Transcript Is the Ponseti Technique of treatment of Clubfoot

Learning the Ponseti
Technique of Treatment For
Clubfoot Deformity
Or can you teach this old dog new
tricks?
Mitchell Goldflies, MD
Old School
• Kite technique
– I began using Kite technique in 1976
– Limited success in complete correction of
deformity
– Weekly casting for up to 6 months
– First stage in posterior medial release (PMR)
– Allows for the soft tissue to better tolerate
PMR
– Labor, time and resource intensive
Old School
• Kite technique
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Heel varus will correct by everting the calcaneus
Each weekly visit you stretch thefoot and then cast
Long leg plaster casts
Soak off cast and remove day prior to clinic visit
Parents stated that foot would look better when the
cast came off than in clinic the following day
– Problems with patients that did not have the cast
removed prior to clinic
Old School
• Kite technique
– Correct each deformity in sequence before
addressing next deformity
• First correct forefoot adductus
• Second correct hindfoot varus
• Third correct equinus
– Wheaton Brace to maintain reduction while
continuing stretching program
Ponseti Technique
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The foot is a bag of wet clay that can be molded
Works in newborns and delayed treatment cases
No force needed to correct deformities
Correct deformities in sequence
Recurrences happen
Expect to perform TAL
Splinting for 3 to 4 years
Requires good parent compliance
Ponseti Technique
• Developed by Ignacio Ponseti, MD over 50
years ago
• More that 100,000 children born worldwide with congenital clubfoot
• Clubfoot in an otherwise normal child can
be corrected with the Ponseti method of
manipulation and plaster cast application
in 2 months or less
Ponseti Technique
• Avoids the posteromedial surgical release
that results in a scarred and stiff foot with
misshapen joints
• Since the collagen in the newborns is
easily stretched the displaced navicular,
cuboid and calcaneus can be gradually
abducted under the talus without cutting
any of the tarsal ligaments
Ponseti Technique
• Clubfoot classification
– Untreated-under 8 years of age
– Corrected-using Ponseti technique
– Recurrent- Supination and equinus develop after
good initial correction
– Resistant-Stiff foot associated with conditions such as
arthrogryposis
– Atypical-short, chubby, stiff feet with a deep crease in
the sole of the foot behind the ankle, shortening of the
first metatarsal with hyperextension of the MTP joint
Ponseti Technique
• Basic clubfoot deformity is a foot with a
deformed talus and a medially displaced
navicular
• Begin treatment soon after birth, 7 to 10
days
• Most clubfoot deformities can be corrected
with the Ponseti technique if treatment is
begun before 9 months of age
Ponseti Technique
• Gentle manipulation followed by casting
• Precise, gentle molding of plaster casts
over the reduced subluxations of the tarsal
bones of a clubfoot results in correction of
the deformities
Ponseti Technique
• Plaster casting technique
– Soak off cast in waiting room
– Treat skin with lotion
– Do not apply benzoin to skin prior to padding
– Limit use of cast padding
– Apply short leg portion of cast first while
molding cast
– Then extend to long leg cast
Ponseti Technique
• Fiberglass Soft Cast avoids many of the
problems with plaster casting
– Does not allow for molding as was as plaster
– Costs more
– Less mess
– Contact dermatitis
– Easier to use with possible poorer results
Ponseti Technique
• Sequence of correction
– Correct midfoot cavus as a result of flexion of the first
metatarsal by supinating the forefoot
– Correct forefoot varus, inversion and adductus by
abducting the foot beneath the stabilized head of the
talus
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Apply lateral pressure to talus just distal to fibular malleolus
Apply medial pressure to first metatarsal head
Corrects rear foot varus
Progressively bring forefoot into 70 deg. of external rotation
relative to the frontal plane of the tibia
Ponseti Technique
• Sequence of correction
– Correct equinus
• Casting in 20 deg. of dorsiflexion
• Percutaneous TAL
– Performed in clinic under local anesthesia
– 1.5 cm above calcaneus with the foot held in maximum
dorsiflexion
– Cast for additional 3 weeks in 30 deg. of dorsiflexion and
the forefoot abducted 60-70 deg.
Ponseti Technique
• Casting tips
– Do not feed child in waiting room
• Start feeding when foot stretching begins
– 2 person cast application
• Most experience person holds foot in corrected
position
• Good cast application technique required
• Trim cast around toes dorsally
Ponseti Technique
• Sequence of correction
– Dennis Brown (Markell) splint
• External rotation of affected leg 70 deg.
– Reduce to 40 deg. if excessive heel valgus
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External rotation of unaffected leg 30 deg.
Use 23 hours/day until walking
Continue night splinting for at least 3-4 years
Change splint and shoes as child grows
– Straight last or tarso-pronator shoes
– High top lace up straight last shoes with Thomas
heels for ambulation
Ponseti Technique
• Family compliance issues with splinting program
• Family does not like 70 deg. external rotation
because foot looks deformed
• Expect recurrences that respond to recasting
• Some feet are supple and correct well in 6
weeks
• Some feet are more rigid and require longer
treatment and surgery
Ponseti Technique
• Relapses
– Evaluate parent compliance
– Recast 1-3 times
– Surgical equinus release-repeat TAL
– Anterior Tibial Tendon transfer to lateral
cuneiform for dynamic supination
Ponseti Technique
• Pirani Severity Scoring
– Clinical assessment of the amount of
deformity in an unoperated clubfoot
– Scores 6 clinical signs
• 0=normal
• 0.5=moderately abnormal
• 1=severely abnormal
Ponseti Technique
• Pirani Severity Scoring
– Midfoot score (MS) 0-3
• Curved lateral border [A]
• Medial crease [B]
• Talar head coverage [C]
– Hindfoot score (HS) 0-3
• Posterior crease [D]
• Rigid equinus [E]
• Empty heel [F]
Ponseti Technique
• Pirani Severity Scoring
– Score every foot weekly for HS, MS and total
score
– Plot scores on graph
– Tenotomy is indicated when HS>1, MS>1 and
the head of the talus is covered
Ponseti Technique
• Management errors
– Pronation or eversion of foot
– External rotation of the foot to correct adduction while
the calcaneus remains in varus
– Failure to manipulate foot
– Short leg cast
– Premature equinus correction
– Failure to night brace
– Attempts to obtain perfect anatomical correction
Ponseti Technique Questions?
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Is it worth the time to switch techniques?
Is it hard to learn the Ponseti technique?
Do I consider going back to the Kite technique?
Do I need a team to treat children with the
Ponseti technique.
• When do I bail out of the Ponseti technique
early?
• Is there more family participation required of the
Ponseti technique?
Ponseti Technique
Reference:
Clubfoot: Ponseti Management
Second Edition
Lynn Staheli, editor
Global-HELP Organization
2003
www.global-help.org
Thank You