Does the Ponseti Method for Clubfoot Treatment Stand Up to the March of Time?

Commentary What can we advise parents about the long-term results expected from the correction of their child’s clubfoot deformity with the Ponseti method? This meticulous 5-year review tells us that there’s a 62% chance of a relapse and a 38% rate of additional surgery (tendon transfer), but that by the age of 5 years, their child should have a cosmetically acceptable, functional foot. These findings are similar to those of the Iowa group1 some 55 years ago and those of Bor et al.2 in 2009. These analyses are important not only from a clinical-treatment point of view but also for prenatal counseling. I well recall being asked to counsel parents of a 4-month fetus in whom a clubfoot had been diagnosed on ultrasound. The parents were requesting an abortion on the basis of the foot deformity! Statistics from this review would have been a great help in reassuring them that their son’s foot deformity could be corrected; ultimately, it was corrected, as they fortunately did not terminate the pregnancy3. What about the 10 years to follow-up at skeletal maturity? We were told by the Iowa group that few relapses occurred after the age of 5 years, but this needs substantiation as well. The prevalence and severity of clubfeet also vary in different geographic areas. In regions where clubfeet are familial, such as Middle Eastern countries or areas with Hawaiian or Canadian aboriginals, the clubfeet are often more rigid, akin to syndromic clubfeet. We need more long-term follow-up data from these areas to assess the global efficacy of the Ponseti method. Also, one of the problems in any review of clubfeet is trying to compare the various severities of the deformities. Even the idiopathic group in this review had variations in severity. The more severe the deformity, the greater the relapse rate and the greater the need for tibialis anterior transfers. The tibialis anterior transfer as recommended by the authors (transfer of the whole tendon under the extensor retinaculum to the lateral cuneiform, held by a cushioned button on the sole of the foot) is an excellent technique and one that I have used with great success for decades. What is still a gray zone, however, is the best timing for the tibialis anterior transfer. My opinion has always been to not risk leaving the transfer until it is too late. If the foot still tends to be in persistent varus after the patient reaches the age of 3 years, proceed with the transfer while the foot is still growing rapidly and can respond to the valgus force of the transfer. Post-cast bracing with a Denis-Browne or similar splint is a critical part of the Ponseti method. Attention to detail here is as important as the casting phase is. Brace failure is often the cause of relapse, in my experience. It is of the utmost importance to ensure parent buy-in via a heart-to-heart discussion with both parents, preferably with the clinician, to emphasize the importance of brace wear in the successful treatment of their child’s clubfoot. If the parents are not on board with the brace treatment, their negative feelings will be subtly transmitted to the child and brace rejection will occur. In older children, to enhance the efficacy of brace management, the child should sleep in only leather boots (never in Oxford-type shoes, as they will ultimately be kicked off) until the boots essentially become part of their pajamas. The feet are then held straight forward on the brace for another week or 2 and then are gradually externally rotated to 45°. A 6 to 8-inch (15 to 20-cm) bar has a comfortable width, and the bar should be bent 30° to 40° convex plantarward to increase the valgus force on the foot with each kick. In older children, a bedclothes elevator can be used to stop the brace from getting tangled in the bedclothes. Although the Ponseti method for the correction of talipes equinovarus has been with us for >50 years, we have been slow learners because it has been a positive triumph of technique over reason. One has had to see it, experience it, and read follow-ups such as this one to appreciate the efficacy of the Ponseti method. Has the Ponseti method for clubfoot treatment stood the test of time? Yes, at least up to the 5-year follow-up. We are now awaiting the 10-year results and the results from patients who have attained skeletal maturity for the final answer to this question. We have more yet to learn from follow-ups such as this one!

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