Objective analysis of intermediate-term outcome of the Ponseti technique: a review of the experience from Los Angeles.

The Ponseti method of manipulative treatment for clubfoot deformity became widely adopted by pediatric orthopaedic surgeons beginning in the mid-1990s. The technique allows correction of most idiopathic clubfeet using gentle manipulation and cast application. The treatment represents a marked advance over past efforts to gain correction of the foot through extensive release surgery. In 2006, we began a Clubfoot Clinic at the Orthopaedic Institute for Children in Los Angeles, California dedicated to managing clubfoot patients using Ponseti's method. An IRB-approved database of patient-related, treatment related, and demographic variables was assembled and used to ascertain the outcome of treatment as well as to address parental questions regarding certain aspects of treatment. Here, we present a review of our body of work, which has improved clinical decision making as well as our ability to better inform our patients' parents regarding the treatment and prognosis of the Ponseti method. Studies from our institution showed that while relapses and the need for extra-articular tibialis anterior tendon transfer (TATT) surgery remain common to the Ponseti method, these events do not adversely affect overall patient function or satisfaction. These findings were not unlike those of classic studies reported from Ponseti's institution. We conclude that the Ponseti method is not only a technique to achieve initial correction of an idiopathic clubfoot, but also how to manage relapses that will inevitably occur in many patients. While relapses and tendon transfer surgery are likely to remain common with this treatment method, these events do not adversely affect overall patient function or satisfaction. The parents of infants whose clubfeet are managed using the Ponseti method should be counselled accordingly.

Does generalized joint hypermobility influence the Ponseti treatment of clubfoot patients?

Previous investigators have suggested a role for generalized joint hypermobility (GJH) in the etiology of clubfoot deformity, while others have suggested its presence may influence treatment outcomes. We sought to determine if GJH was associated with the demographics, treatment, or propensity to relapse of patients whose clubfeet were managed using the Ponseti method. Fifty-seven patients with Ponseti-treated clubfeet comprised the cohort; median age 61 months (range, 38-111 months). A physical therapist evaluated each patient using the nine-point Beighton scale to quantify hypermobility. The scores were then correlated with patient sex, laterality, Dimeglio severity score, treatment, relapse, and surgery. The median Beighton score was 5; 49 of 57 patients (86%) had Beighton scores ≥4. All feet were plantigrade without symptomatic overcorrection at the time of evaluation. Although there was a slightly lower probability of relapse in patients with higher Beighton scores, this was not statistically significant (P = 0.10). Accordingly, the sex, laterality, initial severity, number of pretenotomy casts, need for tenotomy, relapse, and need for tendon transfer surgery were not significantly influenced by the Beighton score. The outcome of Ponseti clubfoot treatment is not altered by the presence of GJH in young children. Joint hypermobility does not appear to influence the likelihood of relapse or surgery. Unlike clubfeet reportedly treated with release surgery, Ponseti-treated clubfeet were not prone to excessive overcorrection regardless of joint laxity. Last, the distribution of Beighton scores in the study's cohort supports an association between GJH and clubfoot deformity.

Quantification of Ankle Dorsiflexion in Ponseti-managed Unilateral Clubfoot Patients During Early Childhood.

