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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 8  |  Issue : 1  |  Page : 30-34

Management of idiopathic congenital talipes equinovarus by standard versus accelerated Ponseti plaster technique: A prospective study


Department of Orthopaedics, V.S.S. Medical College, Burla, Sambalpur, Odisha, India

Date of Web Publication13-Jun-2016

Correspondence Address:
Biswajit Sahu
Sri Ramachandra Appartment, Medical Road, Ranihat, Cuttack - 753 007, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7341.183960

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  Abstract 

Introduction: Ponseti technique has been accepted as the standard method of treatment for clubfoot. Accelerated Ponseti method with casts being done twice weekly, is being utilized recently to reduce the duration of plaster treatment. Materials and Methods: A prospective study was done in 80 feet (53 patients), who were randomly allotted with 40 feet in standard group and 40 feet in accelerated group. In standard group, manipulation and casting were done at weekly intervals, whereas in accelerated group, the same was done at 3 days interval. The initial and final Pirani score, number of casts required, duration of casting and relapse after treatment were recorded for all cases in both the groups and the results were analyzed. Results: Average initial Pirani score was 5.03 and 5.3 in standard Ponseti group and accelerated Ponseti group, respectively. The average final Pirani score was 0.2 and 0.25 in standard Ponseti group and accelerated Ponseti group, respectively. The average number of casts required for correction was 6.2 and the average duration of casting was 8.2 weeks in standard Ponseti group. The average number of casts required for correction was 7.4, and the average duration of casting was 3.4 weeks in accelerated Ponseti group. Conclusion: The advantage of accelerated Ponseti is early correction of the deformity with better acceptability by the parents. Accelerated method can be considered as an effective alternative method for correction of clubfoot.

Keywords: Accelerated Ponseti, clubfoot, Pirani score, standard Ponseti


How to cite this article:
Sahu B, Rajavelu R, Tudu B. Management of idiopathic congenital talipes equinovarus by standard versus accelerated Ponseti plaster technique: A prospective study. J Orthop Traumatol Rehabil 2015;8:30-4

How to cite this URL:
Sahu B, Rajavelu R, Tudu B. Management of idiopathic congenital talipes equinovarus by standard versus accelerated Ponseti plaster technique: A prospective study. J Orthop Traumatol Rehabil [serial online] 2015 [cited 2017 Jul 21];8:30-4. Available from: http://www.jotr.in/text.asp?2015/8/1/30/183960


  Introduction Top


Idiopathic congenital talipes equinovarus (CTEV) is one of the most common congenital deformities of foot and ankle.[1] Treatment for clubfoot in initial stages is serial manipulation and casting.[2] Ponseti popularized the method of correction for CTEV with good short- and long-term success [3],[4] and a considerable reduction in the requirement of surgeries.[5],[6],[7] Ponseti method of correction has been accepted worldwide and has become the standard treatment for CTEV.[8] In standard Ponseti technique, plasters are done at weekly intervals.[9],[10],[11] However, in situations where patients have to come from a long distance to reach the health care facility, will have difficulty as the total duration for correction may take months. Recently, an accelerated Ponseti method with casts being done twice weekly is being utilized to reduce the duration which probably have positive effect on acceptability. We compared the outcome of standard Ponseti technique with that of accelerated technique in the present study.


  Materials and Methods Top


This is a prospective analysis done in a tertiary care center from January 2014 to December 2015. About 90 feet (59 patients) were selected, but 10 feet (6 patients) lost follow-up during the study. Those patients with neurogenic clubfoot, syndromic clubfoot, those who received prior partial treatment elsewhere or treated by methods other than Ponseti were excluded from the study. Finally, 80 feet (53 patients) who were randomly allotted with 40 feet in standard group and 40 feet in accelerated group. In standard group, manipulation and casting were done at weekly intervals, whereas in accelerated group, the same was done at 3 days interval. The corrected foot was followed up at regular intervals.

In standard Ponseti group, there were 23 male and 4 female children. Seven patients had right-sided clubfoot, 7 patients had left-sided clubfoot, and the rest of 13 had bilateral involvement. The average age of the children at presentation was 5.6 weeks. In accelerated Ponseti group, there were 15 male and 11 female children. Eight patients had right-sided clubfoot, 4 patients had left-sided clubfoot, and the rest of 14 had bilateral involvement. The average age of the children was 5.25 weeks at presentation.

