Management of Congenital TalipesEquinovarus by Ponseti Technique:A Clinical Study

Mazhar Abbas, MS,1 Owais A. Qureshi, MS,2 Lateef Z. Jeelani, MS,3 Qamar Azam, MS,3

Abdul Q. Khan, MS,3 and Aamir B. Sabir, MS3

The purpose of this study was to evaluate the early results of treatment of idiopathic congenital talipesequinovarus (CTEV) by the Ponseti method and compare the results with those of other manipulationtechniques and surgical treatment reported in the literature. A total of 100 patients with 156 clubfeet (80males, 20 females), were treated for idiopathic CTEV by the Ponseti method. The average age atpresentation was 4.5 months. Scoring of each foot was done according to the Pirani score. Photographsshowing the deformity and podograms were taken to have an objective record against which the resultswere compared. The mean total Pirani score at the start of treatment was 4.26 and mean foot print angle(FPA) was 14.2°. Post correction, there was a significant difference (P � .001, z � 18.638) in the meanFPA. There was also a statistically significant difference between the pre- and postcorrection Piraniscores (P � .001, z � 55.427). In 95% of the patients correction of the deformity was achieved. ThePonseti technique is based on sound understanding of the pathoanatomy of clubfoot. The good resultsobtained by the Ponseti technique show that posteromedial soft tissue release may no longer be requiredfor most cases of idiopathic CTEV. Level of Clinical Evidence: 2 (The Journal of Foot & Ankle Surgery47(6):541–545, 2008)

Key Words: clubfoot, congenital talipes equinovqrus (CTEV), Ponseti, Pirani, podogram

Treatment of clubfoot remains as controversial as itsetiology. Various conservative methods of treatment havebeen described with variable and often irreproducible re-sults. The surgical methods are fraught with their own list oflimitations and complications.

After many years during which surgical methods weretouted as the treatment of choice, conservative methods likethe Ponseti technique have again become popular.

The Ponseti technique is based on sound understanding ofpathoanatomy of the clubfoot. The aim of this study was toevaluate the results of the Ponseti technique and comparethe results to other manipulation techniques and surgicalmethods reported in the literature.

This was a descriptive hypothesis forming study.

Address correspondence to: Owais A. Qureshi, MS, Registrar, Depart-ment of Orthopaedic Surgery, J. N. Medical College, A.M.U., Aligarh-202002, UP, India. E-mail: drowaisqureshi@gmail.com

1Reader, Department of Orthopaedic Surgery, J.N. Medical College,Aligarh, UP, India.

2Registrar, Department of Orthopaedic Surgery, J.N. Medical College,Aligarh, UP, India.

3Lecturer, Department of Orthopaedic Surgery, J.N. Medical College,Aligarh, UP, India.

Financial Disclosure: None reported.Conflict of Interest: None reported.Copyright © 2008 by the American College of Foot and Ankle Surgeons

1067-2516/08/4706-0009$34.00/0doi:10.1053/j.jfas.2008.07.002

VOLUME 47

Patients and Methods

Between March 2005 and August 2006, a total of 100patients with 156 clubfeet (80 males, 20 females) weretreated for idiopathic congenital talipes equinovarus(CTEV). Children with other associated congenital defectswhere excluded from the study. Mean age was 4.5 monthsat presentation (minimum 0.25 months and maximum 36months). Scoring of each foot was done according to thePirani score (1) by 2 different members of the team. Thedetails of the Pirani score are given in Table 1. This scorewas useful in assessing the severity of the deformity andalso in monitoring the correction (2). Photographs showingthe deformity and podograms were taken to have an objec-tive record against which the results could be compared.Figure 1 is an example of a podogram. The followingparameters were recorded from the podogram:

(1) Forefoot width: Length of the line joining the widestpart of the forefoot.

(2) Hindfoot width: Length of the line joining the widestpart of the heel.

(3) Length: Length of the line joining the tip of the secondtoe with the most convex part of the heel.

(4) Footprint Angle: Taken to be the angle between theline joining the midpoint of the forefoot with the mid-

point of the heel and the line joining the most medial

, NUMBER 6, NOVEMBER/DECEMBER 2008 541

es at

part of the forefoot with the most medial part of thehindfoot. The anteromedial angle was measured.

After this, a corrective cast was applied following thePonseti technique. In this technique all the components ofthe deformity except the equinus are corrected simulta-neously. The first step is the correction of the cavus defor-mity by placing the forefoot in proper alignment with thehindfoot. In subsequent casts, manipulation consisting ofabduction of the foot beneath the stabilized talar head isdone. The talar head acts as the fulcrum of the correctionThe casts were changed weekly and if the tendoachilles was

FIGURE 1 Graph showing positive correlation between number ofcasts and the total Pirani score. r � 0.515.

