The patient presented to a public tertiary referral hospital with previously untreated bilateral clubfoot (Figs. 1-A and 1-B). Because of the family’s low socioeconomic condition, they had not been able to previously access specialized treatment. In the initial pretreatment physical examination, the patient had good gait agility with weight-bearing on the dorsolateral aspect of the feet; there were calluses on the overlying skin. The Pirani score was 5 at the first consultation9. Menarche had begun six months before the beginning of treatment.
Foot manipulation and casting were performed as described by Ponseti5,10, with modifications (calcaneal tendon lengthening was done instead of tenotomy, and there was a change in the length of time that orthoses were used). When the above-the-knee cast was changed, the lower limb was inspected for complications, and the deformed foot was manipulated (as described by Ponseti and Smoley5,10) by the orthopaedist for approximately two minutes before the new cast was applied.
Successive cast changes at seven-day intervals were carried out until all deformities were corrected, except for the equinus deformity. There were ten bilateral non-weight-bearing casts used prior to the lengthening of the calcaneal tendon, and casts were worn for a total of sixty-three days. There were no complications with the use of the casts. When asked about the presence of pain, the patient reported she experienced a slight discomfort at the final stage of casting. Overcorrection of the forefoot adduction was obtained and, at the time the Achilles tendon was lengthened with a percutaneous triple-cut technique (Fig. 1-C) under general anesthesia, the residual equinus deformity was approximately 20° bilaterally. Only one suture was used to close each surgical wound. With the lengthening of the tendon, dorsiflexion of the ankle to approximately 20° was achieved bilaterally. After the tendon lengthening, the patient wore an above-the-knee cast with the ankle in a neutral position for thirty days. The patient had a satisfactory outcome (Figs. 1-D and 1-E). A radiograph demonstrated osteopenia and also showed that the axis of the talus coincided with the axis of the metatarsal (Fig. 1-F). After removal of the immobilization, a foot abduction orthosis was used in order to minimize the chance of recurrence. Exercises for the performance of active movements and for passive stretching at home were taught to the patient; in addition, walking with comfortable soft-sided shoes without the orthosis was recommended for brief periods. The foot abduction orthosis was used for eighteen hours a day in the first three months, but the patient was allowed to remove the brace when she needed to walk; for the following nine months, the brace was used only at night.
In the first year of follow-up, the patient visited the outpatient clinic at an interval of no greater than three months. Throughout this time, the adequacy of the foot abduction orthosis was observed (distance between ankles, bar with attached shoes in its ends that were positioned in 70° of outward rotation). The family reported good compliance with the use of the foot abduction orthosis. After the first year of follow-up, the patient no longer used the orthosis; she returned for annual visits until the age of sixteen years and five months. The calluses that had been located on the dorsolateral region of the feet before treatment showed full spontaneous regression with the correction of the deformity.
The patient had plantigrade feet with no pain at the end of the follow-up period (forty-one months), with functional joint mobility and normal muscle strength (she could run and jump on tiptoes); there were no residual deformities or calluses on the plantar aspect of the feet. Active and passive ankle motion at the last evaluation demonstrated plantar flexion of 30°, dorsiflexion of 20°, inversion of 10°, and eversion of 7°; bilateral symmetry was present.
The upper age limit for using the Ponseti technique on patients with neglected CTEV is hard to specify. It is unclear (but likely) that the age of this patient (twelve years and ten months at the beginning of the treatment) represents the upper age limit for applying the Ponseti method to neglected idiopathic cases. With increasing age, the bones in the midfoot and hindfoot show greater deformation and less remodeling ability; more rigid joints and degenerative changes that take place progressively are likely to limit or impair the application of the Ponseti method in older patients. In this patient, a two-minute manipulation time was adequate, but Lourenço and Morcuende recommended a longer manipulation time and advocated cast changes every two weeks since this allows for a longer foot-remodeling period than weekly changes7. However, this case demonstrates that weekly changes allow a shorter treatment period that suffices to correct neglected CTEV, as advocated by Khan and Kumar8.
It is possible to modify the Ponseti technique in neglected cases, performing the lengthening of the Achilles tendon with a percutaneous triple-cut or open technique and not carrying out a full tenotomy of the tendon based on the hypothesis that, with lengthening, the tendon may preserve greater strength with a shorter postoperative immobilization time. However, additional studies are needed to confirm this observation. Khan and Kumar performed a tenotomy of the calcaneal tendon in all of their cases and did not observe any weakness in the gastrocnemius-soleus complex musculature8.
Another aspect that can possibly be modified with the Ponseti method is the protocol for using the foot abduction orthosis, which must be individualized in neglected cases, for a minimum of one year. It is unclear if recurrence is associated with patient age, but it does seem more likely in younger patients; for this reason, use of an orthosis for one year or less with older patients is supported. Lourenço and Morcuende7 advocated the use of an ankle-foot orthosis for compliance instead of the foot abduction orthosis; however, no difficulties were encountered in this patient concerning compliance with the use of the foot abduction orthosis. Khan and Kumar used only pronation shoes for two years after the removal of the cast8.
While joint mobility is greater in neglected CTEV cases treated with the Ponseti method, the recurrence and incidence of future arthrodeses are theoretically lower in comparison with other treatment methods (e.g., the use of external fixators and surgical procedures that may lead to extensive scarring). Lourenço and Morcuende7 and Khan and Kumar8 showed functional mobility of the ankle and these patients have not yet required arthrodesis for treatment of residual pain secondary to joint degeneration. Ferreira et al. reported a 50% recurrence of the clubfoot deformity, and spontaneous ankylosis of the ankle developed in 73.7% of cases of neglected clubfoot; arthrodesis was indicated because of the occurrence of symptomatic arthrosis in 23.7% of the cases treated with the use of the Ilizarov apparatus11. Degenerative changes and joint rigidity may occur in the tibiocalcaneal joint following astragalectomy12.
Additional studies with more subjects and a longer follow-up are needed in order to better determine the long-term results of the Ponseti method in neglected cases of CTEV; these studies should examine the incidence of arthrosis, the presence of pain, the necessity of future arthrodesis, and the eventual use of this therapeutic approach for older teenagers with neglected clubfeet.