Ponceti techniqe

PPT ON Ponseti Technique by Dr. Bipul Borthakur, Professor, Dept of Orthopaedics, SMCH

1. PRINCIPLES OF PONSETI TECHNIQUE PRESENTER –Dr. BIPUL BORTHAKUR PROFESSOR ,DEPT OF ORTHOPAEDICS,SMCH

2. Introduction Clubfoot is also known as CTEV Stands for- Congenital (meaning present at birth), Talipes (derived from the Latin for ankle and foot) Equino (indicating the heel is elevated) Varus (indicating the foot is turned inwards).

3. Pathophysiology Several hypothesis have been proposed Primary germplasm defect in the talus- causes continued planterflexion and inversion of the bone. Vascular cause - many children with CTEV has hypertrophic anterior tibial artery. Abnormal muscle fibre - abnormal distribution of type I and type II muscle fibre . Intra uterine cause – postural deformity caused by tight packing in overcrowded uterus.

4. Pathoanatomy Talus forced into equinus by calcaneus & navicular . Head and neck of talus deviated medially. Os calcis is internally rotated around talocalcaneal ligament. Posterior part of calcaneus held close to the fibula by tight calcaneofibular ligament leads to equinus and varus . Cuboid displaced medially on calcaneus.

5. Complex deformity of CTEV Hind foot equinus Hind foot varus Mid/forefoot adductus Cavus

6. CTEV Deformity

7. Classification of Club foot Idiopathic – commonest Neurogenic – 1. upper motor neuron lesion(cerebral palsy) 2. lower motor neuron lesion ( spina bifida) Osteogenic – Tibial hemimelia Syndromic – Arthrogryposis , Amniotic band syndrome

8. Types according to treatment stage Untreated – Has not received any treatment Neglected – No treatment received till the age of 1 year. Incompletely treated – Discontinuation of treatment schedule after full deformity correction. Relapsed – The deformity comes back after all the components of defomity were corrected. Recurrent – When deformities reappear while treatment is going on. Complex – Received non ponceti treatment.

9. Pirani score Reliable method for assessing the amount of deformity & progress of treatment. Formulated by Dr Shafique Pirani . A child’s total Score (TS) is between 0 and 6. 6 ‘signs’ are assessed, and each is scored 0, 0.5, or 1, depending on severity. A total score of 0 = no deformity, a total score of 6 = severe deformity. The total Score is comprised of:- Hindfoot Contracture Score (HFCS) between 0 and 3 Midfoot Contracture Score (MFCS) between 0 and 3

10. Six clinical features Medial crease Lateral border of foot Lateral head of talus Posterior crease Empty heel Ankle dorsiflexion.

11. Common errors(Kites error) Pronation/eversion of 1 st metatarsal Premature dorsiflexion of heel Counterpressure at calcaneo -cuboid jt. External rotation. Below knee cast . Short spint .

12. The Ponseti method Developed by Ignacio Ponseti (1960) Specific method of manipulation to stretch contracted ligaments. Serial casting to hold the stretch. Percutaneous tenotomy of TA. Specific method of bracing. Goal of Ponseti method A foot that is FUNCTIONAL , PAIN FREE, PLANTIGRADE , MOBILE , NORMAL IN APPEARANCE.

13. Why it is the best method Easy – simple method, out patient dept. Effective – 90% club foot are successfully treated , results reproduced around the world Efficient – treatment from birth, complete correction after 2-3 months Economical – affordable , no surgery required

14. Key points in manipulation Manipulate the feet to correct, and then apply a well moulded plaster cast. Note that the talus is the fulcrum, NOT THE CUBOlD . The foot should never be everted . Don’t attempt to correct equinus until the foot can be fully abducted and the talar head sinks.

15. Correction Order of Manipulations Cast 1. Correct cavus then cast x 1 week Cast 2. Abduct foot then cast x 1 week Cast 3. Abduct foot then cast x 1 week Cast 4. Abduct foot then cast x 1 week Cast 5. Dorsiflex foot, possible tenotomy , then cast x 3 weeks Keep each plaster on for one week. 3 weeks after tenotomy .

16. Series of plaster cast showing gradual correction

17. Manipulative Correction of Cavus 1 st cast application corrects cavus Forefoot aligned with hindfoot Supination of forefoot Dorsiflexion of 1 st metatarsal Cast applied in two stages

18. Manipulative Correction of Adductus and Varus The whole foot is abducted under the talus. The thumb should be on the head of the talus (not the calcaneous !) The navicular moves away from the medial malleolus and covers the head of the talus. Supination maintained throughout the procedure.

