Article

Gerlach DJ, Gurnett CA, Limpaphayom N, Alaee F, Zhang Z, Porter K, et al. Early results of the Ponseti method for the treatment of clubfoot associated with myelomeningocele

Shriners Hospitals for Children, Tampa, Florida, United States
The Journal of Bone and Joint Surgery (Impact Factor: 5.28). 07/2009; 91(6):1350-9. DOI: 10.2106/JBJS.H.00837
Source: PubMed
ABSTRACT
Myelomeningocele is a common birth defect that is often accompanied by clubfoot deformity. Treatment of clubfoot associated with myelomeningocele traditionally has consisted of extensive soft-tissue release operations, which are associated with many complications. The purpose of the present study was to evaluate the early results of the Ponseti method for the treatment of clubfoot associated with myelomeningocele.
Sixteen consecutive patients with myelomeningocele (twenty-eight clubfeet) and twenty consecutive patients with idiopathic clubfeet (thirty-five clubfeet) were followed prospectively while being managed with the Ponseti method. The average duration of follow-up was thirty-four months for the myelomeningocele group and thirty-seven months for the idiopathic group. Clubfoot severity was graded at the time of presentation with use of the Diméglio system. The initial correction that was achieved, casting and/or bracing difficulties, recurrences, and subsequent treatments were evaluated and compared between the two cohorts by means of appropriate statistical analysis.
Eleven (39%) of the twenty-eight clubfeet in the myelomeningocele group were graded as Diméglio grade IV, compared with only four (11%) of the thirty-five clubfeet in the idiopathic group (p = 0.014). Initial correction was achieved in thirty-five clubfeet (100%) in the idiopathic group and in twenty-seven clubfeet (96.4%) in the myelomeningocele group (p = 0.16). Relapse of deformity was detected in 68% of the feet in the myelomeningocele group, compared with 26% of the feet in the idiopathic group (p = 0.001). Relapses were treated successfully without the need for extensive soft-tissue release surgery for all but four of the clubfeet in the myelomeningocele group and for all but one of the clubfeet in the idiopathic group (p = 0.16).
Our data support the use of the Ponseti method for the initial treatment of clubfoot deformity associated with myelomeningocele, although attention to detail is crucial in order to avoid complications. Longer follow-up will be necessary to assess the risk of late recurrence and the potential need for more extensive clubfoot corrective surgery in this patient population.

Full-text

Available from: Noppachart Limpaphayom, Jun 26, 2015
The PDF of the article you requested follows this cover page.
This is an enhanced PDF from The Journal of Bone and Joint Surgery
2009;91:1350-1359. doi:10.2106/JBJS.H.00837 J Bone Joint Surg Am.
Porter, Melissa Kirchhofer, Matthew D. Smyth and Matthew B. Dobbs
David J. Gerlach, Christina A. Gurnett, Noppachart Limpaphayom, Farhang Alaee, Zhongli Zhang, Kristina
Associated with Myelomeningocele
Early Results of the Ponseti Method for the Treatment of Clubfoot
This information is current as of August 13, 2009
Supplementary material
http://www.ejbjs.org/cgi/content/full/91/6/1350/DC1accessed at
translated abstracts are available for this article. This information can be
Commentary and Perspective, data tables, additional images, video clips and/or
Reprints and Permissions
Permissions] link.
and click on the [Reprints andjbjs.orgarticle, or locate the article citation on
to use material from thisorder reprints or request permissionClick here to
Publisher Information
www.jbjs.org
20 Pickering Street, Needham, MA 02492-3157
The Journal of Bone and Joint Surgery
Page 1
Early Results of the Ponseti Method for the Treatment
of Clubfoot Associated with Myelomeningocele
By David J. Gerlach, MD, Christina A. Gurnett, MD, PhD, Noppachart Limpaphayom, MD, Farhang Alaee, MD, Zhongli Zhang, MD,
Kristina Porter, RN, BSN, Melissa Kirchhofer, MS, Matthew D. Smyth, MD, and Matthew B. Dobbs, MD
Investigation performed at the Department of Or thopaedic Surgery, Washington University School of Medicine,
and St. Louis Shriners Hospital for Children, St. Louis, Missouri
Background: Myelomeningocele is a common birth defect that is often accompanied by clubfoot deformity. Treatment
of clubfoot associated with myelomeningocele traditionally has consisted of extensive soft-tissue release operations,
which are associated with ma ny complications. The purpose of the present study was to evaluate the early results of
the Po nseti method for the treatment of clubfoot associated wi th myelomeningocele.
