XEvans qxd New Letter qxd by mikeholy



A Review of the Ponseti Method and Development of an
Infant Clubfoot Program in Vietnam

                                                                                     Angela M. Evans, PhD*
                                                                                        Do Van Thanh, MD†

Background: The Feet for Walking clubfoot project from Australia formally introduced
the Ponseti technique in Vietnam in 2004 and is based at the Da Nang Orthopedic and
Rehabilitation Centre in central Vietnam.
Methods: We provide an initial overview of the management of infant clubfoot deformity
using the nonsurgical Ponseti method.
Results: Early indicators of the outcome of implementing this clubfoot project are largely
positive but also require ongoing review. Further analyses of the use of the Ponseti
method (or obstacles preventing the same) following training of personnel is underway.
Conclusions: Recent research has improved and refined the technique that must now
be both appreciated and incorporated by clinicians. This technique is used across the
world in both developed and developing countries and is universally regarded as the
best management method for clubfoot deformities. (J Am Podiatr Med Assoc 99(4): 306-
316, 2009)

The presentation of a clubfoot in a newborn infant in          now been replaced by nonsurgical correction as the
a developing country can signal a bleak future of se-          almost-universally accepted standard of initial treat-
rious disability and potential poverty for the child           ment for congenital idiopathic clubfoot.6, 7 Although
and family. Hindered mobility reduces education and            there are many methods of nonsurgical correction
employment prospects. Socially, the child may grow             (manipulation and serial casting, physical therapy
into a marginalized and impoverished adult who will            and continuous passive motion), which can be suc-
depend on family support or external aid sources to            cessful when correctly instituted, clinical reports
survive.1-3 The presence of many neglected adult club-         have found success rates of only 15% to 50%.6 The
foot deformities in developing countries reinforces            frequently reported exception is the Ponseti method,
this reality, a situation not uncommon in many devel-          which is reported to be approximately 90% success-
oping countries of the world, including Vietnam.               ful in both the short- and long-term.2, 7-9
                                                                  Globally, the Ponseti method has gained increas-
   The clubfoot or talipes equino varus deformity has
                                                               ing favor in the past three decades, although it has
long been recognized as a serious pediatric orthope-
                                                               been used by the original author, Dr. Ignacio Ponseti,
dic problem responsible for much suffering, multiple
                                                               since the 1940s. The follow-up results over 30 years
medical interventions, and often disabling outcomes
                                                               are very good in terms of pain and function.10 The
for the child.2-4 The prevalence of infant clubfoot varies
                                                               technique has been refined over many years and cur-
according to ethnicity, ranging from 0.3 per 1,000             rent research continues to inform our practice and
births in China to 7 per 1,000 births in Polynesia.5           method.6, 9, 11-15 The correct use of the Ponseti tech-
The prevalence in Vietnam is estimated to be approx-           nique has repeatedly been shown to radically reduce
imately 1 per 1,000 births. Surgical correction has            the rate of extensive corrective surgical procedures
    *Department of Health Science, University of South Aus-    for clubfoot cases and has been found to be adapt-
tralia, Adelaide, South Australia.                             able to successful use in the developing world.1-3, 7
    †Da Nang Orthopedic and Rehabilitation Centre, Da Nang     Concurrently, the long-term results of clubfoot sur-
City, Vietnam.
                                                               gery have found moderate to severe degenerative
    Corresponding author: Angela M. Evans, PhD, Depart-
ment of Health Science, University of South Australia, City    changes in 56% of patients.16
East Campus, North Terrace, Adelaide, South Australia, 5000       The Ponseti method provides the best long-term
Australia. (E-mail: angela.evans@unisa.edu.au)                 results for clubfoot deformity, has few complica-

