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ORIGINAL ARTICLES A Review of the Ponseti Method and Development of an Infant Clubfoot Program in Vietnam Angela M. Evans, PhD* Do Van Thanh, MD† Background: The Feet for Walking clubfoot project from Australia formally introduced the Ponseti technique in Vietnam in 2004 and is based at the Da Nang Orthopedic and Rehabilitation Centre in central Vietnam. Methods: We provide an initial overview of the management of infant clubfoot deformity using the nonsurgical Ponseti method. Results: Early indicators of the outcome of implementing this clubfoot project are largely positive but also require ongoing review. Further analyses of the use of the Ponseti method (or obstacles preventing the same) following training of personnel is underway. Conclusions: Recent research has improved and refined the technique that must now be both appreciated and incorporated by clinicians. This technique is used across the world in both developed and developing countries and is universally regarded as the best management method for clubfoot deformities. (J Am Podiatr Med Assoc 99(4): 306- 316, 2009) The presentation of a clubfoot in a newborn infant in now been replaced by nonsurgical correction as the a developing country can signal a bleak future of se- almost-universally accepted standard of initial treat- rious disability and potential poverty for the child ment for congenital idiopathic clubfoot.6, 7 Although and family. Hindered mobility reduces education and there are many methods of nonsurgical correction employment prospects. Socially, the child may grow (manipulation and serial casting, physical therapy into a marginalized and impoverished adult who will and continuous passive motion), which can be suc- depend on family support or external aid sources to cessful when correctly instituted, clinical reports survive.1-3 The presence of many neglected adult club- have found success rates of only 15% to 50%.6 The foot deformities in developing countries reinforces frequently reported exception is the Ponseti method, this reality, a situation not uncommon in many devel- which is reported to be approximately 90% success- oping countries of the world, including Vietnam. ful in both the short- and long-term.2, 7-9 Globally, the Ponseti method has gained increas- The clubfoot or talipes equino varus deformity has ing favor in the past three decades, although it has long been recognized as a serious pediatric orthope- been used by the original author, Dr. Ignacio Ponseti, dic problem responsible for much suffering, multiple since the 1940s. The follow-up results over 30 years medical interventions, and often disabling outcomes are very good in terms of pain and function.10 The for the child.2-4 The prevalence of infant clubfoot varies technique has been refined over many years and cur- according to ethnicity, ranging from 0.3 per 1,000 rent research continues to inform our practice and births in China to 7 per 1,000 births in Polynesia.5 method.6, 9, 11-15 The correct use of the Ponseti tech- The prevalence in Vietnam is estimated to be approx- nique has repeatedly been shown to radically reduce imately 1 per 1,000 births. Surgical correction has the rate of extensive corrective surgical procedures *Department of Health Science, University of South Aus- for clubfoot cases and has been found to be adapt- tralia, Adelaide, South Australia. able to successful use in the developing world.1-3, 7 †Da Nang Orthopedic and Rehabilitation Centre, Da Nang Concurrently, the long-term results of clubfoot sur- City, Vietnam. gery have found moderate to severe degenerative Corresponding author: Angela M. Evans, PhD, Depart- ment of Health Science, University of South Australia, City changes in 56% of patients.16 East Campus, North Terrace, Adelaide, South Australia, 5000 The Ponseti method provides the best long-term Australia. (E-mail: email@example.com) results for clubfoot deformity, has few complica- 306 July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association tions, and is cost effective. In Vietnam, the initial cost seti method is suitable for all types of clubfeet, it is estimates revealed a very favorable cost comparison mostly used for congenital idiopathic clubfoot. The between clubfoot surgery and the nonsurgical Pon- extent of deformity of the stiffer syndrome-associat- seti method. The cost of surgery (including surgery, ed clubfoot, as occurs with arthrogryposis or myelo- medication, dressings, radiographs, splint, hospital meningocele, may be reduced with careful technique accommodation, and food) was VND 4,300,000 per use. The technique must