Early Phase of Clubfoot Treatment using Ponseti Method.
Awang M, Sulaiman AR, Munajat I, Fazliq ME.
Malays J Med Sci. 2014 Mar;21(2):40-3.

BACKGROUND:
The objectives of this study were to investigate whether severity of clubfoot, age, and weight of the patients at initial manipulation and casting influence the total number of castings required.
METHODS:
This prospective study was conducted on 38 idiopathic clubfoot patients undergoing weekly manipulation and casting using the method recommended by Ponseti. The patients' age, weight, and foot Pirani score at the start of manipulation and casting were analysed against the total number of castings required to achieve correction to 60° abduction.
RESULTS:
Simple linear regression analysis on the influence of weight, age, and Pirani score at the time of cast initiation showed that the Pirani score was the only significant predictor for the total number of castings required.
CONCLUSION:
The total number of castings required to treat clubfoot was determined by the severity of clubfoot but not by the weight and age of patients.
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NewsBot · Jul 8, 2014

Factors Predictive of Second Recurrence in Clubfeet Treated by Ponseti Casting.
Luckett, Matthew R. MD; Hosseinzadeh, Pooya MD; Ashley, Philip A. MD; Muchow, Ryan D. MD; Talwalkar, Vishwas R. MD; Iwinski, Henry J. MD; Walker, Janet L. MD; Milbrandt, Todd A. MD
Journal of Pediatric Orthopaedics:July 2, 2014

Background: Ponseti serial casting is the most commonly used method in North America to treat children with clubfeet. Despite initial correction, recurrence is common. tibialis anterior tendon transfer (TATT) is commonly used to treat recurrent clubfeet. Recurrence can occur after TATT, and patients at risk of recurrence may benefit from closer monitoring. We studied the rate of second recurrence (recurrence after TATT) and studied the predictive factors for this recurrence.

Methods: Retrospective chart review of patients who have undergone TATT for recurrent clubfeet between 2002 and 2010 at our institution was performed. Recurrence was defined as recurrence of any elements of the clubfoot deformity that requires operative or nonoperative treatment. Effect of age at the time of TATT, initial severity of the deformity, and family history of clubfoot on rate of recurrence was studied.

Results: Sixty patients with 85 clubfeet were included in the study. Sixteen feet in 12 patients (20%) developed recurrence after TATT. Eight feet were treated nonoperatively and the rest (8 feet) required surgical procedure. Young age at time of TATT and brace noncompliance significantly increased the rate of second recurrence. Effect of severity of initial deformity and family history did not reach statistical significance.

Conclusions: Second recurrence can happen in around one fifth of patients with clubfeet after TATT. Patients with young age at TATT and patients with brace noncompliance are at an increased risk of recurrence and should be monitored closely.
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NewsBot · Jul 12, 2014

Volumetric and Growth Changes induced by serial casting treatment of congenital clubfoot on tarsal bones
Philip, Phitha
Thesis, M.S., Biomedical Engineering, Drexel University, 2014.

Clinically identified as talipes equinovarus, clubfoot is a developmental deformity that is treated with the Ponseti method of casting and manipulation. While the success of this procedure in correcting the deformity is well documented, the method of correction is poorly understood. The spatial and temporal composition of the developing tarsal anlagen was first inspected to identify the properties that allow realignment and reshaping of the deformed anlagen. The volumetric changes over the course of treatment were then quantified to see if the Ponseti treatment affected the rate of growth of anlagen and ossific nuclei and the percent ossification of anlagen. The conventional view that the primary effect of the Ponseti treatment was to realign the tarsal anlagen and initiate subsequent changes in the shape of the anlagen was challenged by studying the immediate and overall shape changes introduced by manipulation and casting. Fourier Transform Infrared Spectroscopy (FTIRIS) was utilized to understand the spatial and temporal changes in the anlagen composition during the developmental process. The endochondral ossification progression was marked by an increase in the collagen levels in the deeper region, especially closer to the growing ossific nuclei. The orientation of these collagen fibrils stayed constant till the formation of the ossific nuclei and then the fibrils were randomly oriented to facilitate the transformation from cartilage to bone. The mineralization was also preceded by a decrease in proteoglycan levels. Collagen integrity increased with age and the increased synthesis of collagen was followed by constant formation of newer crosslinks. Three dimensional modeling of MRI images were used to study the effect of Ponseti treatment on the volume and shape of deformed clubfoot. Ponseti treatment affected the compositional changes by stimulating the growth of the deformed anlagen, especially talus, at a higher rate compared to normal anlagen. Volumetric analysis showed that the significantly different clubfoot and normal foot have more comparable volume by the end of treatment. Shape change analyses confirmed the immediate shape changes induced by casting, increased convexity of the wedged talar dome and calcaneus head, and the presence of residual deformity present at the end of treatment. However, over the course of treatment, the smaller and deformed anlagen grow and adapt to obtain the shape and volume that is close enough to the normal foot to mimic normal functionality.
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NewsBot · Aug 13, 2014

