Rev. bras. ortop. vol.51 número3

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

Article

Treatment

of

congenital

clubfoot

using

Ponseti

method

夽

Alceu

José

Fornari

Gomes

Chueire

∗

_,

_Guaracy

_Carvalho

_Filho,

_Otto

_Yosuke

_Kobayashi,

Leonardo

Carrenho

DepartmentofOrthopedicsandTraumatology,FaculdadedeMedicinadeSãoJosédoRioPreto(Famerp),SãoJosédoRioPreto,SP,Brazil

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Articlehistory:

Received30May2015 Accepted18June2015 Availableonline4May2016

Keywords:

Clubfoot

Lowerextremitydeformities Congenital

Manipulation Orthopedic Treatmentoutcome

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Objective:Toquantitativelyandqualitativelyanalyzetheresultsfromtreatmentof congen-italclubfootwithameanfollow-upof4.6years.

Methods:26patientswhounderwenttreatmentbymeansofthePonsetimethodwere ana-lyzed(totalof39feet).Themeanageatthestartofthetreatmentwas5.65months.The meanlengthofthefollow-upsubsequenttotenotomyoftheAchillestendonwas4.6years. Patientswithsecondaryclubfootwereexcluded.Epidemiologicaldata,radiographic mea-surementsontheKiteangleanddatafromasatisfactionquestionnaireandtheLaaveg questionnairewereanalyzed.

Results:Amongthe26patientstreated,onepresentedrecurrenceofthedeformityandhad toreturntothebeginningofthetreatment.Themeanscorefromthequestionnaireand physicalexaminationwas89.76points,andthisresultwasconsideredgood.99%ofthe patientsrespondedthattheirfeetneverhurtorhurtonlyupongreatactivity;88%saidthat theirfeetdidnotlimittheiractivities;and96%saidthattheywereverysatisfiedorsatisfied withtheresultsfromthetreatment.ThemeanKiteangleinanteroposteriorviewwas28.14◦ anditwas26.11◦_in_lateral_view.

Conclusion: TreatmentforidiopathiccongenitalclubfootbymeansofthePonsetimethod bringsbetterresultstogetherwithlesssoft-tissueinjury,thusconfirmingtheeffectiveness andgoodreproducibilityofthismethod.

夽

StudyconductedattheDepartmentofOrthopedyandTraumatology,FaculdadedeMedicinadeSãoJosédoRioPreto(Famerp),São JosédoRioPreto,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:afchueire@gmail.com(A.J.F.G.Chueire). http://dx.doi.org/10.1016/j.rboe.2015.06.020

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Resultados: Dos 26 pacientes tratados, um apresentou recidiva da deformidade, foi necessárioretornaraoiníciodotratamento.Apontuac¸ãomédiadoquestionárioedoexame físicofoide89,76,resultadoconsideradobom;99%dospacientesresponderamqueospés nuncadoemoudoemsomenteaosgrandesesforc¸os;88%responderamqueopénãolimita asatividades;96%responderamqueestãomuitosatisfeitosousatisfeitoscomosresultados dotratamento.AmédiadoângulodeKitenaincidênciaanteroposteriorfoide28,14◦_e_no perfil26,11◦_.

Conclusão:OtratamentoparapétortocongênitoidiopáticopelométodoPonsetiéoquetraz melhoresresultadosassociadoamenorlesãodepartesmoles,oqueconfirmaaeficáciae aboareprodutibilidadedométodo.

Introduction

Congenital clubfoot (CCF), also known as congenital tal-ipesequinovarus,isthemostcommonorthopedicdeformity thatrequiresintensivetreatment1_and_affects_{approximately} 1:1000livebirths.2

Itisacongenitaldysplasiaofallmusculoskeletalstructures (muscles,tendons,ligaments,osteoarticularand neurovascu-larstructures)distaltotheknee.1_The_foot_presents_equinus, cavus,varusandadductedpositions,andissupinated.

