Ponseti treated idiopathic clubfoot - outcome predictive factors in the test of time: analysis of 500 feet followed for five to 20 years

Purpose To investigate a set of risk factors on the outcome of Ponseti treated idiopathic clubfeet (ICF). Methods This study was approved by the institutional review board. A retrospective analysis of prospectively gathered data over a 20-year period, at a single dedicated clubfoot clinic. Records of 333 consecutive infants with 500 ICF were analyzed. Initial Pirani score, number of casts, need for tenotomy, foot abduction brace compliance and functional score had been documented. The need for surgery after initial correction was the outcome measure. All children were followed by the same team throughout the study period. Descriptive statistics, chi-squared and multivariate analysis were performed. Results In total, 82 children (24%) with 119 feet (23.8%) were operated on, with 95.1% of feet being operated up to the age of nine years. There was a significant correlation between the Pirani score at presentation and the number of surgical procedures (chi-squared = 79.32; p < 0.001). Achilles tenotomy was done in 94.8% of patients. Pirani score of > 4.5 before casting was strongly associated with increased surgical risk (odds ratio = 1.95). When six to eight cast changes were needed, surgical prospect was 2.9 more, increasing to 11.9 when nine or more casts were needed. Conclusion Foot severity and number of cast changes were the strongest predictors for future surgery. Estimation of the risk of deformity recurrence after initial correction may help in tailoring a cost-effective personal treatment and follow-up protocol. Personalized focused protocol will help patients and caregivers and will reduce expenses. Level of Evidence Level II - prognostic study.

Factors Associated With The Relapse In Ponseti Treated Congenital Club Foot

Objectives. We retrospectively investigated the clinical materials to seek the factors that lead to relapse after using the Ponseti method.Methods. We retrospectively reviewed all children with congenital club foot treated with the Ponseti method in our hospital from June 2008 to June 2013. The data included the following factors: age, gender, initial Pinari score, number of casts, number of feet (unilateral or bilateral), age at the first casting, age of mother, tenotomy, walking age, and compliance with using bracing. All investigations were conducted in conformity with ethical standards. This study was approved by Guilin Peoples’ Hospital Ethics Committee.Results. In this study, there were 148 cases with 164 feet in total that underwent the Ponseti method. Of them, 64 children presented with left side, 58 with right side, and 26 with bilateral cases. This study included 75 males and 73 females; sex did not affect the outcomes. The mean age of the first casting was 2.50±2.15 months. The average initial Pirani score was 4.98±1.33, 2 and the average number of casts was 5.71±2.28 times. The mean age of mothers at birth was 25.81±2.38 years old. The walking age of children was at a mean of 14.83±1.18 months. Forty-nine cases could not tolerate using braces, namely the rate of noncompliance in this study was 33.1%. Tenotomy was performed on 113 feet (76.4%). The average follow–up period was 7.27±1.29 years (from 5 to 10 years). The rate of relapse was 21.6% (32 cases) at the end of the follow-up. The rate of relapse in the noncompliance with using bracing group was significantly higher compared to the compliance group.Conclusion. The initial Pirani score, compliance with the foot abduction brace and the age at the first casting are three independent factors for relapse in clubfoot.

Bilateral idiopathic club foot in baby of a rheumatoid mother: A rare case report and its management

Congenital clubfoot has a multifaceted etiology, with several hypotheses offered in its etiopathogenesis. The clubfoot has rarely been reported in babies born to women who have rheumatoid arthritis (RA). We present a rare case of a 31-year-old lady with RA on disease-modifying anti-rheumatoid drugs who delivered a child with bilateral congenital clubfoot. She had previously been using Methotrexate, Hydroxychloroquine, and Sulfasalazine regularly, but Methotrexate was stopped seven months before pregnancy. A full-term female baby was born through the cesarean section with bilateral clubfoot deformity and a modified Pirani score of eight out of 10. The deformity correction was done with the Ponseti serial casting method. The final modified Pirani score was two out of ten. In newborns born to rheumatoid arthritis mothers, the club foot deformity was effectively treated with serial Ponseti corrective casts, as was idiopathic clubfoot in babies born to non-rheumatoid mothers. Our findings validate the Ponseti serial casting method for these kinds of patients.

