Questions to confirm that your doctor is using the Ponseti Method.
Some doctors say that they are using the Ponseti Method, but they may be only referring to the fact that they do serial plaster casts, or they may have modified it, or not be following it exactly. Studies show that the best results are achieved by following the protocol of the Ponseti Method exactly as developed by Dr Ponseti and recommended by the Ponseti International Association. There are 60 year follow-ups, so it’s tried and tested. These are some questions to ask, or things to note, if you are not sure that your doctor is using the true Ponseti Method
Q. Do you use half leg or full leg casts?A. The answer should be full leg casts. The Ponseti method uses casts up to the groin and bent at the knee at a 90 degree angle. This helps to immobilise and hold the manipulated foot in the right position so that the ligaments, tendons and skin can grow until the next cast is applied.
Q. How many casts do you need to do before the foot is corrected?A. The answer should be three to six casts – and maybe a couple more if the clubfoot is very severe and stiff. If it takes longer than nine casts, the manipulation is not being done correctly. Dr Ponseti says that casting will not have good results in less than 5% of all clubfoot babies.
If your doctor seems vague even after one or two casts about how many more casts are needed, or tells you to “be patient”, they are not following the method correctly. You should also be able to visibly see progress by the shape and angle of the casts.
Q. Do you do a tenotomy in most cases?A. The answer is likely to be “Yes”, studies show that a tenotomy is recommended in over 80% of cases. The final cast is usually after a tenotomy. This is done in most cases and is the only ‘invasive’ part of the treatment. It is typically a procedure done in the surgeon’s rooms under local anaesthetic. Some surgeons prefer to use general anaesthesia. Either way, it only takes about 10 minutes.
The surgeon first anaesthetises the area, then makes a tiny cut with a scalpel at the back of the heel, the Achilles tendon is cut, so that the foot drops down. The final cast is then applied to hold the foot correctly until the Achilles tendon regenerates in the correct position, which takes three weeks. There may be a little bleeding on the cast at the heel area, which looks worse than it is because the plaster acts like a sponge. All you can see afterwards is a tiny scab, the size of a pinhead, which falls off, there is no scar.
Dr Ponseti used the tenotomy because the Achilles heel is thick and resistant to stretching; he prefers to do it instead of keeping the baby in casts for longer until the tendon is fully stretched. The tendon must be stretched for the foot to be fully corrected and to be able to wear the FAB comfortably. Once the final cast is removed, the brace will hold the correction and stretch of the Achilles tendon/heel cord.
Important note: The procedure used in the Ponseti technique is referred as a Percutaneous Tenotomy. An Open Incision or Z-lengthening Tenotomy or Heel Cord Lengthening is a very different procedure – a surgical procedure that results in scar tissue.
Q. What method of splint/brace do you use?A. The answer should be a foot abduction brace. The brace that was designed in consultation with Dr Ponseti is the Ponseti AFO, also known as the Mitchell Brace. This is an aluminium adjustable brace, on which two shoes are attached. The shoes will be set at a 70º angle (or 60º with Mitchell Brace). If the baby only has one clubfoot, the shoe for the normal foot is set at a 40º angle. It may look wide, but it’s comfortable for the baby that way. Dr Ponseti says that the distance between the heels should equal the width of the shoulders; this is the most comfortable for the baby. The foot is over-corrected at first to allow for the ligaments, tendons and skin to grow. There are other braces available which achieve the same – as long as the principles are the same for the angle of the shoes and width of bar.
Note: The Ponseti Ankle Foot Orthotic (AFO) is very different to a typical AFO, which is a plastic and velcro splint not attached to a bar. The similarity in name can be confusing. The only time that an AFO would ever be used with the Ponseti Method would be in some clubfoot cases where there is spina bifida, cerebral palsy or other neurological conditions, but this is not common.
Q. How long is the brace worn for?A. The answer should be initially two to three months of full time wear (23 hours a day), followed by night and naptime wear that reduces gradually from 20 to about 14 hours by the time the child is weight-bearing/cruising. By the time the child is two, brace wear is typically 10-12 hours at night until about four years of age. In a few cases, the child has loose joints and stops brace wear earlier, but it is generally recommended that they stay in it at least until four years old. Dr Ponseti’s experience has shown that there is a high tendency for relapse between the age of two and two and a half years of age, probably because of growth spurts. It’s important that the doctor follows the bracing protocol and assists you in the first few weeks of your baby adapting. If you comply with brace wear as prescribed in the Ponseti Method, you are 100% assured of avoiding relapse in the majority of clubfoot cases.
Q. Is the cast applied with an assistant in attendance?A. The answer should be “Yes”. Dr Ponseti’s method is to have a person able to apply a cast (nurse, physio, orthotist, etc) to roll on the bandage while he continues to hold and manipulate the foot in the position he requires for the particular cast. The parent can help keep the baby amused and distracted while the cast is being applied. One very successful way is to feed your baby. The Ponseti method is never painful for the baby, but they may cry because they get irritated about being held still during the process. If your baby is so upset that accurate casting is made impossible, Dr Ponseti advises that the doctor stops for a few minutes to calm the baby before continuing with the cast.
Q. How often do you change the cast?A. The cast only needs to be on for five to seven days (with the exception of the final cast if a tenotomy has been done). Not only is it not necessary to keep a cast on for any longer than that, some babies grow so fast they can literally outgrow them in a short space of time.
Q. When and how is each cast removed?A. The cast should only be removed on the morning that the new one is going to be applied, not the night before. A small baby grows so quickly it can only take a few hours for relapse to start. Some doctors ask you to wet the cast and wrap in a damp towel covered with plastic, and will remove it in their rooms. Others might not have the facilities and will ask you to remove it yourself. This is not ideal, but if it’s what your doctor requires, then do it only just before you leave home. Leaving the casts off overnight means slower progress in correction and the risk of more casts.
Q. What is your success rate?A. The typical success rate is 90% (or better), if the Ponseti Method is followed without any modifications. Parents play a major part in the success figures and should attend all appointments and follow correct brace wear protocol as prescribed by Dr Ponseti to avoid relapse. A doctor who is still new to the Ponseti method should be consulting with more experienced doctors who are achieving the success. If the figures are lower, then either the doctor is ‘tweaking’ the method or needs more training.
Note: Some doctors still say things like: “Nobody can reproduce the results that Iowa gets.” Not true. Doctors around the world have published similar results. The proof is out there and what the successful doctors have in common is they establish clubfoot clinics with the same protocols as Dr Ponseti. They don’t deviate from the method.