Scholarly Works Focused on Clubfoot

Below we have collected and organized works that display critical clubfoot knowledge and relevant medical data – with their corresponding web-links. We direct all viewers on our platform to these major academic works and research studies focused on clubfoot. The scope of research surrounding the treatment of congenital talipes equinovarus (clubfoot) goes well beyond what is included here. This list was selected to provide an overview of the academia surrounding the modern approach to treating clubfoot. We will continuously update this list as we uncover new studies as well as other work involving relevant clubfoot research.

The Green Book – Dr. Ignacio Ponseti  

This is Dr. Ignacio Ponseti’s groundbreaking work on clubfoot treatment – The Ponseti Method.

Congenital Clubfoot. Fundamentals of Treatment (Oxford University Press), 1996. Link

Clubfoot: Ponseti Management

Now updated to a completely new 3rd Edition in a variety of languages. Thank you to everyone involved with the production of this new edition, especially those, like Dr. Jose Morcuende at Ponseti International, who edited and proof-read the book for up-to-date medical accuracy.

Staheli L, Ponseti I, et al.. Book. 2009. GHO Publications. 32 Pages. Link

Diagnosis and Treatment of Idiopathic Congenital Clubfoot

Abstract

Idiopathic congenital clubfoot is the most common serious musculoskeletal birth defect in the United States and the world. The natural history of the deformity is to persist into adult life with a significant decrease in function and quality of life. The Ponseti method (serial casting, Achilles tenotomy, and bracing of the clubfoot) has become the most effective and accepted treatment of children born with clubfoot worldwide. The treatment is successful, particularly when the Ponseti-trained practitioner (often a pediatric orthopedic surgeon), the primary care clinician, and the family work together to facilitate success. An important factor in the ultimate success of the Ponseti method is parental understanding of the bracing phase. There is a very high rate of recurrent deformity when bracing is not done properly or is stopped prematurely. The importance of positive education and support for the parents to complete the entire treatment protocol cannot be overstated. The goal of treatment is a deformity-free, functional, comfortable foot. Ponseti clubfoot programs have been launched in most countries throughout the world, including many countries with limited resources. Ultimately, the goal is that every infant born with a clubfoot will have access to care with the Ponseti method. This clinical report is intended for medical practitioners who are involved in the care of pediatric patients with clubfoot. Understanding the standard of care will help these practitioners to care for patients and their families.

Robert Cady, Theresa A. Hennessey, Richard M. Schwend; SECTION ON ORTHOPEDICS, Diagnosis and Treatment of Idiopathic Congenital Clubfoot. Pediatrics February 2022; 149 (2): e2021055555. 10.1542/peds.2021-055555 Link

Club-foot Through the Centuries

Abstract

The early history of club-foot is the history of the lame and crippled child. Throughout the ages the fate of a deformed child depended on the attitude of the society.

Strach, E.H. (1986). Club-foot Through the Centuries. In: Rickham, P.P. (eds) Historical Aspects of Pediatric Surgery. Progress in Pediatric Surgery, vol 20. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-70825-1_16 Link

International Perspective on the Ponseti Method

Abstract

Purpose of review: The purpose of this article is to acquaint the reader with the Ponseti method of clubfoot treatment and to describe the features of the technique that make it superior to other forms of clubfoot treatment. These features make the technique applicable across a wide spectrum of healthcare delivery systems on a truly international basis.

Recent findings: The Ponseti method has proven to be successful around the globe, in both industrialized countries and developing nations. In many settings, non-physician practitioners are primarily responsible for the casting phase of treatment, particularly in areas with a shortage of physicians. Internationally, researchers are effectively expanding the scope of clubfeet treated: older children, postsurgical recurrent deformities, and non-idiopathic clubfeet. The barriers that undermine the outcomes of a Ponseti clubfoot program are primarily poverty and noncompliance with the extended post-casting brace protocol.

Summary: The Ponseti method should be considered the best treatment modality for all children with clubfeet. In the developing world, where most neglected clubfeet occur, emphasis should continue to be the training of practitioners and implementation of programs to reach all affected children. Research will continue to broaden the indications for the method.

van Bosse HJ. Ponseti treatment for clubfeet: an international perspective. Curr Opin Pediatr. 2011 Feb;23(1):41-5. doi: 10.1097/MOP.0b013e328342112a. PMID: 21150445. Link

Results of Ponseti Brasil Program: Multicentric Study in 1621 Feet: Preliminary Results

