Introduction

Club foot (CTEV) is one of the most common congenital musculoskeletal defects which require correction [1]. Treatment of congenital club foot deformity has changed radically with the introduction of the Ponseti method in most centres worldwide. However, most of the studies on Ponseti method are done in infants or children before the walking age [1,2].

But, in our country, late presentation for the treatment for this deformity is common problem due to social stigma, lack of education & ignorance, poverty, lack of proper health services and maltreatment. It often results in significant disability resulting in dependency for activities of daily living, significant financial and psychological impact on the family as well. Many patients with clubfoot end up living as beggars on the streets [3,4].

When the a CTEV child presents late after the walking age, the deformity becomes worse causing further contracture of the medial soft tissues and plastic deformation of bones, which makes treatment difficult. In the past decades many extensive soft tissue and bony surgeries have been performed to treat such deformities, but the results were not very promising because surgeries were associated with many complications such as poor soft tissue healing and higher relapse rate [5,6].

Some studies have shown excellent role of Ponseti method of manipulation in late presenting walking child with club foot deformity [7-10].

Inspired by these, we retrospectively analysed our cases of late presenters of congenital idiopathic club foot deformity, which had been treated in the club clinic of our institution by Ponseti manipulation technique, with the purpose to assess the role of Ponseti method in neglected club foot.

Material and methods

We retrospectively reviewed the records of 29 patients of neglected club feet deformity who had been treated in the club foot clinic of Department of Orthopaedics, at our centre, from April 2015 to March 2018 by Ponseti method of manipulation after the institutional board approval.

All children with idiopathic club foot deformity with age more than 1 year and had not taken any form of treatment previous and who were treated by Ponseti manipulation were included in the study. Secondary club foot, failed cases of previously manipulated or operated feet, atypical club foot, clubfoot deformity with ulcers over callosities for which cast could not be applied and children less than 1 year were excluded from the study.

The mean pre-correction Pirani score was 4.51 (range 2.5 to 6). The mean post-correction Pirani score was 0.55(range 0 to 1). This difference was statistically significant (p < 0.001). The mean number of casts applied to achieve final correction was 9.2 casts (range 6 to 16). In 95% of the feet, satisfactory correction of the deformity was achieved (Figure 1).

The mean follow-up duration was 14.2 (range 2 to 21) months. Percutaneous Achilles tenotomy was done in all cases to correct residual equinus, whereas percutaneous planter fascitomy was done in 6 cases for cavus.

Figure 1: Pre (a) and post (b) correction clinical photography of CTEV case of age 9 year with pirani score pre (6) and post correction (0.5)

Four patients developed erythema and slight swelling of toes, and redness of skin due excessive pressure, for recasting was done. No infections, skin necrosis, neurovascular compromise or profuse bleeding after tenotomy were observed.

No problems with healing were seen after the tenotomy, even in the oldest patients with age 15 year. Repeat Achilles tenotomy was required in 10 feet due to incomplete initial correction of equinus in 4 and recurrence of equinus in 6 feet.

All of the parents were satisfied with the treatment offered to their child as appearance of the feet had been improved and children were able to wear normal shoes for the first time in their lives. Dynamic supination was present in four feet, but caused minimal disturbance of gait and hence was not treated.

Discussion

Neglected clubfeet deformity is a common problem in developing countries, like ours due to lack of awareness, poverty, insufficient medical facility and maltreatment. It cause considerable physical, social, psychological and financial burdens on the patient and their families [3,4]. The treatments of neglected clubfoot deformity in the past have been extensive soft tissue release surgery, osteotomies, and various types of fixators or arthrodesis.

Further a repeat tenotomy was also required in 10 of our case for recurrence of equinus deformity without any open soft tissue release surgery. Although, in our series we achieved painless, plantigrade, and cosmetically acceptable feet in all the cases, but the size of the foot even after correction remain bit smaller.

This is probably because in older child towards the skeletal maturity, bony correction is difficult and soft tissue correction by casting results in a normal shaped foot but smaller foot. Bone could not remodel fully even though the foot gets corrected.

The talar dome and naviculus remained flat and triangular respectively. This poor remodelling of bones of feet in such old patient may have resulted in persistence of small sized foot (Figure 2).

We have also observed that above knee plaster casts and abduction brace were poorly tolerated especially by older children that could have been a risk factor for noncompliance and failure of treatment, but this issue had been dealt with adequate and proper parent’s education and counselling. Despite these difficulties, the patients and parents were satisfied with the results.

Conclusion

Ponseti`s method is a safe, effective and inexpensive method for correction of deformity even in neglected clubfeet deformity child presenting after the age of walking, however, our study is small and further studies will be necessary to understand the effectiveness of this method fully.

References