-Taral Nagda

-Rajeev Niravane

Institute of Paediatric Orthopaedic Disorders

www.ipodindia.org

taralnagda@gmail.com

Who should do Ponseti treatment?

v      J Bone Joint Surg Am. 2009 May;91(5):1101-8.
Comparison of surgeon and physiotherapist-directed Ponseti treatment of idiopathic clubfoot.
Janicki JA, Narayanan UG, Harvey BJ, Roy A, Weir S, Wright JG.

• The introduction of the physiotherapist-supervised clubfoot clinic has been effective without compromising the quality of care of children with clubfoot deformity.

v      Ann R Coll Surg Engl. 2007 Jul;89(5):510-2.Ponseti treatment in the management of clubfoot deformity – a continuing role for paediatric orthopaedic services in secondary care centres.Docker CE, Lewthwaite S, Kiely NT.

• Similar results between tertiary Ped ortho dept and physiotherpy dept

v      J Bone Joint Surg Br. 2006 Aug;88(8):1085-9.
Early results of a physiotherapist-delivered Ponseti service for the management of idiopathic congenital talipes equinovarus foot deformity.
Shack N, Eastwood DM.

• Ponseti technique is suitable for use by non-medical personnel, but a holistic approach and good continuity of care are essential to the success of the programme

Can neglected CTEV be treated with Ponseti method?

v      J Pediatr Orthop B. 2009 Mar;18(2):76-8.Results of treatment of idiopathic clubfoot in older infants using the Ponseti method: a preliminary report.

Hegazy M, Nasef NM, Abdel-Ghani H.

The use of thePonseti method in older-aged infants with idiopathic congenital clubfoot seems to

be an effective method of treatment, obviating the need for extensive surgery.

v      J Bone Joint Surg Br. 2007 Mar;89(3):378-81.
Correction of neglected idiopathic club foot by the Ponseti method.
Lourenço AF, Morcuende JA. Brazil

Only 5/24 needed surgery

• Ponseti method is a safe, effective and low-cost treatment for neglected idiopathic club foot presenting after walking age.

v      Clin Orthop Relat Res. 2006 Mar;444:224-8.
Ponseti management of clubfoot in older infants.
Bor N, Herzenberg JE, Frick SL. Israel

older infants with clubfoot can be treated successfullywithout extensive surgery. Our results in older infants are similar to theresults of a previous study we conducted with younger infants

3 % rate of surgery in children less than 3 years

v      Arch Orthop Trauma Surg. 2006 Jan;126(1):15-21. Epub 2005 Nov 10.
Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complexdeformities.
Göksan SB Turkey

• Our results show that the Ponseti technique is reproducible and effective in children at least up to 12months of age
• Only 3 % need extensive PMR

Ponseti method in post PMR cases??

v      Clin Orthop Relat Res. 2009 May;467(5):1298-305. Epub 2009 Feb 4.
Is it possible to treat recurrent clubfoot with the Ponseti technique after posteromedial release?: a preliminary study.
Nogueira MP, Ey Batlle AM, Alves CG.

• initial and final Pirani scores and range of motion of the ankle and subtalar joint. Plantigrade and fully corrected feet were obtained in 71 feet (86%); 11 feet obtained partial correction; one patient failed treatment and underwent another posteromedial release. Recurrences occurred in ninepatients (12 feet or 14%)

Does FAB give rise to femur/ knee/ tibial tortional deformities ?

v      J Pediatr Orthop. 2007 Sep;27(6):712-6.
Foot abduction brace in the Ponseti method for idiopathic clubfoot deformity: torsional deformities and compliance.
Boehm S, Sinclair M.

• Application of the foot abduction brace did not result in pathological changes of femoral anteversion or tibial torsion

Can Ponseti method avoid surgery?

v      Clin Orthop Relat Res. 2009 Apr 7.
Comparison of Ponseti versus Surgical Treatment for Idiopathic Clubfoot: A Short-term Preliminary Report.
Zwick EB, Kraus T, Maizen C, Steinwender G, Linhart WE.

