Successful Treatment Is Less Invasive!

At Patrick's first birthday party, the gift that received the most applause was a new pair of ordinary baby shoes. What made them so special was that Patrick could actually wear them.
At Patrick's first birthday party, the gift that received the most applause was a new pair of ordinary baby shoes. What made them so special was that Patrick could actually wear them. Is non-surgical treatment the answer?
Patrick was born with a severe foot deformity called idiopathic clubfoot, which affects about one in 750 births in otherwise perfectly healthy infants. Without medical intervention, these children will have a severe functional disability and will never wear normal shoes. The most common medical treatment for clubfoot has been an extensive surgical procedure to straighten the foot. But John Herzenberg, MD, head of pediatric orthopedics at Sinai Hospital of Baltimore, is trying to change this.

"For the first 10 years of my practice, I corrected clubfoot the same way I was taught in my medical training -- with extensive surgery," says Herzenberg. "Surgery is very invasive and the results frequently are stiff, painful feet. In my search for a better way, I learned of a non-surgical treatment called the Ponseti Method. Now, I rarely operate on a clubfoot."

The Ponseti Method involves three phases: casting, cutting of the Achilles tendon and wearing special shoes with a bar. First, the technique begins with weekly casting for four to eight weeks. Before each cast is applied, the affected foot is gently stretched according to the precise method described by Ponseti. The manipulations and casts stretch the ligaments and muscles until the desired positioning of the foot is achieved.

The second phase is the tenotomy, or cutting of the Achilles tendon. This is a minimal surgical procedure requiring only a tiny incision above the heel. It is performed in the doctor's office under local anesthesia. Casts are then put on for three more weeks, which is the time it takes for the tendon to reconnect and heal in the proper position. When the child returns after three weeks, he or she enters the third and last phase involving the special shoes connected by a bar. The shoes are worn continuously for the next three months, and then at nighttime only until the child turns two to three years old.

The traditional clubfoot surgery involves a large incision of up to six inches to the back of the calf and ankle and extensive cutting of the joint ligaments and lengthening of the muscles. This causes extensive scar tissue and weakens muscles. There is often a need for repeat surgeries due to the occurrence of over- or under-corrected feet. In the long run, orthopedic surgeons are finding that babies treated with extensive surgery often grow up to have stiff, painful and weak feet. The Ponseti Method avoids most of these problems.

Since 1997, Herzenberg has treated 75 infants using the Ponseti Method. His success rate is 93 percent in newborns. Even in older infants, up to six months in age and unsuccessfully treated at other hospitals, the success rate with Ponseti patients is 85 percent. Herzenberg, an orthopedic surgeon, runs a clubfoot clinic every Friday, where he sees numerous patients like Patrick. He's one of the first pediatric orthopedic surgeons in the United States to revive and advocate the Ponseti Method over traditional clubfoot surgery.

His research, which has been published in Orthopedics Today and the Journal of Pediatric Orthopedics, shows that extensive surgery can be avoided in 90 percent of children with clubfoot by using the Ponseti Method.

"Parents know very little about clubfoot until they are personally affected," explains Herzenberg. "My clubfoot clinic is full of parents with fascinating stories of how they finally came to know about the Ponseti Method, often through their own research on the Internet. My dream is that one day more parents and physicians will know about this method, making these stories a thing of the past."

Clubfoot affects the foot and ankle, causing the heel and toes to turn inward to the extent that they look like they are turned upside down. Although there is no known cause, possible contributing causes include genetic factors, viral infection, lack of sufficient amniotic fluid and maternal smoking.

As for little Patrick, now two years old, his immediate future will include jumping on the bed, running after his older siblings and definitely more shoe shopping. There is no joint stiffness or limitations facing him, something for which his parents feel especially thankful.

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