“I’d never even really heard of clubfeet and here they were, telling me my son had a severe case, and he would need to see a doctor about surgery as soon as he was born,” says the Eldersburg mother of three.
Frightened at the notion of her newborn undergoing extensive surgery, Coster turned to the Internet for information and advice.
She quickly learned that not only was there a nonsurgical alternative called the “Ponseti Method,” but that a Sinai Hospital doctor was one of a handful of surgeons across the nation using it.
“I was on the phone to Dr. Herzenberg almost right away, and my son ended up seeing him for the first time a few days after he was born,” Coster says. “That one decision has made all the difference for Michael.”
Now an active 2-year-old who prefers running to walking, Michael Coster is one of the more than 75 infants and children that Dr. John Herzenberg has treated over the past six years using the little-known, nonsurgical method of realigning and straightening clubfeet.
“The success rate for this method is almost 100 percent,” says Herzenberg, who is chief of Pediatric Orthopedics at Sinai Hospital.
Named after Dr. Ignacio Ponseti, the University of Iowa orthopedic surgeon who developed it in the 1950s, the procedure involves gradually realigning twisted legs and feet using gentle hand manipulation and a series of hip-high plaster casts that hold the newly aligned limbs in the proper place as they grow.
The realignment process takes about six weeks: Each week, the old cast is removed and a new one applied, moving the legs and feet ever closer to normal as they grow.
Though Ponseti has been quietly using the method since its development, it is only in recent years that the procedure has gained more widespread recognition.
Not only are the results “amazing,” but the procedure can be done in the doctor's office, is less traumatic for the patient and costs about 75 percent less than the extensive surgery traditionally used to correct clubfeet, according to Herzenberg.
Clubfoot, which occurs in about one in 800 births, is a common birth defect that causes malformation of the joints, bones and muscles of the foot and lower leg.
The feet and lower legs bow into a clublike shape, making it difficult—and in some cases, impossible—for a child to eventually learn to stand and walk. In many babies, both legs and feet are affected. In some, only one leg and foot are twisted.
“It may be a common birth defect, but it's devastating in many cases,” says Herzenberg, a Boston University Medical School graduate who grew up in Massachusetts and came to Baltimore in 1991.
Though he had heard of the Ponseti Method early in his career, Herzenberg “paid it no heed” for many years.
“Like most surgeons, I thought surgery was almost always the answer,” Herzenberg says. “I thought in terms of taking something that wasn’t perfect and reconstructing it so it was.”
That changed one evening in 1997, when Herzenberg had dinner with one of Ponseti's protegees, who discussed the method's great benefits.
“I was amazed to hear that, in Iowa, they hardly ever had to do extensive surgery for babies with clubfoot,” Herzenberg says. “It intrigued me to the point where I decided to try it myself to see if there was something to it.”
Soon, Herzenberg “made a pilgrimage” to the University of Iowa, where he learned the method directly from its originator.
He quickly found that what Ponseti claimed was true: Not only was the gradual casting method gentler on the babies and less expensive for parents, but, in the end, it also maintained the strength and flexibility of the children's feet and limbs in a way that surgery could not.
“The results I saw with my Ponseti-treated patients were clearly better than I had seen through the first 10 years of my practice, before I began using that method,” Herzenberg says. “Ponseti patients were more flexible and stronger.”
Indeed, a University of Iowa researcher who followed 45 clubfoot patients treated with Ponseti over the course of three decades found that the subjects’ feet and legs were just as strong as normal feet—an outcome usually not achievable by surgery, which leaves feet and legs less mobile and flexible because of scar tissue.
“No-lose proposition”
The Ponseti method offers another advantage over surgery: If the nonsurgical method does not work—something Herzenberg says rarely, if ever, happens—surgery can then be performed. The reverse is not true, however.
“It’s a no-lose proposition to use Ponseti as the treatment of first choice because, if you needed to, you could always go back and do surgery,” Herzenberg says. “But if you do surgery first, you cannot go back and do Ponseti. It won’t work. So choosing Ponseti first is a win-win decision.”
Nevertheless, many pediatricians and orthopedic surgeons don't seem to be aware of this option for treating clubfoot. Indeed, efforts to get other local doctors to comment on Ponseti were largely fruitless.
Only Dr. Brian Corden, an Easton pediatrician who has referred several clubfoot patients to Herzenberg, ventured an opinion.
“I have been very impressed with Dr. Herzenberg over the years I have referred patients to him,” Corden says. “My patients have been happy and have had nothing but good results.”
Herzenberg is aware that many in the medical community don't know about or understand Ponseti and does what he can to remedy that.
“I have made it a personal mission to evangelize and spread the gospel to my fellow pediatric orthopedists in North America and the world,” he says.
In the meantime, parents of children born with clubfeet are using the Internet to swap information about this nonsurgical approach and to pass around the names of the few doctors using it.
Theresa Saylor is a beneficiary of this. The Anne Arundel mother went online in desperation when 14-month-old Dylan’s clubfeet failed to respond to a series of surgically inserted hip pins as well as a special brace designed to straighten the long bone of each leg.
“At that point, the doctor we were seeing wanted to do surgery. He said he would break Dylan’s bones and put more pins in to straighten them,” says Saylor.
Through a Yahoo! discussion group, Saylor learned about Herzenberg and sought him out.
Although the surgeon worried aloud that the child might be too old for Ponseti to be truly effective—the preferred time for treatment is just after birth—doctor and mother agreed to give it a try.
A year and a half later, Dylan is an active, if slightly shy, little boy with a gait that looks normal to everyone but Herzenberg, whose trained eye detects a little rocking motion as the child trots up and down Sinai's hallway during a recent exam.
“Make sure he is wearing his nighttime shoes,” instructs Herzenberg, referring to the stiff, high-top shoes separated by a metal bar that all Ponseti patients wear—first all day, and later, only at night—for several years post-cast.
(The so-called Denis Brown Bar and corrective shoes also are used—and have been used for years—to correct a number of infantile orthopedic problems.)
Dylan’s mother smiles as she recounts her son’s efforts to wiggle out of the shoes when he is sick or cross.
In her view, however, such everyday battles are a small price to pay for her son’s mobility.
“I'm so glad we found Dr. Herzenberg,” she says. “Sometimes I wonder what would have happened if I hadn’t, but I don’t even want to think about that.”
This article originally appeared in the Owings Mills Times, Patuxent Publishing Company, 2004.
Related Links:
Sinai Hospital
International Center for Limb Lengthening
Rubin Institute for Advanced Orthopedics
Clubfoot Facts and FAQs
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