Residency Insight -- A PRESENT Podiatry eZine

The Ponseti Method Revisited

Ryan Fitzgerald, DPM
PRESENT RI Associate Editor
Hess Orthopedics &
Sports Medicine
Harrisonburg, Virginia

Clubfoot is one of the most common congenital deformities of the foot, occurring in up to 1 per 500 live births in the United States.^1,2 The deformity can present in an otherwise normal infant, but is frequently associated with poliomyelitis, meningitis, cerebral palsy, spina bifida, amniotic band syndrome, and myelomeningocele. The classic pathoanatomy consists of forefoot adduction, rearfoot varus, and rearfoot or ankle equinus. In the affected foot, the muscles and tendons of the flexor compartment are shortened, the girth of the calf is smaller, and the foot is shorter than the contralateral limb.

The goal of treatment is to reduce all of the components of the deformity so the child will have a pain-free, plantar-grade, and mobile foot, without the need to wear modified shoes. Until recently, surgical management, with the posteromedial release or a circumferential incision being the most frequently used, was the treatment of choice. However, the most successful results have not always been achieved from the most extensive surgical approaches. Long-term follow up shows the results of early surgical treatment of clubfoot to be substandard. The patients experienced increasing foot pain, disability, stiffness, weakness, and premature arthritis.^3,4,5,6 These results may be due to the formation of scar tissue, surgical damage of the small articular joints, or weakness from over-lengthening of multiple tendons.⁷ Furthermore, up to 47% of clubfoot patients undergo one or more revision surgeries.⁸ Comparatively, non-operative treatment with the Ponseti method yields satisfactory functional results in 89% of feet.⁹ Long-term follow up of 30 years shows excellent or good functional outcomes in 78% of patients, compared with 85% of control(normal) patients without clubfoot. Furthermore, the Ponseti method can also be used successfully in children up to ~2 years of age when no previous surgical treatment has been attempted.

Dr. Ponseti’s nonoperative approach proposes gentle stretching and manipulaion followed by cast immobilization allowing for relaxation and further softening of tissues and atraumatic remodeling of the abnormal joint surfaces. The Ponseti method corrects all components of the deformity simultaneously, with the exception of equinus, which is corrected last. The varus, which results from pronation of the forefoot in relation to the rearfoot, is corrected together with the adduction by supinating and abducting the forefoot in proper alignment with the rearfoot. The entire foot can be abducted gently and gradually under the talus. Heel varus will correct when the entire foot is fully abducted under the talus. Five or six cast changes are sufficient to correct most clubfeet, with each cast generally being maintained for 5-7 days. A percutaneous tendoachilles lengthening is often performed in the office, using EMLA, prior to the final cast, which is maintained 2-3 weeks. At the completion of the casting the foot will appear overcorrected allowing for 70 degrees of external rotation and at least 15 degrees of dorsiflextion. The correction can be maintained by fulltime wear of a foot-abduction brace, such as the Denis-Browne splint, for 3 months and night wear for approximately 2 to 3 years.¹⁰

After correction with the Ponseti method, noncompliance was the factor most related to the risk of recurrence.⁹ Results demonstrate that the prevalence of recurrence is not dependent on the initial severity of the deformity, the age at the initiation of treatment, or whether the patient had treatment with a cast before referral.

The Ponseti method is a safe and effective nonoperative treatment for idiopathic clubfoot that prevents infants and children from undergoing unnecessary surgery. Because of the unsatisfactory results after surgical soft-tissue releases at 10 to 15 years of follow-up and the long-term success reported with the Ponseti method, efforts are being made by the American Association of Orthopaedic Surgeons to abandon the standard surgical protocol for congenital idiopathic clubfoot. Hopefully, this will encourage both orthopedic and podiatric physicians to replace their treatment protocols. As Dr. Ponseti once said, "Orthopaedic surgeons are generally less willing to cast-out deformities than are podiatric surgeons, since casting is more time consuming and may pay less, but the outcomes using the Ponseti method are consistently reliable." Podiatric surgeons need to take advantage of this method’s success and be confident that they have the power to successfully correct this challenging multiplanar deformity.

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References:

Ponseti IV. Congenital clubfoot: fundamentals of treatment. New York: Oxford University Press, 1996.
Herzenberg J, Lamm H. Altering how the foot is manipulated before casting may obviate surgical correction. Biomechanics October 2005
Green AD, Lloyd-Roberts GC. The results of early posterior release in resistant club feet: a long-term review. J Bone Joint Surg 1985;67-B(4):588-593.
Hutchins PM, Foster BK, Paterson DC, Cole EA. Long-term results of early surgical release in club feet. J Bone Joint Surg 1985;67-B(5):791-799.
Kite JH. Principles involved in the treatment of congenital club-foot. J Bone Joint Surg 1939;
21-A:595- 606.
Aronson J, Puskarich CL. Deformity and disability from treated clubfoot. J Pediatr Orthop
1990;10(1):109-119
Ponseti IV. Clubfoot management. J Pediatr Orthop. 2000;20:699-700.
Vizkelety T, Szepesi K. Reoperation in treatment of clubfoot. J Pediatr Orthop. 1989;9:1441-147
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(2):376-380.
Ponseti IV. Congenital Clubfoot: Fundamentals of Treatment. Oxford England: Oxford University Press: 1996.

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