Early results of a physiotherapist-delivered Ponseti service for the management of idiopathic congenital talipes equinovarus foot deformity

Patients and Methods

Since January 2003, all referrals to the senior author (DE) at the Royal Free Hospital pertaining to the management of a non-syndromic congenital talipes equinovarus deformity have been directed to a physiotherapist (NS). The physiotherapist is a clinical specialist with previous experience and training in neurodevelopmental paediatrics. In addition, she had worked with the senior author for a period of five years before the development of the Ponseti service, during which time she was responsible for overseeing the pre- and post-operative care of babies with a congenital talipes equinovarus deformity. In 2002 she attended a Ponseti Technique Training Course.

During the initial consultation, an appropriate medical history was taken and a general clinical examination performed by the physiotherapist. Occasionally, an antenatal consultation took place. The treatment options were explained. If the family were in agreement with the Ponseti philosophy and treatment schedule as outlined in Table I, treatment was commenced within seven days.

Between January 2003 and October 2005, 41 feet in 25 children were seen and assessed. All feet had an idiopathic congenital talipes equinovarus deformity, although one also had a mild form of amniotic band syndrome. The first patient entered into the Ponseti programme defaulted early. Her parents accepted the treatment philosophy, but after application of the first cast they obtained another opinion and opted to follow the more conventional route (at that time) of ‘modified Ponseti splinting’, culminating with a peritalar release at eight months of age. The following results refer to the remaining 40 feet in 24 children (Table II). The median age at initial consultation and onset of treatment was 3 weeks (mean 4.3; 1 to 12).

All feet were scored using the Pirani method (Columbia Clubfoot Score)¹³ at presentation and at each subsequent attendance. In addition, during the second year of the programme an assessment of dorsiflexor/evertor muscle function was documented using a scoring system modelled on the Pirani scale (Table III).

Manipulation and casting was performed on a weekly basis by the physiotherapist, assisted by a qualified junior colleague, during progressive correction of the foot deformity. Once hyperabduction of the forefoot had been obtained, any residual equinus (defined as < 10° of dorsiflexion) was corrected by a percutaneous Achilles tenotomy. All tenotomies (except the two most recent cases performed by RB) were performed by the senior author (DE). An appropriate explanation of the surgical procedure was given to the parents and a consent form signed.

The tenotomies were performed in the physiotherapy clinic room. The first six were performed using only an injection of local anaesthetic (2 ml 1% lignocaine). Subsequent tenotomies were performed after the application of Ametop (local anaesthetic; Smith & Nephew, Hull, United Kingdom) cream alone.

Subjectively, the surgeon and physiotherapist considered that both methods gave similar overall pain relief, but for the surgeon, palpation of the tendon was easier without the local anaesthetic infiltration. A size 15 scalpel blade was used to perform the tenotomy through a stab incision on the medial aspect of the tendo Achilles. The wound was closed with a steristrip. All parents were advised to contact the physiotherapist if there was any bloodstaining of the plaster cast.

Regardless of whether the foot had required a tenotomy or not, the regimen outlined in Table I was adhered to, with orthopaedic review encouraged at six and 12 months. Pirani scores and dorsiflexor/evertor muscle function were documented at every attendance. Radiological assessment was performed by obtaining standing anteroposterior and lateral radiographs when the child was two years of age (or earlier if there was any clinical concern).

All families were given information sheets including contact telephone numbers, and open access to either the paediatric orthopaedic clinic or to the physiotherapist was provided in cases of parental concern. A parent support group was also formed and informal meetings were encouraged. Apart from the tenotomy itself, all other interventions and patient contact were carried out by the physiotherapist, with the help of a junior colleague at the time of application of the plaster casts. An annual audit of parent satisfaction was carried out, and improvements to the service made where possible.

Results

Overall foot correction was obtained with a mean of five casts (1 to 10), and 25 feet in 16 children required an Achilles tenotomy. The median Pirani score at presentation for those feet requiring a tenotomy was 5.5 (mean 5.4; 4 to 6), compared with a median of 3.5 (mean 3.7; 2 to 6) for those not requiring tenotomy. A Pirani score of ≥5 at presentation was associated with the need for a tenotomy. Children who did not require a tenotomy (n = 15), needed a mean of 3 casts (1 to 5) to obtain full correction, whereas those having a tenotomy (n = 25) required a mean of 6 casts (3 to 10) plus the posttenotomy cast. At presentation of the 19 feet in which a dorsiflexor/evertor score was documented, only seven had poor muscle function. Two children (three feet) had undergone prior treatment in the form of splinting or casting.

