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					                                      THE PONSETI METHOD IS HERE...
                                       (From the Organising Secretary’s Desk)
                                                                         Dr Milind Chaudhary
                                                                         Hon. Asst. Prof of Orthopaedic Surgery,GMC Akola
                                                                         Director-Centre for Ilizarov Techniques
                                                                         Vice-President, ASAMI India
                                                                         Akola India 444 001. akl_drmmc@sancharnet.in

  Clubfoot is the commonest congenital anomaly              orthopaedic operation is discarded after a few years,
seen by an Orthopaedic surgeon but has been                 and a new prosthesis is touted as the latest advance
plagued by ignorance about its Pathoanatomy,                every few months. However, bones like young plants
misconceptions about manipulative therapy and a             and saplings grow slowly and it takes many years to
plethora of operative techniques, each of which claims      see the true results of the procedures we do on
excellent results.                                          growing bones.
     It is said that the definition of an orthopaedic          In this confusing scenario, how does a young and
surgeon is “one who modifies a technique the first time     discerning Orthopaedic surgeon decide which method
he practises it”. This trait probably makes any             of treatment to adopt for clubfoot?
Orthopaedic surgeon believe that his own method of
                                                                 The answer is simple. Choose the technique that
treating clubfoot yields the best of results. While this
may show up as good correction of deformity in the          1)      has a firm scientific foundation
short term, the long term may it may manifest as a          2)      has a clear understanding about the biology of
stiff and painful foot with recurred deformities.                   soft tissue behaviour,
   The number of operations designed for                    3)      follows the kinesiology of tarsal joints to achieve
clubfoot is many, from the minimalist percutaneous                  correction of foot deformities.
TA lengthening, plantar fasciotomies & abductor             4)      uses the simplest and least invasive methods to
hallucis resections to small procedures like Posterior              treat the tiny babies and
Attenborough soft tissue release, going on to               5)      has proved to give excellent results more than
extensive Postero-Medial release popularised by Turco.              40 years later.
At the other end of the spectrum complete subtalar             Only the Ponseti technique fulfils all of these
releases described in the Cincinnati approach               criteria. Hence the old Orthopaedic adage: the oldest
probably leave no soft tissues intact around the subtalar   orthopaedic surgeon for the youngest babies!” is very
joint.                                                      true when we realize that in the entire galaxy of
   Most surgeons believe manipulation to be easy,           Orthopaedic surgeons and teachers, only a
however they rarely complete the treatment with it          Dr. Ponseti—currently 91 years of age—has studied,
and prefer to abandon it and go on to surgery.              researched and most important, followed up his
Recently there is also a big marketing push for             patients for as long as 40 years. It then becomes a
external fixation devices—all claiming extreme              matter of great privilege for us to have a sage amongst
simplicity and perfect results and are being put on feet    us whose experience should guide us in doing the right
of tiny babies leading to much misery.                      thing for this ancient and enigmatic deformity.
  In this Bone & Joint decade we are exposed to a            The Ponseti technique is gathering
very rapid pace of change where every new                   momentum all over the world due to its advantages

                                                                                                              1
of low cost, minimal surgery and good results in trained      It is a matter of great pride and luck that we are able
hands. Parents of young babies are refusing surgery        to host the first Ponseti Clubfoot Course in India with
and demanding Ponseti casting. Babies from all over        the Original Technique coming right from the source.
the world are going to Dr Ponseti. At a ripe old age,      It is our privilege to have Dr. Ponseti’s assistant, Dr
he is at work, casting babies, talking to their parents    Jose Morcuende, M.D. PhD., to come down to Akola
and inspecting their braces.                               and share the technique with us.

   My visit to him at the Ponseti Center at Univ of Iowa      On behalf of the Akola Orthopaedic Society I
Hospitals in 2002 was one of the most                      welcome you all to Akola. I am grateful to Maharashtra
memorable & inspiring in my Orthopaedic career.            Orthopaedic Association & Indian Orthopaedic
His rare wisdom and scientific temper is a heritage        Association for having recognised & supported our
that we must cherish and build on. While he had            academic endevour as an official CME. I am thankful
found the solution for Clubfoot in the late 1940’s the     to the Dean, G. M. C. Akola to allow us to host this
mainstream Orthopaedic community ignored him and           program in this new Medical College. This program
went about operating on most babies—probably               would never have happened except for the help,
because it was more paying. He never gave in to            participation and encouragement from all of my
temptation and persevered with his work. In the 1990’s     colleagues from the Akola Orthopaedic Society &
the world started discovering him due to the power of      Department of Orthopaedics at GMC as well as the
the internet and by now he is a cult figure and rightly    staff of Center for Ilizarov Technique, Akola.
acknowledged as the “living god” of clubfoot
                                                              I am sure you will have an academic feast and use
treatment.
                                                           this opportunity to help your patients.
                                                                                                         ww]ww




                              Dr. Milind Chaudhary with Dr. Ignacio V. Ponseti
                                at the University of Iowa, U.S.A. circa 2002.

                                                                                                          2
                                    I N D E X


THE PONSETI METHOD IS HERE...
(From the Organising Secretary’s Desk)              Dr Milind Chaudhary        01
UNDERSTANDING TARSAL MOVEMENTS                      Dr Milind Chaudhary        04
CURRENT UPDATE IN THE MANAGEMENT OF CLUBFOOT        Jose A. Morcuende          06
IDENTIFICATION AND TREATMENT OF ATYPICAL CASES OF
CONGENITAL IDIOPATHIC CLUBFOOT                      Jose A. Morcuende          08
MANAGEMENT OF LATE-RELAPSES OF CLUBFOOT             Jose A. Morcuende          09
DETAILS OF THE PONSETI TECHNIQUE                    Dr. I. V. Ponseti          10
THE PONSETI METHOD IN BABIES
(Akola Expeirence)                                  Dr Milind Chaudhary        29
PONSETI PRINCIPLES FOR CORRECTION OF RELAPSED
ORUNCORRECTED CLUBFOOT IN
OLDER CHILDREN WITH EXTERNAL FIXATION               Dr Milind Chaudhary        31
RADICAL POSTERO -–
MEDIAL SOFT TISSUE RELEASE                          Dr. Pravin H. Vora         36
MANAGEMENT OF C. T .E .V.                           Dr. Navin M. Shah          40
“EARLY SURGICAL OPTION IN
CLUB FOOT AND LONG TERM RESULT”                     Dr. D.K. Taneja            42
PROPERTIES OF LIGAMENTS                             Dr. Wilfred D’Sa.
                                                    Dr. Milind Chaudhary       43
MANAGEMENT OF IDIOPATHIC CLUBFOOT
BY PONSETI TECHNIQUE                                Dr.V. Thulasiraman         46




                                                                           3
                               UNDERSTANDING          TARSAL MOVEMENTS

                                                                       Dr Milind Chaudhary
                                                                       Hon. Asst. Prof of Orthopaedic Surgery,GMC Akola
                                                                       Director-Centre for Ilizarov Techniques
                                                                       Vice-President, ASAMI India
                                                                       Akola India 444 001. akl_drmmc@sancharnet.in


  Equinus           Initial                                          Equinus          Final




                Equinus or flexion is defined as movement of the tarsal bone with the distal part
                      moving plantarwards around an axis which runs from side to side.
Calcaneus           Initial                                    Calcaneus              Final




             Calcaneus or extension is defined as movement of the tarsal bone with the distal part
                       moving cephalad around an axis which runs from side to side.

 Eversion            Initial                                    Eversion          Final Position




   Eversion is defined as movement of the tarsal bone with the plantar surface moves away from the midline of
                             the body around an axis which runs from back to front.

                                                                                                            4
   Inversion            Initial                                    Inversion            Final




       Inversion is defined as movement of the tarsal bone with the plantar surface moves towards the midline of
                                 the body around an axis which runs from back to front.

 Abduction              Initial                                   Abduction             Final




                       Abduction is defined as movement of the tarsal bone with the distal part
        moving away from the midline of the body plantarplantar around an axis which runs from top to bottom.

                        Initial                                                         Final
 Adduction                                                        Adduction




                      Adduction is defined as movement of the tarsal bone with the distal part
         moving towards the midline of the body plantarplantar around an axis which runs from top to bottom.

Hind foot Supination = Equinus + Inversion + Adduction        Hind foot Pronation = Calcaneus + Eversion + Abduction
Heel varus = Inversion + Adduction                            Heel valgus = Eversion + Abduction



                                                                                                               5
                       CURRENT UPDATE IN THE MANAGEMENT OF CLUBFOOT


                                                                     Jose A. Morcuende, MD, PhD
                                                               Department of Orthopaedic Surgery and Rehabilitation
                                                                      University of Iowa, Iowa City, IA 52242


   Congenital idiopathic clubfoot is a complex foot       tenotomy often is necessary to completely correct the
deformity occurring in an otherwise normal child. In      equinus. The first report of sixty-seven patients
1996, 2,224 children were born with clubfoot in the       younger than 6 month of age treated by the Ponseti
United States, an incidence of approximately 0.6 cases    method demonstrated satisfactory and rapid initial
per 1,000 live births. The goal of treatment is to        correction in the majority of cases (83%) with
correct all components of the deformity so that the       minimal complications. However, there was a relatively
patient has a pain-free, plantigrade foot with good       high incidence clubfoot relapses (56%) in this patient
mobility, without calluses, and without the need of       population. Most relapses were successfully treated
wearing special or modified shoes.                        with repeat manipulation and castings and/or

   Most orthopaedists agree that the initial              anterior tibial tendon transfers. More importantly, the

treatment should be non-surgical and started soon after   long-term functional and clinical results at a thirty-year

birth. Many different methods of correction are used,     follow-up were excellent or good using pain and

most of them involving serial manipulations and           functional limitation as the outcome criteria in the

casting. In many institutions, this treatment approach    majority of these patients (78% compared to 85% of

requires many months of treatment and frequently          a matched-control population born with normal feet).

result in incomplete or defective corrections. As a          The technique has been refined over the years,
result, extensive corrective surgery is indicated in 50   and we have come to realize the necessity of hyper-
to 90% of the cases, often with disturbing failures and   abduction of the foot in the last cast and
complications. In addition, depending on the technique    long-term use of the foot abduction brace.
followed and the residual deformity, up to 47% of         Additionally, our patient referrals have radically
clubfeet undergo one or more revision surgeries.          changed due to the Internet. This has resulted in an

   The results at our institution differ radically from   increase in the number of children presenting at an

these reports. Since the late 1940’s we have followed     age older than 6 months of age, and many who have

the   method     of   correction     developed      by    had previous unsuccessful non-surgical treatment

Dr. Ignacio Ponseti. This method involves weekly          elsewhere. This change in patient population has led

stretching of the deformity followed by application of    us to expand the age range of our traditional

a long leg cast. All components of the deformity          indications for non-surgical treatment rather than

usually correct within 4 to 5 weeks with the exception    defaulting to extensive corrective surgery solely based

of the equinus. A simple percutaneous tendoachilles       on older age or previous treatment. Because of this


                                                                                                           6
more recent experience, we have re-evaluated the              correction was obtained in all but 3 patients (99%).
efficacy of the Ponseti method for the correction of          Ninety percent of patients required £ 5 casts for
congenital idiopathic clubfoot.                               correction. Average time for full correction of the
                                                              deformity was 20 days (range, 14 to 24 days). Only 3
   From October 1992 through December 2003 a
                                                              patients (1.4%) required extensive corrective surgery.
total of 230 patients (319 clubfeet) were treated. All
                                                              There were 36 relapses (15%). Relapses were
patients underwent serial manipulation and casting
                                                              unrelated to age at presentation, previous
as described by Ponseti. Main outcome measures
                                                              unsuccessful treatment, or severity of the deformity
included initial correction of the deformity, extensive
                                                              (as measured by the number of Ponseti casts needed
corrective surgery rate, and relapses. At initial Ponseti
                                                              for correction). Relapses were related to non-
casting, 147 patients (67%) were less than 4 months
                                                              compliance with the foot abduction brace (p=0.0001).
of age, 36 (16%) were between 4 and 6 months, and
                                                              Fifteen patients (6.5%) underwent an anterior tibial
36 (16%) were older than 6 months of age. One
                                                              tendon transfer to prevent further relapses.
hundred and sixty-five patients (72%) had some form
of treatment before their initial visit to our institution.      In conclusion, the Ponseti method is a safe and
Eight patients had physical therapy (6%) and 160              effective treatment for congenital idiopathic
(83%) had serial manipulation and casting. The                clubfoot and radically decreases the need for
number of casts ranged from 1 to 21, with a median            extensive corrective surgery. This technique can be
of 10. Thirty-four patients (20%) had a percutaneous          used in children up to 2 years of age even after
tendoachilles tenotomy prior treatment here. Clubfoot         previous unsuccessful non-surgical treatment.

