More than 50 years ago, Ignacio Ponseti, MD, developed a nonsurgical method to correct clubfoot in infants through gentle manipulation of the feet followed by the application of plaster casts. He practiced and refined the technique at the University of Iowa, where he served in the department of orthopaedics from his arrival in 1941 until his death in 2009.
Today, the Ponseti method is widely recognized as the most effective treatment for clubfoot, achieving correction in more than 90 percent of patients. Its popularity is due, in part, to the facts that it can be readily taught, is relatively inexpensive, and relies on easily obtainable materials.
These factors are important because most of the children born with clubfoot, a congenital condition in which one or both feet are twisted down and inward, live in developing nations. Without treatment, afflicted individuals appear to walk on their ankles or the sides of their feet, resulting in great pain and limiting their ability to work or be economically independent.
At the International Presidents’ Breakfast and World Opinion Forum, held during the 2013 AAOS Annual Meeting, attendees heard about the approaches to clubfoot treatment, particularly the application of the Ponseti method, in countries as diverse as Brazil, China, and Pakistan. In addition, José Morcuende, MD, of Ponseti International, reviewed how national orthopaedic organizations could become involved in establishing a high-quality, locally owned, sustainable clubfoot program.
The importance of training
Speaking on video from Brazil, Monica P. Nogueira, MD, discussed the impact of the Ponseti method in her country. She noted that the first 2-day training session was held in 2003, and within 2 years, those trained in the method were achieving positive results in 95 percent of cases.
As of 2009, the Brazilian Ponseti Study Group had trained 567 professionals in 21 states. This number represents approximately 7 percent of the 8,000 orthopaedic surgeons in Brazil. A recent review of the results, however, showed that few surgeons were properly applying the method, which is more than just a series of casts.
As a result, a new instruction methodology is being implemented, one that relies more heavily on an intense mentorship and the establishment of clinics staffed by healthcare providers who have gone through a 2-week, rather than a 2-day, training program.
A public health approach
Li Zhao, MD, PhD, of Shanghai, China, reported that taking a public health care approach may help overcome some of the barriers to widespread adoption of the Ponseti method in countries in which surgeons are accorded higher status than other healthcare professionals “because they cut.” As part of this approach, reimbursement for Ponseti treatments is equivalent to that for surgeries.
In China, an estimated 18,000 children are born with clubfoot each year. In rural areas, especially, noted Dr. Zhao, some surgeons view the “hands-on” treatment required by the Ponseti approach as beneath them. They have gone through so much schooling and training to become surgeons and they fear that their status as surgeons will be diminished if they focus on nonsurgical treatments.
To overcome this attitude, China has developed a national project, “Healthy Walk,” which focuses on the early recognition and treatment of clubfoot. The hope is that viewing clubfoot treatment as a public health effort will encourage the adoption of the Ponseti method across the country.
According to Mansoor A. Khan, MD, who practices in Karachi, Pakistan, one of the significant appeals of the Ponseti method in developing countries is its low cost. In many countries, patients must bear the costs of surgery themselves, even providing their owon food. For these individuals, the lower costs of the Ponseti method can help encourage them to seek treatment.
Dr. Khan, who works at a private hospital that provides free care, noted that the costs to patients undergoing treatment for clubfoot using the Ponseti method are substantially less than the costs incurred when surgical treatment is used ($349 versus $816). In addition, he said, “the Ponseti method has a higher success rate than surgery.”
The role of professional associations
Dr. Morcuende encouraged members of the audience—all presidents of national, regional, or multinational orthopaedic associations—to get involved in supporting training and practice of the Ponseti method in their countries. He recognized the uphill battle that some might face, because the Ponseti method, like the polio vaccine, eliminates the need for surgeries.
“It can have a tremendous impact,” he said, “but change doesn’t happen just because something works.” The care pathway for clubfoot treatment—identification, referral, diagnosis, treatment, and follow-up—depends not only on training providers and supplying materials and staff, but also on policy awareness.
National orthopaedic associations, he pointed out, are key in creating that policy awareness. Adopting position statements that support the use of the Ponseti method, making the case to healthcare administrators, health ministries, and the media, and institutionalizing training of the Ponseti method in medical education are all ways in which national orthopaedic associations can make a difference.
Other presentations during the forum included the following: Otto Robertsson, MD, PhD, on the website arthroplastywatch.com; Rick Wilkerson, DO, on efforts to reestablish a national orthopaedic association in Libya; and Jose Sergio Franco, MD, providing an update from the Sociedad Latinoamericana de Ortopedia y Traumatologia(SLAOT). William B. Stetson, MD, chair of the AAOS International Committee, moderated the discussion.
This article adapted from the Daily Edition AAOS Now, March 22, 2013.
Mary Ann Porucznik is managing editor, AAOS Now. She can be reached at email@example.com
Guest Nation Presentation: IPV
The AAOS 2013 Guest Nation, Canada, was also recognized during the meeting. Geoffrey H. Johnston, MD, president of the Canadian Orthopaedic Association (COA), provided an overview of orthopaedic services in Canada. Dr. Johnston noted that a drive to recruit more medical students to orthopaedic programs to shorten wait times for patients has resulted in an ironic situation—lots of training programs and residency slots, but few jobs.
Recognizing that one third of Canada’s current orthopaedists are age 55 or older, the COA is developing transition models—agreements between older and younger surgeons that not only enable the older surgeon to retire gracefully but also assure the younger surgeon of a position and patient base. The COA is also introducing care models to ensure quality care for patients. To date, two models have been released—arthroplasty and hip fractures.
A significant initiative of the COA is reducing the incidence of intimate partner violence (IPV). According to Mohit Bhandari, MD, “Every 15 seconds, somewhere across the globe, a woman is beaten. The economic cost of partner abuse is staggering—more than $50 billion each year.”
The COA recognizes that IPV is a significant social determinant of morbidity and mortality, and that orthopaedic surgeons are well positioned to identify patients living with IPV and initiate an intervention. A multicenter study of 282 injured women, however, found that 24 had experienced IPV within the previous year, but only 4 had been asked about IPV by a physician, and none had been asked about IPV by the treating orthopaedic surgeon.
“National orthopaedic associations need to align their position statements in opposing IPV,” said Dr. Bhandari. “We need to educate ourselves and our colleagues, participate and publish research on the topic, and develop tools to help identify victims of IPV. She’s our patient—and that makes this our issue.”