IOl MALAWIMEEJOURNAL;15(3):99-

Ponsetitechniqueof correcting idiopathicclubfoot deformity MkandawireNC,ChipoffaE,LikolecheG,Phiri M, Katete L Departmentof Surgery,QueenElizabethCentralHospitaland Collegeof Medicine,Blantyre,Malawi AddressCorrespondenceto: Dr. NC,Mkandawire,Collegeof Medicine,Private Bag360' Blantyre3, Malawi. Email:[email protected]

ABSTRACT The efficacy of the Ponseti method of clubfoot treatment at Queen Elizabeth Central Hospital (QECH) was analysed from December 2000 to December 2001. Ninety one patients, 60 boys and 31 girls were prospectively and consecutively enrolled. 31 patients had a unilateral clubfoot and 60 had bilateral clubfeet. 77 patients had primary idiopathic clubfoot and 14 patients had clubfeet associated'with other congenital anomalies such as arthrogryposis. 32 patients (35Vo) were lost to follow upl records were inadequate for 6 patients leaving 54 patients (59Vo) available for analysis. Three main groups were assessed.Group | (24 patients): virgin previously untreated primary idiopathic clubfeet: Ponseti method used from outset. Group 2 (19 patients): complex, primary idiopathic clubfeet: Ponseti method introduced after other manipulation techniques. Group 3 (L1 patients): clubfeet associated with other congenital anomalies. In group 1, the mean age at start of treatment was 9.7 weeks and the mean time to correction of deformity was 7.4 weeks. 20 out of 24 patients (84Vo) had correction of deformity and remained

BACKGROUND In December 2000, the Ponseti technique of correcting congenital idiopathic clubfeet was introduced in Malawi at the QECH. The Columbian Clubfoot Scoring systemwas also introduced as a tool for objective measurementof the clubfoot deformity and responseto treatment. Prior to this, the managementof clubfeet was not standardised with various methods of manipulation being used by different people. Monitoring of responseto conservative treatment was subjective; indications and timing for surgery were usually surgeon dependent and objective assessment of outcome was difficult to do. The Ponseti technique has been shown to be easy,efficient, economical and effective '''r. Combined with the Columbian clubfoot scoring system *, there is an objective way of measuring responseto treatment. This method facilitates the standardisation of clubfoot treatment.It has been shown to work in Uganda; an environment similar to that in Malawi.

OBJECTIVES 1.

2.

3.

To evaluatethe Ponseti method of treating idiopathic clubfeet and use of the Columbian Clubfoot Score system as a tool for measuring outcome. This with a view to seeif these techniquescould be adopted as the standardtreatment of clubfoot deformity in Malawi. To assessthe impact of adopting such a treatment regime on the patient, their family and the hospitals; especially with respectto utilisation of limited resources. To assessthe responseof teratologic clubfeet to the Ponseti method of treatment.

corrected. 4 patients had recurrence of deformity mainly due to non compliance with treatment and correction was achieved once treatment restarted. In group 2' 19 patients had been on treatment for a mean period of 32 weeks prior to commencement of Ponseti treatment. In L7 of these patients the deformity was still uncorrected. Ponseti treatment was commenced at a mean age of 36 weeks and correction was achieved in all 17 patients after a mean treat' ment duration of 7.1 weeks. In group 3, correction of defor' mity was initially achieved in only 60Vo. The period to achieve correction was long and incidence of recurrence of deformity was high. The successof conservative treatment of clubfeet using the Ponseti method has resulted in large decreasein the number of surgical procedures performed under general anaesthae' sia such as posteromedial releases in the treatment of clubfeet at QECH. This method has now been adopted as the standard treatment of clubfoot and is being advocated nationwide.

ANDMETHODS PATIENTS In December 2000 a workshop was conducted at QECH in Blantyre instruct orthopaedic surgeons, clinical officers and physiotherapists in the Ponseti method of treating clubfeet. It was decided that the main teaching centres of Blantyre and Lilongwe would adopt the technique as a pilot study and evaluate the results. From January 2001 all new clubfoot patients with no prior treatment and those who had received other forms of non-surgical treatment were prospectively enrolled into the pilot study. They all were treated using the Ponseti method. Patients with teratologic clubfeet were also included in this pilot study. The Ponseti of manipulating clubfeet aims to eliminate all elements of the clubfoot deformity to give a normal looking; pain free; functional; mobile; plantigrade foot. The main elementsof clubfoot deformity, which include forefoot cavus, varus, and adductus and hind foot varus, are all corrected simultaneously and not sequentially.The hind foot equinus is corrected last. A tenotomy of the Achilles tendon may be necessaryto achieve final correction of the equinus deformity. Serial stretching and casting is done weekly ald progress in monitored using the Columbian Clubfoot Score. The Columbian Clubfoot Score system looks at three deformities in the hind foot and three deformities in the mid foot, giving a total of six deformities. The hind foot deformities are: posteri'empty heel' sign and resistant equinus. The mid or skin crease; 'lateral head oftalus; and curfoot signs are: medial skin crease; vature of the lateral border of the foot. Each deformity can have a score of 0 (normal), 0.5 (mild) or 1 (severe).A normal foot would score 0 and a severely deformed foot would score 6. After correction of the foot deformity by serial casting and possibly a tenotomy of the Achilles tendon, the child is fitted into a Malawi Medical Joumal