                                                                                                             ww]ww




                                     Jose A. Morcuende, with Dr. Ponseti




                                                                                                             7
                      IDENTIFICATION AND TREATMENT OF ATYPICAL CASES OF
                                CONGENITAL IDIOPATHIC CLUBFOOT
                                                               JOSE A. MORCUENDE, M.D., PH.D.
                                                               The Ponseti Center for Clubfoot Treatment
                                                               Department of Orthopaedic Surgery and Rehabilitation,
                                                               University of Iowa, Iowa City, Iowa, USA

Background:                                                 be markedly plantar flexed to the same degree
                                                            causing a stiff high arch. There is a deep, transverse
  Congenital idiopathic clubfoot is a complex foot
                                                            skin fold across the sole of the midfoot and another
deformity occurring in an otherwise normal child. In
                                                            deep fold above the prominent heel. The talus is
the majority of cases, manipulation and serial
                                                            prominent in front of the ankle.  The anterior
casting as described by Ponseti result in full correction
                                                            tuberosity of the calcaneus bulges in front of the
of the deformity. However, there are some occasional
                                                            lateral malleolus and could be mistaken for the head
cases that do not respond to this treatment protocol.
                                                            of the talus. The tendo Achilles is very tight and wide,
The purpose of this study was to describe the
                                                            and appears fibrotic up to the middle third of the calf.
characteristics of these atypical clubfeet and to
discuss their treatment.                                      The gastrosoleus muscles are small and bunched
Methods:                                                    up in the upper third of the calf. Repeated modified
                                                            manipulation and serial casting corrected all clubfeet.
  We retrospectively reviewed the cases of
                                                            All required percutaneous Achilles tenotomy. No
patients with congenital idiopathic clubfoot treated at
                                                            patient required extensive corrective surgery. There
our institution from October 1992 to February 2004.
                                                            have been not relapses with the use of the new
There were a total of 242 patients (334 clubfeet).
                                                            modified foot abduction brace.
Patients were treated by serial manipulation and
casting as described by Ponseti. Patients that did not      Conclusions and Clinical Relevance:
respond to the standard treatment protocol were
considered as atypical. Main outcome measures were            The Ponseti method is a safe and effective
the need for extensive corrective surgery and relapses.     treatment for congenital idiopathic clubfoot,
                                                            including atypical cases. Identification of these cases
Results:
                                                            and modification of the treatment protocol allows
  There were 15 atypical cases (2 %) that                   successful correction of the deformity without the need
required modifications on the treatment protocol. In        for extensive corrective surgery.
these cases the foot tends to be short and chubby.
                                                            Level of Evidence:
  The skin is soft and fluffy.  The heel is in very
severe, rigid equinus and in varus, and a thick fat pad       Therapeutic Study, Level III-2 (Retrospective
covers the undersurface of the calcaneus. The               Cohort Study).
forefoot is severely adducted. The metatarsals tend to
                                                                                                          ww]ww

                                                                                                         8
                           MANAGEMENT OF LATE-RELAPSES OF CLUBFOOT

                                                             JOSE A. MORCUENDE, M.D., PH.D.
                                                             The Ponseti Center for Clubfoot Treatment
                                                             Department of Orthopaedic Surgery and Rehabilitation,
                                                             University of Iowa, Iowa City, Iowa, USA

Background:                                               the foot abduction brace 1 year prior to the relapse.

                                                          The deformity recurr very slowly, with increased
  Congenital idiopathic clubfoot is a complex foot
                                                          impairment to walk. Patients required new
deformity with a high tendency for relapses.
                                                          manipulation and casting, and underwent anterior
Previous studies from our institution have
                                                          tibialis transfer to the 3rd cuneiform. All patients had
demonstrated that most relapses happen in the first 3
                                                          the deformity corrected without the need of extensive
years of life. However, we have observed a few cases
                                                          or bony procedures.
of relapses in older children after the brace has been

discontinued. The purpose of this study was to
                                                          Conclusions and Clinical Relevance:
describe the characteristics of these cases and to

discuss their treatment.                                    The tendencies for clubfoot relapses still

                                                          persist in a few patients after the age of 4 years. Prompt

Methods:                                                  identification and treatment by casting and anterior

                                                          tibial transfer allows successful correction of the
  We retrospectively reviewed the cases of
                                                          deformity without the need for extensive corrective
patients with congenital idiopathic clubfoot treated at
                                                          surgery.
our institution from October 1992 to February 2004.

There were a total of 242 patients (334 clubfeet).
                                                          Level of Evidence:
Patients were treated following the method described

by the senior author.                                       Therapeutic Study, Level III-2 (Retrospective

                                                          Cohort Study).

Results:

  There were 6 cases of late-relapses (2.5%). Most

relapses occur at age 5. Patients stopped the use of
                                                                                                         ww]ww

                                                                                                         9
                                   DETAILS OF THE PONSETI TECHNIQUE

                                                                        Dr. I. V. Ponseti, M. D.
                                                                        Emeritus Prof. of Orthopaedic Surgery
                                                                        Univ. of Iowa, U.S.A.

    It is estimated that more than 100,000 babies are        professionals, such as therapists and orthopaedic
born world-wide each year with congenital clubfoot.          assistants. A well-organized health system is needed
                                Eighty percent of the        to ensure that parents follow the instructions for use
                                cases      occur      in     of the foot abduction brace to prevent relapses.
                                developing nations.
                                                                  The treatment is economical and easy on the
                                Most are untreated or
                                                             babies. If well implemented, it will greatly decrease
                                poorly         treated.
                                                             the number of clubfoot cripples.
                                Neglected clubfoot
                                causes        crushing       Development of the technique
                                physical,        social,        In the mid 1940s, I examined 22 patients with
                                psychological, and           clubfoot that had been surgically treated in the 1920s
                                financial burdens on         by Arthur Steindler, a good surgeon. The feet had
                                the patients, their          become rigid, weak, and painful.
families, and the society. Glob-ally, neglected clubfoot
is the most serious cause of physical disability among       Effect of operative correction
congenital musculoskeletal defects.                             In the 1940s, we were doing many posteromedial
   In developed countries, many children with                releases and I saw that most of the important ligaments
clubfoot undergo extensive corrective surgery, often         of the tarsus had to be severed to loosen the subtalar
with disturbing failures and complications. The need         and midtalar joints so that the foot could be abducted
for one or more revision surgeries is common.                under the talus. When operating on relapses, I noticed
Although the foot looks better after surgery, it is stiff,   severe scarring in the foot and stiffness in the
weak, and often painful. After adolescence, pain             misshapen joints. The posterior tibial and toe flexor
increases and often becomes crippling.                       tendons that had been lengthened in the first
                                                             operation, were matted and immobilized in a mass of
     Clubfoot in an otherwise normal child can be
                                                             scar tissue. After a few years of this experience, I was
corrected in 2 months or less with our method of
                                                             convinced that surgery was the wrong approach for
manipulations and plaster cast applications, with
                                                             treatment of Clubfoot.
minimal or no surgery. This was proven by the results
of our 35-year follow-up study and confirmed in many         Anatomical studies
clinics around the world.                                       A study of histological sections of ligaments from
    This method is particularly suited for developing        virgin clubfeet, obtained in the operating room and
countries where there are few orthopaedic surgeons.          from fetuses and stillborns, revealed that the abundant
The technique is easy to learn by allied health              young collagen in the ligaments was wavy, was very


                                                                                                         10
cellular, and could be easily stretched. I conceived,        Varus, inversion, and adduction correction
therefore, that the displaced navicular, cuboid, and
                                                                Next, one must correct simultaneously the varus,
calcaneus could be gradually abducted under the talus
                                                             inversion, and adduction of the hindfoot, because the
without cutting any of the tarsal ligaments. I discovered
                                                             tarsal joints are in a strict mechanical interdependence
that this was so based on cineradiography of clubfeet
                                                             and cannot be corrected sequentially.
I had partially or fully reduced without surgery.
                                                             Maintaining correction
      From dissections of normal feet of children and
adults in the anatomy department and of clubfeet of             The genes responsible for clubfoot deformity are
stillborns, I fully understood the mechanism of the          active start-ing from the 12th to the 20th weeks of
interdependent movements of the tarsal bones and             fetal life and lasting until 3 to 5 years of age. The
realized that clubfoot deformity was simple to correct.      deformity occurs during the very fast period of growth
The Huson thesis, An Anatomical and Functional               of the foot. (Such transient gene activity occurs in
Study of the Tarsal Joints, published in 1961 in Leiden,     many other biological events; it is observed in
Holland, corroborated my understanding of the                devel-opmental dysplasia of the hip, idiopathic
functional anatomy of the foot.                              scoliosis, Dupuytrens contracture, and osteoarthritis).
                                                             With our technique of clubfoot correction, the joint
Casting technique
                                                             surfaces of the bones reshape congruently in their
   My casting technique was learned from Böhler and          normal position. It is important to apply the last plaster
applied during the Spanish Civil War in 1936–1939            cast with the foot in an overcorrected position: 75
when treating more than 2,000 war- wound fractures           degrees of abduction and 20 degrees of ankle
with unpadded plaster casts. Precise, gentle molding         dorsiflexion.dorsiflexion.
of the plaster over the reduced sublux-ations of the            While kicking in the foot abduction brace full time
tarsal bones of a clubfoot is just as basic as the molding   for 3 months, the baby strengthens the peroneal
of a plaster cast on a well-reduced fracture.                muscles and foot extensor muscles that counteract
Cavus correction                                             the pull of the tibialis and gastrosoleus muscles.
                                                             Relapses are rare with the continued use of the foot
   The cavus, or high arch, is a characteristic deformity
                                                             abduction brace for 14 to 16 hours a day (when the
of the forefoot that is associated with inversion, or
                                                             baby sleeps) until 3 to 4 years of age. In a few cases,
supination, of the hindfoot. It results from a greater
                                                             anterior tibialis tendon transfer to the third cuneiform
flexion of the first metatarsal bone, causing pronation
                                                             is necessary to permanently balance the foot.
of the forefoot in relation to the hindfoot. Hicks
described it in the 1950s as a “pronation twist.” The        Delayed acceptance of the technique
surgeons misconception that pronation is necessary               It was disappointing that my first article on
to correct clubfoot causes a further increase of the         congenital clubfoot, published in the The Journal of
cavus: an iatrogenic deformity. When the functional          Bone & Joint Surgery in March 1963, was
anatomy of the foot is well understood, it becomes           disregarded. It was not carefully read and, therefore,
clear that one must correct the cavus first by supinating    not understood. My article on congenital metatarsus
the forefoot to place it in proper alignment with the        adductus, published in the same journal in June 1966,
hindfoot.                                                    was easily understood, perhaps because the deformity