be adapted for the atypical or case. By comparison, the cost of the Ponseti method complex clubfoot as Ponseti19 has clearly described. (including five casts, three braces/shoes) was VND 1,400,000 per case. Therefore in Vietnam, the Ponseti The Ponseti Method Described method is at least two, and possibly three times more cost effective than clubfoot surgery.17 Economics The basic steps involved in the Ponseti method are aside, the clinical results for a pain-free functional outlined below. After initially assessing the clubfoot foot are much better when the Ponseti method is cor- type, the foot is given a score using the Pirani method rectly used.9 to assess severity. The foot is then manually manipu- lated to the correct position for the first cast to be ap- Clubfoot plied. This process is repeated every 5 to 7 days until foot position is corrected, which usually takes approx- Basic Pathology imately five to six casts. It may be necessary to per- form an Achilles tenotomy to gain full correction of The congenital idiopathic clubfoot deformity is iden- the ankle equinus, in which case a final abductory tified by the presence of a retracted and inverted heel cast is applied for an additional 3 weeks. Following (equinus), usually a medial crease on the plantar as- initial castings and Achilles tenotomy if required, the pect of the adducted forefoot, and longitudinal arch foot correction must be maintained with an abduc- cavus. Pathognomonic to this deformity is the inabili- tion brace for 3 to 5 years to prevent relapse of the ty to bring the foot to a plantigrade position. In unilat- deformity. It is vital that children are monitored regu- eral cases, the clubfoot is comparatively stiff and larly. The reader is strongly encouraged to access the smaller because of leg muscle atrophy; and shorten- Ponseti Management publication, which was recent- ing is also common. ly translated into Vietnamese and is available for free In terms of etiology, a normally developing foot de- download from Global Help.2 forms at approximately the 16th fetal week to be- come a clubfoot. Although genetics and environmen- Diagnose Type of Clubfoot tal influences are both probable contributors, it is curious to note that a more precise mechanism of eti- With reference to the above description of clubfoot ology is still unknown. types or categories, it is important to identify the type The primary deformity centers on the shape and of presenting clubfoot so as to select the correct cast- position of the talus and the related misplacement of ing technique (standard Ponseti for the congenital id- the navicular. The Ponseti method focuses on stabiliz- iopathic clubfoot or adapted Ponseti for the complex ing the talus and reducing the clubfoot deformity by or atypical clubfoot) and to realistically predict the abducting the inverted forefoot. This allows for the results (often not as good for the resistant clubfoot calcaneus to abduct, which in turn allows for the seen with arthrogryposis). ankle to be dorsiflexed (often necessitating lengthen- ing of the Achilles tendon).2, 5, 18, 19 Score the Clubfoot Severity with the Pirani Scale Types of Clubfoot The Pirani scoring system is used to assess initial There are three main types of clubfoot to be aware of clubfoot condition and to monitor treatment progress when diagnosing the infant clubfoot. The first and of the Ponseti technique. It has also been found to be most common is the congenital idiopathic clubfoot, a reliable20 (Table 1), predictive for the need of Achilles difficult deformity that affects otherwise healthy chil- tenotomy,14 and prognostic.11 Pirani scoring of club- dren. The second type is the resistant clubfoot often foot consists of examining six areas of the foot that associated with syndromes such as arthrogryposis reflect the hindfoot, midfoot, or total foot status in and is stiffer in nature. Third is the atypical or com- terms of clubfoot severity2 (Fig. 1). plex clubfoot, which is short, fat, stiff, and requires a The initial Pirani score has been shown to predict very adapted casting approach.19 Although the Pon- the likely need for Achilles tenotomy. Initial scores ≥ 5 Journal of the American Podiatric Medical Association • Vol 99 • No 4 • July/August 2009 307 Table 1. Pirani Score Reliability Pilot Studya as Used in that the parents and baby are comfortable for this Vietnam for the Clubfoot Project process. Feeding can greatly assist in relaxing the in- Examiner 1 fant during the casting process. The applied forces Pirani Measure ICC SM 1-way (95% CI) should not distress the infant and must be carefully directed around the stabilized talus (Fig. 2). The new- Lateral border 0.91 Medial crease 1.00 born infant clubfoot is very small, and it is easy to in- Talar head coverage 0.77 correctly manipulate the foot. The basis of the Ponseti Midfoot score 0.94 technique is to abduct the inverted forefoot around Posterior crease 0.73 the stabilized talus (Figs. 3 and 4). The heel is not Rigid equinus 0.86 touched during this process. If the talus is not accu- Empty heel 0.22 rately located, the force of abduction will break the Hindfoot score 0.82 foot at the developing talonavicular joint and the cal- Total foot score 0.96 caneus will not abduct. This was the main problem Abbreviations: ICC, intrarater correlation coefficient; CI, with the Kite technique,22 which applied pressure confidence interval; SM, single measure. over the calcaneocuboid joint, preventing correction aSix infants (10 clubfeet) aged 8 to 18 months (mean age of the heel. We recommend that doctors contemplat- 13.3 mo) were examined for the reliability protocol. There was good correlation between examiner 1 (aid team volun- ing using the Ponseti technique use a skeletal model teer) and a Vietnamese nurse who has been trained to use to review the details of foot anatomy (Fig. 5). the Pirani scoring system (rho = 0.927). However, the inter- rater measures were limited to two subjects, and therefore, Padding provide only preliminary indication. Once the foot has been held in the correctly manipu- lated position for 60 sec, a layer of under-cast padding require tenotomy; scores ≤ 3.5 do not require tenoto- is applied. It is important that the manipulated posi- my; and scores between 3.5 and 5.0 may need tenoto- tion of the foot continues to be held while the padding my.14 Another recent study11 has found that the initial is applied. Clearly, two doctors are now necessary for Pirani score not only predicts the need for tenotomy this process. The padding must be applied with firm but also the number of casts required to gain correc- tension and minimal bulk. Too much padding will tion. This study found that hindfoot scores are most simply compress and allow for cast slippage, less ef- predictive for tenotomy need with initial hindfoot fective foot molding, and skin abrasions. Care must scores of 2.5 or 3.0 (of a possible 3.0) requiring a be taken to ensure that all skin surfaces are covered, tenotomy in approximately 75% of cases. The total from toes to groin (Fig. 6). score of above or below 4 indicates how many cast applications may be required for correction. A total Application of Plaster Cast score of 4 needs at least four casts; a total score of less than 4 needs fewer casts. The manipulated foot position continues to be main- Pirani scores are a very useful guide. The foot tained while the plaster cast is applied over the layer should be scored initially, at each cast change, and at of minimal padding. The plaster is always applied in splint reviews. Evaluating the foot at each cast change two sections: the foot and leg below the knee (Fig. will enable residual components of the deformity to 7A), and above knee, with knee flexed at 90° (Fig. be addressed. It is important to remember that be- 7B). The first section of plaster is applied by one doc- cause each case is individual, the Pirani score system tor (or other trained staff member) while the other may guide, but not dictate, clinical decision making. doctor maintains the corrected foot position. The plaster is molded very well around the arch and hind- Manipulation foot. Once the first section of plaster is set firm and holding the foot position, the knee is flexed to 90° All components of the clubfoot deformity are correct- and the above-knee section is applied up to the groin. ed simultaneously except for the ankle equinus, which Firm tension must be used when applying the plaster is corrected last. The arch cavus is corrected at the to prevent cast slippage. Ensure that all skin is cov- same time the forefoot adduction is reduced. This is ered by padding so that no abrasions will be caused achieved by inverting (supinating) and abducting the from the plaster edges. The knee must be reinforced forefoot to align with the hindfoot.21 to prevent cast breakage and it is helpful to apply an Manual manipulation of the infant clubfoot must anterior plaster slab rather than heavy layers. Once be both anatomically accurate and gentle. Ensure the cast is firmly set, it must be well trimmed to allow 308 July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association Right Left Figure 2. Gentle manipulation of the foot first requires location of the head of talus on the lateral side by pal- pating the tibial