Congenital Clubfoot: Fundamentals of Treatment

Product Description: Clubfoot is the most common congenital foot deformity. The great majoriy of clubfeet can be corrected in infancy in just a few weeks when treated by expert orthopaedic surgeons. The best and safest treatment is manipulation followed by the application of a plaster cast.
This book describes the best and safest treatment for the most common clubfoot deformities. It provides a sound introduction to the theory underlying the approach, and gives full practical details to enable clinicians to carry out the procedures with confidence. It also covers common errors in treatment and how to avoid them.


At 85 years young, Ignacio Ponseti is still vigorously teaching pediatric orthopaedics through his latest publication, Congenital Clubfoot : Fundamentals of Treatment. This highly readable work is the opus magnus of a master surgeon who has reviewed and critically analyzed nearly 50 years of personal experience in treating congenital clubfoot. His message is unique, as he is a nearly lone advocate of his conservative method of treatment, in which only minimally invasive procedures are employed. While minimally invasive surgery may be popular, it is not de rigeur amongst clubfoot surgeons. Most pediatric orthopaedic surgeons advocate extensive open joint releases and tendon lengthenings. All too often, the result is a stiff, scarred, weak foot. Ponseti's book demonstrates that it is possible, using his carefully honed method, to achieve a beautiful, supple and strong foot with simple casting and a percutaneous Achilles tenotomy. As with most things, the devil is in the details. This book describes, therefore, in great detail, how any orthopaedic surgeon can achieve the same results. Every clubfoot surgeon does preliminary casting, but most will concede that major surgery is required in 60-90% of patients. Why then, does only Ponseti (and his acolytes) obtain such reliably good results from casting? As Ponseti explains it, most orthopaedic surgeons do not know the proper method of casting. To summarize, Ponseti lifts up on the first metatarsal for the first cast. This may appear to paradoxically supinate the foot even more, but in fact, it serves to make the slightly supinated forefoot match the even more supinated hindfoot. Thus, the cavus component is decreased. Ponseti's golden rule: Never actively pronate the foot! Each subsequent weekly cast is applied after manipulation using pure abduction of the forefoot, with NO pronation, except that amount that comes naturally as the calcaneus rotates under the talus. Ponseti points out that one should never apply counter pressure on the outside of the calcaneus. Instead, he applies counter pressure on the neck of the talus. Another inviolate Ponseti principle is to always use a long leg cast, bent 90 degrees at the knee. This is the only way to control rotation. Most patients will have some residual equinus after 4 to 6 casts, and in this situation, Ponseti advocates a percutaneous tenotomy of the Achilles tendon, under local anesthesia in the cast room. In this age of cost containment, this approach makes great fiscal sense. I have used Ponseti's method 18 times in the past two years, and I have found patients and families to be quite tolerant of this "office surgery". It is, after all, less invasive than a circumcision. After the tenotomy, a final cast is applied for three weeks. When this cast is removed, the child is placed into straight last shoes with a Denis Brown bar set at 70 degrees external rotation (45 degrees on the normal side, for unilaterals). Now here's the catch: they must wear this device day and night for two months, and night time only for two to three years. Despite this, about 35 percent of patients will need a lateral transfer of the tibialis anterior tendon, for slight residual supination. Not a bad price to pay for a foot that is remarkably supple, with excellent strength. Ponseti has studied his patients at long term follow-up (something that nearly only takes place in Iowa), and found normal strength and function, as compared to a normal control population. True, there are often radiographic abnormalities, but not arthritic changes, as one may see on an extensively operated, stiff foot. This book should inspire pediatric orthopaedists to take a fresh look at this time-tested and proven method of obtaining excellent results in clubfeet without major surgery. There are two major requirements, however: a cooperative family, that will continue using the Denis Browne bar for two years, and a dedicated surgeon, who will read Ponseti's book carefully, and apply each principle as described. Shortcuts, such as not using the Denis Browne bar, or not using long leg casts, will surely result in failure. One word of caution: if you adopt Ponseti's method, as I have, then you will experience a noticeable drop in your income. Instead of an expensive open posteromedial release, you will be doing a relatively inexpensive percutaneous tenotomy. However, the satisfaction of seeing supple, fully corrected feet resulting from conservative treatment will be its own reward. One final note: if Ponseti's method is so effective, why is it not widely used? The fault lies with two parties: we the orthopaedic community, and Ignacio Ponseti himself. We tend to be conservative, closed minded, and not open to new ideas. Ponseti has been guilty, at least until he published this book, of not arguing forcibly enough to promote his ideas. Those who personally know "Papa" Ponseti understand that he is gentle, soft-spoken, non-bombastic, and non-dogmatic. As a result, his quiet voice has been drowned out by the more self-promoting personalities in our profession. Now in the twilight of his career, Ponseti has realized how important it is to teach his method to a wider audience than just residents at the University of Iowa. In this book, he has done an admirable job of explaining and illustrating his method. It is up to the rest of us, now, to carefully read, digest, and apply his principles. Generations of clubfoot babies will thank us.
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