June 11, 2007

Treating Clubfoot Without Surgery
By Thomas G. Dolan
For The Record
Vol. 19 No. 12 P. 34

Refusing to toe the line, a St. Louis orthopedist has championed the noninvasive methods of 1950s pioneer Ignacio Ponseti.

One of the more amazing stories of modern medicine was almost waylaid by conventional thinking. Clubfoot in newborns has traditionally been treated by surgery, often with poor results. In the 1950s, Ignacio Ponseti, MD, professor emeritus of orthopedics and rehabilitation at the University of Iowa, pioneered a method for weekly casting and manipulation of the foot starting soon after birth. This method greatly reduced the need for extensive surgery and, as a result, improved long-term outcomes for clubfoot patients.

However, though Ponseti’s breakthrough gained a number of followers, it did not win wide acceptance in the medical community. When Ponseti retired, his treatment appeared to retire with him. Dismayed at seeing his cure destined to fade away, he came out of retirement at the age of 82 to promote his treatment. He is now aged 92 and still active.

“The use of Dr. Ponseti’s treatment for clubfoot has been one of the most exciting trends in the past 10 years,” says Matthew B. Dobbs, MD, assistant professor of orthopedic surgery at Washington University School of Medicine in St. Louis and a pediatric orthopedic surgeon at St. Louis Children's Hospital. “One of the problems with clubfoot is that even if there appears to be an initial success, if the treatment hasn’t been done correctly, the condition can reoccur. We now have the advantage of being able to follow Dr. Ponseti’s patients for 40 to 50 years. As adults, they are functioning extremely well with flexible and pain-free feet.”

According to Dobbs, clubfoot occurs in roughly one in every 1,000 newborns, with nearly one half having bilateral clubfoot (both feet having the deformity).

Clubfoot, which affects boys twice as much as girls, affects the bones, muscles, tendons, and blood vessels. The foot is usually short and broad in appearance, pointing downward with the toes turned inward and the foot bottom twisted inward. In addition to the foot, the muscles in the lower leg are not as large as usual and will not develop correctly. Also, the joints in the ankle are less flexible, restricting mobility.

The misshapen bones make the foot stick in its clubfoot position. If left untreated, the child will walk on the outer edge of his or her foot, which causes the forefoot to take on a clubbed appearance and makes shoes difficult to wear.

Although clubfoot can occur with other birth defects, most children born with clubfoot have no other congenital problems. However, babies born with clubfoot may also be at an increased risk of having an associated hip condition, known as developmental dysplasia of the hip, in which the top of the thigh bone (femur) slips in and out of its socket because the socket is too shallow.

The causes of clubfoot are uncertain, Dobbs says, but there are several theories, including the following:

• The baby’s foot stops growing at a certain point before birth.

• There is pressure on the baby’s foot in the mother’s womb.

• One of the bones in the foot does not form correctly, causing the rest of the foot to grow crooked.

• Some of the muscles in the foot do not form normally and cause the bones to grow crooked.

• It is inherited.

“Prevention of clubfoot is not possible, and it is unlikely that anything the mother did during pregnancy could cause clubfoot,” Dobbs says. “Fortunately, we have an extremely high success rate for correcting clubfoot using the Ponseti method for a nonsurgical correction.”

In the Ponseti method, as soon as possible after birth, the doctor prepares a cast for the child’s foot. The treatment involves weekly stretching of the foot deformity, followed by the application of a long, plaster leg cast. The cast is changed every one to two weeks, and patients generally go one week with it on and one week with it off, with foot stretching and massaging in between. The deformity is usually corrected in five to six weeks.

Before the application of the final cast, the physician usually performs a tenotomy, a noninvasive surgery that lengthens the Achilles tendon. Then, the child wears a cast for three weeks to allow the tendon to heal, followed by a corrective brace that must be worn full-time for three months. After that, the child still must don the brace when sleeping during the next three to four years.

“I explain to parents that clubfoot correction is 2% in our hands and 98% in theirs,” says Dobbs. “The parents are doing the bracing for several years, and if they don’t put the brace on the child, the clubfoot will recur. If we get a recurrence, at a minimum, repeat casting is required and, worst case, a major clubfoot release surgery.”

The Pediatric Foot Clinic at St. Louis Children’s Hospital has made two enhancements to the Ponseti method. The first is that the clinic instructs parents in the science of stretching and exercising their child’s feet to improve the ankle’s mobility. Ponseti was the first to describe the intricate dynamics of the foot and ankle muscle and tendon interrelationships, out of which emerged practical stretching techniques that can be learned by parents, thus allowing them to apply an ongoing therapy without the need of a doctor.

Also, a study conducted by Dobbs showed that a major hindrance to compliance was the type of brace used. The brace’s metal bar prevented children from moving each leg independently, and the hard leather orthopedic shoes attached to the bar often didn’t fit tiny feet, causing blisters on the back of the child’s heels.