306                            July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association
tions, and is cost effective. In Vietnam, the initial cost    seti method is suitable for all types of clubfeet, it is
estimates revealed a very favorable cost comparison           mostly used for congenital idiopathic clubfoot. The
between clubfoot surgery and the nonsurgical Pon-             extent of deformity of the stiffer syndrome-associat-
seti method. The cost of surgery (including surgery,          ed clubfoot, as occurs with arthrogryposis or myelo-
medication, dressings, radiographs, splint, hospital          meningocele, may be reduced with careful technique
accommodation, and food) was VND 4,300,000 per                use. The technique must be adapted for the atypical or
case. By comparison, the cost of the Ponseti method           complex clubfoot as Ponseti19 has clearly described.
(including five casts, three braces/shoes) was VND
1,400,000 per case. Therefore in Vietnam, the Ponseti         The Ponseti Method Described
method is at least two, and possibly three times more
cost effective than clubfoot surgery.17 Economics             The basic steps involved in the Ponseti method are
aside, the clinical results for a pain-free functional        outlined below. After initially assessing the clubfoot
foot are much better when the Ponseti method is cor-          type, the foot is given a score using the Pirani method
rectly used.9                                                 to assess severity. The foot is then manually manipu-
                                                              lated to the correct position for the first cast to be ap-
Clubfoot                                                      plied. This process is repeated every 5 to 7 days until
                                                              foot position is corrected, which usually takes approx-
Basic Pathology                                               imately five to six casts. It may be necessary to per-
                                                              form an Achilles tenotomy to gain full correction of
The congenital idiopathic clubfoot deformity is iden-         the ankle equinus, in which case a final abductory
tified by the presence of a retracted and inverted heel       cast is applied for an additional 3 weeks. Following
(equinus), usually a medial crease on the plantar as-         initial castings and Achilles tenotomy if required, the
pect of the adducted forefoot, and longitudinal arch          foot correction must be maintained with an abduc-
cavus. Pathognomonic to this deformity is the inabili-        tion brace for 3 to 5 years to prevent relapse of the
ty to bring the foot to a plantigrade position. In unilat-    deformity. It is vital that children are monitored regu-
eral cases, the clubfoot is comparatively stiff and           larly. The reader is strongly encouraged to access the
smaller because of leg muscle atrophy; and shorten-           Ponseti Management publication, which was recent-
ing is also common.                                           ly translated into Vietnamese and is available for free
    In terms of etiology, a normally developing foot de-      download from Global Help.2
forms at approximately the 16th fetal week to be-
come a clubfoot. Although genetics and environmen-            Diagnose Type of Clubfoot
tal influences are both probable contributors, it is
curious to note that a more precise mechanism of eti-         With reference to the above description of clubfoot
ology is still unknown.                                       types or categories, it is important to identify the type
    The primary deformity centers on the shape and            of presenting clubfoot so as to select the correct cast-
position of the talus and the related misplacement of         ing technique (standard Ponseti for the congenital id-
the navicular. The Ponseti method focuses on stabiliz-        iopathic clubfoot or adapted Ponseti for the complex
ing the talus and reducing the clubfoot deformity by          or atypical clubfoot) and to realistically predict the
abducting the inverted forefoot. This allows for the          results (often not as good for the resistant clubfoot
calcaneus to abduct, which in turn allows for the             seen with arthrogryposis).
ankle to be dorsiflexed (often necessitating lengthen-
ing of the Achilles tendon).2, 5, 18, 19                      Score the Clubfoot Severity with the
                                                              Pirani Scale
Types of Clubfoot
                                                              The Pirani scoring system is used to assess initial
There are three main types of clubfoot to be aware of         clubfoot condition and to monitor treatment progress
when diagnosing the infant clubfoot. The first and            of the Ponseti technique. It has also been found to be
most common is the congenital idiopathic clubfoot, a          reliable20 (Table 1), predictive for the need of Achilles
difficult deformity that affects otherwise healthy chil-      tenotomy,14 and prognostic.11 Pirani scoring of club-
dren. The second type is the resistant clubfoot often         foot consists of examining six areas of the foot that
associated with syndromes such as arthrogryposis              reflect the hindfoot, midfoot, or total foot status in
and is stiffer in nature. Third is the atypical or com-       terms of clubfoot severity2 (Fig. 1).
plex clubfoot, which is short, fat, stiff, and requires a        The initial Pirani score has been shown to predict
very adapted casting approach.19 Although the Pon-            the likely need for Achilles tenotomy. Initial scores ≥ 5