• a favorable short-term outcome for the Ponseti method when compared with a traditional treatment protocol

v      Clin Orthop Relat Res. 2009 May;467(5):1271-7. Epub 2009 Jan 14.
Ponseti method: does age at the beginning of treatment make a difference?
Alves C, Escalda C, Fernandes P, Tavares D, Neves MC.

• according to their age at the  beginning of treatment; Group I was younger than 6 months and Group II was > 6 months.
• The rate of the Ponseti method in avoiding extensive surgery was 100% in Groups I and II;
• relapses occurred in 8% of the feet in older children

v      J Pediatr Orthop B. 2007 Sep;16(5):317-21.
Comparative results of the conservative treatment in clubfoot by two different protocols.
Cosma D, Vasilescu D, Vasilescu D, Valeanu M.

• The Ponseti method decreases the number of surgical interventions needed for the correction of the deformation compared with our traditional method.  5 % need surgery

v      Z Orthop Ihre Grenzgeb. 2006 Sep-Oct;144(5):497-501.
Treatment of congenital clubfoot with the Ponseti method
Eberhardt O, Schelling K, Parsch K, Wirth T.

• With the Ponseti methodthe need for extensive corrective surgery is greatly reduced. (2/41)

v      Pediatrics. 2004 Feb;113(2):376-80.
Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method.
Morcuende JA, Dolan LA, Dietz FR, Ponseti IV

• 11 % relapse
• 3 % extensive surgery rate

What are the factors affecting relapse?

v      J Child Orthop. 2009 Jun 3.
Improved bracing compliance in children with clubfeet using a dynamic orthosis.
Garg S, Porter K.

• Non-compliance with foot abduction bracing in children with clubfeet treated with the Ponseti method is the leading risk factor for deformity recurrence.
• A dynamic foot abduction orthosis is believed to result in improved compliance, fewer skin complications, and fewer recurrences

v      J Bone Joint Surg Am. 2007 Mar;89(3):487-93.
Early clubfoot recurrence after use of the Ponseti method in a New Zealand population.
Haft GF, Walker CG, Crawford HA.

• Compliance with the postcorrection abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformitytreated with the Ponseti method.
• When the parents comply with the bracingprotocol, the Ponseti method is very effective at maintaining a correction,although minor recurrences are still common.
• When the parents do not comply with the bracing protocol, many major and minor recurrences should be expected

v      Iowa Orthop J. 2007;27:82
Neuromuscular disease as the cause of late clubfoot relapses: report of 4 cases.
Lovell ME, Morcuende JA.

• Late relapses in patients with idiopathic clubfoot may represent the onset of a previously undiagnosed neuromuscular disease, and should be thoroughly evaluated.

v      J Pediatr Orthop. 2005 Mar-Apr;25(2):225-8.Use of the foot abduction orthosis following Ponseti casts: is it essential?
Thacker MM, Scher DM, Sala DA, van Bosse HJ, Feldman DS, Lehman WB

• The feet of patients compliant with FAOuse remained better corrected than the feet of those patients who were not compliant

v      J Bone Joint Surg Am. 2004 Jan;86-A(1):22-7.
Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet.
Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA.

• Noncompliance and the educational level of the parents(high-school education or less) are significant risk factors for the recurrenceof clubfoot deformity after correction with the Ponseti method. The identification of patients who are at risk for recurrence may allow intervention to improve the compliance of the parents with regard to the use of orthotics,and, as a result, improve outcome

How does one treat a replapse?

v      Instr Course Lect. 2006;55:625-9.
Treatment of a recurrent clubfoot deformity after initial correction with the Ponseti technique.
Dietz FR.Department of Orthopaedics, University of Iowa, Iowa City, Iowa, USA.

• The indication for anterior tibial tendon transfer is the presence of dynamic supination during gait. After tendon transfer, bracing is no longer required because the eversion force of the transferred tendon maintainsthe correction

Is Ponseti method applicable to clubfoot with MMC?

v      J Bone Joint Surg Am. 2009 Jun;91(6):1350-9.
Early results of the Ponseti method for the treatment of clubfoot associated with myelomeningocele.
Gerlach DJ, Gurnett CA, Limpaphayom N, Alaee F, Zhang Z, Porter K, Kirchhofer M,
Smyth MD, Dobbs MB.

