A Parents Research Paper on Congenital Clubfoot

October 12, 2005

This is a reprint of a prior message. I am sorry, but some of the

links in this message no longer work.

A Parents Research Paper on Congenital Clubfoot (Idiopathic – of

unknown cause)

General Information

I am in the process of writing this abbreviated summary of general

information from 3 clubfoot treatment books that I have read and

information from doctors, web sites and our own experiences. It is

in an ongoing state of change as I read or find new bits of

information. I keep trying to review and update it and to try to go

back and put references to sources of the information. Realize that

I am a supporter of the Ponseti " non-surgical " method of treatment

as you read this and although I am trying to be objective, I may not

be totally successful. Also, there are still some areas that need

more detail and clarification and this is by no means a scholarly

review, just what I have understood in doing research as a regular

parent. Each of the 2 surgical method books I have read have 2

chapters, with the second chapter dealing mostly with possible

complications of casting and ankle ligament and joint surgery

(posterior release types of surgery). There are also possibly

things that I have misunderstood or misinterpreted so please also do

your own research about these issues. If you feel that I have

misstated any information, please let me know and I will review and

correct it. Our son, , was born with moderately severe

bilateral clubfeet on March 17, 1999 – The first versions of this

paper were begun in 1999. Egbert, 27th revision, Nov 10, 2004

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

An Article from the Fall 2002 issue of the U of Iowa's Pacesetter

Magazine

http://www.uihealthcare.com/news/pacemaker/2002/fall/ponsetti.html

Statement from Dr. Ignacio Ponseti – University of Iowa

" 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. " (Dr. Ponseti, Virtual

Hospital Web Site)

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

Incidence

There are differing estimates of incidence rates ranging from 1:500

to 1:1,000 births (web sites)

Ratio of Male to Female is between 2:1 to 3:1, 40% of cases are

bilateral (web sites)

If one child in a family has it the chances for a second child are

2.9%

In identical twins, both children have it only 32.5% of the time,

(which would imply that it is not totally genetic or I believe that

100% of identical twins would have it)

In non-identical twins, the chances are the same as for a second

child, 2.9%

Where one parent has clubfeet the incidence for their child is 3%

Rate among the Japanese is ½ that of Caucasians

Rate among South African Blacks is 3 times as frequently as

Caucasians

Rate among Polynesians is 6 times as frequently as Caucasians (Dr.

Ponseti's Book, 1996)

If both parents have it, I believe that it can occur for between 15-

25% of their children.

If one parent and one child have it, then subsequent children have a

25% risk (web site of the American Academy of Pediatrics -

http://www.aap.org/pubserv/essenexp.htm )

Lochmiller et al. reported that 24.4% of affected individuals have a

family history of idiopathic talipes equinovarus

Cause

The cause is currently unknown (idiopathic) although genetic and

perhaps environmental factors may play some role. Some general

information and a Genetics Self Study guide at the U of Iowa can be

found through a message at

http://groups.yahoo.com/group/nosurgery4clubfoot/message/2415

Other information about genetics studies can be seen at

http://health.groups.yahoo.com/group/nosurgery4clubfoot/message/17369

Physically Observable Results after Successful Treatment

The following results show a variation of affects depending on the

severity of each child's condition regardless of treatment with non-

surgical or surgical correction. (Dr. Lehman, chapter 34, Disorders

of the Foot and Ankle, 1979-1987) (Ponseti 1980 study)

1. Shoe Size, Shortening of the Affected Foot, from 0-4 cm

(average 1.6cm) (Ponseti's 1980 study mean difference was 1.3 cm)

2. Difference between the Width of the Feet, 0-.6 cm (average

0.3cm) (Ponseti's 1980 study mean difference was 0.4 cm)

3. Difference in Circumference of the Calves, 0-5.5 cm (average

2.5 cm) (Ponseti's 1980 study mean difference was 2.3 cm)

4. Leg-Length Difference, 0-5cm (average 0.6cm) (Ponseti's 1980

study had no difference)

5. Clubfoot affects the maneuverability of the Ankle Joint

6. Clubfoot affects strength of the foot and calf muscles.

7. Surgical method often has observable scars circling 2/3 of

the foot just below the ankle.

8. Those using the Ponseti method feel that a non-surgical

method leaves a stronger and less stiff ankle joint and stronger

muscles, ligaments and tendons. (Ponseti)

9. Whether done non-surgically or surgically, there is a

tendency for the feet to try to return to the original positions

until as late as 6 yrs. This is called relapse or recurrance.

Non-Surgical Treatment

1. Almost all Doctors that treat clubfoot believe that

treatment should begin within the first week with some type of

manipulations and almost all use casting. (plaster, fiberglass,

taping, etc.; a few use physiotherapy which is more common outside

the US) These methods are tried until the feet are corrected or

until the doctor feels that there is no further progress with

casting. If correct positioning is not achieved then surgery is

performed at between 3-18 months of age depending on the doctor (all

sources)

2. You can see from the Houston Shriners Hospitals discussion

on Clubfoot on the national web site that they have at least 2

different casting methods that they are using. At their web site

they say " Talipes equinovarus, or clubfoot, is a relatively common

foot deformity, affecting one in 1,000 children each year. Clubfoot

is readily identifiable at birth, making it easy to diagnose. Yet

how to best treat clubfoot generates more controversy among

physicians than almost any other orthopaedic condition... "