Journal of the American Podiatric Medical Association • Vol 99 • No 4 • July/August 2009                           307
Table 1. Pirani Score Reliability Pilot Studya as Used in        that the parents and baby are comfortable for this
Vietnam for the Clubfoot Project                                 process. Feeding can greatly assist in relaxing the in-
                                      Examiner 1
                                                                 fant during the casting process. The applied forces
Pirani Measure                   ICC SM 1-way (95% CI)           should not distress the infant and must be carefully
                                                                 directed around the stabilized talus (Fig. 2). The new-
Lateral border                             0.91
Medial crease                              1.00
                                                                 born infant clubfoot is very small, and it is easy to in-
Talar head coverage                        0.77                  correctly manipulate the foot. The basis of the Ponseti
Midfoot score                              0.94                  technique is to abduct the inverted forefoot around
Posterior crease                           0.73                  the stabilized talus (Figs. 3 and 4). The heel is not
Rigid equinus                              0.86                  touched during this process. If the talus is not accu-
Empty heel                                 0.22                  rately located, the force of abduction will break the
Hindfoot score                             0.82                  foot at the developing talonavicular joint and the cal-
Total foot score                           0.96                  caneus will not abduct. This was the main problem
   Abbreviations: ICC, intrarater correlation coefficient; CI,   with the Kite technique,22 which applied pressure
confidence interval; SM, single measure.                         over the calcaneocuboid joint, preventing correction
   aSix infants (10 clubfeet) aged 8 to 18 months (mean age
                                                                 of the heel. We recommend that doctors contemplat-
13.3 mo) were examined for the reliability protocol. There
was good correlation between examiner 1 (aid team volun-
                                                                 ing using the Ponseti technique use a skeletal model
teer) and a Vietnamese nurse who has been trained to use         to review the details of foot anatomy (Fig. 5).
the Pirani scoring system (rho = 0.927). However, the inter-
rater measures were limited to two subjects, and therefore,      Padding
provide only preliminary indication.
                                                                 Once the foot has been held in the correctly manipu-
                                                                 lated position for 60 sec, a layer of under-cast padding
require tenotomy; scores ≤ 3.5 do not require tenoto-            is applied. It is important that the manipulated posi-
my; and scores between 3.5 and 5.0 may need tenoto-              tion of the foot continues to be held while the padding
my.14 Another recent study11 has found that the initial          is applied. Clearly, two doctors are now necessary for
Pirani score not only predicts the need for tenotomy             this process. The padding must be applied with firm
but also the number of casts required to gain correc-            tension and minimal bulk. Too much padding will
tion. This study found that hindfoot scores are most             simply compress and allow for cast slippage, less ef-
predictive for tenotomy need with initial hindfoot               fective foot molding, and skin abrasions. Care must
scores of 2.5 or 3.0 (of a possible 3.0) requiring a             be taken to ensure that all skin surfaces are covered,
tenotomy in approximately 75% of cases. The total                from toes to groin (Fig. 6).
score of above or below 4 indicates how many cast
applications may be required for correction. A total             Application of Plaster Cast
score of 4 needs at least four casts; a total score of
less than 4 needs fewer casts.                                   The manipulated foot position continues to be main-
   Pirani scores are a very useful guide. The foot               tained while the plaster cast is applied over the layer
should be scored initially, at each cast change, and at          of minimal padding. The plaster is always applied in
splint reviews. Evaluating the foot at each cast change          two sections: the foot and leg below the knee (Fig.
will enable residual components of the deformity to              7A), and above knee, with knee flexed at 90° (Fig.
be addressed. It is important to remember that be-               7B). The first section of plaster is applied by one doc-
cause each case is individual, the Pirani score system           tor (or other trained staff member) while the other
may guide, but not dictate, clinical decision making.            doctor maintains the corrected foot position. The
                                                                 plaster is molded very well around the arch and hind-
Manipulation                                                     foot. Once the first section of plaster is set firm and
                                                                 holding the foot position, the knee is flexed to 90°
All components of the clubfoot deformity are correct-            and the above-knee section is applied up to the groin.
ed simultaneously except for the ankle equinus, which            Firm tension must be used when applying the plaster
is corrected last. The arch cavus is corrected at the            to prevent cast slippage. Ensure that all skin is cov-
same time the forefoot adduction is reduced. This is             ered by padding so that no abrasions will be caused
achieved by inverting (supinating) and abducting the             from the plaster edges. The knee must be reinforced
forefoot to align with the hindfoot.21                           to prevent cast breakage and it is helpful to apply an
   Manual manipulation of the infant clubfoot must               anterior plaster slab rather than heavy layers. Once
be both anatomically accurate and gentle. Ensure                 the cast is firmly set, it must be well trimmed to allow