Management of Idiopathic Clubfoot by Ponseti Technique in Children Presenting After One Year of Age
Mohammad Faizan, MS (Orth), Latif Zafar Jilani, MS (Orth), MRCS (Edin)email, Mazhar Abbas, MS (Orth), Mohammad Zahid, MS (Orth), Naiyer Asif, MS (Orth)
The Journal of Foot and Ankle Surgery; Articles in Press

We conducted a study to determine the effectiveness of the Ponseti technique in the management of idiopathic congenital clubfoot in patients older than 1 year of age. A total of 19 patients with 28 clubfeet (16 males [84.2%], 3 females [15.8%]) were included in the present study. The mean age at presentation was 2.7 (range 1 to 3.5) years. The results of treatment using the Ponseti technique were evaluated using the Pirani and Dimeglio scoring systems. The mean precorrection total Pirani score was 4.84 (range 3.5 to 5.5) and the mean precorrection Dimeglio score was 12.96 (range 10 to 14). The mean postcorrection total Pirani score was 0.55 (range 0 to 1), and the mean postcorrection Dimeglio score was 2.32 (range 2 to 3). These differences were statistically significant (p < .001 and p < .001, respectively). In 92.8% of the feet, satisfactory correction of the deformity was achieved. The mean number of casts applied was 8 (range 5 to 12). All but 1 (3.6%) of the clubfeet required tenotomy to achieve correction. The mean follow-up duration was 2.7 (range 1.5 to 3.5) years. We have concluded that the Ponseti technique is an effective method for the management of idiopathic congenital clubfoot, even in toddlers.
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NewsBot · Aug 20, 2014

Calf Circumference Discrepancies in Patients With Unilateral Clubfoot: Ponseti Versus Surgical Release.
Fulton, Zachary BS; Briggs, Dustin MD; Silva, Selina MD; Szalay, Elizabeth A. MD
Journal of Pediatric Orthopaedics: August 13, 2014 Published Ahead-of-Print

Background: Talipes equinovarus is the most common congenital lower limb abnormality. Decreased calf size has been found to have negative impacts on patients' subjective appraisals of long-term outcomes. This study compares calf circumference ratios in 2 groups of patients with unilateral clubfoot, those treated according to the Ponseti method and those treated with extensive surgery, to determine whether the current standard of care achieves better anatomic outcomes.

Methods: Patients >1 year after treatment for unilateral clubfoot were recruited during normal follow-up appointments and both calves were measured using a standardized protocol. A questionnaire concerning their treatment history was also completed. Data were analyzed by comparing calf circumference ratios between treatment modalities.

Results: Thirty-five patients with unilateral clubfoot were recruited after satisfying inclusion criteria. Twenty-four (69%) were included in the Ponseti-managed group, and 11 (31%) were in the extensive surgery group. The affected legs were on average 3% to 10% smaller than the control legs across all groups. The surgery group's average calf ratio was significantly less at 90.8%+/-3.5% compared with 94.4%+/-3.3% in the Ponseti group.

Conclusions: The calf circumference of limbs affected by clubfoot is significantly smaller in those treated with extensive surgery as compared with those treated with the Ponseti method alone, with or without percutaneous tenotomy. This supports the Ponseti method as the standard of care for achieving the most favorable anatomic outcome.
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NewsBot · Aug 26, 2014

Prospective evaluation of the use of Mitchell shoes and dynamic abduction brace for idiopathic clubfeet.
Chong, David Y.; Finberg, Naomi S.; Conklin, Michael J.; Doyle, John Scott; Khoury, Joseph G.; Gilbert, Shawn R.
Journal of Pediatric Orthopaedics B: August 22, 2014

