Ponseti method: Difference between revisions

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The Ponseti method is a conservative and manipulative method that is utilised worldwide to correct clubfoot or [[Congenital talipes equinovarus (CTEV)|Congenital Talpes Equino Varus]] (CTEV)<ref name="Rad">Radler, C., 2013. The Ponseti method for the treatment of congenital club foot: Review of the current literature and treatment recommendations. International Orthopaedics, 37, pp.1747–1753.</ref>. [[Image:Dr Ponsetí.jpg|thumb|right|Ignacio Ponseti Vives, MD]]It was developed by [https://en.wikipedia.org/wiki/Ignacio_Ponseti Dr. Ignacio.V.Ponsetti (1943-2009)] of the University of Iowa hospital and clinics <ref name="Zwi">Zwick, E.B., Kraus, Tanja.,Maizen,C.,Steinwender,G.,Linhart, Wolfgang E. 2009. Comparison of ponseti versus surgical treatment for idiopathic clubfoot: A short-term preliminary report. Clinical Orthopaedics and Related Research, 467, pp.2668–2676.</ref>. This method was developed in response to the complications and poor outcomes which came with surgical management of clubfoot<ref name="Ger">Gerlach, D.J., Gurnett, CA.,Limpaphayom, N.,Alaee, Farhang.,Zhang, Z.,Porter, K.,Smyth, M. D Dobbs, Matthew B 2009. Early results of the Ponseti method for the treatment of clubfoot associated with myelomeningocele. The Journal of bone and joint surgery. American volume, 91, pp.1350–1359</ref>.Dr. Ponseti was convinced there was a more efficient and effective way of treating clubfoot this resulted in him studying extensively functional and patho-anatomy of the normal foot and the one which presented with clubfoot<ref name="Har">Harmer, L. &amp;; Rhatigan, J., 2014. Clubfoot care in low-income and middle-income countries: From clinical innovation to a public Health Program. World Journal of Surgery, 38, pp.839–848</ref>.   
The Ponseti method is a conservative and manipulative method that is utilised worldwide to correct clubfoot or [[Congenital talipes equinovarus (CTEV)|Congenital Talpes Equino Varus]] (CTEV)<ref name="Rad">Radler, C., 2013. The Ponseti method for the treatment of congenital club foot: Review of the current literature and treatment recommendations. International Orthopaedics, 37, pp.1747–1753.</ref>. [[Image:Dr Ponsetí.jpg|thumb|right|Ignacio Ponseti Vives, MD]]It was developed by [https://en.wikipedia.org/wiki/Ignacio_Ponseti Dr. Ignacio.V.Ponsetti (1943-2009)] of the University of Iowa hospital and clinics <ref name="Zwi">Zwick, E.B., Kraus, Tanja.,Maizen,C.,Steinwender,G.,Linhart, Wolfgang E. 2009. Comparison of ponseti versus surgical treatment for idiopathic clubfoot: A short-term preliminary report. Clinical Orthopaedics and Related Research, 467, pp.2668–2676.</ref>. This method was developed in response to the complications and poor outcomes which came with surgical management of clubfoot<ref name="Ger">Gerlach, D.J., Gurnett, CA.,Limpaphayom, N.,Alaee, Farhang.,Zhang, Z.,Porter, K.,Smyth, M. D Dobbs, Matthew B 2009. Early results of the Ponseti method for the treatment of clubfoot associated with myelomeningocele. The Journal of bone and joint surgery. American volume, 91, pp.1350–1359</ref>.Dr. Ponseti was convinced there was a more efficient and effective way of treating clubfoot this resulted in him studying extensively functional and patho-anatomy of the normal foot and the one which presented with clubfoot<ref name="Har">Harmer, L. &amp;; Rhatigan, J., 2014. Clubfoot care in low-income and middle-income countries: From clinical innovation to a public Health Program. World Journal of Surgery, 38, pp.839–848</ref>.   


The Ponseti has become the gold standard of treatment compared to the other interventions because of its better outcomes <ref name="Rad" />.The use of the Ponsetti has spread worldwide with evidence shown in 113 out 193 united nations member countries.<ref name="Sha">Shabtai, L. et al., 2014. Worldwide spread of the Ponseti method for clubfoot. , 5(5), pp.585–590.</ref> Numerous research studies in countries across the globe in the last 20 years have shown that more than 90% of cases of newborn children with idiopathic clubfoot can be treated effectively with the Ponseti technique.  
The Ponseti has become the gold standard of treatment compared to the other interventions because of its better outcomes <ref name="Rad" />.The use of the Ponseti has spread worldwide with evidence shown in 113 out 193 united nations member countries.<ref name="Sha">Shabtai, L. et al., 2014. Worldwide spread of the Ponseti method for clubfoot. , 5(5), pp.585–590.</ref> Numerous research studies in countries across the globe in the last 20 years have shown that more than 90% of cases of newborn children with idiopathic clubfoot can be treated effectively with the Ponseti technique.  