To Evaluate the Role of Pirani Score in Deformity Assessment and Management of Club Foot by Ponseti Method – A Hospital Based Prospective Study from Tirupati

BACKGROUND Pirani scoring system is one of the classification systems in management of club foot which is simple and easy to use. However, there is paucity of studies using Pirani system to determine the severity and monitor progress in the treatment of club foot. We therefore set out with the aim of assessing severity and monitoring the progress of treatment using the Pirani scoring system. The Pirani scoring system, together with the Ponseti method of club foot management, was assessed for its predictive value. METHODS It was a hospital-based prospective study of 57 club foot in 41 patients designed to evaluate the role of Pirani score in deformity assessment and management of club foot by Ponseti method. Consecutive patients presenting at the outpatient department at SVRRGGH, Tirupati with idiopathic club foot, and in-patients department with idiopathic club foot were recruited into the study. Informed consent was obtained from parents/guardians of the patients that were recruited in the study. This was a prerequisite for obtaining the ethical approval. Data collected from the study groups was entered into a worksheet, and analysis was performed using the statistical package for social sciences (SPSS) software for windows version 21. Significant statistical inferences were drawn at p & lt ; 0.05. RESULTS The correlation between the midfoot score, hindfoot score, Pirani score and the number of casts to achieve correction was significant (P = 0.001). Also, there was correlation between the Pirani score and the need for tenotomy (P = 0.001); between the number of casts to achieve correction and the need for tenotomy (P = 0.001). Moreover, the progress of treatment can be monitored with the Pirani score (P = 0.001). CONCLUSIONS Pirani scoring system is a simple, easy, quick and reliable system to determine severity and monitor progress in the treatment of club foot with excellent interobserver variability. KEYWORDS Pirani Score, Club Foot, Ponseti Method

Effectiveness of Ponseti Versus Kite Method for the Management of Club Foot- A Quasi Experimental Trial

Objective: To determine the effectiveness of ponseti versus kite method for the management of club foot among children. Methods: A quasi experimental trial was conducted to determine the most effective conservative method for managing idiopathic club foot. This study was carried out in District Head Quarter Hospital, Layyah. A total of 46 children (60 Feet) aged less than six months of both genders were included in this study using convenience sampling technique. The study sample was divided into Group A (Ponseti) and Group B (Kite). Each treatment group comprises of 30 feet. Patients were called for weekly follow up till ten weeks consecutively. At every follow-up visit, patients were assessed to check the improvement of deformity with the help of the Pirani scoring system for the foot. Pirani score difference was measured in both treatment groups from the baseline until the last follow-up interval until the 10th Week. Pirani score difference was measured in both treatment groups from the baseline until the last follow-up interval until the 10th Week. A greater negative value signified better correction. SPSS 23 was used for data entry and analysis. Results: Children's mean age in both treatment groups (A and B) was 10.83±4.59 and 10.20±4.75 weeks. At presentation mean Pirani score in both treatment groups (A and B) was 5.85±0.67 and 5.86±0.45, respectively, while at 10th follow up it was 1.42±0.39 and 2.35±0.54 for group A and group B, respectively. Conclusion: This study demonstrates that the Ponseti technique significantly improved the management of club foot as that of the Kites method. Ponseti's method is more effective in terms of rapid improvement in the involved group. Key words: Non operative Management, Idiopathic Club foot, Kites method, Ponseti method.

Effectiveness of an Indigenous Orthosis for the Management of Congenital Talipes Equino Varus - A Case Study

Background: Although the orthotic treatment of CTEV has mixed evidence, still it remains the mainstay of conservative management (Ponseti Casting Technique) in economically developing countries, where bracing is a critical component of the current standard of treatment for CTEV or clubfoot. Objective: Thus this study aimed to design a cost-effective Indigenous Orthosis for the Management of Congenital Talipes Equino Varus with Ankle foot orthosis. So that it can avoid unnecessary wearing of CTEV shoes. Study design: A case report Methods: The subject reported was a 2-year-old male child with a Pirani score of 5 congenital bilateral CTEV deformity. An Indigenous CTEV Orthosis with the combination of AFO and Denis Browne Splint was designed by the clinical team and the subject was followed prospectively for the next 1 year using the orthosis. Results: The Pirani score of 2 was achieved after the use of this Indigenous CTEV Orthosis which was 5 before using the orthosis. Conclusion: Indigenous Orthosis can be considered as a very excellent orthosis for the orthotic management of CTEV. As this orthosis fulfills all the desired function with some additions like lightweight, inexpensive, better correction of the angulations and the most important thing are that there is no need to wear any kind of shoes. Key words: CTEV, Pirani Score, AFO, Denis Browne Splint, Indigenous CTEV Orthosis.

Comparative analysis of correction of idiopathic congenital talipes equinovarus by conventional and accelerated Ponseti method with minimum 12 months follow up in a tertiary care hospital in North India

