February 2014

Ponseti method surpasses surgery for long-term clubfoot outcomes

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Photo courtesy of MD Orthopaedics

But both groups fall short of controls

By Samantha Rosenblum

Children treated for clubfoot with the Ponseti method have less pain and fewer gait impairments as adults than those treated with surgery, according to research from Shriners Hospital for Children in Chicago.

In 42 adults aged between 19 and 35 years who were treated for clubfoot as infants (24 surgically, 18 using the Ponseti method) between 1983 and 1987, researchers compared the long-term results of each procedure in terms of foot function, foot biomechanics, and quality of life; they also compared the clubfoot patients to a control group of individuals with no history of clubfoot.

Both treatment groups had strength and motion deficits compared with the control group, but the group treated with the Ponseti method had better outcomes than the surgical group in many areas.

For example, individuals in the Ponseti group demonstrated significantly greater ankle plantar flexion range of motion (ROM), greater ankle plantar flexor and evertor strength, and a lower incidence of osteoarthritis in the ankle and foot. Additionally, the researchers found significantly higher pain levels in the surgical group than in the Ponseti group, as well as significantly reduced gait speed and stride length and more time spent in double support.

Overall, the study supports efforts to correct clubfoot with the Ponseti method, which minimizes surgery to joints to promote ROM and strength—essential elements of adult functioning in the years after treatment. The findings were epublished in November 2013 Clinical Orthopedics and Related Research.

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Children in the Ponseti group began receiving treatment an average of 12.4 days after birth. The Ponseti method, developed by Ignacio Ponseti, MD, consists of manipulation of the foot and casting. Casts are changed weekly with gradually increasing correction and, at the final stage (after about four weeks), surgeons do a heel cord tenotomy to achieve a plantigrade position of the ankle and foot, according to Peter Smith, MD, principal investigator of the study and an orthopedic surgeon at Shriners Hospital for Children in Chicago. Patients then underwent abduction bracing with a Denis-Browne bar and straight laced shoes, which they wore full time for two months, followed by nighttime use for four years.

Children in the surgical group had been treated with conventional casting and had an inadequate response or were approaching age 18 months (the cut-off age for corrective surgery), and subsequently underwent surgery, a comprehensive clubfoot release with a Cincinnati incision.

Despite the growing popularity and positive outcomes associated with the Ponseti method, there are some situations in which surgery might still be used. According to John Herzenberg, MD, director of Pediatric Orthopedics at Sinai Hospital and director of the International Center for Limb Lengthening, both in Baltimore, MD, parents must play a large role in treatment for the Ponseti method to work effectively.

“Less parent participation and compliance is needed for surgery than the Ponseti approach,” Herzenberg said. “The Ponseti approach consists of three months of casting by the physician and then four years of bracing, which has to be supervised daily by the parents. Some parents are not able to maintain this protocol, for a variety of reasons.”

Herzenberg cited social and economic barriers as issues that can adversely affect compliance.

The study’s limitations may have had substantial effects on the data collected. Most importantly, there exists a strong possibility of selection bias, as all patients in the study who underwent Ponseti method therapy received that treatment at the University of Iowa Hospital and Clinics in Iowa City, where surgeons have used the Ponseti method for decades. All individuals in the surgery group were treated at the Shriners Hospital for Children in Chicago, where surgery was the standard of care at the time for patients in whom conventional casting failed. The Ponseti method is now the standard clubfoot treatment at Shriners.

Clubfoot patients treated in more recent years have likely benefited from advances in treatment protocols, Smith said.

“We are always trying to speed correction and prevent recurrence through better casting and bracing, and it is definitely a field that is improving,” he said. “We think the outcomes are a bit better, particularly in achieving initial correction of the foot into an abducted position to prevent recurrence and meticulous detail to bracing. But there is still an intrinsic nature of clubfoot that we don’t understand that seems to result in diminished strength and motion to a varying degree—even with the best current techniques.”

Samantha Rosenblum is a journalism student at Northwestern University in Evanston, IL.

Source:

Smith PA, Kuo KN, Graf AN, et al. Long-term results of comprehensive clubfoot release versus the Ponseti method: Which is better? Clin Orthop Relat Res 2013 Nov 19. [Epub ahead of print]

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