19. Correction of adductus & varus

20. Complications Pressure ulcers — if severe, rest for 1-2 weeks, advising mother to continue stretching. Skin allergy or irritation — as above. Swelling — as above. Cast slipped — remove cast immediately, and reapply, moulding firmly around heel, with knee at 90° and cast extending to groin. Circulation problems — check for compromised skin. Recast, ensuring the cast is not too tight and there will be no pressure areas. Rocker bottom foot — becomes a complex case. Rest the foot and seek advice from supervisor. Muscle atrophy

21. Achilles tenotomy To gain adequate lengthening of Achilles tendon & to prevent rocker bottom deformity. Medical officer/surgeon to perform this minor surgical procedure in the clinic. Local anaesthetic to be used. Mother should stay with the baby and breastfeed during the procedure to minimise distress

22. Timing of tenotomy Pirani score indicates the MFCS is one or less Score for the Lateral Head of Talus is zero (it is covered by the navicular ) Heel is in valgus Foot is in abduction

23. Tenotomy Procedure A competent assistant holds the limb firmly at the knee, knee straight and dorsiflex the foot. The medical officer looks at the tendon from the medial aspect and palpates the most prominent part,usually 1-2cm above the calcaneous . Scalpel blade is inserted immediately anterior to the tendon from the medial side with the orientation of the blade in the direction of the tendon.

24. Foot Abduction Braces (FABs) I ntegral part of the Ponseti Method. P urpose is to maintain the correction that has been achieved with casting and tenotomies . Without proper bracing, recurrence will occur in 90% of cases. They are to be worn fulltime (23 hours per day) for the first 3 months, and then at night (while the child is sleeping) until the child is about 4 years old. Named as Steenbeek foot abduction brace.

25. Essential Features of the FAB Dorsiflexion of 10-15° (due to bent bar). Heelcup (to keep heel firmly in shoe and prevent return of equinus ). Affected foot abducted to 70°. Unaffected foot abducted to 40°. Bar should be as wide as child’s shoulder (+1 inch). Earlier after Kite‘s method of treatment Denis Brown shoe was given. In principle this is different from a Steenbeek brace

26. The degree of external rotation in this is only 15 Degrees whereas it is 70 degrees in Steenbeek brace.

27. Fitting a Foot abduction brace Fit the FAB immediately after the last cast removal to increase compliance . Fit the most difficult foot first . Gently dorsiflex foot & hold it in that position with one hand and then push the foot (heel first) in the SFAB (shoe should be unlaced ). Close the tongue of the shoe and check whether the heel is still in the correct position by looking through the inspection hole . Keep the foot in position with the same hand and lace the shoe with the other hand (may need a second person first few times ). Check that both heels are visible through inspection hole.

28. Early recurrence (1-2 yrs ) Always due to failure of brace wear. Recognised as- Loss of dorsiflexion heel varus adductus ( cavus rare) Treatment – 2-3 more casts at 1-2 weeks interval. +/- repeat tendoachilles tenotomy .

29. Late Recurrance (at 3-5 years of age) Recognized as – Swing phase dynamic supination. Passively correctible. Weight bearing on lateral border of foot Treatment – If the foot easily dorsiflexes 10°, tenotomy alone is needed. If less dorsiflexion is present, more complex surgery is required. Recurrence after 5 years of age is very rare.

30. Role of counselor in Ponseti method Cast and tenotomy treatment by the doctor is only part of the treatment. Successful treatment on a long term is possible only with regular follow up of children for at least 3 or 4 years. Trained counselor is an equally important part of the medical team process. Close follow up ensures that recurrence is prevented or picked up very quickly. Counselor helps to maintain medical records and distribution of FAB to every child enrolled in the designated weekly clubfoot clinic.

31. Operative treatment Surgery rarely required for early correction Rate of surgical inervention fallen to below 5% from the 80% needed in pre- ponseti era. Objectives of surgery – Complete release of joint tethers. Tendon lengthening( foot can be positioned normally without undue tension.

32. Anterior tibial tendon transfer Tendon is divided distally and passed subcutaneously to the proximal incision Window is created Tendon transferred posteriorly through the window Tendon is fixed to calcaneus with bunnel suture.

33. Conclusion Proper understanding of the pathoanatomy is must. Ponseti method is now the standard treatment method. Relapse rate clearly linked to compliane of wearing FAB. Indication of surgery limited but well defined.

34. THANK YOU