Treatment with the
Ponseti cast method achieved normal ankle motion more
frequently than physical therapy methods in children with moderate
clubfoot, according to a recent study out of the University of
Texas Southwestern Medical Center at Dallas.
Additional intervention, including percutaneous tendo-achilles
lengthening, also affected patients’ progress and eliminated the need for
future surgeries, Hilton P. Gottschalk, MD, lead author of the study, said.
|Hilton P. Gottschalk|
Gottschalk, a resident at UT Southwestern, worked with Lori Karol, MD, a
researcher in the department of orthopedics at Texas Scottish Rite Hospital for
Children (TSRHC), and Kelly Jeans, MS, from TSRHC’s Movement Science
Laboratory. For this prospective study, the researchers followed patients at
TSRHC for treatment for clubfoot from 1998 to 2006.
Upon entering the hospital, researchers presented the patients’
parents with two treatment options — physical therapy methods or the
Ponseti cast method — and provided complete explanations of each process.
Parents made the final decision about the course of treatment.
Following treatment, Gottschalk and his colleagues followed up with the
patients at 2 years old to analyze their gait.
“You can’t analyze the gait earlier than that because you have
to have a cooperative child,” he said. “Even at 2 years old,
it’s quite challenging to have a child walk in a gait lab.”
Researchers measured the gait data on the Dimeglio scale, which scores
the level of clubfoot from moderate, to severe, to very severe.
“What we found was that [children with moderate clubfoot who were
treated with the Ponseti cast technique had no foot drop and had more normal
sagittal ankle plane motion compared to those who were treated with the
physical therapy technique,” Gottschalk said.
Additionally, they found no difference between the two groups in normal
gait, or in internal foot progression angle.
Differences between the two groups, however, appeared in the presence of
swing phase foot drop and of normal kinematic ankle motion; those patients
treated with the Ponseti method fared better than those with physical therapy
treatment in both categories.
Gottschalk said that he believes that one of the reasons for the
disparity is the use of other interventions during treatment.
“Within the Ponseti protocol, more patients got a percutaneous
tendo-achilles lengthening, which was done within the office,” he said.
“Of those kids who had physical therapy, only a smaller subset actually
got a tendo-achilles lengthening.”
Another aspect of the research included a comparison between the
study’s patients, with moderate clubfoot, and those reported on by Karol
in a previous study, who had severe and very severe clubfoot. Gottschalk, Karol
and Jeans found that the initial severity of clubfoot does not predict gait
outcome in these patients.
“However, the moderate clubfoot requires fewer surgical operations
to acquire a clinically successful result,” Gottschalk told O&P
Business News. “We were able to clinically successfully say that
moderate club feet treated with nonoperative methods — Ponseti and
physical therapy — required less surgical correction at 2 years, versus
those in the previous study with severe and very severe deformity. About
one-third of those required surgical intervention before the 2-year mark.”
He said he would like to re-evaluate these patients at 5 years old and
perform kinetic testing to determine their muscle power and the amount of
internal rotation at that time. — by Stephanie Z. Pavlou
This article is a very interesting study that evaluated the effects of
the Ponseti method and the French method using a standard clinical examination,
but also a very sophisticated gait analysis. The study showed that patients
with clubfoot treated by the Ponseti method had better results with respect to
gait, which was pretty much normal.
This is a very important finding because our experience before, and just
by using clinical examination, demonstrates that kids with clubfoot, when
treated properly with the Ponseti method, actually have normal functioning
feet. If they maintain by a brace until the age of 4 or 4 and a half, then the
feet are normal for life. So it has tremendous implications for the life of the
The Ponseti method is actually becoming the standard of care for the
treatment of clubfoot worldwide. There is a lot of need for teaching for people
who are doctors and nurses to physical therapists to learn about the method.
Bracing is the most difficult part of the treatment, mostly because it’s a
4-year protocol, that the kid has to use the brace at night only. It’s
something that needs to be always controlled, make sure that the shoes fit
properly, the bar is an appropriate length to make it successful.
— Jose A. Morcuende, MD, PhD
Clubfoot Treatment Center, University of Iowa