|Year : 2019 | Volume
| Issue : 9 | Page : 1266-1270
Ponseti clubfoot management method: Initial experience with 273 clubfeet treated in a clubfoot clinic of a Nigerian regional orthopedic hospital
OA Lasebikan1, IA Anikwe1, NO Onyemaechi2, ED Chukwujindu2, CU Nwadinigwe1, NI Omoke3
1 Orthopaedic Surgery Department, National Orthopaedic Hospital, Enugu, Nigeria
2 Department of Surgery, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
3 Department of Surgery, Ebonyi State University/Federal Teaching Hospital, Abakaliki, Nigeria
|Date of Acceptance||17-May-2019|
|Date of Web Publication||6-Sep-2019|
Dr. N O Onyemaechi
Department of Surgery, College of Medicine, University of Nigeria, Ituku Ozalla, Enugu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: The aim of this study was to evaluate the initial experience and outcome of clubfoot treated using the Ponseti technique in a regional orthopedic hospital setting of a developing country. Methods: This was a retrospective review of all the clubfoot patients who were treated at the clubfoot clinic of National Orthopaedic Hospital Enugu from 1st of August 2013 to 31st January 2015. Result: There were 175 patients with 273 clubfeet. The male to female ratio was 1.2:1, and the age range was 1 week to 27 years with a median age of 11 months. One hundred and fifty-one patients (86.5%) had congenital clubfoot, whereas 24 (13.5%) had acquired clubfoot. The mean Pirani score of the patients at presentation was 4. The mean number of cast sessions needed for correction was 6.3. The majority of the feet (96.6%) were treated and correction achieved with Ponseti method alone, whereas 3.4% had other additional surgical procedures. Seventy-two (41.1%) patients afforded and used foot abduction brace as prescribed. Plaster sores in 12.5% of patients were the most common complication. At a mean follow-up period of 6 months, a relapse rate of 3.4% was observed. Conclusion: Ponseti clubfoot management technique alone is very effective in most cases of clubfoot in our setting. Late presentation of patients and foot abduction brace related challenges observed call for a policy response aimed at educating the public on the importance of early presentation and improving the use of foot abduction brace.
Keywords: Clubfoot, Nigeria, nonoperative, outcome, Ponseti method
|How to cite this article:|
Lasebikan O A, Anikwe I A, Onyemaechi N O, Chukwujindu E D, Nwadinigwe C U, Omoke N I. Ponseti clubfoot management method: Initial experience with 273 clubfeet treated in a clubfoot clinic of a Nigerian regional orthopedic hospital. Niger J Clin Pract 2019;22:1266-70
|How to cite this URL:|
Lasebikan O A, Anikwe I A, Onyemaechi N O, Chukwujindu E D, Nwadinigwe C U, Omoke N I. Ponseti clubfoot management method: Initial experience with 273 clubfeet treated in a clubfoot clinic of a Nigerian regional orthopedic hospital. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 16];22:1266-70. Available from: http://www.njcponline.com/text.asp?2019/22/9/1266/266165
| Introduction|| |
Clubfoot, otherwise known as talipes equinovarus is a musculoskeletal deformity of the foot, commonly occurring as a congenital malformation but can occasionally be acquired after birth., Clubfoot deformity is characterized by four components: equinus ankle, hindfoot varus, midfoot cavus, and fore foot adduction., In clubfoot, the most severe deformity occurs in the hind part of the foot, the talus is generally deformed and in severe equinus, and the calcaneus is in varus angulation and rotated medially with the navicular medially displaced.