• Initial correction was achieved in twenty-seven clubfeet (96.4)
• Relapse of deformity was detected in 68% of the feet in the myelomeningocele group, compared with 26% of the feet in the idiopathic group (p = 0.001).
• Relapses were treated successfully without the need for extensive soft-tissue

v      Journal of Pediatric Orthopaedics. 29(4):393-397, June 2009.
Treatment of Neuromuscular and Syndrome-Associated (Nonidiopathic) Clubfeet Using the Ponseti Method
Joseph A. Janicki, MD,* Unni G. Narayanan, MBBS, MSc, FRCSC,Þ Barbara Harvey, BHScPT,

• Ponseti method is worth applying to nonidiopathic clubfeet in an attempt to avoid surgical release.
• Nonidiopathic clubfeet required significantly more casts (6.4 vs 4.8) to achieve initial correction and had a higher recurrence rate (44% vs 13%).

Is it necessary to change protocol in complex clubfoot ?

Clin Orthop Relat Res. 2006 Oct;451:171-6.
Treatment of the complex idiopathic clubfoot
Ponseti IV

• Modifying the treatment protocol for complex clubfeetsuccessfully corrected the deformity without the need for extensive correctivesurgery

Indications for Tenotomy

Cases of CTEV on treatment with serial plasters by Ponseti method where forefoot is corrected but there is inability to get the ankle dorsiflexion beyond 20º.

Prerequisites

1. Pirani midfoot score 0
2. Forefoot abduction of approximately 60º should be achieved
3. Lateral border should be straight
4. Heel should be neutral or slight valgus

This abduction allows the foot to be safely dorsiflexed without crushing the talus between the calcaneus and tibia If the adequacy of abduction is uncertain, apply another cast or two to be certain. Abduction of approximately 60 degree in relation­ship to the frontal plane of the tibia is possible. Neutral or slight valgus of os calcis is present. This is determined by palpating the posterior os calcis.

Preparing the family-

Parents should be properly informed about the nature of the procedure proper consent should be taken. Post operative elevation, possibility of red discolouration due to blood ooze should also be explained

Anasthesia-

Tendoachilis tenotomy is done under local anesthesia. Before taking the patient on table lignocaine sensitivity test must be done.

Position-

Prone position is given to patient with proper padding for the trunk. An OT assistant

Preparation –

Procedure should be done in operation theatre to maintain the sterility and prepared for any complication though very rare.

Limbs are prepared with antiseptic solution distal to knee joint. Draping is done to isolate the field but care should be taken not to suffocate the child.

Surgeon should always wear the operating gown and sterile gloves.

Inj lignocaine 4%

without adrenaline is infilterated near and just above the tendoachilis insertion

Procedure-

Assistant dorsiflexes the ankle making the tendon tight and prominent keeping knee in extension. Tendon should be palpated at the insertion. 15 no blade (always with the handle for better control) is inserted with the single prick like incision (3-4 mm) just above the tendoachilis insertion medial to lateral side of the tendon with the bevel facing laterallt. The blade is now turned by 90 degrees to remain horizontal on anterior surface of the tendon. Tenotomy is done from inside out fashion from anterior to posterior surface of the tendon. Care should be taken not to damage the calcaneal cartilage.As assistant continues the dorsiflexion sudden “pop” is felt with achieving the full dorsiflexion. Dorsiflexion should be checked both in knee flexed and extended. There is no need to take sutures. Small dressing is applied and child

should immediatetely handed over to mother for feeding.

After 10 minutes once the bleeding is controlled and the child is relaxed an above knee pop is applied with knee in 90 flexion and feet externally rotated 60 and 20 dorsiflexion

Advantages of the prone position-

1. It is very easy to hold the child in the prone position.
2. Child is very comfortable in this position and does not kick while doing the procedure making the surgeon comfortable and in better control to carry out the procedure.
3. Tendoachilis is posterior structure and prominent in this position and therefore only tight tendon fibres are cut and avoid damage to peritendinous soft tissues.
4. Chances of damaging the neurovascular structures are very less.