" Doctors differ widely in their opinions regarding the success rate

of serial casting. Some say the procedure works only five percent of

the time [95% surgery], while some believe almost all cases of

clubfoot [i.e. Ponseti method], when treated early and correctly,

can be corrected with conservative therapy. Dr. [in his

experience] says serial casting works in 20 to 25 percent of cases,

but this percentage could increase, he said, if more physicians were

trained in proper manipulation and casting techniques. "

http://www.shrinershq.org/patientedu/clubfoot2.html

3. There are approximately 600-700 pediatric orthopedic

surgeons in the US although some General Orthopedists, General

Practitioners and Podiatrists may also treat this condition. In the

summer of 1999, only about 15 doctors used the Ponseti Method with

which they are successful 95% of the time in correcting the position

of the feet without ankle ligament and joint surgery. More are

being trained in the method at conferences and clinics. At the May

2002 Convention of the Pediatric Orthopedic Society of North America

in SLC, approximately 50-60% of the ped orthos (approx. 300-400 at

that specific meeting) in attendance indicated that they had begun

to incorporate the Ponseti method into their treatment for

clubfoot. Some of those clinics, meetings and conventions have been

reported on including;

At the Children's Hospital of LA April 2000

http://groups.yahoo.com/group/nosurgery4clubfoot/message/1171;

San Francisco May 2000

http://groups.yahoo.com/group/nosurgery4clubfoot/message/1728

http://groups.yahoo.com/group/nosurgery4clubfoot/message/1737 ;

Iowa, Sept 2000

http://groups.yahoo.com/group/nosurgery4clubfoot/message/3118 ; AAOS

Convention, March 1, 2001

http://groups.yahoo.com/group/nosurgery4clubfoot/message/6140 ;

NYU's Ponseti method training, April 25, 2001

http://groups.yahoo.com/group/nosurgery4clubfoot/message/7147 ;

Canadian Orthopedic Association meetings June 1-4, 2001

http://groups.yahoo.com/group/nosurgery4clubfoot/message/7698 ;

Dr. Herzenbergs Conservative Clubfoot Clinic in Baltimore Sept 5,

2001

http://groups.yahoo.com/group/nosurgery4clubfoot/message/8882 ;

STEPS conference in the U.K. September 25, 2001

http://groups.yahoo.com/group/nosurgery4clubfoot/message/8685

A message about the Feb 2002 Convention of the American Academy of

Orthopedic Surgeons (AAOS)

http://groups.yahoo.com/group/nosurgery4clubfoot/message/10376

A press release by the American College of Foot and Ankle Surgeons

(ACFAS) from their Feb 2002 Convention on the Ponseti method.

http://groups.yahoo.com/group/nosurgery4clubfoot/message/10474

Instructional Course Lecture in Feb 2002 issue of the Journal of

Bone and Joint Surgery (JBJS).

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

The May 2002 Pediatric Orthopedic Society of North America (POSNA)

Convention - Scientific Papers and Posters on Clubfoot

http://groups.yahoo.com/group/nosurgery4clubfoot/message/11030

A presentation on the Ponseti method at the National Association of

Orthopedic Nurses (NAON) May 2002 Convention

http://groups.yahoo.com/group/nosurgery4clubfoot/message/11131

A message about the 3rd International Congress on Clubfoot in San

Diego October 27-28, 2002

http://groups.yahoo.com/group/nosurgery4clubfoot/message/12471

4. In the chapter he co-wrote, Dr. Goldner from Duke stated

that it is impossible to have complete anatomical correction without

surgery unless it is a positional or very mild clubfoot which he

feels are 10% or less of clubfeet. (Goldner)

5. In the chapters they co-wrote, Dr. and Dr. Simons

quoted a Dr. McKay who felt casting is successful in only 5% of

cases. (Chapter 5 of Child's Foot and Ankle)

6. Dr. Drennan of the U of New Mexico indicated that only 10%

of feet could be corrected non-surgically. (phone call) U of New

Mexico switched over to the Ponseti method in 2001 after Dr. Drennan

retired.

7. Primary Children's Hospital, SLC; feel casting is successful

in 25% of cases (phone). Primary Children's has one Ponseti method

doctor as of Summer of 2002. More doctors there began using the

method by the end of 2002.

8. Mayo Clinic feels that casting is successful in 50% of cases

(Mayo web site in 1999). Mayo is now using the Ponseti method.

9. LA Children's hospital estimates that casting is successful

almost 50% of the time. (web in 1999)

10. Dr's Atar and Lehman felt casting will be successful in 50-

65% of cases. (Lehman, 1991). Dr. Lehman and NYU changed over to

the Ponseti method in 2000.

11. Dr. Ponseti feels that using his casting method this will be

successful in 95% of cases and takes 1 ½ to 2 ½ months of casting

(typically 5-7 casts but can be up to 9). His opinion would be if

it is taking over 9 casts to correctly position the foot, then it is

possible that something is being done incorrectly. (Ponseti)

12. In the Ponseti method, an in office heel cord tenotomy under

a local anesthetic is often performed (75-85% of the time) as a part

of the final casting to complete the elimination of the equinus.

Dr. Ponseti referred to this as a non-surgical procedure. The

Wheeless Textbook of Orthopedics also lists a tenotomy as a part of

it's section on non-operative procedures.

13. Some doctors cast for up to a 2 years or longer in trying to

correct by casting. (other books I have seen) Dr. Hiram Kite of

Atlanta was known for his non surgical casting method he wrote about

in the 1930's, but his method took an average of 22 months in

casts. The Atlanta ped orthos who are at the Children's Hospital

that Dr. Kite was at changed over to the Ponseti method in the fall

of 2001.

14. Many, but not all doctors, feel that maintaining corrected

positioning after casting or surgery is completed requires some type

of active retention of the feet (ie, shoes, shoes w/ splints, Denis

Browne bar with shoes, AFO's (ankle foot orthotics, etc.)

