View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Digital Commons@Becker Washington University School of Medicine Digital Commons@Becker Open Access Publications 7-1-2008 Early results of the ponseti method for the treatment of clubfoot in distal arthrogryposis Stephanie Boehm Washington University School of Medicine in St. Louis Noppachart Limpaphayom Washington University School of Medicine in St. Louis Farhang Alaee Washington University School of Medicine in St. Louis Marc F. Sinclair Washington University School of Medicine in St. Louis Matthew .B Dobbs Washington University School of Medicine in St. Louis Follow this and additional works at: http://digitalcommons.wustl.edu/open_access_pubs Part of the Medicine and Health Sciences Commons Recommended Citation Boehm, Stephanie; Limpaphayom, Noppachart; Alaee, Farhang; Sinclair, Marc F.; and Dobbs, Matthew B., ,"Early results of the ponseti method for the treatment of clubfoot in distal arthrogryposis." The ourJ nal of Bone and Joint Surgery.90,7. 1501-1507. (2008). http://digitalcommons.wustl.edu/open_access_pubs/932 This Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in Open Access Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact [email protected]. 1501 COPYRIGHT Ó 2008 BY THE JOURNAL OF BONE AND JOINT SURGERY,INCORPORATED Early Results of the Ponseti Method for the Treatment of Clubfoot in Distal Arthrogryposis By Stephanie Boehm, MD, Noppachart Limpaphayom, MD, Farhang Alaee, MD, Marc F. Sinclair, MD, and Matthew B. Dobbs, MD Investigation performed at Washington University School of Medicine, St. Louis; St. Louis Shriners Hospital for Children, St. Louis; St. Louis Children’s Hospital, St. Louis, Missouri; and Altonaer Kinderkrankenhaus, Hamburg, Germany Background: Clubfoot occurs in approximately one in 1000 live births and is one of the most common congenital birth defects. Although there have been several reports of successful treatment of idiopathic clubfoot with the Ponseti method, the use of this method for the treatment of other forms of clubfoot has not been reported. The purpose of the present study was to evaluate the early results of the Ponseti method when used for the treatment of clubfoot as- sociated with distal arthrogryposis. Methods: Twelve consecutive infants (twenty-four feet) with clubfoot deformity associated with distal arthrogryposis were managed with the Ponseti method and were retrospectively reviewed at a minimum of two years. The severity of the foot deformity was classified according to the grading system of Dimeglio´ et al. The number of casts required to achieve correction was compared with published data for the treatment of idiopathic clubfoot. Recurrent clubfoot deformities or complications during treatment were recorded. Results: Twenty-two clubfeet in eleven patients were classified as Dimeglio´ grade IV, and two clubfeet in one patient were classified as Dimeglio´ grade II. Initial correction was achieved in all clubfeet with a mean of 6.9 ± 2.1 casts (95% confidence interval, 5.6 to 8.3 casts), which was significantly greater than the mean of 4.5 ± 1.2 casts (95% confidence interval, 4.3 to 4.7 casts) needed in a cohort of 219 idiopathic clubfeet that were treated during the same time period by the senior author with use of the Ponseti method (p = 0.002). Six feet in three patients had a relapse after initial successful treatment. All relapses were related to noncompliance with prescribed brace wear. Four relapsed clubfeet in two patients were successfully treated with repeat casting and/or tenotomy; the remaining two relapsed clubfeet in one patient were treated with extensive soft-tissue-release operations. Conclusions: Our early-term results support the use of the Ponseti method for the initial treatment of distal arthrogrypotic clubfoot deformity. Longer follow-up will be necessary to assess the risk of recurrence and the potential need for corrective clubfoot surgery in this patient population, which historically has been difficult to treat nonoperatively. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. lubfoot occurs in approximately one in 1000 live births1 deformity, combined with a percutaneous tenotomy of the and is one of the most common congenital birth de- Achilles tendon to correct ankle equinus followed by several Cfects. It is easily recognizable at birth and can be dif- years of bracing to maintain the correction, has gained wide- ferentiated from some of the more common positional foot spread popularity in recent years for the treatment of idio- anomalies on the basis of the rigid ankle equinus deformity pathic clubfoot2-5. When treatment with the Ponseti method is and resistance to simple passive correction. Most clubfeet oc- initiated in the first few years of life, patients with idiopathic cur as an isolated birth defect and are considered idiopathic. clubfoot deformity rarely require extensive surgical treatment The Ponseti method of serial casting to gradually correct the and commonly have excellent long-term outcomes6. Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Shriners Hospital for Children, the Barnes-Jewish Hospital Foundation, and the St. Louis Children’s Hospital Foundation. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (O and P Lab, Inc., St. Louis, Missouri). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com. J Bone Joint Surg Am. 2008;90:1501-7 d doi:10.2106/JBJS.G.00563 1502 THE J OURNAL OF B ONE &JOINT S URGERY d JBJS. ORG E ARLY R ESULTS OF THE P ONSETI M ETHOD FOR THE T REATMENT VOLUME 90-A d N UMBER 7 d J ULY 2008 OF C LUBFOOT IN D ISTAL A RTHROGRYPOSIS Nonidiopathic clubfoot occurs in patients with addi- The severity of the foot deformity was classified ac- tional malformations, chromosomal abnormalities, or known cording to the grading system of Dimeglio´ et al.21 at the time of genetic syndromes, such as distal arthrogryposis. Although presentation. In this grading system, four parameters are as- there have been multiple reports of successful treatment of sessed on the basis of reducibility with gentle manipulation as idiopathic clubfoot with use of the Ponseti method2,3,5, the use measured with a handheld goniometer: (1) equinus deviation of this treatment for the treatment of nonidiopathic clubfoot in the sagittal plane, (2) varus deviation in the frontal plane, has not been reported, to our knowledge. On the contrary, (3) derotation of the calcaneopedal block in the horizontal nonidiopathic clubfoot is often treated primarily with exten- plane, and (4) adduction of the forefoot relative to the hind- sive soft-tissue-release surgery because the deformities in these foot in the horizontal plane. A score is given to each of the four patients are thought to be too rigid to correct with casting alone7. parameters on a 4-point scale, with 4 points indicating re- Arthrogryposis has been described as a feature of >100 ducibility from 90° to 45°; 3 points, reducibility from 44° to syndromes and is characterized by contractures of two or more 20°; 2 points, reducibility from 19° to 1°; 1 point, reducibility different body areas8. Currently, ten different distal arthro- from 0° to 220°; and 0 points, reducibility of less than 220°. grypotic syndromes have been classified; all are characterized The sum of these parameters constitutes a 16-point scale. Four by hand and foot contractures, limited proximal involvement, additional points, consisting of 1 point each for a posterior and autosomal dominant inheritance9. The traditional treat- crease, a medial crease, the presence of forefoot cavus, or poor ment for clubfoot associated with these syndromes is either a muscle condition (such as fibrous, hypertonic, or contracted radical soft-tissue release10-14 or talectomy15-17, both of which triceps, tibial, or peroneal muscles and the absence of volun- have been associated with mixed results. A high rate of re- tary dorsiflexion in eversion and pronation) can be added, for currence has been reported after radical soft-tissue release a total of 20 points. Atrophy of the calf, a short foot, and for the treatment of arthrogrypotic clubfoot11-13,18, with this decreased limb length are not scored as they are considered recurrence leading to repeat soft-tissue releases or salvage part of the natural history of clubfoot deformity. The foot can procedures. then be classified into four categories with respect to the se- The purpose of the present study was to evaluate the verity of the deformity. Grade-I feet have a mild deformity that early results of the Ponseti method for the treatment of club- is >90% reducible, with a score of 0 to 5 points. Grade-II feet foot associated with distal arthrogryposis. have a moderate deformity, with a score of 6 to 10 points. Grade-III feet have a severe deformity, with a score of 11 to 15 Materials and Methods points.