|Year : 2020 | Volume
| Issue : 2 | Page : 131-136
One-week accelerated PONSETI method in the management of idiopathic clubfeet
Yasser Ali Elbatrawy
Department of Orthopaedic Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
|Date of Submission||23-Oct-2020|
|Date of Decision||18-Dec-2020|
|Date of Acceptance||19-Dec-2020|
|Date of Web Publication||31-Dec-2020|
Prof. Yasser Ali Elbatrawy
Villa 26 E, May Fair, Elsherouk City, Cairo 11837
Source of Support: None, Conflict of Interest: None
Purpose: This study aims to evaluate the results of the 1-week accelerated PONSETI method in the management of idiopathic clubfeet implemented by Ahmad and Aker in which manipulations, five castings, and Achilles tendon tenotomy are done in a week. Methods: We studied 15 patients with 22 moderate-to-severe congenital idiopathic clubfeet treated by the 1-week accelerated PONSETI method. The method involves the manipulation of the deformed foot and the first casting in the 1st day, with the second, third, fourth, and fifth castings (if the foot is not fully corrected, additional casting is done till reaching fully initial correction) in the 4th, 5th, 6th, and 7th day postmanipulation. After removal of the last cast, Achilles tenotomy was performed with subsequent 3-week casting in all patients. The Pirani scores were used for comparing the results before starting the treatment and after removal of the final cast. Results: We had 15 patients (7 bilateral and 8 unilateral) of clubfoot. The average age at the treatment was 15.2 days (range = 1–90 days). All patients, who had moderate-to-severe congenital idiopathic clubfeet with a Pirani score of 4–6 (mean = 5.61), underwent the 1-week accelerated PONSETI technique. After removal of the 3-week cast, the scores were 0 for all cases (except 3 feet with Pirani score of 0.5), which was an indication for deformity correction to achieve acceptable feet in all patients without the experience of any short-term complications. Conclusions: Our study of the 1-week accelerated PONSETI technique was found to be safe and effective for the initial correction of severe idiopathic clubfoot deformity in children less than 3 months of age and confirmed the results reported by Ahmad and Aker's study but still needs more follow-up of the patients to confirm the results on the long term.
Keywords: 1-week accelerated, clubfoot, Pirani score, PONSETI
|How to cite this article:|
Elbatrawy YA. One-week accelerated PONSETI method in the management of idiopathic clubfeet. J Limb Lengthen Reconstr 2020;6:131-6
| Introduction|| |
Clubfoot, or congenital idiopathic talipes equinovarus (CTEV), is a complex three-dimensional deformity that includes ankle equinus, hindfoot varus, midfoot cavus, and forefoot adductus., In Europe, the incidence of congenital clubfoot is 1.2 per 1000 live births. Estimates of clubfoot birth prevalence in lower middle income countries in Africa were 1.11/1000 live birth and in Latin America were 1.74/1000 live birth.
With successful outcomes in the short and long terms of the Ponseti method,,, there is universal agreement that this nonoperative protocol for the initial treatment of clubfoot is the best. Regardless of the method used, the clubfoot treatment method should aim to achieve a plantigrade, pliable, painless foot that is functionally and cosmetically acceptable. These goals should be achieved in a minimum of time with keeping the socioeconomic life of the child and parents is minimally interrupted.
The Pirani scoring system has a good interobserver reliability and reproducibility, is easy to be assess clubfeet in different clinical settings.,,,
Since the classic PONSETI method involves several castings with weekly changes, it is often difficult for patients who reside in areas distant from medical centers and thus may suffer to reach these centers every week. Ahmad and Aker's 1-week accelerated protocol was built on the concept of accelerating the PONSETI technique.,,,,
Ahmad and Aker implemented a PONSETI method with more accelerated treatment course, in which five castings (in average) were applied in a week. After daily manipulation, shortening of the treatment duration lessens the burden on patients and families who travel long distances every week or stay near the medical centers for longer periods seeking treatment, as in the classical PONSETI method.
In our study, we evaluated the 1-week accelerated PONSETI method reported by Ahmad and Aker for the management of idiopathic clubfoot to check its reliability and to compare its results original protocol of PONSETI method.
| Methods|| |
This study included a group of 15 patients with 22 moderate-to-severe congenital idiopathic clubfeet with a mean Pirani score of 5.61 (15 feet with Pirani score 6, 2 feet with Pirani score 5.5, 2 feet with Pirani score 5, 1 foot with Pirani score 4.5, and 2 feet with Pirani score just 4) that were treated by the 1-week accelerated PONSETI method. We excluded clubfeet deformities that were previously surgically treated or classified as postural, neurological, and syndromic types, and also, we excluded children aged more than 3 months.
