Dr. Jay Albright Discusses Clubfoot and the Ponseti Method of Treatment

Posted on August 6, 2012 by john

Dr. Jay Albright, orthopedic surgeon, sports medicine specialist and nationwide expert on the treatment of young athletes and their injuries, took some time to discuss clubfoot and the Ponseti Method of treatment offered at Level One Orthopedics in Orlando, Florida.

What is clubfoot?

Clubfoot is a deformity that most of the time can be identified on prenatal ultrasound but is certainly present at birth. It is a foot deformity where the foot has an extremely high arch, the sole of the foot is turned in and the toes are pointed down like a ballerina. In other words, when the baby is resting the foot is turned to point into the diaper and not in a normal position. Idiopathic means that there is no identifiable cause for the clubfoot to occur whereas non-idiopathic means that the clubfoot is associated with some known reason, either genetic or a syndrome such as arthrogryposis.

What kind of stimulus spurs this abnormality? (Genetic, medication, alcohol, etc?)

Idiopathic types have no identifiable cause; low volume of amniotic fluid (oligohydramnios) can sometimes be associated with this.

Non-idiopathic clubfoot is also called syndromic, it can be genetically carried, or associated with a disorder such as arthrogryposis, which presents in a variety of severity, as well as other syndromes.

How common is clubfoot? How common is the bilateral version?

The rate of children born with clubfoot varies across ethnicities; the highest rate known is the Maoris, the indigenous population of New Zealand, at a rate of 7 per 1,000 live births. The United States has a rate of 1.5 per 1,000 live births. In perspective, Winnie Palmer Hospital for Women and Babies (one of the busiest birthing centers in the US) has close to 15,000 births a year, coming out to approximately 22 babies born with clubfoot each year. The rate of single or bilateral clubfoot varies as well, however about 30-40 percent at our center are born with clubfoot on both sides.

 What is life like for a child with untreated clubfoot? What would life be like in mild cases? In extreme cases?

Life with untreated clubfoot is difficult; children with it can walk and maybe run but do so by walking on the tops of their feet not the sole. This eventually leads to pain and sometimes to use of a wheelchair. While very mild clubfoot may result in more normal function, true clubfoot requires treatment in order for 97-98 percent of non-idiopathic clubfeet to function normally.

How long has the Ponseti Method been around?

Dr Ponseti developed his casting method around 65 years ago and should only be called the Ponseti clubfoot casting method. Other methods are not nearly as effective of producing long lasting success with no or minimal surgery.

Is it the most popular/successful method to date? What are the alternative treatments?

The Ponseti technique is by far the most successful treatment regimen in the world for treatment of clubfoot. Other methods are either surgical in nature or require fall back onto significant surgical treatment over 50-60 percent and up to 90 percent of the time. There is one treatment called the French method which is a daily intensive physiotherapy method that takes place at a physical therapy center, but this has a higher invasive surgical rate than the Ponseti method.

Walk me through the steps or phases of this treatment.

The treatment is a gentle manipulation of the foot on a weekly basis that is then held in position with a long leg plaster cast. The foot is corrected in a gradual fashion and each week improvement is seen. While the baby may be fussy during the gentle manipulation process, the method is not painful. We do not want pain at all, we want to stretch the tight tissues, not tear them to get them into position as tearing causes both pain and inflammation which can cause scarring and slow down the correction process. The average number of casts or weeks of new casts placed is 5-7 once the treatment is started. In some non-idiopathic conditions it can take 10-12 casts or more. Once the high arch and the foot turn in is completely corrected, almost all idiopathic or non-idiopathic clubfeet will require a procedure to release the heel cord immediately prior to the last cast being placed. At Arnold Palmer Hospital for Children this is usually done in clinic, painlessly with the use of numbing cream. No general anesthesia is required for these babies unless they are too old and strong to keep still, in which case they might need to have general anesthesia. If a release of the heel cord is required, the last cast stays on for 3 weeks for the released heel cord to completely heal.

After active casting is over, the child wears a maintenance of correction device that comes in three forms, Dennis-Browne bar and shoes, Ponseti AFOs, or the Dobbs bar and AFOs. This is worn 22 hours for 2-3 months. After this it is worn during the night and nap time until the child is five years old. With this treatment, by the time the child is crawling age they are only wearing the maintenance device at night and during naps.

With the maintenance device worn as prescribed, the clubfoot is for all intensive purposes normal for the rest of their life, with long term studies showing that the well-corrected clubfoot with the Ponseti method has no more risk of having foot pain than people born without a foot deformity. 85 percent of those wearing the maintenance device as prescribed will never require more casting or other treatment, but when not worn correctly only 30 percent will avoid more casting or surgery. Most clubfoot recurrences can be treated with casting alone even in children under ten.

How has the Ponseti Method changed the prognosis for children born with this condition?

The Ponseti technique has allowed not only an option, but the best option for treatment of children born with clubfoot. Properly performed, the Ponseti method is the best chance of a normal life (from a foot standpoint) for a child born with clubfoot.