CCF etiology may be associated with myelodysplasia, arthrogryposis,ormultiplecongenitalabnormalities,butthe mostcommonpresentationistheisolateddeformity,which isconsideredtobeidiopathic.Manytheorieshavebeen pro-posed to explain the etiology of idiopathic CCF. They are relatedwithvascularimpairment,externalfactors (intrauter-ine positioning), abnormal muscle insertions, and genetic factors.3 _In _normal _fetal _development _of _the _lower _limbs, betweenthe 6thand 8th weekofintrauterinelife,feet are similar to clubfeet (equinus, cavus, varus, adducted, and supinated),butbythe12thweekthe feetmovetothe nor-malposition.Thismeansthattheconditionmay bedueto thepermanenceofthefootpositionatthebeginningof devel-opment.ItissafetostatethattheCCFetiologyismultifactorial andmodulatedbychangesinembryonicdevelopment.1

CCF treatment has been a challenge to orthopedic sur-geons.Thefirsttreatmentreportscomefromthe19thcentury, withtheuseofdevicesforforcedmanipulations.Inthe1980s and1990s,soft-tissueposteromedial releasesurgeries were

performed.Thisproceduresyieldedpooroutcomes,with stiff-ness,pain,andfunctionalimpairmentofthefoot.4

ThePonsetimethodiswidespreadworldwide.Itconsists ofaseriesofmanipulationsandimmobilizations,aswellas AchillestenotomytocorrectCCFdeformities.Aftertenotomy, anorthosisisusedtomaintainthecorrectionobtainedand preventrecurrence.3,5–7

Thisstudyaimedtoquantitativelyandqualitatively ana-lyze the results of treatment for CCF performed by the PediatricOrthopedicsteamofourservice.Dataanalysisrefers topatientsonwithmeanfollow-upof4.6years.Throughthe dataobtained,thedegreeofefficiencyandsatisfactionwith thetreatmentinourservicewereassessed.

Methods

TheresearchprojectwasapprovedbytheMedicalEthics Com-mitteeoftheinstitution.

Thestudyretrospectivelyevaluated26patientsundergoing CCFtreatmentwiththetechniquedescribedbyPonseti,5_from August2003toMay2012,comprisingatotalof39feet.The meanageoftreatmentonsetwas5.65months(1monthto3 yearsand10months).Themeanfollow-uptimeafterAchilles tenotomywas4.6years(3monthsto8.58years).

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Fig.1–Kiteangleinanteroposteriorview.

numberofplastercastexchanges, ageat(anddateof) the Achillestenotomy,andtheneedforotherprocedures.

Afterreviewingthemedicalrecords,patientswerereferred foroutpatientfollow-up,whengaitandrangeofmotionwere assessed,andansweredtheevaluationquestionnaire devel-opedbyLaavegand Ponseti8 _(Appendix_1)._{Anteroposterior} andlateralradiographicimagingofthetreatedfeetweremade tomeasuretheKiteangle(talocalcanealangle;Figs.1and2). Beforeansweringthequestionnaireandundergoingphysical examination,patientswereinformedaboutthestudyandthe parent/guardiansignedtheinformedconsent.

Ponsetimethod

This technique, developed by Ignacio Ponseti, combines manipulation, serial plaster cast immobilizations, percuta-neousAchillestenotomy,andabductionorthosis.

Manipulations and immobilizations were conducted by residentsof the OrthopedicSurgeryteam inan outpatient

Fig.2–Kiteangleinlateralview.

Fig.3–Longlegplastercastcorrectingcavus,varus,and adduction.

clinic, under the supervision of an experienced pediatric orthopedicsurgeon.

Thecastchangesweremadeweeklyoreverytwoweeks, accordingtotheevolutionaspect,andalwaysstartedbycavus correction,followedbygradualcorrectionoftheadduction, supination,andvarus(Fig.3).

After correction of the cavus, varus, adduction and supination,thepercutaneousAchillestenotomyforequinus correctionwasscheduled.

Achillestenotomieswereperformedinthesurgeryward withpatientsundergeneralanesthesiabytrainingresidents, underthesupervisionofanexperiencedpediatricorthopedic surgeon.

Afterasepsisandantisepsisofthesurgicalsite, percuta-neousAchillestenotomywasperformedwithaNo.11scalpel blade.Aftersutureanddressing,alonglegplastercastwas placedtomaintainthecorrectionachievedbysurgery.

After three weeks of tenotomy, the plaster cast was removedandtheuseaDenis-Browneabductionorthosiswas initiated,with70◦_of_external_rotation_for_the_pathological_foot

and40◦_for_the_normal_foot,_used₂₃_h/day_in_the_first_three

months,andthenonlyatnight(12–14h/day)untilfouryears ofage.

Results

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Fig.4–Seven-year-oldpatient,fiveyearsafterAchillestenotomy.

months).Themeannumberofplastercastusedwas8.3per patient,rangingfrom3to14.

Ofthe26patientstreated,onehaddeformityrecurrence. In this case, it was necessary to resume treatment from the beginning, with new serial casting and new Achilles tenotomy.

