Predictive Value of the Initial Degree of Abduction in Clubfoot Management

Dante Enrico A. Fajutrao, MD; Gracia Cielo Balce, MD, FPOA

Introduction
According to the 2013 report of Global Clubfoot Initiative, Talipes Equinovarus affects

160-200,000 children born each year. They estimated that 80% comes from low and middle-

income countries. The incidence rate of clubfoot is estimated to be 1.2 in 1000 live births. The

Philippine estimate for yearly new cases of clubfoot is 3,123(1). It is one of the most common

congenital orthopaedic condition requiring intensive treatment(2). The ratio of male to female

is 3:1, and 40% of cases are bilateral. (3)

The prediction of number of casts in the Ponseti method has always remained a subject

of interest. Agarwal et al did a study in 2013 that positively correlated severity with the number

casts done. The study, however, only proved that the more severe the clubfoot, the more casts

required. No data as to how many casts for a given severity was presented. No data exists as

to how much correction is achieved with each Ponseti casting. Lack of data translates to the

difficulty to prognosticate treatment duration. To be able to predict the number of treatment

sessions would help immensely in the compliance and motivation of parents in developing

countries such as the Philippines. This study aims to validate the degree of correction achieved

with each Ponseti casting session.

Review of Related Literature

The Ponseti Method was introduced by Ignacio Ponseti in the early 1940s. It is a non-

operative approach for clubfoot treatment that consists of serial manipulation and specific

casting technique of the foot. Eventually, this will progress to a percutaneous tenotomy of the

Achilles Tendon.(2,4)
 As the weekly manipulation and casting treatment ensues, the foot’s cavus, adduction

and varus deformities are corrected. It is required that the hidfoot be in neutral to slight valgus

and the foot be able to abducted 70 degrees in relation to the leg before attempting to correct

the equinus deformity. (2)

The Achilles tenotomy is an integral part of Ponseti management of clubfoot. This is

done due to the reason that the tendon of Achilles is unlike the ligaments of the foot. They are
(7)
thick and not as stretchable. The maximum age when tenotomy can be used has not been

established; even older children shows tendon regrowth 6 weeks post-tenotomy.

In a study in 2010, the different clubfoot classification schemes frequently cited,

Demeglio and Pirani, were evaluated as to how they correlate with Ponseti cast treatment.

Initial scores in the classification schemes did not correlate well with the number of Ponseti

casts required for the treatment15. Furthermore, there was no difference between the two

schemes in measuring their correlation with number of Ponseti casts. The scoring systems does

not quantify the degree of correction with each passing of a casting session; on whether the

foot has gained 70 degrees of abduction. The prediction of number of casts in the Ponseti

method has always remained a subject of interest; Ponseti International postulates that with
(7)
each casting session, the foot is corrected by 10 to 15 degrees . However, data is lacking

verifying that claim. Lack of data makes it difficult to prognosticate parents regarding the

duration of treatment which is closely related to financial and motivational aspects in

developing countries (8,1).

OBJECTIVES

General Objectives:

To determine the average degree of abduction correction with each Ponseti casting

To determine how accurately the initial degree of abduction can predict the number of
Ponseti sessions necessary to abduct the foot to 70o prior to Achilles tenotomy

METHODOLOGY

We retrospectively analysed the records of enrolled children with idiopathic clubfoot

managed at East Avenue Medical Center and Mabuhay-Deseret Foundation from the year that

our Insitution was enrolled to International Clubfoot Registry to present (2015-2016).

Inclusion criteria were idiopathic clubfeet corrected by Ponseti method requiring tenotomy for

equinus correction in children up to ten years of age. Defaulters (noncompliance with serial

casting schedule), children with postural, non-idiopathic, previously surgically treated,

recurrent clubfoot and clubfoot not requiring tenotomy were not included in this study.

A standardized database depicting the patient’s initial abduction and Pirani score upon

presentation was utilized. The data sheet indicated the demographic data of the patient, Pirani

scores and abduction at presentation and during follow ups, number of corrective casts for each

patient, and the timing of tenotomy.

The tenotomy criteria were foot correctible to 70 degrees abduction, and equinus that

does not go beyond neutral. The number of degrees to be achieved to reach 70 degrees of

abduction, number of casts prior to tenotomy and the degree of abduction upon each casting

session were used for result evaluation. From these data, the following records were garnered:

1. Age of the child in years at time of presentation

 2. The initial degree of abduction

3. Predicted number of casting sessions

4. The number of degrees to be achieved

5. The pre-treatment Pirani score

6. The actual number of sessions

7. The average degrees of correction attained after each casting session for each

patient

8. The average degrees of correction attained for each session for all patients

Results
 Expected
Age Degrees number of casts Average
Patient (completed Pirani to degrees per Number
Number Sex Years) Laterality Score Abduction correct cast of casts
6-9
1 M 2 Left 3 -20 90 18.0 5
4-6
2 F 0 Right 4.5 10 60 12.0 5
6-8
3 M 0 Right 2.5 -10 80 10.0 8
6-9
Left 5 -20 90 12.9 7
6-9
4 M 1 right 5 -20 90 12.9 7
4-6
5 F 4 Left 4 10 60 8.6 7
4-7
6 F 0 Left 3.5 0 70 4.1 17
4-7
Left 4 0 70 11.7 6
4-7
7 M 0 right 4 0 70 11.7 6
4-6
8 M 0 Left 3 10 60 8.6 7
6-10
Left 6 -30 100 6.3 16
6-10
9 M 7 right 6 -30 100 6.3 16
6-9
10 M 0 right 4 -20 90 11.3 8
6-9
11 M 2 right 3 -20 90 11.3 8
6-10
12 M 1 Left 4.5 -30 100 6.7 15
6-10
Left 4 -30 100 6.7 15
6-10
13 M 4 right 4 -30 100 6.7 15
5-6
Left 3.5 10 60 10.0 6
5-6
14 M 0 right 3.5 10 60 10.0 6
6-10
15 M 3 Left 3.5 -30 100 12.5 8
4-7
16 M 0 Left 3 0 70 17.5 4
4-7
Left 3 0 70 5.8 12
4-7
17 F 6 right 3 0 70 5.8 12
4-5
Left 4 20 50 6.3 8
4-5
18 M 0 right 4 20 50 6.3 8
 6-9
Left 3.5 -20 90 9.0 10
6-9
19 F 0 right 3.5 -20 90 9.0 10
6-10
Left 3.5 -30 100 7.2 14
6-10
20 F 1 Right 3.5 -30 100 7.2 14
6-8
21 M 1 Left 4.0 -10 80 10 8
Statistical Methods

All valid data from evaluable subjects satisfying the inclusion/exclusion criteria were included

in the analysis. Missing values were not replaced or estimated during the statistical analysis of

outcome variables. Summary statistics were presented in summary tables and reported as mean

± SD and median (IQR) for quantitative characteristics with skewed distribution and as n (%)

for qualitative characteristics. Kruskal Wallis test was used to compare more than two averages.

Presence and degree of linear correlation was established based on Spearman’s rho. Statistical

significance was based on p-values ≤ 0.05. SPSSv20 was used in data processing and analysis

Twenty-one cases with 31 clubfeet were studied. Majority were male (71.4%; Table 1).

Average age was 1.2 years, range from 1 month to 7 years, majority were younger than 1 year

(66.7%). There were 57.1% unilateral and 42.9% bilateral cases. Of 12 unilateral cases, 8

(66.7%) were left clubfeet cases.

Table 1. Patients Included in the Study

Table 2: Demographic and clinical characteristics of children

 All Children
Characteristics
(n=21)
Gender, n (%)
Male 15 (71.4%)
Female 6 (28.6%)
Age in years, median (IQR) 1.2 (3.1)
Age in years, n (%)
≤1 14 (66.7%)
2–4 5 (23.8%)
5 – 10 2 (9.5%)
Laterality, n (%)
Unilateral 12 (57.1%)
Right 4 (33.3%)
Left 8 (66.7%)
Bilateral 9 (42.9%)
Characteristics All Children
(n=21)
IQR: interquartile range
Data presented as median (IQR) for variable with skewed distribution or n (column %) for categorical variables.

Characteristics that were significantly correlated with number of Ponseti casts

were age in years, initial abduction and degrees to correct (Table 3). The older the

patient the higher the number of casts (rho=0.491; p=0.006). The higher the initial

abduction, the lower the number of casts (rho=-0.582; p=0.001) while the higher the

number of degrees to correct, the higher number of casts (rho=0.582; p=0.001).

Table 3: Characteristics of clubfeet cases and their association with number of casts
Mean ± SD Median (IQR) Correlation
Characteristics p-value
(n=31) (n=31) Coefficient rho
Age in years 1.88 ± 2.19 1.15 (3.10) 0.491 0.006*
Pirani score 3.85 ± 0.83 3.75 (0.60) 0.157 0.406
Initial abduction -10.33 ± 16.9 -15.0 (33.0) -0.582 0.001*
Degrees to correct 80.33 ± 16.91 85.0 (33.0) 0.582 0.001*
Number of casts 9.60 ± 3.92 8.0 (7.0) 1.000 **
SD: standard deviation, IQR: interquartile range
* Significant at 5% alpha level
** No statistic can be computed.

There was insufficient evidence to show significant differences in average degrees to

correct (p=0.165; Table 4). Average degrees of correction per cast, however, were

significantly different across age groups (p=0.087).

Table 4: Degrees of correction attained with each casting session by age

Degrees to Correct Correction per Cast

Age in Number of Number of
median
years Children Feet mean ± SD median (IQR) mean ± SD
(IQR)
≤1 14 20 76.50±16.63 75 (30) 9.72±3.04 10 (4)
2–4 5 6 90.00±15.49 95 (18) 10.63±4.32 9.95 (7)
5 – 10 2 4 85.00±17.32 85 (30) 6.05±0.29 6.05 (1)
All 21 30 80.33±19.91 85 (33) 9.41±3.35 9 (5)
SD: standard deviation, IQR: interquartile range

Comparing across age groups, average degrees to correct were significantly different

(p=0.036) while average number of cases were comparable across age groups (p=0.071).

