Ponseti method for late presentation of clubfoot

Abstract

Dear Editor, We read with much interest the review article on clubfoot treatment with the Ponseti method by Radler [1]. The Ponseti method has found most use in developing countries where late presentation of clubfoot is also fairly common. Several papers now routinely recommend this technique up to two years of age and depict success rates almost equivalent to infants [2–9]. We would like to broaden the review to include clubfoot treatment by Ponseti method in older children with late presentation and raise some issues related to this extended use. A review of studies using the Ponseti technique for clubfoot in children over two years of age and their outcome is presented in Table 1. An interesting observation which has emerged from these studies is that the number of casts correlates poorly with increasing age. Spiegel et al. postulated that clubfeet in older child may be more supple as a result of weight bearing forces or other factors [4]. Table 1 Studies using the Ponseti technique for clubfoot in children > 2 years: success rate and relation with age With use of the Ponseti technique in older children, several new challenges have emerged. Initial severity scoring applicable in infants is problematic as there are no empty heel signs, distinct medial and posterior creases in walking children [4]. The Ponseti technique has also been adapted for older children. Manipulation time is increased, lesser foot abduction and dorsiflexion are acceptable, knee flexion in an above knee cast is decreased, cast duration is extended, different casting material is proposed, increased cast duration post tenotomy for tendo Achilles healing and an altered brace regime is suggested (Table 1). The surgical intervention has increased beyond percutaneous tenotomy with open Achilles tendon lengthening and posterior release added as modifications of the Ponseti technique in older children [4, 9]. Some series recommend an additional split tibialis anterior transfer at the time of equinus correction to tide over the brace compliance problem, while others do not recommend it [3]. An early and higher recurrence rate is documented in several series (29 % [3]; 23 % [8]; 19 % [5]; 24 % [7]). A total failure of treatment with the Ponseti technique in late presentation is also reported by observers (33.33 % [3]; 7.27 % [8]; 14.3 % [7]). Complications such as prolonged bleeding, erythema, swelling, redness of the skin due to excessive pressure, osteopenia, wound dehiscence, etc. are also described [2, 4]. Parents need more counselling as there is often little progress in the first three to four casts, a walking child becomes non-ambulatory for several months and requires supportive care of parents for daily activities, there is increased need for supplementary operations and brace compliance is difficult. Several questions regarding these adaptations of the Ponseti technique remain unanswered. Foremost is upper age limit for the technique. The oldest patient on record treated with this method is probably an 18-year-old girl with unilateral club foot [6]. Other important investigational issues are appropriate severity grading, ideal abduction and dorsiflexion definitions to prevent early recurrences, upper age limit for percutaneous tenotomy (up to ten years is reported), most appropriate technique for equinus correction in older children, definition of corrected foot and parameters of appropriate functional outcome and bracing. The preventive health care strengthening to reduce the number of neglected cases also remains a big challenge.