Abstract and Figures

Background: The Ponseti method has been shown to be the most effective treatment for congenital clubfoot. The current challenge is to establish sustainable national clubfoot treatment programs that utilize the Ponseti method and integrate it within a nation’s governmental health system. The Brazilian Ponseti Program (Programa Ponseti Brasil) has increased awareness of the utility of the Ponseti method and has trained >500 Brazilian orthopaedic surgeons in it. Methods: A group of 18 of those surgeons had been able to reproduce the Ponseti clubfoot treatment, and compiled their initial results through structured spreadsheet. Results: The study compiled 1040 patients for a total of 1621 feet. The average follow-up time was 2.3 years with an average correction time of approximately 3 months. Patients required an average of 6.40 casts to achieve correction. Conclusions: This study demonstrates that good initial correction rates are reproducible after training; from 1040 patients only 1.4% required a posteromedial release. Level of evidence: Level IV.

Monica P. Nogueira, MD, PhD,*Ana C.d.B.F. Queiroz, MD, Alessandro G. Melanda, MSc, et al. Results of Ponseti Brasil Program: Multicentric Study in 1621 Feet: Preliminary Results. June 2016. Journal of Pediatric Orthopaedics 37(3). DOI:10.1097/BPO.0000000000000801 Link

A comprehensive outcome comparison of surgical and Ponseti clubfoot treatments with reference to pediatric norms

Abstract and Figures

Isolated congenital clubfoot can be treated either operatively (posteromedial release) or conservatively (Ponseti method). This study retrospectively compared mid-term outcomes after surgical and Ponseti treatments to a normal sample and used multiple evaluation techniques, such as detailed gait analysis and foot kinematics. Twenty-six children with clubfoot treated surgically and 22 children with clubfoot treated with the Ponseti technique were evaluated retrospectively and compared to 34 children with normal feet. Comprehensive evaluation included a full gait analysis with multi-segment and single-segment foot kinematics, pedobarograph, physical examination, validated outcome questionnaires, and radiographic measurements. The Ponseti group had significantly better plantarflexion and dorsiflexion range of motion during gait and had greater push-off power. Residual varus was present in both treatment groups, but more so in the operative group. Gait analysis also showed that the operative group had residual in-toeing, which appeared well corrected in the Ponseti group. Pedobarograph results showed that the operative group had significantly increased varus and significantly decreased medial foot pressure. The physical examination demonstrated significantly greater stiffness in the operative group in dorsiflexion, plantarflexion, ankle inversion, and midfoot abduction and adduction. Surveys showed that the Ponseti group had significantly more normal pediatric outcome data collection instrument results, disease-specific indices, and Dimeglio scores. The radiographic results suggested greater equinus and cavus and increased foot internal rotation profile in the operative group compared with the Ponseti group. Ponseti treatment provides superior outcome to posteromedial release surgery, but residual deformity still persists.

Thabet, A., Church, C., Coplan, J., et al. A comprehensive outcome comparison of surgical and Ponseti clubfoot treatments with reference to pediatric norms. Journal of Children’s Orthopaedics 6(1). 2012. DOI:10.1007/s11832-012-0387-1 Link

Is Ponseti’s method superior to Kite’s for clubfoot treatment he?

Abstract

Objectives: In literature, there is very little data of prospective randomized trials comparing Ponseti and Kite methods for clubfoot treatment. The goal of this study was to compare the results of two different protocols (Ponseti and Kite) for the treatment of idiopathic clubfoot.

Method: Ponseti’s and Kite’s methods of conservative management in idiopathic congenital clubfoot were compared in a prospective randomized study consisting of 100 infants (150 ft) younger than 3 months. There were 76- and 74-ft infants that underwent treatment by Ponseti’s and Kite’s methods, respectively.

Results: After an average follow-up of 36.2 months in the Ponseti group, correction was achieved in 73 ft (96 %), with only three patients requiring surgical management. There were ten relapses (13.2 %); all of which were corrected conservatively. However, two of these required surgical intervention on showing a relapse again in the second year. In the Kite group, we achieved correction in 55 ft (74.3 %) after an average follow-up of 35.1 months, with 19 patients requiring surgical intervention. There were ten relapses of which only five could be corrected conservatively. Both groups were reviewed by blinded reviewers and rated according to Pirani score.

Conclusion: We think that Ponseti’s method is superior to Kite’s method in achieving correction in idiopathic clubfeet in a relatively shorter time.

