Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Stuart L. Weinstein, MD*
Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa
In the past decade, there has been a "rediscovery" of a method of treatment for clubfoot that was developed more than fifty years ago in Iowa City1. This resurgence was brought about by information about this method, formerly only available to physicians but now available on the Internet and embraced by parents of affected children. Using the Internet, parents read the success stories as related by other parents of affected children and learned about the success of this nonsurgical method, which had been documented in the literature in long-term follow-up studies2,3 but which had not been widely accepted. Parents of newborns with clubfoot began to seek out orthopaedic surgeons who were familiar with the technique, and this drove pediatric orthopaedists to revisit the technique and its reported results and to learn from the few doctors who are employing it correctly. The short-term successful reports that have come from other institutions added to the enthusiasm and aided the now widespread adoption of this method around the world4.
From the 1970s through the end of the twentieth century, most orthopaedic surgeons were performing major surgical soft-tissue releases of the midfoot and hindfoot for failure of nonsurgical management of clubfeet. The failures of the nonsurgical methods were in large part due to a failure to understand the pathoanatomy of the clubfoot and particularly the failure to understand the important linkage of movement between the foot components (forefoot; midfoot and hindfoot) and the mechanics of the subtalar joint that are so necessary to successful nonsurgical correction of the clubfoot deformity.
In reviewing this article by Dobbs et al., many questions are raised, not the least of which is the effect of the extensive long-term immobilization in casts necessitated by the commonly used Kite method of manipulation that was used in the index patients prior to surgical intervention. The prolonged immobilization in the non-corrected position at a very formative time in foot development may have contributed to the ultimate poor radiographic and functional outcome of these patients. The prognosis for long-term satisfactory function in these relatively young patients is guarded. One can only wonder what the alternatives of treatment will be for them in the future.
Dobbs et al. have added the major piece to the "evidence-based" puzzle that had to be completed to convince orthopaedic surgeons around the world that they must study and master the Ponseti technique to ensure long-term successful management of patients with clubfoot. It also reinforces the current trend toward the adoption of this method of management of clubfoot as pioneered by Ponseti over fifty years ago.
*The author did not receive grants or outside funding in support of his research for or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.
References
1. Ponseti IV, Smoley EN. Congenital club foot: the results of treatment. J Bone Joint Surg Am. 1963;45:261-75.
2. Laaveg SJ, Ponseti IV. Long-term results of treatment of congential club foot: J Bone Joint Surg Am. 1980;62:23-31.
3. Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up note. J Bone Joint Surg Am. 1995;77:1477-89.
4. Herzenberg JE, Radler C, Bor N. Ponseti versus traditional methods of casting for idiopathic clubfoot. J Pediatr Orthop. 2002;22:517-21.
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