Nonsurgical treatment is inexpensive, widely applicable, and effective

For decades, the only treatment for idiopathic congenital talipes equinovarus, commonly known as clubfoot, was surgery to adjust the tendons, ligaments, and joints in the foot and ankle. But the work of Ignacio V. Ponseti, MD, would change the lives of patients with clubfoot around the world.

Developing the Ponseti method
When Dr. Ponseti arrived at the University of Iowa in 1941, he was asked to review the results of clubfoot surgeries. He found that, as adults, patients often experienced foot stiffness, pain, arthritis, and limited mobility; many patients required additional surgery.

By studying stillborn infants with the condition, Dr. Ponseti found that the ligaments were wavy and could be stretched gently without damage. He found that a gradual repositioning to stretch the ligaments and remodel immature bones, held in place with a cast, would result in a normal foot after approximately one month.

Dr. Ponseti began treating patients with his nonsurgical method in the early 1950s. “You invite the foot to come back in the normal position,” he has said. “Already, the foot knows what this position is. It was in that position for the first half of the pregnancy. The foot was normal until then.”

Changing patients’ lives
Dr. Ponseti has successfully treated hundreds of patients with clubfoot throughout the years. One of his patients is now an avid runner who has participated in several marathons.

Another patient, Allison Mauck, had clubfeet when she was adopted from China at age three. Her condition was so severe that she faced possible amputation.

“When we first traveled to Iowa, I thought Allison’s case was unique, because she was older and had been walking on her uncorrected feet,” said her mother. “I saw first-hand many families, even from the United States, whose children had gone through surgeries since they were newborns, and still had uncorrected feet.”

Over the course of three months, Allison had her casts changed by Dr. Ponseti every four or five days. “I felt like I was witnessing a miracle unfold one cast change at a time,” said her mother. After the serial casting was completed, Allison still required a tenotomy. Months later, due to relapses, an anterior tibial tendon transfer was performed on both feet, and an osteotomy of the tibia was performed on the right side to bring Allison’s foot back to the proper position. “She has +20º dorsiflexion on the left foot and +10º on the right foot where the osteotomy was done. She is now running, jumping, and doing everything again with no pain or limits,” said Ms. Mauck.

Teaching the Ponseti method
Dr. Ponseti and some of his colleagues—José A. Morcuende, MD, PhD; Stuart L. Weinstein, MD; and Frederick R. Dietz, MD—have done much to give children in the United States and in developing countries access to the Ponseti method. On a weekly basis, pediatric orthopaedic surgeons from around the world travel to the University of Iowa to learn the Ponseti method.

Dr. Morcuende has participated in and helped organize workshops on clubfoot treatment in more than 20 countries, and now serves as the president of the Ponseti International Association for Clubfoot Treatment, and as director of the International Clubfoot Project sponsored by the U.S. Bone and Joint Decade. Both organizations promote the use of the Ponseti method through education, research, and improved access to care.

Today, the technique is being used throughout Africa, Asia, Europe, and South America. According to Dr. Dietz, the Ponseti method is easy to adopt in developing countries because it is inexpensive and can be performed by allied health professionals in areas where doctors are scarce.

“I think it’s rare that the best technique is also the cheapest,” he said. “All the Ponseti method requires is the ability to put on a plaster cast and the education to do the manipulation properly. Of all the techniques for initial correction of clubfeet, it is the most effective.”

Establishing the new standard of care
When he retired from the operating room in 1984, Dr. Ponseti continued to treat clubfoot patients. He authored Congenital Clubfoot: Fundamentals of Treatment, which remains a major text on the subject.

By 2002, parents began spreading word of his technique on Internet message boards. In addition, the University of Iowa Health Care launched a media campaign that involved some of the parents whose children were treated with the Ponseti method. These educational efforts, paired with Dr. Ponseti’s presentations at national orthopaedic conferences, helped the Ponseti method gain acceptance, as have the positive long-term study results.

“There has been a major turnaround, no question,” Dr. Ponseti has said. “Many colleagues who used to doubt the technique now realize it is best for the children and that traditional surgery has not produced the best possible long-term outcomes for these kids.”

Matthew B. Dobbs, MD, a Ponseti-trained orthopaedist, acknowledges that some surgeons are still apprehensive about adopting the Ponseti method.

“The technique is rapidly becoming the gold standard,” he said, “but, unfortunately, some still believe that surgery is the correct way to go, even though multiple studies from various centers have been published showing equally good results with the Ponseti method.”

Surgery may be used in some resistant cases. However, “the consensus is that the Ponseti method should be used initially,” said Dr. Dietz.

“I recently evaluated a patient who has had 17 surgeries for clubfoot,” said Dr. Morcuende. “In many cases, patients are in so much pain that they have considered amputation. If we could, in the next year or two, make sure that physicians understand that surgery is not the best option for clubfoot, that would be a huge accomplishment.”

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