Selmani, E. Is Ponseti’s method superior to Kite’s for clubfoot treatment he?. Eur Orthop Traumatol 3, 183–187 (2012). https://doi.org/10.1007/s12570-012-0116-8 Link

Ponseti method compared to previous treatment of clubfoot in Norway. A multicenter study of 205 children followed for 8–11 years

Abstract

Purpose: Despite few studies comparing Ponseti treatment and traditional treatment of clubfoot (talipes equinovarus), the Ponseti method is now accepted as standard treatment for this deformity. The Ponseti method was introduced in Norway in 2003 and the purpose of this multicenter-study was to compare the results of Ponseti treatment with the results of the previous treatment for clubfoot in Norway.

Methods: 90 children (134 clubfeet) treated with previous treatment (pre-Ponseti group), were compared to 115 Ponseti treated children (160 clubfeet) (Ponseti group). The previous treatment consisted of casting and surgery if needed. At 8–11 years of age, all children were examined by the same orthopaedic surgeon, the parents answered a questionnaire, all feet were X-rayed and information about surgical procedures was obtained from the patient records.

Results: The number of surgeries was higher in the pre-Ponseti group, and the number of extensive surgeries was 119 in the pre-Ponseti group compared to 19 in the Ponseti group. The range of motion in the ankle joint was better in the Ponseti group. Children in this group had better function, higher satisfaction and less pain according to patient and parent reported outcome measures. The incidence of moderate or severe talar flattening was higher in the pre-Ponseti group.

Conclusion: Ponseti treatment seems to be superior to the previous treatment in Norway, with regards to number and severity of operations, flexibility of the foot and ankle, parent/patient reported outcome and the presence of talar flattening on X-ray.

Sætersdal, C., Fevang, J.M., Bjørlykke, J.A. et al. Ponseti method compared to previous treatment of clubfoot in Norway. A multicenter study of 205 children followed for 8–11 years. J Child Orthop 10, 445–452 (2016). https://doi.org/10.1007/s11832-016-0760-6 Link

Management of idiopathic clubfoot by Ponseti’s method: a comparative clinical study on toddlers with radiological correlation

Abstract

Background: In developed countries, many children with clubfoot undergo extensive corrective surgery, often with disturbing failures and complications. The need for one or more revision surgeries is common. Although the foot looks better after surgery, it is stiff, weak, and often painful. Non-operative treatment of clubfoot provides a lower complication rate, less pain, and higher function as the patient ages. Lack of information regarding reasons for adherence to the regimen makes it difficult for health providers and health planners to determine the impact of treatments on health status or weigh the cost/benefit ratio for prescribing costly treatments to the patients. Therefore, it is important to understand how parents and health care givers manage their children’s treatment and the potential barriers these parents encounter during the utilization of clubfoot treatment services. It is important to determine the compliance of patients to clubfoot correction treatment in order to identify and target factors that may positively or negatively influence cases attending the clinic.

Methods: 25 cases with clubfoot were studied in the Department of Orthopaedics, Katihar Medical College. Out of these, 13 cases (Group A) were children over 1 year of age with neglected clubfoot and 12 cases (Group B) were children under one year of age with idiopathic clubfoot.

Results: The Ponseti method delivers excellent correction of clubfoot without the associated risks and complications of major foot surgery. Patients treated with Ponseti’s method have leverage in treatment of clubfoot than those treated by other conservative methods. The method provides more flexible foot and ankle than those treated surgically.

Conclusions: Treatment of clubfoot if commenced early will have better result. Children of age less than 1 year respond better than children of older age group. Younger children require fewer correction casts.

Kumar R, Anshupriya. Management of idiopathic clubfoot by Ponseti’s method: a comparative clinical study on toddlers with radiological correlation. International Journal of Research in Orthopaedics (Int J Res Orthop). 2016; 2:52-9. DOI: https://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20161862 Link

The Drop Toe Sign: An Indicator of Neurologic Impairment in Congenital Clubfoot

Abstract

Nine patients presenting during infancy were identified with clubfeet and absent anterior and lateral compartment functions. We considered these to be neurogenic clubfeet. All patients had the drop toe sign: resting posture of the toes in plantarflexion and absent active dorsiflexion movement after plantar stimulation of the foot. Two patients (three feet) underwent exploration of the peroneal nerve, which revealed anatomic abnormalities. Six patients required more casts than typical for initial correction of deformity; all but two had Achilles tenotomy. Four relapsed despite full-time bracing and eventually needed intraarticular surgery to achieve a plantigrade foot. Idiopathic absent peroneal nerve function is not a well-described entity in the clubfoot literature. All babies with clubfoot should be examined for the drop toe sign. When noted, the feet will likely be more difficult to correct initially, may need early Achilles tendon lengthening, will likely need permanent bracing, are likely to relapse and need intraarticular surgery, and may need multiple surgeries to remain plantigrade throughout growth.