Ponseti treatment for clubfoot has been successful, but recurrence continues to be an issue. After correction, patients are typically braced full time with a static abduction bar and shoes. Patient compliance with bracing is a modifiable risk factor for recurrence. We hypothesized that the use of Mitchell shoes and a dynamic abduction brace would increase compliance and thereby reduce the rate of recurrence. A prospective, randomized trial was carried out with consecutive patients treated for idiopathic clubfeet from 2008 to 2012. After casting and tenotomy, patients were randomized into either the dynamic or static abduction bar group. Both groups used Mitchell shoes. Patient demographics, satisfaction, and compliance were measured with self-reported questionnaires throughout follow-up. Thirty patients were followed up, with 15 in each group. Average follow-up was 18.7 months (range 3-40.7 months). Eight recurrences (26.7%) were found, with four in each group. Recurrences had a statistically significant higher number of casts and a longer follow-up time. Mean income, education level, patient-reported satisfaction and compliance, and age of caregiver tended to be lower in the recurrence group but were not statistically significant. No differences were found between the two brace types. Our study showed excellent patient satisfaction and reported compliance with Mitchell shoes and either the dynamic or static abduction bar. Close attention and careful education should be directed towards patients with known risk factors or difficult casting courses to maximize brace compliance, a modifiable risk factor for recurrence.
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NewsBot · Sep 2, 2014

Relapse of Clubfoot after Treatment with the Ponseti Method and the Function of the Foot Abduction Orthosis.
Zhao D, Liu J, Zhao L, Wu Z.
Clin Orthop Surg. 2014 Sep;6(3):245-252.

Ponseti clubfoot treatment has become more popular during the last decade because of its high initial correction rate. But the most common problem affecting the long-term successful outcome is relapse of the deformity. Non-compliance with Ponseti brace protocol is a major problem associated with relapse. Although more comfortable braces have been reported to improve the compliance, they all have the same design and no significant changes have been made to the protocols. After refinement in the Ponseti method and emphasizing the importance of brace to parents, the relapse rate has been markedly decreased. Nevertheless, there are patients who do not have any recurrence although they are not completely compliant with the brace treatment, whereas other patients have a recurrence even though they are strictly compliant with the brace treatment. The aim of this article is to review the relapse of clubfoot and the function of the brace and to develop an individualized brace protocol for each patient by analyzing the mechanism of the brace and the biomechanical properties of muscles, tendons, and ligaments.
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NewsBot · Sep 2, 2014

Good results after Ponseti treatment for neglected congenital clubfoot in Ethiopia.
Ayana B, Klungsøyr PJ.
Acta Orthop. 2014 Sep 1:1-5.

Background and purpose - Neglected clubfoot deformity is a major cause of disability in low-income countries. Most children with clubfoot have little access to treatment in these countries, and they are often inadequately treated. We evaluated the effectiveness of Ponseti's technique in neglected clubfoot in children in a rural setting in Ethiopia.

Patients and methods - A prospective study was conducted from June 2007 through July 2010. 22 consecutive children aged 2-10 years (32 feet) with neglected clubfoot were treated by the Ponseti method. The deformity was assessed using the Pirani scoring system. The average follow-up time was 3 years.

Results - A plantigrade functional foot was obtained in all patients by Ponseti casting and limited surgical intervention. 2 patients (4 feet) had recurrent deformity. They required re-manipulation and re-tenotomy of the Achilles tendon and 1 other patient required tibialis anterior transfer for dynamic supination deformity of the foot.

Interpretation - This study shows that the Ponseti method with some additional surgery can be used successfully as the primary treatment in neglected clubfoot, and that it minimizes the need for extensive corrective surgery.
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NewsBot · Sep 6, 2014

Good results after Ponseti treatment for neglected congenital clubfoot in Ethiopia
A prospective study of 22 children (32 feet) from 2 to 10 years of age
Birhanu Ayana and Peter J Klungsøyr
Acta Orthopaedica 1 September

Background and purpose — Neglected clubfoot deformity is a major cause of disability in low-income countries. Most children with clubfoot have little access to treatment in these countries, and they are often inadequately treated. We evaluated the effectiveness of Ponseti’s technique in neglected clubfoot in children in a rural setting in Ethiopia.

Patients and methods — A prospective study was conducted from June 2007 through July 2010. 22 consecutive children aged 2–10 years (32 feet) with neglected clubfoot were treated by the Ponseti method. The deformity was assessed using the Pirani scoring system. The average follow-up time was 3 years.

Results — A plantigrade functional foot was obtained in all patients by Ponseti casting and limited surgical intervention. 2 patients (4 feet) had recurrent deformity. They required re-manipulation and re-tenotomy of the Achilles tendon and 1 other patient required tibialis anterior transfer for dynamic supination deformity of the foot.

