Correction of Arthrogrypotic Clubfoot With a Modified Ponseti Technique

Abstract

Surgical releases for arthrogrypotic clubfeet have high recurrence rates, require further surgery, and result in short, painful feet. We asked whether a modified Ponseti technique could achieve plantigrade, braceable feet. Ten patients (mean age, 16.2 months; range, 3-40 months), with 19 arthrogrypotic clubfeet, underwent an initial percutaneous Achilles tenotomy to unlock the calcaneus from the posterior tibia followed by weekly Ponseti-style casts. A second percutaneous Achilles tenotomy was performed in 53%. Mean number of casts was 7.7 (range, 4-12). From pretreatment to completion of initial series of casts, mean scores of Dimeglio et al. improved from 16 to 5 (ranges, 12-18 and 2-9, respectively), Catterall scores (as modified by Pirani and colleagues) from 4.8 to 0.9 (ranges, 1.5-6.0 and 0.0-2.0), and maximum passive dorsiflexion from À45°( range, À75°to À20°) to 10°(range, 0°to 40°). Ankle-foot orthoses maintained correction. At the minimum followup of 13 months (mean, 38.5 months; range, 13-70 months), the mean maximum dorsiflexion was 5°(range, -20°to 20°), two patients had posterior releases and no patient's ambulatory ability was compromised by foot shape. Arthrogrypotic clubfeet can be corrected without extensive surgery during infancy or early childhood. Limited surgery may be required as the children age.

Treatment of Foot Deformities in Arthrogryposis Multiplex Congenita

“…To date, we are aware of seven reports presenting the relatively short-term results of the Ponseti technique for the treatment of a total of 119 clubfeet in patients with amyoplasia and/or distal arthrogryposis [13][14][15][16][17][18][19] . The authors of those reports supported the thesis that conservative treatment of arthrogrypotic clubfoot should be started as soon after birth as possible, before the occurrence of adaptive changes of bones and periarticular soft-tissue contractures 8 .…”

“…In some patients, this allows the avoidance or delay of repeated operative interventions, which are known to have adverse effects, including increased scarring and stiffness [5][6][7][8] . To avoid these adverse consequences of excessive operative procedures, van Bosse et al postulated that orthopaedic surgeons should attempt to achieve the desired outcomes with as few procedures as possible and with use of the least ablative procedures possible 16 .…”

“…With the introduction of the method of Ponseti et al for the initial treatment of idiopathic clubfoot, the results improved substantially worldwide, making this protocol the treatment of choice-the so-called gold standard-for the treatment of classic idiopathic clubfoot as well as so-called neglected or recurrent complex deformities 10-12 . Starting in 2008, there have been reports of promising early results of the application of the Ponseti method for the treatment of foot deformities associated with arthrogryposis multiplex congenita [13][14][15][16][17][18][19] . Those reports may potentially change the traditional orthopaedic approach to the treatment of this condition.…”

Pé torto congênito

“…94 The Ponseti method 1,4,53 , composed basically of manipulations and serial plaster cast changes, percutaneous sectioning of the calcaneal tendon and use of abduction orthosis, has become the preferential method for the treatment of idiopathic CC in many countries, in the last ten years (Bor; Bor, 2002). With widespread acceptance, it was extended for use on older children [95][96][97][98] ; complex and resistant feet 99 ; relapsed feet 100 , including relapses after extensive surgical release 101 , and also, in non-idiopathic cases, such as in myelomeningocele 102,103 and distal arthrogryposis 104,105 . The grounds of the manipulation technique consist of correcting deformities by means of the plastic change of the contractured and shortened elements, which have a high elastic capacity in the younger child.…”

“…The Ponseti method has been used for the treatment of CC in arthrogryposis with satisfactory short-term results 104,105,132 , although with modifications such as performing percutaneous sectioning of the calcaneal tendon as a first corrective measure 104 or even accepting abduction gain of 40-50˚1 32 , including in the abduction orthosis. Apparently, flexibility of the foot improves with the evolution of treatment and a lower degree of surgical correction is necessary, yet relapses are common.…”