Orthopaedics and physiotherapy clinical outcomes

This page gives an overview of the Ponseti treatment and how it measures the results of treatment for patients seen in the orthopaedics service.

Overview of orthopaedics and physiotherapy

The orthopaedic team at Great Ormond Street Hospital (GOSH) aim to provide a comprehensive assessment of complaints of the musculoskeletal system and then arrange the appropriate management for the patient. The orthopaedic team includes specialist physiotherapists.

Physiotherapy is available in many different clinical areas, providing a service to both inpatients and outpatients. It supports a number of clinical specialities.

One part of the service is provision of the Ponseti technique for treating children with clubfoot. This is overseen by the orthopaedic speciality and lead by a specialist physiotherapist.

The following section details the clinical results for this part of the service.

Overview of Ponseti Service

The Ponseti technique is used at GOSH to correct clubfoot (talipes) deformity in children enabling the child’s foot to bear weight in a normal way and allowing it to develop normally over time.

The technique has become the preferred treatment option for clubfoot because it is more effective than alternative surgical methods and has been associated with significantly better long term results for the majority of patients.

The Ponseti treatment involves a manipulation and casting technique which is performed on a weekly basis until the foot has corrected fully. Most children require a minor operation in the outpatient clinic under local anaesthetic to release the Achilles tendon and allow full correction to be achieved. This is called an Achilles tendon release. Children are then fitted with splints (called ‘boots and bars’) to keep the corrected foot in place.  

The Ponseti Service at GOSH was established in 2005 and over the last three years has accepted on average a further 19 new clubfoot patients a year.

The service treats children with both idiopathic and complex clubfoot and often patients are referred from other hospitals where treatment has not succeeded.

Over half of the patients treated by the service have significant other medical conditions which may influence the management of the clubfoot itself.

How do we measure the results of treatment?

In order to assess the results of the technique, the Ponseti service records the success of treatment for each patient. Success is defined as a patient in whom the clubfoot has been corrected without the need for a major surgical procedure.

The Ponseti technique is used across the world and the results of treatment for patients have been reviewed in a number of hospitals. Most recent research has indicated that the Ponseti technique should result in a success rate of 90-98 per cent.

Ponseti Technique:  Success Results

105 patients have been treated by the GOSH Ponseti Service since 2005.The average success rate for initial correction is 98 per cent.

Following initial correction 100 patients have continued to be treated successfully using the Ponseti technique and have not required surgical treatment. This represents a 94 per cent overall success rate for the Ponseti Service at GOSH and is comparable with global gold standards for the technique.

The Ponseti Service also records when there has been a relapse of the foot after initial treatment. Relapse is defined as recurrent deformity following an initial successful correction. This may happen over time and as the foot (and the child) grow.

While patients may have relapses, further manipulation and casting often results in successful correction again. Treatment success is undoubtedly related to the family’s compliance in wearing the ‘boots and bars’.

Of the 105 patients treated by the GOSH Ponseti Service, 10 have had at least one relapse but have responded well to further Ponseti treatment to correct their recurrent deformity.

A further five patients of the 105 have had at least one relapse and required further surgical treatment to correct the recurrent clubfoot. The majority of these patients had undergone successful Ponseti treatment for a few years before the foot relapsed and surgery was considered. All of these patients had significant other medical conditions.

Overall, 80 per cent of patients require an Achilles tendon release as part of the initial Ponseti treatment: at GOSH the figure is lower for idiopathic clubfeet (72 per cent) and higher for patients with complex clubfoot (92 per cent).

Our overall tenotomy rate is lower than that reported in some studies but there have been no relapses in children that did not require a tenotomy.

During the Ponseti treatment, children will require a number of casts before and after a tendon release (if this is required). On average patients with an idiopathic clubfoot treated at GOSH had six casts before a tendon release and the complex clubfoot had seven casts. Those patients that had a tendon release had on average one to two casts afterwards.

The following table provides more information on the patients that were treated by the Ponseti Service by year of their first appointment in the service:

 About the information

The service records the treatment provided and results of the technique for every patient that is treated by the team in a Ponseti Service database.

The information provided was reviewed from the Ponseti service database in February 2012. We plan to update this information in July 2013.

 Glossary

• Idiopathic clubfoot -  these feet have stiffness mainly on the inside and back of the foot: they do not have an underlying identifiable cause for the clubfoot deformity

• Complex clubfoot – these feet have stiffness mainly on the sole of the foot and back of the foot. This results in a short, fat foot with a deep crease in the sole and an over extended big toe. It is often associated with other medical conditions e.g. Spina Bifida and Arthrogryposis

• Patients treated elsewhere previously –failed Ponseti or similar casting treatment at their local hospital

• Average – the measure calculated by adding up all the results and dividing the total by the number of patients

• Success of treatment -  is defined as a patient in whom the clubfoot has been corrected without the need for a major surgical procedure