BACKGROUND: Following the initial correction of a clubfoot using the Ponseti method, diminished passive ankle dorsiflexion may be observed over time, which could represent a possible relapsed deformity. Alternatively, the change may be attributable to patient age or other variables. Our purpose was to quantify passive ankle dorsiflexion in the involved and contralateral unaffected limbs of Ponseti-managed unilateral clubfoot patients, and to determine what patient-related variables influence this finding. METHODS: In total, 132 unilateral clubfoot patients were studied. Passive ankle dorsiflexion was measured in both limbs at each visit. Data were excluded from visits in which patients showed clear evidence of a relapse. Mean ankle dorsiflexion for clubfeet and contralateral unaffected limbs were reported for annual age intervals and compared using paired t tests. A general linear model was established to assess the effects of age, severity, sex, and side on ankle dorsiflexion. RESULTS: Mean ankle dorsiflexion for unaffected limbs declined with age, measuring 53±6 degrees between 0 and 1 year of age and decreasing to 39±7 degrees by 4 to 5 years of age. Similarly, mean ankle dorsiflexion in treated clubfeet declined with age, measuring 44±7 degrees between 0 and 1 year and 29±7 degrees between 4 and 5 years. Overall, the difference between limbs in these patients averaged ~10 degrees for every age interval through 9 years (P<0.001). Ankle dorsiflexion of clubfeet in 95% of patients aged 0 to 2 years was at least 20 degrees, and in 95% of patients aged 3 to 5 years this was at least 15 degrees. Patient age (P<0.001) and severity of deformity (P<0.001) were found to be the only significant factors affecting ankle dorsiflexion in the affected limbs. CONCLUSIONS: Ankle dorsiflexion in the Ponseti-treated clubfeet was influenced by age of the patient and the initial severity of the affected limb. Furthermore, our data suggest that, in patients who showed no relapse, a minimum of 20 degrees of ankle dorsiflexion in the corrected clubfoot is maintained through age 3 years and a minimum of 15 degrees is maintained through age 5 years. LEVEL OF EVIDENCE: Level IV-this is a retrospective case series.

Relapse Rates in Patients with Clubfoot Treated Using the Ponseti Method Increase with Time: A Systematic Review.

BACKGROUND: The Ponseti method is the preferred technique to manage idiopathic clubfoot deformity; however, there is no consensus on the expected relapse rate or the percentage of patients who will ultimately require a corrective surgical procedure. The objective of the present systematic review was to determine how reported rates of relapsed deformity and rates of a secondary surgical procedure are influenced by each study's length of follow-up. METHODS: A comprehensive literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed to identify relevant articles. The definition of relapse, the percentage of patients who relapsed, the percentage of feet that required a surgical procedure, and the mean duration of follow-up of each study were extracted. Pearson correlations were performed to determine associations among the following variables: mean follow-up duration, percentage of patients who relapsed, percentage of feet that required a joint-sparing surgical procedure, and percentage of feet that required a joint-invasive surgical procedure. Logarithmic curve fit regressions were used to model the relapse rate, the rate of joint-sparing surgical procedures, and the rate of joint-invasive surgical procedures as a function of follow-up time. RESULTS: Forty-six studies met the inclusion criteria. Four distinct definitions of relapse were identified. The reported relapse rates varied from 3.7% to 67.3% of patients. The mean duration of follow-up was strongly correlated with the relapse rate (Pearson correlation coefficient = 0.44; p < 0.01) and the percentage of feet that required a joint-sparing surgical procedure (Pearson correlation coefficient = 0.59; p < 0.01). Studies with longer follow-up showed significantly larger percentages of relapse and joint-sparing surgical procedures than studies with shorter follow-up (p < 0.05). CONCLUSIONS: Relapses have been reported to occur at as late as 10 years of age; however, very few studies follow patients for at least 8 years. Notwithstanding that, the results indicated that the rate of relapse and percentage of feet requiring a joint-sparing surgical procedure increased as the duration of follow-up increased. Longer-term follow-up studies are required to accurately predict the ultimate risk of relapsed deformity. Patients and their parents should be aware of the possibility of relapse during middle and late childhood, and, thus, follow-up of these patients until skeletal maturity may be warranted. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management of Clubfoot Relapses With the Ponseti Method: Results of a Survey of the POSNA Members.