                                                                                                           11
occurs in one plane. The approach was immediately          the second trimester of pregnancy. Clubfoot is rarely
accepted, and the illustrations were copied in most        detected with ultrasonography before the 16th week
textbooks.                                                 of gestation. Therefore, like developmen-tal hip
                                                           dysplasia and idiopathic scoliosis, clubfoot is a
  A few orthopaedic surgeons studied my technique
                                                           develop-mental deformation.
and began to apply it only after the publication of
our long-term follow-up article in 1995, the                  A 17-week-old male fetus with bilateral clubfoot,
publication of my book a year later, and the posting       more severe on the left, is shown [A]. A section in the
of Internet support group web sites by parents of          frontal plane through the malleoli of the right clubfoot
babies whose clubfoot I had treated. I have been           [B] shows the deltoid, tibionavicular ligament, and
reprimanded for not pushing the method more                the tibialis posterior tendon to be very thick and to
forcefully from the beginning.                             merge with the short plantar calcaneonavicular
                                                           ligament. The interosseous talocalcaneal ligament is
   The reason that congenital clubfoot deformity was
                                                           normal.
not under-stood for so many years and was so poorly
treated is related, I believe, to the misguided notion       A photomicrograph of the tibionavicular ligament
that the tarsal joints move on a fixed axis of motion.     [C] shows the collagen fibers to be wavy and densely
Orthopaedists try to correct the severe supination that    packed. The cells are very abundant, and many have
is associated with clubfoot by forcefully pro-nating the   spherical nuclei (original magnification, x475).
forefoot. This causes an increase of the cavus and a
                                                              The shape of the tarsal joints is altered relative to
breach in the midfoot. The breach in the midfoot is
                                                           the altered positions of the tarsal bones. The forefoot
caused by jamming the anterior tuberosity of the
                                                           is in some pronation, causing the plantar arch to be
adducted calcaneus against the undersurface of the
                                                           more concave (cavus). Increas-ing flexion of the
head of the talus. Clubfoot is easily corrected when
                                                           metatarsal bones is present in a lateromedial direction.
the functional anatomy of the foot is well understood.
The completely supinated foot is abducted under the           In the clubfoot, there appears to be excessive pull
talus that is secured against rotation in the ankle                                      of the tibialis posterior
mortise by applying counterpressure with the thumb                                       abetted       by      the
against the lateral aspect of the head of the talus. The                                 gastrosoleus, the tibialis
varus, inversion, and adduction of the hindfoot are                                      anterior, and the long
corrected simultaneously, because the tarsal joints are                                  toe flexors. These
in strict mechanical interdependence and can-not be                                      muscles are smaller in
corrected sequentially.                                    size and shorter than in the normal foot. In the distal
Scientific Basis of Management                             end of the gastrosoleus, there is an increase of
   Our treatment of clubfoot is based on the biology       connective tissue rich in collagen, which tends to
of the defor-mity and of the functional anatomy the        spread into the tendo
foot.                                                      Achillis and the deep
Biology                                                    fasciae.

  Clubfoot is not an embryonic malformation. A                In the clubfoot, the
normally devel-oping foot turns into a clubfoot during     ligaments     of    the


                                                                                                       12
                         posterior and medial aspect          pronating the foot on this axis, the heel varus and
                         of the ankle and tarsal joints       foot supination can be corrected. This is not so.
                         are very thick and taut,
                                                                  Pronating the clubfoot on this imaginary fixed axis
                         thereby severely restraining
                                                              tilts the forefoot into further pronation, thereby
                         the                          foot
                                                              increasing the cavus and pressing the adducted
                          in equinus and the navicu-lar
                                                              calcaneus against the talus. The result is a breach in
and calcaneus in adduction and inversion. The size
                                                              the hindfoot, leaving the heel varus uncorrected.
of the leg muscles correlates inversely with the severity
of the deformity. In the most severe clubfeet, the               In the clubfoot [D], the anterior portion of the
                                               gastrosoleus   calcaneus lies beneath the head of the talus. This
                                               is seen as     position causes varus and equinus deformity of the
                                               a muscle       heel. Attempts to push the calcaneus into eversion
                                               of small       without abducting it [E] will press the calcaneus
                                               size in the    against the talus and will not correct the heel varus.
                                               upper          Lateral dis-placement (abduction) of the calcaneus
                                               third of       to its normal relation-ship with the talus [F] will correct
                                               the calf.      the heel varus deformity of the clubfoot.
Excessive collagen synthesis in the ligaments, tendons,          The clubfoot deformity occurs mostly in the tarsus.
and muscles may persist until the child is 3 or 4 years       The tar-sal bones, which are mostly made of cartilage,
of age and might be a cause of relapses.                      are in the most extreme positions of flexion, adduction,
   Under the microscope, we see an increase of                and inversion at birth. The talus is in severe plantar
collagen fibers and cells in the ligaments of neonates.       flexion, its neck is medially and plantarly deflected,
The bundles of collagen fibers display a wavy                 and its head is wedge shaped. The navicular is
appearance known as crimp. This crimp allows the              severely medially displaced, close to the medial
ligaments to be stretched. Gentle stretching of the           malleolus, and articulates with the medial surface of
ligaments in the infant causes no harm. The crimp             the head of the talus. The calcaneus is adducted and
reappears a few days later, allowing for further              inverted under the talus.
stretching. That is why manual correction of the                 As shown in [A], in a 3-day-old infant, the navicular
deformity is feasible.                                        is medi-ally displaced and articulates only with the
Kinematics                                                    medial aspect of the head of the talus. The cuneiforms
                                                              are seen to the right of the navicular, and the cuboid
   The correction of the severe displacements of the
                                                              is underneath it. The calcaneocuboid joint is directed
tarsal bones in clubfoot requires a clear understanding
                                                              posteromedially. The anterior two-thirds of the
of the functional anatomy of the tarsus. Unfortunately,
                                                                                      calcaneus is seen underneath
most orthopaedists treat-ing clubfoot act on the wrong
                                                                                      the talus. The tendons of the
assumption that the subtalar and Chopart joints have
                                                                                      tibi-alis anterior, extensor
a fixed axis of rotation that runs obliquely from
                                                                                      hallucis longus, and extensor
anteromedial superior to posterolateral inferior,
                                                                                      digitorum longus are medially
passing through the sinus tarsi. They believe that by
                                                                                      displaced.

                                                                                                             13
                                                            improve the degree of correc-tion of the deformity.
     No single axis of motion (like a mitered hinge)
exists on which to rotate the tarsus, whether in a             The bones and joints remodel with each cast change
                                                            because of the inherent properties of young
                                                            connective tissue, cartilage, and bone, which respond
                                                            to the changes in the direction of mechanical stimuli.
                                                            This has been beautifully demonstrated by Pirani,
                                                            comparing the clinical and magnetic resonance
                                                            imaging appearance before, during, and at the end
                                                            of cast treatment. Note the changes in the
                                                            talonavicular joint [B] and calcaneocuboid joint [C].
normal or a clubfoot. The tarsal joints are functionally    Before treatment, the navicular (red outline) is
interdependent. The move-ment of each tarsal bone           displaced to the medial side of the head of the talus
                                            involves        (blue). Note how this relationship normalizes during
                                            simultaneous    cast treatment. Similarly, the cuboid (green) becomes
                                            shifts in the   aligned with the calcaneus (yellow) during the same
                                            adjacent        cast treatment.
                                            bones. Joint
                                                                 Before applying the last plaster cast, the tendo
                                            motions are
                                                            Achillis may have to be percutaneously sectioned to
                                            determined
                                                            achieve complete cor-rection of the equinus. The
                                            by        the
                                                            tendo Achillis, unlike the tarsal ligaments that are
                                            curvature of
                                                            stretchable, is made of non-stretchable, thick, tight
                                            the joint
                                                            collagen bundles with few cells. The last cast is left in
                                            surfaces
                                                            place for 3 weeks while the severed Achilles tendon
and by the orientation and structure of the binding
                                                            regenerates in the proper length with minimal scarring.
ligaments. Each joint has its own specific motion pat-
                                                            At that point, the tarsal joints have remodeled in the
tern. Therefore, correction of the extreme medial
                                                            corrected positions.
displacement and inversion of the tarsal bones in the
clubfoot necessitates a simultaneous gradual lateral          In summary, most cases of clubfoot are corrected
shift of the navicular, cuboid, and calcaneus before        after five to six cast changes and, in many cases, a
they can be everted into a neutral position. These          tendo Achillis tenotomy. This technique results in feet
                                        displacements       that are strong, flexible, and plantigrade. Maintenance
                                        are feasible        of function without pain has been demonstrated in a
                                        because the         35-year follow-up study.
                                        taut tarsal liga-   Overview of Ponseti Management Can clubfoot
                                        ments can be        be classified?
                                        gradually
                                        stretched.             Yes, classifying clubfoot into categories improves
                                                            understand-ing for communication and management
                                         Correction of
                                       clubfoot       is    [A].
                                       accomplished         Untreated clubfoot: under 2 years of age
                                       by abducting         Neglected clubfoot: untreated after 2 years
the foot in supination while counterpressure is applied     Corrected clubfoot: corrected by Ponseti
over the lateral aspect of the head of the talus to
prevent rotation of the talus in the ankle. A well-         management
molded plaster cast maintains the foot in an improved       Recurrent clubfoot: supination and equinus develop
position. The ligaments should never be stretched           after initial good correction
beyond their natural amount of give. After 5 days,          Resistant clubfoot: Stiff clubfoot seen in association
the ligaments can be stretched again to further             with syn-dromes such as arthrogryposis

                                                                                                         14
Complex clubfoot: initially treated by a method other      As viewed from behind [B opposite page], note that
than Ponseti management                                 correc-tion of the heel varus occurs during this
How does Ponseti management correct the                 manipulation.
deformity?                                              When should treatment with Ponseti manage-
                                                        ment be undertaken?
                                                           When possible, start soon after birth (7 to 10 days).
                                                        When started before 9 months of age, most clubfoot
                                                        deformities can be corrected by using this
                                                        management.
                                                        When treatment is started early, how many cast
                                                        changes are usually required?
                                                           Most clubfoot deformities can be corrected in
                                                        approximately 6 weeks by weekly manipulations
                                                        followed by plaster cast ap-plications. If the deformity
                                                        is not corrected after six or seven plaster cast changes,
                                                        the treatment is most likely faulty.

                                                        How late can treatment be started and still be
                                                        helpful?
                                                           Treatment is most effective if started before 9
Keep in mind the basic clubfoot deformity with the
                                                        months of age. Treatment between 9 and 28 months
deformed talus and the medially displaced navicular
                                                        is still helpful in correcting all or much of the deformity.
[B].
  Ponsetis model shows the mechanism of correction.     Is Ponseti management useful for neglected
In the sequence [A opposite page], observe that all     clubfoot?
                                                          Management that is delayed until early childhood
                                                        may be start-ed with Ponseti casts. In most cases,
                                                        operative correction will be required but the
                                                        magnitude of the procedure may be less than would
                                                        have been necessary without Ponseti management.