Methods: Sixteen consecutive patients with my elomeningocele (twenty-eight clubfeet) an d twenty consecutive
patients with idiopathic clubfeet (thirty-five clubfeet) were followed prospectively while being managed with the Ponseti
method. The average duration of follow-up was thirty-four months for the myelomeningocele group and thirty-seven
months for the idiopathic group. Clubfoot severity was graded at the time of presentation with use of the Dim
´
eglio
system. The initial correction that was achieved, casting and/or bracing difficulties, recurrences, and subsequent
treatments were evaluated and compared between the two cohorts by means of appropriate statistical analysis.
Results: Eleven (39%) of the twenty-e ight clubfeet in the myelomeningocele group were graded as Dim
´
eglio grade IV,
compared wit h only four (11%) of the thirty-five clubfeet in th e idiopathic group (p = 0.014). Initial correction was
achieved in thirty-five clubfeet (100%) in the idiopathic group and in twenty-seven c lubfeet (96.4%) in the
myelomeningocele group (p = 0.16). Relapse of deformity was detected in 68% of the feet in the myelomeningocele
group, compared with 26% of the feet in the idiopathic group (p = 0.001). Relapses were treated successfully without
the need for extensive soft-tissue release surgery for all but four of the clubfeet in the myelomeningocele group and for
all but one of the clubfeet in the idiopathic group (p = 0.16).
Conclusions: Our data support the use of the Ponseti method for the initial treatment of clubfoot deformity associated
with myelomeningo cele, although attention to detail is cru cial in order to avoid complications. Longer follow-up will be
necessary to assess the risk of late recurrence and the potential need for more extensive clubfoot corrective surgery in
this patient population.
Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete descriptio n of levels of evidence.
C
lubfoot is a complex congenital foot deformity that is
both common (occurring in one in 1000 live births
1
)
and difficult to correct. It is easily recognizable at birth,
and it can be differentiated from common positional foot
disorders on the basis of the rigid equinus deformity and its
resistance to passive correction. The deformity consists of four
components (equinus, hindfoot varus, forefoot adductus, and
cavus)andisgradedaccordingtoseveritywithuseofthe
Dim
´
eglio system
2
. Most clubfeet occur as an isolated birth
defect and are considered to be idiopathic.
Historically, treatment of idiopathic clubfoot deformity
has been variable. Both nonoperative methods of manipulation
3-5
and extensive soft-tissue releases
6-16
have been advocated. Early
methods of manipulation, such as the Kite technique
3
, dem-
onstrated inconsistent results, leading to unpredictable out-
comes after extended periods of casting. Ex tensi ve surgical
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the
authors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or
agreement to provide such benefits from a commercial entity (D-Bar Enterprises, Webster Groves, Missouri). No commerc ial entity paid or directed, or
agreed to pay or direct, any benefits to any research fund, found ation, division, center, clinical practice, or other charitable or nonprofit organization with
which the authors, or a member of their immediate families, are affiliated or associated.
1350
COPYRIGHT Ó 2009 BY THE JOURNAL OF BONE AND JOINT SURGERY,INCORPORATED
J Bone Joint Surg Am. 2009;91:1350-9
d
doi:10.2106/JBJS.H.00837
Page 2
releases
6,9
were proposed in order to avoid the complications and
duration of the casting techniques. Despite the initial correction
of the deformity, these surgical releases often led to variability in
short-term outcome
6,12
, the need for revision procedures
8,9
,and
significant limitations at the time of long-term follow-up
15,16
.
