In the introduction to Dr. Ponseti's 1996 book "Congenital Clubfoot, Fundamentals of Treatment", Dr. Ponseti explains some of the history of the development of is "non-surgical" method of treatment. I thought that this might be helpful in understanding how his method was created.

Martin Egbert (USA)

The following are some excerpts from the introduction to Dr. Ponseti's book.

Ponseti, I.V. "Congential Clubfoot, Fundamentals of Treatment", OXFORD UNIVERSITY PRESS, Oxford, 1996 pages 3-7

"...The treatment of clubfoot has been controversial throughout the last 150 years. When I arrived in the University of Iowa Medical School to complete my training in orthopedic surgery in 1941, the clubfoot was treated by different members of the staff, some with manipulations and plaster casts, others by taping the feet in Denis Browne splints, and still others by using the Kite's (1930) method: removing some wedges from a plaster shoe to correct the components of the deformity. The Thomas wrench was occasionally used to correct residual deformities but finally most feet ended up in surgery. The Brockman technique for the medial release of the subtalar and midtarsal joints was one of the most common operations performed in the department (Brockman 1930). My colleagues and I expanded the medial release operation to include a posterior release and often we made a lateral incision to free the tarsal joints so as to align the tarsal bones with the cuneiforms and metatarsals (Le Noir 1966).... The techniques of treatment and results in our department before 1948 were reported by Steindler, Le Noir, and others (Blumenfeld et al. 1946; Steindler 1950, 1955; Le Noir 1966)."

"Robert Jones from Liverpool and London wrote in 1923 that he had never met with a case where treatment has been started in the first week where the deformity could not be completely rectified by manipulation and retention in two months (Jones 1923). His experience could not be duplicated in our department nor in other clinics I visited, and the results were far from perfect after a very prolonged treatment. Faced with these disappointing results, I set out to discover how a clubfoot could be corrected through manipulation and retention casts in a two-month period after birth, as Robert Jones had claimed."

"Although [Dr. Hiram] Kite was the leading advocate of the conservative treatment of clubfoot for many years and should be commended for his lifetime efforts to try to resolve the clubfoot problem without surgery, his treatment was lengthy and short of satisfactory. I was determined to discover the flaws that prevented him from reaching Robert Jones's claimed results. In 1960, I visited Kite in Atlanta for a few days to observe his method of treatment. In 1965, we gave a course together in Caracas, Venezuela, during which each of us applied plaster casts. Our methods differed greatly."

"Kite corrected each component of the deformity separately instead of simultaneously, and although he managed to correct the cavus and to avoid foot pronation and its harmful consequences, the correction of the heel varus took him an inordinate amount of time since he did not realize that the calcaneus must abduct before it can be everted. However, he managed to obtain plantigrade feet. I shall go into further detail in Chapter 7 where I discuss the manipulative treatment."

"From my observations in the clinic and in the operating room, I realized that the orthopedists' failures in the [manipulative non-surgical] treatment of clubfoot were related, in part, to a poor understanding of the functional anatomy of the normal foot as well as of the clubfoot. Without this understanding, it is impossible to alter the forces that caused the deformity and apply the proper corrective manipulations and retaining casts. I then studied the pathological anatomy of the clubfoot. I dissected several normal feet and three clubfeet of stillborn babies, and obtained serial sections of the two clubfeet of a 17-week aborted fetus. Under cineradiography, I studied the range of motions of the tarsal joints of normal feet and of clubfeet. I trained my fingers to palpate the joints and bones and feel their motions both in normal feet and in clubfeet."

"Based on these studies, I developed and refined a uniform type of treatment in the late forties. By the late fifties, when reviewing our patients for a short term follow-up article (Ponseti and Smoley 1963), I knew that I had found the proper approach to the treatment of clubfoot, a treatment that has been followed to the present day in our department with optimum results. Fellows joining our pediatric orthopedic program were impressed to discover the ease with which most clubfeet can be well corrected without surgery in a relatively short time..."

"...A well-conducted orthopedic treatment, based on a sound understanding of the functional anatomy of the foot and on the biological response of young connective tissue and bone to changes in direction of mechanical stimuli, can gradually reduce or almost eliminate these deformities in most clubfeet. Less than 5 per cent of infants with very severe, short, fat feet with stiff ligaments unyielding to stretching will need surgical correction. The parents of all the other infants may be reassured that their baby, when treated by expert hands, will have a functional, plantigrade foot which is normal in appearance, requires no special shoes, and allows fairly good mobility."

"The guidelines for the clubfoot method of treatment which I developed in 1948, described in full detail in Chapter 7, are as follows:

1. All of the components of the clubfoot deformity have to be corrected simultaneously with the exception of the equinus [foot pointing down] which should be corrected last.

2. The cavus [high arch], which results from a pronation of the forefoot in relation to the hindfoot, is corrected as the foot is abducted by supinating the forefoot and thereby placing it in proper alignment with the hindfoot.

3. While the whole foot is held in supination and in flexion, it can be gently and gradually abducted under the talus secured against rotation in the ankle mortice by applying counter-pressure with the thumb against the lateral aspect of the head of the talus.

4. The heel varus and foot supination will correct when the entire foot is fully abducted in maximum external rotation under the talus. The foot should never be everted.

5. Now the equinus can be corrected by dorsiflexing the foot. The tendo Achilles may need to be subcutaneously sectioned to facilitate this correction...."

A full copy of the Preface and Introduction to Dr. Ponseti's book has been reprinted in a reference folder in the files section of the Ponseti method parents support group at http://groups.yahoo.com/group/nosurgery4clubfoot/ .

You will have to join the nosurgery4clubfoot group to be able to access the files section, but it is free.