TABLE 1 Pirani score

Hindfoot contracture scoreSeverity of posterior crease (PC) 0 � multiple fine creas

0.5 � 1 or 2 deep crea1 � deep creases cha

The emptiness of the heel (EH) 0 � tuberosity of calca0.5 � tuberosity of cal1 � tuberosity of calca

The rigidity of equinus (RE) 0 � ankle dorsiflexes f0.5 � ankle dorsiflexes1 � ankle dorsiflexion

than 90°Midfoot contracture score

Severity of medial crease (MC) 0 � multiple fine creas0.5 � 1 or 2 deep crea1 � deep creases cha

Palpation of lateral part of the headof the talus (LHT)

0 � navicular complete0.5 � navicular partiall1 � navicular does not

Curvature of the lateral border (CLB) 0 � straight border0.5 � mild distal curve1 � lateral border curv

tight and acceptable dorsiflexion (20° to 25°) could not be

542 THE JOURNAL OF FOOT & ANKLE SURGERY

achieved by manipulation, a simple percutaneous tenotomyof the tendoachilles was done without any local anesthesiaon the sedated child, using syrup pedichloryl, under asepticprecautions. The last cast was removed and the child wasput on a foot abduction brace. The brace we used consistedof leather shoes connected to a metal bar. The width of thebar was kept equal to the shoulder width. The affected footwas kept in 75° of abduction. In case of unilateral deformi-ties, the affected foot was kept at 70° to 75° of abductionand the normal foot at 45° of abduction. After 3 months of24-hour bracing except for cleaning purposes, the Piraniscore and podographic parameters were recorded to get thepostcorrection values. Further follow-up of the child wascontinued.

Results

The mean precorrection Pirani score was 4.26 and the

ontour of the archs easily palpableus more difficult to palpates not palpable

llow lateral border of foot and leg to make an angle of 90° or lessly limited. Lateral border of foot and leg make an angle of greater

ontour of the archduces, lateral talar head cannot be feltuces, lateral talar head less palpablece, lateral talar easily felt

rdercalcaneocuboid joint

TABLE 2 Descriptive analysis of the cohort (n � 156 clubfeetin 100 patients)

Variable Mean (Range) or %

Age, mo 4.5 (0.25–36)Male gender 80%Right sided 29%Left sided 15%Bilateral 56%Length, cm 7.4 (5.3–11.2)Forefoot width, cm 3.5 (2.4–5.5)Hindfoot width, cm 1.7 (0.8–2.8)Foot print angle, degrees 14.2 (8–23)

esses

nge cneoucaneoneouullyto a

sever

esses

nge cly re

y redredu

d bo

postcorrection mean score was 1.3. A normal foot would

have a score of zero. A percutaneous tenotomy was requiredin 96% of patients and a repeat tenotomy was required in5% of patients because of inability to get a satisfactoryamount of dorsiflexion after the first tenotomy. None of thechildren developed any weakness of ankle plantarflexionafter the percutaneous tenotomy. The average number ofcasts required was 6.6. Three patients required post-tenot-omy manipulations because of unsatisfactory correction. Amean dorsiflexion of 12° was achieved after correction ofthe deformity. The response rate in this study was 95%. Themost common residual deformity noted was forefoot adduc-tion and only 5 patients had an incomplete correction thatrequired a posteromedial soft tissue release. These patientshad poor compliance with the bracing protocol. Age of thesepatients ranged from 0.75 months to 18 months.

Table 2 depicts a descriptive analysis of the cohort stud-ied and Table 3 compares the precorrection and postcorrec-tion values of the Pirani score and podographic parameters.

FIGURE 2 Graph showing positive correlation between number ofcasts and the midfoot Pirani score. r � 0.39.

TABLE 3 Comparison of the precorrection andpostcorrection results (n � 156 clubfeet in 100 patients)

Variable PrecorrectionMean

(Min, Max)

PostcorrectionMean

(Min, Max)

P Value

Pirani score 4.26 (1, 6) 1.3 (0.5, 2) �.001 (55.427)Length, cm 7.4 (5.3, 11.2) 8.3 (6.1, 11.8) �.001 (15.682)Forefoot width,

cm3.5 (2.4, 5.5) 4.0 (2.4, 6.1) �.001 (56.675)

Hind foot width,cm

1.7 (0.8, 2.8) 2.1 (0.8, 3.2) �.001 (53.035)

Foot print angle,degrees

14.2 (8, 23) 10.1 (6, 12) �.001 (18.638)

There was a statistically significant difference between the

VOLUME 47

mean precorrection and mean postcorrection footprint an-gles, (P � .001, z � 18.638). The difference between themean precorrection and mean postcorrection Pirani scorewas also significant (P � .001, z � 55.427). There was ahigh degree of positive correlation between the initial Piraniscore and the number of casts required, as is clear fromFigure 2. There was a strong positive correlation betweenthe initial midfoot score and the number of casts (Figure 3)and also between the initial hindfoot score and the numberof casts needed for correction (Figure 4).

The results showed that there was a good response totreatment by Ponseti technique in a majority of the patientsin this study (Figures 5–8). An improvement in the podo-graphic parameters was clearly demonstrated, which wasstatistically significant. Moreover a strong positive correla-tion was demonstrated between the initial Pirani score and

FIGURE 3 Graph showing positive correlation between number ofcasts and the hindfoot Pirani score. r � 0.441.