and fibular malleoli with one hand and holding the toes and metatarsals with the other hand. Slide thumb and forefinger from malleoli to the front of the ankle mortice. The navicular is small (forming) and being medially displaced, will be found under the me- dial malleolus. The anterior calcaneus will be felt just below the talar head. Stabilize the head of the talus lat- erally so the foot can be abducted around the talus. Do not touch the calcaneus for this movement. A B C Figure 1. The Pirani scoring method. A, Lateral border; B, medial crease; C, talar head coverage; D, posterior Figure 3. Gentle manipulation of the foot requires re- crease; E, rigid equinus; F, empty heel. Each of the six duction of the cavus deformity (A). The cavus defor- criteria is scored 0, normal findings; 0.5, moderate or mity is attributable to pronation (eversion) of forefoot partial deformity; or 1.0, severe deformity. The total Pi- in relation to rearfoot. Cavus is always a supple defor- rani score is 6, with two subscores for the midfoot and mity in newborn infants, so inversion (supination) of hindfoot scores of 3 each. (Reprinted with permission the forefoot will flatten out the arch (B, C). (Reprinted from Global Help.) with permission from Global Help.) Journal of the American Podiatric Medical Association • Vol 99 • No 4 • July/August 2009 309 first 24 hours. The position of the toes in the cast should not change. If the toes become less visible, this is an indication that the cast has slipped, foot cor- rection will be reduced, and the likelihood of skin abrasions (possible infections) increased. In this case, the cast must be removed and reapplied. Cast slip- page will occur if the standard Ponseti technique, rather than the adapted technique, is applied to an atypical or complex clubfoot.19 Again, the importance of diagnosing the type of clubfoot is very important in selecting the casting technique. Repeat Casting until Foot Position is Corrected or Achilles Tenotomy is Required Figure 4. Stabilize the talus laterally and abduct the foot while in supination as far as possible, without The casting process is repeated every 5 to 7 days and hurting the infant. Hold this position with gentle pres- is guided by the initial Pirani score,14 especially the ini- sure for 60 seconds. Note the correct positions of the tial hindfoot score.11 It is now known that casting for 5 hands. Repeat this gentle manipulation at each cast days gives the same results as casting for 7 days23 and change to gain elongation of the connective tissues can shorten the overall casting process (average of six prior to cast immobilization. cast repeats) from 42 days to 30 days. This may be very useful for families from remote regions. To avoid upsetting or cutting the infant, cast saws for toe clearance dorsally. It is important that the toe are not used. Instead, it is recommended that all casts extensor muscles can activate because these are anti- be soaked off 1 hour before the next cast is to be ap- clubfoot mechanisms (Fig. 8). It is also important to plied. This can be easily achieved by having the par- monitor blood perfusion to the foot, especially in the ents wrap the cast in wet newspaper or wet towels Figure 5. Foot skeleton references. Notice that with the talus stabilized laterally, the simultaneous supination (re- duces the cavus) (A) and abduction of the forefoot also abducts the heel (B). This is essential for successful reduc- tion of clubfoot deformity. (Reprinted with permission from Global Help.) 310 July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association ducted before performing an Achilles tenotomy to in- crease ankle dorsiflexion. The best sign of sufficient abduction is being able to palpate the anterior process of the calcaneus as it abducts from under the talus.2 At this stage the heel should be in a neutral position and the foot abducted 60° to the tibia (coronal plane). It is better to apply another one or two casts to be sure of the hindfoot abduction, rather than perform- ing a premature and ineffective tenotomy. It is also important that the foot not be forcibly pronated in an attempt to reduce the equinus. Remember that unless the calcaneus can abduct beneath the talus, the foot cannot dorsiflex. The impatient use of excessive force will cause a midtarsal break of the infant foot and will not reduce the ankle equinus. The calcaneus must be Figure 6. Minimal under-cast padding is applied while the correctly manipulated foot position is maintained. able to abduct beneath the talus to reduce the equi- The padding can be applied in two sections, ie, below nus (with or without a