                                                        What is the expected outcome in adult life for
                                                        the infant with clubfoot treated by Ponseti
                                                        management?
                                                           In all patients with unilateral clubfoot, the affected
                                                        foot is slightly shorter (mean, 1.3 cm) and narrower
                                                        (mean, 0.4 cm) than the normal foot. The limb
                                                        lengths, on the other hand, are the same, but the
elements are cor-rected when the foot is rotated        circumference of the leg on the affected side is smaller
around the head of the talus. This occurs during cast   (mean, 2.3 cm). The foot should be strong, flexible,
correction.                                             and pain free.


                                                                                                        15
What is the incidence of clubfoot in children                Is Ponseti management useful for resistant
with one or two parents who also are affected?               clubfoot?
                                                                Ponseti management is appropriate for use in
   When one parent is affected with clubfoot, there is
                                                             children with arthrogryposis, myelomeningocele, and
a 3% to 4% chance that the offspring will also be
                                                             Larsen syndrome. The results may not be as gratifying
affected. However, when both parents are affected,
                                                             as they are in the child with idiopathic clubfoot treated
the offspring have a 15% chance of developing
                                                             from birth, but there are advantages to this approach.
clubfoot.
                                                             The first is that the clubfoot could respond completely
How do the outcomes of surgery and Ponseti                   to Ponseti management, with or without the need for
management compare?                                          an Achilles tenotomy. Additionally, even partial
   Surgery improves the initial appearance of the foot       preoperative correction of these severe deformities can
but does not prevent recurrence. Importantly, no             decrease the extent of surgery and improve the ability
long-term follow-up studies of operated patients have        to approximate the edges of the contracted skin.
been published to date. Adult foot and ankle surgeons
                                                               Arthrogrypotic clubfoot is perhaps the most
report that these surgically treated feet become weak,
                                                             challenging. Often, initial percutaneous heel cord
stiff, and often painful in adult life.
                                                             tenotomy is required to enable any manipulative
How often does Ponseti management fail and                   deformity correction. Creating a cal-caneocavus
                                                             deformity is not a concern because of the severe
                                                             contracture of the posterior joint capsules. Anticipate
                                                             the need for surgery.

                                                             Is Ponseti management useful in myelodysplasia?
                                                               Concern has been raised regarding manipulation
                                                             and casting of the insensate clubfoot in children with
                                                             myelomeningocele. The physician must apply
                                                             pressure based on his/her experience with idiopathic
                                                             clubfoot, in which the childs comfort dictates
                                                             appropriateness. One must be patient during
                                                             manipulation and expect that more than the usual
                                                             number of casts will be needed. The maneuvers are
                                                             gentle. Concentrated forceful molding over bony
                                                             prominences is avoided, as it is in all children.

operative correction become necessary?                       Is Ponseti management useful for complex
   The success rate depends on the degree of stiffness       clubfoot?
of the foot, the experience of the surgeon, and the             Personal experience, and that of others, has shown
reliability of the family. In most situations, the success   that Ponseti management can often be successful
rate can be expected to exceed 90%. Failure is most          when applied to feet that have been manipulated and
likely if the foot is stiff with a deep crease on the sole   casted by other practitioners who are not yet skilled
of the foot.                                                 in this very exacting management.


                                                                                                          16
What are the features of recurrent clubfoot?                Reduce the cavus
 The foot usually develops supination and equinus.             The first element of management is correction of
                                                            the cavus deformity by positioning the forefoot in
What are the usual steps of clubfoot
                                                            proper alignment with the hindfoot. The cavus, which
management?
                                                                                         is the high medial arch
   Most clubfeet can be corrected by brief
                                                                                         [C, yellow arc] is due to
manipulation and then casting in maximum
                                                                                         the pronation of the
correction. After approximately five cast-ing periods
                                                                                         forefoot in relation to the
[C], the adductus and varus are corrected. A
                                                                                         hindfoot. The cavus is
percu-taneous heel cord tenotomy [D] is performed
                                                                                         always supple in
in nearly all feet to complete the correction of the
                                                                                         newborns and requires
equinus, and the foot is placed in the last cast for 3
                                                                                         only supinating the
weeks. This correction is maintained by night splinting
                                                                                         forefoot to achieve a
using a foot abduction brace [E], which is con-tinued
                                                                                         normal longitudinal
until approximately 2 to 4 years of age. Feet treated
                                                                                         arch of the foot [D and
by this management have been shown to be strong,
                                                                                         E]. In other words, the
flexible, and pain free [F], allowing a normal life.
                                                                                         forefoot is supinated to
Details of the Ponseti Technique
                                                                                         the extent that visual
First four or five casts (more if necessary)
                                                                                         inspection of the plantar
                                                                                         sur face of the foot
                                                                                         reveals a normal
                                                                                         appearing arch—neither
                                                                                         too high nor too flat.
                                                                                         Alignment of the
                                                            forefoot with the hindfoot to produce a normal arch
                                                            is necessary for effective abduction of the foot to




   Start as soon after birth as possible. Make the infant
and family comfortable. Allow the infant to feed during
                                                            correct the adductus and varus.
the manipulation and casting processes [A]. Casting
should be performed by the surgeon when possible            Manipulation
[B]. Each step in management is shown for both the            The manipulation consists of abduction of the foot
right and left feet.                                        beneath the stabilized talar head. Locate the head of


                                                                                                        17
the talus. All components of clubfoot deformity, except      calcaneal-fibular ligament to pull the fibula posteriorly
for the ankle equinus, are corrected simultaneously.         during manipulation.
To gain this correction, you must locate the head of
                                                             Manipulate the foot
the talus, which is the fulcrum for correction.
                                                                Next, by abducting the foot in supina-tion [A], with
Exactly locate the head of the talus                         the foot stabilized by the thumb over the head of the
   This step is essential [F]. First, palpate the malleoli   talus, as shown by the yellow arrow, abduct the foot
with the thumb and index finger of hand A while the          as far as can be done without causing discomfort to
toes and metatarsals are held with hand B. Next, slide                                           the infant. Hold
your thumb and index finger of hand A forward to                                                 the correction with
palpate the head of the talus (red) in front of the ankle                                        gentle pressure for
mortis. Because the navicular (yellow) is medially                                               about 60 seconds,
displaced and its tuberosity is almost in contact with                                           then release. The
the medial malleolus, you can feel the prominent                                                 lateral motion of
lateral part of the talar head (red) barely covered by                                           the navicular and
the skin in front of the lateral malleolus. The anterior                                         of the anterior part
part of the calcaneus (blue) will be felt beneath the                                            of the calcaneus
talar head.                                                                                      increases as the
                                                                                                 clubfoot deformity
  While moving the forefoot laterally in supination
                                                                                                 cor-rects [B]. Full
with hand B, you will be able to feel the navicular
                                                             correction should be possible after the fourth or fifth
move ever so slightly in front of the head of the talus
                                                             cast. For very stiff feet, more casts may be required.
as the calcaneus moves laterally under the talar head.
                                                             The foot is never pronated.
Stabilize the talus
                                                             Second, third, and fourth casts
  Place the thumb over the head of the talus, as
                                                               During this phase of treatment, the adductus and
shown by the yellow arrows in the skeletal model [A].
                                                             varus are fully corrected. The distance between the
Stabilizing the talus provides a pivot point around
                                                             medial malleolus and the tuberosity of the navicular
                                  which the foot is
                                                             when palpated with the fingers tells the degree of
                                  abducted. The
                                                             correction of the navicular. When the clubfoot is
                                  index finger of the
                                                                                                      corrected,
                                  same hand that is
                                                                                                      t h a t
                                  stabilizing the talar
                                                                                                      distance
                                  head should be
                                                                                                      measures
                                  placed behind that
                                                                                                      approximately
                                  lateral malleolus.
                                                                                                      1.5 to 2 cm
                                  This        fur ther
                                                             and the navicular covers the anterior surface of the
                                  stabilizes the ankle
                                                             head of the talus.
                                  joint while the foot
                                                             Each cast shows improvement
                                  is       abducted
                                                               Note the changes in the cast sequence [C].
beneath it and avoids any tendency for the posterior


                                                                                                          18
  Adductus and varus Note that the first cast shows        Steps in cast application
the cor-rection of the cavus and adductus. The foot
                                                           Preliminary manipulation
remains in marked equinus. Casts 2 through 4 show
                                                             Before each cast is applied, the foot is manipulated
correction of adductus and varus.
                                                           [A].

  Equinus The equinus deformity gradually improves
                                                           Applying the padding
with correction of adductus and varus. This is part of
                                                             Apply only a thin layer of cast pad-ding [B] to make
the correction because the calcaneus dorsiflexes as it
                                                           possible effective molding of the foot. Main-tain the
abducts under the talus. No direct attempt at equinus
                                                           foot in the maximum corrected position by holding
correction is made until the heel varus is corrected.
                                                           the toes while the cast is being applied.

Foot appearance after the fourth cast                      Applying the cast
  Full correction of the cavus, adductus, and varus          First apply the cast below the knee and then extend
are noted [D]. Equinus is im-proved, but this              the cast to the upper thigh. Begin with three to four
correction is not adequate, necessitating a heel cord      turns around the toes [C], and then work proximally
tenotomy. In very flexible feet, equinus may be            up the leg. Apply the plaster smoothly. Add a little
corrected by additional casting without tenotomy.          tension [D] to the turns of plaster above the heel.
When in doubt, per-form the tenotomy.                      The foot should be held by the toes and plaster
                                                           wrapped over the “holders” fingers to provide ample
Cast Application, Molding, and Removal                     space for the toes.
   Success in Ponseti management requires good
casting tech-nique. Those with previous clubfoot           Molding the cast
casting experience may find it more difficult than those      Do not try to force correction with the plaster. Use
learning clubfoot casting for the first time.              light pressure.

                                                              Do not apply constant pressure with the thumb over
                                                           the head of the talus; rather, press and release
                                                           repetitively to avoid pres-sure sores of the skin. Mold
                                                           the plaster over the head of the talus while holding
                                                           the foot in the corrected position [E]. Note that the
                                                           thumb of the left hand is molding over the talar head
                                                           while the index finger of the left hand is molding above
                                                           the calcaneus. The arch is well molded to avoid flatfoot
                                                           or rocker-bottom deformity. The index finger of the
                                                           right hand is maintaining the correction. There is no
                                                           pressure over the calcaneus. The calcaneus is never
                                                           touched during the manipulation or casting. Molding
  We recommend that plaster material be used               should be a dynamic process; constantly move the
because the material is less expensive and plaster can     fin-gers to avoid excessive pressure over any single
be more precisely molded than fiberglass.                  site. Continue molding while the plaster hardens.


