Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Jose A. Morcuende, MD, PhD*,
The Ponseti Clubfoot Treatment Center, University of Iowa, Iowa City, Iowa
Posted July 2008
Because of unsatisfactory functional long-term results and
suboptimal quality of life following surgical corrections for the treatment of
idiopathic clubfoot1,2, current management has evolved from
extensive soft-tissue releases toward nonoperative methods such as the Ponseti
method and the French physical therapy method.
This short-term, prospective study
reports the results of gait analysis for two-year-old children who had been
managed with the Ponseti or French method as practiced by the authors. The
results provide evidence that approximately half of the patients who had been
successfully treated by either method had normal kinematic ankle motion in the
sagittal plane. When deviations from normal occurred, they generally consisted of
knee hyperextension, foot drop, and limitation in dorsiflexion in the French group
(representing residual deformity or relapse), or a mild increase in stance-phase
dorsiflexion in the Ponseti group (of uncertain clinical and functional implication).
But importantly, both nonoperative methods resulted in rates of normal ankle
kinematics that were much better than what had been reported by the same group
following surgical correction of clubfoot.
There are some striking differences between the Ponseti and
French methods and overall results are considered. Although no specific data were
reported, based on the treatment protocols, the number of clinic visits and time
to foot correction varied dramatically. With the Ponseti method, only five weekly
visits were required compared with months of daily visits with the French
method. In today's health care environment of cost-containment and both parents
working, this difference should be taken into consideration when advising
families, as there is a huge investment in time and indirect cost for them.
More importantly, the reported rates of surgical releases (23%
in the Ponseti group, and 36% in the French group) are extremely high when
compared with that reported in the contemporary literature with the Ponseti
method (less that 3%, including treatment performed by physiotherapists and
orthopaedic officers)3,4. The authors do not discuss these data or
the specific reasons for the failures, but it should be emphasized that strict adherence to all of the tenets of the Ponseti
method, including use of the brace after correction, lead to a very high rate
of success and avoidance of surgery in patients who are as old as eight years
of age and who have neglected, severe clubfoot5,6.
This study also leads us to
reflect on the manner in which our specialty advances. With the introduction of
new techniques, early results lead to subsequent modifications in an attempt to
improve outcomes. As reported by the authors, they now recommend performing an
Achilles lengthening in patients treated with the French method to improve
dorsiflexion and avoid hyperextension of the knee. Since this method relies on
continued physiotherapy for several years to prevent relapses, it would be interesting
to test if this group would benefit from the night-time use of the simple foot
abduction brace as in the Ponseti method. Finally, on the basis of the long-term
follow up of patients who have been managed with the Ponseti method, we now
know that ankle dorsiflexion decreases over time7,8; therefore, the mild
increase in dorsiflexion that were observed in the Ponseti group at this young
age will most likely improve and cause no adverse functional implications.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.
References
1. Ippolito E, Farsetti P, Caterini R, Tudisco C. Long-term comparative results in patients with congenital clubfoot treated with two different protocols. J Bone Joint Surg Am. 2003;85:1286-94.
2. Dobbs MB, Nunley R, Shoenecker PL. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am. 2006;88:986-96.
3. Shack N, Eastwood DM. Early results of a physiotherapist-delivered Ponseti service for the management of idiopathic congenital talipes equinovarus foot deformity. J Bone Joint Surg Br. 2006;88:1085-9.
4. Tindall AJ, Steinlechner CW, Lavy CB, Mannion S, Mkandawire N. Results of manipulation of idiopathic clubfoot deformity in Malawi by orthopaedic clinical officers using the Ponseti method: a realistic alternative for the developing world? J Pediatr Orthop. 2005;25:627-9.
5. Göksan SB, Bursali A, Bilgili F, Sivacioğlu S, Ayanoğlu S. Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complex deformities. Arch Orthop Trauma Surg. 2006;126:15-21.
6. Lourenço AF, Morcuende JA. Correction of neglected idiopathic clubfoot by the Ponseti method. J Bone Joint Surg Br. 2007;89:378-81.
7. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am. 1980;62:23-31.
8. Cooper DM, Dietz FR. Treatment of idiopathic clubfoot: a thirty-year follow-up note. J Bone Joint Surg Am. 1995;77:1477-89.
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