The congenital clubfoot is usually idiopathic but may be associated with other conditions in about 20% of cases. It is the most common congenital abnormality affecting the lower limb, occurring as developmental malformation after the first trimester of pregnancy. It has a global incidence of 1–2 per 1000 newborns., However, a study done in South East Nigeria gave an incidence of 3.4 per 1000 births. Approximately, 50% of cases are bilateral, and first-degree relatives are at a significantly increased risk of the deformity compared with the general population. The etiology of congenital talipes equirovarus is unknown. However, various theories have been proposed, including vascular deficiencies, environmental factors, genetic factors, and effects of the intra-uterine position of the fetus.,
The goal of treatment is a functional plantigrade pain-free foot with good mobility.,, Most orthopedic surgeons have agreed that non-operative treatment should be the initial treatment modality of clubfeet., The Ponseti method of clubfoot management has been shown to be the most effective, producing better long-term results, and fewer complications than other non-operative and surgical methods., This is more evident in the long term because surgically managed clubfoot tends to become stiff and painful later in life. There is also a high risk of recurrence, which the Ponseti treatment protocol reduces by the use of a foot abduction brace that is worn for at least 23 hours daily, for the first 3 months after correction. Thereafter, the brace is worn when the child is sleeping at night and during the day naps until 4 years of age.
In Ponseti method, the deformity is reduced by weekly manipulations and plaster casting., The manipulations to correct the deformities are done sequentially; first the cavus, the varus and forefoot adduction, lastly the equinus. A percutaneous tenotomy is often required to complete the correction,, which is usually done in the cast room, with good outcome. This also reduces the number of casts required to correct the equinus component of the deformity. Prior to the onset of our clubfoot clinic in August 2013, most clubfoot patients underwent surgical treatment especially soft tissue releases, after a period of unsuccessful 2 weekly castings by our plaster technicians, without the involvement of the attending surgeon in the manipulation, as advocated by the Ponseti treatment management protocol. The Ponseti protocol was formally adopted as the treatment modality for all clubfoot patients in National Orthopaedic Hospital Enugu in August 2013, with the establishment of a club foot clinic, where all club foot patients that present to the hospital are managed in line with the Ponseti management protocol.
In West African sub-region, there is paucity of data on Ponseti method of non-operative management of clubfoot, which has necessitated this study. The aim of this study was to evaluate the initial experience and outcome of clubfoot treated using Ponseti technique in a regional orthopedic hospital setting of a developing country.
| Methods|| |
This was a retrospective study of all patients with clubfoot seen and treated in the clubfoot clinic of National Orthopaedic Hospital Enugu between August 2013 and January 2015. National Orthopaedic Hospital Enugu is a regional orthopedic and trauma center located in Enugu southeast Nigeria. It serves the Southeast, South-South, and part of the North-Central geopolitical zones of Nigeria, a population of about 30 million people.
An ethical approval for this study was given by the hospital Research and Ethics Committee. The hospital records and patient case notes were the sources of data. Data collection was done using a data entry form designed for the study. Information such as demographic data, severity of clubfoot at presentation, affected side, family history, management details, and outcome was entered. Pirani scoring system that applies a point score according to different physical findings, which when summed, gives a score that correlates with clubfoot severity was used to assess the foot.
All patients who attended the clubfoot clinic until full correction of deformity were included in this study, whereas those with incomplete records and patients who did not complete their treatment were excluded from the study.
Data analysis was done with a statistical package for social sciences (SPSS) version 20 (SPSS Inc Chicago IL, USA). Quantitative variables were expressed as means and standard deviations. Frequency tables, cross tabulation, Pearson's Chi-square test of significance were used. For all statistical analysis at 95% confidence level, P value < 0.05 was considered significant.
| Results|| |
Within 18 months period, 175 patients with 273 clubfeet completed treatment in the clubfoot clinic. One hundred and forty-eight patients (84.6%) had congenital talipes equirovarus, whereas 23 (13.1%) had acquired talipes equirovarus. There was no documented etiology in 4 (2.3%) of the patients. There were 95 males (54.3%) and 80 females (45.7%) with a male to female ratio of 1.2:1.
