IOl
MALAWIMEEJOURNAL;15(3):99-
Ponsetitechniqueof correcting idiopathicclubfoot
deformity
MkandawireNC,ChipoffaE,LikolecheG,Phiri M, Katete L
Departmentof Surgery,QueenElizabethCentralHospitaland Collegeof Medicine,Blantyre,Malawi
AddressCorrespondenceto: Dr. NC,Mkandawire,Collegeof Medicine,Private Bag360' Blantyre3, Malawi.
Email:ncmkandawire@malawi.net
The efficacy of the Ponseti method of clubfoot treatment at
Queen Elizabeth Central Hospital (QECH) was analysed
from December 2000 to December 2001. Ninety one patients,
60 boys and 31 girls were prospectively and consecutively
enrolled. 31 patients had a unilateral clubfoot and 60 had
bilateral clubfeet. 77 patients had primary idiopathic club-
foot and 14 patients had clubfeet associated'with other con-
genital anomalies such as arthrogryposis. 32 patients (35Vo)
were lost to follow upl records were inadequate for 6 patients
leaving 54 patients (59Vo) available for analysis. Three main
groups were assessed.Group | (24 patients): virgin previ-
ously untreated primary idiopathic clubfeet: Ponseti method
used from outset. Group 2 (19 patients): complex, primary
idiopathic clubfeet: Ponseti method introduced after other
manipulation techniques. Group 3 (L1 patients): clubfeet
associated with other congenital anomalies. In group 1, the
mean age at start of treatment was 9.7 weeks and the mean
time to correction of deformity was 7.4 weeks. 20 out of 24
patients (84Vo) had correction of deformity and remained
BACKGROUND
In December 2000, the Ponseti technique of correcting congen-
ital idiopathic clubfeet was introduced in Malawi at the QECH.
The Columbian Clubfoot Scoring systemwas also introduced as
a tool for objective measurementof the clubfoot deformity and
responseto treatment. Prior to this, the managementof clubfeet
was not standardised with various methods of manipulation
being used by different people. Monitoring of responseto con-
servative treatment was subjective; indications and timing for
surgery were usually surgeon dependent and objective assess-
ment of outcome was difficult to do.
The Ponseti technique has been shown to be easy,efficient, eco-
nomical and effective '''r. Combined with the Columbian club-
foot scoring system *, there is an objective way of measuring
responseto treatment. This method facilitates the standardisa-
tion of clubfoot treatment.It has been shown to work in Uganda;
an environment similar to that in Malawi.
OBJECTIVES
1. To evaluatethe Ponseti method of treating idiopathic
clubfeet and use of the Columbian Clubfoot Score
system as a tool for measuring outcome. This with a
view to seeif these techniquescould be adopted as the
standardtreatment of clubfoot deformity in Malawi.
2. To assessthe impact of adopting such a treatment
regime on the patient, their family and the hospitals;
especially with respectto utilisation of limited
resources.
3. To assessthe responseof teratologic clubfeet to the
Ponseti method of treatment.
ABSTRACT
corrected. 4 patients had recurrence of deformity mainly
due to non compliance with treatment and correction was
achieved once treatment restarted. In group 2' 19 patients
had been on treatment for a mean period of 32 weeks prior
to commencement of Ponseti treatment. In L7 of these
patients the deformity was still uncorrected. Ponseti treat-
ment was commenced at a mean age of 36 weeks and cor-
rection was achieved in all 17 patients after a mean treat'
ment duration of 7.1 weeks. In group 3, correction of defor'
mity was initially achieved in only 60Vo. The period to
achieve correction was long and incidence of recurrence of
deformity was high.
The successof conservative treatment of clubfeet using the
Ponseti method has resulted in large decreasein the number
of surgical procedures performed under general anaesthae'
sia such as posteromedial releases in the treatment of
clubfeet at QECH. This method has now been adopted as the
standard treatment of clubfoot and is being advocated
nationwide.
ANDMETHODS
PATIENTS
In December 2000 a workshop was conducted at QECH in
Blantyre instruct orthopaedic surgeons, clinical officers and
physiotherapists in the Ponseti method of treating clubfeet. It
was decided that the main teaching centres of Blantyre and
Lilongwe would adopt the technique as a pilot study and evalu-
ate the results.
From January 2001 all new clubfoot patients with no prior treat-
ment and those who had received other forms of non-surgical
treatment were prospectively enrolled into the pilot study. They
all were treated using the Ponseti method. Patients with terato-
logic clubfeet were also included in this pilot study.
The Ponseti of manipulating clubfeet aims to eliminate all ele-
ments of the clubfoot deformity to give a normal looking; pain
free; functional; mobile; plantigrade foot. The main elementsof
clubfoot deformity, which include forefoot cavus, varus, and
adductus and hind foot varus, are all corrected simultaneously
and not sequentially.The hind foot equinus is corrected last. A
tenotomy of the Achilles tendon may be necessaryto achieve
final correction of the equinus deformity. Serial stretching and
casting is done weekly ald progress in monitored using the
Columbian Clubfoot Score.
The Columbian Clubfoot Score system looks at three deformi-
ties in the hind foot and three deformities in the mid foot, giving
a total of six deformities. The hind foot deformities are: posteri-
'empty heel' sign and resistant equinus. The mid
or skin crease;
'lateral head oftalus; and cur-
foot signs are: medial skin crease;
vature of the lateral border of the foot. Each deformity can have
a score of 0 (normal), 0.5 (mild) or 1 (severe).A normal foot
would score 0 and a severely deformed foot would score 6.
After correction of the foot deformity by serial casting and pos-
sibly a tenotomy of the Achilles tendon, the child is fitted into a
Malawi Medical Joumal

