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Scientific Articles:
B. Stephens Richards, Shawne Faulks, Karl E. Rathjen, Lori A. Karol, Charles E. Johnston, and Sarah A. Jones
A Comparison of Two Nonoperative Methods of Idiopathic Clubfoot Correction: The Ponseti Method and the French Functional (Physiotherapy) Method
J Bone Joint Surg Am 2008; 90: 2313-2321 [Abstract] [Full text] [PDF]
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[Read Letter to the Editor] Dr. Richards and colleagues respond to Ms. Issler-Wuthrich
B. Stephens Richards, MD, Shawne Faulks, RN, CNS; Karl E. Rathjen, MD; Lori A. Karol, MD   (5 February 2009)
[Read Letter to the Editor] Ponseti and the French Method: a European perspective
Ursula Issler-Wüthrich, Stefan Dierauer, Christian Issler , Frédérique Bonnet-Dimeglio   (20 January 2009)

Dr. Richards and colleagues respond to Ms. Issler-Wuthrich 5 February 2009
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B. Stephens Richards, MD,
Assistant Chief of Staff
Texas Scottish Rite Hospital for Children,
Shawne Faulks, RN, CNS; Karl E. Rathjen, MD; Lori A. Karol, MD

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Re: Dr. Richards and colleagues respond to Ms. Issler-Wuthrich

steve.richards{at}tsrh.org B. Stephens Richards, MD, et al.

We thank Ms. Issler-Wuthrich for her letter. We share many similar perspectives with her regarding the approach to the nonoperative treatment of clubfoot.

Beginning in 1996, Frederique Bonnet and Alain Dimeglio were instrumental in teaching the physical therapists at our institution the correct methods of the French technique. Like Ms. Issler-Wuthrich, our physical therapists have gained a tremendous amount of experience and expertise with this method. In a similar fashion,in 1999, our medical staff learned directly from Professor Ponseti how to properly utilize his method. It is based on these solid foundations of learning that we have gained our institutional experience in both treatment techniques.

We want to respond to several points made by Ms. Issler-Wuthrich.

1. Measurement. We agree that functional dynamic assessments of clubfeet will provide optimal information on the outcomes. As such, we have used gait analysis studies to accurately, and objectively, determine functional results. This information is published in another recent study from our institution (1). There were no significant differences in cadence parameters between patients treated by the Ponseti method and those treated by the French functional method. More of the children treated with the French method walked with knee hyperextension, a mild equinus gait, and mild footdrop. In contrast, more of the patients in the Ponseti group demonstrated mildly increased stance- phase dorsiflexion and a mild calcaneus gait. These measurements will be repeated when the children are older, and will likely serve as the future gold standard for functional assessment. In addition, our physical therapy department is performing Functional Assessments (Peabody) in patients between 4.5-5.5 years of age, and we will likely repeat this assessment at 10 yrs of age.

2. Sample Selection. We agree with Ms Issler-Wuthrich that the best outcomes will be obtained when treatment is begun at a very early age, preferably within the first two weeks of life. Either method has a high degree of success – we didn’t demonstrate a preference for one over the other.

3. Treatment procedures. We agree that professional expertise and experience is essential for good outcomes to be expected using the French method. We limit this treatment method to several experienced physical therapists in order to maximize good outcomes. This study only included children with idiopathic clubfeet. Those patients found to have other disabilities were excluded from this study, but have been taken care of in a similar fashion, particularly in light of the fact that their disabilities may not be evident early in their treatment program.

4. Surgical interventions. Several years ago,our Montpellier colleague, Professor Alain Dimeglio, began performing lengthening of the gastrocsoleus complex more frequently than he had previously, as he noted a persistence of equinus in too many feet. This persistent equinus may not be appreciated as well on the clinical assessment as it is on the radiographic assessment. Professor Dimeglio has not yet published his recent experience with lengthening of the gastroc-soleus, but it has become a routine part of his French treatment program, as it has in ours.

In conclusion, either treatment method, when performed properly, can provide good clinical outcomes. For some patients, optimal outcomes can only be achieved when certain aspects of both methods are combined. We look forward to seeing the results from Zurich’s “Universitatskinderklinil” and Montpellier’s “Institut Saint Pierre” in future publications.

References

1. El-Hawary R, Karol LA, Jeans KA, et al: Gait Analysis of Children Treated For Clubfoot With Physical Therapy Or The Ponseti Cast Technique. J Bone Joint Surg Am 2008;90:1508-1516.
Ponseti and the French Method: a European perspective 20 January 2009
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Ursula Issler-Wüthrich,
Physiotherapist
University Children's Hospital Zurich, Switzerland,
Stefan Dierauer, Christian Issler , Frédérique Bonnet-Dimeglio

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Re: Ponseti and the French Method: a European perspective

ursula.issler{at}klumpfuss.ch Ursula Issler-Wüthrich, et al.

