Tippie MBA Students Help Spread the Word about Ponseti Clubfoot Treatment

Release: May 15, 2008

A group of Tippie MBA marketing students has spent the last year looking for ways to market the Ponseti method of treating children with clubfoot. They found that good news doesn't always travel fast.

Despite 50 years of success, many physicians in the United States are still not fully aware of, or even practicing, the revolutionary nonsurgical treatment developed by University of Iowa Health Care's Dr. Ignacio Ponseti. A marketing report compiled by the Tippie students over the past year said this lack of awareness comes despite the fact that the Ponseti method has been declared the standard of care for clubfoot by major U.S. health care professional organizations.

"There's still such a low rate of occurrence of clubfoot, with only about 5,000 children born each year in the United States with the condition, that doctors don't see patients very often," said Amber Fourcault, a second-year full-time MBA student and a member of the group. "Quite often, we heard from doctors that they see only two or three clubfoot cases every five years."

The report was commissioned by the University of Iowa-based Ponseti International Association as part of its effort to increase awareness and usage of the Ponseti method, first developed more than 50 years ago by the professor of orthopaedics at the UI Carver College of Medicine. His method involves gentle, manual manipulation of the child's foot and application of toe-to-groin plaster casts. The casts are changed weekly after a clinician manipulates softened foot ligaments to gradually achieve near-normal muscle and bone alignment.

Five Tippie MBA students -- Fourcault, Adnan Fazal, Emily Gander, Brandi Gibbs and Su Zhang -- worked on the marketing plan during the past year as part of a marketing class taught by John Murry, professor of marketing in the Tippie College of Business. The students came to their recommendations after talking with hundreds of orthopedists, obstetricians-gynecologists and family practice physicians across the United States, as well as in India and China.

In their report, the students suggested the Ponseti International Association take steps to better manage the information flow regarding the method to improve awareness and reduce confusion.

"We suggest they make Ponseti a brand, to manage it and control it and establish a presence that would make them the authority on the Ponseti method," said Fourcault.

One easy and inexpensive step would be to establish a comprehensive Web site about Ponseti, and market it is as the authoritative source of information about the method. The Web site would eventually replace pamphlets and other printed materials that the students discovered don't always get to the doctors or the patients.

"Print materials are an ineffective use of resources," said Fourcault. "Electronic material is easy to send and update, and it doesn't cost much money."

During their research, the students found physicians who said they used the Ponseti method, but in fact were not, or were using modified versions. Fourcault said the doctors weren't maliciously trying to trade on the Ponseti name, but simply didn't realize they weren't doing the Ponseti method as it was developed by Dr. Ponseti.

"Many of these doctors treat so few patients that they've forgotten some of the details, or they added steps that aren't a part of Dr. Ponseti's method," Fourcault said. "The problem is that if they say they're using the Ponseti method but they're not, and it doesn't work, then that reflects badly on Ponseti."

The students recommended that once the brand is established, the association should publicize it at national medical conferences, publish a Ponseti newsletter, and create a network of Ponseti-qualified physicians to promote the method.

The Ponseti International Associate has already taken steps to build the Ponseti brand. A Web presence was established in 2007 at www.ponseti.info, and the first-ever international conference of Ponseti practitioners was held in Iowa City. A second international conference is planned for 2009.

Jose Morcuende, M.D., associate professor of orthopaedics in the UI Carver College of Medicine and president of the Ponseti Association, said board members appreciated the group's work and ideas.

"They did a great job of looking at things from the perspective of the business side, not physicians, and they identified areas we have to work on to make the Ponseti name more widespread," said Morcuende. "They also identified that we have to use different programs and different messages in different countries."

He said the report shows the association must do more to correct misconceptions about the Ponseti method (for instance, that the treatment lasts for years; in fact, it is usually only three to six weeks for the correction of the foot by casting, followed by a simple, comfortable nightbrace for two to three years to prevent relapses). The report also suggested the association look for new ways to introduce the method to China and India, where clubfoot patients are seen as social pariahs and little is done to help them lead a normal life.

"Clubfoot can be eradicated around the world in 10 years if we had the resources to implement the programs," he said. "This report will help us find new ways to get the word out."

Source: UI News Services
Writer: Tom Snee
Contact: Tom Snee
UI News Services
319-384-0010

Ponseti Method

"Parents of infants born with clubfeet may be reassured that their baby, if otherwise normal, when treated by expert hands will have normal looking feet with normal function for all practical purposes. The well treated clubfoot is no handicap and is fully compatible with normal, active life." Ignacio Ponseti, M.D.

The majority of clubfeet can be corrected in infancy in about six to eight weeks with the proper gentle manipulations and plaster casts. The treatment is based on a sound understanding of the functional anatomy of the foot and of the biological response of muscles, ligaments and bone to corrective position changes gradually obtained by manipulation and casting.