308                             July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association
                                                                         Right                        Left

                                                             Figure 2. Gentle manipulation of the foot first requires
                                                             location of the head of talus on the lateral side by pal-
                                                             pating the tibial and fibular malleoli with one hand and
                                                             holding the toes and metatarsals with the other hand.
                                                             Slide thumb and forefinger from malleoli to the front of
                                                             the ankle mortice. The navicular is small (forming) and
                                                             being medially displaced, will be found under the me-
                                                             dial malleolus. The anterior calcaneus will be felt just
                                                             below the talar head. Stabilize the head of the talus lat-
                                                             erally so the foot can be abducted around the talus. Do
                                                             not touch the calcaneus for this movement.




Figure 1. The Pirani scoring method. A, Lateral border;
B, medial crease; C, talar head coverage; D, posterior        Figure 3. Gentle manipulation of the foot requires re-
crease; E, rigid equinus; F, empty heel. Each of the six      duction of the cavus deformity (A). The cavus defor-
criteria is scored 0, normal findings; 0.5, moderate or       mity is attributable to pronation (eversion) of forefoot
partial deformity; or 1.0, severe deformity. The total Pi-    in relation to rearfoot. Cavus is always a supple defor-
rani score is 6, with two subscores for the midfoot and       mity in newborn infants, so inversion (supination) of
hindfoot scores of 3 each. (Reprinted with permission         the forefoot will flatten out the arch (B, C). (Reprinted
from Global Help.)                                            with permission from Global Help.)

Journal of the American Podiatric Medical Association • Vol 99 • No 4 • July/August 2009                          309
                                                             first 24 hours. The position of the toes in the cast
                                                             should not change. If the toes become less visible,
                                                             this is an indication that the cast has slipped, foot cor-
                                                             rection will be reduced, and the likelihood of skin
                                                             abrasions (possible infections) increased. In this case,
                                                             the cast must be removed and reapplied. Cast slip-
                                                             page will occur if the standard Ponseti technique,
                                                             rather than the adapted technique, is applied to an
                                                             atypical or complex clubfoot.19 Again, the importance
                                                             of diagnosing the type of clubfoot is very important in
                                                             selecting the casting technique.

                                                             Repeat Casting until Foot Position is Corrected
                                                             or Achilles Tenotomy is Required
Figure 4. Stabilize the talus laterally and abduct the
foot while in supination as far as possible, without         The casting process is repeated every 5 to 7 days and
hurting the infant. Hold this position with gentle pres-     is guided by the initial Pirani score,14 especially the ini-
sure for 60 seconds. Note the correct positions of the       tial hindfoot score.11 It is now known that casting for 5
hands. Repeat this gentle manipulation at each cast          days gives the same results as casting for 7 days23 and
change to gain elongation of the connective tissues          can shorten the overall casting process (average of six
prior to cast immobilization.
                                                             cast repeats) from 42 days to 30 days. This may be
                                                             very useful for families from remote regions.
                                                                 To avoid upsetting or cutting the infant, cast saws
for toe clearance dorsally. It is important that the toe     are not used. Instead, it is recommended that all casts
extensor muscles can activate because these are anti-        be soaked off 1 hour before the next cast is to be ap-
clubfoot mechanisms (Fig. 8). It is also important to        plied. This can be easily achieved by having the par-
monitor blood perfusion to the foot, especially in the       ents wrap the cast in wet newspaper or wet towels

Figure 5. Foot skeleton references. Notice that with the talus stabilized laterally, the simultaneous supination (re-
duces the cavus) (A) and abduction of the forefoot also abducts the heel (B). This is essential for successful reduc-
tion of clubfoot deformity. (Reprinted with permission from Global Help.)