Ponseti treatment for clubfoot has, in many countries, completely replaced the previous methods of treating clubfoot, which were a mix of surgical and conservative techniques, such as strapping. The Ponseti method consists of 2 equally important phases: the corrective phase and the maintenance phase and consist of serial manipulation, casting and tenotomy of the Achilles Tendon. Posteromedial medial release may be required in some patients to achieve correction<ref name="Gop">Gopakumar, T. &amp; Rahul, M., 2014. Ponseti technique in the management of Idiopathic club foot. Kerala Journal of Orthopaedics, 27(1), pp.15–17.</ref>. This is followed by the use of the use of foot abduction brace to prevent the occurrence of relapse. All these procedures can be divided into two i.e. casting phase which consist of manipulation, casting and tenotomy and maintenance phase which is the use of the foot abduction brace to prevent relapse<ref name="Sta">Staheli, L., 2003. Clubfoot: Ponseti Management. GlobalHELP Publicatioons, pp.1–32.</ref>.  
Ponseti treatment for clubfoot has, in many countries, completely replaced the previous methods of treating clubfoot, which were a mix of surgical and conservative techniques, such as strapping. The Ponseti method consists of 2 equally important phases: the corrective phase and the maintenance phase and consist of serial manipulation, casting and tenotomy of the Achilles Tendon. Posteromedial medial release may be required in some patients to achieve correction<ref name="Gop">Gopakumar, T. &amp; Rahul, M., 2014. Ponseti technique in the management of Idiopathic club foot. Kerala Journal of Orthopaedics, 27(1), pp.15–17.</ref>. This is followed by the use of the use of foot abduction brace to prevent the occurrence of relapse. All these procedures can be divided into two i.e. casting phase which consist of manipulation, casting and tenotomy and maintenance phase which is the use of the foot abduction brace to prevent relapse<ref name="Sta">Staheli, L., 2003. Clubfoot: Ponseti Management. GlobalHELP Publicatioons, pp.1–32.</ref>.  
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Less than 5% of infants born with clubfeet may have very severe, short, plump feet with stiff ligaments, unyielding to stretching with a deep transverse skin fold across the sole of the foot and another crease above the heel. These babies require special treatment and may need surgical correction. The results are better if bone and joint surgery can be avoided altogether. Surgery in the clubfoot is invariably followed by scarring, stiffness and muscle weakness which becomes more severe and disabling after adolescence.
Less than 5% of infants born with clubfeet may have very severe, short, plump feet with stiff ligaments, unyielding to stretching with a deep transverse skin fold across the sole of the foot and another crease above the heel. These babies require special treatment and may need surgical correction. The results are better if bone and joint surgery can be avoided altogether. Surgery in the clubfoot is invariably followed by scarring, stiffness and muscle weakness which becomes more severe and disabling after adolescence.
=== Corrective Phase ===
During the corrective phase the position of the foot is gradually corrected using a series of manipulations and plaster of Paris casts, then finally a small outpatient procedure is performed to cut the Achilles Tendon (Tenotomy). The Corrective Phase usually takes 4–8 weeks and the baby is seen weekly for the treatment.


The treatment should begin in the first week or two of life in order to take advantage of the favorable elasticity of the tissues forming the ligaments joint capsules and tendons. With our treatment these structures are stretched with weekly, gentle manipulations. A plaster cast is applied after each weekly session to retain the degree of correction obtained and to soften the ligaments. Thereby, the displaced bones are gradually brought into the correct alignment.
The treatment should begin in the first week or two of life in order to take advantage of the favorable elasticity of the tissues forming the ligaments joint capsules and tendons. With our treatment these structures are stretched with weekly, gentle manipulations. A plaster cast is applied after each weekly session to retain the degree of correction obtained and to soften the ligaments. Thereby, the displaced bones are gradually brought into the correct alignment.
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Five to seven plaster casts extending from the toes to the upper thigh with the knees at right angle should be sufficient to correct the clubfoot deformity. Even the very stiff feet require no more than 8 or 9 plaster casts to obtain maximum correction. Before applying the last plaster cast which is to be worn for three weeks, the Achilles tendon is often cut in an office procedure to complete the correction of the foot. By the time the cast is removed the tendon has regenerated to a proper length. After two months of treatment the foot should appear overcorrected. Recently we found that the treatment can be shortened by changing the plaster casts every five days.
Five to seven plaster casts extending from the toes to the upper thigh with the knees at right angle should be sufficient to correct the clubfoot deformity. Even the very stiff feet require no more than 8 or 9 plaster casts to obtain maximum correction. Before applying the last plaster cast which is to be worn for three weeks, the Achilles tendon is often cut in an office procedure to complete the correction of the foot. By the time the cast is removed the tendon has regenerated to a proper length. After two months of treatment the foot should appear overcorrected. Recently we found that the treatment can be shortened by changing the plaster casts every five days.