Less than 5% of infants born with clubfeet may have very severe, short, plump feet with stiff ligaments, unyielding to stretching with a deep transverse skin fold across the sole of the foot and another crease above the heel. These babies require special treatment and may need surgical correction. The results are better if bone and joint surgery can be avoided altogether. Surgery in the clubfoot is invariably followed by scarring, stiffness and muscle weakness which becomes more severe and disabling after adolescence.

The treatment should begin in the first week or two of life in order to take advantage of the favorable elasticity of the tissues forming the ligaments joint capsules and tendons. With our treatment these structures are stretched with weekly, gentle manipulations. A plaster cast is applied after each weekly session to retain the degree of correction obtained and to soften the ligaments. Thereby, the displaced bones are gradually brought into the correct alignment.

Five to seven plaster casts extending from the toes to the upper thigh with the knees at right angle should be sufficient to correct the clubfoot deformity. Even the very stiff feet require no more than 8 or 9 plaster casts to obtain maximum correction. Before applying the last plaster cast which is to be worn for three weeks, the Achilles tendon is often cut in an office procedure to complete the correction of the foot. By the time the cast is removed the tendon has regenerated to a proper length. After two months of treatment the foot should appear overcorrected. Recently we found that the treatment can be shortened by changing the plaster casts every five days.

Following correction the clubfoot deformity tends to relapse. To prevent relapses, when the last plaster cast is removed a splint must be worn full-time for two to three months and thereafter at night for 3-4 years. The splint consists of a bar (the length of which is the distance between the baby's shoulders) with high top open-toed shoes attached at the ends of the bar in about 70 degrees of external rotation. A strip of plastizote must be glued inside the counter of the shoe above the baby's heel to prevent the shoes from slipping off. The baby may feel uncomfortable at first when trying to alternatively kick the legs. However, the baby soon learns to kick both legs simultaneously and feels comfortable. In children with only one clubfoot, the shoe for the normal foot is fixed on the bar in 40 degrees of external rotation. During the daytime the children wear regular shoes. Shoes attached to the bar often cause pressure blisters and sores. To prevent such distressing problems, we have devised a new foot and ankle abduction orthosis that holds the foot firmly and comfortably in place, causing no sores.

Since the surgeon can feel with his fingers the position of the bones and the degree of correction, X-rays of the feet are not necessary except in complex cases.

When the deformity relapses in spite of proper splinting a simple operation may be needed when the child is over two years of age. The operation consists in transferring the anterior tibial tendon to the third cuneiform.

Poor results of cast and manipulative treatments of clubfeet in many clinics indicate that the attempts at correction have been inadequate because the techniques used are flawed. Without a thorough understanding of the anatomy and kinematics of the normal foot and of the deviation of the bones in the clubfoot, the deformity is difficult to correct. Poorly conducted manipulations and casting will further compound the clubfoot deformity rather than correct it making treatment difficult or impossible.

Surgeons with limited experience in the treatment of clubfoot should not attempt to correct the deformity. They may succeed in correcting mild clubfeet, but the severe cases require experienced hands. Referral to a center with expertise in the non-surgical correction of clubfoot should be sought before considering surgery.

Dear Malaysian readers,

If you can afford, I would advise you to go straight to Dr Amnuay Jirasirikul at Bumrungrad Hospital, Bangkok as he is a certified Ponseti Method doctor.He is strongly recommended by Dr Ponseti himself.Full non-US based doctor list can be browsed here.

But if you think that you want to give our local doctors a chance to prove their skills, all you need to do is to bring along a referral letter from the current doctor and contact any of the Paed Orthopedic below. I got this list from Prof Sharaf.


abdrazak@kb.usm.my, Dr Abd Razak Sulaiman HUSM
abdrazak_muhamad@yahoo.com, Dr Abd Razak HKL
ahmadtajuddin@yahoo.com, Dr Ahmad Tajuddin HKT
atiqahsuzanna@yahoo.com.my, Dr Atiqah HKT
azliukm@yahoo.com, Dr Azli HKL
bobpenafort@yahoo.com, Dr Robert DSH
burza92@yahoo.co.uk, Dr Burhan Hosp Ampang
drhalimrashid@yahoo.com, Dr Abd Halim HUKM
drmuhammadafif@yahoo.com, Dr Afif HKL
ismailmu@kb.usm.my, Dr Ismail HUSM
kamariahnor@yahoo.com, Dr Kamariah HKL
joharishikin@yahoo.com, Dr Shikin HKL
rahata@fmhs.unimas.my, Dr Hata Sarawak GH
sawaik@hotmail.com, Dr Saw Aik UH
shukrimi72@yahoo.com, Dr Shukrimi Hosp Kuantan
ssenkl@hotmail.com, Dr Sengupta UH
sumei_y@yahoo.com, Dr Yong Su Mei UH
yaacobas@yahoo.com, Dr Yaacob Hosp Seberang Jaya
zulpeadortho@yahoo.com Dr Zul Osman HKL
sharaf@mail.hukm.ukm.my Dr Sharaf HUKM

Please bear in mind, none of the Doctors listed as above is a certified Ponseti Method Doctor, but we hope someday, one of them will.

Anyway, whenever you have doubt with the treatment given, you can always email to Dr Ponseti at ignacio-ponseti@uiowa.edu for his opinion and do not forget to attach the patient's clubfoot photo.

Facts

What is Clubfoot?
Clubfoot, or talipes equinovarus, is a treatable birth defect that affects approximately 150,000-200,000 children each year. When clubfoot occurs the foot is twisted inward and down, and this condition occurs during development in the womb. Physicians have observed that fetuses that develop clubfoot start with a normal foot and then the foot begins to turn inward around the third month. Most children born with clubfoot are not missing any bones, muscles, or connective tissue. It is a congenital condition, meaning that when it occurs it is always present at birth. It is one of the most common congenital deformities. One or both feet may be affected and the affected feet can range from relatively flexible to stiff and rigid. The condition is not painful for the new born, though when a child gets to walking age, walking with an uncorrected clubfoot can be very painful and difficult, if not impossible.

When will you know?
Parents will know at birth if their child has clubfoot because the foot will be twisted inward. Some cases are diagnosed during a routine ultrasound. If you are wondering if your child has clubfoot, contact a physician who has experience in diagnosing this condition (not all pediatricians know how to diagnose clubfoot).

Malaysia's fact (shared by Prof Sharaf of HUKM)
Boo NY, Ong LC.
Department of Pediatrics, Faculty of Medicine, National University of Malaysia.
A study was carried out on 8,369 neonates delivered in the Maternity Hospital, Kuala Lumpur over a period of four months. Forty-nine neonates (5.6 per 1000 livebirths) had congenital talipes. The incidence of congenital talipes equinovarus (CTEV) was 4.5 per 1000 livebirths while that of congenital talipes calcaneovalgus (CTCV) was 1.3 per 1000 livebirths. 6/11 (54.5%) of the CTCV was unilateral, the ratio of right to left feet involvement being 1:1. Only 12/38 (31.5%) of the CTEV were unilateral, the ratio of right to left feet involvement being 1:2. Congenital talipes was significantly more common in the low birthweight neonates (p less than 0.001). However, the condition was not significantly more common in neonates with breech presentation nor in those born to primigravida mothers. Our data suggested that multifactorial genetic background as the most likely underlying cause of congenital talipes in Malaysian neonates.


Residual deformity following surgical treatment of congenital talipes equinovarus.
Simbak N, Razak M.
Universiti Sains Malaysia, Kelantan.
A study was carried out on 24 patients (36 clubfeet) surgically treated at the Orthopaedic Department National University of Malaysia, Kuala Lumpur, over a period of four and half years. Nine feet underwent posterior release, 24 feet underwent posteromedial release combined with Evan's procedure. The overall operative result was 63.3% good, 9.5% fairly and 27.2% poor. Patients who underwent surgery between 3 to 12 months showed a high percentage of good results (66.7%). Metatarsal adduction was found to be the commonest residual deformity (63.9%), followed by heel varus (11.1%), cavus (11.1%) and equinus (5.6%). Inadequacy of primary surgery and post operative period of immobilization resulted in a significant high failure rate.

What does Dr Ponseti thinks on the surgery?
Ignacio Ponseti, MDDepartment of Orthopaedic Surgery, University of Iowa Hospitals and Clinics
Surgery does not "cure" clubfoot. It improves the appearance of the foot but diminished the strength of the muscles in the foot and leg, causes stiffness in the second and third decade of life, if not earlier, limits the motions of the foot joints, and the foot becomes often painful at midlife. Surgery does not prevent the recurrence of the deformity in a number of cases. To my knowledge not followup studies of operated patients older than 16 years of age has been published to date. Therefore, orthopaedic surgeons are ignorant of the results of their surgeries.
Foot and ankle surgeons, however, who treat adult patients have noticed that those surgically treated for congenital clubfoot in infancy have weak, stiff and often very painful feet.

The objectives

Dear readers,

Thank you for your visit.
This blog is dedicated to the parents of the babies & children born with clubfoot, was a clubfoot's patient, and clubfoot's supporters. This blog is also for the public who are able to contribute in terms of ideas, opinion, experiences, motivation to us.Feedback are welcome. However, please bear in mind that every comments are viewed by others as well.

For a start, as a parent of unilateral clubfoot baby, I would like to inform to all parents that this deformity is able to be corrected WITHOUT surgery(s). Please seek for early treatment once it is detected from the expertise, the real one. If possible, find the certified Ponseti method doctor. You can't find anyone in Malaysia YET, but we hope to have at least one soon.