By Emily Delzell
The shift away from aggressive surgery to correct clubfoot in now all but complete, according to research published in July in the Journal of Pediatric Orthopaedics (JPO). The study shows the Ponseti method is now the treatment of choice for the vast majority of practitioners and that increased understanding of the technique has resulted in better outcomes.
The JPO article reported on results of a recent survey of members of the Pediatric Orthopaedic Society of North America (POSNA) regarding their approach to clubfoot treatment. In the 11 years since the last such survey was done, use of the Ponseti method among responding practitioners rose from 65% to 97.6%.
Study lead author Lewis E. Zionts, MD, clinical professor of orthopaedics at the David Geffen School of Medicine, University of California-Los Angeles, noted, “It is a bit unusual for surgeons to move from an operative approach to a method that, for the most part, does not involve surgery.”
About 75% of responders said their approach to clubfoot treatment has changed since their residency or fellowship training. Zionts believes parents of children with clubfoot deformity, armed with information gleaned from the Internet, drove the change.
“As Internet access became increasingly available at the turn of the century, parents learned about less-invasive treatment options online,” he said. “On a number of occasions parents traveled to the University of Iowa from all over the country to have their babies treated by Dr. [Ignacio] Ponseti to avoid extensive surgery. Often, these infants would then be followed by local orthopedists who were able to directly observe the benefits of this technique. With time, more practitioners adopted the method.”
Zionts and colleagues reported what appears to be a better understanding of the Ponseti method among practitioners. The technique calls for a series of four to six manipulation and long leg cast applications, a heel cord tenotomy in most patients, and the use of a foot abduction orthosis to prevent relapse.
In the years since the last survey utilization of long leg casts increased from 79% to 98.7%. Postcorrection brace use also increased, from 85% to 99%, while the application of braces not traditionally used in the Ponseti technique—ankle foot orthoses and knee ankle foot orthoses—decreased by 50% and 7%, respectively. In addition, practitioners had children wear the brace longer: the age at which brace use was discontinued averaged 11 months in 2001 and 33 months in 2012.
Collectively, Zionts noted, these changes in practice are probably responsible for the dramatic drop in the number of children requiring extensive release surgery, from 54% in 2001 to 7% in 2012.
“At the moment, the Ponseti method is the state of the art for treatment of clubfoot, and no surgical treatment has proven to work as well,” said Norris C. Carroll, MD, professor emeritus of orthopedic surgery at Northwestern University in Chicago. “The main problem I see with the Ponseti method is maintaining the correction obtained in active kids who don’t like to continue wearing their brace.”
Zionts emphasized that practitioners need to encourage parents to adhere to postcorrective bracing protocols and noted, “Occasional relapses are expected, but they are easily managed with a short course of manipulation and cast application followed by resumption of bracing.”
Carroll recently authored an article on the past—and possible future—of clubfoot treatment in an edition of the Journal of Pediatric Orthopaedics dedicated to the condition and said that, along with other possibilities, advanced biomaterials that dramatically reduce the scar formation that make surgery problematic are becoming available.
Zionts LE, Sangiorgio SN, Ebramzadeh E, Morcuende JA. The current management of idiopathic clubfoot revisted: results of a survey of the POSNA membership. J Pediatr Orthop 2012;32(5):515-520.
Carroll NC. Clubfoot in the twentieth century: where we were and where we may be going in the twenty-first century. J Pediatr Orthop B 2012;21(1):1-6.