International Clubfoot Symposium focuses on congenital defect

The International Clubfoot Symposium, held at the University of Iowa in September, brought together a diverse group of scientists, clinicians, and policy makers to advance the general understanding of clubfoot, a common condition that affects approximately one per 1,000 newborns.

More than 200 physicians and other healthcare providers from 44 countries attended the symposium to explore clubfoot research, patient care, and education. After the symposium, participants also received hands-on training in the Ponseti method, a nonsurgical method for treating clubfoot developed by Ignacio V. Ponseti, MD, that has increasingly won acceptance in the orthopaedic community as the standard of care for the condition.

50 years of successful outcomes
During the symposium, participants discussed successful corrections and a 50-year follow-up study of patients treated with the Ponseti method.

The study showed that most patients’ quality of life and foot function are the same as those of individuals without any foot deformities.

José A. Morcuende, MD, PhD, symposium director, has been on the faculty of the University of Iowa since 2001. He and his colleagues treat 120 to 150 clubfoot patients with the Ponseti method each year.

“We have a 100 percent correction rate,” said Dr. Morcuende. “I have only done one surgery in the last six years. That was a case of syndromic clubfoot that had a malformation, not a typical, idiopathic clubfoot. We do surgery for relapses on 2.5 percent of patients. It’s a minor surgery that doesn’t affect the motion of the foot—just the transfer of a tendon to improve the balance of the foot.”

A study performed by Matthew B. Dobbs, MD; Ryan Nunley, MD; and Perry L. Schoenecker, MD, showed that many patients who were treated with an extensive soft-tissue release have poor long-term foot function.

“When we studied young adults a minimum of 25 years after surgery, we found that many had multiple surgeries over the course of early childhood and adolescence to address residual deformities,” said Dr. Dobbs. “Over the long term, the feet were generally stiff, and patients had a high level of arthritis and a high incidence of pain. Patients treated with the Ponseti method have a much lower incidence of those problems.”

Research directions
According to symposium participant and Ponseti-trained orthopaedist Frederick R. Dietz, MD, clinical care of clubfoot and the etiology of the condition are two main issues that need more research.

“From the clinical standpoint, more research is needed on how to optimize the use of the brace the patient wears after serial casting is completed to avoid recurrence of clubfoot,” said Dr. Dietz. “We also need to look at the acceptance of the technique and the bracing in different localities and cultures around the world.”

James W. Hanson, MD, of the National Institutes of Health, and Margaret “Peggy” Honein, PhD, MPH, of the Centers for Disease Control and Prevention, both believe that the symposium did much to encourage clubfoot research.

“Few meetings have this spectrum of first-rate science spanning the entire translational research continuum—from basic research to epidemiological and clinical research, clinical trials, and policy discussions,” said Dr. Hanson. “The overwhelming data supporting the Ponseti method and the patient stories were powerful testimonials to the value of a comprehensive approach to an international problem, and a tribute to the contributions of an effective partnership between families and the biomedical research and healthcare communities. This was a real joy to witness.”

“It was an excellent opportunity for scientists to begin discussing collaborative research efforts with the potential to significantly contribute to our understanding of the causes of clubfoot,” said Dr. Honein.

According to Dr. Dobbs, if studies show that certain genes cause or predispose a person to clubfoot, physicians will be able to provide genetic counseling and tell families what their risk factors are for having a child with clubfoot.

“The ultimate achievement would be to identify what causes clubfoot and to find a way to prevent it from happening,” said Dr. Dobbs.

At the conclusion of the symposium, participants composed the “Iowa Clubfoot Declaration” (see below) to advance the efforts of the Ponseti International Association and other organizations to promote the Ponseti method as the gold standard for clubfoot treatment throughout the world.

To learn more about the Ponseti method and to contact the Ponseti International Association, visit www.ponseti.info

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

Iowa Clubfoot Declaration – “A Promise Made”
In view of the frequency, severity, clinical implications, treatment options, and public health significance, the undersigned declare that every child born with clubfoot in the world has the right to:

• Early and effective treatment by the best current practice—the Ponseti method
• Access to care, including services by a health care provider trained in the Ponseti method

To support the provision of these rights, the undersigned endorse the following:

• Every country should build the capacity for the early detection and treatment of clubfoot, including collection of data on the frequency, distribution and public health implications of clubfoot and other relevant disorders, and assessment of the impact of interventions and formulation of effective public policy.
• Every country should support and build capacity for the appropriate education of health care providers and the public on clubfoot.
• Every country should foster and encourage the development of family education and support organizations for early recognition and treatment of clubfoot.
• A global collaborative effort should be undertaken to ensure that the highest priority research and care objectives are achieved, including, but not limited to:

-epidemiologic research related to causes, mechanisms, risk factors and outcomes

-prevention research

-behavioral, social, and public policy research

-translational research, including clinical trials and outcomes, services, and systems research

-development of essential research infrastructure elements

-basic biomedical research