Postcasting orthotic protocol retooling could improve Ponseti technique success rates

Ramirez N. J Pediatr Orthop. 2011. doi: 10.1097/BPO.0b013e318221eaa1

Success rates in treatment with the Ponseti technique can be improved through a reevaluation of the postcasting orthotic protocol, according to researchers in New York.

Norman Ramirez, MD, and his team treated 73 idiopathic talipes equinovarus feet with the Ponseti technique, following patients for 48 months after the completion of cast treatment. Twenty patients (38%) were reported as having bilateral involvement. Manipulation and casting treatments went on for a mean of 6 weeks, with 38 patients requiring Achilles tenotomy. A deterioration in Dimeglio severity score that required remanipulation and casting was considered the definition for recurrence in the study.

According to the study results, 24 of the 73 feet (33%) in the study displayed evidence of recurrence. The majority of demographic data did not demonstrate a significant correlation to risk of recurrence, but the authors noted that noncompliance with use of the orthotic was significantly correlated with recurrence rate. Demographics were not found to have any correlation with noncompliance rate.

“The use of the brace is extremely relevant with the Ponseti technique outcome (recurrence) in the treatment of idiopathic talipes equinovarus,” the authors wrote. “The Ponseti postcasting orthotic protocol needs to be reevaluated to a less demanding option to improve outcome and brace compliance.”

This article articulates issues that Ponseti devotees worldwide experience. They cite the method as new. The Ponseti technique was new in response to open surgery over 50 years ago and was first reported in the early 60's. It is now the preferred method of initial management of clubfeet internationally and has been instrumental in Pediatric orthopaedist preforming better manipulation and casting techniques with greater successes. The technique works well when performed as described. The feet are more subtle, with less residual deformity when managed as described by Ponseti.

The current authors as well as others have to be aware that the open surgery of the 70's to 90's came about when there was reevaluation and change of the Ponseti principles and the slippery slope they may descend in their quest to "modify" the established technique, a process not unknown to Pediatric orthopaedist.

Recent reports of earlier Achilles tenotomies and anterior tibialis tendon transfers may take us back to the future with an advancing approach to more aggressive surgeries. The need for bracing post cast and/or tenotomy correction remains an integral aspect of its success. The authors have proven in their population compliance to bracing is more of a human problem, has little to do with economics, education or culture and is indeed a relevant problem to obtaining consistent success.

— Alvin H. Crawford, MD
Crawford Spine Center
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio