Management of Idiopathic Clubfoot After Formal Training in the Ponseti Method: A Multi-Year, International Suryey

Abstract

Background

Over the past decade, the Ponseti method has become the standard of care to treat clubfoot amongst orthopaedic surgeons around the world. Since 2001, the University of Iowa, under the guidance of the late Dr. Ignacio Ponseti, has been teaching the Ponseti method through a standardized training course. This study examines the current clubfoot management practices of those who have participated in the course and the effectiveness of formal Ponseti Training Courses.

Methods

An online survey was administered to practitioners who participated in the University of Iowa Ponseti Training Course from 2001-2011.

Results

One hundred and thirty-one practitioners responded to the survey representing 33 different countries and 70 different orthopaedic societies. Ninety-seven percent of practitioners reported currently using the Ponseti method as the preferred treatment for clubfoot. The respondents reported the average duration of each cast was 9.21 days (SD=9.04 d) and the average cast phase of treatment lasted 7.62 weeks (SD=2.43 w). Physicians were responsible for applying the cast 79% of the time. Braces were utilized following casting by 96% of physicians. The average age of brace use was 41 months (SD=16 m). The reported relapse rate was 21% (SD=17%).

Ninety-seven percent of practitioners changed their practice after completion of the course. The preferred method prior to the course was surgical release (48%). Sixty-one percent of practitioners preferred review articles as an additional educational support; 49% preferred training videos. Sixty-seven percent believed an ‘on-site’ visit to their hospital by an expert in the Ponseti method would be very beneficial. Seventy-three percent suggested improving the course by providing more ‘hands on’ experience. Ninety-five percent of practitioners were satisfied with the course.

Conclusion

The Ponseti Training Course is an effective way to educate physicians on how to treat clubfoot with the Ponseti method. However, improvements should include more hands-on learning as well as an ‘on-site’ visit with an expert Ponseti practitioner.

Introduction

Over the past decade, the Ponseti method has become the standard of clubfoot care around the world^1-17. Surveys of the Pediatric Orthopaedic Society of North America (POSNA) membership from 2001 and 2012 suggest that the use of the Ponseti method has increased among their members¹⁸,¹⁹. Of those surveyed in 2010, nearly 83% reported receiving formal training in the Ponseti method¹⁹. The majority of those respondents reportedly received their training directly from Dr. Ignacio Ponseti¹⁹.

The University of Iowa’s Department of Orthopaedics has been conducting a formal CME course on the Pon-seti method each year since 2001. This course attracts a more international attendance than the previously characterized clubfoot management surveys, which have a high North American prevalence¹⁸,¹⁹.

The purpose of this study is to assess the clubfoot management practices of those who attended Dr. Pon- seti’s formal Ponseti Training Course at the University of Iowa (which typically is taught in weekend-long work-shops). Furthermore, this study analyzes the pedagogical effectiveness of these courses and solicits specific improvements for this educational approach.

Methods

Population

An international survey of health care practitioners who attended the University of Iowa CME Ponseti Training Courses was conducted. Those who attended these courses are presumed to be practitioners of the Ponseti method in their respective practice settings.

Survey Design and Testing

The study investigators designed the survey instrument by utilizing both information reported in the existing literature and investigator hypotheses. The survey was divided into three main segments: respondent characteristics, clubfoot management, and course feedback. An online survey program (Qualtrics, Inc., Provo, UT) was used to administer the survey. The instrument underwent trial by two high-level clubfoot practitioners for functionality and quality. This study was granted exemption from consent by the Institutional Review Board of the University of Iowa.

Data Collection

The initial request for survey participation was sent by email (via Qualtrics, Inc.) from the medical director of the Ponseti International Association. A follow-up reminder was sent to the same list three weeks later. The survey was open for three months from December 2011 to February 2012.

Measures and Variables

Questions with free response answers that were categorical variables were organized and tabulated with the most common answers being reported. Questions with free response answers that were numerical (i.e., days before casting) were organized and reported as a mean, standard deviation (SD), and median. When a large amount of participants responded ‘other’ and reported similar answers, the similar answer was reported as a ‘write-in’ and included in the reported responses.

Results

Respondent Characteristics

Responses were received from 131 participants (32%). The responses are summarized in Tables 1–3. The majority of respondents were MDs or DOs (65%). The next most common type of practitioner was physical therapists (10%). The respondents were mostly from the United States (53%), however, 32 other countries were also represented. Seventy orthopaedic societies were represented with AAOS (43 respondents), POSNA (35 respondents), and AOA (11 respondents) being the societies most commonly represented. The most common type of practice was academic (43%), followed by multi-disciplinary group practice (28%). The number of respondents ranged from 13 to 35 depending on the year of the training course (mean = 19.9 respondents).

Table 1.

Respondent Characteristics

Respondents	131 (32%)
Degrees
MD/DO	89 (65%)
PT	14 (10%)
PhD	8 (6%)
DPM	8 (6%)
ARNP/BSN/RN	6 (4%)
PA	4 (3%)
Other	16 (12%)
Practice Type
Academic practice	57 (43%)
Multidisciplinary group	37 (28%)
Private pediatric orthopaedic practice	26 (20%)
Private general orthopaedic practice	12 (9%)
Country of practice
USA	72 (55%)
Other	59 (45%)
Orthopaedic Society
AAOS	43
POSNA	35
AOA	11
Other	106
Year of course participation
2001	25 (19%)
2002	19 (15%)
2003	14 (11%)
2004	13 (10%)
2005	18 (14%)
2006	16 (12%)
2007	35 (27%)
2008	17 (13%)
2009	27 (21%)
2010	21 (16%)
2011	14 (11%)

Table 3.

CME Ponseti Educational Course

Preferred treatment method prior to course
Surgical method	64 (48%)
Ponseti method	56 (42%)
Other	14 (10%)
changed practice after program
Yes	117 (97%)
How practice changed
Less patients had surgery	47 (41%)
More patients had Ponseti method	61 (53%)
No change but better understood methods	45 (39%)
If no change, why not
Program not relevant to practice	1 (1%)
Lack of support from hospital	1 (1%)
Proper clinical setting not available	1 (1%)
Preferred form of future educational support
University of Iowa Website	41 (33%)
Webinar/Virtual Forum	35 (28%)
Training videos	60 (49%)
Quarterly Update	45 (37%)
Review articles	75 (61%)
Other	18 (15%)
*Hands on workshops (write in)	8 (7%)
Believe үn-siteҠvisit would compliment training
Yes	85 (67%)
Suggested improvements to program
More hands on experience	87 (73%)
More patient demonstration	54 (45%)
More lectures on technique	43 (36%)
More patient testimonials	11 (9%)
Section on billing for the Ponseti method	25 (11%)
# patients until felt comfortable with technique
0-10	40 (33%)
10-20	45 (37%)
20-30	19 (16%)
30-40	5 (4%)
40-50	4 (3%)
50+	8 (7%)
# patients until felt comfortable teaching technique to other providers
0-10	24 (20%)
10-20	30 (25%)
20-30	19 (16%)
30-40	17 (14%)
40-50	12 (10%)
50+	20 (16%)
Satisfaction with course
Extremely Dissatisfied	2 (2%)
Very Dissatisfied	1 (1%)
Dissatisfied	0 (0%)
Neither Dissatisfied nor Satisfied	2 (2%)
Satisfied	23 (18%)
Very Satisfied	53 (41%)
Extremely Satisfied	47 (37%)

Current Clubfoot Management

An overwhelming majority of respondents currently use the Ponseti method (97%) to treat clubfoot, while only 5% use the physical therapy/French method. Providers reported that they initially treated approximately 95% (SD = 20%, median = 100%) of their clubfoot patients with the Ponseti method. The preferred method of casting was the long leg cast (98%). Practitioners preferred plaster of paris (81%) to synthetic cast material (12%) while 7% reported using both materials. The casts are most often molded by the physicians (79%), while residents, physical therapists, and cast technicians each mold about 11% of the casts.

Table 2.

Clubfoot Management

Physical therapy/French method
Yes	6 (5%)
Ponseti Method
Yes	121 (97%)
Percentage initially treated with Ponseti method
Mean (SD)	95% (20%)
Median	100%
Type of case
Long leg	122 (98%)
Short leg	1 (1%)
Splint	1 (1%)
Cast material
Plaster of paris	98 (81%)
Synthetic	15 (12%)
Both equally	8 (7%)
Who applies cast (responsible for molding)
Physician	98 (79%)
Resident	14 (11%)
Cast Technician	14 (11%)
Physical Therapist	14 (11%)
Nurse Practitioner	5 (4%)
Physician Assistant	5 (4%)
Other	6 (5%)
Preferred age to initiate cast treatment (d)
Mean (SD)	7.51 (7.25)
Median	7
Age Ponseti method is no longer an option
< 3 months	2 (2%)
< 6 months	8 (7%)
< 1 year	10 (8%)
< 2 years	20 (17%)
Any age	80 (67%)
Average duration of each cast (d)
Mean (SD)	9.21 (9.04)
Median	7
Average duration of cast phase of treatment (wk)
Mean (SD)	7.62 (2.43)
Median	8
Percentage that require Achilles tenotomy
Mean (SD)	82% (21%)
Median	90%
Type of Achilles Tenotomy
Percutaneous	110 (94%)
Mini-open	5 (4%)
Open	0 (0%)
Other	2 (2%)
Anesthesia for Achilles Tenotomy
Local	65 (57%)
Conscious Sedation	21 (18%)
General	51 (44%)
Other	5 (4%)
Ancillary Treatment
Formal physical therapy	37 (41%)
Stretching by parents	71 (81%)
Botox	6 (7%)
Other	13 (15%)
Brace used following cast treatment
Yes	116 (96%)
Type of brace
Dennis-Brown FAO Mitchell FAO	60 (54%) 48 (43%)
Dobbs Dynamic Bar	16 (14%)
Other foot abduction orthosis not listed above	16 (14%)
AFO	5 (4%)
KAFO	2 (2%)
Orthopaedic shoes	5 (4%)
Age brace is discontinued (mo)
Mean (SD)	41 (16)
Median	48
Percentage of patients treated with casts that relapse
Mean (SD)	21% (17%)
Median	20%
Percentage of patients who require extensive soft tissue release
Mean (SD)	4.52 (6.71)
Median	2

The preferred age to initiate cast treatment was 7.51 days (SD = 7.25 d, median = 7 d). The average duration of each cast was 9.21 days (SD = 9.04 d, median = 7 d). The average duration of the casting phase of treatment was 7.62 weeks (SD = 2.43 w, median = 8 w). Eighty-one percent of patients required an Achilles tenotomy (SD = 21%, median = 90%). Providers preferred the percutaneous Achilles tenotomy (94%) versus the mini-open (4%) and open (0%) tenotomies. Fifty-seven percent of respondents reported use of local anesthesia for the Achilles tenotomy while 44% utilized general anesthesia and 18% used conscious sedation.

Ancillary treatments included stretching exercises by parents (81%), formal physical therapy (42%), and Botox injections (7%). A brace was used following the cast treatment by 96% of practitioners. The most common types of braces included the Dennis-Brown FAO (54%), the Mitchell FAO (43%), the Dobbs Dynamic Bar (14%), and other orthopaedic FAOs not listed (14%). The brace was discontinued on average at 41 months (SD = 16 m, median = 48 m). Twenty-one percent of patients treated using the Ponseti method had a relapsed deformity (SD = 17%, median = 20%) and 4.52% (SD = 6.71%, median = 2%) required an extensive soft tissue release.

Training Course Impact

Prior to attending the clubfoot treatment course, the preferred method of treatment was surgical release (48%). The Ponseti method was only used 42% of all cases while 10% of practitioners used another method to treat clubfoot. After attending the course, 97% of practitioners changed their practices. Fifty-three percent increased the amount of patients who were treated with the Ponseti method, 41% practiced less surgery and 39% did not specifically change their practice but reported a better understanding of the method. Of the three respondents who did not change their practice, one reported that the program was not relevant to their practice, the other cited a lack of support from the hospital, and one practitioner stated that the proper clinical setting was not available.

Course Evaluation

Additional review articles were the preferred form of educational support (61%), followed by training videos (49%), quarterly updates (37%), the University of Iowa website (33%), and webinars/virtual forums (28%). The majority of physicians (67%) believed that an ‘on-site’ visit would compliment their training. Suggestions for improvement to the program included more hands on experience (73%), more patient demonstration (45%), more lectures on technique (36%), a section on billing (11%), and more patient testimonials (9%).

Most providers (70%) felt comfortable with the technique after seeing between 0 – 20 patients. However, only 45% felt comfortable teaching the technique after seeing 0 – 20 patients.

Ninety-six percent of practitioners were satisfied, very satisfied or extremely satisfied with the course.

Discussion

The current study documented a response rate from course participants of 32%, which is comparable to the rate of response from recent studies of the POSNA membership¹⁹,²⁰. As expected, the rates of adherence to standard Ponseti method protocol after attending the CME Ponseti Training Courses were quite high (97%). This is similar to the reported use of Ponseti method in a recent survey of the POSNA membership (Table 4)¹⁸. The high rate of utilization of the Ponseti method among the Ponseti Training Course participants mirrors the well-documented decline in surgery and the rise of the Ponseti method as the standard of care in clubfoot management¹,¹⁹.

Table 4.

Response to identical questions on previous clubfoot management surveys

Study	Heilig et al.	Zionts et al.	this study
Year	2001	2010	2012
Use of Ponseti method	65%	97%	97%
Long leg casts	79%	99%	98%
Use of brace	85%	99%	96%
Type of brace
Dennis-Brown FAO	49%	82%	54%
Mitchell FAO	N/A	28%	43%
Mean duration of brace use (mo)	11	33	41
Patients requiring extensive release surgery	54%	7%	5%

When compared to the work of Zionts et al¹⁹. and Heilig et al.¹⁸, the present study supports the various trends documented by those authors¹⁹. Specifically, both this study and that by Zionts et al. suggest that current management of clubfoot deformity reflects increased adherence to the principles of the Ponseti method as indicated by the increase use of long leg casts, foot abduction orthoses, an increased duration of brace use, and a decrease in extensive release surgery than when compared to Heilig’s survey of POSNA membership in 2001.

Additionally, this study reveals that when compared to the clubfoot management of the POSNA membership in 2010, participants in the CME Ponseti Training Courses prefer local anesthesia at a higher rate than the POSNA membership (57% vs 39%)¹⁹. This may be attributable to differences in access to an operating room between the mostly North American POSNA respondents and the more international respondents in the present study. Pon- seti Training Course participants also utilize the brace for an average duration of 8 weeks longer (41 weeks vs 33 weeks) than the 2010 POSNA membership¹⁹. Finally, Ponseti Training Course participants have a slightly decreased rate of extensive surgery (7% vs 5%) than the POSNA membership in 2010¹⁹.

Ultimately, there is an inherent bias in comparing those who participated in a CME Ponseti Training Course to the general POSNA membership. Those who sought out participation in a workshop likely have a higher interest in clubfoot than the general POSNA membership. However, the results of this study provide further support to two major concepts: the use of the Ponseti method is increasing compared to a decade ago, and that this increase is likely correlated to a decrease in the rate of patients who require extensive release surgery.

Furthermore, this study provides insight on the effectiveness of the CME Ponseti Training Course conducted at the University of Iowa. Ninety-six percent were satisfied, very satisfied or extremely satisfied with the course and 97% changed their clubfoot management after the program. However, despite the perceived satisfaction with the two-day workshop format, several suggestions were solicited. First, most participants felt comfortable with their own technique after about 17.8 patients. However, they did not feel comfortable teaching their technique until after about 26.7 patients. This suggests that a two-day workshop is not satisfactory to train practitioners to comfortably teach their peers. Additionally, the majority of participants (67%) believed an on-site visit would greatly compliment their training. These results support an alternate Ponseti teaching pedagogy, which may include on-site visits from expert practitioners as a means to enhance Ponseti method teaching in the future.

Conclusion

The CME Ponseti Training Course is an adequate means to educate practitioners in the Ponseti method. However, in order to train practitioners comfortable in training other practitioners in the method, more than a weekend-long workshop may be necessary. Specific suggestions include an on-site visit with an expert practitioner.