Ponsetitechnique 100 ;i' '

foot abduction brace (Steenbeek Foot Abduction Brace SFAB), which is wom day and night for t}ree month. After 3 months the brace is worn only at night for 2 to four years. If deformity of the foot recurs after fitting of the braces, serial casting has to be recommencedand repeat tenotomy may be necessary. The intensive phase of the treatment is the period of weekly cast change till correction is achieved and the child fitted into foot abduction braces.This intensive phase takes 5 to 8 weeks. Once the brace has been fitted and the mother instructed on application of the brace, attendancecan be once a month to monitor recurrence of deformity and may be to change the size of the brace as the child grows.

RESUTTS Demographicdata

Complexprimary idiopathicclubfeet 19 patients had other non-surgical treatment prior to commencing the Ponseti method for a mean duration of 32.6 weeks. During this time only 2 patients (lIVo)had achieved satisfactory corection of deformity. In 17 patients (89Vo)the deformity was not coffected. Ponseti treatment was the commenced at a mean age of 36 weeks. The mean duration of ffeatment to correction of deformity (SFAB fitted) was 7.1 weeks and all 17 patients achieved correction of deformity. The mean CCFS at the start of Ponseti method was 3.6 and at the time of fittins SFAB was 0.86 (Table 4) Table 4:

91 patients were enrolled in the study. 38 (41Vo)of the patients could not be analysed due tb non-attendance of clinics (32 patients) and lost records (6 patients) The high loss of patients from follow up may be due to difficulties and expenseof getting transport to come the hospital especially for_women coming from distant rural areas. There were no major differences between the patients that were analysedand those that were lost to follow up (Tables I and2)

Idiopathic complex clubfeet: Prior other treatment then Ponseti Method (19 patients)

Mean age at start of Rx

PRIOR

PONSETI

TREATMENT

TREATMENT

lnadequaterecords

36 weeks (12 - 104)

Mean Rx duration (to correction 32.6 weeks (12 - 104) 7.1 weeks (3 - 10) Or change of Rx) Deformity corrected

2 (ll%o)

17(l00%o)

Deformity not conected

17(89Vo)

0 (o%o)

Mean CCFS at start of Rx

Not done

3.6(2 - 6)

Mean CCFS at end of Rx

3.6(2 - 6)

0.86(0- 1.s)

Table1: Demographic data Number of patients enrolled:

91

Males: Female:

JI

Unilateml left clubfoot:

16

Unilateral risht clubfoot:

15

Bilateral clubfeet:

60

Idiooathic Clubfeet:

Lost to follow up:

77 I4 32 (35Eo)

Records missing:

6( 6Vo)

Teratolosic Clubfeet

Number of oatients not analvsed

38 (41Vo)

Number of patients analysed:

s4 (59Vo)

Or review

CCFS - Columbia Foot Score

Teratologicclubfeet

Table 2: Comparison of analysed and unanalysed patients Idiopathic Untreated Clubfoot

Idiopathic ComplexClubfoot

Teratologic Clubfoot

AnalysedGroup

24 (45Vo)

Unanalysed Group

22 (59Vo)

19(35Va) 12(32Vo)

3 (8Vo)

rr (20Vo)

Virgin primary idiopathicclubfeet For previously untreated clubfeet commencedon Ponseti treatment from the outset, the mean age at start of treatment was 9.7 weeks and the mean treatment duration to achieve correction of deformity (fitted with SFAB) was 7.4 weeks. 20 of 24 patients (83Vo),in this group had satisfactorycorrection of the deformity and remained coffected. 4 patients had recurrence of deformity after initial satisfactory correction (Table 3). Table 3:

Idiopathic untreated clubfeet: Ponseti Method from beginning (24 patients)

5 patients with teratologic clubfeet had Ponseti technique used from the outset. The remaining 6 had prior treatment using other techniquesfollowed by the Ponseti method. Using the previous methods of treatment 6 patients with teratologic clubfeet failed to achieve correction of the deformity after mean treatment duration of 42.7 weeks. Ponseti method was then tried for a mean duration of l7 weeks and the deformity was corrected in only 3 of the 6 patients. In 5 patients the Ponseti method was used from the outset. 3 out ofthe 5 patients achieved correction of the deformity. These results confirm the resistanceof teratologic clubfeet to conservativetreatment (Table 5).

Table5: Teratologic Clubfeet:TArthrogryposis;2 Spinabifida;2other (llpatients) anomalies.