                                                                                                       19
Extend cast to thigh                                        Decision to perform tenotomy
  Use much padding at the proximal thigh to avoid              A major decision point in management is
skin irritation [F]. The plaster may be layered back        determining when sufficient correction has been
and forth over the anterior knee for strength [G] and       obtained to perform a percutane-ous tenotomy to gain
for avoiding a large amount of plaster in the popliteal     dorsiflexion and to complete the treat-ment. This point
fossa area, which makes cast removal more difficult.        is reached when the anterior calcaneus can be
                                                            abducted from underneath the talus. This abduction
Trim the cast
                                                            allows the foot to be safely dorsiflexed without
   Leave the plantar plaster to support the toes [H],
                                                            crushing the talus between the calcaneus and tibia
and trim the cast dorsally to the metatarsal phalangeal
                                                            [E]. If the adequacy of abduction is un-certain, apply
joints, as marked on the cast. Use a plaster knife to
                                                            another cast or two to be certain.
remove the dorsal plaster by cutting the center of the
plaster first and then the medial and lateral plaster.
                                                            Characteristics of adequate abduction
Leave the dorsum free. Note the appearance of the
first cast when completed [I]. The foot is in equinus,        Confirm that the foot is sufficiently abducted to
and the forefoot is fully supinated.                        safely bring the foot into 15 to 20 degrees of
                                                            dorsiflexion before performing tenotomy.
Cast removal
  Remove each cast in clinic just before a new cast is         The best sign of sufficient abduction is the ability
applied. Avoid cast removal before clinic because           to palpate the anterior process of the calcaneus as it
considerable correction can be lost from the time the       abducts out from be-neath the talus.
cast is removed until the new one is placed. Although
                                                               Abduction of approximately 60 degrees in
a cast saw can be used, use of a plaster cast knife is
                                                            relationship to the frontal plane of the tibia is possible.
                  recommended because it is less
                  frightening to the infant and family
                                                               Neutral or slight valgus of os calcis is present. This
                  and also less likely to cause any
                                                            is deter-mined by palpating the posterior os calcis.
                  accidental injury to the skin. Soak
                  the cast in water for about 20              Remember that this is a three-dimensional
                  minutes, and then wrap the cast           deformity and that these deformities are corrected
                  in wet cloths before removal. Use         together. The correction is accomplished by abducting
                  the plaster knife [A], and cut            the foot under the head of the talus.
                  obliquely [B] to avoid cutting the        The final outcome
                  skin. Remove the above-knee
                                                               At the completion of casting, the foot appears to
                  portion of the cast first [C]. Finally,
                                                            be overcorrected into abduction with respect to normal
                  remove the below-knee portion of
                                                            foot appearance during walking. This is not in fact an
                   the cast [D].
                                                            overcorrection. It is actually a full correction of the
                                                            foot into maximum normal abduction. This correction
                                                            to complete, normal, and full abduction helps prevent
                                                            recurrence and does not create an over-corrected or
                                                            pronated foot.


                                                                                                           20
Equinus Correction and Fifth Cast Indications               Post-tenotomy cast
  Make certain the indications for equinus correction          Apply the fifth cast [F] with the foot abducted 60 to
have been met.                                              70 degrees with respect to the frontal plane of the
                                                            tibia. Note the extreme abduction of the foot with
Percutaneous heel cord tenotomy
                                                            respect to the leg and the overcor-rected position of
  Plan to perform the tenotomy in clinic.
                                                            foot. The foot is never pronated. This cast is left in
Preparing the family                                        place for 3 weeks after complete correction.
  Prepare the family by explaining the procedure.
                                                            Cast removal
   Sometimes a mild sedative may be given to the              After 3 weeks, the cast is removed. Note the
infant [A].                                                 correction [G]. Thirty degrees of dorsiflexion is now
Equipment                                                   possible, the foot is well corrected, and the operative
  Select a tenotomy blade such as a #11 or #15 or           scar is minimal. The foot is ready for bracing.
any other small blade such as an ophthalmic knife.          Bracing
Skin preparation                                            Bracing protocol
  Prep the foot medially, posteriorly, and laterally [B].
                                                               The brace is applied immediately after the last cast
Anesthesia                                                  is removed, 3 weeks after tenotomy. The brace
  A small amount of local anesthetic may be infiltrated     consists of open toe high-top straight last shoes
near the tendon [C]. Be aware that too much local           attached to a bar [A]. For unilateral cases, the brace
                                                            is set at 75 degrees of external rotation on the clubfoot
                                                            side and 45 degrees of external rotation on the normal
                                                            side [B]. In bilateral cases, it is set at 70 degrees of




anesthetic makes palpation of the tendon difficult and      external rotation on each side. The bar should be of
makes the procedure more dangerous.                         sufficient length so that the heels of the shoes are at
                                                            shoulder width.
Heel cord tenotomy
                                                              A common error is to prescribe too short a bar,
                                                            which the child finds uncomfortable [C]. A narrow
  Perform the tenotomy [D] approximately 1 cm
                                                            brace is a common reason for a lack of compli-ance.
above the calca-neus. Avoid cutting into the cartilage
                                                            The bar should be bent 5 to 10 degrees with the
of the calcaneus. A “pop” is felt as the tendon is
                                                            convexity away from the child, to hold the feet in
released. An additional 10 to 15 degrees of
                                                            dorsiflexion [D].
dorsiflexion is typically gained after the tenotomy [E].


                                                                                                         21
                           The brace should be worn         calls for a brace to maintain the abduction. This is a
                        full time (day and night) for       bar attached to straight last open toe shoes. This
                        the first 3 months after the        degree of foot abduction is required to maintain the
                        tenotomy cast is removed.           abduction of the calcaneus and forefoot and prevent
                        After that, the child should        recurrence. The foot will gradually turn back inward,
                        wear the brace for 12 hours         to a point typically of 10 degrees of external rotation.
                        at night and 2 to 4 hours in        The medial soft tissues stay stretched out only if the
                        the middle of the day for a         brace is used after the casting. In the brace, the knees
                        total of 14 to16 hours during       are left free, so the child can kick them “straight” to
                        each 24-hour period. This           stretch the gastrosoleus tendon. The abduction of the
protocol continues until the child is 3 to 4 years of       feet in the brace, combined with the slight bend
age.                                                        (convexity away from the child), causes the feet to
                                                            dorsiflex. This helps maintain the stretch on the
Types of braces
                                                            gastrocnemius muscle and Achilles tendon [D].
   Several types of commercially made braces are
                                                            Importance of bracing
available. With some designs, the bar is permanently
attached to the bottoms of the shoes. With other              The Ponseti manipulations combined with the
designs, it is removable. With some designs, the bar        percutaneous tenotomy regularly achieve an excellent
length is adjustable, and with others, it is fixed. Most    result. However, without a diligent follow-up bracing
braces cost approximately US $100. In Uganda,               program, recurrence and relapse occur in more than
Steen-beek designed a brace, which is made at a cost        80% of cases. This is in contrast to a relapse rate of
of approximately US $12 (see p. 24). Parents should         only 6% in compliant families (Morcuende et al.).

                                                            Alternatives to foot abduction brace

                                                               Some surgeons have tried to “improve” Ponseti
                                                            management by modifying the brace protocol or by
                                                            using different braces. They think that the child will
                                                            be more comfortable without the bar and so advise
                                                            use of straight last shoes alone. This strategy always
be given a prescription for a brace at the time of the      fails. The straight last shoes by themselves do nothing.
tenotomy. This gives them 3 weeks to organize               They function only as an attachment point for the
themselves. In the United States, the Markell shoe          bar.
and brace is most commonly used, but other countries          Some braces are no better than the shoes by
have differ-ent options [E].                                themselves and, therefore, have no place in the
Rationale for bracing                                       bracing protocol. If well fitted, the knee-ankle-foot
                                                            braces, such as the Wheaton brace, maintain the foot
  At the end of casting, the foot is abducted [A] to an
                                                            abducted and externally rotated. However, the knee-
exaggerated amount, which should measure 75
                                                            ankle-foot braces keep the knee bent in 90 degrees
degrees (thigh-foot axis). After the tenotomy, the final
                                                            of flexion. This position causes the gastrocnemius
cast is left in place for 3 weeks. Ponsetis protocol then

                                                                                                        22
muscle and Achilles tendon to atrophy and shorten,           initial casting phase, during which the doctor does all
leading to recurrence of the equinus deformity. This         the work, and the bracing phase, during which the
                                                             parents do all the work. On the day that the last cast
                                                             comes off after the tenotomy, “pass the baton” of
                                                             responsibility to the parents.

                                                                During the initial instructions, teach the parents how
                                                             to ap-ply the brace. Suggest they practice putting it
                                                             on and taking it off several times during the first few
                                                             days and have them leave the brace off for brief
                                                             periods of time during these few days to allow the
                                                             childs feet to get accustomed to the shoes. Teach the
                                                             parents to exercise the childs knees together as a unit
                                                             (flex and extend) in the brace, so that the children get
is particularly a problem if a knee-ankle-foot brace is
                                                             accustomed to moving two legs simultaneously. (If
used during the initial 3 months of bracing, when the
                                                             the child tries to kick one leg at a time, the brace bar
braces are worn full time.
                                                             interferes, and the child may get frustrated). Warn
   In summary, only the brace as described by Ponseti        the parents that there may be a few rough nights until
is an acceptable brace for Ponseti management and            the child gets accustomed to the brace [A]. Suggest
should be worn at night until the child is 3 to 4 years      the analogy of “saddle training” a horse: it requires a
of age.                                                      firm but patient hand. There should be no
                                                             “negotiations” with the child. Schedule the first return
Strategies to increase compliance to bracing
                                                             visit in 10 to 14 days. The main pur-pose of that visit
protocol
                                                             is to monitor compliance. If all is well, then the next
   The families who are the most compliant to the            scheduled visit is in 3 months, when the child
bracing protocol are those who have read about the           advances to the nighttime only protocol (or “nights
Ponseti method of clubfoot management on the                 and naps”).
Internet and have chosen that method. They come
                                                               It is useful to approach brace compliance as a public
to the office educated and motivated. The least
                                                                                               health issue, similar to
compliant parents are often from families who did no
                                                                                               tuberculosis
background research on the Ponseti method and need
                                                                                               treatment. It is not
to be “sold” on it. The best strategy to ensure
                                                                                               sufficient to prescribe
compliance is to educate the parents and indoctrinate
                                                                                               anti-tuberculosis
them into the Ponseti culture. It helps to see the Ponseti
                                                                                               medications; you
method of management as a lifestyle that demands
                                                                                               must also monitor
certain behavior.
                                                                                               compliance through a
  Take advantage of the face-to-face time that occurs                                          public health nurse.
during the weekly casting to talk to the parents and                                           We monitor compli-
emphasize the importance of bracing. Tell them that                                            ance by frequently
the Ponseti management method has two phases: the                                              calling the families of

                                                                                                           23
our patients, who are in the brace phase, between
                                                            •     2 weeks (to troubleshoot compliance issues)
office visits. All families are encouraged to call us if
                                                            •     3 months (to graduate to the nights-and-naps
they hit a period of difficulty with brac-ing, so that we
                                                                  protocol)
can work through the issues. In the beginning, for
example, children may kick off the shoes if they arent      •     every 4 months until age 3 years (to monitor
tight-ened correctly. Gluing a small pad at the upper             compliance and check for relapses)
rim of the heel counter can help keep the feet captured     •     every 6 months until age 4 years
in the shoes [B].
                                                            •     every 1 to 2 years until skeletal maturity
When to stop bracing
                                                                     Early relapses in the infant show loss of foot
  Occasionally, a child will develop excessive heel
                                                            abduction and/or loss of dorsiflexion correction and/
valgus and external tibial torsion while using the brace.
                                                            or recurrence of metatar-sus adductus.
In such instances, the physician should dial the
external rotation of the shoes on the bar from                 Relapses in toddlers can be diagnosed by examining
approximately 70 degrees to 40 degrees.                     the child walking. As the child walks toward the
                                                            examiner, look for supination of the forefoot,
   How long should the nighttime bracing protocol
                                                            indicating an overpowering tibialis anterior muscle
continue? There is no scientific answer to this question.
                                                            and weak peroneals [A]. As the child walks away from
Severe feet should be braced until age 4 years, and
                                                            the examiner, look for heel varus [B]. The seated child
mild feet can be braced until age 2 years [C]. It is not
                                                            should be examined for ankle range of motion and
always easy to distinguish which foot is mild and which
                                                            loss of passive dorsiflexion.
is severe, especially when observing them at age 2
years. Therefore, it is recommended that even the mild
                                                            Reasons for relapses
feet should be braced for up to 3 to 4 years, provided
the child still tolerates the nighttime bracing. Most
                                                              The most common cause of relapse is
children get used to the bracing, and it becomes part
                                                            noncompliance to the post-tenotomy bracing
of their life style. However, if compliance becomes
                                                            program. Morcuende found that re-lapses occur in
very problematic after age 2 years, it may become
                                                            only 6% of compliant families and more than 80% of
necessary to discontinue the bracing to ensure that
                                                            noncompliant families. In brace-compliant patients,
the child and parents get a good nights sleep. This
                                                            the basic underlying muscle imbalance of the foot is
leniency is not tolerable in the younger age groups.
                                                            what causes relapses.
Below age 2 years, the children and their families must
be encouraged to comply with the bracing protocol
                                                            casting for relapses
at all costs.