Interpretation — This study shows that the Ponseti method with some additional surgery can be used successfully as the primary treatment in neglected clubfoot, and that it minimizes the need for extensive corrective surgery.
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NewsBot · Sep 19, 2014

Does the Ponseti technique affect the vascular development in patients with congenital talipes equinovarus?
Yildirim T, Bursali A, Tonbul M, Sakizlioglu SS, Camurcu Y.
J Pediatr Orthop B. 2014 Sep 16

In this study, we have evaluated the changes observed in the main arteries of the foot before and after the Ponseti technique. Arterial structures of seven patients were examined using Doppler ultrasound and the parameters studied included the course of the arteries, lumen filling, flow direction, pattern, and velocity. Before the treatment, the side with congenital talipes equinovarus deformity showed decreased blood flow in all arteries, except for the posterior tibial artery. At the second examination, the increase in the flow velocity of both arteries except tibialis anterior arteries was statistically significant. The Ponseti method results in normalization of the arterial structures in extremities with congenital talipes equinovarus.
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NewsBot · Oct 1, 2014

Ultrasonographic findings after Achilles tenotomy during Ponseti treatment for clubfeet: Is ultrasound a reliable tool to assess tendon healing?
Nasr P, Berman L, Rehm A.
J Child Orthop. 2014 Sep 30.

INTRODUCTION:
Several studies have claimed ultrasound to be useful and accurate in assessing the healing phase of Achilles tendons after tenotomy during Ponseti treatment for clubfoot deformity. The purpose of our study was to assess the healing process of Achilles tendons ultrasonographically after tenotomy as part of Ponseti clubfoot management and to assess the effects of previously not considered ultrasound properties (anisotropy, partial volume effect), and whether these practical considerations affect accurate measurements which have been claimed possible in previous studies.
MATERIALS AND METHODS:
We monitored the post-tenotomy healing process in 15 patients (22 tendons) using high frequency ultrasound for a minimum of six months (range 6-14 months). The scanning was discontinued once a tendon looked normal or when the appearance remained unchanged between scans. We also studied nine patients (11 tendons) who had undergone Achilles tenotomies up to seven years previously (range 34-83 months).
RESULTS:
In the immediate postoperative period, ultrasound showed large variations in the distance of the tenotomy from the calcaneum as well as the obliquity and completeness of the surgical division. We encountered pitfalls in the use of ultrasound to define healing stages that were not described previously. Sonography was inaccurate and subjective in assessing both completeness of the surgical division and tendon measurements. Despite ultrasonographically proven incomplete tendon division in 63 % of cases, the clinical effect of an immediate increase of passive foot dorsiflexion from the pretenotomy position with an obvious palpable tendon gap was achieved in all patients. At the end of the study, 65 % of tendons did not achieve a normal appearance.
CONCLUSIONS:
We do not think that routine ultrasound studies are of any value as an adjunct to clinical assessment intra- and post-operatively. It can give misleading information regarding the need to complete the tenotomy, which may increase risks associated with a further pass of the scalpel blade.
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NewsBot · Oct 1, 2014

Walking Age of Infants with Idiopathic Clubfoot Treated Using the Ponseti Method
Lewis E. Zionts, MD; Davida F. Packer, MD; Shannon Cooper, BS; Edward Ebramzadeh, PhD; Sophia Sangiorgio, PhD
J Bone Joint Surg Am, 2014 Oct 01;96(19):e164.

Background: The Ponseti method is an established approach to treating idiopathic clubfoot in infants. The method involves a period of cast immobilization and postcorrective bracing that potentially interferes with normal movements of the lower extremities. In the present study, we investigated the age at which infants who had idiopathic clubfoot treated using the Ponseti method achieved independent walking.

Methods: We prospectively evaluated patients of a single surgeon. Included in the study were all patients with idiopathic clubfoot who were full term at birth, were no more than twelve weeks of age at the start of treatment, had received no prior outside treatment, and were followed for a minimum of twenty-four months.

Results: Ninety-four patients were included. The mean age at which patients began walking independently was 14.5 ± 2.6 months (range, ten to twenty-two months). By eighteen months, 90% of the patients were walking without assistance. Patients with moderate or severe clubfoot deformity began walking earlier than did patients with very severe deformity (a mean of 14.2 months compared with 15.8 months; p = 0.03). Patients who experienced a relapse before learning to walk began walking later than those who did not relapse (a mean of 15.9 months compared with 14.2 months; p = 0.04). Other patient and treatment-related variables had no significant influence on the onset of walking.