15. The Ponseti method treats relapses with casting and then if

needed and the child is over 2 years of age with transfer of the

anterior tibial tendon which is on top of the foot and not inside

the ankle joint and a relengthening of the achilles tendon (although

not a posterior release) . (Ponseti)

16. The Ponseti method of treatment has been in use since about

1950 at the U of Iowa. There have been long term results studies

done on patients about every ten years since 1963. They have 40+

years of good outcomes as shown in 4 longer term studies. Ponseti

feels that not having the surgery leaves the foot more flexible,

less stiff, with a stronger joint and with fewer incidences of foot

pain or other long term problems. (Ponseti)

17. The Surgical method books I read did not specifically

address the Ponseti " non-surgical " method in their discussions.

They do not explain much about their own casting methods.

18. Using the Ponseti or other non-surgical methods first does

not mean that you can't do a surgical method at from 3-12 months if

the non-surgical method doesn't work. Every doctor begins by trying

to correct the feet non-surgically. The reverse of course is not

true.

19. The Ponseti method is 95% successful if begun within a few

weeks of birth. For a child at 6 months of age, the chances that it

will work without surgery drop to about 50%. (Since 1999, this

information has changed and the U of Iowa has published a study

indicating that the Ponseti method appears to work well up even when

treatment with it didn't begin until up to at least one year and

maybe as far out as 18 months.) For a child changing over to the

Ponseti method, the chances depend on the age, severity, and the

degree of correction obtained by the prior doctors.

20. In March, 2001, Dr. Herzenberg presented at poster at

the AAOS Convention in San Francisco on a short term comparison of

the standard casting to the Ponseti method)

http://www.aaos.org/wordhtml/anmt2001/poster/pe132.htm

21. It appears that for years, many doctors had felt that Dr.

Ponseti's method was not reproducible outside of Iowa or were told

by their mentors to disregard the Ponseti method. Some have tried

to " politely " explain it away by saying that there was something

different about the water, food or genetics in Iowa which somehow

generated easier, milder clubfeet which then allowed Iowa to report

a high percentage of non-surgical success. The Ponseti methods long

term outcome studies and other details about it have been reported

on in the main orthopedic publications repeatedly since 1963.

22. Recent reports on the Ponseti method in Journals and at the

American Academy of Orthopedic Surgeons (AAOS). January 4, 2002 new

studies being reported at the 2002 AAOS convention-

http://groups.yahoo.com/group/nosurgery4clubfoot/message/10056

Dr. Pirani's study on MRIs of Ponseti method children in the Nov/Dec

2001issue of the Journal of Pediatric Orthopedics -

http://groups.yahoo.com/group/nosurgery4clubfoot/message/9583

Feb 2, 2001 – studies and posters presented at the 2001 AAOS

Convention

http://groups.yahoo.com/group/nosurgery4clubfoot/message/5495

A message about the Feb 2002 Convention of the American Academy of

Orthopedic Surgeons (AAOS)

http://groups.yahoo.com/group/nosurgery4clubfoot/message/10376

A press release by the American College of Foot and Ankle Surgeons

(ACFAS) from their Feb 2002 Convention on the Ponseti method.

http://groups.yahoo.com/group/nosurgery4clubfoot/message/10474

Instructional Course Lecture in Feb 2002 issue of the Journal of

Bone

and Joint Surgery (JBJS)

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

The May 2002 Pediatric Orthopedic Society of North America (POSNA)

Convention - Scientific Papers and Posters on Clubfoot

http://groups.yahoo.com/group/nosurgery4clubfoot/message/11030

A presentation on the Ponseti method at the National Association of

Orthopedic Nurses (NAON) May 2002 Convention

http://groups.yahoo.com/group/nosurgery4clubfoot/message/11131

Possible Complications from Non-Surgical Casting Corrections

1. Ponseti's method as reported on for those treated in the

1950's and 1960's appeared to have a relapse rate of 30-40%. Now

because of a better understanding of what was needed to reduce the

rate of relapse that rate has been reduced. Because of the

importance of the Parents proper use of the derotational shoes and

splints (Foot Abduction Brace (FAB) aka. Denis Browne Bar (DBB)) the

incidence of relapse needing the anterior tibial tendon transfer can

be reduced to between 10-15% ((Ponseti) College of Medicine Article

http://www.uiowa.edu/~hsr/pubs.html . Relapses are treated by 3-4

casts in about a month. Relapses occur most often at about age 2,

but can occur up until 6 years of age. Repeat relapses or a relapse

after 2 years of age will need a transfer of the tibialis anterior

tendon after the child is about 2 years old can be made (tendon on

the top of the foot, not in the ankle joint). If the equinus can

not be recasted out, an open incision heel cord lengthening is also

performed, but it is not expanded into a posterior release. The

recent report by the U of Iowa at the 2002 AAOS Convention indicted

that the rate of relapse since 1991 was 7% for those who used the

FAB/DBB as prescribed.

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

2. Foot and leg bones can be fractured by excessive

manipulation. (Surgical books)

3. Rocker-Bottom from lifting the front of the foot too

forcefully in casting (All sources) Dr. Ponseti told me that he has

only had one incidence of this occurring in the 1950's, which they

were able to successfully resolve.

4. Toenail Infections (Lehman)

5. Pressure sores from casts (Lehman)

6. Deformities of toes due to cast pressure (Lehman)

7. Many surgically oriented surgeons feel that x-rays of feet

showing an incorrect anatomical positioning of bones and joints

should be operated on. Their opinion would be that many of the

Ponseti method and other non-surgically corrected clubfeet would

still show incorrect anatomical positioning of bones and joints.