Managing Relapses                                              Do not ignore relapses! At the first sign of relapse,
                                                            consider reapplying one to three casts to stretch the
Recognizing relapses                                        foot out and regain correction. This may appear at
   After applying the brace for the first time after the    first to be a daunting task in a wriggly 14-month-old
tenotomy cast is removed, the child returns according       toddler, but it is important. The casting management
to the following suggested schedule.                        is identical to the original Ponseti casting used in


                                                                                                        24
infancy. Once the foot is re-corrected with the casts,     [D] and should be treated by re-casting in the child
the bracing program is again begun.                        between age 12 and 24 months, followed by
Equinus relapse                                            reinstitution of a strict bracing protocol.

   Recurrent equinus is a structural deformity that can
                                                           Dynamic supination
compli-cate management. Equinus can be assessed
clinically, but to illustrate the problem, a radiograph       Some children will require anterior tibialis tendon
is included to show the deformity [C].                     transfer (see page 26) for dynamic supination
                                                           deformity, typically between ages 2 and 4 years.
  Several plaster casts may be needed to correct the
                                                           Anterior tibialis tendon transfer should be considered
equinus to at least a neutral position of the calcaneus.
                                                           only when the deformity is dynamic and no structural
Sometimes, it may be necessary to repeat the
                                                           deformity exists. Transfers should be delayed until
percutaneous tenotomy in children up to 1 or even 2
                                                           radiographs show ossification of the lateral cuneiform
years of age. They should undergo casting for 4 weeks
                                                           that typically occurs at approximately 30 months of
postoperatively, with the foot abducted in a long leg
                                                           age. Normally, bracing is not required after this
bent knee cast, and then go back into the brace at
                                                           procedure.
night. In rare situations, open Achilles lengthening may
be necessary in the older child.                             One thing is certain: relapses that occur after Ponseti
                                                           man-agement are easier to deal with than relapses
Varus relapse
                                                           that occur after traditional posteromedial release
   Varus heel relapses are more common than equinus        surgery.
relpases. They can be seen with the child standing




                                                                                                        25
Common Management Errors                                   the calcaneus and interferes with correction of the

Pronation or eversion of the foot                          heel varus.

  This condition worsens the deformity by increasing
                                                           Casting errors
the cavus. Pronation does nothing to abduct the
adducted and inverted cal-caneus, which remains            1.      The foot should be immobilized with the

locked under the talus. It also creates a new deformity            contracted liga-ments at maximum stretch

of eversion through the mid and forefoot, leading to               obtained after each manipulation. In the cast,

a bean-shaped foot. Thou shall not pronate!”                       the ligaments loosen, allowing more stretching
                                                                   at the next session.
External rotation of foot to correct adduction
while calcaneus remains in varus                           2.      The cast must extend to the groin. Short leg
                                                                   casts do not hold the calcaneus abducted.
  This causes a posterior displacement of the lateral
malleolus by externally rotating the talus in the ankle    3.      Attempts to correct the equinus before the heel

mortise. This displace-ment is an iatrogenic deformity.            varus and foot supination are corrected will

Avoid this problem by abducting the foot in flexion                result in a rocker-bottom de-formity. Equinus

and slight supination to stretch the medial tarsal                 through the subtalar joint can be corrected by

ligaments, with counter- pressure applied on the lateral           calcaneal abduction.

aspect of the head of the talus. This allows the
calcaneus to abduct under the talus with correc-tion       Failure to use night brace

of the heel varus.                                              Failure to use shoes attached to a bar in external
                                                           rotation full time for 3 months and at night for 2 to 4
                           Kites       method        of    years is the most common cause of recurrence.
                           manipulation                    Attempts to obtain per fect anatomical
                                                           correction
                             Kite believed that the heel
                           varus would correct simply                                       It is wrong to assume that
                           by evert-ing the calcaneus.                                    early alignment of the
                           He did not realize that the                                    displaced skeletal elements
calcaneus can evert only when it is abducted (i.e.,                                       will   result   in    normal
laterally rotated), under the talus.                                                      anatomy. Long-term follow-
  Abducting the foot at the midtarsal joints with the                                     up     radiographs        show
thumb pressing on the lateral side of the foot near the                                   abnormalities. However,
calca-neocuboid joint (red “X”) blocks ab-duction of       good long-term function of the clubfoot can be


                                                                                                               26
                       expected.        There   is   no     Transfer the tendon
                       correlation      between      the
                                                              Transfer the tendon to the dorsolateral incision [E].
                       radiographic appearance of the
                                                            The tendon remains under the extensor retinaculum
                       foot and long-term function.
                                                            and the extensor ten-dons. Free the subcutaneous
                                                            tissue to allow the tendon a direct course laterally.
                       Anterior Tibialis Transfer
                                                            Option: localize site for insertion
                       Indication

  Transfer is indicated if the child has persistent varus     Using a needle as a marker, radiography may be

and supination during walking. The sole shows               useful in ex-actly localizing the site of transfer in the

thickening of the lateral plantar skin. Make certain                                            third cuneiform

that any fixed deformity is corrected by two or three                                           [F].    Note     the

casts before performing the transfer. Transfers are best                                        position of the hole

performed when the child is between 3 and 5 years                                               in the radiograph

of age.                                                                                         (arrow).

  Often, the need for transfer is an indication of poor                                         Identify site for
compli-ance to brace management.                                                                transfer
                                                                                                   This should be
Mark the sites for incisions
                                                                                                in the mid-dorsum
The dorsolateral incision is marked on the mid-dorsum
                                                                                                of the foot and
of the foot [A].
                                                                                                ideally into the
Make medial incision                                                                            body of the third
The dorsomedial incision is made over the insertion                                             cuneiform. Make a
of the an-terior tibialis tendon [B].                                                           drill hole large
                                                                                                enough              to
Expose anterior tibialis tendon
                                                                                                accommodate the
  The tendon is exposed and detached at its insertion                                           tendon [G].
[C]. Avoid extending the dissection too far distally to
avoid injury to the growth plate of the first metatarsal.   Thread sutures

                                                              Thread a straight needle on each of the securing
Place anchoring sutures
                                                            sutures. Leave the first needle in the hole while passing
  Place a #0 dissolving anchoring suture [D]. Make          the second needle to avoid piercing the first suture
multiple passes through the tendon to obtain secure         [H]. Note that the needle pen-etrates the sole of the
fixation.
                                                            foot (arrow).


                                                                                                           27
Pass two needles                                          Local anesthetic

  Place the needles through a felt pad and then             A long-acting local anesthetic is injected into the
through different holes in the button to secure the       wound [E] to reduce immediate postoperative pain.
tendon [A].                                               Skin closure

Secure tendon                                               Close the incisions with absorbable subcutaneous
                                                          sutures [F]. Tape strips reinforce the closure.
  With the foot held in dorsiflexion, pull the tendon
into the drill hole by traction on the fixation sutures   Cast immobilization
and tie the fixation su-tures with multiple knots [B].      A sterile dressing is placed [G], and a long leg cast
                                                          is applied [H].
Supplemental fixation                                     Postoperative care

                                                            This patient was discharged on the same day of
  Supplement the button fixation by suturing the
                                                          the procedure. Usually, the patients remain
tendon to the periosteum at the site where the tendon
                                                          hospitalized overnight. The sutures absorb. Remove
enters the cuneiform [C], using a heavy absorbable
                                                          the cast at 6 weeks. No bracing is necessary after the
suture.
                                                          procedure. See the child again in 6 months to assess
Neutral position without support
                                                          the effect of the transfer.
  Without support, the foot should rest in
approximately 10 de-grees of plantar flexion [D] and
neutral valgus-varus.
                                                                                                    ww]ww




                                                                                                      28
THE PONSETI METHOD IN BABIES
       (Akola Expeirence)
                             Dr Milind Chaudhary
                             Hon. Asst. Prof of Orthopaedic Surgery,GMC Akola
                             Director-Centre for Ilizarov Techniques
                             Vice-President, ASAMI India
                             Akola India 444 001. akl_drmmc@sancharnet.in




                     We have been performing casting and
                  manipulation with the Ponseti technique since the last
                  3½ years and have finished treatment of morethan
                  56 feet in 42 babies. Some of the salient points we
                  have discovered are as follows:


                     We keep the baby on the mothers lap & frequently
                  encourage breast feeding while the casting is going on


                                                                 29
                                                              Once the BK portion is hard then AK is applied with
                                                              hip held in extension
                                                              No anesthesia is given
                                                              No cotton padding is used
                                                              Gentle technique and moulding is the key to
                                                            success

                                                              4 feet required Soft tissue release as they were
                                                            myelomenigocoele and non-compliance

                                                              There was recurrence seen in 6 feet early and they
                                                            needed casting again.
                                                              Tenotomy was incomplete in two cases

the lap must be made small with support to the                Rocker bottom was seen in 2 feet.

parents’ thigh on the head side                               We feel that this is indeed a wonderful technique
                                                            but feel sure that we have a long way to reach the
  The childs buttocks must rest at the edge of the lap      level of perfection of Dr Ponseti.
someone talks to the child or shows toys assistant holds    This anecdote should say it all:
the upper tibia and the toes initial casting is done upto     Dr Ponseti was heard remarking at age 86 at a
knee thereafter assistant leaves toes. Surgeon moulds       conference: “ I think I have only recently started
the pop around the talar head and the heel.                 giving a good plaster cast!”
                                                                                                       ww]ww

                                                                                                      30
    PONSETI PRINCIPLES FOR CORRECTION OF RELAPSED OR UNCORRECTED CLUBFOOT
                    IN OLDER CHILDREN WITH EXTERNAL FIXATION

                                                                           Dr Milind Chaudhary
                                                                           Hon Astt Prof of Orthopaedic Surgery,GMC Akola
                                                                           Director-Centre for Ilizarov Techniques
                                                                           Akola India 444 001. akl_drmmc@sancharnet.in

