Step by Step: Treating clubfoot with the Ponseti Method
Posted on 12 March 2020
A growing number of orthopaedic specialists are using a new form of treatment to help children who are born with clubfoot.
Clubfoot affects about one in every 500 children born in Southern Africa, according to research by local advocacy groups. Too often, the condition is misunderstood, going untreated – and even traditional treatment involves long, arduous and frequently unsuccessful surgery.
A non-invasive treatment, known as the Ponseti Method, is changing that, one child at a time.
Clubfoot is a congenital deformity that causes a baby’s foot to turn unnaturally inward or downward. The condition can occur in one or both feet, and affects the structures on the inside of the foot and calf, resulting in a small calf muscle and smaller foot.
In some cases, the deformity can cause the sole of the child’s foot to face sideways or even upward. While clubfoot does not cause any discomfort or pain, if left untreated, the child will not be able to learn to walk normally.
“There is no official source of reliable data to track the prevalence of clubfoot in South Africa,” explains Karen Moss, the founder of STEPS, a non-profit organisation dedicated to improving the lives of children born with clubfoot in the region. “Instead, we rely on independent research papers and data collected from clinics throughout the country – and from those, it is generally agreed by experts that the region has the second-highest rate of the condition in the world.”
Today, STEPS works with about 2 000 new cases each year. However, many more children, especially those in rural areas, are born with the condition and never undergo treatment, living their whole lives with a deformity that is ultimately curable.
Clubfoot is the most common musculoskeletal congenital abnormality affecting children, explains Dr Greg Firth, a paediatric orthopaedic surgeon who worked in specialised clubfoot clinics at Mediclinic Sandton and Chris Hani Baragwanath Hospital. At the time, the clinic saw about 200 patients a month.
Despite its prevalence, there is little evidence that points to a definitive cause of clubfoot but genetic factors are certainly involved. Babies born with clubfoot suffer from shorter-than-usual tendons connecting the muscles in the leg to bones in the heel and foot, says Dr Firth, who works with STEPS and is currently working in the UK.
It is an easily noticeable condition: once born, these children will have a foot that is twisted downward and inward, or turned so severely that it appears to be upside down. A child whose clubfoot goes untreated may live with a leg that is slightly shorter than the other, or underdeveloped calf muscles in the affected leg.
Moss was motivated to raise awareness after her son, Alex, was born with clubfoot in both feet in 2003. “At the time, our treatment options were limited. Doctors were pushing his feet quite forcefully, which was painful and made no difference. So I started doing some research online.”
Her reading led her to the work of Dr Ignacio Ponseti, an orthopaedic surgeon in Iowa, who had invented a nonsurgical method of correcting clubfoot – and at just nine weeks old, Alex was flown to the United States for treatment.
Initial treatment involved a simple consultation, during which Dr Ponseti manipulated the ankle and fitted a cast. It took 15 minutes. Two weeks later, Alex’s feet were straight.
The Ponseti Method consists of two phases, says Dr Firth: casting, and wearing a brace. In the first week or two after birth, doctors will assess the extent of the deformity in the foot, stretch it correctly and apply a cast to correct the deformity. Often the Achilles tendon is tight and requires a small surgery to lengthen it. The casts are replaced once a week, and in most cases, the foot will have been corrected after five casts. After the Achilles
tendon is lengthened, children are then required to wear a brace full time for three months and then at night till four years of age. Without the brace, there is a far higher chance that the condition will recur.
This is a markedly less invasive approach than had been previously used, explains Dr Jason Crane, an orthopaedic surgeon at Mediclinic Cape Town. “Before the Ponseti Method became the global standard, we would treat these cases surgically, in a massive, open procedure called a posterior medial release: we would slice through the tendons, and lengthen them.”
This surgery would leave patients in pain, facing long recovery times, and with the prospect of complications requiring regular follow-up operations. “The real problem was that, by and large, these surgeries were unsuccessful – either over- or under-corrected. In a majority of cases, these patients would be left with some form of
The Ponseti Method has eliminated the need for surgery to correct clubfoot, he says, and improved results at the same time. Best of all, agrees Moss, it is a gentle procedure that is child-friendly. “At one stage, I was sitting on a chair with Alex on my lap while Dr Ponseti was fitting a cast. It was so gentle that Alex fell asleep while his foot was being treated.”
Today, STEPS partners with doctors and clinics across South Africa to bring the Ponseti Method to more and more corners of the country, by training paediatric orthopaedic surgeons at specialist workshops and conferences.
“When Alex was treated, Dr Ponseti was 89 years old,” says Moss. “So this has been around for many years and the SA Orthopaedic Association agreed to recognise the Ponseti Method as best practice in the treatment of clubfoot back in 2012. So there is no reason why children born with clubfoot should live in pain.”