(Goldner)

8. Ponseti's opinion is " that it is wrong to assume that early

alignment of the displaced skeletal elements results in a normal

anatomy and good long term function of the clubfoot. We found no

correlation between the radiographic appearance of the foot and long-

term function.(as shown in their long term studies) " Ponseti

further states, " An immediate surgical correction of the clubfoot

components is anatomically impossible. After extensive dissections

to release joint capsules and ligaments and to lengthen tendons, the

tarsal joints do not match. In order to hold the bones roughly in a

proper alignment, the surgeon is forced to transfix them with

wires. " (Ponseti) Information from published studies relating to

these issues can be found at

http://groups.yahoo.com/group/nosurgery4clubfoot/message/9583

9. The Surgical Method books did not specifically address their

opinion of the " Ponseti method " of casting or their opinion of

complication issues relating to the Ponseti method. There was

however an exchange of letters to the editor of the Journal of

Pediatric Orthopedics that discussed some of the surgically oriented

doctors issues relating to the Ponseti method. A link to a message

about this can be seen at

http://groups.yahoo.com/group/nosurgery4clubfoot/message/7654

10. I assume that some of the complications that are not

necessarily surgery related that are stated under complications of

surgical ankle joint corrections can also occur with a non-surgical

correction such as flat feet, over or under corrections, etc.

11. Dr. Ponseti and Dr. Herzenberg have both indicated to me

that even if a child who has been treated with the Ponseti method

ends up having to have the surgery; that because of using the

Ponseti method first that the ligaments and tendons are stretched

more that they would have been with traditional manipulation and

casting methods. This allows them to do fewer things during the

release type surgery than would have otherwise been the case.

12. In his 1999 Video " A 43 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. "

13. It appears that modifications to the Ponseti method can

greatly affect how well it works. A message about this can be found

at

http://health.groups.yahoo.com/group/nosurgery4clubfoot/message/25824

French Physiotherapy Methods

The physiotherapy methods also try to correct the position of the

feet non-surgically and only use surgery if it is not successful.

It is a more prevalent form of initial treatment (instead of

casting) outside of the US and Canada, but a few hospitals here have

been trying it recently. The most active of the US Hospitals that

offers Physiotherapy seems to be Dallas's ish Rite. They meet

with parents and discuss alternative treatment methods including

physiotherapy, traditional casting and surgery and just recently

adding the Ponseti method (since about November 99).

Since December 2000, Texas ish Rite has begun offering only the

French and Ponseti methods

http://groups.yahoo.com/group/nosurgery4clubfoot/message/6994

There have been some posts about this method at Parentsplace at

http://boards2.parentsplace.com/messages/get/ppclubfoot22/47.html

which includes an article from Dallas's ish Rite Hospital.

In addition, apparently NYU's Hospital for Joint Diseases was

offering some French Physiotherapy as well as the Ponseti method as

indicated at their site at

http://www.hjdcares.com/html/body_club_feet.html (I think that this

was back in 1999 and since 2000, the Ponseti method has been NYU's

initial method of treatment)

Also there is a internet report on treatment method studies reported

at a 1997 Symposium on Clubfoot Treatment methods in Paris, France

that can be found at http://www.afcp.net/efas_97.html At this site

is also the reports of the outcomes of the Ponseti method from a

hospital in Madrid Spain as well as physiotherapy and surgical

method outcome reports from other doctors in Europe and the US that

attended.

It appears that the French Physiotherapy methods are successful in

the US at about 50-60% of the time in avoiding the ankle ligament

and joint surgery. From what I understand, the main French methods

are by a Dr. Bensahel and Dr. Dimeglio. The Dimeglio method

includes the use of what is called a passive motion machine to which

the children's feet can be attached to do joint flexion and

extension exercises. I assume that physiotherapy methods in the UK

are at least slightly different from these, but I have found no

sites that specifically describe them. There has recently been an

abstract of a study by Dr. Dimeglio posted at the POSNA web site at

http://www.posna.org/Meetings/Vancouver/abstracts3.htm#Foot

A report on Dr. Bensahels method was posted near that same site at

http://www.posna.org/meetings/vancouver/abstracts3.htm#FT_Physio

A more detailed view of the Dimeglio report can be found at

http://groups.yahoo.com/group/clubfoot_French_method/files and at

the French Method parents support web site at

http://groups.yahoo.com/group/clubfoot_French_method

Dr. Dimeglio's home web site can be seen at

http://opm.ifrance.com/opm/Pages/onglet.html Click on Presentations

and then Le Pied Bot to see a slide presentation on the method. In

France, Dr. Dimeglio has been successful in avoiding the surgery

between 50% up to 87% for children treated in 1997, when reported in

early 1999 in a one to two year followup.

A Recent Study at Texas ish Rite and Shriners SLC

http://health.groups.yahoo.com/group/nosurgery4clubfoot/message/32722

Electrical Muscle Stimulation, Botox Injections and other Non-

Surgical Methods.

There have occasionally been parents on the internet who have

mentioned these other methods of trying to prevent surgery but I do

not have much specific information on these methods or who provides

them. The messages that I have seen about Botox have not felt that

it helped much in the long term.

http://groups.yahoo.com/group/nosurgery4clubfoot/message/5071

http://groups.yahoo.com/group/nosurgery4clubfoot/message/5077

http://groups.yahoo.com/group/nosurgery4clubfoot/message/5116

http://groups.yahoo.com/group/nosurgery4clubfoot/message/5118

The Texas ish Rite Hospital wrote a report on 4 children from

whom Botox had been used but have since discontinued Botox's use.

http://www.applesforhealth.com/clubfeet1.html

There has recently, (in 2001-2002) been a Dr. Alvarez in Vancouver

B.C. who has been using a modified version of the Ponseti method

that uses Botox instead of a tenotomy and has reported good early

results at the 2002 POSNA convention.

http://www.cw.bc.ca/orthopaedics/botoxres.asp

A message that combines a lot of links to prior messages on Botox.

http://health.groups.yahoo.com/group/nosurgery4clubfoot/message/26927

Article from Feb 2004

http://www.langleyadvance.com/issues02/093102/news/093102nn2.html

Ankle Ligament and Joint Surgical Corrections

If the non-surgical methods are not successful, then ankle ligament

and joint surgical procedures are used. This is usually done

between 6-12 months although some doctors go earlier or later.

