Long Term Outcomes in the Ponseti method

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This is a reprint of a prior message about the Ponseti " Non-Surgical "

method of treatment. This message was originally written about 2

years ago but has some details on the long term outcome studies done

at the U of Iowa on Ponseti method children treated at the U of Iowa

in the 1950's and 1960's.

Here is some information relating to reported long, long term

outcomes into adulthood in the Ponseti method. Please realized that

I am a parent and not a doctor, that the treatment of clubfoot is

still a controversial issue among doctors and that many doctors may

still not agree with the use of the Ponseti method. That being said,

I think that it is important for new parents to be aware of all

alternatives available to them as they are making decisions regarding

the treatment of their own child.

An Instructional Course Lecture on Clubfoot in the Feb 2002 issue of

the Journal of Bone and Joint Surgery (JBJS). The following excerpts

are from that 23 page article called " Congenital Clubfoot " An

Instructional Course Lecture, American Academy of Orthopaedic

Surgeons are as follows:

" The literature from about 1970 to 1990 contains enthusiastic reports

on the correction of congenital clubfoot through extensive surgical

release procedures. Over time, we have come to recognize the

complications of such surgery, including recurrence, overcorrection,

stiffness, and pain. Perhaps because of these findings, there seems

to be a renewed interest in nonoperative techniques for the

correction of congenital clubfoot. Recent studies have documented the

effectiveness of the two leading techniques involving serial

manipulation and cast treatment. The Ponseti technique appears to be

effective and requires only a reasonable amount of time out of the

lives of the patient and his or her parents. The technique frequently

includes some minimal invasive surgery. The Kite and Lovell technique

requires minimally invasive surgery less often [avoiding things like

a tenotomy] but is more time-consuming. " [Elsewhere in the report,

they state that the Kite method takes an average of 22 months in long

legged casts and also that the Kite method uses a Phelps splint which

is worn until the age of ten years to help prevent relapsing.

Although there may be some somewhere, I have yet to hear of any

doctor that is still using the original 22 month Kite method. I have

talked to a Dr. who was a student under Dr. Wood Lovell (Kites

Partner) who said that there is no one he is aware of who still uses

the original Kite method]

" French investigators and others have introduced new ideas that may

reduce the need to immobilize the foot. The French approach requires

fairly extensive physical therapy and demands substantial parental

time and attention. It is not yet clear that the French technique is

more successful in obviating the need for surgery than is expertly

applied serial manipulation and cast immobilization. It also has not

been proved that the long-term results of the French technique are

better than those of serial manipulation and cast immobilization. It

is probable that unless the French technique is found to

substantially decrease the need for surgery, it will prove to be less

cost-effective than serial manipulation and cast immobilization. "

" It is likely that a small number of clubfeet will require surgery

even after expertly applied nonoperative treatment. However, it is

hoped that such surgery will be less extensive than procedures

commonly performed in the recent past. " The Journal of Bone and

Joint Surgery (American) 84:290 (2002)

http://groups.yahoo.com/group/nosurgery4clubfoot/message/10996

Regarding the Ponseti method, the U of Iowa has done 4 long term

outcome studies on Adults who were treated with the Ponseti method as

children mostly born in the 1950's and 60's. The studies were done in

1963, 1972, 1980 and 1993. Summaries of the studies can be read in

Dr. Ponseti's 1996 book " Congenital Clubfoot, Fundamentals of

Treatment " . The actual studies can probably be downloaded from

Medline or the Journal of Bone and Joint Surgery web sites. The more

recent long term studies are:

Laaveg, S.J., and I.V. Ponseti. " Long-term results of treatment of

congenital clubfoot. " Journal of Bone & Joint Surgery - American

Volume. 62(1): 23-31, 1980 Jan.

, M., and Frederick R. Dietz. " Treatment of Idiopathic

Clubfoot. A Thirty-Year Follow-up Note. " The Journal of Bone and

Joint Surgery - American Volume. 77(10): 1477-1489, 1995 Oct.

The 4 studies done in 1963, 1972, 1980 and 1993 detail the

statistics. About 4 years ago, I tried to summarize my understanding

of the outcomes of those studies as discussed in Dr. Ponseti's book.

It is possible that I may have misstated or misunderstood something

in my reading of this material in Dr. Ponseti's book, but I think

that this is an accurate summary. If someone knows where I have

misstated something please advise me.

