Questions to ask your doctor will determine if he or she is using the Ponseti Method of Clubfoot Treatment. Your doctor might say the Method is being used...but chances are greater that they are not. This page will help you determine the truth, and help you find where to go if that truth is not in your child's best interests. Questions to consider in finding out if your doctor is using the true Ponseti Method. Some doctors say that they are using the Ponseti Method, but they may be only referring to the fact that they do serial plaster casts, or they may have modified the method, or not be following it exactly either by design or ignorance. Independent research has shown that the best results are achieved by following the protocol of the Ponseti Method exactly as developed by Dr Ponseti (with over 50 years experience). The following are some questions to ask, or things to note, if you are not sure that your doctor is using the true Ponseti Method Q. Do you use half leg or full leg casts? A. The answer should be Full Leg casts. The Ponseti method uses casts up to the groin and bent at the knee. This helps to immobilize and hold the manipulated foot in the right position so that the ligaments, tendons and skin can stretch until the next cast is applied. Q. How many casts do you need to do before the foot is corrected? A. The answer should be 4 - 6 casts with the average range being between 3, for minor cases and 9 for extreme cases. If it takes longer than 9 weeks of casting, the manipulation is not being done correctly. Dr Ponseti says that casting will not have good results in less than 5% of all clubfoot babies. That is FIVE percent, not 50! Most non- Ponseti Method treatments boast a low fifty percent success rate non-surgically (and surgery isn't a cure, it's a temporary fix requiring more surgery)
A. The answer is likely to be "Yes". The tenotomy, if done, will be performed on the day the final cast is applied; in the Ponseti Method, it is usually a small office procedure where an extremely small scalpel blade is inserted in to the Achilles tendon, snipping it slightly to increase it's ability to stretch. This procedure is so mild that in Dr. Ponseti's office, parents are invited and encouraged to stay with their infant during the process for comfort. The final cast is applied over this incision, and this is considered the final phase of casting as well as the final cast. There are many forms of tenotomies and a parent should question their doctor extensively to find out specifically what the doctor intends to do. Open incision tenotomies involve major surgery and often result in more crippling affects than the child suffered previously because of the build-up of scar tissue over time. A tenotomy is the only 'invasive' part of the Ponseti treatment. The cast is then applied to hold the foot correctly until the Achilles tendon regenerates in the correct position, which takes two to three weeks. There may be a little bleeding on the cast at the heel area, which looks worse than it is because the plaster acts like a sponge. All you can see afterwards is a tiny scab, the size of a pinhead, which falls off, there is no scar. Dr Ponseti uses the tenotomy because the Achilles heel is thick and resistant to stretching; he prefers to do it instead of keeping the baby in casts for longer until the tendon is fully stretched. The tendon must be stretched for the foot to be fully corrected and to be able to wear the FAB comfortably. Q. What method of splint / brace do you use? A. The answer should be the FAB (Foot Abduction Brace) also known as the DBB (Denis Browne Bar). This is an aluminium adjustable bar, on which two shoes are attached. The shoes will be set at a 60 or 70º angle based on the style of FAB and a few other factors, if the baby only has one clubfoot, the shoe for the normal foot is set at a 40º angle. The bar is adjusted so the child's heels will be shoulder width apart. It may look wide, but it is comfortable for the baby that way. Dr Ponseti says that the distance between the heels should equal the width of the shoulder. The foot is over-corrected at first to allow for the ligaments, tendons and skin to grow. The shoes are by Markell, model #1644 Ponseti (a special shoe has been designed specifically for Ponseti babies), or made by MD Orthopedics, specifically for Ponseti Method clubfoot children. Know Your FAB! Q. How long is the FAB (Foot Abduction Brace) worn for? A. The answer should be initially 2 to 3 months of full time wear (23 hours a day), followed by a gradual reduction in hours, for example 23 hours, 20 hours, 18, 16, 14, 12, 10 over the course of about two years, then worn there-after for 10 to 12 hours a night until the child is about four years old. If treatment is started in early infancy, it is likely the child's time in the FAB will be reduced down to approximately 14 hours by the first birthday - which equates to nighttime wear only. As the child ages, the hours will be reduced again to the 12 to 10 hours per night, and will continue at that rate until the age of 4 years old in most cases. This information sounds daunting to many parents - please keep in mind however that 10 to 12 hours a night is the recommend number of hours a young child should sleep. The FAB will become part of the normal bed time routine, as a part of their pajamas going on for bed, and coming off the next morning so that it really does not interfere at all with any daily life or activity. In a few cases, the child has loose joints and stops FAB wear earlier, but this is not the norm. If you comply with brace wear as prescribed in the Ponseti Method, you are 95% assured of avoiding relapse in the majority of clubfoot cases. Q. Is the cast applied with an assistant in attendance? A. The answer should be "Yes". Dr Ponseti's method is to have a person able to apply a cast (nurse, etc) to roll on the bandage while he (the person trained in the method) continues to hold and manipulate the foot in the position required for the particular cast. The parent can help keep the baby amused and distracted while the cast is being applied. The Ponseti method is never painful for the baby, but they may cry because they are annoyed with the process. Should your child become extremely upset, treatment should stop temporarily until