  Recurrent & Untreated Clubfoot at ages of 4 and              hindfoot equinus persists. Hindfoot deformities are
above present specific difficulties. These may be due          stiff due to previous soft tissue releases and offer no
to neglect, improper treatment or inadequate                   leverage to bring the heel down .
bracing ( in which case the deformties are likely to be           At this stage the Ilizaorv apparatus may be applied
soft) or they may follow soft tissue releases & are stiff      with the sole aim of correcting the hindfoot equinus
& have severe deformities of cavus-adductus &                  and perhaps some inversion. The fixator
equino-varus.                                                  duration is therefore short and full correction of the
   The treatment algorithm is decided by age,                  hindfoot equinus may be achieved. The description
stiffness of the ankle and sphericity of the Talar dome.       of this technique is at end of the next section.
If the talar dome is significantly flattened and               Ilizarov Correction using Ponseti principles in
movement in the ankle joint is reduced, it is best to          Stiff Feet.
achieve correction of the foot deformities by applying
the Ilizarov fixator and performing a V osteotomy the
older children. This gives a full correction as well as
prevents recurrence due to the subtalar arthrodesis that
occurs when a wedge shaped bone gets regenerated
at the level of the anterior subtalar joint.
   When the talar dome is spherical and some
movement is retained in the ankle, there is a posssiblity
of achieving correction of the clubfoot deformities
                                                                                           5 Yrs. old with previous
using Ponseti principles with a versatile external
                                                                                           PSTR with rigid and stiff
fixation system like the Ilizarov.
                                                                                           feet. Initial 4 casts at fort-
Casting and Ilizarov in relatively supple feet                                             nightly intervals corrected
   In children of ages between 4 to 8 years when the                                       the forefoot. Next Ilizarov
foot deformities are not very stiff, repeat casting is still                               was applied only to correct
a choice. The casts are applied without anesthesia                                         hindfoot equinus.
using all the Ponseti principles for correcting the                In older children or in those with very stiff feet, the
forefoot deformities. 6 to 9 casts may be needed at            Ilizarov external fixator offers significant advantages
larger intervals of 2 to 3 weeks.                              due to modularity & flexibility in application. The
  The casting itself can allow some softening of the           Ponseti principles can be incorporated in the
foot and almost full correction of the forefoot can be         construction of the Ilizarov frame to ensure that the
achieved along with the abduction of the                       correction is accurate & follows the kinematics of the
calcaneum. At the end of this period of casting,               ankle and hindfoot joints.


                                                                                                               31
Tibia is fixed with two rings (TR). Forefoot is fixed with a half ring with two wires (FR). Calcanaeum is fixed with two wires and
half ring (HR). Initial manoeuvre is supination by force couple action on the two connections between the TR & FR.




Next comes abduction by pushing from the TR to the FR. When calcaneus comes out of abduction then equinus is corrected
by a couple of motors from TR to HR. The angle needed is much more than described in standard Ilizarov books.

  The tibia is fixed with two rings with either wires or            the medial side and pushing down on the lateral
half pins. (TR)                                                     side.(Fig2)
  The forefoot is fixed with a half ring (FR) with two                Correction of the forefoot initially into supination is
wires—one of them being an olive from the                           important as it aligns it with the hindfoot supination.
medial side.                                                        This would prevent the occurance of cavus at the
  The hindfoot is fixed with two wires and if possible              mid-foot and also allow the forefoot to transmit forces
a half pin.(HR)                                                     congruently to push the calcaneum into abduction.

Forefoot Supination                                                 Forefoot abduction
                                                                       For the forefoot to be able to abduct we need a
  Initially the FR is connected to the anterior part of             counter-pressure on the head of the talus. We insert
TR by two parallel connections with multiplane                      an olive wire passing through the lateral side of the
hinges.(Fig1) Supination is achieved by pulling up on               talar head. This is attached to the TR with long dropped


                                                                                                                     32
                                                             An AP x-ray of the foot will show that the Anterior
                                                           Talo-Calcaneal angle has reached about 20 degrees.
                                                           Once the forefoot has been fully abducted and has
                                                           pushed the heel into abduction, it is possible to evert
                                                           the heel by attaching two connections ( between the
                                                           HR & TR) and distracting the medial one more than
                                                           the lateral one.
                                                           Hindfoot Equinus Correction
                                                              The correction of equinus may be constrained or
                                                           non-constrained. In Non-Constrained correction, no
                                                           hinges are applied and one relies on applying
Next comes abduction by pushing from the TR to the FR.
                                                           corrective forces and natural constraints of the joints
When calcaneus comes out of abduction then equinus is
                                                           ( articular shape, joint capsule and ligaments & the
corrected by a couple of motors from TR to HR. The angle
                                                           Instant Centre of Rotation) to achieve correction.
needed is much more than described in standard Ilizarov
                                                           Non-Constrained correction of equinus with any
books.
                                                           external fixation hardware is fraught with risk of
posts. On the medial side it may be attached to a screw    anterior subluxation of the ankle joint. Typically the
traction mechansim to pull the talus                       TR are perpendicular to the lower tibia and the HR is
medially as well. This wire gives counter pressure on      in as much equinus as the calcaneum. If the MR for
the talar head to allow the forefoot to abduct and the     correction of equinus are brought straight down
calcaneum be pushed into abduction. Absence of this        perpendicular to the TR, its’ resultant force will push
wire causes the same effect as seen in faulty              the talus anteriorly out of the ankle mortice. It is
manipulation—posterior displacement of the fibula,         recommended to place the MR angled at about 7
which is an iatrogenic deformity.                          degrees posteriorly to prevent anterior subluxation.
   The HR is kept free and is not attached to the TR at      Computer simulation & dynamics and
the this stage(Fig3). There is a medial                    kinesiology of the ankle teach us that 7 degrees is
projection from the TR and this attaches a motor           inadequate.
rod(MR) to the medial side of the FR. (Fig4).This is
                                                              When the talus moves from plantarflexion into
distracted apart at 1 mm per day. The origin of this
                                                           dorsifexion, it not only rolls but also glides a little
MR needs to be changed at least once to adapt to the
                                                           posteriorly. Hence our motor rods must be able to help
more abducted forefoot.(Fig5) On the lateral side, the
                                                           in this normal motion and should be placed almost
FR and HR may be connected with loose connections.
                                                           tangential to the curvature of the talar dome. In
Hindfoot eversion                                          practice, it is essential to maintain an acute angle
  At the end of this stage of correction, the              between the motor rod and the long axis of the
calcaneum is palpated and we can ensure that the           calcaneum anteriorly to about 75 to 80 degrees at all
distance between the lateral malleolus and the             times.(Fig6)
posterior tuberosity of the calcaneum has increased.         When we start the treatment with the heel in 30 to
This is proof that abduction of the calcaneum is           40 degrees of equinus, (Fig7)this usually means the
adequate.                                                  MR needs to come from way anterior angling


                                                                                                       33
posteriorly, attached to the hindfoot ring with                The correction is monitored carefully by
multiplanar hinges. As the correction proceeds, the         taking frequent xrays. This allows us to focus on the
angle between the calcaneum and the motor rod               ankle joint at all times and ensure that the cartilage is
anteriorly becomes more acute and hence the motor           neither getting crushed nor the ankle is undergoing
rod now has to be anchored on the lower tibial ring at      excessive distraction. The biggest risk is the anterior
a more posterior level.(Fig8)                               subluxation or dislocation of the talus. Asymmetric
   Using Computer simulation we can determine the           distraction of the joint is also possible if the hinges are
position of the Center of rotation of the ankle joint.      placed inaccurately.
The wire is inserted thru this point in the talus and is      If MR are placed inaccurately, there can be
attached to the lower tibial rings with long dropped        posterior subluxation of the ankle or the lower growth
posts. This wire itself may act as the hinge around         plate may separate posteriorly ( seen in one foot in
which ankle is brought out of equinus.                      our series).This was corrected by modifying the
  The other way to achieve this would be to have a          apparatus and after one year a valgus and external
Constrained       correction,      with      accurate       rotation deformity has developed.
placements of hinges at the level of instant centre of         Towards the end of the hindfoot equinus
rotation of the ankle and a single motor rod                correction, it is observed that the MR tend to push the
posteriorly. The anterior rods may be kept loose and        calcaneum without bringing the talus along with it and
adjust to the changing position of the forefoot.            a talo-calcaneal separation results.
  The ankle is pulled out of equinus into mild                This can be prevented by attaching the talar wire
overcorrection within a few weeks. The apparatus is         now to the HR assembly and also converting the
now retained for at a further 4 to 6 weeks. Upon            equinus correction into a Constrained type. The other
removal a cast retains the overcorrection and               way to prevent this from happening would be to
thereafter foot abduction orthoses & shoes need to be       gradually pull up on the talar wire( pulling up the
worn.                                                       anterior part of the talus out of equinus) and
   The first stage is performed similar to that described   simultaneously pushing the calcaneum.
in the previous section. It cannot be emphasized that          Rate of complications using this protocol is
the two MR are placed with a significant angulation         significantly lower as compared to previous method
from anterior to posterior to ensure that they are          of correction using the Ilizarov frame—that we have
almost tangential to the shape of the talar dome.           used in more than 60 feet in the first 11 years of Ilizarov
  The talus wire can be distracted to help                  usage.
adjust the position of the talus and also give an           Results
anterior part of the force couple to achieve good              We have finished treatment in 22 feet in 18
correction of equinus.                                      children with this method in the last 2 years. (Fig 9 to
Complications                                               12)Inadquate correction was seen in three feet. In one
   Wires in the calcaneum need careful                      this was because of flattening of the talar dome & he
insertion and tensioning as the hindfoot is frequently      should have been treated with a v osteotomy. In
osteoporotic. The hindfoot fixation must be stable and      another child inadequate follow-up caused the
be able to last the duration of the treatment.              incomplete correction in both his feet. Mild persistent
                                                            cavus remained in the forefoot and varus in the heel.

                                                                                                           34
The parents are not unhappy as he got at least 90%          constrained correction that is being offered is also
improvement.                                                inadequate, as it is impossible to alter the direction of
                                                            forces that are applied to various parts of the foot at
   There are compatibility issues with                      various times.
post-operative bracing in older children, who do not
tolerate both feet tied together in a Foot Abduction           Lastly the lack of modularity of the JESS and UMEX
Orthosis. This leads to partial recurrence in some          fixators do not permit the correction of any
children. Just wearing corrective shoes is not enough       complications if and when they may arise. It is also
to retain the correction in some children.                  seen that the motor rods are easily manipulated by
  We have tried the Dimeglio method of taping a foot-       older children who will frequently reverse the turning
ruler to the shoes which forces the foot into external      and hence jeopardise the treatment.
rotation; without too much success.
                                                              The basic flaw lies in the scientific basis or the lack
   We are pleased with the quality of early                 of it. It was propogated for many years by these
post-operative results with this method. We seem to         marketing teams that one has to correct the varus first
be getting consistent results with better correction of     —that was done by everting the heel—which is
the deformity and well retained function in the ankle       described as an error in the Ponseti technique.
joint.
                                                              There is a strong tendency to cause anterior
  Modularity of the Ilizarov fixator permits us to          subluxation of the talus due to the direction of the
conform to the Ponseti principles which allows us to        motor rods and inability to change the directions.
have a kinesiological correction with fewer
complications. The salient features of this technique          Finally the half life of half pins in fixation of the foot
are novel and have been described for the first time. It    is very poor and the pins tend to become loose very
has become possible to translate the principles of          soon as opposed to the thin wires of the Ilizarov
Ponseti accurately. This “AKOLA”technique has now           system.
spread to the USA as well as Europe.
                                                              The discerning surgeon should not be worried about
                                                            the seeming complexity of the Ilizarov fixator and
Ilizarov vs Simpler Fixators :
                                                            should try to master it as it gives total control and
                                                            better results.
   Simpler Fixators using half pins have been
propogated since the last 12 yrs. as the perfect               It is quite possible that the simplicity of the fixators
answer to clubfeet at all ages. This marketing
                                                            is more for the sake of the surgeon and is makes life
hype has totally ignored the scientific realities of the
                                                            more difficult for the patients.
situation.

