New Standard of Care for Clubfoot

Holly and Patrick Wasilewski were devastated at Holly's 18-week pregnancy check-up -- they found out their son would be born with a clubbed right foot.

Clubfoot is one of the most common birth defects, occurring in one out of every 1,000 U.S. births. With a clubbed foot, a normal infant is born with a stiff, in-turned foot that cannot be returned to a normal position. About 50 percent of clubfoot newborns have both feet affected. If not treated, clubfoot does not self-correct, causing the person to walk abnormally for life.

The Wasilewskis' doctor reassured them that clubfoot was an easily treatable abnormality. Yet Holly found it unsettling that in their home state of Michigan, 95 percent of clubfoot newborns underwent surgery for treatment.

Holly, 33, started to research on her own. She came across a support group on the Internet for parents of children with clubfoot. The other parents warned her away from surgery, saying, "You have to go to Dr. Ignacio Ponseti."

A New Twist on an Old Idea

In the late 1940s, Ignacio Ponseti of the University of Iowa noticed that many of his patients whose clubbed foot had been treated surgically faced problems later in life. He decided there must be a better way to treat the deformity.

For years, surgery was the standard practice, Ponseti explained, because "it gives quick, visual results." However, patients often reported severe foot pain years later due to stiff scar tissue and twisted joints.

Clubbed feet occur when a fetus develops with its feet twisted in toward one another. Ponseti reasoned that he should be able to twist the feet back out into their normal position.

Previous methods had followed this same line of reasoning, but with little success. The trouble was that as a clubbed foot grows it is following a bent blueprint. Ponseti carefully studied newborns' foot joints, using stillborn babies in order to understand how best to reform the feet. The technique he came up with corrected an infant's clubbed foot continuously as it grew.

In the first phase, a series of casts are used to stretch the foot. The casts are replaced every few days, to deepen the corrective stretch. In the second stage, the Achilles tendon in the clubfoot is cut by a small incision. The baby is then sent home with a cast to be worn for three weeks.

The last stage uses a corrective brace. The brace consists of baby shoes that are attached to a bar which is the same length as the child's shoulders. The shoes are mounted on the bar so that the feet cannot revert back to their twisted shape. For the first three months, the brace is worn day and night. Afterwards, the brace is worn only at night and nap time, until the child is 4 years old.

When done correctly, the Ponseti method is 95 percent successful. The once-clubbed foot looks and functions normally and no pain develops later. But almost 60 years later, 95 percent of children born in Michigan still have their clubbed feet treated with surgery.

A No-Brainer

Even though Ponseti is 91, he still treats clubfooted children. So when the Wasilewskis' son Zack was born, they decided to make the 12-hour drive to Iowa for treatment. Although their Michigan doctors questioned the Wasilewskis' choice, Holly said, "It was a no-brainer."

The Wasilewskis remained in Iowa for three weeks.

It has only been within the last five years that the Ponseti method has become a common treatment for clubfoot. Ponseti credits his method's recent popularity to mothers searching the Internet for clubfoot treatment solutions.

As more parents asked their doctors about the Ponseti method and older clubfoot patients complained of foot pain, many doctors have started to go to Iowa to learn the therapy. The training for this technique has been translated into 12 languages and is being promoted by the World Health Organization.

One orthopedist estimated that in the past he was likely to operate on a clubfoot about six times per week. Since learning the Ponseti method, he said, it about six times per year.

Orthopedic surgeon Stephen Sundberg of Gillette Children's Specialty Healthcare in St. Paul, Minn., said that today, the only people not using the Ponseti method are the ones who don't know about it. Once you use it, Sundberg reports, "it's a bit of an epiphany."

Matthew Dobbs, pediatric orthopedist at the St. Louis Children's Hospital agreed: "The Ponseti method is rapidly becoming the standard of treatment."

Ninety Percent Parent

The biggest problem that orthopedists have with the Ponseti method is that the brace is an awkward piece of equipment, and parents often slack on requiring that their children wear it.

As Dobbs pointed out, success with the treatment is "10 percent physician, 90 percent parent." The Ponseti method is only about 5 percent successful when brace wearing compliance is low.

This problem led Dobbs to develop a new brace consisting of individually cast Velcro shoes for each child's foot, which are connected by a hinged bar to allow for more movement. Dobbs said the noncompliance rate has dropped from "about 30 percent with the old bar, to less than 5 percent with the new" bar.

After three weeks in Iowa, Zack was sent home in his last cast, which was removed three weeks later. Zack then started wearing a corrective brace to make sure his feet would not turn inward.

Today, 3-year-old Zack's feet look normal and he will continue to wear the traditional brace for another year. Holly said that the brace "is just part of [Zack's] life. He thinks all people wear shoes to bed."

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