;i' '
foot abduction brace (Steenbeek Foot Abduction Brace -
SFAB), which is wom day and night for t}ree month. After 3
months the brace is worn only at night for 2 to four years. If
deformity of the foot recurs after fitting of the braces, serial cast-
ing has to be recommencedand repeat tenotomy may be neces-
sary. The intensive phase of the treatment is the period of week-
ly cast change till correction is achieved and the child fitted into
foot abduction braces.This intensive phase takes 5 to 8 weeks.
Once the brace has been fitted and the mother instructed on
application of the brace, attendancecan be once a month to mon-
itor recurrence of deformity and may be to change the size of the
brace as the child grows.
Ponsetitechnique 100
Complexprimary idiopathicclubfeet
19 patients had other non-surgical treatment prior to commenc-
ing the Ponseti method for a mean duration of 32.6 weeks.
During this time only 2 patients (lIVo)had achieved satisfacto-
ry corection of deformity. In 17 patients (89Vo)the deformity
was not coffected. Ponseti treatment was the commenced at a
mean age of 36 weeks. The mean duration of ffeatment to cor-
rection of deformity (SFAB fitted) was 7.1 weeks and all 17
patients achieved correction of deformity. The mean CCFS at
the start of Ponseti method was 3.6 and at the time of fittins
SFAB was 0.86 (Table 4)

RESUTTS Table 4: Idiopathic complex clubfeet: Prior other treatment then Ponseti
Demographicdata Method (19 patients)
91 patients were enrolled in the study. 38 (41Vo)of the patients
could not be analysed due tb non-attendance of clinics (32 PRIOR PONSETI
patients) and lost records (6 patients) The high loss of patients TREATMENT TREATMENT
from follow up may be due to difficulties and expenseof getting
transport to come the hospital especially for_women coming Mean age at start of Rx lnadequaterecords 36 weeks (12 - 104)
from distant rural areas. There were no major differences
Mean Rx duration (to correction 32.6 weeks (12 - 104) 7.1 weeks (3 - 10)
between the patients that were analysedand those that were lost
to follow up (Tables I and2) Or change of Rx)

Deformity corrected 2 (ll%o) 17(l00%o)