Following correction the clubfoot deformity tends to relapse. To prevent relapses, when the last plaster cast is removed a splint must be worn full-time for two to three months and thereafter at night for 3-4 years. The splint consists of a bar (the length of which is the distance between the baby's shoulders) with high top open-toed shoes attached at the ends of the bar in about 70 degrees of external rotation. A strip of plastizote must be glued inside the counter of the shoe above the baby's heel to prevent the shoes from slipping off. The baby may feel uncomfortable at first when trying to alternatively kick the legs. However, the baby soon learns to kick both legs simultaneously and feels comfortable. In children with only one clubfoot, the shoe for the normal foot is fixed on the bar in 40 degrees of external rotation. During the daytime the children wear regular shoes. Shoes attached to the bar often cause pressure blisters and sores. To prevent such distressing problems, we have devised a new foot and ankle abduction orthosis that holds the foot firmly and comfortably in place, causing no sores.
=== Maintenance Phase ===
Following Correction Phase the clubfoot deformity tends to relapse without adequate management. To prevent relapses, when the last plaster cast is removed a brace must be worn full-time for two to three months and thereafter at night for 3-4 years. The brace, known as a Foot Abduction Brace, consists of a bar (the length of which is the distance between the baby's shoulders) with high top open-toed shoes attached at the ends of the bar in about 70 degrees of External Rotation. A strip of plastizote must be glued inside the counter of the shoe above the baby's heel to prevent the shoes from slipping off. The baby may feel uncomfortable at first when trying to alternatively kick the legs. However, the baby soon learns to kick both legs simultaneously and feels comfortable. In children with only one clubfoot, the shoe for the normal foot is fixed on the bar in 40 degrees of external rotation. During the daytime the children wear regular shoes. Shoes attached to the bar can cause pressure blisters and sores. To prevent these problems, a new foot and ankle abduction orthosis that holds the foot firmly and comfortably in place has been developed, causing no sores.


Since the surgeon can feel with his fingers the position of the bones and the degree of correction, X-rays of the feet are not necessary except in complex cases.
Since the surgeon can feel with his fingers the position of the bones and the degree of correction, X-rays of the feet are not necessary except in complex cases.

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Introduction[edit | edit source]

The Ponseti method is a conservative and manipulative method that is utilised worldwide to correct clubfoot or Congenital Talpes Equino Varus (CTEV)[1].

Ignacio Ponseti Vives, MD

It was developed by Dr. Ignacio.V.Ponsetti (1943-2009) of the University of Iowa hospital and clinics [2]. This method was developed in response to the complications and poor outcomes which came with surgical management of clubfoot[3].Dr. Ponseti was convinced there was a more efficient and effective way of treating clubfoot this resulted in him studying extensively functional and patho-anatomy of the normal foot and the one which presented with clubfoot[4].

The Ponseti has become the gold standard of treatment compared to the other interventions because of its better outcomes [1].The use of the Ponseti has spread worldwide with evidence shown in 113 out 193 united nations member countries.[5] Numerous research studies in countries across the globe in the last 20 years have shown that more than 90% of cases of newborn children with idiopathic clubfoot can be treated effectively with the Ponseti technique.

Ponseti treatment for clubfoot has, in many countries, completely replaced the previous methods of treating clubfoot, which were a mix of surgical and conservative techniques, such as strapping. The Ponseti method consists of 2 equally important phases: the corrective phase and the maintenance phase and consist of serial manipulation, casting and tenotomy of the Achilles Tendon. Posteromedial medial release may be required in some patients to achieve correction[6]. This is followed by the use of the use of foot abduction brace to prevent the occurrence of relapse. All these procedures can be divided into two i.e. casting phase which consist of manipulation, casting and tenotomy and maintenance phase which is the use of the foot abduction brace to prevent relapse[7].

The video below shows a short documentary on clubfoot treatment from the National Geographic [8]

Goals of Ponseti Method[edit | edit source]

  • Functional, Pain-free Feet
  • Wear Normal Shoes
  • Avoid Permanent Disability

Description of Procedure[edit | edit source]

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 with a deep transverse skin fold across the sole of the foot and another crease above the heel. These babies require special treatment and may need surgical correction. The results are better if bone and joint surgery can be avoided altogether. Surgery in the clubfoot is invariably followed by scarring, stiffness and muscle weakness which becomes more severe and disabling after adolescence.

Corrective Phase[edit | edit source]

During the corrective phase the position of the foot is gradually corrected using a series of manipulations and plaster of Paris casts, then finally a small outpatient procedure is performed to cut the Achilles Tendon (Tenotomy). The Corrective Phase usually takes 4–8 weeks and the baby is seen weekly for the treatment.