Conclusions: On the basis of our findings, parents of infants with idiopathic clubfoot treated using the Ponseti method may expect their child to achieve independent walking approximately two months later than infants without clubfoot deformity. A greater delay may be expected for those patients who have a very severe deformity or those who experience a deformity relapse.
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NewsBot · Oct 7, 2014

The effect of a dedicated Ponseti service on the outcome of idiopathic clubfoot treatment
A. I. W. Mayne et al
Bone Joint J 2014;96-B:1424–6

We report the effect of introducing a dedicated Ponseti service on the five-year treatment outcomes of children with idiopathic clubfoot.

Between 2002 and 2004, 100 feet (66 children; 50 boys and 16 girls) were treated in a general paediatric orthopaedic clinic. Of these, 96 feet (96%) responded to initial casting, 85 requiring a tenotomy of the tendo-Achillis. Recurrent deformity occurred in 38 feet and was successfully treated in 22 by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, The remaining 16 required an extensive surgical release.

Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls) were treated in a dedicated multidisciplinary Ponseti clinic. All responded to initial casting: 60 feet (83.3%) required a tenotomy of the tendo-Achillis. Recurrent deformity developed in 14, 11 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The other three required an extensive surgical release.

Statistical analysis showed that children treated in the dedicated Ponseti clinic had a lower rate of recurrence (p = 0.068) and a lower rate of surgical release (p = 0.01) than those treated in the general clinic.

This study shows that a dedicated Ponseti clinic, run by a well-trained multidisciplinary team, can improve the outcome of idiopathic clubfoot deformity.
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NewsBot · Oct 16, 2014

Insurance Status As a Predictor of Outcomes in Patients Undergoing Ponseti Treatment for Idiopathic Clubfoot
Rachel Y. Goldstein, MD, MPH, Suezie Kim, MD, Alice Chu, MD, Debra A. Sala, MS, PT and Wallace B. Lehman, MD
American Academy of Pediatrics Conference; October 2014

Purpose: Previous studies have demonstrated that children with public insurance have more limited access to orthopaedic care and may have poorer outcomes for treatment of their healthcare needs. The purpose of this study was to explore the relationship between insurance status and outcomes of patients with idiopathic clubfoot deformity.
Methods: All patients with idiopathic clubfoot treated with Ponseti method at our institution with greater than three years of follow-up were evaluated. Age at presentation, history of previous treatment, number of casts used, need for percutaneous Achilles tenotomy (PAT), age of initiation of foot abduction orthosis (FAO), compliance with FAO, need for additional casts, and need for surgical interventions were recorded. Dimeglio/Bensahel and Catterall/Piriani scores were recorded at initial presentation, at initiation of FAO, at one, two, three year follow-up, and at the most recent follow-up. Patients were divided into two groups for evaluation: publicly insured and privately insured.
Results: A total of 86 patients met inclusion criteria. There were 39 privately and 47 publicly insured patients. There were no significant differences between the two groups at presentation, including age at presentation and initial Dimeglio/Bensahel and Catterall/Piriani scores. There were no significant differences in the number of casts required for correction, need for PAT, or severity scores at initiation of the FAO. There were, however, significant differences between the groups with regards to Dimeglio/Bensahel and Catterall/Piriani scores at one year, two years, and at most recent follow-up. Patients who were publicly insured had worse severity scores at all time points. Patients who were publicly insured were also more likely to require additional casting, though they were not significantly more likely to undergo a surgical intervention. There was an association between public insurance and FAO noncompliance. Publicly insured patients were 3.11 times more likely to be noncompliant with the FAO.
Conclusion: Despite treatment in the same setting utilizing the same techniques by the same clinicians, publicly insured patients had higher severity scores at all time points after initiating the FAO, and demonstrated an increased risk of needing additional casts. Public insurance was also associated with noncompliance in prescribed FAO use.
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NewsBot · Nov 8, 2014

Ultrasonographic findings after Achilles tenotomy during Ponseti treatment for clubfeet: Is ultrasound a reliable tool to assess tendon healing?
P. Nasr, L. Berman, A. Rehm
Journal of Children's Orthopaedics; October 2014, Volume 8, Issue 5, pp 405-411

