Where Are We Now?

This important paper reflects the following reality: Surgeons do not consistently apply the strict protocol developed by Dr. Ignacio Ponseti, even though his approach has been proven to be the most effective means of treating children with clubfoot [5, 8].

The reasons for this are outlined in the current study, and also by others [8]. Previous modifications to the Ponseti method have included alternative cast manipulations, taping, short leg orthotics, varying cast materials, interruptions in cast treatment suggested by families, and selective use of surgical procedures, including Achilles tendon lengthenings and posteromedial approaches. Perhaps these modifications request some frustration on the part of surgeons or patients’ families with what is, legitimately, a difficult condition to treat. To perform the Ponseti method properly takes time, care, and training. The alternative—large, invasive posteromedial results—do not provide better results, and have even-larger problems than we see with the Ponseti method [1].

Where Do We Need To Go?

Very simply, we need Ponseti reference centers that apply the Ponseti method without modifications. The current paper shows that the correct application of Ponseti method can treat about 98% of clubfeet sucessfully without the need of extensive surgical interventions. To try to improve things even further, future efforts should focus on efficient and effective educational approaches. Simple lectures do not give attendees enough practice using the technique in real-world settings. Even hands-on workshops appear to be insufficient, since this is a complex skill that needs to be practiced over time in a supervised setting. The Brazilian Ponseti Program, which taught 556 professionals in 21 cities, was important for diffusion of the Ponseti method, but resulted in only about 7% of these “trained” providers applying the Ponseti method in an efficient way. In Vietnam, the same training method was used, and the results were similarly disappointing [6, 7]. Mentorship programs like those held in Mexico or Pakistan have been much more successful [3, 4].

Referral centers in clubfoot treatment can extend their reach and effectiveness by providing education and mentorship of this sort. Professionals who see only one or two patients a month will not be able to develop the skills they need without good access to this sort of guidance; access to referral centers can also help address the more difficult or treatment-resistant patient presentation [1]. That is the approach used to treat cardiac congenital deformities, cleft palate, and certain kinds of oncologic pathology [2].

How Do We Get There?

The outcomes achieved by such referral centers should be the benchmark to which all providers aspire. Possible indicators of good practice in the Ponseti method could include the number of casts used, the percentage of patients undergoing more extensive surgical approaches, and the frequency and management of patients with relapses. Future papers should focus on these endpoints. The potential next steps could also include Cochrane reviews, as well as development and dissemination of clinical practice guidelines from the Ponseti International Association.