111

CASE SERIES
Ponseti treatment for idiopathic clubfoot deformity — Role of secondary care
hospitals
Shahid Muhammad Khan, Safdar Muhammad Khanzada

Abstract ankle equinus. In maintenance phase foot abduction

Ponsetti method has an excellent outcome in the brace is worn for 2-3 years to maintain the correction.12
management of club foot. The presented case series will Using Ponseti method correctly including initial casting,
spread awareness by showing the results of this compliance with brace and treatment of recurrence by
technique used in secondary care centers, to share the recasting and/or Achille's tenotomy the success rate was
burden of care from tertiary care hospitals. A descriptive reported to be 93%.13 Severity of club foot deformity is
case series was conducted at Shah Bhitai District most commonly assessed by Pirani scoring system.14 A
Government Hospital, Hyderabad Sindh. Patients total score of six represents a severe clubfoot with a score
presenting with Idiopathic Clubfoot between birth and 12 of zero representing a normal foot.
months of age of either sex were included. The patients
In this study we are sharing short term results of our
were followed for 5 months from the removal of their last
experience with the Ponseti method in correcting
cast. We were able to achieve correction in 80.6 % of the
idiopathic clubfoot deformity in a secondary care center
patients. Tendo Achilles tenotomy was performed in
to attract other secondary care centers to offer the same,
90.3% of the patients. Ponseti method is a reliable and
so that burden of care can shared from tertiary care
efficient way to manage club foot deformity. Spreading
hospitals. Objective of this study is basically spreading the
this message among primary and secondary health care
systems will help to overcome this problem more awareness regarding the management of club foot by
effectively. Ponseti method in secondary care centers where
appropriate concerned faculty and staff is available.
Keywords: Ponseti method, idiopathic club foot,
Secondary care hospital. Cases
The study was conducted at Shah Bhitai District
Introduction Government Hospital, Hyderabad Sindh, from December
Idiopathic club foot deformity is a disabling problem with 2013 to November 2014. It was a descriptive case series
an incidence of 0.9/1,000 live to 7/1,000 live births with study. This center is offering multidisciplinary services in
approximately 50 % cases involving bilaterally.1,2 Different the field of medicine, surgery and allied specialties.
techniques for management are in practice, most Patients presenting with Idiopathic Clubfoot between
involving manipulation and casting. In many institutions, birth and 12 months of age of either sex were included in
manipulation and serial casting require many months of the study. Patients having other congenital problems like
treatment and frequently result in incomplete or Arthrogryposis, Meningomylocele, spina bifida and
defective corrections.3,4 As a result, extensive corrective patients who had undergone previous surgical treatment
surgery is indicated in 50% to 90% of the cases, often with for management of club foot were excluded from the
disturbing failures and complications.5-9 In 1950s, Ignacio study. Course of treatment, including possible need of
Ponseti (1914-2009), a Spanish physician developed the Achille's tendon tenotomy, was explained to the parents
Ponseti Method for the non-operative treatment of and a written informed consent was taken. All the patients
clubfoot.10 Currently this method is the gold standard of were managed by qualified orthopaedic specialists.
clubfoot treatment.11 Ponseti method comprises of two Patients were classified according to the Pirani scoring
phases, treatment and maintenance phase. In treatment system14 and then manipulation followed by weekly
phase serial manipulations and casting are done to above-knee castings were done. Two days in a week were
gradually correct the deformity and a percutaneous fixed for cast application in OPD so that patient's families
tenotomy of the Achilles tendon to correct the residual could also interact with each other and share their
experience. On an average of 4th to 6th cast, application,
Shah Bhitai District Government Hospital, Hyderabad, Sindh. equinus was assessed and if required percutaneous
Correspondence: Shahid Muhammad Khan. Email: khan.shahid1945@gmail.com Achilles' tenotomy under local anaesthesia was done and

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112 S. M. Khan, S. M. Khanzada

cast was re-applied. Patient's progress was monitored

regularly every week by Pirani scoring system. The final
outcome (as indicated by Pirani score) was recorded at the
time of removal of final cast. Feet were then placed in the
foot abduction brace. Parents were advised to keep the
feet of the child in the brace for 23 hours in a day for the
first 3 months and then for 12 to 14 hours during the night
and napes for the next 3 years. The patients were followed
till 5 months from the removal of their last cast. After
starting brace treatment, patients were called first at two
weeks for the first month and then every 4 weeks for the
following 4 months. Data was analyzed with the help of
SPSS version 10.