310                          July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association
                                                                ducted before performing an Achilles tenotomy to in-
                                                                crease ankle dorsiflexion. The best sign of sufficient
                                                                abduction is being able to palpate the anterior process
                                                                of the calcaneus as it abducts from under the talus.2
                                                                At this stage the heel should be in a neutral position
                                                                and the foot abducted 60° to the tibia (coronal plane).
                                                                It is better to apply another one or two casts to be
                                                                sure of the hindfoot abduction, rather than perform-
                                                                ing a premature and ineffective tenotomy. It is also
                                                                important that the foot not be forcibly pronated in an
                                                                attempt to reduce the equinus. Remember that unless
                                                                the calcaneus can abduct beneath the talus, the foot
                                                                cannot dorsiflex. The impatient use of excessive force
                                                                will cause a midtarsal break of the infant foot and will
                                                                not reduce the ankle equinus. The calcaneus must be
Figure 6. Minimal under-cast padding is applied while
the correctly manipulated foot position is maintained.          able to abduct beneath the talus to reduce the equi-
The padding can be applied in two sections, ie, below           nus (with or without a tenotomy).
the knee and then above the knee, or completely from                A tenotomy, if required, can be performed percuta-
toes to groin.                                                  neously with either topical or locally infiltrated anes-
                                                                thesia. Some authors14 have commented that both of
                                                                these methods of anesthesia appear to provide the in-
and then put the cast leg in a plastic bag. After an            fant with similar pain relief but that the topical skin
hour, the cast is soft and can be easily removed with           approach enables easier palpation of the tendon. If
plaster scissors.                                               local anesthetic solution is injected, a small amount is
                                                                advised. Full skin disinfection and good sterile tech-
Achilles Tenotomy Decision                                      nique must be used for this procedure. As seen in Fig-
                                                                ure 9, the tenotomy is performed with a small blade
The foot is scored with the Pirani scale at each cast           to sever the Achilles tendon approximately 1.5 cm
change so that progress can be monitored. If adequate           above the calcaneus. The foot is held in maximal dor-
dorsiflexion is not achieved with sequential cast ab-           siflexion while this is performed, and increased dorsi-
ductions, an Achilles tenotomy may be required. This            flexion is immediate once the tendon is released. The
will have been indicated from the initial Pirani score.11, 14   incision is lightly dressed and the post-tenotomy cast
It is very important that the foot is sufficiently ab-          applied with the foot abducted 60° to 70° and knee

A                                                               B

Figure 7. The cast is applied in two sections. A, The cast is applied first to the foot and the leg below the knee.
Note the maintained manipulated foot position until the plaster has set firm. B, The second section of cast connects
the knee and thigh with an above-knee cast that extends to the groin. The knee is flexed at 90° and needs to be re-
inforced to avoid breakage.

Journal of the American Podiatric Medical Association • Vol 99 • No 4 • July/August 2009                           311
                                                              ly for the months and years following correction. We
                                                              now know that clubfoot relapse following good cast/
                                                              tenotomy correction is enormously increased when the
                                                              foot abduction brace is not used consistently.6, 15, 23, 24
                                                              Given the genetically driven tendency of the clubfoot
                                                              to be deformed, bracing and monitoring must be very
                                                              diligent until the child is at least 5 to 6 years of age
                                                              and beyond.2
                                                                  The foot abduction brace is applied immediately
                                                              after the last cast is removed, 3 weeks after the teno-
                                                              tomy. The brace bar measures shoulder width of the
                                                              baby and will need to be increased with growth. For
                                                              bilateral clubfoot the boots are ideally abducted 70°;
                                                              for unilateral cases, the clubfoot is abducted 70° and
                                                              the unaffected side abducted 30°. However, it should
Figure 8. The plaster is removed to allow dorsal ex-          be emphasized that the initial brace abduction angle
posure of all toes. This allows toe extensors to work
and strengthen against stronger flexors. Vascular sta-        should be the same as that obtained with the post-
tus and cast position must also be monitored.                 tenotomy cast. Bracing the feet in greater abduction
                                                              than that achieved with the final casts may well in-
                                                              crease the baby’s discomfort and a higher chance of
                                                              early noncompliance. The knees are free so the baby
                                                              can kick to exercise and stretch the gastrocnemius
flexed at 90° (Fig. 10). This cast remains for 3 weeks,       muscles. A slight 10° bend in the bar maintains dorsi-
during which the tendon heals. Upon removal of this           flexion.
cast, the foot abduction brace must be immediately                The brace used in Vietnam is now manufactured in
applied.                                                      Da Nang by the Orthotics Department of Da Nang Or-
                                                              thopedic and Rehabilitation Centre and comes in
Abduction Brace                                               three sizes. The attached boots are also locally pro-
                                                              duced in nine sizes to accommodate for growth. The
Although the casting and tenotomy (usually required)          child usually needs three to four different sizes for
achieve the correction of the clubfoot, it will all be        the duration of bracing (Fig. 11).
wasted if the foot abduction brace is not used proper-            The brace is worn 23 hours per day for the first 3