Though the overall average correction attained per casting was 9.4, there was however,

insufficient evidence to suggest that this is significantly different from the claim of at least 10

degrees per cast (p=0.386).

No significant differences on average number of casts could be seen across

age groups (p=0.056; Table 5). Deviations from the expected range on number of

casts were observed in 56.7% of the children, majority among infants at most 1 year

old (52.9%) with differences of 1 to 10 casts. Among children with deviations from the

expected range, highest average deviation was observed in the older children.

Table 5: Deviation of actual number of cast from predicted range by age

Children with
deviation from Deviation from expected
Actual number of cast
Age in years expected range range on number of cast
on number of cast
median (IQR) min - max n (%) median (IQR) min - max
≤1 8 (4) 4 – 17 9 (52.9%) 3 (4) 1 – 10
2–4 8 (9) 5 – 15 4 (23.5%) 3 (4) 1–5
5 – 10 14 (4) 12 – 16 4 (23.5%) 5.5 (1) 5–6
All 8 (7) 4 – 17 17 (56.7%) 4 (4) 1 - 10
IQR: interquartile range, min: minimum, max: maximum
Data presented as median (IQR) for continuous discrete variables with skewed distribution
Similarly, there was no significant differences in average number of casts (p=0.513)
and average deviations from expected range on number of casts (p=0.115) across
clubfoot severity (Table 6).

Table 6: Deviation of actual number of cast from predicted range by clubfoot severity
Children with
deviation from Deviation from expected
Actual number of cast
Pirani Score expected range of number of cast
cast
median (IQR) min - max n (%) median (IQR) min - max
2.5 – 3.0 8 (7) 4 – 12 4 (23.5%) 3 (4) 1–5
3.5 – 4.0 8 (8) 6 – 17 10 (58.8%) 3.5 (4) 1 – 10
4.5 – 6.0 11 (10) 5 – 16 3 (17.6%) 6 5–6

Figure 1. Average number of casts in each age group.

16

14

12

10

0
>1 year 2-4 years 5-10 years

Average number of casts

 Figure2. Average Correction Achieved in each Casting
Session within an age group
12

10

0
0-6 months 2-5 years 5-10 years

Average Correction per Cast

Discussion

The Ponseti Method has become the gold standard in the treatment of idiopathic clubfoot (9)..

Pirani scores have been frequently used to track treatment progress, predict tenotomy requirements,

number of casts of treatment and relapse rates. (10; 11; 12;5). Nonetheless, parents of children still pose the

question as to how long or how many weekly visits will be required for the treatment of their child’s

condition. In our country’s setting, this has an enormous impact on the parent’s compliance and,

therefore,in the success of treatment.

Studies has been done as to the correlation of age and Pirani score to the number of casting

procedures. Dyer and Davis reported on predictive value of Pirani scoring on 70 idiopathic club feet [6].

They found a positive correlation (r =0.72) between initial Pirani score and number of casts required to

correct the deformity. A foot scoring of 4 or more is likely to require at least four casts, and one scoring

less than 4 will require three or fewer. (5). There was no linear relationship between initial Pirani scores

and number of corrective casts in this study.

In a study on the use of Ponseti method in clubfoot in toddlers, the number of casts in younger

children was less compared to older children (one to two years, six to ten casts; two to three years, nine
 (13)
to12 casts). Older childer seemed to require more casts. . No data is available as to how many degrees

are indeed corrected for each casting and manipulation. Knowing this vital information can greatly

predict the the duration of treatment and, thus, bring the parents into the light of what and how long to

expect the treatment will be done.

In this study, it was shown that across all the patients recorded, an average of 9.4 degrees is

achieved per casting and manipulation. Once the data is grouped into age categories, a decreasing trend

is observed in as to how the foot is corrected into abduction; an average of 6 degrees in children in the

5 to 10 years of age.

There is a deviation from the claim of 10 to 15 degrees of correction achieved per cast; with

the 5 – 10 years of age group having the highest average deviation. This is consistent with previous

studies that advanced age correlates to more casting sessions. With regard to clubfoot severity, the actual

number of casts deviates from the predicted value by at least eight casting sessions.

Though the overall average correction attained per casting was 9.4, there was however,

insufficient evidence to suggest that this is significantly different from the claim of at least 10 degrees

per cast (p=0.386).

There are several limitations in this study. One of which is that it did not put into equation the

technical skill of the surgeon-in-charge. The skill of the practitioner may play a role in the degree of

correction achieved. It is recommended that this study be continued with a specific group of surgeons

handling the cases. Since this is only a preliminary study, the sample size, and therefore the significance,

can be increased in the ensuing years of being a part of the International Clubfoot Registry. The long

term follow up was not available to ascertain any relapse or maintenance of the initial correction; this is

one of the aspects to be tackled in further studies

Although this study estimates the number of casts until a tenotomy procedure, it should be

reiterated that the data still varies.

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