Background: Congenital talipes equinovarus varus (CTEV) is one of the most common congenital anomalies of foot and ankle affecting 1/1000 live birth approximately. With a male dominance pattern, this deformity is bilateral in 50% cases. It has four basic components: cavus, adduction, varus and equinus. Severity of clubfoot is accessed using Pirani score (0 to 6). Insights into the basic pathoanatomy of this complex 3 dimensional deformity has helped to correct it using the method given by Ignacio Ponseti, a Spanish orthopaedician, in which serial manipulations of foot are done and weekly casts are applied, followed by a tendoachilles tenotomy in selected cases to correct the equinus component which is then followed by splintage of the feet in Steenbeek splint initially for 23 hours day for 3 months and then 12 hours a day for 3 years. The most important component of this treatment is parental counselling regarding the need for compliance with treatment which is often loophole responsible for relapse in initially corrected feet.Methods: This was a prospective study including 40 patients (61 feets) of idiopathic clubfoot with age <3 month at presentation who were randomly distributed in two groups, group 1 (accelerated Ponseti casting group) in which twice weekly casts were applied and group 2 (standard Ponseti casting group) in which weekly casts were applied. Initial Pirani score was calculated in all the patients and was rechecked and documented in every successive visit. All the patients were followed upto 12 months and there was no lost to follow up in this study.Results: The mean days of plaster duration in accelerated casting group was 18.45 days as compared to 47.25 days in standard casting group (statistically significant, p value <0.05). Also, Pirani score at the end of last follow up was comparable in both the groups. Tenotomy rate was slightly higher in accelerated casting group (89.5%) as compared to standard group (85.7%) which may be attributed to higher initial Pirani score in former (5.5) as compared to later (5.0).Conclusions: Accelerated biweekly Ponseti casting reduces the overall days of treatment with similar results compared to standard weekly casting regime.

Can clubfoot scoring systems predict the number of casts and future recurrences in patients undergoing Ponseti method?

Background Congenital clubfoot is one of the common congenital orthopaedic deformities. Pirani and Dimeglio scoring systems are two classification systems for measuring the severity of the clubfoot. However, the relation between the initial amount of each of these scores and the treatment parameters is controversial. Methods Patients with severe and very severe idiopathic clubfoot undergoing Ponseti treatment were entered. Their initial Pirani and Dimeglio scores, the number of castings as a short-term treatment parameter, and the recurrences as a long-term parameter until the age of three were prospectively documented. Results One hundred patients (143 feet) with mean age of 9.51 ± 2.3 days including 68 males and 32 females and the mean initial Pirani score of 5.5 ± 0.5 and the mean initial Dimeglio score of 17.1 ± 1.6 were studied. The incidence of relapse was 8.4 %( n = 12). The mean initial Pirani score (P < 0.001) and the mean initial Dimeglio score (P < 0.003) of the feet with recurrence were significantly more than the non-recurrence feet. The mean number of casts in the recurrence group (7 ± 0.9) was significantly more than the feet without recurrences (6.01 ± 1.04) (P = 0.002). The ROC curve suggested the Pirani score of 5.75 and the Dimeglio score of 17.5 as the cut-off points of these scores for recurrence prediction. Conclusion In our study, Pirani and Dimeglio scores are markedly related with more number of casts and recurrence in patients with severe and very severe clubfoot. Also, we have introduced new cut-off points for both classification systems for prediction of recurrence. To the best of our knowledge, this finding has not been introduced into the English literature.

A COMPARATIVE STUDY TO EVALUATE THE OUTCOME OF PONSETI'S TECHNIQUE AND ACCELERATED PONSETI'S TECHNIQUE FOR CORRECTION OF CLUBFOOT

Introduction: Clubfoot is a common congenital deformity with incidence of1-6.8/1000 live births. Ponseti method is currently the gold standard for treatment of clubfoot which conventionally involves weekly plaster changes. A prospective comparative study was carried out at our hospital where we compared one group with weekly plaster change to other group with twice weekly plaster change, using the classical Ponseti protocol of manipulation. A total 50 feet (36 children ), divided into two Methods: groups, were randomly allocated to either Group 1 – 25 feet(accelerated Ponseti) or Group 2 – 25 feet (standard Ponseti). Group 2 underwent serial manipulations and casting once a week and Group 1 received manipulations and castings twice a week. Pirani score was documented at the time of presentation, after each cast, and at the time of removalof nal cast to assess the success of treatment ( Pirani score ≤1). A tota Results: l 43 feet (29 patients) underwent the entire course of treatment, while 7 patients discontinued the treatment during the course of the study. 14 patients, i.e, 21 feet were treated with Accelerated Ponseti Protocol (APP),i.e Group -1, and 15 patients, i.e, 22 feet were treated with Standard Ponseti Protocol (SPP), i.e Group-2. Mean duration of treatment from the rst cast to tenotomy in the accelerated ponseti protocol group was 20.57 ± 4.5 days (ranging from 12 to 29 days), and in standard ponseti protocol group was 39.66 ± 6.9 days (ranging from 29 to 51 days). Conclusion: Both the methods proved to be equally efcacious for the management of clubfoot in our study. However, the accelerated method had an overall shorter treatment duration making it convenient for the parents. As the patient is under direct observation of surgeons, complications, in any, are detected early and easily. Overall, the accelerated technique is more practical, benecial, and equally efcacious as standard ponseti technique, providing a more rapid correction of the deformity.