ponseti-technique
Introduction: A Brief History of the Ponseti Method
Ignacio V. Ponseti can be credited with developing a comprehensive technique for treating congenital clubfoot in the 1940s. One of the major principles of this technique is the concept that the tissues of a newborn’s foot, including tendons, ligaments, joint capsules, and certain bones, will yield to gentle manipulation and casting of the feet at weekly intervals. By applying this technique to clubfeet within the first few weeks of life, most clubfeet can be successfully corrected without the need for major reconstructive surgery.
This technique is based upon Ponseti’s experiences with the wide variety of treatments being applied at that time and his observations in the clinic and operating room, as well as his anatomic dissections and analysis by using a movie camera to produce radiographic images. Utilizing these principles and his understanding of clubfoot anatomy, Dr. Ponseti began employing this technique in 1948 at the University of Iowa. Recently, his observations have been confirmed using modern techniques, including Magnetic Resonance Imaging (MRI).
The Ponseti technique has become the most widely practiced method for initial treatment of infants born with clubfeet. It is an easy technique to learn and, when applied accurately, it yields excellent results.
The Ponseti Technique
The corrective process utilizing the Ponseti technique can be divided into two phases:
- The Treatment Phase – during which time the deformity is corrected completely
- The Maintenance Phase – during which time a brace is utilized to prevent recurrence
During each of these phases, attention to the details of the technique is essential to minimize the possibility of incomplete correction and recurrences.
- The Treatment Phase
The treatment phase should begin as early as possible, optimally within the first week of life. Gentle manipulation and casting are performed on a weekly basis. Each cast holds the foot in the corrected position, allowing it to gradually re-shape. Generally, five to six casts are required to fully correct the alignment of the foot and ankle. At the time of the final cast, the majority of infants (70% or higher) will require a percutaneous surgical procedure (with a small incision through the skin) to gain adequate length of their Achilles tendon.
- The Maintenance Phase
The final cast remains in place for three weeks, after which the infant’s foot is placed into a removable orthotic device. The orthosis is worn 23 hours per day for three months and then during the night-time until 5 years of age. Failure to use the orthosis correctly may result in recurrence of the clubfoot deformity. Good results have been demonstrated at multiple centers, and long-term results indicate that foot function is comparable with that of normal feet.
Maintenance and Recurrence Prevention
Upon removal of the final cast, the infant is placed into an orthosis, or brace, which maintains the foot in its corrected position. The purpose of this splinting, after the casting phase in the Ponseti method, is to maintain the foot in the proper position, with the forefeet set apart and pointed upward. This is accomplished with a brace consisting of shoes mounted to a bar. The brace is worn 23 hours per day for the first three months following casting and then while sleeping for several years to follow, usually until around age five. Multiple studies have demonstrated the high risk for recurrence if the brace is not worn according to these guidelines. The reasons for recurrence in feet that appear to be corrected fully have not yet been clearly proven, but regardless of the cause, recurrence appears to be close to zero when the bracing regimen is followed accurately.
Management of Recurrence
The risk of recurrence persists for several years after the casting is completed. Ponseti reported a recurrence rate of approximately 50% in his early series, but noted a decrease with greater emphasis placed on the use of the foot orthotic. Early recurrences are best treated with several long-leg plaster casts applied at two-week intervals. The first cast may require correction of recurrent foot deformity, with subsequent casts to correct ankle tightness.
An Achilles tendon lengthening may be necessary if there is insufficient correction at the ankle, and a tendon transfer (of the tibialis anterior tendon) may be performed in older children to help maintain the correction. Following this additional surgery, the child is then placed in a long-leg cast for four weeks with the foot in neutral position.