Almost 60 years after it was conceived, Washington University orthopaedic surgeon Matthew B. Dobbs, MD, has revived a nonsurgical technique to correct talipes equinovarus, or clubfoot, a congenital foot deformity. By combining the venerable procedure with the latest genetic science and translational research, Dobbs aims to drastically improve treatment and perhaps eventually reduce the incidence of the malady.
The revived procedure employs weekly stretching of the infant’s foot followed by the application of long-leg casts that gently reshape an infant’s relatively plastic foot. Dobbs says the procedure serves his patients well, “The casting technique is applicable to all clubfeet from birth to the age of 2 years.”
Ignacio Ponseti, MD, developed this nonsurgical technique to treat clubfeet almost 60 years ago because he saw that children treated surgically for clubfoot often went on to develop pain, stiffness, early onset arthritis, and complications that threatened the quality of their lives, even in their 20s. Dobbs confirmed, with a 25-year follow-up study on surgically treated clubfeet, that indeed many patients had poor foot function by early adulthood. A 35-year follow-up study has been performed on patients treated with the Ponseti technique, which found them to be functioning well, without arthritis. These results called into question the value of the traditional clubfoot surgery: a three- to four-hour operation to release all of the muscles, bones and tendons in the foot and create a reconstruction held in place with metal pins.
In the casting procedure Ponseti developed as an alternative treatment, the first cast is often applied in the newborn nursery, ideally within days of birth. “Ligaments and soft tissue respond to stretch better when we’re very young,” says Dobbs. The first cast stays in place only a week. Then the surgeon examines the progress and applies a second cast designed to reshape the foot slightly more. After four to five weeks and the same number of casts, the foot is completely corrected.
“It’s a visual process. Parents see improvement every week,” Dobbs says. It also requires training and great judgment by the surgeon. Although the procedure is endorsed by the Pediatric Orthopedic Society of North America, it still is not practiced widely. Only 25 orthopaedic surgeons are certified in the Ponseti technique nationally.
After casting is complete, young patients must wear orthopaedic shoes and a brace for a number of months, though the procedure usually doesn’t interfere with learning to walk. “Compliance with the regimen is essential to success,” Dobbs says. If the brace is not worn as prescribed, recurrence is inevitable. Most recurrences can be treated with repeat casting. Those few cases that don’t respond to casting can always be treated surgically.
Dobbs has successfully treated children as old as 19 months and now is gradually advancing the age at which the casting procedure can be initiated. Parents of young patients from around the world have learned of the procedure, and 50 percent of Dobbs’ practice now comprises pediatric foot deformities.
Interested in learning all he can about clubfoot, Dobbs also is engaged in translational research to identify the genes that play a role in the congenital and hereditary disorder that appears in approximately 1 in 1,000 live births in the United States and perhaps seven times that many children among Pacific Islanders. Grateful patients contribute to his DNA library, and a genome-wide scan has allowed initial localization of the involved gene. Next: narrow down the search to find the specific gene and its protein product to improve prenatal counseling. Ultimately, Dobbs would like to devise gene therapy to eliminate the malformation.
Washington University School of Medicine’s full-time and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked second in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.