tenotomy). the knee and then above the knee, or completely from A tenotomy, if required, can be performed percuta- toes to groin. neously with either topical or locally infiltrated anes- thesia. Some authors14 have commented that both of these methods of anesthesia appear to provide the in- and then put the cast leg in a plastic bag. After an fant with similar pain relief but that the topical skin hour, the cast is soft and can be easily removed with approach enables easier palpation of the tendon. If plaster scissors. local anesthetic solution is injected, a small amount is advised. Full skin disinfection and good sterile tech- Achilles Tenotomy Decision nique must be used for this procedure. As seen in Fig- ure 9, the tenotomy is performed with a small blade The foot is scored with the Pirani scale at each cast to sever the Achilles tendon approximately 1.5 cm change so that progress can be monitored. If adequate above the calcaneus. The foot is held in maximal dor- dorsiflexion is not achieved with sequential cast ab- siflexion while this is performed, and increased dorsi- ductions, an Achilles tenotomy may be required. This flexion is immediate once the tendon is released. The will have been indicated from the initial Pirani score.11, 14 incision is lightly dressed and the post-tenotomy cast It is very important that the foot is sufficiently ab- applied with the foot abducted 60° to 70° and knee A B Figure 7. The cast is applied in two sections. A, The cast is applied first to the foot and the leg below the knee. Note the maintained manipulated foot position until the plaster has set firm. B, The second section of cast connects the knee and thigh with an above-knee cast that extends to the groin. The knee is flexed at 90° and needs to be re- inforced to avoid breakage. Journal of the American Podiatric Medical Association • Vol 99 • No 4 • July/August 2009 311 ly for the months and years following correction. We now know that clubfoot relapse following good cast/ tenotomy correction is enormously increased when the foot abduction brace is not used consistently.6, 15, 23, 24 Given the genetically driven tendency of the clubfoot to be deformed, bracing and monitoring must be very diligent until the child is at least 5 to 6 years of age and beyond.2 The foot abduction brace is applied immediately after the last cast is removed, 3 weeks after the teno- tomy. The brace bar measures shoulder width of the baby and will need to be increased with growth. For bilateral clubfoot the boots are ideally abducted 70°; for unilateral cases, the clubfoot is abducted 70° and the unaffected side abducted 30°. However, it should Figure 8. The plaster is removed to allow dorsal ex- be emphasized that the initial brace abduction angle posure of all toes. This allows toe extensors to work and strengthen against stronger flexors. Vascular sta- should be the same as that obtained with the post- tus and cast position must also be monitored. tenotomy cast. Bracing the feet in greater abduction than that achieved with the final casts may well in- crease the baby’s discomfort and a higher chance of early noncompliance. The knees are free so the baby can kick to exercise and stretch the gastrocnemius flexed at 90° (Fig. 10). This cast remains for 3 weeks, muscles. A slight 10° bend in the bar maintains dorsi- during which the tendon heals. Upon removal of this flexion. cast, the foot abduction brace must be immediately The brace used in Vietnam is now manufactured in applied. Da Nang by the Orthotics Department of Da Nang Or- thopedic and Rehabilitation Centre and comes in Abduction Brace three sizes. The attached boots are also locally pro- duced in nine sizes to accommodate for growth. The Although the casting and tenotomy (usually required) child usually needs three to four different sizes for achieve the correction of the clubfoot, it will all be the duration of bracing (Fig. 11). wasted if the foot abduction brace is not used proper- The brace is worn 23 hours per day for the first 3 A B C D Figure 9. Apply skin preparation to disinfect the foot on all surfaces (A). Use a small amount of local anesthetic so- lution or topical anesthetic cream if available (B). Using a No. 11 or No. 15 blade, a small incision is made 1.0 to 1.5 cm above the calcaneus, while the foot is held in dorsiflexion (C). As the tendon releases, a “pop” is felt or heard, and 10° to 20° dorsiflexion should be gained (D). (Reprinted with permission from Global Help.) 312 July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association A B Figure 10. A final cast is applied after the Achilles tenotomy and remains for 3 weeks. The cast