Klumpfußtherapie nach Ponseti – aktueller Standard

Zusammenfassung

In dieser Übersicht wird die Klumpfußbehandlung unter besonderer Berücksichtigung der von Ponseti entwickelten konservativen Methode dargestellt. Im Kontext der verfügbaren Literatur werden die pathoanatomischen Grundlagen, die zu der Entwicklung der einfachen Korrekturhandgriffe führten, beschrieben. Die Auswirkungen der verschiedenen Ruhigstellungsmaterialien auf das Behandlungsergebnis werden ebenso beleuchtet wie die Probleme bei der Abduktionsschienentherapie. Weiterhin werden das Erkennen von Rezidiven und das von Ponseti entwickelte Konzept zur Rezidivbehandlung erörtert. Dass die Methode sich zum weltweiten Goldstandard entwickelt hat, belegen neben der globalen Verbreitung auch in Ländern mit geringem Einkommen Untersuchungen, die zeigen, dass sie auch bei nicht idiopathischen, vernachlässigten und voroperierten Klumpfüßen gute initiale Ergebnisse bewirkt. In verschiedenen Untersuchungen wurde auch mit instrumenteller Bewegungsanalyse gezeigt, dass konservativ behandelte Klumpfüße deutlich besser funktionieren, weil sie weniger arthrotische Veränderungen und Schmerzen zeigen als ausgedehnt operierte. Diese Informationen sind für den Behandler nicht nur nützlich bei der pränatalen Beratung hinsichtlich der besten verfügbaren Therapie, sondern helfen auch, die Compliance der Eltern bei der mehrjährigen Abduktionsschienenbehandlung hoch zu halten. Zu diesem Zweck wird auch der Vergleich zur konservativen physiotherapeutischen bzw. französischen Methode gezogen. Abschließend wird der Forschungsstand hinsichtlich der genetischen Ursachen der Klumpfußentwicklung beleuchtet.

Abstract

This manuscript evaluates the recent standard concept for clubfoot treatment. With regard to the history of clubfoot therapy and the return to conservative methods, the focus is laid on Ponsetiʼs treatment concept. Due to its development according to the precise analysis of the pathoanatomy, the practical principle is simple and easy to learn and consists basically of two redression maneuvers, percutaneous achillotenotomy, and boots and bar abduction treatment. Therefore, about 60 years after its implementation in Iowa it can be said to be the worldwide golden standard. It is known that Ponseti treated feet are better with regard to function and pain when compared to surgically treated clubfeet. The best results can be achieved when one sticks exactly to the method. Hence, plaster of Paris above the knee casts yield better results than fibreglass materials or short-leg casts. The brace should be worn 23 hours a day for 3 months and during sleep until the fourth birthday of the child. For reasons including the structured concept of treating relapses, the method is applicable in high and low income countries. Before transferring the tibialis anterior tendon, it is mandatory to correct the relapse of the heel varus. The Ponseti method can also correct clubfeet of non-idiopathic origin. Although a higher rate of relapses must be expected in these cases, initial Ponseti treatment lowers the extent of the necessary surgery. Emphasis is put on the importance of counselling prenatally as well as during the boots and bar period. To yield the best results, it is necessary to train and counsel physicians as well as parents. There is no need to fear significant delay in reaching motor milestones when clubfeet are treated conservatively. Other conservative methods – such as the French physiotherapy method – are able to correct the deformity, but usually do not consist of a concept as structured as the Ponseti method. They are also often more time consuming for the families when compared to Ponsetiʼs technique and are not available ubiquitously. While the diagnosis of the clubfoot deformity is still a clinical one and scores are the main tools for grading the severity today followed by X-rays and to some extent sonography, in experimental settings MRI may be helpful in finding abnormalities in muscles, blood vessels, and cartilage structures. The study of genetic associations of pathway abnormalities and single nucleotide polymorphisms with regard to the development of clubfeet enhances our knowledge concerning the origin of the deformity during limb development. In the future, this may enable us to provide not only a better prognosis for the outcome but also a more individualised therapy for each child born with a clubfoot.

Schlüsselwörter

Klumpfuß - Ponseti - Therapiestandard - Kinderorthopädie - Review

Key words

clubfoot - Ponseti - therapy standard - pediatric orthopedics - review

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