Other than the few mentioned above (this has changed from 1999 to

2004), most pediatric orthopedic surgeons are not able to correct

the positioning of the feet non-surgically and proceed with doing

the ankle ligament and joint surgical corrections in 65-95% of

cases, although there appear to be a few at 50% -35%. For Doctors

using the Ponseti method, surgery is needed for about 5% of children.

Dr. Goldner, of Duke University feels that some form of ankle

ligament and joint surgical correction is needed in any true

clubfoot. This would be approximately 90% of the time. (Goldner,

chapt. 33)

Primary Children's Medical Center, SLC, feels that the surgery is

required 75% of the time and that 2nd surgeries occurred 10% to 25%

of the time.(talked to 2 different people there, phone in 1999). By

December of 2002, there were a number of Ponseti method doctors at

Primary Childrens. By March 2004, the Ponseti method is the main

method of initial treatment at Primary Children's.

The Mayo clinic feels that the surgical correction is required only

50% of the time. (web site) I had learned during the summer of 1999

from a parent who went there for a 2nd opinion that a Dr.

Shaungnessy at the Mayo Clinic uses some of the Ponseti method

techniques in his treatment although not following it completely.

(Recently, doctors from the Mayo Clinic went to Iowa for Ponseti

method training in 2001.)

Dr. Drennan of U of New Mexico feels that 90% of children need

surgical correction. (phone) Dr. Drennan has retired since 1999 and

the doctors taking his place have been using the Ponseti method

since 2000.

Dr. Atar and Dr. Lehman of Mt. Sinai Hospital, NY; feel that

surgical correction is required only 35-50% of the time. (Lehman,

chapter 34 and chapter 6) In late 1999, Dr. Wallace Lehman switched

over to the Ponseti method and within a few months all of the

doctors at NYU also switched. They have now been actively promoting

the use of the Ponseti method prior to evaluation whether or not a

child needs to have the surgery.

Dr. Ponseti and those who use his method of treatment feel that

ankle ligament and joint surgical correction is only needed in 5% of

cases. (Ponseti)

A clubfoot surgery article in the Cincinnati Post dated 1-7-2000

indicated that " The operation, lengthy and difficult, involves

lengthening the tight tendons and repositioning several tiny bones. "

(it can also involve cutting ligaments and opening joint capsules.)

Dr. Wall of Cincinnati's Children's Hospital was quoted as

saying " It is major surgery. It is one of the most technically

difficult of all orthopedic surgeries. "

http://www.cincypost.com/living/2000/foot010700.html

The procedures for the ankle ligament and joint surgical corrections

are listed below. There are also different incision methods and

different names attached to methods of how to do these procedures.

Descriptions of these methods and which tendons and ligaments are

cut or lengthened with each can be found at the Internet's Wheeless

Textbook of Orthopedics http://www.medmedia.com/o14/117.htm . There

appear to be about 25 different ligaments, tendons or joint

procedures that can be done in the release type procedures. The

processes involved and how may of these are done depends on the

severity and the surgeon:

1. Soft tissue procedures usually begin with some or all

components of a Posterior release

a. Posterior release – All books

b. Medial release – Wheeless Textbook

c. Posteromedial release – All books

d. Lateral release – Wheeless Textbook

e. Plantar release – Wheeless Textbook

f. Circumferential release – Surgical books

g. Tarsometatarsal Capsulotomies – Surgical books

h. Talectomy – Wheeless Textbook

i. In treating relapses, some doctors (and Ponseti method

doctors) can use what is called an anterior tibial tendon transfer

instead of doing a posterior release or other relapse procedures

discussed below.

2. Procedures involving Bone – I believe that these are

typically not done as a part of a 1st surgery, but may be done on

subsequent surgeries, (if any)

a. Metatarsal osteotomies

b. Calcaneal osteotomy

c. Triple arthrodesis

d. Rotational Tibial osteotomy – (Dr. Goldners chapter) This

surgical procedure is sometimes used to treat residual tibial

torsion. In this procedure, the lower leg bone is cut through

completely and then rotated and reattached to straighten out the

alignment of the feet. I believe that Dr. Ponseti's view would be

that this problem is a result of improper treatment. In the Ponseti

method, tibial torsion does not appear to be a post treatment

problem. A recent medical web site called e-medicine said

this; " Persistent intoeing: This is quite common. Persistent

intoeing is not due to tibial intorsion but rather is due to

insufficient external rotation correction of the subtalar joint. "

http://www.emedicine.com/orthoped/topic598.htm

e. Dr. Ponseti states in his book pg 87, " Osteotomies or wedge

resections of the bones on the outer aspect of the foot are not

necessary in clubfoot treatment if manipulations and plaster cast

applications are properly done. " For the most severe cases, where

the Ponseti method had already used the posterior release types of

surgery initially, they could also utilize the anterior tibial

tendon transfer. For a very few children in the Ponseti method, it

is possible that a talectomy or triple arthrodesis might be used.