The Ponseti method
17,18
involves the use of serial casting
to gradually cor rect the clubfoot deformity and a percutaneous
tenotomy of the Achilles tendon to correct residual ankle
equinus, followed by several years of foot abduction bracing to
maintain correction. This method has gained widespread
popularit y and h as been successful in recent years for the
treatment of idiopathic clubfoot deformity, and its efficacy in
achieving shor t-term correction has been demonstrated in
several studies
19-23
. Long-term follow-up studies also have
demonstrated excellent results in association with the Ponseti
method in terms of quality of life and foot function
19,20
.
Non-idiopathic clubfoot occurs in patients with genetic
syndromes, chromosomal abnormalities, or neurological disor-
ders such as myelomeningocele. Despite the reported successful
treatment of idiopathic clubfeet with use of the Ponseti
method
19,20,23
, we are not aware of any reports on the use of the
Ponseti method for patients with myelomeningocele. On the
contrary, clubfeet associated with myelomeningocele tradition-
ally have been treated with extensive soft-tissue release surgery,
with many short-term complications having been reported,
including skin complications related to the l ack of n orma l
sensation in the lower limbs
24
, recurrent deformities
25,26
, and the
need for revision and salvage procedures
24,26-28
.Wearenotaware
of any long-term follow-up studies investigating the outcomes
for these patients. Presumably, however, they may follow a
similar, if not worse, long-term course compared with that in
patients with surgically corrected idiopathic clubfeet
15
.
The present study was performed to evaluate whether the
Ponseti method could be used to achieve initial correction of a
clubfoot deformity associated with myelomeningocele. For the
purposes of comparison, we examined the effectiveness of the
Ponseti method in a cohort of age and sex-matched patients
with an idiopathic clubfoot deformity who were managed by the
same surgeon during the same time period. Given the recent
data demonstrating that the use of a foot abduction brace is the
most predictive factor of the maintenance of clubfoot correc-
tion
23,29
, we also analyzed bracing tolerance in each group.
Materials and Methods
T
he Washington University School of Medicine Human Re-
search Protection Committee approved the study, and
written informed consent was obtained for all individuals.
Eighteen consecutive patients with a clubfoot deformity and
myelomeningocele were managed with the Ponseti method
17,18,23,30
between July 2001 and July 2006. All patients were followed
prospectively and were managed solely by the senior auth or
(M.B.D.). These patients were managed at both St. Louis Chil-
drens Hospital (thirteen patients) and the St. Louis Shriners
Hospital (five patients). Two patients, both of whom had un-
dergone extensive surgical releases before presentation, were
excluded from addit ional analysis. Thus, sixteen patients were
included in the final analysis. Nine patients (56%) were female.
Five patients had received some treatment for clubfoot de-
formity before referral to our institution; specifically, three
patients had had casting and two had had physical therapy
and splinting. No patient was lost to fo llow-up. The average
TABLE I Prevalence of Clubfoot in Patients with
Myelomeningocele, 1995 to 2006
No. of Patients
(N = 67)
Level of myelomeningocele lesion
High (L3/L4 combined lesions or above) 12 (18%)
Low (L4 or below) 55 (82%)
Foot deformity present 18 (27%)
Clubfoot deformity present 13 (19%)
High-level lesion 4
Low-level lesion 9
TABLE II Demographic and Clinical Characteristics
Myelomeningocele Group (N = 16) Idiopathic Group (N = 20) P Value
Age at first cast* (wk) 12.4 (21.2 to 25.9) 4.7 (2.7 to 7.6) 0.248
Female 9 (56%; 32% to 81%) 6 (30%; 10% to 50%) 0.112
Family history 0 2 (10%; 0% to 23%) 0.492
Full term (36 weeks) 13 (81%; 69% to 100%) 15 (75%; 56% to 94%) 0.393
Cesarean section 10 (63%; 56% to 94%) 8 (40%; 19% to 61%) 0.118
First-born child 2 (13%; 0% to 29%) 7 (35%; 14% to 56%) 0.446
Duration of follow-up* (mo) 33.8 (25.0 to 42.7) 36.8 (30.1 to 43.4) 0.572
Bilateral clubfoot 12 (75%; 56% to 94%) 15 (75%; 56% to 94%) 1.000
*The data for continuous variables are presented as the mean, with the 95% confidence interval in parentheses. The data for categorical
variables are given as the number of patients, with the frequency (percentage) and the 95% confidence interval in parentheses.