CONTROVERSIAL

Treating older children (over the age of two) with the Ponseti method has, from the beginning, raised many doubts — even among trained physicians. This technique works exceptionally well in newborns and infants, as their bone structure, joint flexibility, and ligament elasticity make correction easier and lead to excellent treatment outcomes. In older children, although the skeletal system is still immature, it is more difficult to correct with such a minimally invasive method. This is why opinions among doctors about the results of treating older children with the Ponseti method often differ. However… initiating treatment in this group of “little-big” patients shows good promise and can yield equally positive and encouraging results. There is evidence to support this!

TRY IT

Despite many doubts, attempts to treat older children have been made — and with success! Numerous studies show that the Ponseti method can be effective for children with neglected deformities, those who were treated improperly, and even those who experienced relapse after surgery.

The age range of children beginning treatment is very broad: from 2 years old up to 19 years old. This clearly demonstrates that the Ponseti method is applicable not only in young children but also in adolescents, offering many the chance for a normal life. In such age groups, the method is most often used in developing countries, where treatment options are LACKING.

However, the fact that in more developed countries access to medical care, staff, and technology is far greater should not obscure a basic principle: “first, do no harm.” Introducing non-invasive treatment should always remain the top priority.

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IF YOU HAVE 2 YEARS OLD CHILD, OR OLDER, WITH NEGLECTED DEFORMATION, OR IF YOU SUSPECT A RELAPSE, OR IF YOUR CHILD IS AFTER A FAILED SURGERY- YOU CAN ALWAYS CONSULT WITH A DOCTOR POSSIBILITY OF RESTARTING THE PONSETI METHOD.

A LITTLE DIFFERENT...

The Ponseti method, when applied to older children, differs slightly from the classic version used for infants. Your doctor should provide you with all the necessary information about this. Below are some of the possible modifications that may be applied:

Clubfoot treatment with Ponseti method in older child – long leg cast after Achilles tenotomy by Hoke called triple hemisection, smiling boy in hospital bed, non-surgical correction of congenital clubfoot using plaster casting in Vienna

  • The physician should spend more time manipulating the foot (gentle stretching) before applying the cast (about 3–10 minutes). This makes the soft tissues more responsive to stretching and may reduce the total number of casts needed for correction.

  • The number of casts required to achieve full correction is usually greater — often 10 or more, depending on the child’s age.

  • Casts may be changed every 1–2 weeks, depending on the stiffness of the foot.

  • A so-called short cast (from the toes to just below the knee) may be applied to avoid immobilizing the knee and to allow the child to walk. In such cases, a lightweight soft cast is often used, enabling the muscles to keep working. However, applying a long cast (from the toes to the groin, with the knee flexed) is not considered a mistake.

  • The degree of foot abduction in the cast is set at 30°–40° (compared to up to 70° in younger children). This “smaller” external rotation does not reduce the effectiveness of treatment.

AFO orthosis with ADM shoe for older child after clubfoot treatment – nighttime brace to prevent relapse, non-surgical Ponseti method support

  • A percutaneous Achilles tendon tenotomy can be performed; however, in much older children, another type of tenotomy (e.g., Hoke tenotomy) may be necessary.

  • To prevent relapse, all children must wear an abduction brace (at least until the age of 4). For older children, the doctor may recommend wearing high-quality AFO orthoses during the day, ADM orthoses (for nighttime use), or, in rare cases, a custom-made AFO with prescribed settings (e.g., dorsiflexion).

  • There is no need for invasive surgeries such as posteromedial release, lateral release, osteotomies, or open tenotomies (e.g., Z-tenotomy).

  • Physiotherapy and physical activity are important tools to help older children maintain correction. Natural use of the foot strengthens muscles and tendons, making the foot stronger, more flexible, and functional. It is important to remember, however, that physiotherapy is directed at the whole child, not just the foot.

UNNECESSARY!

Invasive surgeries should always be a last resort! They should never be the first treatment option.

  • Posteromedial release (PMR)
  • Posterior release (PR)
  • Total clubfoot release via Cincinnati or Turco approach
  • Achilles tendon lengthening using open techniques, e.g., Z-tenotomy or “mini-open” method
  • Lateral (medial) release
  • Dorsal release
  • McKay, Turco, or Goldner methods
  • Dwyer or Evans osteotomy

These are NOT appropriate treatments for congenital clubfoot.

THE PONSETI METHOD, WHEN APPLIED TO OLDER CHILDREN, SIGNIFICANTLY REDUCES THE NEED FOR INVASIVE SURGICAL INTERVENTIONS – RESTORING FULL FUNCTIONALITY TO THEIR FEET!

MEDICAL RESEARCH & MEDICAL SOURCES
  1. Bashi R.H. et al.: „Modified Ponseti method of treatment for correction of neglected clubfoot in older children and adolescents. A preliminary report.”
  2. Lourenço A.F., Morcuende J.A.: „Correction of neglected idiopathic club foot by the Ponseti method.”
  3. Ganesan B., Luximon A.: „Ponseti method in the management of clubfoot under 2 years of age: A systematic review.”
  4. Elgazzar A.S.: „Ponseti management of clubfoot after walking age.”
  5. Yagmurlu M.F.: „Ponseti management of clubfoot after walking age.”
  6. Spiegel D.A. et al.: „Ponseti Method for Untreated Idiopathic Clubfeet in Nepalese Patients From 1 to 6 Years of Age.”
  7. Verma A. et al.: „Management of idiopathic clubfoot in toddlers by Ponseti’s method.”
  8. Dimeglio A., Canavese F.: „Management of resistant, relapsed, and neglected clubfoot.”
  9. Penny J.N.: „The Neglected Clubfoot.”
  10. El Tayeby H.M.: „Multiple tenotomies after Ponseti method for management of severe rigid clubfoot.”
  11. Ponseti International Association
  12. Laaveg S.J., Ponseti I.: „Long-term results of treatment of congenital club foot.”
  13. Morcuende J.A.,  Ponseti I.V. et al.: „Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method.”
  14. Smith P.A. et al.: „Long-term results of comprehensive clubfoot release versus the Ponseti method: which is better?”
  15. Dobbs M.B: „Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release.”
  16. Ippolito E.et al.: „Long-term comparative results in patients with congenital clubfoot treated with two different protocols.”
  17. Nogueira M., Tokechi D.: „How Much Remodeling is Possible in a Clubfoot Treatment? Magnetic Resonance Imaging Study in a 7-Year-Old Child”
  18. Alves C. et al.: „Neglected clubfoot treated by serial casting: a narrative review on how possibility takes over disability.”
PHOTOS & GRAPHICS

Photos: own