FIGURE 4 A podogram.

the number of casts required. This implies that an estimate

, NUMBER 6, NOVEMBER/DECEMBER 2008 543

of the duration of treatment can be made from the Piraniscore, which becomes important when discussing the treat-ment with the patient’s parents.

Discussion

CTEV is the commonest congenital deformity of the footthat we encounter in the pediatric age group (3). Despitethis, its treatment remains confusing. Various manipulationtechniques have been described with variable results. Dan-gelmajer (4) gave a response rate of 40%. Kite (5) reporteda response rate of 90% with his technique. These results

FIGURE 5 Precorrection photographs of a patient (anterior view).

FIGURE 6 Precorrection photographs of a patient (posterior view).

could not be reproduced and Zimbler (6) reported a response

544 THE JOURNAL OF FOOT & ANKLE SURGERY

rate of only 10% with Kite’s technique. The Ponseti techniqueis based on sound understanding of the pathoanatomy of club-foot (7). Various workers have given consistently better resultswith this technique. Lehman et al (8) reported a response rateof 92%. Colburn and Williams (9) reported a response rateof 94.1%. Morcuende et al (10) reported a response rate of98%. Various studies on surgical treatment have also givenvariable results. Brockman (11) reported a relapse rate of46%. Turco (12) reported a relapse rate of 50%. Morcuendeet al (10) reported a relapse rate of 11% with the Ponsetitechnique. Herzenberg et al (13) reported a relapse rate of3.7% with the Ponseti technique. There was a strong posi-tive correlation between the initial Pirani score and thenumber of casts required. The difference between the meanprecorrection and mean postcorrection Pirani score was

FIGURE 7 Postcorrection photographs of a patient (anterior view).

FIGURE 8 Postcorrection photographs of a patient (posteriorview).

statistically significant (P � .001, z � 55.427). The differ-

ence between the mean footprint angle before and aftercorrection was statistically significant (P � .001, z �18.638). Thus Pirani scoring and podography can be used tomonitor the treatment. The Pirani score can also be used toestimate the duration of treatment.

The good results obtained by the Ponseti technique showthat posteromedial soft tissue release may no longer berequired for most cases of idiopathic CTEV. However, alonger follow-up is required to further validate the goodresults obtained in this study and to assess the need oftendon transfers in these patients.

References

1. Pirani S, Outerbridge HK, Sawatzky B, Stothers K. A reliable methodof clinically evaluating a virgin clubfoot. 21st Annual InternationalConference of the Société Internationale de Chirurgie Orthopédiqueset de Traumatologie (International Society of Orthopaedic Surgery andTraumatology), Sydney, Australia, 1999, proceedings published bySICOT aisbl, Brussels, Belgium.

2. Dyer PJ, Davis N. The role of the Pirani scoring system in themanagement of club foot by the Ponseti method. J Bone Joint Surg Br88(8):1082–1084, 2006.

3. McKeown T, Record RG. Malformation in a population observed for

five years after birth. In Ciba Foundation, Symposium on Congenital

VOLUME 47

Malformations, p 2, edited by GEW Wolstenholme, CM O’Connor,Churchill, London, 1960.

4. Dangelmajer RC. A review of 200 clubfeet. Bull Hosp Spec Surg4:73–80, 1961.

5. Kite JH. Non-operative treatment of congenital clubfeet: a review ofone hundred cases. Southern Med J 23:337, 1930.

6. Zimbler S. Nonoperative management of the equinovarus foot: longterm results. In The Clubfoot, p 191, edited by GW Simons, Springer-Verlag, New York, 1994.

7. Ponseti IV. Clubfoot—Fundamentals of Treatment. Oxford UniversityPress, New York, 1996.

8. Lehman WB, Mohaideen A, Madan S, Scher DM, Van Bosse HJ,Iannaconne M, Bazzi JS, Feldman DS. A method for early evaluationof the Ponseti technique for the treatment of idiopathic clubfoot.J Pediatr Orthop B 12(2):133–140, 2003.

9. Colburn M, Williams M. Evaluation of the treatment of idiopathicclubfoot by using the Ponseti method. J Foot Ankle Surg 42(5):259–267, 2003.

10. Morcuende JA, Dolan LA, Deitz FR, Ponseti IV. Radical reduction inthe use of extensive corrective surgery for clubfoot using the Ponsetimethod. Pediatrics 113(2):376–380, 2004.

11. Brockman EP. Congenital Club Foot, John Wright and Sons, Bristol,UK, 1930.

12. Turco VJ. Surgical correction of the resistant clubfoot. J Bone JointSurg 53A:477, 1971.

13. Herzenberg JE, Radler C, Bor M. Ponseti versus traditional meth-ods of casting for idiopathic clubfoot. J Pediatr Orthp 22(4):517–

521, 2002.

, NUMBER 6, NOVEMBER/DECEMBER 2008 545