Club foot – or, more correctly, congenital talipes equinovarus (CTEV)¹ – describes a specific foot deformity of midfoot cavus, forefoot adduction, hindfoot varus and equinus. The World Health Organisation has estimated that 100’000 children are born with CTEV, with 80% occurring in the developing world.² Ignacio Ponseti died on October 18 2009 aged 95. He was a pioneer in paediatric orthopaedics and the inventor of the Ponseti Method: a cheap, yet revolutionary, way of treating CTEV in babies which has now become the standard procedure worldwide. It has transformed millions of children’s lives.


After completing his medical degree at the University of Barcelona in 1936, Dr. Ponseti’s life path changed several times as a result of war. He lived and worked in France and Mexico before moving to Iowa in the USA. In 1944 he finished his residency and became a member of the orthopaedic faculty at the University of Iowa, where he spent the remainder of his career. After his review of long-term surgical outcomes in the State of Iowa, Dr. Ponseti concluded that surgery for CTEV resulted in stiff, painful and poorly functioning feet, and he developed his system of manipulation and serial casting in the late 1940s. Based on his anatomic and embryological studies of the condition,³ his system consisted of a carefully constructed sequence of plaster casts after gentle repetitive manipulation and gradual reduction of the malaligned joints. Many before had tried casting with limited success, but Ponseti’s understanding of the complex interrelationship of the tarsal bone led to the principles for his successful system. In 1984, at the age of 70, he retired briefly, but subsequently returned to focus solely on his CTEV practice. The university awarded him an honorary Doctor of Humane Letters degree in 2007. Despite a hip fracture in January 2009 at the age of 94 he fully recovered and returned to work. Dr. Ponseti was at his office desk at the age of 95 when he suffered a stroke, and he died four days later.

The Ponseti Method is a system of treatment for CTEV in babies that stretches the ligaments rather than surgery, manipulating the foot into the optimum shape by hand, casts and braces. It avoids cutting tight ligaments, joint capsules and tendons and makes use of the biomechanics of stress relaxation of collagen. "It's a simple technique based on the understanding of the mechanics of how the joints move," Ponseti said. "Nature has provided us with a great gift. When cutting ligaments and joint capsules, you destroy nature's way of bringing about normal foot motion."


The foot is manipulated for about a minute, after which an above-knee plaster cast is applied. This cast is typically changed weekly for 4-8 weeks, depending on the severity and rigidity of the deformity. The first cast is used to align the forefoot with the hindfoot by correcting midfoot cavus. This is done by raising the first metatarsal into a position of supination that matches the hindfoot supination (varus). Subsequent casts maintain the foot in a position of supination and plantarflexion as the forefoot adduction is corrected. Then the foot is abducted using the thumb pressed against the lateral aspect of head of talus as the fulcrum. As the forefoot abducts, the hindfoot will automatically pronate through the subtalar joint. The fulcrum must be maintained on the talar head, as pressure on the calcaneus or cuboid will block hindfoot correction. Long leg casts with a flexed knee help promote external rotation of the foot, which corrects the foot-thigh angle, and prevents the casts being kicked off. During the sequence of serial casts, the forefoot must never be pronated and the heel must never be actively pushed into valgus. Once foot supination and heel varus are corrected by full abduction with maximal external rotation of the calcaneus under the talus, equinus can be corrected. Percutaneous Achilles tenotomy is often required to correct this persistent deformity. Casts are continued for 3 more weeks after tenotomy.


Long term abduction splinting is used after casting to prevent relapse. A foot abduction orthosis (FAO) such as the Denis Browne boots and bar are used to maintain external rotation of 70 degrees on the affected side and 45 degrees on the normal side. The FAO is worn for 24 hours a day until the child wants to stand and cruise. After this, the bar is worn at night and when resting until three years of age. Most CTEV feet can be corrected without extensive surgery with this method. It works best when started at birth, when ligaments and muscles are flexible. The mild form rarely requires surgery, while the severe “teratological” variety invariably requires surgery. In such cases, the Ponseti method tends to reduce the extent of surgery required.


The rate of relapse after three years is 10 percent. For a mild relapse below the age of 2, repeat serial casting is used followed by the FAO. After age 2 years, repeat casting is used to optimize the foot prior to transfer of the tibialis anterior tendon to the lateral cuneiform +/- repeat tendoachilles lengthening.
Dr. Ponseti’s method of clubfoot management is inexpensive and effective. Long-term follow-up studies show that feet so treated are strong, flexible and pain-free despite persistent calf wasting, and that these results occur in all countries and cultures.⁴ He first published details of his system in a peer-reviewed journal in 1963.⁵ This was followed with further major publications on its success in 1972, 1980 and 1994.^6-8 In 1995, Cooper and Dietz published their excellent long term results with this method.⁹ Unfortunately, these publications did little to increase the popularity of the method outside Iowa. Dr Ponseti was critical of other surgeons’ eagerness to operate, and frustrated that children were subjected to surgical procedures when he felt that he had already solved the problem. It is believed that the lack of popularity was partly due to his colleagues’ failure to believe in the technique. Economic considerations may have also been involved. This method produced less profit for institutions in insurance-based medical systems. The fact that it is cheaper makes the technique suitable for developing countries, and has spread to the furthest reaches of the developing world, enabling medical technicians to transform the lives of millions of children destined to severe deformity and suffering.

In 1996, Ponseti published his book “Congenital Clubfoot: The Fundamentals of Treatment”, detailing dissections and anatomic modeling of how his technique worked. It was only then that his method gained momentum, encouraged by parental demand and the internet, where the Ponseti International Association maintains a website at www.ponseti.info. It was only in 2006 that the Ponseti method was eventually endorsed by the American Association of Paediatrics, when Dr. Ponseti was aged 91, but now it is the preferred treatment for CTEV throughout the world because its results are better than operative techniques for the primary idiopathic CTEV. Ponseti’s work on congenital clubfoot will be remembered as one of the key contributions to paediatric orthopaedics and childhood deformity. Only in his last years did Dr. Ponseti see his life’s work achieve the recognition it deserved.

RA Haene, MM Stephens
Children’s University Hospital, Temple Street, Dublin 2

References
1. Stephens MM, Congenital talipes equinovarus. Ir Med J, 1990. 83: 48-9.
2. Bridgens J, Kiely N. Current management of clubfoot (congenital talipes equinovarus). BMJ. 340: c355.
3. Ponseti I, Staheli LT. Clubfoot : Ponseti management. 2005, [Seattle, Wash.]: Global-HELP.
4. Gupta A et al., Evaluation of the utility of the Ponseti method of correction of clubfoot deformity in a developing nation. Int Orthop, 2008. 32: 75-9.
5. Ponseti IV, Smoley EN. The classic: congenital club foot: the results of treatment. 1963. Clin Orthop Relat Res, 2009. 467: 1133-45.
6. Ponseti IV, Campos J. Observations on pathogenesis and treatment of congenital clubfoot. Clin Orthop Relat Res, 1972. 84: 50-60.
7. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am, 1980. 62: 23-31.
8. Ponseti IV. The treatment of congenital clubfoot. J Orthop Sports Phys Ther, 1994. 20: 1.
9. Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up note. J Bone Joint Surg Am, 1995. 77: 1477-89.