should be applied with the foot abducted 60° to 70° (A). After removal of this final cast, 20° to 30° of ankle dorsiflexion should be pos- sible (B). The foot is now ready for splinting, which must begin immediately to avoid loss of any initial correction. To reduce early noncompliance with the boots and abduction brace, the initial abduction angles should not be greater than that achieved with the final casts. (Reprinted with permission from Global Help.) months. After 3 months, the brace is worn for 16 parents know how to apply the splint and warn them hours per day, at night and during daytime naps. The that a few difficult nights are normal. use of the brace is continued 10 to 12 hours per day up to age 4 years, and is still worn at night up to 5 to 6 Monitor years of age. The longer the brace can maintain cor- rection against genetic clubfoot activity, the better the Because the brace use is so critical to good long-term long-term results. results, it is important to monitor compliance regular- The parents need to be informed of the impor- ly. Follow-up after the initial fitting of the brace should tance of brace use right from the start of managing occur at 2 weeks, 1 month, and 3 months. After 3 the clubfoot. It is a mistake to allow parents to think months, brace use is reduced to 16 hours per day. that the cast correction alone has fixed their baby’s clubfoot, and they must be clearly informed that the clubfoot will relapse if the brace is not worn as in- structed (Fig. 12). A printed information sheet and regular review appointments are advised. Ensure the Figure 11. The brace boots are made in nine sizes to allow for growth. In unilateral cases of clubfoot, differ- Figure 12. The use of the foot abduction brace is es- ent sized boots may be required because the clubfoot sential to prevent relapses, and its use must be regu- is usually smaller than the foot without deformity. larly monitored. Journal of the American Podiatric Medical Association • Vol 99 • No 4 • July/August 2009 313 Continue to check every 3 months until the child is 12 capacity for medical staff to treat this condition with months old (depending upon the age the process the Ponseti method wherever possible; and incorpo- began), three to six monthly checks until the child is 5 rate necessary surgical correction for old and neglect- to 6 years old, and then six to twelve monthly checks ed cases. until age 15 years or at skeletal maturity. Many seminars have been conducted in provinces The risk of relapse is greatly increased with brac- in central Vietnam to provide education to hospital ing noncompliance. It has been shown that insuffi- and clinic staff. Seminar content is consistently re- cient use of the brace accounts for more than 80% of viewed and updated. Educational posters and book- relapses7, 15, 23 and that noncompliance with the brace lets have been produced and distributed to increase is the most predictive factor for clubfoot recurrence. awareness, and doctors have been trained to use the Noncompliant patients are 27 times more likely to re- Ponseti technique in workshops. The boots and bar lapse than those who comply with brace use.25 comprising the foot abduction brace are now devel- The management of the relapsed clubfoot is large- oped and manufactured at DORC, which is develop- ly avoidable if the Ponseti method is used correctly ing as the center of the Ponseti method expertise in and in particular if the foot abduction brace is used to Vietnam, with one of the authors of this paper (D.V.T.) maintain correction during the early years. Signs of a coordinating the program. relapsing clubfoot include reduced abduction, re- The International Committee of the Red Cross duced ankle dorsiflexion, increased metatarsal ad- (ICRC) convened three seminars for doctors in Ho duction, heel varus, and forefoot supination. If the Chinh Minh City in 2007 and 2008 for the Ponseti clubfoot does relapse, the patient should undergo re- technique to be further conveyed to doctors and casting and rebracing. For equinus, the patient should physical therapists by the FFW team. To date, 271 be recast; another tenotomy may be needed, and then doctors and therapists have attended for briefing, and cast and splint again. For gait supination, the patient 67 have been trained to use the technique locally. may need tibialis anterior transfer to the third cunei- Prior to 2006, approximately 10 to 12 children aged 4 form. For further detail regarding relapse manage- to 10 years were presenting annually to the Centre of ment, the reader is referred to the Ponseti monograph.2 Paediatric Orthopedic Rehabilitation, Ho Chinh