If the Ponseti Method is done correctly, most clubfeet are corrected within four to six casting sessions. The casts are changed weekly. Less than 5% of clubfeet may be very stiff and severe; they may need more casting, but Dr Ponseti says that even they should be corrected within eight to 10 casting sessions. For the most severe cases, surgery is occasionally required, but it’s less radical than it would have been without the correct casting method.
Dr Ponseti uses very gentle manipulations while the baby is seated comfortably on the mother’s lap. Each time, the manipulation is done slightly differently to stretch another part of the foot. Then the plaster is applied. An assistant rolls on the plaster while he is still holding and moving the foot into the position he requires. A lot of plaster is wrapped around the knee, which is bent at almost a 90 degree angle. Dr Ponseti does a full-leg cast right up to the groin. The position of the knee and the full leg cast helps to immobilise the foot into the correct position.
The cast is left on for five to seven days to hold the correction achieved and allow the baby’s ligaments and tendons to soften into the new position. The next manipulation is done and re-casted until the displaced bones are brought into the correct alignment and the foot is correctly positioned.
The Ponseti Method of treatment should begin as early as possible, even when the baby is only a week or two old. This is because the tissues forming the ligaments, joint capsules and tendons are still very elastic and stretch easily with each manipulation. Dr Ponseti and other doctors have treated some babies who were up to a year old successfully, and avoided major surgery on the foot.
In many cases, before applying the last plaster cast, the Achilles tendon is cut in the doctor’s rooms. This is a simple procedure, done with a local anaesthetic, a tiny cut at the back of the heel and not even a stitch required. By the time the cast is removed after three weeks, the tendon has regenerated to a proper length. The foot should appear overcorrected at first; this will change over time as the baby starts walking.
Following correction, the congenital condition that caused the clubfoot deformity in the first place tends to stay active and the foot can sometimes relapse. To prevent relapses, when the last plaster cast is removed a splint must be worn full-time, usually for three months and thereafter at night until four years of age. The splint, called a Foot Abduction Brace (FAB) consists of a bar, with high top open-toed shoes attached to the ends of the bar. The shoes must be shoulder width apart, at 60-70º of external rotation and slightly angled up (toe higher than heel) to maintain the Achilles tendon dorsiflexion correction. In children with only one clubfoot, the shoe for the normal foot is fixed on the bar in 40º of external rotation. During the daytime the children are barefoot or wear regular shoes. No stretching of the foot or physiotherapy is required.
The surgeon can feel the position of the bones and the degree of correction, so X-rays of the feet are not required. Apparently the bones are still like cartilage and do not show up well on X-rays anyway.
If the FAB wear is complied with completely according to Dr Ponseti’s instructions, we are assured of 95% success rate. If the foot relapses after the Ponseti Method further casting may be done if the child is young enough, or a simple operation called an ATT transfer may be needed when the child is over four years of age. The operation consists of transferring the anterior tibial tendon to the third cuneiform. This does not have the negative after effects of full clubfoot surgery (Postero Remedial Release – PMR).
Dr Ponseti’s opinion was that the poor results of cast and manipulative treatments of clubfeet by some doctors 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 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 doctor with training and expertise in the Ponseti non-surgical correction of clubfoot should be sought before considering surgery.