The severity of clubfoot was evaluated using Pirani score [12] initially and during the subsequent follow-ups. In the midfoot contracture, medial skin crease, curved lateral border, and palpation of lateral part of the head of talus were considered. The hind foot contracture components are posterior skin crease, emptiness of heel, and rigidity of equinus. Each component was given a score according to the severity as 0, 0.5, or 1, which were mild, moderate, and severe deformity, respectively. Each foot was finally given a score out of 6.

Each foot was manipulated and corrected using Ponseti method. In first plaster, cavus was corrected, and in subsequent casts, adduction was corrected. The equinus deformity was corrected at the last with or without percutaneous tendo-Achilles (TA) tenotomy. After correction of deformity, the foot was maintained in foot abduction brace with 70° of external rotation for affected foot and 40° of external rotation for nonaffected foot with a bar connecting between the foot with 15° of dorsiflexion [Figure 1] and [Figure 2].
Figure 1: (a) Standard Ponseti method: Preplaster image, (b) after 1st plaster, (c) after 2nd plaster, (d) after 3rd plaster, (e) after 4th plaster, (f) after 5th plaster, (g) after 6th plaster, (h) after full correction, with splint

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Figure 2: (a) Accelerated Ponseti method: Preplaster image, (b) after 1st plaster, (c) after 2nd plaster, (d) after 3rd plaster, (e) after 4th plaster, (f) after 5th plaster, (g) after 6th plaster, (h) after 7th plaster, (i) after full correction, with splint

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The initial Pirani score, number of casts required for correction, duration of casting, need for TA tenotomy, and relapse after treatment were recorded for all cases in both the groups and the results analyzed.


  Results Top


Initial Pirani score was 5.03 (range: 2.5-6) and 5.3 (range: 3-6) in standard Ponseti group and accelerated Ponseti group, respectively. The average final Pirani score was 0.2 and 0.25 in standard Ponseti group and accelerated Ponseti group, respectively. About 31 out of 40 (77.5%) feet required TA tenotomy for equinus correction in standard group, whereas 33 (82.5%) out of 40 feet required tenotomy in accelerated group. The average number of casts required for correction was 6.2 (range: 4-10) and the average duration of casting was 8.2 weeks in standard Ponseti group. The average number of casts required for correction was 7.4 (range: 5-10), and the average duration of casting was 3.4 weeks in accelerated Ponseti group. One patient in accelerated Ponseti group required soft tissue release. About 9 feet (22.5%) had a relapse in standard Ponseti group, whereas 13 out of 40 feet (32.5%) had relapse in accelerated Ponseti group.


  Discussion Top


Ponseti method of correction has been the standard treatment for CTEV. In developing countries, though this method has shown good results,[13] the duration of treatment was of a notable concern. In recent years, accelerated Ponseti method of correction shows a promising result as like that of standard Ponseti with a shorter period of casting. In accelerated Ponseti method of correction, plasters are done twice [14],[15] in a week using the same manipulation technique of standard Ponseti correction method.

The initial median Pirani score in Harnett et al.[16] was 5.0 in standard group and 5.5 in accelerated group. In a study by Elgohary and Abulsaad,[15] cases with a Pirani score not <4 were included. In our study, initial average Pirani score was 5.03 and 5.3 in standard Ponseti group and accelerated Ponseti group, respectively.

The final Pirani score considerably reduced in both the groups invariably in our study, which were 0.2 and 0.25 in standard Ponseti group and accelerated Ponseti group, respectively [Chart 1 [Additional file 1]]. In the study by Harnett et al.[16] showed an average drop of 4.0 in Pirani score for standard group and 4.5 for accelerated group.

The average number of cast required for correction by Morcuende et al.[14] was five or fewer casts in 90% of their cases without any difference between the groups. Elgohary and Abulsaad [15] required 4.88 ± 0.88 casts in the traditional group and 5.16 ± 0.72 casts in accelerated group. In our study, the average casts required for correction was 6.2 in the standard group and 7.4 in the accelerated group.

