November 2012

Benefits of Ponseti method extend to older children

By Jordana Bieze Foster

Clubfoot correction ideally should be performed during infancy, before children learn to walk, but experts agree that the Ponseti treatment method can also be effective in older children. Speakers at the International Clubfoot Symposium in October presented successful outcomes for Ponseti treatment of neglected clubfoot in patients aged up to 21 years.

Cases of neglected clubfoot are most prevalent in underserved areas where ambulation is essential for survival, which means not only do children learn to walk on malaligned feet but also that time spent in a cast can be more than just an inconvenience. As a result, practitioners treating older children make an extra effort to keep casting to a minimum.

“Fewer casts mean less weakness. The children are better able to get their strength back,” said Julyn A. Aguilar, MD, MHA, head of the Section of Pediatric Orthopedics at St. Luke’s Medical Center in Quezon City, Philippines, who reported a 100% plantigrade correction rate in 57 feet with severe or very severe clubfoot in 37 children with a mean age of 8 years. “I also ask these kids to undergo physical therapy so they can have a normal gait as quickly as possible.”

Anna Ey Batlle, MD, a pediatric orthopedic surgeon at Sant Joan de Déu in Barcelona, Spain, who also treats patients in India, reported using a mean of just 2.2 casts per patient in 32 patients (46 clubfeet) whose ages ranged from 3 years to 21 years. Batlle, who prefers to change casts every four to five days rather than every week, achieved a mean final Pirani score of 1.1 with no relapses in her neglected clubfoot population.

Jennifer McCahill, BScPT, MPhysio, MCSP, a physiotherapist at Nuffield Orthopaedic Centre in the UK, described her group’s successful use of the Ponseti method in 15 patients (19 clubfeet) aged between 2 and 15 years who had previously undergone strapping as a primary clubfoot treatment but had relapsed to the point where they were walking on the lateral edge of the foot with no apparent heel strike.

After Ponseti casting for a mean of 7.4 weeks and, in most cases, tenotomy, lengthening, or tibialis anterior tendon transfer, all patients were heel striking and mediolaterally balanced during gait. Heel varus was corrected in 13 of 16 feet and internal foot progression was corrected in 14 of 17 feet.

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