Pediatric Orthopedics
Michaels Story - Ponseti Method of Treating Clubfoot Avoids Major Surgery

Pediatric Orthopedics

Michaels Story - Ponseti Method of Treating Clubfoot Avoids Major Surgery

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It was a joyous moment when Christine and Paul Maher welcomed their first child into the world on June 4, 2002. Several ultrasounds had indicated that they were going to have a girl, but when the delivery room doctor flipped their newborn upright and pronounced, "Here he is," the Mahers were nothing but happy about their little surprise.
But shortly after their son Michael was born - when Christine and Paul did the requisite check for 10 fingers and 10 toes - they immediately noticed that something was amiss with Michael's tiny feet, which appeared to be inverted.
Three weeks later, Christine went into a tailspin when she took Michael to see an orthopedist at a Milwaukee-area hospital. There, she says, the doctor started spitting out technical terms that she didn't understand and informed her - "with no bedside manner" - that her son had Clubfoot, a congenital malformation characterized by one or both feet turning inward or on their sides.
In many cases, it's impossible for the foot to lie flat, leading to a lifetime of disability if left untreated. To correct Michael's feet, the doctor quickly recommended a casting process which would soon be followed by major reconstructive surgery.
"That's all they kept saying - 'Your son's going to need surgery,'" Christine said. "I was thinking, 'My child's three weeks old!' I was scared to death."
Michael, it seems, was just as scared. Christine said he was terrified during the weekly casting sessions, and all the screaming and crying was breaking the new mother's heart.
"He was sobbing, I was sobbing - the whole thing was just horrible. But the minute you took his casts off, it just freed him - he was a different kid, a different baby," she said. "And at that point I just said, I'm not going to do this anymore. There has to be another way."
An Alternative to Surgery
They found it at UW Children's Hospital (now known as the American Family Children's Hospital), after an Internet search on non-surgical clubfoot treatment led them to Kenneth Noonan, MD.
Offering an alternative to once-standard surgical treatment that often leads to mobility and stiffness problems later in life, Dr. Noonan has been practicing a gentle manipulation and stretching approach known as the "Ponseti Method" for more than 10 years, three of them here in Wisconsin.
Though it was developed more than 50 years ago by Dr. Ignacio Ponseti at the University of Iowa, the Ponseti method has only recently taken hold outside of Iowa, where Dr. Noonan learned about the approach from its creator.
Since the mid-1990s, Ponseti's work has been bolstered by studies showing that the feet of children treated with the Ponseti method are generally more supple, flexible and mobile than the feet of patients who underwent major surgery to correct clubfoot deformities.
Also, through support group Web sites for parents whose babies were treated with the Ponseti approach, the word has spread far past the borders of Iowa.
"Pediatric orthopedic surgeons are learning of it and they're doing it, and they're finding their successes with it," says Noonan, who is working with Dr. Blaise Nemeth in Pediatric Orthopedics at the American Family Children's Hospital to perpetuate the technique that is practiced by only a handful of physicians in Wisconsin.
Specific, Gentle Foot Manipulation
Rather than moving the bones in the clubfoot surgically, the Ponseti method practiced by Noonan and Nemeth calls for a very specific manipulation of the foot to stretch the contracted tissues.
A cast is then applied to maintain the correction and the foot is held in the corrected position for approximately seven days, allowing the muscles and ligaments to stretch enough to make further correction possible. The cast is then removed and another process of gentle massage and manipulation is repeated.
The casting process can take three to four months. Then the baby is fitted with shoes attached to a metal bar that must be worn 24 hours a day for about six months, and then at night until the child is three or four years old.
So in order for the technique to be successful, parents must be dedicated to maintaining the correction obtained through casting by adhering to orthosis at home.
"It's not a quick, easy fix. I think it requires a lot of effort on our part and on the families' part," said Dr. Nemeth, who has also made several trips to the University of Iowa to work with Dr. Ponseti.
Parents Play Key Role
Christine Maher says the parental involvement that's necessary under the Ponseti method is a small price to pay to avoid the trauma of major surgery at such a young age.
She said she was overwhelmed by the care that Dr. Noonan and staff at UW Children's Hospital took to make Michael comfortable during the weekly castings. For example, the Mahers were advised to feed Michael during the casting to make him more relaxed and comfortable.
"So we brought him in hungry and the child never cried - not once," she said. "It was not this screaming, horrible nightmare experience that we'd had before… The whole hospital just treated us with such respect and dignity."
To receive that kind of care and attention for the weekly castings and follow-up care, the Mahers were more than happy to drive more than an hour to Madison from their home in Sussex, Wis.
"It's just a totally different experience," Christine Maher said. "People need to know that options are out there."
Those options are expanding at the American Family Children's Hospital with Dr. Nemeth having also entered the clubfoot practice, says Dr. Noonan. Nemeth trained as a pediatrician before entering into pediatric orthopedics, so his background offers a unique perspective to understand how a child's general health interacts with orthopedic conditions.
"Tune-Up Surgery" Possible
When the Ponseti approach is used, only about one percent of patients will require a major operation on the affected feet. In about one-third of the Ponseti patients, slight residual deformities may emerge at age two or three, requiring what Dr. Noonan characterizes as a "tune-up surgery" in which a tendon may be transferred or lengthened. Noonan says it's an operation with much less morbidity than the major clubfoot surgery practiced at other institutions.
"With or without minimal tune-up surgery, (the Ponseti method) is much better for the foot and the long-term function than major reconstructive surgery," Noonan said. "I feel quite strongly that this is the treatment of choice."
With an active two and a half year old son who likes to run and jump, the Maher family agrees.
"You would never know he had a disability," Christine Maher says.