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Speed Up the Treatment for Clubfoot

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If once a week treatment for clubfoot works well, would twice a week get better, faster results? That's the question Dr. Rui Jiang Xu from the Department of Pediatric Orthopaedic Surgery in Beijing, China asked and answered.

The clubfoot is an unmistakable deformity present at birth. The foot is twisted (turned under and towards the other foot). The medical terminology for this position is equinus and varus. Equinus means that the toes are pointed down and the ankle flexed forward (like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.

The medical term for clubfoot is Congenital Talipes Equinovarus. Congenital means that the condition is present at birth and occurred during fetal development. Clubfoot mainly affects three bones of the foot: the calcaneus (heel bone), talus (just above the heel bone), and navicular (bone next to the talus).

The standard treatment for a clubfoot deformity in infants and young children is a procedure called the Ponseti Method. Developed in the 1950s by an an orthopedic surgeon (Dr. I. Ponseti from the University of Iowa), the Ponseti Method involves manipulating (moving) the bones of the foot and ankle toward a neutral position of alignment. The bones are then held in place by a cast.

Each week the cast is removed, the bones are moved again as close to normal as possible and another cast wrapped around the leg to hold everything in place. This weekly treatment continues for about five to six weeks (or until maximum correction possible is achieved).

Dr. Xu applied the standard once-a-week Ponseti treatment to 32 clubfeet and compared the results against another group of 40 clubfeet treated with the modified (twice weekly) approach. Children in the modified Ponseti group were corrected in three weeks compared to five weeks for the standard Ponseti group.

That is a significant difference and a big cost savings. This is true for families in China, or America, or any country who must travel from outlying (rural) areas to a more centralized hospital or clinic where this service is offered.

Taking a closer look at the two groups, the author reports the severity of deformity was the same between these two groups. Age ranged from seven days (one week old) to six months in the standard group and seven days (one week) to 18 months old in the modified group.

Children in the modified group were slightly older and yet still responded well to the treatment. The modified group came from a farther distance away, so in some cases, diagnosis and treatment were delayed.

It is well documented from previous studies that many (not all) children who have the Ponseti method of treatment for clubfeet must still need surgery to lengthen the Achilles tendon.

The Achilles tendon attaches to the calcaneus (heel bone) and pulls the foot into the equinus (toes down) position. Manipulation works well to stretch the joint capsule ligaments, tendons, and muscles in infants and young children. The Ponseti method corrects the abnormal relationships of the bones in the foot.

But the treatment is not always enough to stretch the Achilles tendon and restore full ankle dorsiflexion. Dorsiflexion is the movement of foot and toes towards the face. This is the opposite direction from the pointed (equinus) position.

In this study, an equal number of children in each group (87.5 per cent) required a percutaneous Achilles tenotomy (lengthening the tendon by entering through the skin and cutting it).

In all cases, after surgery, feet were maintained in the corrected position using a special brace or splint called Dennis Browne abduction boots. High-top shoes attached to a bar between the shoes hold the child's feet and ankles apart. The splint is worn 24 hours/day everyday for three months. After three months, the brace is only applied at night while the child is sleeping. Bracing was continued for two more years.

The final measure of effectiveness for the modified Ponseti versus standard Ponseti method is a long-term look at outcomes. In this study, all the children were followed for an average of four years (range: two to six years). Dr. Xu found that in either group, if the Dennis-Browne splint was not worn as prescribed for the full two years, then the foot slipped back into the deformed clubfoot position.

Dr. Xu's conclusion at this point is that the modified (twice weekly) Ponseti treatment for clubfeet is safe and effective. This approach shortens treatment time by a full two weeks. Family cooperation with applying the brace is equally important. Long-term results after further follow-up will be reported for these two groups in a later publication.

Reference: Rui Jiang Xu, MD. A Modified Ponseti Method for the Treatment of Idiopathic Clubfoot: A Preliminary Report. In Journal of Pediatric Orthopaedics. April/May 2011. Vol. 31. No. 3. Pp. 317-319.

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