BACKGROUND: Despite the high rate of initial success using the Ponseti method to manage idiopathic clubfoot deformity, relapse continues to be a problem. We surveyed the Pediatric Orthopedic Society of North America (POSNA) members about their experience with relapsed deformity following the initial correction of clubfeet. METHODS: We created a survey to focus on the management of clubfeet after initial correction of deformity. The survey included questions on postcorrective bracing, clinical findings used to identify relapse, the observed frequency of relapsed deformity, and how relapses are managed. The questionnaire was approved by the POSNA Evidence Based Committee and was sent electronically to all POSNA members. RESULTS: We received responses from 321 members (26%). Of those, 94% were fellowship trained in pediatric orthopaedics. The Ponseti method was used by 98% of respondents. The Mitchell-Ponseti orthosis was most commonly used (51%), followed by the Denis-Browne brace (25%). The duration of bracing used varied among members with 23% recommending only 2 years, 33% recommending 3 years, and 34% recommending 4 years. A tight heel cord was felt to be the first sign of relapse by 59% of respondents, and dynamic supination by 30%. The rate of relapse was observed to be <10% by 22% of the respondents, 10% to 20% by 52%, and 20% to 40% by 25%. Manipulation and cast treatment alone (55%) and cast treatment with tenotomy (23%) were reported as the 2 most common initial treatment approaches for a relapsed deformity. Cast treatment to correct relapsed deformity before tibialis anterior tendon transfer was reported by 62% of respondents. Heel cord tenotomy (75%) and posterior capsular release (43%) were the 2 most common procedures used in addition to tibialis anterior tendon transfer for the treatment of clubfoot relapse. CONCLUSION: This study highlights the wide variation with which clubfoot relapses are evaluated and treated among the POSNA membership with differences in the recommended duration of bracing, identification of relapses, and their management. These wide differences highlight the need for future research and educational programs to inform and standardize the management of clubfoot using the Ponseti Method. LEVEL OF EVIDENCE: Not applicable.

Sixty Years On: Ponseti Method for Clubfoot Treatment Produces High Satisfaction Despite Inherent Tendency to Relapse.

BACKGROUND: Developed at the University of Iowa in 1950, the Ponseti method to manage idiopathic clubfoot deformity was slow to gain wide acceptance until the mid-1990s. There is a paucity of intermediate and long-term outcome studies involving this technique, with nearly all such studies coming from a single institution. The purpose of this study is to report the contemporary outcome of patients with clubfoot deformity whose feet were managed with the Ponseti method and who were followed to ≥5 years old, to provide outcome expectations for parents and for clinicians managing patients with idiopathic clubfoot. METHODS: Families of infants seen in our clinic diagnosed with idiopathic clubfoot since July 2006 were prospectively invited to participate in our institutional review board-approved study. Patients who received no prior outside treatment and had a minimum follow-up to the age of 5 years were included. Demographic, treatment, and outcome data were collected. To provide an array of outcome measures, both the Dallas outcome criteria and the Roye disease-specific instrument (DSI) were used. RESULTS: One hundred and one patients met the inclusion criteria. The mean length of follow-up (and standard deviation) was 81.1 ± 17.1 months. Initial correction was achieved in all feet. Thirty-seven percent of families reported that they were adherent with the bracing protocol; 68% of patients had ≥1 relapse, and 38% underwent a tendon transfer. With the Dallas criteria, 62% had outcomes rated as good, 38% had outcomes rated as fair, and no patient had an outcome rated as poor. With the Roye DSI, most families were generally very satisfied with the function and appearance of the feet. CONCLUSIONS: Satisfactory results at intermediate follow-up were achieved using the Ponseti method. However, despite a better understanding of the Ponseti method and the importance of longer post-corrective brace use, the need for anterior tibial tendon transfer remains an important adjunct to the Ponseti method. Brace adherence also continues to be a critical clinical issue. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

How Many Patients Who Have a Clubfoot Treated Using the Ponseti Method are Likely to Undergo a Tendon Transfer?

BACKGROUND: The Ponseti method has become the standard of care for the treatment of idiopathic clubfoot. A commonly reported problem encountered with this technique is a relapsed deformity that is sometimes treated in patients older than 2.5 years by an anterior tibial tendon transfer (ATTT) to the third cuneiform. Presently, there is insufficient information to properly counsel families whose infants are beginning Ponseti treatment on the probability of needing later tendon transfer surgery. METHODS: All idiopathic clubfoot patients seen at the authors' institution during the study period who met the inclusion criteria and who were followed for >2.5 years were included (N=137 patients). Kaplan-Meier Survival analysis was used to determine the probability of survival without the need for ATTT surgery. In addition, the influence of patient characteristics, socioeconomic variables, and treatment variables on need for surgery was calculated. RESULTS: On the basis of the survivorship analysis, the probability of undergoing an ATTT remained below 5% for all patients at 3 years of age, but exceeded 15% by 4 years of age, increasing steadily afterwards such that by 6 years of age, the probability of undergoing an ATTT reached 29% of all patients. Overall, controlling for all other variables in the analysis, parent-reported adherence with bracing reduced the odds of undergoing surgery by 6.88 times, compared with parent-reported nonadherence (P<0.01). CONCLUSIONS: This is the first study to report the probability of undergoing ATTT surgery as a function of age using survivorship analysis following Ponseti clubfoot treatment. Although the overall probability reached 29% at 6 years, this was significantly reduced by compliance with bracing. This information may be useful to the clinician when counseling families at the start of treatment. LEVEL OF EVIDENCE: Level III-theraputic.