The severity of the deformity was determined by the Pirani scoring system. The average age of the patients at the treatment initiation was 15.2 days, with a range of 1–90 days, and all patients were treated by a single orthopedic surgeon from April 2019 till February 2020.
The procedures of the technique came from the principles of the PONSETI method. In the first session, we performed gentle manipulation of the deformed foot through elevation of the first metatarsal and abduction of the forefoot with counter-pressure applied against the head of the talus to achieve a simultaneous correction of the cavus component of the deformity along with the other components. This allowed a proper alignment with the hindfoot, after which the first casting was applied above the knee.
The patients were seen again in the 4th-day postmanipulation when the cast was removed. This was followed by more manipulation and application of the second cast. Likewise, the third, fourth, and fifth castings were applied daily on the 5th, 6th, 7th day postmanipulation (more manipulation and casting might be needed daily if the full initial correction was not be achieved). The 3-day free casting interval between the first and second casting is thought to help decrease the risk of edema associated with the manipulation of first session.,
After the fifth cast removal and to correct the limitation of ankle dorsiflexion because we cannot get 10° of ankle dorsiflexion, Achilles tenotomy was performed with a subsequent 3-week casting in all patients. The procedure was performed in the operating room under general anesthesia.,,
After obtaining the consent, the patients' general information and Pirani score were obtained before starting the treatment, before each cast, after removal of each cast, and after removal of the 3-week castings. General as well as procedure-specific complications were monitored in every visit. Follow-up measurements after applying the foot abduction orthosis (FAO, Dennis Browne splint) were performed in the latest follow-up visit. The Pirani scores before initiating the treatment were compared with that after the removal of the final cast.
The bracing protocol and follow-up are the same as PONSETI's protocol.
| Results|| |
In our study, the number of casts needed to reach to adequate initial correction was 4–6 casts. Moreover, all of them had Achilles tenotomy in the operation room under general anesthesia. The deformity was found to be corrected within 28–30 days, whereas it is expected to take at least 49–63 days if the classic PONSETI method was performed, assuming 4–6 weekly castings in addition to the tenotomy procedure and subsequent 3-week casting. All treated clubfeet had no difficulty to wear Dennis brown splint (FAO) [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h, [Figure 1]i, [Figure 1]j.
|Figure 1: (a) Patient with right club foot, Pirani score 6 (3 weeks old (b) Same bottom view showing the severity of the medial crease. (c) after accelerated 1-week correction with Pirani score 0.5. (d) notice the flexion deformity of the second toe). (e,f) post tenotomy cast removal with excellent dorsiflexion and Pirani score 0. (g) Top view. (h) wearing Dennis Brown splint to prevent relapse. (i) Same patient after 8 months of follow-up with right foot: Pirani score 0. (j)|
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The follow-up period was 6–10 months (minimum 6 months, mean = 7 months and 21 days). The Pirani score after the last follow-up was 0. None of the patients needed more surgeries for his/her feet. Further, none of the patients needed repeat tenotomy.
During follow up, two patients showed early relapse after about one month of TAT cast removal and they were noncompliant to bracing, one unilateral case did not wear the brace at all.
The third and fourth feet in the master table were in bilateral case who was suffering from premature closure of anterior fontanel of the skull which precipitates convulsions. Furthermore, parents were noncompliant to brace and removed it earlier than the protocol and the patient showed very early relapsing after about 2 months of tendoachilles tenotomy (TAT) cast removal. Very early bilateral metatarsus adductus with Pirani score 0.5 of forefoot adduction was noticed, and no relapses were shown in other Pirani score parameters in the three feet.
The two affected cases (3 feet) were manipulated and put in a cast again one more time for 1 week; then, the cast was removed and the brace was worn again. Compliance was improved with providing continuous guidance and education to the parents. Until the last follow-up session (4 months after relapse correction), the two relapsed cases (3 feet) showed no relapses again and the Pirani scores at the end of the study for the 3 feet were 0.
Finally, the mean of feet Pirani score was 5.61 at the beginning of study and was 0 after 6 months of follow-up in all patients.
| Discussion|| |
There is a universal agreement on the PONSETI technique application as a first-line treatment of congenital idiopathic clubfoot, with excellent results in the short and long run. After nearly 30 years of follow-up, PONSETI reported that his conservative method yielded 74% of good or excellent results. More excellent clinical outcomes of the PONSETI method were reported in other long-term studies.,
In addition to the clinical improvement, the PONSETI treatment method has been associated with the correction of abnormal shapes of the tarsal osteochondral components and the relationships between tarsal bones, as evident by magnetic resonance imaging and ultrasound imaging.,
In some cases, it can be difficult to implement the PONSETI method due to the high expenses needed for transportation, or leaving family and work behind for long periods, which may last for 4–8 weeks in the case of conventional PONSETI treatment. These conditions make families unable to complete the treatment protocol of the clubfeet of their children. The difference in time used for correction between the accelerated PONSETI technique and the classic one can have good benefits for parents in these conditions.
