Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Haemish A. Crawford, FRACS*,
Starship Children's Hospital, Auckland, New Zealand
Posted November 2008
The paper "A Comparison of Two Nonoperative Methods of
Idiopathic Clubfoot Correction," by Richards et al. provides an excellent
comparison of two techniques for the treatment of clubfeet in a population. It
is particularly valuable because neither technique was developed at this
center. Dr. Ponseti and Dr. Bensahel have published excellent results of their
techniques used in their own centers; however, the ultimate success of a
technique is that it can be reproduced in different population groups around
the world1,2. Richards et al. used the two techniques at Texas
Scottish Rite Hospital and prospectively recorded their results. They used the
identical manipulation and casting technique of Dr. Ponseti, but used boots and
bars for a shorter period of time (until two years of age). The French
technique was learned from Professor Dimeglio and was carried out very
similarly to that in France.
The pendulum has swung in North America and elsewhere in recent
years toward treating all idiopathic clubfeet with use of the Ponseti
technique. The "French" method is largely confined to parts of Europe. The two
techniques are appealing as they prevent the extensive surgery that has
traditionally been used to treat this condition. When one critically reviews
the literature, neither of these techniques is "nonoperative" as a number of
patients require surgical correction1-3. Richards et al. found
that sixty-one of the 252 feet that were treated with use of the Ponseti
technique required an operation because of relapse. This is similar to a review
of my own series at a minimum of two years of follow-up, in which 37% of the
patients had a relapse requiring surgical intervention4. The number
of surgical interventions needed in these series will likely increase with
further follow-up and will surpass the number of surgical interventions
reported in Dr. Ponseti's series, in which forty-eight clubfeet out of 104
required subsequent surgical intervention1.
Almost all reports with less than two years of follow-up
have minimal relapse rates. This reflects the fact that achieving the
correction is not difficult but maintaining the correction, especially when the
braces are not worn, is difficult. Similar surgical intervention rates are seen
with the French method. Richards et al. found that 29% of feet required
surgical intervention. In their earlier series, 49% of their patients required
surgery3. The important feature of both the Ponseti and French
techniques is that they substantially decrease the prevalence of
intra-articular surgery, which traditionally has been the treatment of choice5.
This paper highlights the fact that both techniques can be used
by surgeons outside of the institutions at which the techniques were developed.
Both techniques are straightforward to learn and apply; however, they require
strict adherence to treatment protocols by the patient's family. Importantly, the
patient and his or her family are also determinants of the success or failure
of the treatment. In the study by Richards et al., fifty-seven patients were
lost before the two-year follow-up, and the authors also report that there was poor
compliance with brace-wearing in 61% of the feet in the Ponseti group. In this
prospective study, parents selected the Ponseti technique twice as often as they
selected the French method because it was more convenient and cheaper. With
similar clinical results in both treatment groups, this paper supports the more
widespread preference for the Ponseti method over the French method in most
countries.
*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. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am. 1980;62;23-31.
2. Bensahel H, Catterall A, Dimeglio A. Practical applications in idiopathic clubfoot: a retrospective multicentric study in EPOS. J Pediatr Orthop. 1990;10:186-8.
3. Richards BS, Johnston CE, Wilson H. Nonoperative clubfoot treatment using the French physical therapy method. J Pediatr Orthop. 2005;25:98-102.
4. Haft GF, Walker CG, Crawford HA. Early clubfoot recurrence after use of the Ponseti method in a New Zealand population. J Bone Joint Surg Am. 2007;89:487-93.
5. Dobbs MB, Nunley R, Schoenecker PL. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am. 2006;88:986-96.
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