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Long-term results for Ponseti clubfoot repair better than traditional surgical treatments
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The Ponseti method for treating pediatric idiopathic clubfoot produced better results compared with traditional posteromedial release, according to a minimum 5-year follow-up evaluation.
“The improved outcomes included better range of motion, more normal gait parameters, more normal radiographic parameters, and better functional and subjective patient outcomes.” said John E. Herzenberg, MD, FRCSC, director, International Center for Limb Lengthening, and chief of Pediatric Orthopedics, Sinai Hospital, Baltimore.
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.
Poorer long-term results
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Image: Herzenberg JE |
Overall, the results showed poorer long-term results for the operative group. Patients in the operative group had reduced dorsiflexion, while the Ponseti group had normal values. The operative group had significantly reduced calcaneal inversion/eversion and midfoot abduction/adduction. Pedobarographs revealed residual varus in the operative group and mild residual varus in the Ponseti group.
Walking kinematics for both groups displayed mild limitations in dorsiflexion/plantar flexion. The operative group had a significant limitation in power generation, whereas the Ponseti group had only a mild limitation. The Ponseti group had significantly better pain/comfort and global functioning scores on the pediatrics outcome data collection instrument.
‘Less surgery, better outcome’
“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.”
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
Reference:
- 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.
- John E. Herzenberg, MD, FRCSC, is director of International Limb Lengthening and chief of Pediatric Orthopedics. He can be reached at the Rubin Institute for Advanced Orthopedics, Sinai Hospital, 2401 W. Belvedere Ave., Baltimore, MD 21215-5271; 410-601-9562; e-mail: jherzenberg@lifebridgehealth.org.
- Disclosure: Herzenberg has no relevant financial disclosures.