Results Figure-2: Child underwent Ponseti treatment and deformity gradually improved.
Out of 31 patients, there were 19 (61.3%) male and 12
(38.7%) female patients (Table-1). Right side was involved
in 14 (45.2 %) patients, left side in 7 (22.6%) patients while
10 (32.3%) patients had bilateral deformity. Family history
of club foot was positive in 16% patients (5 out of 31).
Mean age of the patients at start of treatment was

Table-1: Results.

Total number of patients 31

Male 19 (61.3%)
Female 12 (38.7%)
Family history of club foot Positive in 5 (31%)
History of previous treatment Present in 64.5%
Bilateral involvement 10 (32.3%)
Right foot involvement 14 (45.2%)
Left foot involvement 7 (22.6%)
Mean Pirani score at start of treatment 5.71±0.52 (Range 4-6).
Mean age at start of treatment 5.58±5.16 weeks (Range 1-28 weeks) Figure-3: After 4 casts. Same child after completion of treatment with full correction
Total number of casts required (mean) 6.29±0.93 (Range 5-9) of deformity.
Tendo Achilles Tenotomy required 90.3% patients

5.58±5.16 weeks (Range 1-28 weeks). Patients had a

history of different types of treatment before presentation
to our institute. Seven (22.6%) patients had history of
serial manipulations alone, 9 (29%) patients had
manipulation and below knee casting, 4 (12.9%) patients
had above knee casting while 11 (35.5%) patients had no
treatment. Mean Pirani score at start of treatment in our
institute was 5.71±0.52 (Range 4-6). Average number of
casts applied (per patient) to achieve correction was
6.29±0.93 (Range 5-9). Tendo Achilles tenotomy was
performed in 90.3% of the patients (28 out of 31 patients).
Timing of Tendo Achilles tenotomy was after the 4th cast
in 61.3% of the patients, after 3rd cast in 32.3% of the
patients and after 5th cast in 6.5% of the patients. We
were able to achieve correction (i.e. Pirani score < 1) in 25
Figure-1: A child with typical club foot deformity involving left foot at presentation. (80.6 %) (Figure-1-4). In rest of the 6 cases who developed

J Pak Med Assoc

Ponseti treatment for idiopathic clubfoot deformity — Role of secondary care hospitals 113
other affected families to adopt this line of management
despite wide variety of treatment being available.
Another important aspect of this technique is that it can
be learned easily so the results can be replicated in other
institutions especially the secondary health care systems
where required faculty and staff is available. The
technique is especially suited for developing countries,
where people mostly belong to low socioeconomic
status, there are few skilled orthopaedic surgeons in
remote areas and where tertiary care centers are facing
enormous number of other serious health problems. By
increasing awareness for this technique among primary
and secondary health centers resources of tertiary care
Figure-4: The child in maintenance phase with shoe brace. system can be utilized for more complicated and difficult
health problems. Furthermore decrease travel time to a
secondary health center in comparison to a tertiary care
center results in decreased physical and financial burden
recurrent deformity (i.e. Pirani score > 2) 4 patients were
to the families and leads to increased compliance to the
lost to follow-up. Two patients who had recurrent
treatment which demands several visits that need to be
deformity were managed successfully with repeat
regular to achieve the desired results.20
manipulation and casting.

Discussion Conclusion
To conclude, Ponseti method for the treatment of club
The Ponseti method has shown excellent outcome for the
foot deformity is reliable and efficient which also radically
management of club foot and its ability to radically
decreases the need for traditional extensive corrective
decrease the need for extensive corrective surgery.15 The
surgeries. Spreading this message among primary and
technique is economical and easy to learn as well by allied
secondary health care systems will help to overcome this
health professionals.16
problem more effectively and will also help to share the
In this study we are sharing our experience with Ponseti burden of care from tertiary hospitals so that their
method of treatment for club foot deformity correction. resources can be utilized to address more difficult health
Mean number of casts required in our study was problems.
6.29±0.93 (Range 5-9) which was similar to other
studies.16,17 We were able to achieve correction of the Acknowledgements
deformity in 25 out of 31 patients (80.6 %). Similar results There are no acknowledgements.
have been shown by Kampa et al17 and Morcuende et al.18
Achilles tenotomy was done in 90.3% which is also
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J Pak Med Assoc