Comparative Analysis of Results Between Conventional and Accelerated Ponseti Technique for Idiopathic Congenital Clubfoot

Sirsikar A, Turkar R, Verma HS.

Sir,

                I read with great interest the article by Sharma P et al.[1] titled as “Comparative Analysis of results between Conventional and Accelerated Ponseti Technique for idiopathic congenital clubfoot”. The application of best available evidence to any health care setting is important, particularly if there are clear benefits to the recipients of this care. The rescheduling of the weekly clubfoot clinic for casting, to at least twice weekly, is now a possible shift in contemporary evidence based practice. We congratulate the authors for conducting this study of its first kind in the Indian population.

However, there are a few concerns that we would like to share:

1.                The article does not mention about the pre-casting manipulation, which is important and indications are that more time spent may be beneficial in correcting the clubfoot deformity. Notable in the current findings on accelerated casting is the longer manipulation time, (two minutes) specified by Xu et al.[2], an additional departure from the original Ponseti Protocol. Whilst the effect of manipulation time has not been formally studied, histological investigations directs maintained loading of ligaments to promote the lengthening or ‘uncrimping’ of these structures.Paying more attention to time spent on careful manipulation might render cast changefrequency less relevant. Hence, it is important to underline the fact of undergoing ‘more rather than less’ manipulation prior to casting, as suggested by Sutcliffe et al [3].

2.                Morcuende et al reported a recurrence rate of 8% & 7% for the five and seven-days group, respectively, with an 8.5 times greater risk of recurrence, if compliance with abduction bracing was not adhered to [4]. Unfortunately, limitations on this study did prevent further follow-up with patients to identify cases of relapse and this is something that certainly needs consideration in this area of research. It is too early to know how or if accelerated casts would affect long term outcomes.

The authors of this study were fortunate enough not to have encountered any case of relapse in both the groups. It is only a kind suggestion to the author to keep all the cases in follow-up & to report the relapse, if any, in the near future, so as also to validate the study in terms of long term outcome.

3.                Morcuende et al in their study, were concerned that further acceleration in the casting procedure may give rise to problems like swelling in the cast [4]. Does the author encounter any such problems in this Indian study?

Reference

1.                Sharma P, Yadav V, Verma R, Gohiya A, Gaur S. Comparative Analysis of results between Conventional and Accelerated Ponseti Technique for idiopathic congenital clubfoot. OrthopJMPC 2016;22(1):3-7.

2.                Xu RJ. A modified Ponseti method for the treatment of idiopathic clubfoot: a preliminary report. J Pediatr Orthop 2011 31: 317-319.

3.                Sutcliffe A, Vaea K, Poulivaati J, Evans AM. ‘Fast casts’: Evidence based and clinical considerations for rapid Ponseti method. Foot Ankle Online J 2013;6(9):2.

4.                Morcuende J, Dolan L, Dietz F, Ponseti I. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics 2004 113:376-80.

Author’s Reply

Sir ,

We thank Sirsikar et al.[1] for their  keen interest in our research titled “Comparative Analysis of results between Conventional and Accelerated Ponseti Technique for idiopathic congenital clubfoot” [2].

The authors have very rightly emphasized the importance of manipulating the feet before casting and the fact of undergoing ‘more rather than less’ manipulation prior to casting to achieve better and faster correction seems the right approach, further studies are warranted in this direction to establish its conclusiveness [3]. In our study we had kept the manipulation time same in

both the groups to exclude any confounding factor among the two groups.

We have published only the early results of accelerated Ponseti technique, we are closely following the children in that group and plan to publish the results after a longer follow up has been done, only then we will be able to address the concerns of a higher relapse rate in that group as shared by Morcuende et al [4].

We did not encounter any problem like swelling in the cast in accelerated group.

References

1.                Sirsikar A, Turkar R, Verma HS . Comparative Analysis of results between Conventional  and Accelerated Ponseti Technique for idiopathic congenital clubfoot. . OrthopJMPC 2016;22(2): ------.

2.                Sharma P, Yadav V, Verma R, Gohiya A, Gaur S. Comparative Analysis of results between Conventional and Accelerated Ponseti Technique for idiopathic congenital clubfoot. OrthopJMPC 2016;22(1):3-7.

3.                Sutcliffe A, Vaea K, Poulivaati J, Evans AM. ‘Fast casts’: Evidence based and clinical considerations for rapid Ponseti method. Foot Ankle Online J 2013;6(9):2.

4.                Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot.Journal of Pediatric Orthopaedics. 2005 Sep;25(5):623-626