Introduction
Several studies have claimed ultrasound to be useful and accurate in assessing the healing phase of Achilles tendons after tenotomy during Ponseti treatment for clubfoot deformity. The purpose of our study was to assess the healing process of Achilles tendons ultrasonographically after tenotomy as part of Ponseti clubfoot management and to assess the effects of previously not considered ultrasound properties (anisotropy, partial volume effect), and whether these practical considerations affect accurate measurements which have been claimed possible in previous studies.
Materials and methods
We monitored the post-tenotomy healing process in 15 patients (22 tendons) using high frequency ultrasound for a minimum of six months (range 6–14 months). The scanning was discontinued once a tendon looked normal or when the appearance remained unchanged between scans. We also studied nine patients (11 tendons) who had undergone Achilles tenotomies up to seven years previously (range 34–83 months).
Results
In the immediate postoperative period, ultrasound showed large variations in the distance of the tenotomy from the calcaneum as well as the obliquity and completeness of the surgical division. We encountered pitfalls in the use of ultrasound to define healing stages that were not described previously. Sonography was inaccurate and subjective in assessing both completeness of the surgical division and tendon measurements. Despite ultrasonographically proven incomplete tendon division in 63 % of cases, the clinical effect of an immediate increase of passive foot dorsiflexion from the pretenotomy position with an obvious palpable tendon gap was achieved in all patients. At the end of the study, 65 % of tendons did not achieve a normal appearance.
Conclusions
We do not think that routine ultrasound studies are of any value as an adjunct to clinical assessment intra- and post-operatively. It can give misleading information regarding the need to complete the tenotomy, which may increase risks associated with a further pass of the scalpel blade.
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NewsBot · Nov 14, 2014

Can Radiographs Predict Outcome in Patients With Idiopathic Clubfeet Treated With the Ponseti Method?
O'Halloran CP, Halanski MA, Nemeth BA, Zimmermann CC, Noonan KJ.
J Pediatr Orthop. 2014 Nov 12

BACKGROUND::
The aim of this study was to determine if radiographic measurements, taken before tenotomy, can predict outcome in children with idiopathic clubfoot treated by the Ponseti method.
METHODS::
A retrospective chart and radiographic review was performed on children with idiopathic clubfoot treated with the Ponseti method over a 10-year period with minimum 2-year follow-up that had a forced dorsiflexion lateral foot radiograph before tenotomy. All angles were measured in duplicate on the pretenotomy radiographs, including: foot dorsiflexion (defined as the 90 minus the angle between the tibial shaft and a plastic plate used to dorsiflex the foot), tibio-calcaneal, talo-calcaneal, and talo-first metatarsal angles. Clinical review of patient records identified different patient outcomes: no additional treatment required, relapse (additional casting and/or surgery required), recurrence (any additional surgery required), or reconstruction (surgery not including repeat tenotomy).
RESULTS::
Forty-five patients (71 feet) were included in the study. The median age at follow-up was 4.6 years. The intrareader reliability was acceptable for all measures. Thirteen of the 71 (18%) feet required additional surgery, occurring at a median age of 3.6 years. Of the 4 radiographic measures, only pretenotomy foot dorsiflexion predicted recurrence (hazard ratio=0.96, P=0.03). Youden's method identified 16.6 degrees of dorsiflexion as the optimal cutoff. Feet with at least that amount of dorsiflexion pretenotomy (n=21) experienced no recurrences; feet with less than that amount of dorsiflexion (n=50) experienced 13 recurrences (P=0.007).
CONCLUSIONS::
Reduced foot dorsiflexion on lateral forced dorsiflexion pretenotomy radiograph was associated with an increased risk of recurrence. Radiographic dorsiflexion to 15 degrees past neutral before tenotomy appears to predict successful treatment via the Ponseti method.
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NewsBot · Nov 22, 2014

Can Radiographs Predict Outcome in Patients With Idiopathic Clubfeet Treated With the Ponseti Method?.
O’Halloran, Conor P. BS; Halanski, Matthew A. MD; Nemeth, Blaise A. MD; Zimmermann, Catherine C. MD; Noonan, Kenneth J. MD
Journal of Pediatric Orthopaedics:: November 12, 2014

Background: The aim of this study was to determine if radiographic measurements, taken before tenotomy, can predict outcome in children with idiopathic clubfoot treated by the Ponseti method.

Methods: A retrospective chart and radiographic review was performed on children with idiopathic clubfoot treated with the Ponseti method over a 10-year period with minimum 2-year follow-up that had a forced dorsiflexion lateral foot radiograph before tenotomy. All angles were measured in duplicate on the pretenotomy radiographs, including: foot dorsiflexion (defined as the 90 minus the angle between the tibial shaft and a plastic plate used to dorsiflex the foot), tibio-calcaneal, talo-calcaneal, and talo-first metatarsal angles. Clinical review of patient records identified different patient outcomes: no additional treatment required, relapse (additional casting and/or surgery required), recurrence (any additional surgery required), or reconstruction (surgery not including repeat tenotomy).