3. Combined soft tissue and bone. I believe that these are

typically not done as a part of a 1st surgery, but may be done on

subsequent surgeries, (if any)

a. Dillwyn (calcaneocuboid wedge and fusion)

b. Lichtblau (calcaneal osteotomy)

c. Cuboid decancelation

d. Open wedge osteotomy first cuneiform

e. The above procedures also are not needed if a child is

treated with the Ponseti method and had a relapse.

Possible Risks and Complications from First Time Clubfoot Surgery

I have asked many doctors if they were aware of any long term

outcome studies on surgically treated patients. No one could tell

me of any and Dr. Ponseti has indicated to me that apparently none

exist beyond about an average age of 16 years. Some doctors

indicated that the surgery has continued to evolve. It used to be

that the surgeries were done somewhat in a series such as a

posterior release first and then later doing a medial release and

then later other releases if needed. A Dr. Turco popularized

combining the posterior and medial releases into one operation

called the Turco method of posterio-medial release. Dr. Ponseti

mentioned that some form of the posterio-medial release has been in

existence since 1906 and that he and his associates made

improvements to the posterio-medial releases at the U of Iowa in the

1940's before the Ponseti method began. There have also been other

advances in surgical techniques such as types of initial incisions

and the use of micro surgical tools, but all of these different

techniques are still not entirely agreed on as to which may be any

better in a long term sense than an other. My impression is that

since most doctors have been trained and accepted that a uniformly

successful non-surgical method is impossible, that their focus has

been mostly emphasized trying to perfect and improve the surgical

techniques.

Dr.'s Lehman and Atar estimate complications or ultimately

unsuccessful surgeries based on their analysis of about 10 other

outcome studies to occur 13-50% of the time (average of 25%)

although their own recurrence rate was only 6.3% in 159 feet. Their

hospitals 25% recurrence rate included patients referred to them

after an initial surgery elsewhere. Their most common surgical

method for revision clubfoot was a repeat (75% of the time) complete

soft tissue release (redo of the major surgical ankle joint

surgery). As mentioned before, in late 1999, Dr. Lehman and the

other doctors at NYU switched over to the Ponseti method.

Parkview Orthopedics web site in the Chicago area also indicated

that 2nd surgeries are needed about 25% of the time.

http://www.parkviewortho.com/pedclub.htm

Dr.'s and Simons estimated that complications from the

surgery occur approximately 5% of the time. Satisfactory results

can be expected 72-88% of the time (pg 120)

Dr. Goldner's initial surgeries from 1949-1959 had a 67% recurrence

rate by the time the child reached maturity. A much lower

recurrence rate since 1965 although % not stated numerically, on a

chart in the book it appears to be less than 10%. (Goldner)

Dr.'s Lehman and Atar in Drennan's book said that recurrence after

surgery from studies is 5-20%, I assume that this means relapses not

including complications which is different than how they stated it

in the other book's chapter on complications. Since Dr. Lehman's

books and chapters were written, he visited with Dr. Ponseti in Iowa

in October 1999 and along with Dr. Feldman of NYU's Hospital

for Joint Diseases have now incorporated the Ponseti method into the

treatment alternatives offered at NYU.

http://www.hjdcares.com/html/body_club_feet.html

Ponseti states that " 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 " (Ponseti web site)

I am aware of 3 doctors and one internet web site who have indicated

that one of the more severe but rare potential complications of the

posterior release types of surgery can be surgically related

problems that could lead to the eventual amputation of the foot.

Between them the first 2 doctors had seen where this had occurred 4

times for patients that had been referred to them. More recently, I

heard another doctor speak who mentioned that he was aware of 14

cases where a child had to have a foot amputated. My assumption is

that his information was from either a wide area or national basis

over the course of many years. Although I would hope and think that

this is rather rare, it is still a potential risk and complication.

http://www.footlaw.com/news/13.html

Listing of Possible Complications of First Time Clubfoot Surgery

1. Skin Necrosis of the Medial Incision – Skin incision cuts

across blood flow fields that have to heal. If they don't heal well

the skin in that area starts to die. (Goldner 4 in 300 feet),(Lehman)

2. Wound Infection (Goldner 2:400)(Lehman 1 in 250 from 1980-

89) We have had 2-3 parents whose child has had this occur at

parentsplace who posted from June – Dec 99

3. Pin-Tract Infection (Goldner 6:400)

4. Displacement of the Cast – Cast moves after surgery

affecting the healing foot alignment

5. Tourniquet Blisters (Goldner 2:400) – From tourniquet placed

on the leg to slow bleeding

6. Deep Skin Fibrosis and Contracture, Medial and Posterior

Flap Necrosis (Goldner)

7. Entrapment of tendons in the ankle joint (Goldner)

8. Adherence of the Flexor Hallucis Longus to ligaments of the

sustentaculum tali

9. Calcaneus Deformity - Heel Cord Overlengthening (Goldner

12:100)

10. Damage to the Neurovascular Bundle and Laceration of

Adherence of the Sural Nerve to the Heel Cord (Goldner 6 of ?400?)

(Lehman)

11. Overcorrection that results in Progressing Valgus Deformity

(Goldner 12:100)

12. Incomplete Correction (Goldner)

13. Necrosis of Plantar Skin (Goldner)

14. Persistent Hallux Varus and Metatarsus Adductus (Goldner

32:100 of referred patients)

15. Injury to bones and joints and Avascular Necrosis of Talus

and Navicular (Lehman 2:81)

16. Injury to growth plates (Lehman) Dr. Ponseti in his book

says this can affect limb length.