Table1: Demographic
data
Deformity not conected 17(89Vo) 0 (o%o)
Number of patients enrolled: 91
Males:
Mean CCFS at start of Rx Not done 3.6(2 - 6)
Female: JI
Mean CCFS at end of Rx 3.6(2 - 6) 0.86(0- 1.s)
Unilateml left clubfoot: 16
Unilateral risht clubfoot: 15 Or review
Bilateral clubfeet: 60
Idiooathic Clubfeet: 77 CCFS - Columbia Foot Score
Teratolosic Clubfeet I4
Lost to follow up: 32 (35Eo)
Records missing: 6( 6Vo) Teratologicclubfeet
Number of oatients not analvsed 38 (41Vo) 5 patients with teratologic clubfeet had Ponseti technique used
Number of patients analysed: s4 (59Vo) from the outset. The remaining 6 had prior treatment using other
techniquesfollowed by the Ponseti method. Using the previous
Table 2: Comparison of analysed and unanalysed patients methods of treatment 6 patients with teratologic clubfeet failed
to achieve correction of the deformity after mean treatment
Idiopathic Idiopathic Teratologic duration of 42.7 weeks. Ponseti method was then tried for a
Untreated Clubfoot ComplexClubfoot Clubfoot
mean duration of l7 weeks and the deformity was corrected in
AnalysedGroup 24 (45Vo) 19(35Va) rr (20Vo)
only 3 of the 6 patients. In 5 patients the Ponseti method was
Unanalysed
Group 22 (59Vo) 12(32Vo) 3 (8Vo)
used from the outset. 3 out ofthe 5 patients achieved correction
of the deformity. These results confirm the resistanceof terato-
Virgin primary idiopathicclubfeet logic clubfeet to conservativetreatment (Table 5).
For previously untreated clubfeet commencedon Ponseti treat-
ment from the outset, the mean age at start of treatment was 9.7
weeks and the mean treatment duration to achieve correction of Table5: Teratologic
Clubfeet:TArthrogryposis;2
Spinabifida;2other
deformity (fitted with SFAB) was 7.4 weeks. 20 of 24 patients (llpatients)
anomalies.
(83Vo),in this group had satisfactorycorrection of the deformity
and remained coffected. 4 patients had recurrence of deformity PRTOR PONSETIRX PONSETIRX
after initial satisfactory correction (Table 3). TREATMENT GAILEDPRIOR (FROM
RX) OUTSET)

Table 3: Idiopathic untreated clubfeet: Ponseti Method from beginning Number of patients
(24 patients)
Mean Rx duration 42.7 weeks 17weeks 24.4Weeks

Mean age at start of Ponseti Rx 9.7 weeks(0 *28) (to corection (24 - 60) (6- s2) (8 -24)
or change of Rx)
Mean Rx duration to correction (SFAB fitted) 7.4weeks(3 - 19)
.Deformity corrected 0 (0Eo) 3 (50Vo) 3 (6OVo)
Deformity corrected 20 (83Vo)
Deformity not 6 (lOOVo) 3 (5OVa) 2 (40Vo)
Deformity not corected or recurred 4 (1'lVo) corrected

Malawi Medical Joumal

101 Ponsetitechnique

Recurrence of deformitY (Table 6)

MEAN COLUMBIA FOOT SCORE

AT START ATFITTING ATFOLLOW AFTER

SFAB UP 2NDRX
.:
Untreated 4.8 0.9 3.0 t.2

Clubfeet 20
Complex

Clubfeet
+.J 1.8 3.3
'3.
15:

4.4 1.0 3.5 2.1 0

Teratologic

Clubfeet Year
SFAB - Steenbeek Foot Abduction Brace

(JntreatedClubJeet
4 patients in this group had recurrencaof deformity after previ- DtscussloN
clubfoot
ous satisfactory correction. For 3 patients the cause was most The introduction of the Ponseti method of treatment of
For
likely poor clinic attendanceand non-compliance with the treat- has proved to be very successfulat the pilot study at QECH'
younger'
meni regime. In the remaining patient the cause for the recur- previously untreated clubfeet in children one year or
of deformity within an
rence was not obvious. All patients underwent serial recasting it ponr"ri method achieved correction
" had undergone
and 2 required repeat tenotomy of the Achilles tendon' The averageof 7.4 weeks. Complex clubfeet, which
poor cor-
deformity was conected in all patients' prior ireatment for an averageperiod of 32 weeks with
treatment result-
iection of deformity, respondedwell to Ponseti
period of 7'1
Complex clubfeet ing in correction of deformity within an average
5 patients in this group had recurrence of the deformity' The
weeks. This reduction in the treatment period when deformity
probubl" causewas difficulty in fitting the SFAB' The mothers correction is achieved is very important as it meanspatients are
complained that the feet kept coming out of the braces' required to attend fewer clinics and thus improve compliance
Followingthecomplaint,thebracesweremodified.Serialcast. with treatment.
The
ing was iestarted and 2 patierts required repeat tenotomy'
deformity was corrected in all patients' The loss to follow up of up 35Vaof the patients is of
concern'
espe-
This may be due to transport problems to get to the clinics
Teratologic clubfeet
cially for patients from rural areas'
7 patienis in this group had recurrence of deformity' The diffi-
cuity with this group was keeping the brace on the children to treatment as would be
with Teratologic clubfeet are resistant
because of the added lower limb deformities in children is achieving about 507o success
and expected. The Ponseti method
arthrogryposisand spina bifida. Serial casting was restarted of patients howev-
4 rate in correcting the deformity' The number
+ patients required repeat tenotomy' After the retreatment
er is smallto makeany concreteconclusions'
puii".t,, still had uncorrected deformities' 1 patient who had
spina bifida later underwent extensive posteromedial releases shown by
and spinal swgery to releasea tethered spinal cord' The successof introducing this method is indirectly
other pro-
the reduction in the number of surgical operationsand
year 2001'
lmpacton utilisationof resources cedures done under general anaesthesiaduring the
has when Ponseti method was being used' Due to this success' the
Foliowing the introduction of the Ponseti technique' there
as the way to treat idiopathic
been a definite decreasein the number of posteromedialreleas- technique is being advocated
of the Achilles tendon under general clubfeet in previously untreated children or in children who have
es and lengthening
of 1 to 1'5
Anaesthaesia.Alltenotomiesarebeingdoneunderlocalanaes- received prior non-surgical treatment under the age
up years. Orthopaedic surgeons,clinical officers and physiothera-
thesia in a special areain the outpatient clinics' This has freed
easy'
precious theatre space and time (Table 7, Figure i)' pirt, ut QECH are convinced that this method is indeed
Nation wide courses on the
General
effectiue, efficient and economical'
Table 7: Clubfoot surgery and procedures done under recommendations will be made
Anaesthaesia
'Pre and Post Ponsetit: Ponseti introduced Ponseti method are planned and
adopted as
December 2000. to the relevant health authorities that this method be
clubfoot deformity'
NUMBER OF CASES(PATIENTS) the national policy on the managementof
References
of idiopathic clubfoot A thirty yem
1999 2001 1. Cooper, D.M. and Dietz, F.R (1995) Treatment
PROCEDURE 1998
follow up note. J Bone Joint Sarg"17 L' 1417
22 15 on pathogenesisand treatment of
Tendo Achilles t'7 2. Ponseti, I.V and Campos, J (197i; Obsenations
congenital clubfoot. Clin Orthop', 84' 50
Lengthentng Theresultsoftreatment J
3. Ponseti,I.VandSmoley,E'N 1ilO:; Congenitalclubfoot
Posteromedial Bone Joint Surg ,45A,261'
officers and
4. Pirani, S. Uganda clubfoot project A manual for orthopaedic
Release PhYsiotheraPists
Change of Cast
Bone Procedures
Malawi Medical Journal