Edmonds, E.W., Frick, S.L. The Drop Toe Sign: An Indicator of Neurologic Impairment in Congenital Clubfoot. Clin Orthop Relat Res 467, 1238–1242 (2009). https://doi.org/10.1007/s11999-008-0690-9 Link

Orthopaedic management of spina bifida—part II: foot and ankle deformities

Abstract

Both congenital and acquired orthopaedic deformities are common in patients with spina bifida. Examples of congenital deformities, which are present at birth, include clubfoot and vertical talus. Acquired developmental deformities are related to the level of neurologic involvement and include calcaneus and cavovarus. Orthopaedic deformities may also result from postoperative tethered cord syndrome. The previously published Part I reviewed the overall orthopaedic care of a patient with spina bifida, with a focused review of hip, knee, and rotational deformities. This paper will cover foot and ankle deformities associated with spina bifida, including clubfoot, equinus, vertical talus, calcaneus and calcaneovalgus, ankle and hindfoot valgus, and cavovarus. In addition, this paper will address the issues surrounding skin breakdown in patients with spina bifida.

Swaroop, V., and Dias, L. Orthopaedic management of spina bifida – part II: foot and ankle deformities. Journal of Children’s Orthopaedics 5:430-414. 2011. DOI 10.1007/s11832-011-0368-9 Link

Clubfoot treatment with Ponseti method relies on teamwork, family support

“It is not easy for a family to keep a child in a brace every night for four years, especially when the foot looks and functions normally. Fortunately, significant improvements in brace design have made them much easier for parents to apply and for children to tolerate. The old stiff shoes that were rigidly fixed to the bar have been replaced by detachable shoes or splints with soft linings. The child’s pediatrician and pediatric orthopedic surgeon need to work as a team in helping families comply with the bracing phase” (2022:2).

Robert B. Cady, M.D., Theresa A. Hennessey, M.D., and Richard M. Schwend, M.D., FAAP. Clubfoot treatment with Ponseti method relies on teamwork, family support. American Academy of Pediatrics. 2022. Link

A cross-sectional study investigating impressions and opinions of medical rehabilitation professionals on the effectiveness of the Ponseti method for treatment of clubfoot in Harare, Zimbabwe

Abstract

Background: The Ponseti method of managing clubfoot was introduced in Zimbabwe in 2011. This followed massive training of health workers such as medical rehabilitation practitioners through a programme called the Zimbabwe Sustainable Clubfoot Programme. Today, the Ponseti method is the technique of choice for managing clubfoot in hospitals. However, since then, there is no published evidence documenting the efficacy and the relevance of the technique especially comparing to previously used methods. This is a significant shortcoming if sustainability issues are to be considered. Therefore, this study was designed to investigate the impressions and opinions of medical rehabilitation practitioners on the method in terms of its effectiveness, perceived challenges and possible recommendations for improvement of the technique application in their setting.

Methods: A descriptive cross-sectional study was conducted targeting medical rehabilitation practitioners previously trained on the method and working in public or private clinics that offer clubfoot management in Harare. A questionnaire was self-administered to 41 participants who volunteered to participate in the study. Data from open-ended questions was analysed thematically. Statistica version 12 was used for analysis for quantitative data.

Results: The Ponseti method was perceived as an effective method in the treatment of children with clubfoot by all the participants. All the participants 41 (100 %) felt that the method was relevant because of better clinical outcomes. Amongst challenges faced when using Ponseti method, 25 (61 %) participants agreed that caregivers to the children with clubfoot were not compliant to treatment. A total of 22 (54 %) participants felt that lack of adequate insight by the caregivers of this new method was a challenge which hinder progress in treating clubfoot.

Conclusions: The medical rehabilitation professionals in Harare, Zimbabwe trained to use the Ponseti technique for the management of clubfoot, perceived the method as an effective method resulting in better clinical outcome than previous methods. This probably highlights the need to continue training medical rehabilitation professionals so that there is widespread use of the technique in the country. However, there is need to increase awareness of the method among caregivers to improve compliance, which is key to successful rehabilitation of the clubfoot.

Munambah, N., Chiwaridzo, M. & Mapingure, T. A cross-sectional study investigating impressions and opinions of medical rehabilitation professionals on the effectiveness of the Ponseti method for treatment of clubfoot in Harare, Zimbabwe. Arch Physiother 6, 7 (2016). https://doi.org/10.1186/s40945-016-0021-5 Link