Discussion

This was a small study, with a short follow-up, representing the learning curve of a clinical specialist physiotherapist in applying the Ponseti technique to children with idiopathic congenital talipes equinovarus deformities but with encouraging early results. Correction was achieved in all feet. Full correction was not maintained in four feet in three children owing to non-compliance with the foot abduction orthosis. One of these feet required a surgical release. In the published series success is defined as treatment that avoids a surgical soft-tissue release, and thus our success rate is 97.5% (39 of 40 feet), a figure that compares favourably with other series that quote success rates of 83% to 98%.^{7–9,11,12,14}

Success rates have improved with modifications to the manipulation and casting technique, and this has encouraged physicians to expand the indications for the use of this treatment method.¹¹ Many recent published series include a greater range of patients, including older children, the child with failed previous conservative treatment including prior Achilles tenotomy, and the child whose foot deformity is part of a generalised disorder.^6,11,15 The severity of the deformity at presentation is not always stated. We do accept that this study included only idiopathic club feet. They presented early and had not been treated previously. We also agree that they were perhaps the feet most likely to obtain a successful result, but our median Pirani score of 5.5 (mean 4.75) suggests that they did have a severe deformity and all achieved correction. The mean number of casts per foot was in keeping with other studies.^11,14,16 An accelerated programme that reduces the time between cast changes does reduce the total length of time in casts, but not necessarily the number of casts needed.¹⁴ Our overall tenotomy rate was low but not in the sub-group with a Pirani score > 5.

Recent publications^5,6,11,16 have stressed the importance of compliance with the full Ponseti programme in terms of the continued use of the foot abduction orthosis in order to maintain the good results achieved by the manipulation/ casting part of the programme. Non-compliance with the splinting programme is the most significant risk factor for recurrence of deformity.⁵ In other areas of the literature^17–19 there is evidence to suggest that continuity of medical care improves compliance with treatment methods. Continuity of care correlates with increasing trust in the physician, as assessed by the Stanford Trust Study, and is related to the parent’s belief that the practitioner can and does care for more than just a single part of the child.²⁰ We believe that the most important aspect of our programme is that all the care is delivered by a single practitioner, who knows the family and the child well at the time of application of the orthoses. The same practitioner is then actively involved in helping the child and the family cope with the prolonged treatment regimen, and is also able to give advice on developmental aspects of care and general health issues. In order to maintain this continuity, occasional alterations to the treatment programme were made to cope with absence of the physiotherapist. For example, a splint would not be applied to a child if the physiotherapist was unavailable for advice over the subsequent few days. We do appreciate that such one-to-one care may be difficult to maintain with service expansion, but we believe that it is essential to the success of the programme.

In the NHS setting, specialist medical time is often an expensive and scarce resource. Prior to the development of this physiotherapist-delivered Ponseti service, the management protocol for a congenital talipes equinovarus deformity at our hospital involved physiotherapy stretching and strapping, provided by the community services and overseen by the hospital physiotherapist, with a surgical release in those who failed to obtain a plantigrade and functional foot. With the increasing popularity of the Ponseti technique many surgeons have found that it is no longer necessary to perform many soft-tissue releases. However, their time is still taken up with the conservative management of these cases. With our physiotherapy-delivered service, the medical input is limited to one 45-minute session per patient (uni- or bilateral cases). Specialist physiotherapist resources are also scarce and their time should also be respected, but children with a congenital talipes equinovarus deformity are an important and challenging group to treat, and senior input is often required.

Our study agrees with the findings of Scher et al,²¹ who suggest that those feet presenting with a Pirani score of > 5 are highly likely to need an Achilles tenotomy. They also require more cast changes, and so the surgeon can to an extent be forewarned when they will be required. Our hypothesis had been that dorsiflexor/evertor muscle function would correlate with the risk of dynamic deformity once walking was established, and might predict the need for a tendon transfer. Currently, there is no suggestion that the three feet with a dorsiflexor/evertor score of 1 have a more dynamic deformity than those with a score of 0. With longer follow-up we hope to be able to study this further.

In the developing countries, tenotomies are undertaken by non-medical personnel.^12,13 In the United Kingdom, although there has been an expansion in the use of surgical care practitioners, it may be difficult to develop acceptable guidelines for the training and supervision of non-medically trained personnel to perform an Achilles tenotomy on an infant. A large-gauge needle has been used to release tendon sheaths in the hand²² and has also been described for the tendo Achilles as a modification of the Ponseti technique.²³ Perhaps such a technique may be more suitable and applicable for the non-medically trained personnel.

Our early results with a physiotherapist-delivered Ponseti service for the management of idiopathic congenital talipes equinovarus deformity are as good as those from other published series using medical personnel.^7–9,11,14 We would agree with Tindall et al¹² that “the Ponseti method is readily transferable to non-doctor practitioners”, but we believe that this philosophy should be followed in developed countries as well as the less developed ones. The most important factor is that these practitioners are appropriately trained and experienced. We believe that there is additional benefit in providing a service that emphasises total continuity of holistic patient care delivered by a single practitioner performing all interventions, apart from the tenotomy.