Themeanscoreofthequestionnaireandphysical exami-nationwas89.76,rangingfrom69to100(Appendix2).

Theresultswereclassifiedasexcellentwhenthescorewas between90and100points;good,80–89;fair,70–79;andpoor, lowerthan70.

Fiftysevenpercentofthepatientsansweredthattheirfeet neverached; 42%hadpainonexertion; 88%answeredthat thefootdidnotlimittheiractivities;7%reportedoccasional limitationsduringactivities;5%reportedfrequentlimitations duringactivities;73%saidtheywereverysatisfiedwiththe resultsoftreatment;23% were satisfied;4%reportedbeing neithersatisfiednordissatisfied(Fig.4).

Themeanpassivemotionscorewas7.61,rangingfrom2 to10.

ThemeananteroposteriorviewKiteangleofrightfeetwas 28.62◦_and_of_left_feet,_27.68◦_._Mean_lateral_view_Kite_angle_of

rightfeetwas27.34◦ _and_of_left_feet,_24.93◦_._The_mean

over-allanteroposteriorviewanglewas28.14◦_,_and_mean_overall

lateralview26.11◦_.

Discussion

ThePonsetitechniqueforthetreatmentofCCFhasbeen avail-ableandusedforover50years,butithasgainedpopularity onlyinrecentdecades.9

Boretal.9 _conducted_a_study_in_which₇₄ _patients_were treatedwiththePonsetimethodandwerefollowed-upfora meanof6.3years.TheyassessedfootmotionandappliedaDSI questionnaire,inwhichallpatientsshowedhighsatisfaction withtheendresultand89%presentedgoodfootmotion.In thepresentstudy,themeanpatientfollow-upaftertenotomy was4.6years,andthequestionnaireandphysical examina-tion developedby Laavegand Ponsetiwere assessed.8 _The resultsofthe questionnaireandphysicalexaminationwas 89.76points,classifiedasagoodscore.

In a study that compared the results of surgical treat-mentbyopenCCFreleasewiththoseobtainedbyLaveegand Ponseti,8_Dobbs_et_al.10_observed_a_mean_score_of_65.3_points

versus87.5points,andexcellentandgood resultsin33%of patientsversus74%respectively.Theyreportedthatpatients treatedwithopensurgerypresentedweaknessinthe tibio-tarsal andsubtalar joints,arthritis, lossofmuscle strength (especiallythesuraltriceps),painandresidualdeformity.They also reported need of furthersurgery in 47% of cases.11,12 Nonetheless,theauthorsindicatedthatthisistheonlyoption incaseoffailuretothePonsetimethod.

Ipolitoet al.13 _compared_the _Ponseti_method_to_another method(Marino-Zuco)anddemonstratedtheeffectivenessof theformerindeformitycorrectionusingonlyasimpleAchilles tenotomy,incontrastwiththelattermethod,whichrequired moreaggressivereleasesurgeriesthatinfluencedtheoutcome of thetwo groups (78%vs. 43% excellent and good results respectively).

Ponsetietal.6_published_a_study_with₃₂₂_CCF_cases_treated by their team, including not onlyidiopathic CCF, but also patients with neurological diseases and arthrogryposis, in which most had severe clubfeet. Due to the greater sever-ityofdeformities,56%presentedrecurrences;ofthese,18% hadasecondrecurrenceand10%hadathirdrelapse, need-ing notonlyAchillestenotomy, but alsomedialsofttissue release.6_In_the_present_study,_all_patients_had_idiopathic_CCF, whichisconsideredtobethemildestform,withthebest treat-mentoutcomes.Inourseries,onlyonepatienthaddeformity recurrence,requiringtorestartthetreatment,withnewserial castingandnewAchillestenotomy.

Conclusion

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Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Appendix

1. CCF

Questionnaire

–

Ponseti

method

Patient: Chart:

Birth date:

Mother's Name:

Telephone:

Age at start of treatment:

Side : ___ Right ___ Left ___ Bilateral

Had been treated in another hospital before: ___ Yes ___ No

Comorbidities: ___ Yes ___ No

If yes, which?

Submitted to another surgical procedure:

Number of casts before tenotomy:

Date of tenotomy:

Age at tenotomy:

Required any other surgical procedures for correction of foot deformity:

___ No

___ Yes

Which? Date?