The average duration of casting by Harnett et al.[16] was 42 days in the standard group and 16 days in the accelerated group. It was 24 days for the standard group and 16 days for the accelerated group in the study by Morcuende et al.[14] Mean time required for correction from onset of manipulation till tenotomy or correction of equinus without tenotomy in the study by Elgohary and Abulsaad [15] was 33.36 ± 6.69 days in the traditional Ponseti group and 18.13 ± 3.02 days in accelerated Ponseti group. In our study, the average duration of casting was 8.2 weeks in standard Ponseti group and 3.4 weeks in accelerated Ponseti group [Chart 2 [Additional file 2]].

Morcuende et al.[14] reported a relapse of 36 out of 319 feet. In the study by Elgohary and Abulsaad,[15] relapses were observed in 14.7% in the traditional group and in 15.6% in the accelerated group. In our study, 22.5% had relapse in standard Ponseti group, whereas 32.5% had relapse in accelerated group.


  Conclusion Top


Standard Ponseti method has been accepted as the gold standard for correction of CTEV. Accelerated Ponseti method of correction has been started recently. The advantage of accelerated Ponseti is early correction of the deformity with better acceptability by the parents. The results of accelerated Ponseti are similar to that of standard Ponseti method. Hence, accelerated method can be considered as an effective alternative method for correction of clubfoot.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Wynne-Davies R. Genetic and environmental factors in the etiology of talipes equinovarus. Clin Orthop Relat Res 1972;84:9-13.  Back to cited text no. 1
    
2.
Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg 2004;86: 22-7.  Back to cited text no. 2
    
3.
Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am 1980;62:23-31.  Back to cited text no. 3
    
4.
Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up note. J Bone Joint Surg Am 1995;77:1477-89.  Back to cited text no. 4
    
5.
Wimbley RL. Idiopathic clubfoot. Curr Opin Orthop 2005;16:451-6.  Back to cited text no. 5
    
6.
Zimbler S. Nonoperative management of the equinovarus foot: Long-term results. In: The Clubfoot. New York: Springer-Verlag; 1994. p. 191-3.  Back to cited text no. 6
    
7.
Zionts LE, Zhao G, Hitchcock K, Maewal J, Ebramzadeh E. Has the rate of extensive surgery to treat idiopathic clubfoot declined in the United States? J Bone Joint Surg Am 2010;92:882-9.  Back to cited text no. 7
    
8.
Herzenberg JE, Radler C, Bor N. Ponseti versus traditional methods of casting for idiopathic clubfoot. J Pediatr Orthop 2002;22:517-21.  Back to cited text no. 8
    
9.
Karski T, Wosko I. Experience in the conservative treatment of congenital clubfoot in newborns and infants. J Pediatr Orthop 1989;9:134-6.  Back to cited text no. 9
    
10.
Lovell WW, Farley D. Treatment of congenital clubfoot. ONA J 1979;6:453-6.  Back to cited text no. 10
    
11.
Ponseti IV, Smoley EN. Congenital club foot: The results of treatment. J Bone Joint Surg Am 1963;45:261-75.  Back to cited text no. 11
    
12.
Pirani S. A method of assessing the virgin clubfoot. Orlando, FL: Pediatric Orthopaedic Society of North America (POSNA); 1995.  Back to cited text no. 12
    
13.
Gupta A, Singh S, Patel P, Patel J, Varshney MK. Evaluation of the utility of the Ponseti method of correction of clubfoot deformity in a developing nation. Int Orthop 2008;32:75-9.  Back to cited text no. 13
    
14.
Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J Pediatr Orthop 2005;25: 623-6.  Back to cited text no. 14
    
15.
Elgohary HS, Abulsaad M. Traditional and accelerated Ponseti technique: A comparative study. Eur J Orthop Surg Traumatol 2015;25:949-53.  Back to cited text no. 15
    
16.
Harnett P, Freeman R, Harrison WJ, Brown LC, Beckles V. An accelerated Ponseti versus the standard Ponseti method: A prospective randomised controlled trial. J Bone Joint Surg Br 2011;93: 404-8.  Back to cited text no. 16
    


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  [Figure 1], [Figure 2]



 

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