The Timing and Relevance of Relapsed Deformity in Patients With Idiopathic Clubfoot.

BACKGROUND: The timing and relevance of relapsed deformity after correction of idiopathic clubfoot have not been well documented. METHODS: All patients with idiopathic clubfoot seen at the authors' institution during the study period who were followed for ≥2 years (range, 2.0 to 9.8 years) were included (N = 191). Survival analysis and multivariate regression analysis were used to analyze the data. RESULTS: The median age at first relapse was 20 months. The probability of relapse remained approximately 30% at age 2 years and increased to 45% by 4 years and 52% by 6 years. Parent-reported adherence with bracing reduced the odds of a relapse by 15 times (P < 0.01). After an initial relapse, adherence with bracing was successful in avoiding a subsequent relapse in 68% of patients. Feet graded as very severe on the Diméglio scale were 5.75 times more likely to relapse than those graded severe and were 7.27 times more likely than those graded as moderate. DISCUSSION: Patients whose parents reported nonadherence with bracing and patients with very severe deformities were most likely to relapse. After an initial relapse, regaining correction of the foot and resuming bracing were beneficial to avoid further relapses. These findings can be useful to clinicians in advising families regarding the prognosis of treatment. CONCLUSIONS: The development of a relapse affects the subsequent management and outcome of clubfoot deformity. The importance of bracing should be reinforced to parents. Bracing until at least age 4 years may be beneficial. For patients whose families are especially resistant to brace use and for older patients who experience a second relapse, regaining correction of the deformity via cast treatment followed by an Achilles lengthening procedure and/or tendon transfer may be the best alternative.

Management of the Relapsed Clubfoot Following Treatment Using the Ponseti Method.

The Ponseti method to treat idiopathic clubfoot deformity has proven to be reliable, and several centers have reported excellent outcomes. Although the method has been dependable in obtaining initial correction of the foot, relapse rates ranging from 26% to 48% have been reported. When a relapsed deformity is detected early, treatment with a short series of manipulations and cast applications followed by resumption of postcorrective bracing may be all that is required to regain and maintain correction. In patients aged >2.5 years, especially those who may be refractory to further brace use, deformity correction by preoperative cast treatment, followed by anterior tibial tendon transfer to the third cuneiform, is a good treatment option. Other procedures, such as combined cuboid-cuneiform osteotomy, posterior ankle and subtalar release, and, rarely, comprehensive posteromedial release or correction by gradual distraction, may be useful in select patients.

The Influence of Sex and Laterality on Clubfoot Severity.

BACKGROUND: Idiopathic clubfoot is bilateral in approximately 50% of cases and has been widely reported to affect males more frequently than females. Despite these observations, the correlation between sex and severity of the deformity has not been established. As well, the difference in severity between unilateral and bilateral clubfeet has not been extensively investigated. Therefore, the goals of the present study were to: (1) examine the relationship between sex and severity of deformity and (2) determine the relationship between laterality and severity of deformity. METHODS: The families of infants with idiopathic clubfoot deformity treated at our institution were prospectively invited to participate in this institutional review board-approved study. Severity of the deformity was assessed by a single surgeon for each patient using the Dimeglio criteria at the first clinic visit. After evaluating the distributions, the correlations were quantified by nonparametric analyses. RESULTS: Over 8 years, 240 infants met the inclusion criteria. There was no significant difference in the severity of deformity due to sex (P=0.61): the median Dimeglio score for males was 13 (variance 4.8) and for females, the median was 13.0 (variance of 5.1). In contrast, severity was distributed differently among unilateral versus bilateral patients. Although both unilateral and bilateral patients had a median Dimeglio score of 13, the ratio of bilateral patients was higher among those with moderate or very severe deformities compared with those with severe deformities (P<0.01). CONCLUSIONS: Although idiopathic clubfoot is commonly considered to affect male patients disproportionately, this is the first study to document no difference in severity due to sex. Further, this study demonstrated that on average, bilateral patients did not have increased severity, but presented with a larger range of severity than those patients with unilateral deformity. LEVEL OF EVIDENCE: Level III-prognostic.