Morcuende et al. reported that children were uncomfortable with edema developed in the feet after serial castings for 3–4 days and that the most rapid way to get a safe correction of the deformity was with 5-day casting interval. Yet, the accelerated PONSETI technique with casting twice a week as reported by Xu et al., Evans et al., and Elgohary and Abulsaad,,,, was found safe and effective without any complaints of edema in the feet of the patients. In these studies,,, there was a significant reduction in the duration of treatment in comparison with the classical PONSETI method, with no significant difference in the correction of the foot gained or the needed number of casts.
A systematic review of multiple studies that implemented the accelerated PONSETI method revealed a strong relation between shortening cast change interval and decreasing treatment duration. However, no relation was found between the cast change interval and the number of casts needed or the rate of tenotomy.
Ahmad accelerated the classical Ponseti technique so that five sessions of manipulation and castings were done within a week, with the first manipulation and casting were followed by 3 days of immobilization, and then, all castings were changed daily. Achilles tenotomy and a final 3-week casting were done as the traditional PONSETI. All patients, who had severe idiopathic clubfeet, after removing the 3-week casting, showed significant correction with getting of plantigrade, accepted, and pain-free feet.
[Table 2] compares the findings of the different studies addressing the acceleration of the PONSETI method, Ahmad and Aker's study, and our study.,,,,
In the 1-week accelerated PONSETI method, the number of castings needed in all of the patients was five, and this number was found to be sufficient to reach adequate initial correction. Compared with other studies, Laaveg and Ponseti reported that the mean number of casts needed to reach initial correction in their study was seven. Morcuende et al., reported that five or fewer casts were needed to reach initial correction in 90% of the patients.
Yet, the treatment duration in this study showed a dramatic difference compared with that in studies implementing the conventional PONSETI method in the literature. For example, Laaveg and Ponseti reported that 8.6 weeks was the average treatment duration.
The need for Achilles tenotomy varied in the literature, with studies reporting a rate between 80% and 90%.,, However, in Ahmad and Aker's study, the procedure was needed in 100% of patients after an abduction of at least 60° because all of them were 6 severe Pirani score., In our study, Achilles tendon tenotomy was performed in all patients due to the presence of less than 15°–20° of dorsiflexion after achieving abduction of at least 60°. This may be attributed to the severe presentation of cases since most cases had a Pirani score of 6 at presentation.,
Morcuende et al. reported that in both the conventional and the accelerated groups, patients who were noncompliant with the wearing their brace were found to have greater odds of relapse 8.5 times compared with those who were compliant. In Ahmad and Aker's study and after an average follow-up of 16 months, none of the patients showed a relapse of the deformity.
Pirani reported that the correction in tarsal osteochondral anlagen with PONSETI casting was due to growth changes, resulting from the changing of mechanical loading on rapid-growing tissues. Therefore, it was suggested that accelerated PONSETI protocols were not supported because they do not allow sufficient time of casting to let the tissues adapt through mechanical and growth loading changes. Despite that, the correction was evident in patients submitted to the 1-week accelerated PONSETI by Ahmad and Aker's study and our study and might be due to the following speculations:
The author followed the procedural method strictly as described in the principles by PONSETI. It was thought that applying the technique at an early age allowed for the adaptation and correction of the deformity as the osteochondral components and tendons are still flexible for adaptation.
Although the casting duration might be inadequate to induce sufficient osteochondral adaptation as suggested by Pirani, the relatively long duration of the first cast, in addition to the 3-week casting after Achilles tenotomy with the feet in the corrected position, may compensate for it.,,
Our study demonstrates the efficacy and safety of the 1-week accelerated PONSETI method as an accelerated protocol for the treatment of idiopathic clubfoot in children below 3 months of age. However, we must note limitations of this study which are small study sample, limited follow-up time, and compliance to the splint cannot be controlled.
Decreasing the time needed for correction of a clubfoot into 1-week can ease the burden of travel on families and reduce the drop-out rates. In addition, decreasing the time required to achieve correction of the deformity will help missionary orthopedists to provide effective service to clubfoot patients within a short time frame. In addition, it will help them cover wide areas of high incidence with a minimal but sufficient stay. Therefore, the 1-week accelerated PONSETI technique provides a conservative treatment for the clubfoot deformities implemented in a time that is convenient to the families and suitable the available resources.
| Conclusions|| |
Our study of the 1-week accelerated PONSETI technique method found that this method was safe and effective for the initial correction of severe idiopathic clubfoot deformity in children less than 3 months of age and confirmed the results reported by Ahmad and Aker's study, but this still needs more follow-up of the patients to confirm the results on the long term.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]