The 1963 study was of 67 cases out of 286 cases of clubfeet treated

from 1948 to 1956 (I assume children from 7-15 yrs old by 1963). Of

the original 286 cases they did not include 46 patients with mild

clubfeet that corrected by simple manipulations with 1-3 casts or 149

other patients that were originally treated in other clinics and

referred later to Iowa and 24 were lost to followup. The age of the

67 studied patients (94 clubfeet) at the beginning of treatment was

from one week to 6 months with the average being one month of age.

Relapses were treated with remanipulation and 3-4 casts and repeat

relapses were treated with a transfer of the tibialis anterior

tendon. This tendon is on the top of the foot and not inside the

ankle joint. None of the children had pain and all could walk on

their toes.

In 1972, they did a second study addressing the effect of the

tibialis anterior tendon transfer by studying 58 feet of 34 patients

aged 9-20 yrs (average 16 yrs). This procedure had only been done on

children who had had recurrent relapses. 43 feet had a transfer of

the tibialis anterior tendon. There are a number of details about the

things that appeared to work better than others. None of the patients

had pain or complaints about their feet. Many of them were

participating in High School athletics. All could walk on their toes.

Some joint stiffness and muscle weakness was observed in the four

feet that had been also treated with a medial release. In 1972,

there had been a higher incidence of relapsing that has been greatly

reduced by a greater emphasis on parents use of the FAB. Recent

studies have shown that for those who use the Ponseti method and FAB

as designed, the risk of relapsing is about 6-7% while for those who

do not use the FAB as prescribed have about a 70-80% risk of

relapsing.

In 1980, they did a study on 70 patients with 104 clubfeet followed

for 10-27 years after treatment. It was of children who had been less

than six months old when treatment began and had not been treated

elsewhere. The mean age at follow-up was 18.8 years. The objective of

the study was to see if the conservative treatment method had given

the patient a functional, painless foot.

Of the 70 patients involved, their mean age at the start of treatment

was 6.9 weeks, the mean duration of plaster casting was 8.6 weeks.

The mean number of casts used for all treatment (initial treatment

and from any relapses) was 9 casts.

All 70 patients had an orthopedic and neurological examination in

which the strength of the muscles were recorded, along with stance,

gait, and motion of the ankle and foot. X-rays were taken and

analyzed.

In other measures, none of the 104 feet experienced pain when

walking. 89% stated that their corrected clubfoot was normal or close

to normal in appearance, and 99 percent were able to wear normal

shoes of the same size. 72% of the patients were very satisfied with

the end result of their treatment, 19% were satisfied and only 4%

were not satisfied. All 70 patients could walk without limping and

could also walk on their toes.

In the fourth study, by Dr. Dietz and in 1992-3, the clubfoot

patients treated between 1950 and 1967 were contacted. 45 patients

ranging in age from 25 to 42 years of age with 71 total clubfeet were

able to return for evaluation. They have about 3 pages of details of

the 1992-3 study, methods and results that relating to x-rays, pain,

function, etc. that seem to show that their long term results are

almost functionally equivalent to that of a population born with

normal feet.

Dr. Ponseti also mentions that there have not been univerally

accepted rating systems for the assessments of results compared to

initial severity. He also says that comparison of the results of

their long term studies to those of short term studies of other

clinics is not appropriate because the measurements of results are

based on different factors. Ponseti's method emphasizes patient

satisfaction and painless functional performance into adult life

based on a treatment that is primarily manipulative with limited

surgery. Most other clinics treatment is primarily surgical after a

period of manipulation and casting

Dr. Posneti gave a lecture on relapsing in the Ponseti method in

October 2001 that was published in the Iowa Orthopedic Journal.

Iowa Orthopedic Journal: Volume 22, 55-56, 2002

RELAPSING CLUBFOOT: CAUSES, PREVENTION, AND TREATMENT, Ignacio V.

Ponseti. In that lecture he said.

" In the first 20 years of my practice, relapses occurred in about

half of the patients at ages ranging from ten months to five years,

averaging two-and-one-half years. Usually, relapses were observed

from two to four months after the splints were prematurely discarded

at the families' own initiative, believing that the correction was

stable. More recently, relapses have been less frequent because, for

one thing, I have further overcorrected the deformity in the last

plaster and to be certain that the calcaneus is fully abducted and

its anterior joint surface is well under the head of the talus.

Secondly, there has been greater awareness on the part of the Parents

regarding the importance of maintaining the night splints after

correction for three to four years. "

" In recent years, I have treated 90 patients - 52 of them initially

seen from birth to three months of age, and 38 from three Months to

one year of age. Seventy Percent of the patients had plaster casts or

physical therapy elsewhere. Forty patients had been previously

indicated for surgery by the initial treating Physician. To my

surprise, it was possible to successfully correct all these feet with

manipulations, and four or five plaster casts, changed every five

days. I performed percutaneous Achilles tenotomy in 84 percent of the

patients. Eighty-eight percent of the patients were compliant with

the use of the foot abduction splint. There were 14 relapses. The

rate of relapse was seven percent in compliant patients, compared to

78 Percent in non-compliant patients. Relapses were unrelated to age

at presentation or to the number of casts required for correction. "

At the 2002 Convention of the American Academy of Orthopedic Surgeons

in Dallas, there were a number of Ponseti method papers presented.

