Current management of clubfoot (congenital talipes equinovarus)BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c355 (Published 02 February 2010) Cite this as: BMJ 2010;340:c355
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One of the many delights afforded to a surgical SHO at Great Ormond
in 1962 was attending the great "DB", by then well retired but still an
enthusiast who just couldn't help teaching.
Bridgens and Kiely describe the shift from surgery for congenital
club foot in
the last decade , to less invasive (manipulative) methods. Credit is
I am sure correctly, to Ponseti, but the statement "although manipulation
casting were used in the past, this was not performed according to a
protocol,and extensive surgery was often used" suggests ignorance of "DB"s
DB had described carefully and fully the use of a 3-piece splint over
prolonged period, each arm of the splint serving gradually to correct one
aspect of the deformity, No pain was caused, as no force was used , with
each limb of the splint merely maintaining the position of maximum
correction for each of the three aspects for some days, after which the
gentle process was repeated and continued as long as necessary. DB
that the key to success was adhering precisely to the method, in which the
foot was strapped gently to the first splint limb in maximum attainable
(without pain) correction, then similarly to the second splint piece . The
were then fitted together, the foot/ankle bandaged similarly to the third
and that assembled to the first two. A brace or strap connecting the two
was not used.
When this protocol was followed , excellent results were achieved,
slowly. The parent, physiotherapist or whoever was to apply the splints
be trained to apply the method scrupulously and meticulously.
Understandably, orthopaedic surgeons sought methods less tedious, and not
requiring the obsessive repeated gentle application of these simple, but I
believe, inspired contraptions, which also demanded commitment of vast
time from a physiotherapist or an understanding, trainable parent. In the
long term follow-up clinics were largely excellent results.
I find it sad that in a clinical review in the BMJ, this great
contribution from Sir
Denis Browne, the Father of British Paediatric Surgery, is not
simple method, once properly understood and then meticulously applied, was
probably as good or better than Ponseti, and in not requiring analgesia,
plaster casts, or strut, was surely kinder to both child and parent: once
technique had been mastered the child could be bathed frequently , and
crawl about a bit without the inhibiting strut.
There are are many instances of the wheel having to be reinvented,
the original wheelwright should be given some credit where possible.
JOHN SQUIRE KIRKHAM, Retired Consultant Surgeon.
Garden Cottages, Water Lane, Drayton Saint Leonard, OXON<OX10 7BE
Competing interests: No competing interests
We were delighted to read the Clinical Review of Bridgens and
Keily(1) regarding the current management of clubfoot. It is heartening to
see the Ponseti method presented to the wider clinical community in such
clear and concise terms, it having only gained widespread awareness and
support within the orthopaedic community in the last decade. Undoubtedly
the Ponseti method has lead to a change from a condition associated with
lifelong disability to an entirely treatable one in the vast majority of
cases. Indeed we assert that the success rates are higher than 85% quoted
by the authors in the review [Tips for non-specialists](1). A recent
evaluation in Iowa (the “birthplace” of the Ponseti method) reported
successful clubfoot correction in 98% with a rate of recurrence of just
11%. In their series only 2.5% required tibialis anterior transfer(2).
It is imperative that these excellent outcomes are given to expectant
mothers. Antenatal trans-abdominal ultrasonic diagnosis of clubfoot is
increasingly common. However accuracy is only 60-70% (3,4). Such an
antenatal diagnosis, if considered against the now historical belief of a
congenital condition associated with the potential for life-long
disability, tragic decisions could be made regarding the continuance of
the pregnancy. Therefore it is mandatory that this condition instead be
presented to expectant mothers as a "Transient Developmental Deformation",
with excellent rates of successful treatment within the first few years of
childhood. We commend the authors of the Clinical Review for taking steps
in disseminating the positive message to the clinical community and the
1. Bridgens J, Kiely N. Current management of clubfoot
(congenital talipes equinovarus). BMJ.340:c355.
2. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical
reduction in the rate of extensive corrective surgery for clubfoot using
the Ponseti method. Pediatrics. 2004 Feb;113(2):376-80.
3. Bar-On E, Mashiach R, Inbar O, Weigl D, Katz K,
Meizner I. Prenatal ultrasound diagnosis of club foot: outcome and
recommendations for counselling and follow-up. J Bone Joint Surg Br. 2005
4. Keret D, Ezra E, Lokiec F, Hayek S, Segev E,
Wientroub S. Efficacy of prenatal ultrasonography in confirmed club foot.
J Bone Joint Surg Br. 2002 Sep;84(7):1015-9.
Competing interests: No competing interests