 A                              B                                C                            D

Figure 9. Apply skin preparation to disinfect the foot on all surfaces (A). Use a small amount of local anesthetic so-
lution or topical anesthetic cream if available (B). Using a No. 11 or No. 15 blade, a small incision is made 1.0 to
1.5 cm above the calcaneus, while the foot is held in dorsiflexion (C). As the tendon releases, a “pop” is felt or
heard, and 10° to 20° dorsiflexion should be gained (D). (Reprinted with permission from Global Help.)

312                          July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association
                               A                                                         B

Figure 10. A final cast is applied after the Achilles tenotomy and remains for 3 weeks. The cast should be applied
with the foot abducted 60° to 70° (A). After removal of this final cast, 20° to 30° of ankle dorsiflexion should be pos-
sible (B). The foot is now ready for splinting, which must begin immediately to avoid loss of any initial correction. To
reduce early noncompliance with the boots and abduction brace, the initial abduction angles should not be greater
than that achieved with the final casts. (Reprinted with permission from Global Help.)

months. After 3 months, the brace is worn for 16               parents know how to apply the splint and warn them
hours per day, at night and during daytime naps. The           that a few difficult nights are normal.
use of the brace is continued 10 to 12 hours per day
up to age 4 years, and is still worn at night up to 5 to 6     Monitor
years of age. The longer the brace can maintain cor-
rection against genetic clubfoot activity, the better the      Because the brace use is so critical to good long-term
long-term results.                                             results, it is important to monitor compliance regular-
   The parents need to be informed of the impor-               ly. Follow-up after the initial fitting of the brace should
tance of brace use right from the start of managing            occur at 2 weeks, 1 month, and 3 months. After 3
the clubfoot. It is a mistake to allow parents to think        months, brace use is reduced to 16 hours per day.
that the cast correction alone has fixed their baby’s
clubfoot, and they must be clearly informed that the
clubfoot will relapse if the brace is not worn as in-
structed (Fig. 12). A printed information sheet and
regular review appointments are advised. Ensure the

Figure 11. The brace boots are made in nine sizes to
allow for growth. In unilateral cases of clubfoot, differ-     Figure 12. The use of the foot abduction brace is es-
ent sized boots may be required because the clubfoot           sential to prevent relapses, and its use must be regu-
is usually smaller than the foot without deformity.            larly monitored.