Dr. Morcuende presented the U of Iowa's paper that essentially said

that they felt that Ponseti method treatment was successful up to

about 1 year of age and maybe as far as to 18 months of age. It also

indicated that it could be used successfully for almost all children

for whom other doctors had indicated a need the surgery.

http://www.aaos.org/wordhtml/anmt2002/sciprog/052.htm .

Dr. Lehman presented NYU's paper was on comparing 3 different foot

severity rating systems as well as their success with the Ponseti

method. http://www.aaos.org/wordhtml/anmt2002/sciprog/051.htm

Dr. Noam Bor presented his and Dr. Herzenbergs Age related success

with the Ponseti method after prior methods had not worked

http://www.aaos.org/wordhtml/anmt2002/sciprog/053.htm

All three of those papers would have included information on children

from our internet groups.

The U of Iowa has done long term studies on patients 25 to 42 but

surgical method studies haave only reported out about an average of

16 years. I think that Dr. Ponseti's opinion would be that surgery

can add potential risks and potential complications that can be

lessened or avoided by not using surgical treatment unless there is

no alternative. But there are probably other doctors who do not

agree.

Some stories of adults who were treated in the 1950's and 60's can be

read at Dr. Ponseit's web site:

Ross Snyder, born in 1956.

http://www.vh.org/pediatric/patient/orthopaedics/clubfeet/snyder.html

Woods, born in 1964.

http://www.vh.org/pediatric/patient/orthopaedics/clubfeet/woods.html

Beth Clewell, born in the early 1960's.

http://www.vh.org/pediatric/patient/orthopaedics/clubfeet/clewell.htm

l

A video of all of the procedures in the Ponseti method starring Ross

Snyder as a baby in 1956 can be seen on the internet at Dr. Ponseti's

web site. It is a downloadable video that can be viewed on your

computer in 2 to 4 minute sections or all at once (21 minutes)

depending on your computers capabilities. It shows all of the

procedures including Ponseti method manipulation, casting, tenotomy

as well as following Ross as a baby, at 3 years, 8 years, 18 years

and at 42 years with an interview of Ross. It can be found at the

bottom of the testimonials site at

http://www.vh.org/pediatric/patient/orthopaedics/clubfeet/patientlist

..

html

Dr. Ponseti states that " Parents of infants born with clubfeet may be

reassured that their baby, if otherwise normal, when treated by

expert hands will have normal looking feet with normal function for

all practical purposes. The well-treated clubfoot is no handicap and

is fully compatible with a normal, active life. "

" The majority of clubfeet can be corrected in infancy in about six to

eight weeks with the proper gentle manipulations and plaster casts.

The treatment is based on a sound understanding of the functional

anatomy of the foot and of the biological response of muscles,

ligaments and bone to corrective position changes gradually obtained

by manipulation and casting. "

" Less than 5% of infants born with clubfeet may have very severe,

short plump feet with stiff ligaments unyielding to stretching.

These babies may need surgical correction. The results are better if

bone and joint surgery can be avoided altogether. "

http://www.vh.org/pediatric/patient/orthopaedics/clubfeet/parents.htm

l

Dr. Ponseti and others at the U of Iowa have done 4 long term outcome

studies on adults who were treated with the Ponseti method as

children in the 1950's and 60's. These studies were done in 1963,

1972, 1980 and 1993. Concerning the most recent study, they

indicated: " In a recent review of our patients treated 25 to 42 years

ago, it was found that although the treated clubfeet were less supple

than the normal foot, there were no significant difference in

function or performance compared to a population of a similar age

born with normal feet. " (the studies included evaluations of whether

or not foot pain existed)

http://www.vh.org/pediatric/provider/orthopaedics/Clubfoot/Clubfoot.h

t

ml

In his 1999 Video " A 42 Year Case Study " , Dr. Ponseti said; " When

compared to other techniques for correction of the deformity, our

manipulation, casting and splinting procedure has never resulted in

any disability for the patients. "

I hope that this information is helpful to those who may be

interested in it.

and (3-17-99)

http://www.vh.org/pediatric/patient/orthopaedics/clubfeet/egbert.html