To The Editor:
The new comparative study of the Ponseti and the French functional method "A Comparison of Two Nonoperative Methods of Idiopathic Clubfoot Correction: The Ponseti Method and the French Functional (Physiotherapy) Method" (2008;90:2313-21), by Richards et al., is an important contribution to the advancement of the knowledge and the practice of these two methods. This extensive study, covering about five years and involving 256 patients with 386 clubfeet in total, provides an excellent overview of the impact of the two methods as practiced at the Texas Scottish Rite Hospital for Children. Indeed, the evaluation of outcomes with an average patient age of 4.3 years provides a very good vision of the evolution over time, in particular with respect to relapses.
The French method was developed by Frédérique Bonnet in Montpellier, France, on the basis of the innovative approach of Professor Bensahel in Paris. In Zurich, Switzerland, at the Universitätskinderklinik (University Children's Hospital), both methods have been used for about six years. The physiotherapists' training has been regularly monitored by Frédérique Bonnet from the Institut Saint Pierre near Montpellier, France. The choice of the treatment, the Ponseti or French method, is made after a presentation of both methods to the parents during a first meeting with the patient.
On the basis of our experience, we practitioners believe that a few comments will be useful in furthering the understanding of the relative performance of the two methods. We will address issues of outcome measurement, sample selection, treatment procedures, and surgical intervention.
1. Measurement
While studies of idiopathic clubfoot correction dispose of valid and reliable measurement of the initial severity of the clubfoot with the Dimeglio scoring method, the evolution and the outcome, normally observed at four years of age, are more difficult to appreciate. In the study, the outcome scale emphasizes the operative interventions required to achieve a good result, i.e., a plantigrade foot. This measurement focuses on static corrections and does not pursue the functional dynamic quality evolving for the patient such as foot length, muscular tonus, and walking balance. Moreover, an evaluation by means of a gait analysis when the child is four years old would be appropriate.
2. Sample selection
Patients with previously untreated idiopathic clubfoot deformity were up to three months of age in the sample of the study. But according to our experience, the two methods differ as to the most appropriate time for the treatments to be implemented. The Ponseti method works well, even for children who are two months old or more, while the French method is intended to accompany and orient the early development of the foot. Although good results have been obtained even with late starters, the earlier the manipulations begin, the softer and more malleable are the tissues and the gristle. Newborns and, in particular, premature patients are likely to obtain the maximum benefit from the French method when they are treated within forty-eight hours after birth. The age of the patient could therefore be an important parameter in the achievement of good outcomes. This potentially has an impact on the choice of the method, as some parents may be able to start treatment only after a couple of weeks.
3. Treatment procedures
The Ponseti method has the characteristic of being relatively easy to learn, and it can be implemented by several professionals intervening successively in the case of a patient. In several respects, this constitutes an advantage in the flexibility of implementation. While the treatment with the Ponseti method is weekly, the French method requires daily manipulation, i.e., four to five times a week during the first two months. This entails a special commitment from the parents and availability, particularly with respect to transportation and concerns about the distance, as mentioned in the study. Also, there is a need for parental intervention in the treatment. The taping is critical and, for a good result, should probably not be performed by nonprofessionals. Instead, parents have a key role in following up with the treatment, in particular, with returning for the application of an abduction orthosis or splint to maintain the corrected position and avoid relapses.
In comparison, the two treatments require highly qualified personnel, but the effectiveness of the French method is more critically dependent on the quality of the professional training of the therapists in pediatric development. Furthermore, it is definitely preferable that the entire French functional treatment for each child be carried out by only a few therapists. If too many hands are involved, it is not possible to ensure that the foot development will be properly followed.
The overall development of the patient is not mentioned, although it is a factor that deserves attention. Indeed, one of the advantages of the French method is that it allows the child a large freedom of movement as opposed to the Ponseti method, which is essentially static. Children with other disabilities, including neurological disorders such as cerebral palsy, have a particular advantage from minimal interference with their overall mobility.
4. Surgical interventions
The experience accumulated with the French method in Zurich and Montpellier suggests a major difference with the data presented in the study. Treatment of the newborns during the first three months provides overall good to very good results. A thorough evaluation of the patient in the third to fourth month has led to a decision for tenotomy only in some patients, as a preventive measure. On the basis of this protocol, surgical interventions and posterior release in particular were not required in our experience.
5. Concluding remarks
The above comments are intended to complement the comparative study with some of our questions that are based on the experience accumulated in the Zurich and Montpellier regional context. The study showed that the two methods offer overall good results with a slight advantage to the Ponseti method. This seems at least partly related to the measurement of the outcomes.
We would further like to emphasize that it has been our experience that the Ponseti method can achieve superior results when children are older than a couple of weeks, while the French functional method is most efficacious for newborns and generally yields good results without tenotomy. For all patients, the professionalism with which the treatments are carried out and the commitment of the parents in the process were found to be important determinants of success.
Finally, it is particularly encouraging for the wider diffusion of these treatment methods that independent centers, such as the Universitätskinderklinik in Zurich, Institut Saint Pierre in Montpellier, and Texas Scottish Rite Hospital for Children in Dallas, have evolved very similar practices and converging experience with most satisfactory outcomes.