The Objective Measurement of Brace-Use Adherence in the Treatment of Idiopathic Clubfoot.

BACKGROUND: A successful outcome for the treatment of idiopathic clubfoot is believed to require adequate adherence to brace use. Previous studies have relied on parental reporting of brace application. We used temperature sensors to determine the adherence to the bracing protocol, the accuracy of parent-reported use, and differences in adherence between patients who experienced relapse of deformity and those who did not. METHODS: Using wireless sensors attached to brace sandals, we monitored brace wear over a 3-month period in this cross-sectional study involving 48 patients in 4 age-based groups: 6 to 12 months (Group 1), >1 to 2 years (Group 2), >2 to 3 years (Group 3), and >3 to 4 years (Group 4). Parents were blinded to the purpose of the sensors. The mean number of hours of daily brace use as measured by the sensors was compared with the physician-recommended hours and parent-reported hours of brace use. RESULTS: Sensors were retrieved from 44 of 48 patients. Overall, the median brace use recorded by the sensors was 62% (range, 5% to 125%) of that recommended by the physician, and 77% (range, 6% to 213%) of that reported by the parents. For Groups 1 to 3, the difference between the physician-recommended and measured number of hours of daily brace use was significant (p ≤ 0.002), and the difference between the parent-reported and measured number of hours of daily brace use was also significant (p ≤ 0.013). Eight (18%) of the 44 patients who completed the study experienced relapse during the period of monitoring; most importantly, the mean number of hours of brace wear for these patients, 5 hours per day (median, 4; and standard deviation [SD], 3 hours per day) was significantly lower than the 8 hours per day for those who did not experience relapse (median, 9; and SD, 5 hours per day) (p = 0.045). CONCLUSIONS: The present study objectively quantified the number of daily hours of post-corrective brace wear for patients with clubfoot in varying age groups and provides an estimate of the number of hours required to avoid relapse. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

What's New in Pediatric Flatfoot?

BACKGROUND: Children with flatfeet are frequently referred to pediatric orthopaedic clinics. Most of these patients are asymptomatic and require no treatment. Care must be taken to differentiate patients with flexible flatfeet from those with rigid deformity that may have underlying pathology and have need of treatment. Rigid flatfeet in infants may be attributable to a congenital vertical talus (CVT); whereas those in older children and adolescents may be due to an underlying tarsal coalition. We performed a review of the recent literature regarding evaluation and management of pediatric flatfeet to discuss new findings and suggest areas where further research is needed. METHODS: We searched the PubMed database for all papers related to the treatment of pediatric flatfoot, tarsal coalition, and CVT published from January 1, 2011 to December 31, 2014, yielding 85 English language papers. RESULTS: A total of 18 papers contributed new or interesting findings. CONCLUSIONS: The pediatric flexible flatfoot (FFF) remains poorly defined, making the understanding, study, and treatment of the condition extremely difficult.Pediatric FFF is often unnecessarily treated. There is very little evidence for the efficacy of nonsurgical intervention to affect the shape of the foot or to influence potential long-term disability for children with FFF. The treatment of tarsal coalition remains challenging, but short-term and intermediate-term outcome studies are satisfactory, whereas long-term outcome studies are lacking. Management of the associated flatfoot deformity may be as important as management of the coalition itself. The management of CVT is still evolving; however, early results of less invasive treatment methods seem promising. LEVEL OF EVIDENCE: Level 4-literature review.

