The Ponseti method is
fast approaching the status of being the mainstream method of clubfoot treatment. This
minimally invasive, incredibly effective protocol was relatively obscure less than a decade ago, although it has been used
successfully at the University
of Iowa for half a century. The general
public’s ability to obtain clubfoot treatment information on the internet, and the conversion of some of the world’s
top pediatric orthopaedic surgeons, have contributed significantly to this change in tide from surgical-oriented correction
to non-surgical correction.
Unfortunately, the term “Ponseti method” has become a buzzword
or “catch phrase” within the orthopaedic community, and, as such, is sometimes misused. Many doctors claim to be using the method, when, in fact, they are not following the protocol exactly. It can be difficult to determine what is and what is not standard protocol in the
true Ponseti method without doing personal research. The following general guidelines
can be used by the parent or guardian to initially screen doctors. Variations of the questions below can be used to determine
whether or not the physician is following the Ponseti method exactly as it was developed by Dr. Ponseti and his colleagues
at the University of Iowa, or if the
physician has “tweaked” the method or is only using parts of it. Even small deviations can dramatically reduce
its effectiveness.
Please note that doctors who are listed on the University
of Iowa’s qualified physicians list (http://www.uihealthcare.com/topics/medicaldepartments/orthopaedics/clubfeet/physicians.html) are not necessarily using Dr. Ponseti’s method as it was developed. They are not tracked to ensure that they continue
to have successful results with the method. Having been to Iowa, or training
under Dr. Ponseti himself, is not necessarily a guarantee of a physician’s success in using the method. Even when a
physician is listed, parents should still take on the responsibility of questioning them about their philosophy of treatment,
technique and results. Any deviations from the expected answers to the following questions should raise a warning flag that
further research is called for.
1) "What kind of casts do you use?"
Long (toe-to-groin) leg casts are always used. Casting material is preferably
plaster, not fiberglass, though some older children might receive a plaster cast with fiberglass overlay for added strength.
2) “On average, how long does it take to achieve correction, and how frequent are casting appointments?”
Complete correction should be obtained with an average of 5 to 7 casts, changed every 5-7 days. No more than 9 casts
should be required except possibly in cases complicated by such conditions as arthrogryposis.
The cast should not be removed the night before the appointment. If a
foot is left without a cast for just a few hours, some or all of the correction obtained can be lost.
3) “Are any surgical procedures required to complete correction?”
Most cases (about 80%) require a lengthening of the Achilles tendon with a procedure called a tenotomy. The Ponseti
method uses a percutaneous tenotomy only. It is a quick procedure (10-15 minutes
start to finish), usually done in the office/clinic with local anesthesia. A
scalpel is inserted into the back of the heel. No stitches are required to close the puncture, and the resulting mark is small,
like a pinprick. If a doctor conducts the tenotomy under general anesthesia,
which is not typical, make sure that the procedure will be a simple percutaneous tenotomy and not a more extensive procedure
(an open-incision release). The post-tenotomy cast is left on for 3 weeks to
allow the tendon to heal. All other aspects of the clubfoot should have been
corrected prior to the tenotomy, so, once the post-tenotomy cast comes off, the foot should be completely corrected.
4) “What percentage of your patients require surgical reconstruction or major release types of procedures
for correction?”
If a doctor
is using the Ponseti method successfully, he or she should have at least a 90 percent success rate (hopefully even higher)
stated up front. Almost all of his/her patients should be completely corrected
using casting and percutaneous tenotomy procedures only. You should ask how long
the doctor has been using the method exclusively, how many patients he or she has treated with the method and what percentage
of those patients have been successfully corrected without any release type of surgery (posterior medial release etc.). The doctor may be able to tell you what their non-surgical success rate was prior
to converting to the Ponseti method of treatment for comparison.
5) "What kind of bracing is used
after correction is obtained?"
After the last cast is removed, immediate use of the foot abduction brace (FAB, also known as Denis Brown Bar or DBB)
is expected. Standard protocol is for the child to wear the foot abduction brace
for two to three months full-time (23 hours/day), and then at night-time and naps (16-18 hrs/day), eventually down to about
10-12 hours/day until the child is 4-5 years old. No AFOs (ankle-foot orthotic)
or other devices are used for bracing in this method. The risk of relapse is greatest until age 4 or 5. You can ask the doctor about the percentage of their patients that have relapsed, and what protocol
is used to treat relapses.
6) "What should I expect the foot to look like during correction and afterward?"
There should be a dramatic improvement at each cast change. By the last cast, the foot will be set at an outward (external)
rotation of 70° (it will look extreme; initial overcorrection is intentional). The rotation of the shoes on the brace should
match this 70° angle. Using an abduction angle less than 70° is not acceptable. There are documented studies from the
University of Iowa showing that the risk of relapse is much higher if the foot is abducted to a lesser angle (see the medical
paper/journal section). Additionally, for those relapse cases, the need for more-invasive surgical correction is higher.
The foot will be completely corrected before going into the brace. There should be no claim that the brace will accomplish
further correction.
Other indicators that a doctor is committed to the Ponseti method:
-
A sense of urgency and willingness to see your child right away
-
No "wait
and see" approach; instead, a confidence that the method will work, and that major surgery will not be needed
-
No "breaks"
from casts or taking them off the night before appointments
-
Manipulations
during casting shouldn't be painful
-
X-rays
generally not taken
-
Close collaboration
with a dedicated orthotist, who will fit and prepare the child for immediate use of the brace after the last cast is
removed and provide continuing support thereafter
See the
Global HELP organization's booklet for details on the Ponseti method protocol http://www.global-help.org/publications/books/help_cfponseti.pdf
When calling a hospital/clinic to arrange an appointment for your child, many times the receptionist who answers the
phone and schedules appointments does not realize the urgent nature of clubfoot treatment. To avoid having to wait
weeks (or months) to see the doctor, you might want to ask to speak with the physician's nurse, assistant, casting technician,
or the physician directly. These individuals understand the need for immediate care and will get your child in
as soon as possible.
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