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      Prolonged use of foot abduction brace reduces the rate of surgery in Ponseti-treated idiopathic club feet

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          Abstract

          Purpose

          There is conflicting evidence related to factors affecting the rates of recurrence of idiopathic club feet using the Ponseti method. We attempt to evaluate the predictors of success and failure in our physiotherapy-led Ponseti club foot clinic.

          Methods

          We evaluated 189 children with 279 club feet with a mean follow-up of 6.3 years for the following: Pirani score at presentation, number of casts for correction, indication for Achilles tenotomy, and the duration of foot abduction brace (FAB) use, in relation to outcome. Outcome measures were the need for additional surgery and functional scores. Based on the pattern and rate of ossification of the tarsal bones in idiopathic club foot, a much longer FAB weaning protocol was designed and practiced since 2000. The objective of this study was to answer the question of whether a prolonged period of FAB use reduces the need for surgery in Ponseti-treated idiopathic club foot.

          Results

          Thirty-six feet (12.9 %) underwent additional surgery. The Pirani score and the number of cast changes had no influence on the rate of surgery. The duration of FAB use had a significant effect on the outcome, i.e., the rate of surgery and functional scoring. Operated children used the FAB for 28 months versus 33 months in the non-operated group ( p < 0.05). Only a minor delay in the attainment of walking age was noted (average 15 months).

          Conclusions

          The duration of FAB treatment was found to be the most influential on the functional results and on rate of surgery. Close follow-up and longer FAB weaning program reduced the rates of recurrence.

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          Most cited references26

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          Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet.

          The nonoperative technique for the treatment of idiopathic congenital talipes equinovarus (clubfoot) described by Ponseti is a popular method, but it requires two to four years of orthotic management. The purpose of this study was to examine the patient characteristics and demographic factors related to the family that are predictive of recurrent foot deformities in patients treated with this method. The cases of fifty-one consecutive infants with eighty-six idiopathic clubfeet treated with use of the Ponseti method were examined retrospectively. The patient characteristics at the time of presentation, such as the severity of the initial clubfoot deformity, previous treatment, and the age at the initiation of treatment, were examined with use of univariate logistic regression analysis modeling recurrence. Demographic data on the family, including annual income, highest level of education attained by the parents, and marital status, as well as parental reports of compliance with the use of the prescribed orthosis, were studied in relation to the risk of recurrence. The parents of twenty-one patients did not comply with the use of orthotics. Noncompliance was the factor most related to the risk of recurrence, with an odds ratio of 183 (p < 0.00001). Parental educational level (high-school education or less) also was a significant risk factor for recurrence (odds ratio = 10.7, p < 0.03). With the numbers available, no significant relationship was found between gender, race, parental marital status, source of medical insurance, or parental income and the risk of recurrence of the clubfoot deformity. In addition, the severity of the deformity, the age of the patient at the initiation of treatment, and previous treatment were not found to have a significant effect on the risk of recurrence. Noncompliance and the educational level of the parents (high-school education or less) are significant risk factors for the recurrence of clubfoot deformity after correction with the Ponseti method. The identification of patients who are at risk for recurrence may allow intervention to improve the compliance of the parents with regard to the use of orthotics, and, as a result, improve outcome. Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.
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            Management of congenital talipes equinovarus using the Ponseti method: a systematic review.

            We present a systematic review of the results of the Ponseti method of management for congenital talipes equinovarus (CTEV). Our aims were to assess the method, the effects of modifications to the original method, and compare it with other similar methods of treatment. We found 308 relevant citations in the English literature up to 31 May 2010, of which 74 full-text articles met our inclusion criteria. Our results showed that the Ponseti method provides excellent results with an initial correction rate of around 90% in idiopathic feet. Non-compliance with bracing is the most common cause of relapse. The current best practice for the treatment of CTEV is the original Ponseti method, with minimal adjustments being hyperabduction of the foot in the final cast and the need for longer-term bracing up to four years. Larger comparative studies will be required if other methods are to be recommended.
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              Ponseti treatment for idiopathic clubfoot: minimum 5-year followup.

              Ponseti clubfoot treatment has become more popular during the last decade. We reviewed the medical records of 74 consecutive infants (117 club feet) who underwent Ponseti treatment. Minimum followup was 5 years (mean, 6.3 years; range, 5-9 years). We studied age at presentation, previous treatment, the initial severity score of the Pirani scoring system, number of casts, need for Achilles tenotomy or other surgical procedures, and brace use. We measured final ankle motion and parents' perception of outcome. Late presentation and previous non-Ponseti treatment were associated with lower initial severity score, fewer casts, and less need for tenotomy. Forty-four percent of patients had poor brace use. We observed better brace use (75%) in babies who presented late for treatment. Good brace use predicted less need for extensive surgical procedures. Twenty-four (32%) babies underwent additional surgical procedures other than tenotomy, including 21% who underwent tibialis anterior tendon transfer. At followup, 89% of feet had adequate dorsiflexion (5 degrees or greater). Parents indicated high satisfaction with the treatment results. Ankle motion was not associated with parents' satisfaction. The Ponseti method is effective, even if treatment starts late or begins after failure at other centers. Brace use influenced the success of treatment. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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                Author and article information

                Contributors
                +972-52-4262007 , hemo.yoram@gmail.com
                Journal
                J Child Orthop
                J Child Orthop
                Journal of Children's Orthopaedics
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                1863-2521
                1863-2548
                20 June 2015
                20 June 2015
                June 2015
                : 9
                : 3
                : 177-182
                Affiliations
                Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, 64239 Tel Aviv, Israel
                Article
                663
                10.1007/s11832-015-0663-y
                4486506
                26091918
                dd911d5c-6a9f-47e8-97c4-1cee65bb98ba
                © The Author(s) 2015

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 2 April 2015
                : 8 June 2015
                Categories
                Original Clinical Article
                Custom metadata
                © The Author(s) 2015

                Orthopedics
                club foot,foot abduction brace,ponseti,delayed ossification,cartilaginous anlagen,ossific nuclei of tarsal bones

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