Commentary & Perspective

Commentary & Perspective on
"Factors Predictive of Outcome After Use of the Ponseti Method for the Treatment of Idiopathic Clubfeet"
by Matthew B. Dobbs, MD, et al.

Commentary & Perspective by
Jose A. Morcuende, MD, PhD, and Stuart L. Weinstein, MD*,
Department of Orthopaedic Surgery and Rehabilitation, University of Iowa, Iowa City, Iowa

Clubfoot is a complex deformity and its treatment is a matter of great controversy. In the last few years, there has been a renewed interest in the Ponseti method. This method, developed more than forty years ago, is based on manipulation and serial cast application, followed by a simple percutaneous Achilles tenotomy and the use of a brace at night and at nap time until the child is three to four years of age. Use of the Ponseti method at our institution has yielded excellent results in most patients.

Dobbs et al. have made a very important contribution to the orthopaedic community by providing evidence of the success of the Ponseti method at another institution and by studying the issue of noncompliance with regard to the use of a brace. The authors evaluated fifty-one consecutive patients (eighty-six clubfeet). Importantly, the study population included patients who had received previous unsuccessful nonoperative treatment with a cast elsewhere (41%) and patients up to the age of fifteen months. Notably, the demographic data suggested a socioeconomically disadvantaged population: 67% of parents had a high-school education or less, and 61% of the families had incomes of less than $20,000 a year.

The authors report correction of the deformity in all patients (100%) with an average of four casts. No patients required extensive corrective surgery. This is remarkable given the original severity of the deformities, the number of patients who had previous treatment elsewhere, and the age of some of the patients. These results should strongly encourage orthopaedic surgeons who are reluctant to treat these seemingly more challenging patients to use the Ponseti method.

We would like to make a few comments with respect to the treatment regimen. For a successful technique, it is very important that the child be relaxed during the manipulation and cast application. If treatment is started just after birth, this usually is not a problem. However, when the children are older, it is sometimes very difficult to distract them. Dobbs et al. have used general anesthesia in these cases. However, some risks may accompany the need for weekly general anesthesia. We have used conscious sedation with chloral hydrate very successfully.

The same concern can be expressed about the Achilles tenotomy. This is a very simple procedure that is very well tolerated by the patients. We perform it in the outpatient clinic with the patient under local anesthesia. We use EMLA cream and 1% lidocaine. A word of caution, however: very little anesthetic should be used because its use makes palpation of the tendon difficult, which makes the procedure potentially more hazardous.

Unfortunately, 41% of the parents in the study by Dobbs et al. were noncompliant with use of the brace, resulting in a relapse rate of 31%. Importantly, relapses were successfully treated by repeated manipulation and serial cast application, with only three patients requiring a posterior release. Two factors found in this study are significantly associated with relapses: bracing noncompliance and parental education level (high-school education or less). In our experience, however, there are also instances of families with very high levels of education who are also noncompliant. We recommend that every family, regardless of socioeconomic status, should be educated and advised on the importance of bracing.

The authors developed several strategies for follow-up of these high-risk families, including weekly phone calls, home nursing visits, and/or frequent follow-up clinical visits. These challenging cases are labor intense, but the children will benefit dramatically from the effort.

The authors are to be commended for bringing forward this valuable information. As more physicians practice the Ponseti method, we will see an increasing need for new educational programs and clinical follow-up strategies that improve compliance. In addition, new brace designs will be needed to replace the current device, which requires many adjustments for a proper fit.

*The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Copyright © 2004 by the The Journal of Bone and Joint Surgery, Inc.