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The work of a lifetime has become a crusade to change the way orthopedic surgeons correct congenital clubfoot. Armed with 50 years of successful outcomes and the support of a few colleagues and scores of thankful parents, Ignacio V. Ponseti, MD, an 85-year-old orthopedic surgeon at the University of Iowa Health Care in Iowa City, has set off on the lecture circuit, hitting medical conferences and major teaching hospitals worldwide to promote a nonsurgical, low-cost treatment for correcting clubfoot deformity.
"It’s my hope that vehicles such as these classes and the new Web site launched by the University of Iowa Health Care will inspire other physicians and parents to more actively and vocally promote nonsurgical treatment for clubfoot," says Ponseti. "Ultimately, each child with clubfoot should have the least traumatic and most effective treatment possible." (See box on p. 6 for Web address and other resources on treatment of congenital clubfoot.)
The Ponseti Method for clubfoot treatment is a nonsurgical procedure that begins with the orthopedist’s understanding of foot anatomy mechanics, says Ponseti. The technique involves manual manipulation and straightening of the foot and the application of toe-to-groin plaster casts. The casts are changed weekly in the outpatient setting after the clinician manipulates the softened foot ligaments to gradually achieve near normal muscle and bone alignment. Five or six cast changes spaced one week apart are sufficient to correct most clubfeet.
The bones of an infant’s feet are mostly cartilage, making the foot easy to manipulate without any pain to the infant. Roughly 80% of the children must have their Achilles tendon severed with a thin, cataract knife using local anesthetic after the third or fourth cast is removed. "It is very difficult to release the heel chord by stretching alone. In infants this young, the tendon regenerates to the proper length in a few weeks with no lesions. After the tendon is severed, a last cast is applied that remains in place about three weeks," says Ponseti.
After the last cast is removed, the infant must wear shoes attached to a metal splint full-time for about two months followed by nighttime-only wear for anywhere from two to four years to prevent the correction from reversing itself. "You have some families who will not comply with the brace. Not everyone is going to faithfully continue to put the brace on every night. You have to make families aware that the brace is an important part of the entire treatment. The alternative is reversal of the correction and surgery," says John E. Herzenberg, MD, associate professor of orthopedic surgery at the University of Maryland Medical School in Baltimore.
Herzenberg began using the Ponseti Method three years ago after 10 years of performing the traditional invasive procedure used by 98% of orthopedic surgeons for clubfoot correction. "I had dinner one night with a friend who works with Ponseti at the University of Iowa. Every orthopedic surgeon has heard about the method, but no one really believes it works. My friend told me it really did work and I trusted him. Then, Ponseti wrote a book that describes the procedure in detail and I read it three times before deciding to try the method on my own patients."
Looking back on correction
In a recent review of the first patients he treated with the Ponseti Method, Herzenberg compared 12 patients treated with Ponseti’s Method to 12 patients treated with traditional invasive surgery. "Only one patient in the Ponseti group required a follow-up surgery to provide further correction, compared to 11 out of 12 of the patients treated with traditional surgery," he says. However, the reason he’s decided to make Ponseti’s Method his standard treatment for congenital clubfoot is the appearance and function of his patient’s feet. "Children treated with Ponseti’s Method have marvelous-looking feet that are strong and supple compared to the feet of children treated with traditional surgery. Those children tend to have feet that are stiff and not as strong."
Ponseti agrees. "The feet of children treated with surgery appear good in the beginning. The feet appear aligned," he notes. "But later, the feet become painful and stiff. The reason is that the ligaments of the foot are severed and replaced by scar tissue. Orthopedic surgeons are now seeing patients who are 30 or 40 years old who had surgical clubfoot corrections as children. Now these adults have painful feet and the surgeons are at a loss to help them."
Ponseti, Herzenberg, and the handful of other orthopedic surgeons worldwide who now regularly use the Ponseti Method to correct clubfeet have documented thousands of successful outcomes. In addition, because it is done on an outpatient basis, the Ponseti Method is much less costly than surgical correction. At the University of Iowa Health Care, the Ponseti Method costs $2,000 from start to finish compared to average surgical charges of $11,000 for the traditional procedure.
In addition, as many as 25% of children treated surgically require a second surgery later, which can cost as much as $25,000, note Ponseti and Herzenberg. "A number of children treated with the Ponseti Method, roughly 30%, require surgery to move a tendon from the inside of their foot to the center to straighten out the foot alignment. That is usually an inpatient surgery often done at about 2½ years, and parents should be aware of that possibility," adds Herzenberg.
Why have surgeons been so reluctant to adopt a method that is both cost-effective and produces such positive outcomes? One reason may be economics, notes Herzenberg. "I have a friend who works as an orthopedic surgeon in Israel. He introduced the Ponseti Method to his colleagues there at a medical meeting and one stood up and said, Why are you doing this? You’re taking away one of the last good operations we have!’ That may be part of the answer. I can’t say for sure. Personally, I’m willing to take a drop in my income if it means doing something good for kids."