Results: Forty-five patients (71 feet) were included in the study. The median age at follow-up was 4.6 years. The intrareader reliability was acceptable for all measures. Thirteen of the 71 (18%) feet required additional surgery, occurring at a median age of 3.6 years. Of the 4 radiographic measures, only pretenotomy foot dorsiflexion predicted recurrence (hazard ratio=0.96, P=0.03). Youden's method identified 16.6 degrees of dorsiflexion as the optimal cutoff. Feet with at least that amount of dorsiflexion pretenotomy (n=21) experienced no recurrences; feet with less than that amount of dorsiflexion (n=50) experienced 13 recurrences (P=0.007).

Conclusions: Reduced foot dorsiflexion on lateral forced dorsiflexion pretenotomy radiograph was associated with an increased risk of recurrence. Radiographic dorsiflexion to 15 degrees past neutral before tenotomy appears to predict successful treatment via the Ponseti method
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NewsBot · Nov 28, 2014

Idiopathic Clubfoot Treated with the Ponseti Method: Factors Associated with Patient Follow-up.
Kim S, Goldstein RY, Park J, Shapiro P, Boo AE, Sala DA, Chu A, Lehman WB.
Bull Hosp Jt Dis (2013). 2014;72(3):204-209.

Background: Follow-up after treatment with the Ponseti method is important because of the known association be- tween lack of brace wear and recurrence. This study was designed to ascertain factors associated with patients who did not return for the recommended follow-up versus those who did.
Methods: Between January 1, 2000, and December 31, 2009, 222 patients were treated for idiopathic clubfoot at the New York Ponseti Clubfoot Center at NYU Hospital for Joint Diseases, of which 93 patients (143 feet) were poten- tially available for follow-up (i.e., ≤ 7 years of age, had not moved, or transferred care to another institution). Attempts were made to contact all patients' parents or guardians by telephone to respond to a survey, which included questions from the Disease Specific Instrument and the Oxford Ankle Foot Questionnaire. Forty-two of the 93 patients (45%) responded. The responder group, those who answered the survey, was compared to the group of non-responders. The responder group was further divided into a returning group (35 out of 42, 83%) and a lost to follow-up group (17%, not followed-up in over a year). A chart review was performed for demographics, Dimeglio/Bensahel and Catterall/Pirani scores, and treatment.
Results: When comparing the responder and non- responder groups, the responder group had significantly lower (p < 0.05) Catterall/Pirani scores at initial visit than the non-responder group (5.0 versus 5.5), but otherwise these two groups were similar. Among the responders, 91% or more were very satisfied/satisfied with status and appearance of foot in both lost to follow-up and returning groups. The lost to follow-up group was significantly (p < 0.05) older at the time of the survey (5 years versus 3.7 years), required significantly fewer casts (4.4 versus 5.5), had significantly lower Dimeglio/Bensahel scores at time of the start of foot adbuction orthoses (FAO) (0.0 versus 2.0), and trended toward greater footwear limitations (p = 0.051) compared with the returning group.
Conclusions: Number of casts, severity scores at the start of FAO, and footwear limitations are possible factors to dif- ferentiate between lost to follow-up and returning patients. This information may help other clubfoot centers provide vigilant outreach and therefore decrease recurrence rate.
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NewsBot · Nov 29, 2014

Club foot management by accelerated Ponseti technique
Sana Ullah, Muhammad Inam, Muhammad Arif.
RMJ. 2014; 39(4): 418-420

Objectives: To evaluate the outcome of accelerated Ponseti technique for the treatment of clubfoot.
Methodology: This prospective experimental study was conducted at orthopedic and spine surgery unit Hayatabad Medical Complex, Peshawar and a private clinic from December 2013 to July 2014. A total of 28 patients (40 feet) with congenital telipes equinovarus (CTEV) were included in the study. Patients with other congenital anomalies and previous surgical or non surgical treatment for club foot were excluded from the study. Patient’s feet were scored according to Pirani scoring system. Accelerated Ponseti technique (2 casts per week) was applied on all patients. On each cast removal, improvement in Pirani score was noted. Primary outcome measure was deformity correction.
Results. Out of 28 Patients, males were 16(57%) and females were 12(43%). 12(43%) had bilateral CTEV and 16(57%) were unilateral. In unilateral feet, 11(40%) were right sided and 5(17%) were left sided. Median Pirani Score was 5.2. Percutaneous tenotomies of tendo achillis were done in 32(80%). 34(85%) feet were fully corrected (Pirani score = or <1)
Conclusion: Accelerated Ponseti technique for club foot management is equally effective in relatively shorter period of time.
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NewsBot · Dec 3, 2014