17. Persistent Equinus – front of foot pointing somewhat down.

(Lehman)

18. Ankle, Subtabular or Sinus Tarsi Pain (Lehman, Ponseti). Dr.

Ponseti indicated that this surgical complication can 1st occur as

late as the second or third decade of life. Although surgical

treatment has been the prevailing method of treatment since the

1950's, to date there have been no studies have been done to

indicate how often this may occur in adults. A May 2000 report by

the Mayo clinic on a 16 year outcome study indicated that just over

50% of those in the study were experiencing foot pain. (POSNA web

site)

19. Pes Planus – Flat Feet (Lehman); Pes Cavus - High arched

(Lehman)

20. Skew Foot - Serpentine Foot (Lehman)

21. Forefoot Supination, Claw Toes, Tarsal Navicular

Subluxation, Dorsal Bunion (Lehman)

22. Dr. Lehman – He reports that analysis of 10 other studies

show surgical fair or poor outcomes 13-50% (25% average) from either

complications or incomplete success. Relapses occur most often at

about age 2, but can occur up until 6 years of age (some as late as

12 yrs).

23. Dr. Lehman - 75% of relapses need the major joint surgery

redone to some degree.

24. Dr. Atar – for 22 feet relapse surgery was 2-6.5 years since

first surgery (35 month ave)

25. Dr. Atar – for 7 feet relapse surgery was at 6-13 months

since first surgery (ave. 9 mo.)

26. Dr. Ponseti – " In a recent publication (Simons 1994) of the

papers presented at a congress on clubfeet, there are scores of

reports on surgical procedures, many of them untested, and some

exclusively designed for [the treatment of complications caused by

the initial surgery]. The chapters in that publication on

complications of clubfoot surgery attest to the tragic failures of

early surgery. " (Ponseti, pg. 5)

27. Dr. Ponseti indicated that he gets calls from adults with

surgically treated clubfoot from other areas of the country who

indicate that their clubfoot pain did not develop until their teens

to thirties who are wondering if Dr. Ponseti can do anything to help

them. He also gets calls from Orthopedists and Foot and Ankle Dr.'s

who see older surgically treated clubfoot patients who have

developed foot pain and are trying to figure out what if anything

can be done to help them. Dr. Ponseti has indicated to me that

there are currently no studies to show what percentage of surgically

treated feet will experience those kinds of problems as they age.

(Ponseti, conversation) With those kind of studies, there could

also be studies done on what might be good, better and best methods

of dealing with the pain or other complications of the clubfoot

treatment for adults.

28. In the Instructional Course Lecture in Feb 2002 issue of the

Journal of Bone

and Joint Surgery (JBJS). A small excerpt of their reports

concluding overview states:

" 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.... 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

Comparisons of Outcomes

Realize that this comparison is strictly from my perception of a

Ponseti method point of view and does not present a view from the

surgically oriented perspective, which is still the prevailing view

of doctors (at least prior to 2002). In Dr. Ponseti's book, he

presents the results of 4 long term studies performed on his

patients (1963, 1972, 1980, 1993) since the beginning use of his

method about 1950. Dr. Ponseti states " A comparison between the

results of our long term follow-up studies of our severe cases (with

the exclusion of mild cases necessitating fewer than four plaster-

cast changes for correction) and those of short term follow up

studies in other clinics is not appropriate because our results

address correction of the deformity emphasizing patient satisfaction

and painless functional performance into adult life: our treatment

is primarily manipulative with limited surgery to maintain the

correction in the more severe cases. In other clinics treatment is

primarily surgical including extensive joint release operations

usually after a period of inadequate manipulation and cast treatment

that fails to correct the deformity. Furthermore, evaluation

schemes `lack a universally accepted rating system for assessment of

results' as Cummings et al (1994) have warned. In addition most

follow-ups are short term and their assessment of results derives

primarily from radiographic measurements and presence of absence of

pain as a measure of success rather than to foot function. There is

no correlation between the values of angles measured in (x-rays) and

the functional results within the range found in our treatment.

Furthermore, the presence or absence of pain is not an appropriate

criterion when applied to children, since pain does not usually

develop even in untreated clubfeet until adolescence or later in

life; and the available follow-ups do not go beyond adolescence. It

is regrettable that there are no long term follow ups of clubfoot

surgery, although posterio-medial release operations have been

performed since Codivilla's time (1906) at the beginning of this

century to the present day. " (Ponseti) (It appears that there are

no long-term studies of the outcomes of surgical treatment methods

that extend longer than about 16 years of age. In March, 2001, Dr.

Herzenberg presented at poster at the AAOS Convention in San

Francisco on a short term comparison of the standard casting to the

Ponseti method)

http://www.aaos.org/wordhtml/anmt2001/poster/pe132.htm

" In 1985, Hutchins et. al. (1985) reported results on 252 feet

treated by early posterior release (major ankle surgery) followed

for an average of 15 years and 10 months, the longest of the short

term follow ups. He used our (University of Iowa's 1980) grading

system and found satisfactory results in 81 per cent of cases, but

excellent and good results in only 57 per cent of the cases.

(Ponseti's method patients received 74% good or excellent results in

his 1993 study on those from 25 to 42 years of age). (Hutchins)

attributes the poor results to restricted ankle movement owning to

the flattening of the talus. In 1990, Aronson et al (1990) compared

different types of treatment. They found that feet treated with

plaster casting or casting plus tendo Achilles lengthening resulted

in less deformity and disability. They also found that

posteriomedial release improved the talocalcaneal index but reduced

both the range of motion of the ankle and the strength of the

plantarflexion as compared to the casting groups. These

observations coincide with my (Ponseti's) experience with extensive

clubfoot surgery since the forties. Our functional results and

patient satisfaction improved greatly when we learned to correct

clubfeet with our improved techniques of manipulation and plaster

cast treatments. Joint release operations were performed only in

the very few unyielding severe cases. " (Ponseti)

A message on Long Term Outcomes of the Ponseti method can be found

at

http://health.groups.yahoo.com/group/nosurgery4clubfoot/message/16462

Again, please realize that I am just a parent who has read and

researched a bit and am trying to understand the books, web sites

and doctors I have talked to. I may not have totally interpreted

each book or doctors opinion correctly, so please also do your own

research to try to understand each issue and method. Also this is

not a medical review, just my own parental research paper. Please

follow the advise of whoever you decide that you want to ultimately

use as your doctor for your child.