CCFfunctionalassessmentscale–Laaveg,Ponseti. Satisfaction(20points)

I’m

• Verysatisfiedwiththeendresult(20points)

• Satisfiedwiththeendresult(16points)

• Neither satisfied nor unsatisfiedwith the end result(12

points)

• Unsatisfiedwiththeendresult(8points)

• Veryunsatisfiedwiththeendresult(4points)

Function(20points) Inmydailylife,myclubfoot

• Doesnotlimitmyactivity(20points)

• Occasionallylimitsmystrenuousactivities(16points)

• Usuallylimitsmeinstrenuousactivities(12points)

• Limitsmeoccasionallyinroutineactivities(8points)

• Limitsmeinwalking(4points)

Pain(30) Myclubfoot

• Isneverpainful(30points)

• Occasionallycausesmildpainduringstrenuousactivities

(24points)

• Usuallyispainfulafterstrenuousactivitiesonly(18points)

• Isoccasionallypainfulduringroutineactivities(12points)

• Ispainfulduringwalking(6points)

Positionofheelwhenstanding(10points)

• Heelvarus0◦orsomevalgus(10points)

• Heelvarus0–5◦(5points)

• Heelvarus6–10◦(3points)

• Heelvarusgreaterthan10◦(0points)

Passivemotion(10points)

• Dorsiflexion–(1pointforevery5◦(maximum5points))

• Totalvarus–valgusmotionoftheheel(1pointforevery10◦

(maximum3points))

• Totalinversion–eversionoffoot(1pointper25◦(maximum

2points))

Gait

• Normal(6points)

• Cantoewalk(2points)

• Canheelwalk(2points)

• Limp(−2points)

• Noheelstrike(−2points)

• Abnormaltoe-off(−2points)

Physicalexam:

• Dorsiflexionankle

• Heelvarus–valgus

• Inversionandeversionoftheforefoot

• Heelorthostatismposition

• Metatarsaladductioninorthostaticposition

Radiologicalassessment(AP+lateral) Anteroposterior:

• Talocalcanealangle–assessesthevarus–valgusofthe

hind-foot

Lateral:

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10

10 21/08/2003 1m bilatnão 9 18/01/2004 não 20 20 24 3+2+1=6 10 20 22 20 24 90 20

26 10

5+3+2=10

10

10 30 20 20 não

10/05/2005 7 não dir 20/12/2004 1m rho

11 100

12 11/07/2005 1m bilatnão 6 05/11/2005 não 20 16 24 5 3+3+2=8 10 21 20 22 24 83

13 13/03/2008 1m dir não 5 29/07/2008 não 20 20 30 5+3+2=10 10 32 43 100

14 11/05/2007 1m esq não 10 15/12/2007 não 20 20 24 5 3+2+1=6 10 22 25 85

15 28/06/2006 1m esq não 7 03/12/2006 não 20 20 30 5+3+2=10 10 32 29 100

16 10/08/2008 1m bilatnão 9 02/02/2009 não 20 20 30 5 5+2+2=9 10 28 30 38 42 94 17 13/01/2009 1m bilatnão 7 11/06/2009 não 20 20 30 5+3+2=10 10 22 28 25 30 100 18 11/05/2005 1a5m esq sim 6 15/07/2007 2a2m não 20 20 30 3+2+1=6 8 35,7 18,9 94 19 13/02/2009 2a3m bilatnão 14 23/04/2012 3a2m não 20 20 30 3+2+1=6 8 30 32 24 28 94 20 07/07/2003 1m bilatnão 10 07/01/2004 6m não 20 20 24 5+3+2=10 10 23 26 27 30 96 21wrgf 29/07/2007 2m bilatnão 14 04/05/2007 11m não 16 20 24 3 0+1+1=2 6 29,1 36,3 14,1 14,5 71 22 05/04/2004 2m esq não 10 09/12/2004 8m não 20 20 30 3+3+2=10 10 29,3 15,8 100 23 23/01/2007 1m bilatnão 7 24/05/2007 4m sim 12 16 30 5 3+3+1=7 6 32 17 28 26 76 24 13/09/2006 esq não 20 12/03/2007 6m não 16 12 24 5 2+3+2=7 10 32 15 74

25 13/04/2007 1m esq não 13 23/08/2007 4m não 16 20 30 0+3+2=5 6 27 15 87

26 26/06/2005 2a3m dir não 9 12/01/2008 2a7m não 20 20 24 2+3+2=7 8 30,3 20,4 89 2334 krm

lmb rmc

chbs

sff

jlpv

kns

acm gfs

dms rpcm

mpp hpb

2m

4m

4m 5m 7m

6m

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