The age of patients at presentation ranged from 1 week to 27 years of age with a median and modal age of 11 and 1 month, respectively. Twenty-seven (15.4%) patients presented within the first month of life. Seventy-six (43.4%) patients presented within in the first 6 months of birth, whereas ninety-six (55%) patients were within 1 year of age on presentation. The age distribution of the patients as shown in [Figure 1] indicated a peak age group incidence of 1–2 years and a gradual decrease in incidence with increasing age. One hundred and thirty-three patients (76%) presented within the first 2 years of life. A majority 95 (53.7%) of these patients were residents in Enugu, whereas 80 (43.7%) of them were residents in other states that are on the average 150 km away from the hospital.
Seventy-seven (44%) patients had unilateral deformity involving the right foot in 36 (20.6%) and the left foot in 41 (23.4%). Bilateral deformities occurred in 98 (56%) patients. There was a positive family history of clubfoot in seven (4%) of the patients. Fifty-three (30.3%) of the patients had previous treatment for clubfoot before presenting to our clubfoot clinic. The three top modalities of previous treatment received by these patients were serial manipulation and Plaster of Paris (POP) casting, traditional bonesetter's massage and splintage, and physiotherapy and strapping as shown in [Table 1].
The Pirani score at presentation ranged from 1.5 to 6 with a mean score of 4 ± 1.7. A majority of the patients presented with a Pirani score of 4.6–6, whereas the least of them presented with a Pirani score of 0–1.5 as shown in [Figure 2].
|Figure 2: Distribution of patients by Pirani score of the clubfoot deformities at presentation|
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The majority of the clubfoot 264 (96.7%) were treated and full correction of deformities achieved with Ponseti technique alone. The number of cast sessions to achieve full correction ranged from 1 to 20 with a mean of 5.7 ± 3.1. Majority of the patients had full correction of deformity after 3–4 cast sessions as shown in [Figure 3]. The mean number of casts used for patients with idiopathic clubfeet was 4.1 ± 1.2 compared to 7.2 ± 2.3 for patients with syndromic and acquired clubfeet (P = 0.001).
|Figure 3: Distribution of patients by number of cast sessions required to achieve correction of the deformity|
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Thirty-eight (21.7%) of the patients underwent percutaneous tenotomy as and when indicated in the technique. Nine (3.3%) of the clubfoot in seven patients required further operative surgical intervention after a period of Ponseti method of manipulation and serial casting to correct as much of the deformity as possible. Late presentation after the age of one was associated with an increase in the number of casts and the need for additional surgical procedures (P = 0.001).
Four (2.3%) of the patient underwent open elongation of Achilles tendon (ETA) only, whereas three (1.7%) patients had an open ETA and calcaneocuboid wedge osteotomy.
After full correction of deformities by serial manipulation and casting, only 98 (56%) patients used foot abduction braces. Superficial pressure sores from casting that occurred in 12.5% of patients was the most common complication among the patients. At a mean follow-up period of 6 months, a relapse was observed in six patients giving relapse rate of 3.4%.
| Discussion|| |
The results of this study indicate that clubfoot is an important health concern in our setting and the bulk of these patients presented with congenital talipes equinovarus. Non-operative and conservative treatment of clubfoot should preferably begin in the neonatal period, as early as a day or two after birth. In this series, the proportion of the patient that presented in the first month of life is quite less than 42.5% as reported by Adewole et al. in Lagos South West Nigeria. Late presentation of patients with clubfoot, which was quite common, in our setting is at variance with an early presentation in the United Kingdom reported by Changulani et al. The exact reason/s for the much later presentation of the patients to clubfoot clinic in this series is not evident and calls for another study.
The slight male preponderance observed in this study is similar to the findings reported by Ukoha et al. and Adewole et al. However, it differs from a higher male to female ratio of 2:1 reported by Siapkara et al. The incidence of positive family history of clubfoot in this series (4%) is in sharp contrast with a rate of 23% reported by Morcuende et al. However, the reason for this difference is not evident. The incidence of bilateral clubfeet (56%) in this study is almost similar to the incidence of 50% reported by Nordin et al.
In this study, 30.3% of the patients had some prior treatment before presentation, while Morcuende et al. reported that 73% of their patients had previous treatment for the clubfoot. The disparity in access to healthcare services in the two study settings may explain this finding.