Journal of the American Podiatric Medical Association • Vol 99 • No 4 • July/August 2009                             313
Continue to check every 3 months until the child is 12                  capacity for medical staff to treat this condition with
months old (depending upon the age the process                          the Ponseti method wherever possible; and incorpo-
began), three to six monthly checks until the child is 5                rate necessary surgical correction for old and neglect-
to 6 years old, and then six to twelve monthly checks                   ed cases.
until age 15 years or at skeletal maturity.                                Many seminars have been conducted in provinces
    The risk of relapse is greatly increased with brac-                 in central Vietnam to provide education to hospital
ing noncompliance. It has been shown that insuffi-                      and clinic staff. Seminar content is consistently re-
cient use of the brace accounts for more than 80% of                    viewed and updated. Educational posters and book-
relapses7, 15, 23 and that noncompliance with the brace                 lets have been produced and distributed to increase
is the most predictive factor for clubfoot recurrence.                  awareness, and doctors have been trained to use the
Noncompliant patients are 27 times more likely to re-                   Ponseti technique in workshops. The boots and bar
lapse than those who comply with brace use.25                           comprising the foot abduction brace are now devel-
    The management of the relapsed clubfoot is large-                   oped and manufactured at DORC, which is develop-
ly avoidable if the Ponseti method is used correctly                    ing as the center of the Ponseti method expertise in
and in particular if the foot abduction brace is used to                Vietnam, with one of the authors of this paper (D.V.T.)
maintain correction during the early years. Signs of a                  coordinating the program.
relapsing clubfoot include reduced abduction, re-                          The International Committee of the Red Cross
duced ankle dorsiflexion, increased metatarsal ad-                      (ICRC) convened three seminars for doctors in Ho
duction, heel varus, and forefoot supination. If the                    Chinh Minh City in 2007 and 2008 for the Ponseti
clubfoot does relapse, the patient should undergo re-                   technique to be further conveyed to doctors and
casting and rebracing. For equinus, the patient should                  physical therapists by the FFW team. To date, 271
be recast; another tenotomy may be needed, and then                     doctors and therapists have attended for briefing, and
cast and splint again. For gait supination, the patient                 67 have been trained to use the technique locally.
may need tibialis anterior transfer to the third cunei-                 Prior to 2006, approximately 10 to 12 children aged 4
form. For further detail regarding relapse manage-                      to 10 years were presenting annually to the Centre of
ment, the reader is referred to the Ponseti monograph.2                 Paediatric Orthopedic Rehabilitation, Ho Chinh Minh
The Ponseti method is not quick, but it is cost effec-                  City, for revision of previous clubfoot surgery. Since
tive in Vietnam and gives the best long-term results                    2006, this same center has seen approximately 30
for the life of the growing child.                                      younger infants annually with untreated clubfoot who
                                                                        are treated with the Ponseti method by doctors and
Ponseti Method Research                                                 therapists who have attended the ICRC trainings (TV
                                                                        Tan, oral communication, 2008). Dr. Lea Tho Hiean
The results of research investigating the efficacy of                   Nhi from the TuDu Maternity Hospital, Ho Chinh
the Ponseti method are summarized and presented in                      Minh City, completed the ICRC Ponseti method train-
Table 2.1, 3, 6-10, 13-15, 19, 23, 24, 26-30 These results illustrate   ing in 2007 (Table 3). At the subsequent seminar in
very clearly why the Ponseti method has now become                      May 2008, she presented a summary of the use of the
the technique of choice in the developed world. It be-                  Ponseti method on 30 infants (49 clubfeet) in this
comes implicit that this approach is also suitable and                  hospital over a 6-month period (Table 4). Of the 30 in-
beneficial for use in developing countries where                        fants, 19 were male and 11 female. There were 11 uni-
scant health-care resources make the cost-effective                     lateral clubfeet (nine right feet, two left feet) and 19
Ponseti method very suitable. There is still much to                    bilateral cases. Twenty cases were idiopathic clubfeet
learn regarding both the universally similar and coun-                  and ten had other associated pathologies. Initial Pi-
try specific barriers for families adhering to the Pon-                 rani scores were ≤ 3.5 in nine feet, between 3.5 and
seti method.31, 32                                                      5.0 in 11 feet and ≥ 5.0 in 24 feet.
                                                                           The liaison between the ICRC and the FFW team
The Vietnam Experience to Date                                          is ongoing, which will further promote the best man-
                                                                        agement of infant clubfoot deformity for infants in
The Feet for Walking clubfoot project (FFW) in Viet-                    Vietnam. The FFW Web site provides current infor-
nam began in 2004 as a collaborative venture be-                        mation about the progress of this very worthwhile,
tween the Da Nang Orthopedic and Rehabilitation                         collaborative project (www.feetforwalking.org).
Centre (DORC) and the Australian College of Podi-
atric Surgeons (ACPS). The project aims to increase                     Acknowledgment: The following bodies have sup-
community awareness of clubfoot as a deformity that                     ported and continue to facilitate the clubfoot project:
is best identified and treated early from birth; build a                The Medical Director, Mr. Cuc, Medical, Nursing and