Minh The Ponseti method is not quick, but it is cost effec- City, for revision of previous clubfoot surgery. Since tive in Vietnam and gives the best long-term results 2006, this same center has seen approximately 30 for the life of the growing child. younger infants annually with untreated clubfoot who are treated with the Ponseti method by doctors and Ponseti Method Research therapists who have attended the ICRC trainings (TV Tan, oral communication, 2008). Dr. Lea Tho Hiean The results of research investigating the efficacy of Nhi from the TuDu Maternity Hospital, Ho Chinh the Ponseti method are summarized and presented in Minh City, completed the ICRC Ponseti method train- Table 2.1, 3, 6-10, 13-15, 19, 23, 24, 26-30 These results illustrate ing in 2007 (Table 3). At the subsequent seminar in very clearly why the Ponseti method has now become May 2008, she presented a summary of the use of the the technique of choice in the developed world. It be- Ponseti method on 30 infants (49 clubfeet) in this comes implicit that this approach is also suitable and hospital over a 6-month period (Table 4). Of the 30 in- beneficial for use in developing countries where fants, 19 were male and 11 female. There were 11 uni- scant health-care resources make the cost-effective lateral clubfeet (nine right feet, two left feet) and 19 Ponseti method very suitable. There is still much to bilateral cases. Twenty cases were idiopathic clubfeet learn regarding both the universally similar and coun- and ten had other associated pathologies. Initial Pi- try specific barriers for families adhering to the Pon- rani scores were ≤ 3.5 in nine feet, between 3.5 and seti method.31, 32 5.0 in 11 feet and ≥ 5.0 in 24 feet. The liaison between the ICRC and the FFW team The Vietnam Experience to Date is ongoing, which will further promote the best man- agement of infant clubfoot deformity for infants in The Feet for Walking clubfoot project (FFW) in Viet- Vietnam. The FFW Web site provides current infor- nam began in 2004 as a collaborative venture be- mation about the progress of this very worthwhile, tween the Da Nang Orthopedic and Rehabilitation collaborative project (www.feetforwalking.org). Centre (DORC) and the Australian College of Podi- atric Surgeons (ACPS). The project aims to increase Acknowledgment: The following bodies have sup- community awareness of clubfoot as a deformity that ported and continue to facilitate the clubfoot project: is best identified and treated early from birth; build a The Medical Director, Mr. Cuc, Medical, Nursing and 314 July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association Table 2. Ponseti Technique Success Rates in the Literature, 1980–2007 No. of No. of Average Age Initial Author Date Patients Clubfeet of Patients Correction (%) Comment Laaveg and Ponseti 27 1980 70 104 < 6 mo 88.5 Ponseti et al28 1981 32 32 infant 87.5 Cooper and Dietz10 1995 45 71 < 4 mo 78 Herzenberg et al9 2002 27 34 < 3 mo 97 Randomized controlled trial: 3% required posterior medial release versus 94% in control group Lehman et al13 2003 63 87 10.8 wks 92 Correction reduced to 50% if brace not used properly Morecuende et al7 2004 157 256 most < 6 mo 98 Relapses due to poor brace use Dobbs et al6 2004 51 86 12 wks 100 Relapses (31%) correlates with brace use: 183 times increased recurrence risk Thacker et al24 2005 30 44 < 6 mo 70 Brace use avoids relapse Tindall et al3 2005 75 100 11.5 wks 98 Malawi study Morecuende et al23 2005 230 319 3–5 mo 92–93 Brace use improves results Gupta et al1 2006 96 154 infant a 100 India study Changulani et al8 2006 66 100 96 Relapses due to poor brace use Shack and Eastwood29 2006 24 40 3 wks 97.5 Treatment delivered by physical therapist Ponseti et al19 2006 50 75 3 mo 100 Complex clubfeet, 14% relapse with poor brace use Goksan et al30 2006 92 134 97 Relapses due to poor brace use, previous treatment, doctor s experience Haft et al15 2007 51 73 15 days 100 Relapses (41%) correlates with brace use a Age of patient was not defined in this study. Table 3. The Scale of Treatment Provided for Infants with Table 4. Clinical Results of Ponseti Management for 30 Clubfoot at TuDu Maternity Hospital, Ho Chinh Minh City, Infants (49 Clubfeet) During A 6-month Period (2007–2008) 2005–2007 Sex Year Treated Male 19 (63%) 2005 2006 2007 Female 11 (37%) Foot affected (30 infants) Clinical data Right 9 No. of all patients seen 6,427 7,621 10,646 Left 2 No. with clubfoot 64 23 36 Bilateral 19 Results of clubfoot treatment Type (30 infants) Excellent/good 52 18 31 Normal clubfoot: 20 Normal/poor 7 3 3 Clubfoot with other pathology: 10 Quit program 5 2 2 Initial Pirani scores ≤ 3.5: 9 (20%) 3.5–5.0: 11(25%) ≥ 5.0: 24 (55%) Allied Health staff at the Da Nang Orthopedic and Re- Treatment stage at time of report habilitation Centre, Da Nang City, Vietnam; Variety Casts 27% Club of Australia and Clarks Shoes/Pacific Brands for Boots/splint 73% project sponsorship; Australian College of Surgical Podiatrists (especially Paul Wade, DPM, and Andrew van Essen); East Meets West Foundation, Da Nang City, Vietnam (especially Mark Conroy); International cially Dr. Tan); Vietcot, Hanoi, Vietnam (especially Committee of the Red Cross, Ho Chinh Minh City, Mr. Thanh); Dr. I. Ponseti, Iowa; Dr. N. Davis, Booth Vietnam (especially Leo Gasser); Centre of Paediatric Hall, Manchester; Ms. D. Watson, Chelsea and West- Orthopedic Rehabilitation, Ho Chinh Minh City (espe- minster Hospitals, London; Dr. E. Goergens, Ham- Journal of the American Podiatric Medical Association • Vol 99 • No 4 • July/August 2009 315 burg, for generous collegial support and sharing their 15. HAFT GF, WALKER CG, CRAXFORD AD: Early clubfoot recur- invaluable experience. Many individual donors of fund- rence after use of the Ponseti method in a New Zealand population. J Bone Joint Surg Am 89: 487, 2007. ing, assistance, and supplies. All are very gratefully 16. S IAPKARA A, D UNCAN R: Congenital talipes equinovarus. acknowledged. A review of current management. J Bone Joint Surg Br Financial Disclosure: None reported. 89B: 995, 2007. Conflict of Interest: None reported. 17. A GARWAL AK: Step by Step Management of Clubfoot by Ponseti Technique, Jaypee Brothers, New Delhi, India, 2007. References 18. PONSETI IV: Common errors in the treatment of congen- ital clubfoot. Int Orthop 21: 137, 1997. 1. GUPTA A, SINGH S, PATEL P, ET AL: Evaluation of the util- 19. PONSETI IV, ZHIVKOV M, DAVIS N, ET AL: Treatment of the ity of the Ponseti method of correction of clubfoot de- complex idiopathic clubfoot. Clin Orthop Relat Re- formity in a developing nation. Int Orthop 32: 75, 2006. search 451: 171, 2006. 2. P ONSETI IV, M ORECUENDE JA, M OSCA V, ET AL : Clubfoot: 20. EVANS AM: “Pirani Severity Scoring for the Clubfoot Pro- Ponseti Management, 2nd Ed, ed by LT Staheli, Global- gram in Vietnam: A Reliability Study,” in 22nd Australasian HELP, 2003. Available at: http://www.global-help.org. Ac- Podiatry Conference Book of Abstracts, p 73, 2007. cessed May 1, 2009. 21. MORECUENDE JA, WEINSTEIN SL, DIETZ FR, ET AL: Plaster 3. 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THACKER MM, SCHER DM, SALA DM, ET AL: Use of the foot dictive of outcome after use of the Ponseti method for abduction orthosis following Ponseti casts: is it essen- the treatment of idiopathic clubfeet. J Bone Joint Surg tial? J Pediatr Orthop 25: 225, 2005. Am 86: 22, 2004. 25. CHEN RC, GORDON JE, LUHMANN SJ, ET AL: A new dynamic 7. MORECUENDE JA, DOLAN LA, DIETZ FR, ET AL: Radical re- foot abduction orthosis for clubfoot treatment. J Pedi- duction in the rate of extensive corrective surgery for atr Orthop 27: 522, 2007. clubfoot using the Ponseti method. Pediatrics 113: 376, 26. L OURENCO AF, M ORCUENDE JA: Correction of neglected 2004. idiopathic club foot by the Ponseti method. J Bone Joint 8. CHANGULANI M, GARG NK, RAJAGOPAL TS, ET AL: Treatment Surg Br 89B: 378, 2007. of idiopathic clubfoot using the Ponseti method. Initial 27. LAAVEG SJ, PONSETI IV: Long term results of treatment of experience. J Bone Joint Surg Br 88: 1385, 2006. congenital club foot. 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PIRANI S, ZEZNICK L, HODGES D: Magnetic resonance im- for the correction of idiopathic clubfeet presenting up aging study of the congenital clubfoot treated with the to 1 year of age. A preliminary study in children with Ponseti method. J Pediatr Orthop 21: 719, 2001. untreated or complex deformities. Arch Orthop Trauma 13. L EHMAN WB, M OHAIDEEN A, M ADAN S, ET AL : A method Surg 126: 15, 2006. for the early evaluation of the Ponseti (Iowa) technique 31. MCELROY T, KONDE-LULE J, NEEMA S, ET AL: Understand- for the treatment of idiopathic clubfoot. J Pediatr Or- ing the barriers to clubfoot treatment adherence in thop 12: 133, 2003. Uganda: a rapid ethnographic study. Disabil Rehabil 29: 14. J ANICKI JA, N ARAYANAN UG, H ARVEY BJ, ET AL : Compari- 845, 2007. son of surgeon and physiotherapist-directed Ponseti 32. LAVY CBD, MANNION SJ, MKANDAWIRE NC, ET AL: Club foot treatment of idiopathic clubfoot. J Bone Joint Surg Am treatment in Malawi: a public health approach. Disabil 91: 1101, 2009. Rehabil 29: 857, 2007. 316 July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association
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