Thirty-two percent of fractures were complicated initially: nerve injury (n=17), vascular injury (n=12) (including three cases with nerve and vascular injury), open fractures (n=7). The medial nerve was injured in most cases (n=12). Ulnar palsy was noted in four patients and radial palsy in one. Vessel injury led to abolition of the radial pulse in eight patients and the ulnar pulse in one; all resolved after reduction. Ischaemia of the hand was noted in two cases before reduction of the fracture but vascular surgery was not required. Most of the fixations were achieved with cross pinning (percutaneous insertion in 47 patients and open surgery in 13). Despite minimal medial skin incision, ulnar nerve deficiency was observed after surgery in seven cases; four were rapidly regressive and three required surgical exploration with neurolysis. Six revision procedures were required for secondary displacement (10%). The 26 Judet fixations led to ten secondary displacements requiring surgical revision for cross pinning. Four cases of postoperative ulnar nerve deficiency were noted: reoperation to release the nerve pinched in the fracture was required for only one patient. The Blount technique was used in nine cases with four secondary displacements, including one related to two sites of nerve impingement. Five cases of superficial pin tract infection which resolved rapidly and two cases of deep infection were noted in the early postoperative period. Formation of a varus ulnar callus was noted in five cases: two required secondary surgery for correction.
The initial treatment of the congenital clubfoot is still a debated subject among different schools. We report our current experience with Ponseti method. Materials and Methods: From April 1999 to May 2001 we have consecutively treated with this method 80 idiopathic clubfeet of 57 children put under treatment at neo-natal period. Progressive correction of the deformity has been obtained with 7 toe-to-groin plaster casts changed weekly. When complete derotation of the hind-foot and forefoot has been reached, subcutaneus tenotomy of the tendon Achilles has been performed. At the end of this first period, the feet have been adapted in Denis Browne splint, worn full time for four months and thereafter just at night. The feet have been evaluated clinically (score of Dimeglio and Bensahel), radiologically and some with MRI. Results: Whole correction of the deformity at the end of treatment with plaster casts, has been achieved for 71 times. When the plaster casts are removed, the talocalcaneal divergence, on antero-posterior and lateral views and the tibial-calcaneal angle (x-ray in maximum dorsal flexion ), were respectively, as an average of 20; 30,7; 21,9 degrees. At an average of 20 months follow up, 54 feet of 80 had a score of 0 or 1 of 20, and 14 had a score of 2; on radiological aspect the talo-calcaneal divergence in antero-posterior and lateral views and the tibial-calcaneal angle were respectively as an average of 29; 24,5; 14 degrees. At this evaluation the percentage of relapses of the deformity was 20% (17 cases). All the relapses have been treated again in plaster casts with 40% of success. So far, only four medial release operations have been necessary. Six feet benefited by the transfer of the tibialis anterior tendon to the third cuneiform and slight medial release. Discussion and Conclusion: The Ponseti’s method presents several advantages: high quality reduction of the clubfoot with the restoration of a “sub-normal” anatomy, low cost and small displeasing worry for the parents, with this method the functional re-education does not seem to improve the quality of results. The prevention of the relapse goes by good compliance to the splint.
