Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Stuart L. Weinstein, MD*,
University of Iowa Hospitals and Clinics, Iowa City, Iowa
Posted March 2007
Successful outcomes of clubfoot treatment by the method
pioneered by Ponseti at the University of Iowa in the 1950s requires attention
to detail in three areas1. It requires a thorough understanding of
the pathoanatomy of the deformity to be able to do appropriate corrective
manipulations, meticulous technique in applying postmanipulation plaster casts
to maintain correction, and prolonged use of a postcorrection orthosis to prevent
recurrence of the deformity.
Information regarding the success of this well-documented
method of management has been accessible to physicians through long-term
follow-up studies2,3 in the literature, but the method itself had never
been widely accepted. Over the last ten years, however, the Ponseti method has
enjoyed a "rediscovery" as information about the technique became more readily available
to the general public through the Internet. After reading the success stories
posted by other parents, the parents of children affected by clubfoot began to
seek out orthopaedic surgeons who were familiar with the technique. This drove
the world pediatric orthopaedic community to change practice: to revisit the
technique and its reported results and to learn from the few doctors who were employing
it correctly. Short-term successful reports coming from other institutions
added to the enthusiasm and aided the now widespread adoption of this method
around the world4.
The most common complication of clubfoot treatment is
recurrence of deformity, the correction of which often requires extensive
surgery. In their paper, Haft and colleagues examined the predictive factors
responsible for the recurrence of the deformity and the need for major or minor
corrective surgery. The study has three unique features: it was carried out in
New Zealand, a country with a national healthcare system, thus ensuring good
patient follow-up; it had a largely ethnic Polynesian population; and the
primary treating physician was skilled in the Ponseti method. The authors
sought to determine if recurrence rate was related to the severity of the
deformity on initial presentation, the timing of presentation, the number of
casts needed to obtain full correction, a family history of clubfoot, and/or
compliance with abduction bracing. Intuitively, and from previous studies in
the literature, one might think that recurrence rates would be related to the severity
of the deformity and the number of casts required to obtain correction in
skilled hands. One might also think that there may be differences related to
ethnicity; as Polynesians made up nearly two-thirds of the study group and because
that ethnic group is known to have a high incidence of clubfoot, there may have
been more patients with severe clubfeet and with higher rates of recurrence.
However, the startling results of this study demonstrated that the
key factor associated with recurrence was noncompliance with the bracing
protocol. The children of noncompliant parents had a five times higher risk of
recurrence than did the children of compliant parents.
Currently, the greatest emphasis by orthopaedic surgeons in
"reintroducing" the Ponseti method has been to understand the pathoanatomy of
the deformity, learn the appropriate manipulation maneuvers, and perfect the
application of postmanipulation holding casts. This study instructs us on the
importance of the postcast brace regimen with regard to the ultimate outcome. While
this aspect of care has long been emphasized by Ponseti as a critical part of
the management scheme, it is little discussed in the literature, is not under
direct physician supervision, and is totally regulated by the parents of each
child.
Haft et al. provide some useful suggestions that should be incorporated into practice by physicians who treat clubfeet. These suggestions include emphasizing the need for compliance with the bracing at the outset of treatment and at each subsequent visit and implementing enhanced surveillance of patients by the physician or his or her designee during the bracing period to ensure compliance, address orthotic problems, and allow early identification of recurrences so that prompt remanipulation and casting can occur. Early detection and remanipulation and casting may prevent the need for "major" surgery and allow minor procedures to achieve a good outcome when there is recurrence in older children. It is clear that strict adherence to all the tenets of the Ponseti method of management, including prolonged use of the brace after correction, will lead to a high rate of success and to avoidance of surgery in 95% of idiopathic cases5.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received 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, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, 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, 344.
2. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital 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.
5. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics. 2004;113:376-80.
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