Does Clubfoot Treatment Need to Begin As Soon As Possible?

INTRODUCTION: Parents of an infant with an idiopathic clubfoot deformity are often urged by their primary care physician to seek treatment as soon as possible. This advice frequently appears in many general pediatric and pediatric orthopaedic textbooks and monographs on the subject. This recommendation has not changed since the wide acceptance of the minimally invasive Ponseti method to treat clubfoot. We determined the correlations among patient-related variables, early treatment variables, and the age at which the patient was first seen to begin treatment. METHODS: Infants with moderate to very severe idiopathic clubfoot deformity were invited to participate. Age at which the patient presented to begin treatment was correlated against early treatment-related variables, including number of casts required, cast slippage, cast-related skin problems, brace-related skin problems, early noncompliance with brace wearing, and relapse before 1 year. Patient-related variables were also correlated against age at first visit. RESULTS: Over 7 years, 176 infants met the inclusion criteria. There were no significant differences in the aspects of the early management as a function of age at first visit, with the exception of cast slippage (P=0.05). CONCLUSIONS: The age at first visit influenced the incidence of cast slippage, but otherwise did not affect the early treatment of clubfoot. CLINICAL RELEVANCE: The treatment of idiopathic clubfoot deformity should not be considered an orthopaedic emergency, and parents whose infants are born with this deformity should be counseled accordingly.

What's New in Idiopathic Clubfoot?

This update summarizes selected research highlights pertaining to idiopathic clubfoot deformity that were published in peer-reviewed journals between January 2010 and December 2013.

Walking age of infants with idiopathic clubfoot treated using the ponseti method.

BACKGROUND: The Ponseti method is an established approach to treating idiopathic clubfoot in infants. The method involves a period of cast immobilization and postcorrective bracing that potentially interferes with normal movements of the lower extremities. In the present study, we investigated the age at which infants who had idiopathic clubfoot treated using the Ponseti method achieved independent walking. METHODS: We prospectively evaluated patients of a single surgeon. Included in the study were all patients with idiopathic clubfoot who were full term at birth, were no more than twelve weeks of age at the start of treatment, had received no prior outside treatment, and were followed for a minimum of twenty-four months. RESULTS: Ninety-four patients were included. The mean age at which patients began walking independently was 14.5 ± 2.6 months (range, ten to twenty-two months). By eighteen months, 90% of the patients were walking without assistance. Patients with moderate or severe clubfoot deformity began walking earlier than did patients with very severe deformity (a mean of 14.2 months compared with 15.8 months; p = 0.03). Patients who experienced a relapse before learning to walk began walking later than those who did not relapse (a mean of 15.9 months compared with 14.2 months; p = 0.04). Other patient and treatment-related variables had no significant influence on the onset of walking. CONCLUSIONS: On the basis of our findings, parents of infants with idiopathic clubfoot treated using the Ponseti method may expect their child to achieve independent walking approximately two months later than infants without clubfoot deformity. A greater delay may be expected for those patients who have a very severe deformity or those who experience a deformity relapse. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Accuracy of radiographs in assessment of displacement in lateral humeral condyle fractures.

PURPOSE: Determining the magnitude of displacement in pediatric lateral humeral condyle fractures can be difficult. The purpose of this study was to (1) assess the effect of forearm rotation on true fracture displacement using a cadaver model and to (2) determine the accuracy of radiographic measurements of the fracture gap. METHODS: A non-displaced fracture was created in three human cadaveric arms. The specimens were mounted on a custom apparatus allowing forearm rotation with the humerus fixed. First, the effect of pure rotation on fracture displacement was simulated by rotating the forearm from supination to pronation about the central axis of the forearm, to isolate the effects of muscle pull. Then, the clinical condition of obtaining a lateral oblique radiograph was simulated by rotating the forearm about the medial aspect of the forearm. Fracture displacements were measured using a motion-capture system (true-displacement) and clinical radiographs (apparent-displacement). RESULTS: During pure rotation of the forearm, there were no significant differences in fracture displacement between supination and pronation, with changes in displacement of <1.0 mm. During rotation about the medial aspect of the forearm, there was a significant difference in true displacements between supination and pronation at the posterior edge (p < 0.05). CONCLUSION: Overall, true fracture displacement measurements were larger than apparent radiographic displacement measurements, with differences from 1.6 to 6.0 mm, suggesting that the current clinical methods may not be sensitive enough to detect a displacement of 2.0 mm, especially when positioning the upper extremity for an internal oblique lateral radiograph.