Effect of unintentional partial Achilles tenotomy on Ponseti clubfoot management outcomes
Karami, Mohsena; Dehghan, Poonehb; Moshiri, Farshidc; Shamami, Mehrdad Sadighia
Journal of Pediatric Orthopaedics B: January 2015 - Volume 24 - Issue 1 - p 1-5

The congenital talipes equinovarus (clubfoot) is one of the most common congenital conditions requiring orthopedic intervention. This study was carried out to evaluate the effect of unintentional partial Achilles tendon cut during percutaneous tenotomy on the success rate of Ponseti management. Percentage of Achilles tendon cut following percutaneous tenotomy was measured by ultrasound in 16 clubfeet (11 patients). After a mean of 21 months of follow-up, the final results (Dimeglio score) were compared between two groups of patients: those with complete tendon cut and those with partial cut. Complications and parameters such as feeling of pop during tenotomy and ankle dorsiflexion during tenotomy were also compared. There was no significant correlation between the percentage of Achilles tendon cut and increase in ankle joint dorsiflexion, age at diagnosis, or pop sensation. There was no statistically significant difference between the two groups in their ankle joint dorsiflexion, feeling of pop, and final follow-up Dimeglio score. No complications were encountered following tenotomy. One patient needed tibialis anterior transfer at his last follow-up visit. Partial cut of Achilles tendon following tenotomy does not necessarily compromise the final results of Ponseti management. Achieving more than 10°–20° ankle dorsiflexion even with a partial tendon cut can ensure good final results
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NewsBot · Dec 3, 2014

Does the Ponseti technique affect the vascular development in patients with congenital talipes equinovarus?
Yildirim, Timura; Bursali, Aysegulb; Tonbul, Muratc; Sakizlioglu, Secil S.a; Camurcu, Yalkina
Journal of Pediatric Orthopaedics B: January 2015 - Volume 24 - Issue 1 - p 6-10

In this study, we have evaluated the changes observed in the main arteries of the foot before and after the Ponseti technique. Arterial structures of seven patients were examined using Doppler ultrasound and the parameters studied included the course of the arteries, lumen filling, flow direction, pattern, and velocity. Before the treatment, the side with congenital talipes equinovarus deformity showed decreased blood flow in all arteries, except for the posterior tibial artery. At the second examination, the increase in the flow velocity of both arteries except tibialis anterior arteries was statistically significant. The Ponseti method results in normalization of the arterial structures in extremities with congenital talipes equinovarus.
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NewsBot · Dec 23, 2014

The role and ability of orthopaedic postgraduate resident's clubfoot treatment with ponseti's methodology." A comparative study of resident's versus consultant's directed treatment
Anisuddin Bhatti et al
JPMA; December, 2014

Objective: To evaluate the outcome of Ponseti treatment carried out by the Postgraduate Orthopaedic Trainees compared with the treatment given by their Mentors.
Methods: The prospective comparative case series study was conducted at Jinnah Postgraduate Medical Centre, Karachi, and comprised idiopathic Congenital Clubfoot Deformity patients treated from September 2012 to December 2013. Also included were a few cases treated between September 2006 and September 2012, who had complete record, serial photograph and updated follow-up. The patients were divided into two groups. Those treated by residents formed Group A and those by consultants were in Group B. The follow-up duration ranged from 06 months to 05 years. Outcome measures included the number of casts required to achieve correction with Pirani score 0.5, the rate of Per-Cutaneous Achilles Tenotomy (PCAT), the rate of early relapse and treatment and failure to maintain correction. SPSS 13 was used for statistical analysis.
Results: Of the 172 patients in the study, 111(64.5%) patients with 185 feet were treated by the residents, while 61(35.5%) patients with 96 feet were treated by consultant. The overall mean age was 25.8±32.88 weeks (range: 1-156 weeks). The difference in age between the two groups was significant (p=0.01). A total of 166(96.51%) patients were on maintenance phase in Foot Abduction Bracing and 6(3.48%) completed the treatment successfully without residual deformity. The median number of cast per patient given by Group A was 6 and 5 in Group B. The number of 8+ casts given in Group A were 46 (24.86%) and 17 (17.7%) in Group B. Tenotomies performed in Group A were 106 (57.27%) and 70 (73%) in Group B, and overall PCAT performed were 183 (65.12%). The overall success rate was nearly similar between the two groups, with the difference of<1%.
Conclusion: The best practice to achieve excellent to good results from the beginners in Ponseti technique is to provide mentorship training for the skill of Ponseti manipulation, application of cast and continued treatment.
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Ponseti Method for clubfoot

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