314                                 July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association
Table 2. Ponseti Technique Success Rates in the Literature, 1980–2007
                                              No. of       No. of    Average Age        Initial
Author                          Date         Patients     Clubfeet    of Patients   Correction (%)             Comment
Laaveg and Ponseti     27       1980           70           104        < 6 mo           88.5
Ponseti et al28                 1981           32           32          infant          87.5
Cooper and Dietz10              1995           45           71         < 4 mo            78
Herzenberg et al9               2002           27           34         < 3 mo            97          Randomized controlled trial: 3%
                                                                                                      required posterior medial release
                                                                                                      versus 94% in control group
Lehman et al13                  2003           63           87        10.8 wks           92          Correction reduced to 50% if
                                                                                                      brace not used properly
Morecuende et al7               2004           157          256      most < 6 mo         98          Relapses due to poor brace use
Dobbs et al6                    2004           51           86         12 wks            100         Relapses (31%) correlates with
                                                                                                      brace use: 183 times increased
                                                                                                      recurrence risk
Thacker et al24                 2005           30           44         < 6 mo            70          Brace use avoids relapse
Tindall et al3                  2005           75           100       11.5 wks           98          Malawi study
Morecuende et al23              2005           230          319        3–5 mo          92–93         Brace use improves results
Gupta et al1                    2006           96           154        infant a         100          India study
Changulani et al8               2006           66           100                          96          Relapses due to poor brace use
Shack and Eastwood29            2006           24           40          3 wks           97.5         Treatment delivered by physical
Ponseti et al19                 2006           50           75          3 mo             100         Complex clubfeet, 14% relapse
                                                                                                      with poor brace use
Goksan et al30                  2006           92           134                          97          Relapses due to poor brace use,
                                                                                                      previous treatment, doctor s
Haft et al15                    2007           51           73         15 days           100         Relapses (41%) correlates with
                                                                                                      brace use
   a   Age of patient was not defined in this study.

Table 3. The Scale of Treatment Provided for Infants with               Table 4. Clinical Results of Ponseti Management for 30
Clubfoot at TuDu Maternity Hospital, Ho Chinh Minh City,                Infants (49 Clubfeet) During A 6-month Period (2007–2008)
                                            Year Treated                  Male         19 (63%)
                                       2005    2006      2007             Female       11 (37%)
                                                                        Foot affected (30 infants)
Clinical data
                                                                          Right         9
 No. of all patients seen              6,427     7,621     10,646
                                                                          Left          2
 No. with clubfoot                      64        23         36
                                                                          Bilateral     19
Results of clubfoot treatment                                           Type (30 infants)
 Excellent/good                         52           18      31           Normal clubfoot: 20
 Normal/poor                            7            3       3            Clubfoot with other pathology: 10
 Quit program                           5            2       2
                                                                        Initial Pirani scores
                                                                           ≤ 3.5:    9 (20%)
                                                                           3.5–5.0: 11(25%)
                                                                           ≥ 5.0:    24 (55%)
Allied Health staff at the Da Nang Orthopedic and Re-
                                                                        Treatment stage at time of report
habilitation Centre, Da Nang City, Vietnam; Variety                       Casts        27%
Club of Australia and Clarks Shoes/Pacific Brands for                     Boots/splint 73%
project sponsorship; Australian College of Surgical
Podiatrists (especially Paul Wade, DPM, and Andrew
van Essen); East Meets West Foundation, Da Nang
City, Vietnam (especially Mark Conroy); International                   cially Dr. Tan); Vietcot, Hanoi, Vietnam (especially
Committee of the Red Cross, Ho Chinh Minh City,                         Mr. Thanh); Dr. I. Ponseti, Iowa; Dr. N. Davis, Booth
Vietnam (especially Leo Gasser); Centre of Paediatric                   Hall, Manchester; Ms. D. Watson, Chelsea and West-
Orthopedic Rehabilitation, Ho Chinh Minh City (espe-                    minster Hospitals, London; Dr. E. Goergens, Ham-

Journal of the American Podiatric Medical Association • Vol 99 • No 4 • July/August 2009                                          315
burg, for generous collegial support and sharing their           15. HAFT GF, WALKER CG, CRAXFORD AD: Early clubfoot recur-
invaluable experience. Many individual donors of fund-               rence after use of the Ponseti method in a New Zealand
                                                                     population. J Bone Joint Surg Am 89: 487, 2007.
ing, assistance, and supplies. All are very gratefully           16. S IAPKARA A, D UNCAN R: Congenital talipes equinovarus.
acknowledged.                                                        A review of current management. J Bone Joint Surg Br
Financial Disclosure: None reported.                                 89B: 995, 2007.
Conflict of Interest: None reported.                             17. A GARWAL AK: Step by Step Management of Clubfoot by
                                                                     Ponseti Technique, Jaypee Brothers, New Delhi, India,
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316                             July/August 2009 • Vol 99 • No 4 • Journal of the American Podiatric Medical Association

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