9.7 weeks(0 *28)

Mean Rx duration to correction (SFAB fitted)

7.4weeks(3 - 19)

Deformity corrected

20 (83Vo)

Deformity not corected or recurred

4 (1'lVo)

Malawi Medical Joumal

PONSETIRX

TREATMENT

GAILEDPRIOR

PONSETIRX (FROM

RX)

OUTSET)

Number of patients Mean Rx duration

Mean age at start of Ponseti Rx

PRTOR

(to corection or change of Rx) .Deformity corrected Deformity not corrected

42.7 weeks

17weeks

(24 - 60)

(6- s2)

(8 -24)

0 (0Eo)

3 (50Vo)

3 (6OVo)

3 (5OVa)

2 (40Vo)

6 (lOOVo)

24.4Weeks

101 Ponsetitechnique Recurrence of deformitY (Table 6)

MEAN COLUMBIA FOOT SCORE AT START

Untreated

ATFITTING

ATFOLLOW

AFTER

SFAB

UP

2NDRX 3.0

0.9

4.8

.:

t.2 20 15:

Clubfeet Complex

+.J

1.8

3.3

4.4

1.0

3.5

'3.

Clubfeet Teratologic

2.1

0 Year

Clubfeet SFAB - Steenbeek Foot Abduction Brace

(JntreatedClubJeet 4 patients in this group had recurrencaof deformity after previous satisfactory correction. For 3 patients the cause was most likely poor clinic attendanceand non-compliance with the treatmeni regime. In the remaining patient the cause for the recurrence was not obvious. All patients underwent serial recasting and 2 required repeat tenotomy of the Achilles tendon' The deformity was conected in all patients'

DtscussloN

clubfoot The introduction of the Ponseti method of treatment of For has proved to be very successfulat the pilot study at QECH' younger' previously untreated clubfeet in children one year or an within deformity of ponr"ri correction method achieved it " undergone had which clubfeet, averageof 7.4 weeks. Complex poor corprior ireatment for an averageperiod of 32 weeks with resulttreatment iection of deformity, respondedwell to Ponseti of 7'1 period Complex clubfeet ing in correction of deformity within an average The 5 patients in this group had recurrence of the deformity' weeks. This reduction in the treatment period when deformity probubl" causewas difficulty in fitting the SFAB' The mothers correction is achieved is very important as it meanspatients are complained that the feet kept coming out of the braces' required to attend fewer clinics and thus improve compliance Followingthecomplaint,thebracesweremodified.Serialcast. with treatment. The ing was iestarted and 2 patierts required repeat tenotomy' concern' deformity was corrected in all patients' The loss to follow up of up 35Vaof the patients is of espeThis may be due to transport problems to get to the clinics clubfeet Teratologic cially for patients from rural areas' 7 patienis in this group had recurrence of deformity' The difficuity with this group was keeping the brace on the children to treatment as would be with Teratologic clubfeet are resistant because of the added lower limb deformities in children about 507o success achieving is and expected. The Ponseti method arthrogryposisand spina bifida. Serial casting was restarted of patients howev4 rate in correcting the deformity' The number + patients required repeat tenotomy' After the retreatment er is smallto makeany concreteconclusions' puii".t,, still had uncorrected deformities' 1 patient who had spina bifida later underwent extensive posteromedial releases shown by The successof introducing this method is indirectly and spinal swgery to releasea tethered spinal cord' other prothe reduction in the number of surgical operationsand year 2001' cedures done under general anaesthesiaduring the lmpacton utilisationof resources the success' this to Due used' has when Ponseti method was being Foliowing the introduction of the Ponseti technique' there idiopathic treat to as the way been a definite decreasein the number of posteromedialreleas- technique is being advocated or in children who have general children under tendon untreated previously Achilles in the of clubfeet es and lengthening of 1 to 1'5 received prior non-surgical treatment under the age Anaesthaesia.Alltenotomiesarebeingdoneunderlocalanaesup years. Orthopaedic surgeons,clinical officers and physiotherathesia in a special areain the outpatient clinics' This has freed easy' i)' (Table Figure 7, time and space precious theatre pirt, ut QECH are convinced that this method is indeed the on courses wide Nation effectiue, efficient and economical' General made Table 7: Clubfoot surgery and procedures done under be will recommendations Ponseti method are planned and 'Pre and Post Ponsetit: Ponseti introduced Anaesthaesia adopted as to the relevant health authorities that this method be December 2000. deformity' clubfoot the national policy on the managementof NUMBER OF CASES(PATIENTS) PROCEDURE Tendo Achilles Lengthentng

1998

1999

t'7

22

2001 15

References of idiopathic clubfoot A thirty yem 1. Cooper, D.M. and Dietz, F.R (1995) Treatment follow up note. J Bone Joint Sarg"17 L' 1417 on pathogenesisand treatment of Ponseti, I.V and Campos, J (197i; Obsenations 2. 50 84' Orthop', Clin clubfoot. congenital Theresultsoftreatment J Ponseti,I.VandSmoley,E'N 1ilO:; Congenitalclubfoot 3.

Posteromedial 4.

Release

Bone Joint Surg ,45A,261' officers and Pirani, S. Uganda clubfoot project A manual for orthopaedic PhYsiotheraPists

Change of Cast Bone Procedures

Malawi Medical Journal

Ponseti technique of correcting idiopathic clubfoot deformity.

The efficacy of the Ponseti method of clubfoot treatment at Queen Elizabeth Central Hospital (QECH) was analysed from December 2000 to December 2001. ...
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