“Wearing the brace often caused children to become frustrated and fussy and start crying,” says Dobbs. “The parents then tended to take their child out of the brace, which is understandable. However, once the brace is removed, it’s harder to get the child back into it.”

To remedy these problems, Dobbs developed a new type of brace with a dynamic bar that allows each leg to move independently. The Ankle Foot Orthosis features a customized, soft plastic mold of the child’s foot that is placed inside the shoe for a perfect fit.

“This new, patented brace has resulted in our compliance rate increasing to 98%,” says Dobbs. “This compares to a paper we published on the use of the traditional brace which showed up to a 40% noncompliance rate.” Compliance is critical, he adds, since that means there’s more than a 95% chance nothing else will need to be done to the feet.

Dobbs, who studied under Ponseti, has adapted his mentor’s methods of the treatment of congenital vertical talus (CVT), or rockerbottom flat foot. Less common than clubfoot, this deformity occurs in approximately one in 10,000 newborns. Left untreated, the patient would walk on the inside of the ankle rather than the bottom of the foot. This is the opposite of clubfoot.

As with clubfoot, treatment for CVT involves gently manipulating the foot and applying long leg casts weekly for four to six weeks to gradually correct the deformity. After the casting period, an x-ray is taken to determine the success of these efforts.

“Much of the correction is achieved with casting alone,” says Dobbs. “In the cases where we are not able to reach full correc-tion with casting, we reach the rest of the correction with a minimally invasive surgery. This type of surgery is very small compared to the extensive release surgery that has been done in the past.”

In the minor surgical procedure, Dobbs inserts a small pin into a joint in the foot where it meets the ankle to hold the correct position for roughly two months. After the casting treatments or surgical pinning, CVT patients wear a nighttime brace for several years to prevent recurrence. (Details about the treatment of 11 CVT patients are discussed in the March issue of The Journal of Bone and Joint Surgery [JBJS].)

Dobbs explains that the difference between his method and past casting techniques is the way forces are applied to the foot and the casts are molded. “What has previously been lacking in any cast treatments for CVT is a lack of understanding by orthopedists as to how the joints in the foot move and work together,” says Dobbs. “Now, thanks to the work of Ignacio Ponseti, we do have a better understanding of the mechanics of the foot and ankle, which has made it possible to figure out how best to gradually correct the deformity in CVT.”

Dobbs adds that he hopes to refine his technique so even minor surgery will be unnecessary. “Our ultimate goal is that our new, minimally invasive treatment for CVT will result in better long-term outcomes for patients, just as the Ponseti method has done for clubfoot,” he says.

Long-term follow-up studies have shown favorable results after clubfoot was treated with serial manipulations and casts, Dobbs says. Among those was one conducted by Ponseti on 45 of his patients. “However, we were not aware of any long-term follow-up studies of patients in whom clubfoot was treated with extensive surgical soft-tissue release,” says Dobbs.

So Dobbs and a colleague, Ferry Schoenecker, MD, the orthopedic surgeon-in-chief at St. Louis Children’s Hospital, examined 45 patients who underwent surgical correction of clubfoot over a minimum of 25 years. Their results, published in the May 2006 issue of JBJS, show that many of these patients had poor long-term foot function.

“We found a correlation between the extent of the soft-tissue release and the degree of functional impairment,” explains Dobbs. “Our study showed that repeated soft-tissue releases may result in a stiff, painful, and arthritic foot, significantly impairing quality of life. This is the first comparison available with this length of follow-up that enables us to compare surgery with the casting method.”

Dobbs adds that not all flat feet are the same. Many who have it in childhood grow out of it. The difference is between rigid and flexible fIat feet. “It used to be that just having flat feet kept you out of the military, but now it’s better understood,” says Dobbs. “The one category that may create a problem is if there is an associated tight heel cord.” He adds that while the Ponseti method for treating clubfoot is focused on infants, it may still be helpful for adults.

When asked why this method of treatment has been so slow to catch on in the medical community, Dobbs replies, “It’s the surgical mindset. It’s the way doctors have been taught. They often haven’t thought that any other way was possible.” Also, Dobbs says there have been many surgeons who believed in casting, but their techniques were flawed. Unlike a drug, in which all the components are easily replicated, the implementation of the Ponseti techniques were perfected over time and require skill, training, and experience.

Currently, Dobbs is one of a handful of specialists with the required expertise. “We’re now seeing unqualified physicians claiming to perform this method,” says Dobbs. “In fact, we are receiving more and more patients who have been treated elsewhere with a poor result.”

Dobbs notes that the Pediatric Orthopedic Society of North America already endorses the Ponseti method as the standard of care, and it has been adopted into the national healthcare initiatives of many other countries.

— Thomas G. Dolan is a medical/business writer based in the Pacific Northwest.