the baby is again calm and cooperative - meaning stopped for a short period of time at the office, not stopped for hours or days. If your doctor tries to rush the casting, physically restraining an upset baby, the parent should insist the doctor stop until the parent can calm the child. Applying a cast to a child who if fighting and upset can easily result in a cast that is applied incorrectly, leading to damage and pain in the foot. Q. What is your success rate? A The typical success rate of your doctor should be at least 90% (or better), if the Ponseti Method is followed without any modifications. Doctors who are new to the method should be willing to consult with more experienced doctors, such as Dr. Ponseti personally, Dr. Dobbs, or others who have been practicing this method with out modifications for many years and enjoy a 90% or better nonsurgical success rate. If your doctor is hesitant to consult - you should be hesitant to trust him. Parents should follow correct FAB wear protocol as prescribed by Dr. Ponseti to avoid relapse. Other General Red Flags a Parent Should Heed: A doctor who suggests using knee-high casts instead of toe-to-goin casts. Knee high casts will not hold the manipulation nor stretch the proper tendons. A doctor who will bend to a parent's will to use knee-casts instead of full length casts. A doctor who is vague about the length of time the child will be in casts. By the 2nd or third cast, your doctor should have a pretty firm idea of how many more will be needed. A doctor who prescribes the child wear a cast for longer than seven days at a time. Five to seven days are all that are necessary although some doctors try to make a baby wear the same cast for two weeks. A doctor who tells you to remove the cast at home the night before a new cast will be applied. Removing the cast the night before allows several hours for the foot to lose correction - and it will! This is a major cause for treatment delay and failure. A doctor who is vague about his bracing protocol following castings. A doctor who prescribes a brace system that is not a FAB as prescribed in the Ponseti Method. Any doctor who suggests a 'surgery' will be done at or around the age of three months (a typical non-Ponseti idea that a tenotomy should be done later at this age, and it will be a major surgery). A doctor who is already predicting surgery in the future before the casting is complete. A doctor who is unwilling to listen, learn, or read about the Ponseti Method, or who says the Ponseti Method does not work (he obviously has not done his own investigating, nor is he willing to find out there is a non-surgical route with extremely high success rates). Ultimately - follow your gut instinct. No body knows your child better than you do. Nobody has a higher vested interest in your child's treatment than you do. Nobody is going to look for a better alternative to treatment than you are. Your baby cannot speak for himself - but if you could ask him, "Do you want surgery?" do you honestly think he's going to answer "yes" ? |
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| Questions to Ask Your Doctor or Will the REAL Ponseti Method Please Stand Up! |
| Lets Compare. Traditional Method: cast foot in "best position possible". Ponseti Method: Precisely move each bone in a specific sequence. Traditional: 50% failure rate. Ponseti: 95% success rate. Traditional: Failure often results in surgery. Ponseti: Failure is generally because parents don't use the brace - but is usually corrected with an additional 1 to 3 casts followed by proper parental compliance. Traditional: Surgery generally predicted at 3 months old. Ponseti: 95% non- surgical correction rate is achieved in as little as 3 weeks (not months!) Correction can also be achieved through casting children up to 3 or 4 YEARS old, non- surgically. Traditional: foot is re- casted weekly for up to six weeks. Ponseti: Correction is accomplished in an average of 5 casts placed 5 days apart. Traditional: Casting is followed by a Wheaton Brace or an AFO brace for about one year, with a 25%+ failure rate leading to surgical corrective attempts. Ponseti: Foot Abduction Braces are worn according to a strict protocol for a minimum of three years, and hold the foot in the proper position with a 5% failure rate over the course of wear. Traditional: When re- occurrence of the clubfoot happens, further surgery is needed. (automatically assumes a surgery will be needed to begin with!) Ponseti: Relapse can be treated with a brief period of serial casting followed by proper FAB wear. Traditional: Surgery is risky, i.e., reaction to drugs, risk of infection, surgical errors and more. Surgery requires the child to fast (starve) for several hours prior to the operation, and a very painful recovery afterwards - not to mention the financial costs. Ponseti: None of the surgical risks because there is no surgery. Traditional: Babies are often physically restrained during treatment because it is painful. Ponseti: Babies often drink from bottles or nurse from their mother, or even sleep happily, during the casting procedures because it is not painful.. Traditional or Ponseti? You decide. Read More About it Here |
Los Angeles Shrine Hospital: (Traditional Treatment Methods) Surgery: be needed to improve foot position. Rigid clubfeet often require release of tight soft tissues and may require surgical realignment of bones, both of which are usually performed during infancy. Persistent cases may require more surgical correction in later childhood and adolescence. Clubfoot surgery accounts for 80% of foot surgeries at SHC-LA. http://www.shrinershq.org /Hospitals/Los_Angeles/c onditions/Club_feet.aspx Those are some pretty dire words. If this sounds at all like your current doctor / hospital, please (!) look further! Not all Shrine Hospitals are the same. The St. Louis Missouri Shrine practices the Ponseti Method with very good success! Learn More About Non- Surgical Clubfoot Correction Here |
| Garrison's feet at birth (above) - and the day his last cast came off about a month after treatment started (photo right) |
| Return to Questions To Ask Your Doctor Top of Page Six-feet.com Home Page |
| Learn more about the Ponseti Method of Clubfoot Treatment Here at the University of Iowa's Clubfoot Pages. |