To the Editor:

The new comparative study of the Ponseti and the French functional method is an important contribution to the advancement of the knowledge and the practice of these two methods. This extensive study covering about five years involves 256 patients with 386 club feet in total gives an excellent overview of the impact of the two methods, as practiced at the Texas Scottish Rite Hospital for Children. Indeed, the evaluation of outcomes with an average patient age of 4.3 years gives a very good vision of the evolution over time, in particular with respect to relapses.

The French method was developed by Frédérique Bonnet in Montpellier, France, on the basis of the innovative approach of professor Bensahel in Paris. In Zurich, Switzerland, at the “Universitätskinderklinik” (University Childrens’ Hospital) both methods have been used for about six years. Physiotherapist’s training has been regularly monitored by Fédérique Bonnet from the “Institut Saint Pierre” near Montpellier, France. The choice of the treatment, Ponseti or French method, is made after presentation of both methods to the parents during a first meeting with the patient.

On the basis of our acquired experience, we practitioners believe that a few comments will be useful in furthering the understanding of the relative performance of the two methods. We will address issues of outcome measurement, sample selection, treatment procedures, and surgical intervention.

1. Measurement

While studies of idiopathic clubfoot correction dispose of valid and reliable measurement of the initial severity of the clubfoot with the Dimeglio scoring method, the evolution and the outcome, normally observed at four years of age, are more difficult to appreciate. In the study the outcome scale emphasizes the operative interventions required to achieve a “good” result, i.e. plantigrade. This measurement focuses on static corrections and does not pursue the functional dynamic quality evolving for the patient like foot length, muscular tonus and walking balance. Moreover, an evaluation by means of ambulatory analysis when the child is four years old would be appropriate.

2. Sample selection

Patients with previously untreated idiopathic clubfoot deformity were up to three months of age in the sample of the study. But according to our experience, the two methods differ as to the most appropriate time for the treatments to be implemented. The Ponseti method works well, even for children of two months or more, while the French method is intended to accompany and orient the early development of the foot. Though good results have been obtained even with late starters, the earlier the manipulations begin the softer and malleable the tissues and the gristle. Newborns and in particular premature patients are likely to have maximum benefit from the French method when treated within 48hours from birth. The age of the patient could therefore be an important parameter in the achievement of good outcomes. This potentially has an impact on the choice of the method, as some parents may be able to start treatment only after a couple of weeks.

3. Treatment procedures

The Ponseti method has the characteristic of being relatively easy to learn and it can be implemented by several professionals intervening successively on a case. In several respects this constitutes an advantage in the flexibility of implementation. While the treatment by the Ponseti method is weekly, the French method requires daily manipulation, i.e. four to five times a week during the two first months. This entails special commitment from the parents and availability, in particular with respect to transportation and distance concerns, as mentioned in the study. Also, there is need for parental intervention in the treatment procedure. The taping is critical, this operation should probably not be performed by non-professionals for good results. Instead parents have a key role in following up the treatments in particular for abduction orthosis or splints to maintain the corrected position and avoiding relapses.

In comparison, the two treatments require highly qualified personnel, but the effectiveness of the French method is more critically dependent on the quality of the professional training of the therapists in paediatric development. Further to this, it is definitely preferable that the whole French functional treatment for each child be carried out by just few therapists. Too many hands will not provide the possibility of properly following the foot development.

The overall development of the patient is not mentioned though it is a factor that deserves attention. Indeed, one of the advantages of the French method is that it leaves a large freedom of movement to the child as opposed to the Ponseti method that is essentially static. Children suffering other disabilities, including neurological disorders like cerebral palsy have particular advantage from minimal interference with their overall mobility.

4. Surgical interventions

The experience accumulated with the French method in Zurich and Montpellier suggests a major difference with the data presented in the study. Treatment during the three first months of the newborns gives overall good to very good results. A thorough evaluation of the patient in the third to fourth month has led to decide for tenotomy in some cases only, in a preventive way. On the basis of this protocol, surgical interventions and posterior release in particular were not required in our experience.

5. Concluding remarks

The above comments are intended to complement the comparative study with some of our questioning based on the experience accumulated in the Zurich and Montpellier regional context. The study has shown that the two methods offer overall good results with a slight advantage to the Ponseti method. This seems at least partly related to the measurement of the outcomes.

We would further like to emphasise that in our experience the Ponseti method can achieve superior results when children are older than a couple of weeks, while the French functional method is most efficaceous for newborns, and generally yields good results without tenotomy. In all cases, the professionalism with which the treatments are carried out and the commitment of the parents in the process were found to be important determinants of success.

Finally, it is particularly encouraging for the wider diffusion of these treatment methods that independent centres like Zurich’s “Universitätskinderklinik”, Montpellier’s “Institut Saint Pierre” and Dallas’ Scottish Rite Hospital for Children have evolved very similar practices and converging experience with most satisfactory outcomes.

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families 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 authors, or a member of their immediate families, are affiliated or associated.