The treatment should begin in the first week or two of life in order to take advantage of the favorable elasticity of the tissues forming the ligaments joint capsules and tendons. With our treatment these structures are stretched with weekly, gentle manipulations. A plaster cast is applied after each weekly session to retain the degree of correction obtained and to soften the ligaments. Thereby, the displaced bones are gradually brought into the correct alignment.

Five to seven plaster casts extending from the toes to the upper thigh with the knees at right angle should be sufficient to correct the clubfoot deformity. Even the very stiff feet require no more than 8 or 9 plaster casts to obtain maximum correction. Before applying the last plaster cast which is to be worn for three weeks, the Achilles tendon is often cut in an office procedure to complete the correction of the foot. By the time the cast is removed the tendon has regenerated to a proper length. After two months of treatment the foot should appear overcorrected. Recently we found that the treatment can be shortened by changing the plaster casts every five days.

Maintenance Phase[edit | edit source]

Following Correction Phase the clubfoot deformity tends to relapse without adequate management. To prevent relapses, when the last plaster cast is removed a brace must be worn full-time for two to three months and thereafter at night for 3-4 years. The brace, known as a Foot Abduction Brace, consists of a bar (the length of which is the distance between the baby's shoulders) with high top open-toed shoes attached at the ends of the bar in about 70 degrees of External Rotation. A strip of plastizote must be glued inside the counter of the shoe above the baby's heel to prevent the shoes from slipping off. The baby may feel uncomfortable at first when trying to alternatively kick the legs. However, the baby soon learns to kick both legs simultaneously and feels comfortable. In children with only one clubfoot, the shoe for the normal foot is fixed on the bar in 40 degrees of external rotation. During the daytime the children wear regular shoes. Shoes attached to the bar can cause pressure blisters and sores. To prevent these problems, a new foot and ankle abduction orthosis that holds the foot firmly and comfortably in place has been developed, causing no sores.

Since the surgeon can feel with his fingers the position of the bones and the degree of correction, X-rays of the feet are not necessary except in complex cases.

When the deformity relapses in spite of proper splinting a simple operation may be needed when the child is over two years of age. The operation consists in transferring the anterior tibial tendon to the third cuneiform.

Poor results of cast and manipulative treatments of clubfeet in many clinics indicate that the attempts at correction have been inadequate because the techniques used are flawed. Without a thorough understanding of the anatomy and kinematics of the normal foot and of the deviation of the bones in the clubfoot, the deformity is difficult to correct. Poorly conducted manipulations and casting will further compound the clubfoot deformity rather than correct it making treatment difficult or impossible.

Surgeons with limited experience in the treatment of clubfoot should not attempt to correct the deformity. They may succeed in correcting mild clubfeet, but the severe cases require experienced hands. Referral to a center with expertise in the non-surgical correction of clubfoot should be sought before considering surgery.[1]

Resources[edit | edit source]

  1. ↑ 1.0 1.1 Radler, C., 2013. The Ponseti method for the treatment of congenital club foot: Review of the current literature and treatment recommendations. International Orthopaedics, 37, pp.1747–1753.
  2. ↑ Zwick, E.B., Kraus, Tanja.,Maizen,C.,Steinwender,G.,Linhart, Wolfgang E. 2009. Comparison of ponseti versus surgical treatment for idiopathic clubfoot: A short-term preliminary report. Clinical Orthopaedics and Related Research, 467, pp.2668–2676.
  3. ↑ Gerlach, D.J., Gurnett, CA.,Limpaphayom, N.,Alaee, Farhang.,Zhang, Z.,Porter, K.,Smyth, M. D Dobbs, Matthew B 2009. Early results of the Ponseti method for the treatment of clubfoot associated with myelomeningocele. The Journal of bone and joint surgery. American volume, 91, pp.1350–1359
  4. ↑ Harmer, L. &; Rhatigan, J., 2014. Clubfoot care in low-income and middle-income countries: From clinical innovation to a public Health Program. World Journal of Surgery, 38, pp.839–848
  5. ↑ Shabtai, L. et al., 2014. Worldwide spread of the Ponseti method for clubfoot. , 5(5), pp.585–590.
  6. ↑ Gopakumar, T. & Rahul, M., 2014. Ponseti technique in the management of Idiopathic club foot. Kerala Journal of Orthopaedics, 27(1), pp.15–17.
  7. ↑ Staheli, L., 2003. Clubfoot: Ponseti Management. GlobalHELP Publicatioons, pp.1–32.
  8. ↑ National Geographic.For Children With Clubfoot, Treatment Can Be Life Changing.Available from:https://www.youtube.com/watch?v=psdsqsdAxc0[last accessed 2/28/2016]

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]


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