“The improved outcomes included better
range of motion, more normal
gait parameters, more normal radiographic parameters, and
better functional and subjective patient outcomes.” John E. Herzenberg,
MD, FRCSC, director of the International Center for Limb Lengthening, and chief
of Pediatric Orthopedics at Sinai Hospital, Baltimore said.
Herzenberg and colleagues retrospectively followed two groups of
patients who underwent clubfoot treatment. There were 26 patients (43 feet) in
the posteromedial release group, who ranged in age from 5 to 11 years and 22
patients (35 feet) who received the Ponseti treatment, ranging in age from 5 to
10 years. The researchers followed all patients for a minimum of 5 years.
Patients in the Ponseti group had an average of five casts, and 18
patients underwent Achilles tenotomy. After relapsing, five feet in the Ponseti
group needed additional casting, according to the abstract. Three feet required
surgery; there were two anterior tibialis tendon transfers and one Achilles
lengthening. The researchers obtained physical exam measurements,
pedobarographs, gait analyses and outcome measurements, which they compared
with the published values for normal feet.
Overall, the results showed poorer long-term results for the operative
group. Patients in the operative group had reduced dorsiflexion (-0.6°
± 8.6°; P < .01), while the Ponseti group had normal values (9.7° ± 5.2°). The operative group had significantly reduced calcaneal inversion/eversion (17.1° ± 8.7° vs. 37.6° ± 12.4°; P < .01) and midfoot abduction/adduction (14.4° ± 12.6° vs. 37.7° ± 16.9°; P < .01). Pedobarographs revealed residual varus in the operative group (-36.8 psi ± 24.7 psi; P < .01) and mild residual varus in the Ponseti group (-15.7° ± 18.9°; P < .01).
|After a 5-year follow-up, infants
with idiopathic clubfoot treated with the Ponseti method produced better
results than counterparts treated surgically.
|Image: Herzenberg JE|
Walking kinematics for both groups displayed mild limitations in
dorsiflexion/plantar flexion. The operative group had a significant limitation
in power generation (13.5 watts/kg +3.9 watts/kg; P < .01), whereas the Ponseti group had only a mild limitation (18.2 watts/kg ± 5.8 watts/kg; P < .01). The Ponseti group had significantly better pain/comfort and global functioning scores on the pediatrics outcome data collection instrument.
“Ponseti has taught us that careful casting, paying careful
attention to the Ponseti principles, results in a supple, strong foot,”
Herzenberg said. “Extensive surgical releases, on the other hand, often
lead to variable amounts of stiffness, scarring and weakness. In clubfoot, it
seems that for most patients, the less surgery, the better the outcome.”
However, the Ponseti method can involve surgery. About 90% of children
require an Achilles tenotomy, and 15% of children require anterior tibialis
tendon transfer to balance the foot, he said.
“But [it’s] much less invasive and aggressive surgery than
posteromedial release,” he said.
Worldwide, the popularity of the Ponseti method has eclipsed traditional
surgical treatments, Herzenberg said. And while there are many studies
describing the good short-, medium- and long-term results with the Ponseti
method, there is a dearth of research directly comparing it to surgery.
“To recommend one treatment method over another, we are obligated
to carefully and scientifically evaluate the two methods, side by side, looking
at similar populations, and using the same outcome measurements.”
— by Colleen Owens
For more information:
- Herzenberg JE. A comparison of children with clubfoot who underwent
surgical or Ponseti treatment. Presented at the 2011 Annual Meeting of the
American Academy of Orthopaedic Surgeons. Feb. 15-19. San Francisco.