Introduction

The incidence of congenital talipes equinovarus (clubfoot) ranges from 1-3 per 1000 live births across the world. [1] Ponseti method has transformed the management of clubfoot in children producing good long-term results and in the last two decades has gained acceptance in the worldwide orthopaedic community.[2- 5]

The Conventional Ponseti method uses serial application of weekly above knee plaster casts to gradually correct the deformity, using a strictly defined sequence of molded plaster changes. The last deformity to be corrected is equines, which often requires a percutaneous tendo Achilles tenotomy followed by a final plaster. This final plaster is removed after three weeks and foot abduction braces are given to the child which are to be worn for twenty three hours per day for three months and thereafter for twelve hours at night, till the age of three years.

We run a clubfoot clinic at our hospital. The patients who come to our clinic often have to travel long distances for treatment. Transport facilities for these patients are often erratic and not always available. In addition, keeping a plaster clean and dry for a week can be challenging and failure to do so may result in a loss of position.

There is now strong evidence to suggest that accelerated frequency of cast changes has comparable outcomes to those of the conventional Ponseti method with the benefit of limiting the time spent is casts during the corrective phase of treatment. The researchers have modified the frequency of casting from weekly basis to as less as thrice a week and produced comparable results [6-8]. There is still very little published data about effectiveness of accelerated Ponseti technique in the Indian patients. We conducted this study to determine the feasibility and compare the results of accelerated and conventional Ponseti technique in idiopathic congenital clubfoot.

Methods

A prospective experimental randomized controlled trial was conducted from July 2014 to June 2015 in the clubfoot clinic at our tertiary care center. Forty cases with 53 clubfeet were taken up for the study. The International Guidelines for Biomedical Research involving Human Subjects issued by CIOMS, (Geneva 1982) were complied.

The Inclusion Criteria were;age less than three months, unilateral or bilateral idiopathic clubfoot and willingness to take part in the study while theExclusion Criteria were;age more than three months, earlier treated with other methods of

plaster cast application, earlier operated for clubfoot, concomitant major illness, atypical or secondary clubfoot and unwillingness to take part in the study.All the patients who fulfilled the inclusion criteria were registered in the clubfoot clinic for the study. Randomization was done using computer table and patients were allocated to one of the treatment groups either conventional or accelerated Ponseti casting.

Table 2: Comparison between conventional and the accelerated Ponseti technique

Discussion

Over the last decade Ponseti method has become the standard method of treating children with clubfoot deformities.[2,3] Various authors have published reports of up to 98% success with this technique.[4,10,11] The Ponseti technique has shown good results in non idiopathic as well as syndromic clubfeet .[12] It has also shown relatively good results in older children who present late for treatment .[13] Even in post-surgical patients who have residual deformity Ponseti technique has shown good results.[14]

Our results suggests that comparable results can be achieved with an accelerated method, changing the plaster two times per week. Morcuende et al [6] undertook a non-randomized retrospective study of 230 patients (319 clubfeet) over an 11- year period. Patients were assigned to a five- or seven-day frequency of plaster changes based solely on geography. The authors found that an accelerated five-day interval can be equally effective. They were concerned that further acceleration in the casting might give rise to problems like swelling in the cast.

Harnettet al [7] further accelerated the regimen to three times a week and got comparable results .They did not come across any problems which Morcunde et al [6] had suggested with faster regimens. Our final results were similar to the results published by Harnettet al.

There are many factors that have contributed to the research in decreasing interval between cast application as part of the Ponseti clubfoot correction. Firstly, there is now good evidence to support that shortening cast time for the idiopathic congenital clubfoot deformity gives equally good results.[6-8,15]

Secondly, there is lot of inconvenience to the patients and their family, who often have to travel long distances over a period of two to three months, to distant clinics for treatment. The time away from home, loss of working hours, economic burden on family all of which are a common concern in developing countries, may be greatly improved if the duration of treatment is cut short. [6-18] This could provide great savings for costs incurred whilst living away from home, and time lost from work. In turn, compliance may also benefit. The patients who come from remote areas can be admitted for this period and upon application of the last cast after tenotomy can be discharged with a foot abduction brace.