As you can tell I am an advocate for the Ponseti method and hope to

be able to help parents know that it exists so that they can have

more information when trying to decide a course of treatment for

their child. Obviously, I feel that the Ponseti method is a great

alternative method of manipulation and casting that appears to work

better than the traditional manipulation and casting techniques in

use today allowing for fewer children to have to have the more

difficult and complicated surgical procedures. I do feel that the

surgical techniques are good and important and even the Ponseti

method doctors use those techniques for the 5% of children for which

Ponseti method manipulation and casting is not successful. I hope

that all children can have the best possible treatment method for

them and their particular situation with the fewest possible risks

and complications. I hope that this information can be of some help

to parents trying to decide a course of treatment for their child.

, Allyson and Egbert

egbert@...

These notes were begun in June 1999 and added to, revised and

modified up to June 2003.

A longer message about our story -

http://groups.yahoo.com/group/nosurgery4clubfoot/message/15815

Bibliography

Excellent Web Sites and Books

http://pages.ivillage.com/ponseti_links – Trevillian has put

together this great web site of Ponseti method related web sites and

information.

http://pages.ivillage.com/clubfootboard/clubfoot.html -

Parentsplace's " Clubfoot Bulletin Boards Links " . This site has

about 160 different links to web sites on all clubfoot related

topics from general information to surgical and non-surgical

treatment methods. It is the most comprehensive internet library on

the subject and has translation capabilities into many languages.

It also has an active parent support message board.

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

- This is information from Dr. Ponseti at the U of Iowa regarding

his " non-surgical " method of treatment

http://groups.yahoo.com/group/nosurgery4clubfoot – The Yahoo E-

groups Ponseti method parents support web site. There are many

links and files of information here on clubfoot and the Ponseti

method. The site was begun in Dec, 1999 and as of Feb 2002 has 230

members. There are also other parents support clubfoot internet

sites that can be located from this site.

http://www.clubfoot.net - This site has a lot of information about

different methods of treatment including traditional casting and

surgery, Ponseti and Physiotherapy with links to many other sites.

It also has translation capabilities of most clubfoot web sites

linked to it into Spanish, French, German, Portuguese and Italian.

http://groups.yahoo.com/group/nosurgery4clubfoot/message/7170 - An

Article in Orthopedics Today's April 2001 edition on Dr. Ponseti

called " Pioneers in Orthopedics, the People that Shaped the

Specialty " . To access the article you can use my user ID of 19001

and password of " martin "

http://www.posna.org/meetings/vancouver/abstracts3.htm#Foot –

Abstracts of Papers on Clubfoot treatment presented at the Pediatric

Orthopedic Society of North America's web site that were presented

at their May 2000 Convention in Vancouver, BC. (this site may no

longer be open to the public)

" Congenital Clubfoot, Fundamentals of Treatment " , Ignacio Ponseti,

University of Iowa, Oxford University Press, New York, 1996

" The Child's Foot and Ankle " , edited by Drennan, University of

New Mexico, Raven Press, New York 1992

Chapter 5 - Congenital Talipes Eqinovarus (Clubfeet), by

, Case Western Reserve Hospital, Cleveland, Ohio; W.

Simons III, Medical College of Wisconsin, Milwaukee, Wisc.

Chapter 6 – Complications in the Management of Talipes Equinovarus,

by Wallace B Lehman and Dan Atar, Hospital for Joint Diseases, New

York and Soroka Hospital, Ben Gurion University, Beer-Sheva, Israel

(Discusses how to minimize the risks and complications of casting

and surgery. Dr. Lehman learned the Ponseti method in late 1999 and

has since help all of the doctors at NYU switch over to it as their

manipulation and casting technique.)

" Disorders of the Foot and Ankle " , edited by Melvin Jahss, Hospital

for Joint Diseases, Mount Sinai School of Medicine, New York;

Published by WBSaunders Co, Philadelphia, 1991 2nd ed.

Chapter 33 – Idiopathic Congenital Talipes Equinovarus (Clubfoot),

by J. Leonard Goldner, MD and Fitch MD, Duke University

Chapter 34 – Revision Clubfoot Surgery, by Dan Atar (Ben Gurion

University, Beer-Sheva, Israel), Wallace Lehman (Hospital for Joint

Diseases, NYU, New York), Alfred Grant, Allan Strongwater (Discusses

the possible complications of 1st surgeries and how to do subsequent

surgeries)

All of these books except Jahss's are available at either

Amazon.com, andNoble.com or Medbooksite.com. The following

books I do not have and have not read.

" Clubfoot: the Present and a View of the Future " , by Simons

(I assume the same Simons from Chapter 5 of The Child's Foot

and Ankle, Springer-Verlag, 1993 (I had this book on order for 3

months and it never came so I cancelled the order)

" Clubfoot: Current Problems Orthopedic " , by Turco (Created

the Turco Method)

" The Clubfoot " , by Wallace B. Lehman, (The same Dr. Lehman from

Hospital for Joint Diseases, NYU, NY who wrote the chapters on

complications of clubfoot surgery ref. Above and who in 1999,

switched over to the Ponseti method)

" Idiopathic Clubfoot and Its Treatment " , by Gunter Imhause

October 12, 2005