Effectiveness of Ponseti technique in management of arthrogrypotic clubfeet - a prospective study

Abstract

Background: Clubfoot constitutes roughly 70 percent of all foot deformities in arthrogryposis syndrome and 98% of those in classic arthrogryposis. Treatment of arthrogrypotic clubfoot is difficult and challenging due to a combination of factors like stiffness of ankle-foot complex, severe deformities and resistance to conventional treatment, frequent relapses and the challenge is further compounded by presence of associated hip and knee contractures.

Method: A prospective clinical study was conducted using a sample of nineteen clubfeet in twelve arthrogrypotic children. During weekly visits Pirani and Dimeglio scores were assigned to each foot followed by manipulation and serial cast application according to the classical Ponseti technique. Mean initial Pirani score and Dimeglio score were 5.23 ± 0.5 and 15.79 ± 2.4 respectively. Mean Pirani and Dimeglio score at last follow up were 2.37 ± 1.9 and 8.26 ± 4.93 respectively. An average of 11.3 casts was required to achieve correction. Tendoachilles tenotomy was required in all 19 AMC clubfeet.

Result: The primary outcome measure was to evaluate the role of Ponseti technique in management of arthrogrypotic clubfeet. The secondary outcome measure was to study the possible causes of relapses and complications with additional procedures required to manage clubfeet in AMC an initial correction was achieved in 13 out of 19 arthrogrypotic clubfeet (68.4%). Relapse occurred in 8 out of 19 clubfeet. Five of those relapsed feet were corrected by re-casting ± tenotomy. 52.6% of arthrogrypotic clubfeet were successfully treated by the Ponseti technique in our study. Three patients failed to respond to Ponseti technique required some form of soft tissue surgery.

Conclusion: Based on our results, we recommend the Ponseti technique as the first line initial treatment for arthrogrypotic clubfeet. Although such feet require a higher number of plaster casts with a higher rate of tendo-achilles tenotomy but the eventual outcome is satisfactory. Although, relapses are higher than classical idiopathic clubfeet, most of them respond to re-manipulation and serial casting ± re-tenotomy.

Keywords: Arthrogryposis multiplex congenita (AMC); Dimeglio score; Pirani score; Ponseti technique; clubfeet; relapse; tenotomy.

Figure 1

A, B. Pre-correction bilateral clubfeet in AMC child. C, D. Post correction image showing plantigrade feet after Ponseti technique.

Figure 2

A, B. Pre-correction bilateral clubfeet in AMC child. C, D. Post correction plantigrade feet after Ponseti technique.

Figure 5

Significant positive correlation between initial Pirani Score (pre-treatment PS) and initial Dimeglio Score (pre-treatment DS).

Figure 6

Shows significant positive correlation between Pirani Score at SFAB (post-treatment PS) and Dimeglio Score at SFAB (post-treatment DS).

Figure 3

A. Clinical image showing calcaneo-valgus foot on right side and equino-varus foot on left side in an AMC child. There was no significant correction despite Ponseti casting. B. Intra-operative image of showing soft tissue releases. C-E. Post correction image showing plantigrade feet from front, side and back.

Figure 4

A, B. Bilateral clubfeet in an AMC patient. C, D. JESS application for ligamentotaxis. E, F. Clinical image showing plantigrade feet.

Figure 7

A. Plaster cast slippage and breakage. B. Pressure Sore over Dorsal aspect. C. Sore over Dorsolateral aspect of foot. D. Eczematization with Scaling. E. Distal tibial metaphyseal fracture due to forced dorsiflexion.