Most patients presented with Pirani score of greater than 4.5, which implies severe deformities. This is similar to the majority (68%) of patients with Pirani scores greater than 4 reported by Adewole et al. The mean Pirani score of 4 in this study is almost similar to 4.2 reported by Kampa et al. The mean number of cast sessions of 6.3 required to achieve full correction in this study is also almost similar to 6 reported by Changulani et al. and 6.3 reported by Kampa et al. in a District General Hospital Setting. However, the range of number of cast to achieve correction (1–20) observed in this study differ from (2–12) reported by Changulani et al. in a setting where early presentation is the norm. In our setting, late presentation is common, and older children are more likely to present with stiffer feet that require more sessions of manipulation and casting. This perhaps explains the differences in the range of cast sessions needed to achieve correction in these two settings. We also observed that patients with syndromic and acquired clubfeet needed more cast sessions and additional surgical procedures to achieve correction. These types of clubfeet are usually associated with stiffer and more severe deformities.
Percutaneous tenotomy rate in this study was lower than 26.6% to 85% in published reports.,,, Ponseti technique was newly introduced in the hospital, and initially, there was system related resistance to have percutaneous tenotomy carried out in the casting room. The earlier cases that needed tenotomy had it in the operating room, which increased the cost beyond the reach of indigent patients. Initially, there was also associated delay in recognition of patients in need of tenotomy as well as inadequate expertise for the procedure, as part of the learning curve for the new treatment protocol. The correction in these patients was achieved with more casts. In addition, some parents did not consent to percutaneous tenotomy for socio-cultural reasons. Fortunately, after a longer period of casting, the correction was achieved without tenotomy in these groups. These perhaps explain the relatively low rate of tenotomy observed in this study.
Foot abduction brace is important after correction of deformity to prevent recurrence. The proportion of patients that afforded and used foot abduction brace as prescribed was similar to 56.8% reported by Adewole et al. This could be owing to the high cost of brace for most patients, especially the indigent ones that have exhausted funds on transportation to clinic and casting. Provision of cost-effective braces by either governmental agencies or donor organizations may improve the compliance to bracing because the mostly indigent patients usually pay for braces out-of-pocket.
Most of our patients; 264 feet (96.6%) were treated with only Ponseti technique. This is comparable to work by Morcuende et al. who reported 98% success with Ponseti method and also work by Herzenberg et al. who reported 97% success rate with the same technique. The relapse rate of 3.4% after a mean follow-up period of 6 month is comparable to 5.2% after 1-year follow-up reported by Adewole et al. However, the low relapse rate observed may not be the same after a long follow-up period because of foot abduction brace related challenges. Only 3.4% of our patients required further surgeries after a few sessions of Ponseti manipulation and serial casting to correct as much of the deformity as possible. The surgeries done were mainly elongation of Tendo-Achilles ± calcaneocuboid wedge osteotomy/fusion. This is similar to 2.5% extensive surgery rate reported by Morcuende et al. Furthermore, the study by Adegbehigbe et al. involving 105 clubfoot patients reported that major clubfoot surgery was not commonly indicated among patients treated with Ponseti technique in all age groups of his patient series.
Complications noted in our study were mainly pressure sores from casting that occurred in 12.5% of cases. This is similar to the complication rate of 8% reported by Morcuende et al. Improvement in casting technique may reduce the rate of this complication.
Limitations of the study
The follow-up period of 6 months seems quite short to effectively monitor relapses from our treatment. The relapse rate may increase after a longer follow-up period, especially with the poor brace use observed in our study. This, therefore, constitutes a limitation to this study.
| Conclusion|| |
Conservative management of clubfoot with Ponseti technique alone is a simple and effective method of treating clubfoot in our environment, a low resource setting. Idiopathic clubfeet and early presentation were indicators of a good outcome with Ponseti technique alone. Late presentation of patients and foot abduction brace related challenges observed call for a policy response aimed at educating the public on the importance of early presentation and improving the use of foot abduction brace.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]