Management of idiopathic clubfoot after formal training in the Ponseti method: a multi-year, international survey.

BACKGROUND: Over the past decade, the Ponseti method has become the standard of care to treat clubfoot amongst orthopaedic surgeons around the world. Since 2001, the University of Iowa, under the guidance of the late Dr. Ignacio Ponseti, has been teaching the Ponseti method through a standardized training course. This study examines the current clubfoot management practices of those who have participated in the course and the effectiveness of formal Ponseti Training Courses. METHODS: An online survey was administered to practitioners who participated in the University of Iowa Ponseti Training Course from 2001-2011. RESULTS: One hundred and thirty-one practitioners responded to the survey representing 33 different countries and 70 different orthopaedic societies. Ninety-seven percent of practitioners reported currently using the Ponseti method as the preferred treatment for clubfoot. The respondents reported the average duration of each cast was 9.21 days (SD=9.04 d) and the average cast phase of treatment lasted 7.62 weeks (SD=2.43 w). Physicians were responsible for applying the cast 79% of the time. Braces were utilized following casting by 96% of physicians. The average age of brace use was 41 months (SD=16 m). The reported relapse rate was 21% (SD=17%). Ninety-seven percent of practitioners changed their practice after completion of the course. The preferred method prior to the course was surgical release (48%). Sixty-one percent of practitioners preferred review articles as an additional educational support; 49% preferred training videos. Sixty-seven percent believed an 'on-site' visit to their hospital by an expert in the Ponseti method would be very beneficial. Seventy-three percent suggested improving the course by providing more 'hands on' experience. Ninety-five percent of practitioners were satisfied with the course. CONCLUSION: The Ponseti Training Course is an effective way to educate physicians on how to treat clubfoot with the Ponseti method. However, improvements should include more hands-on learning as well as an 'on-site' visit with an expert Ponseti practitioner.

The use of the Ponseti method to treat clubfeet associated with congenital annular band syndrome.

BACKGROUND: A clubfoot deformity may be associated with congenital annular band syndrome (CABS), and has, until recently, been thought to be resistant to nonoperative management. The purpose of this report was to describe the use of the Ponseti method in the treatment of 5 patients whose clubfeet were associated with this syndrome. METHODS: All patients with a diagnosis of clubfoot, who were treated at the Orthopaedic Hospital Clubfoot Clinic, over a period of 4 years, were reviewed. During that period, a total of 131 infants with 194 clubfeet were treated. We identified 5 infants (3.8%) with 6 clubfeet associated with CABS. The patients were managed using the Ponseti method. One of the patients, with a contralateral amputation of the limb opposite to the side with a clubfoot, required the use of a unilateral foot abduction orthosis rather than a conventional foot abduction orthosis. The outcomes evaluated included: the number of casts needed to obtain correction, the percentage of patients requiring a tendo-Achilles tenotomy, the number of relapses, and the need for additional secondary procedures. RESULTS: The mean age at presentation for the 5 patients was 6.2 weeks. Four of the clubfeet had an ipsilateral band and 2 did not. None of the patients had a neurological deficit distal to a band. The mean number of casts used to correct the deformity was 6, and a percutaneous tendo-Achilles tenotomy was done in all cases. All of the feet achieved initial correction. Four patients (5 feet) experienced a relapse attributed to failure to use the postcorrective brace as prescribed. Correction of the foot in 3 of these patients was regained and maintained by another series of manipulation and cast application followed by resumption of bracing. One patient underwent an anterior tibial tendon transfer. The patients were followed for an average of 32.6 months (21 to 49 mo). All feet were supple and plantigrade at latest follow-up evaluation. CONCLUSIONS: The Ponseti method may be successfully applied to clubfeet associated with CABS. LEVEL OF EVIDENCE: Level IV.