Orthopaedics and physiotherapy clinical outcomes
Clinical outcomes are measurable changes in health, function or quality of life that result from our care. Constant review of our clinical outcomes establishes standards against which to continuously improve all aspects of our practice.
Overview of orthopaedics and physiotherapy
The orthopaedic team at Great Ormond Street Hospital (GOSH) aims to provide a comprehensive assessment of complaints of the musculoskeletal system and then arranges 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 (Congenital Talipes Equinvarus - CTEV) deformity in children enabling the child’s foot to bear weight in a normal way and develop normally over time.
The technique has become the preferred treatment option for CTEV 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 13 years has accepted on average 16 new CTEV patients per year.
Therefore treatment tends to start at an older age and initial treatment has begun as late as seven years old.
More than half of the patients treated by the service have significant other medical conditions which may influence the management of the CTEV. The chart below shows the total of idiopathic clubfoot (n = 88) and non-idiopathic clubfoot (n = 121) patients seen in the service since 2005. Seven patients were over the age of two years before treatment started, and 65 patients were referred to GOSH following previous treatment/relapse from another trust.
Fig 1.1 Total number of new clubfoot patients, 2005 to 2018
Ponseti Service clinical outcome measures
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.
1. Ponseti Technique
209 CTEV 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, 192 patients have continued to be treated successfully using the Ponseti technique and have not required corrective clubfoot surgical treatment. This represents a 92 per cent overall success rate for the Ponseti Service at GOSH and is comparable with the global gold standard 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 the child's wearing of the ‘boots and bars’, but also normal muscle power around the ankle affects success rates. Therefore, a small number of patients will require repeated casting and/or surgical intervention with a tibialis anterior tendon transfer (TATT) to maintain a corrected foot.
Of the 209 patients treated by the GOSH Ponseti Service, 47 have had at least one relapse. Most have responded well to further Ponseti treatment, and 25 required further casting and a TATT to correct the recurrent CTEV. All these patients had undergone successful Ponseti treatment for a few years before the foot relapsed and surgery was considered.
The majority of patients require an Achilles tendon release as part of the initial Ponseti treatment: at GOSH the figure is lower for idiopathic clubfeet (63 per cent) and higher for patients with non-idiopathic clubfoot (83 per cent).
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 five casts before a tendon release and the non-idiopathic clubfoot had seven casts. Most patients who had a tendon release had one cast afterwards.
The table below provides data on the patients that were treated by the Ponseti Service by year of their first appointment in the service.
Table 1.1 Number of patients treated by the Ponseti Service by year of first appointment, 2005 to 2018
|Type of patient||2005 to 2006||2007 to 2008||2009 to 2010||2011 to 2012||2013 to 2014||2015 to 2016||2017 to 2018||Total||Percentage of overall 209 patients|
|Number of patients that previously failed treatment elsewhere||5||9||15||7||14||7||8||65||31%|
|Number of patients that relapsed in year||0||1||6||6||14||14||6||47||22%|
|Number of patients where initial treatment at GOSH was successful||11||36||40||32||31||25||30||205||98%|
The chart below shows the success of initial Ponseti treatments, by year.
Fig 1.2 Success of initial Ponsetti treatment, 2005 to 2018
This information was published in April 2019.
- 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
- Non-idiopathic clubfoot – these feet are associated with other medical conditions e.g. Spina Bifida, Arthrogryposis and other syndromes. These feet are considered more resistant to treatment.
Dunkley M, Gelfer Y, Jackson D et al. Mid-term results of a physiotherapist-led Ponseti service for the management of non-idiopathic and idiopathic clubfoot, Journal of Children's Orthopaedics, June 2015, Volume 9, Issue 3, pp 183-189.
Gelfer Y, Dunkley M, Jackson D et al. Evertor muscle activity as a predictor of the mid-term outcome following treatment of the idiopathic and non-idiopathic clubfoot, Bone & Joint Journal, September 2014, 96-B:1264-1268.
Kampa R, Binks K, Dunkley M et al. Multidisciplinary management of clubfeet using the Ponseti method in a district general hospital setting, Journal of Children's Orthopaedics, January 2009, 2(6):463-7.