Two different approaches used to correct clubfoot both bring positive outcomes for most children

Nov 4 2008

Two non-surgical treatments most commonly used to correct the condition known as clubfoot have similarly high levels of success, according to a new study published in the November 2008 issue of The Journal of Bone and Joint Surgery.

While both treatment strategies use different approaches, each brings positive outcomes for most children.

Clubfoot is a birth defect that occurs in approximately one in every 1,000 births, with boys slightly outnumbering girls. The exact cause is not known, but the condition does seem to run in families.

When a baby has clubfoot, one or both feet are turned inward, some so severely that the sole of the foot seems to be facing upward. The involved foot, calf, and leg are smaller and shorter than the normal side. It is not a painful condition, but if it is not treated, clubfoot will cause difficulty when the child learns to walk, and can lead to significant discomfort and disability by the teenage years. The goal of treatment is to correct clubfeet when children are infants, before they learn to walk.

The two non-surgical treatments are:

• The Ponseti Method
• The French Functional Method

“These treatments have been around for decades, but they hadn't received wide acceptance,” says B. Stephens Richards, M.D., primary author of the study. Dr. Richards is assistant chief of staff and medical director of inpatient services at Texas Scottish Rite Hospital for Children and the current president of the Pediatric Orthopaedic Society of North America. “Until about 15 years ago, the common treatment for clubfoot was still surgery. However, things began to change with the emergence of the Internet. Parents began researching treatment options for their children and found information about the Ponseti and French methods, so interest in these treatments began to spread, and we saw how successful they can be.”

In the Ponseti method, the foot is stretched and then placed in a cast extending above the knee. Each week, the orthopaedist removes the cast, stretches the foot further toward the correct position, and recasts it. After three to five casts, the foot is straightened but the heel cord (or Achilles tendon) often remains too tight. The heel cord is then surgically lengthened so the foot can be placed in the normal position. A final cast is worn for three weeks as the heel cord mends. After the cast is removed, the child must then wear a brace full-time for three months and then at night for about two years.

The French functional method consists of daily stretching, exercise, massage, and immobilization of the foot with nonelastic tape to slowly move the foot to the correct position. These therapy sessions are performed primarily by a physical therapist for the first three months, when most of the improvement occurs, but parents receive training during this time in order to perform some of the treatments at home. The taping and splinting continues until the child is two years old. It is important to note that this method is currently not available in many parts of the United States.

In the study, parents were given the choice of the two treatment methods. More than twice as many parents chose the Ponseti Method, in part because of the difficulty for some parents to make the daily visits to the hospital required by the French Functional Method. The average severity of the condition within both groups was about the same. The patients were then followed through the next two years of treatment.

The results were similar:

In the Ponseti group:

• 94.4 percent achieved satisfactory initial correction
• 37 percent had some recurrence of the condition requiring repeated casting treatments

In the French group:

• 95 percent achieved satisfactory initial correction
• 29 percent had some recurrence of the condition requiring further intervention later

In both groups, 16 percent of the patients eventually required surgery

“One of the main reasons for recurrence is noncompliance,” says Dr. Richards. “For example, the parents might not brace the child's feet for the required number of hours or may not perform the stretching every day. We know now that non-surgical treatment can have a very good chance of a positive outcome, but parents need to know that complying with the treatment plan is extremely important.”

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