   These fixators offer no control over the talus at all.                                                    ww]ww
Hence it frequently leads to external rotation of the
talus and pushing the lateral malleolus behind.

  The other main issue is the inability to offer
constrained correction using hinges. The non-


                                                                                                            35
               RADICAL POSTERO – MEDIAL SOFT TISSUE RELEASE

                                                       .
                                                   PROF PRAVIN H. VORA
                                                   CHILDREN’S ORTHOPAEDIC HOSPITAL
                                                   HAJI ALI,MUMBAI



PHILOSOPHY OF MANAGEMENT OF C.T.E.V.               · ROUNDED OUTER BORDER OF THE FOOT WITH
                                                   PROMINENCE OF CUBO – METATARSAL AREA
  EITHER CORRECT BY GENTLE REPEATED                · CLINICAL FINDINGS FURTHER COROBORATED
MANIPULATIONS OR DO ONE TIME SOFT TISSUE           BY FOOT PRINTS AND X-RAYS
SURGERY OF ALL THE TIGHT CONTRACTED AND
                                                   INDICATIONS FOR SURGERY – II
FIBROUS SOFT STRUCTURES & DO THE DYNAMIC
CORRECTION OF TIGHT MUSCULATURE AND                3. FAILED PREVIOUS SURGERY
ALTER BONE SHAPES BY CORRECTIVE SPLINTAGE               · INCOMPLETE CORRECTION
AND FOOTWEAR                                            · RECURRENCE
USUAL   PROTOCOL               FOR      C.T.E.V.   4.   OLDER AGE GROUP PATIENTS
MANAGEMENT                                         FACTORS RESISTING CORRECTION – I
* 1 WEEK : GENTLE MANIPULATION BY MOTHER
  ST
                                                   A)   TIGHT TOUGH FIBROUS CONTRACTURES OF
*2 – 5 WEEKS     :   GENTLE   MANIPULATION     &
                                                   1.   DEEP FASCEA
STRAPING
* 6 WEEKS TO     : MANIPULATION UNDER G.A. & POP   2. TENDON SHEATHS
4 MONTHS B.K. CAST CHANGED EVERY 4 WEEKS           3. LIGAMENTS
*AFTER 4 MTHS: SOFT TISSUE – RADICAL POSTERO–
                                                   4. JOINT CAPSULES
MEDIAL RELEASE
                                                   *** PRIMARY SURGICAL CORRECTION NEEDED
*EARLY CHILDHOOD : AS ABOVE                    –
SUPPLEMENTARY BONY SURGERY IF NEEDED               FACTORS RESISTING CORRECTION – II
                                                   B)   MUSCLES & TENDONS:
*LATE CHILDHOOD : SOFT TISSUE SURGERY
WITH BONY SURGERY                                    TENDONS DO NOT NEED LENGTHENING
                                                   EXCEPT
INDICATIONS FOR SURGERY – I
                                                   1.   INTERSTITIAL MUSCLE FIBROSIS
1. WHERE CONSERVATIVE TREATMENT OF THE
                                                   2.   TO EXPOSE DEEPER STRUCTURES
FEW MONTHS HAVE FAILED
                                                   (E.G. TENDO-ACHILIS & TIBIALIS POSTERIOR
2. SEVERE DEFORMITY CHARACTERISED BY:
                                                   TENDONS)
· POINTED UPTURNED TRIANGULAR HEEL
                                                   C) OTHERS:
· WELL MARKED POSTERIOR AND MEDIAL
CREASE                                             F.H.L & F.D.L. – DYNAMIC SPLINTING AND SERIAL
· GROSS INVERSION OF THE HEEL                      PLASTERING

                                                                                       36
FACTORS RESISITING CORRECTION – III             11. LENGTHENING OF TENDO ACHILIS

D)      BONE SHAPE & JOINT CONFIGURATION        12. DIVISION OF TOUGH FIBROUS THICKENING
                                                OF DEEP FASCIA DEEP TO T.A.
- DYNAMIC SPLINTING IN MILD ABERATION IN
EARLY CASES                                     13. ISOLATION AND RETRACTION OF F.H.L

- DEFINITIVE BONY SURGERY IN LATE CASES         14. OPENING OF POSTERIOR CAPSULE OF ANKLE

SURGERY – UNDER TOURNIQUET                      15. DIVISION OF POSTERIOR TIBIO-FIBULAR
                                                LIGAMENT
1.   LAZY S SKIN INCISION
                                                16. DIVISION OF CALCANEO-FIBULAR LIGAMENT
2. EXPOSURE        OF   TIBIALIS-   POST   &
                                                AND SHEATH OF THE PERONEII
LENGTHENING
                                                17. OPENING OF THE POSTERIOR TALO-
3. EXPOSURE OF INSERTION OF TIBIALIS
                                                CALCANEAL JOINT
ANTERIOR
                                                18. OPENING TALO-CALCANEAL              JOINT
4. OPEN THE CAPSULE OF CUNEO METATARSAL
                                                COMPLETELY MEDIALLY
JT. MEDIALLY, SUPERIORLY AND INFERIORLY
                                                19. EXPOSE AND DIVIDE INTEROSSEOUS TALO-
5. DIVIDE THE ATTACHMENT OF TIBIALIS
                                                CALCANEAL LIGAMENT
ANTERIOR TO MEDIAL CUNEIFORM, IF ANY
                                                20. EXCISE THE SHEATHS OF TIB. POST., F.H.L.
6. DO CAPSULOTOMY OF ALL THE THREE SIDES
                                                AND F.D.L.
OF NAVICULO- CUNEIFORM JOINT & SEPARATE
TIGHT   PLANTAR    STRUCTURES     FROM          21. EXCISE ARCH OR ORIGIN OF FLEXOR AND
UNDERNEATH THIS AREA                            ADDUCTOR HALLUCIS

7. DO CAPSULOTOMY OF TALONAVICULAR JOINT        22. DIVIDE FIBROUS CONTRACTURE OVER
AND DIVIDE ALL EXTENSIONS OF TIB. POST. TO      HENRY’S KNOT
VARIOUS TARSAL BONES AND CUT THE SPRING
                                                23. BRING THE FOOT IN FULLY CORRECTED
LIGAMENT
                                                POSITION
8.     DISSECT NAVICULAR ON PLANTER
                                                24. SUTURE T.A. AND TIB. POST. IN FULLY
ASPECT AND EXPOSE THE BIFURCATE LIGAMENT
                                                CORRECTED POSITION
AND DIVIDE IT, AND OPEN CALCANEO-NAVICULAR
JOINT AND CALCANEO-CUBOID JOINT                 25. CLOSE SUBCUTANEOUS TISSUE & SKIN

9. OPEN      ANTERIOR          PART        OF   26. APPLY B.K. CAST IN UNDERCORRECTED
TALO-CALCANEAL JT.                              POSITION AND RELASE THE TOURNIQUET

                                                         .
                                                POST - OP MANAGEMENT
10. DIVIDE SUPERFICIAL PART OF DELTOID,
SPANNING MEDIAL ASPECT OF TALO- CALCANEAL       1. B.K. CAST IN SLIGHT UNDER CORRECTION FOR
JOINT, BUT SPARING TIBIO-TALAR PART             FIRST TWO WEEKS UNTIL SKIN HEALS


                                                                                   37
2. TOTAL CAST IMMOBILISIATION 10 – 12 WEEKS   1.     SKIN Z PLASTY NOT NEEDED
WITH PERIODIC CHANGES 3 – 4 WEEKS             2.     PLANTER TENOTOMY AND TENDON
3. DYNAMIC SPLINTAGE POST – CAST PERIOD              LENGTHENING OF F.H.L. & F.D.L. NOT
TILL WEIGHT BEARING IS STARTED                       NEEDED

4. CORRECTIVE FOOTWEAR ON WEIGHT              3.     POST-OP ONLY B.K. CAST IS NEEDED – A.K.
BEARING RESISTANT STRUCTURES OF                      CAST NOT REQUIRED
IMPORTANCE                                    4.     RESIDUAL FOREFOOT ADDUCTION
                                                     CORRECTS BY SERIAL CASTING, DYNAMIC
1. DEEP FASCEA OF LEG UNDER TENDO –
                                                     SPLINTING & CORRECTIVE FOOTWEAR AS
ACHILIS
                                                     CHILD GROWS – CORRECTIVE BONY
2. FIBROUS FLEXOR SHEATHS OF LONG FLEXOR             SURGERY NEEDED ONLY IN OLDER
TENDONS AND NOT THE TENDONS THEMSELVES               CHILDREN WITH BONY CHANGES

3. TALO – CALCANEAL PART OF DELTOID           5.     PERSISTANT INTORTION OF TIBIA CORRECTS
LIGAMENT SOMETIMES REPLACED BY                       AS CHILD GROWS WITH DYNAMIC SPLINTING
CARTILAGENOUS      MASS OVER    THE                  AND CORRECTIVE FOOTWEAR
SUSTANTACULUM TALI

4. INTEROSSEOUS      TALO   –   CALCANEAL     OBSERVATIONS
LIGAMENT                                      1.   SKIN Z PLASTY NOT NEEDED
5. FIBROCARTILAGENOUS MASS DEVELOPING IN      2.   PLANTER TENOTOMY AND TENDON
CALCANEO – NAVICULAR PART OF BIFURCATED Y          LENGTHENING OF F.H.L & F.D.L NOT NEEDED
LIGAMENT
                                              3.   POST – OP ONLY B.K. CAST IS NEEDED – A.K.
6. SPRING      LIGAMENT      ANAMALOUS             CAST NOT REQUIRED
OBSERVATIONS AT SURGERY.                      4. RESIDUAL FOREFOOT ADDUCTION CORRECTS
1. TIB. ANT. : THICK BIFID, INSERTED IN          BY SERIAL CASTING, DYNAMIC SPLINTING &
MEDIAL CUNEIFORM ALSO                            CORRECTIVE FOOTWEAR AS CHILD GROWS –
2. TIB. POST. : VERY THICK AND SOMETIMES         CORRECTIVE BONY SURGERY NEEDED ONLY
MUSCULAR UNTIL LOWER END                         IN OLDER CHILDREN WITH BONY CHANGES
: SOMETIMES REPLACED BY FIBROUS TISSUE        5.   PERSISTANT INTORTION OF TIBIA CORRECTS
3. TALOCALCANEAL    :    SYNDESMOSIS    OR         AS CHILD GROWS WITH DYNAMIC SPLINTING
SYNOSTOSIS                                         AND CORRECTIVE FOOTWEAR

4. TALONVICULAR      :   SYNDESMOSIS    OR    HOW TO AVOID PROBLEMS
SYNOSTOSIS
                                              SKIN:
 1, 3, & 4 CANNOT BE REMEDIED WITHOUT
RADICAL, MEDIAL, AND PLANTER EXPOSURE         -    LAZY S CURVED INCISION

OBSERVATIONS                                  -    AVOID UNDERMINING OF SKIN


                                                                                   38
- IMMOBILISE THE FOOT IN SLIGHTLY UNDER      * POOR                             5%
CORRECTED POSITION FOR FIRST TWO WEEKS
                                             CAUSES OF FAILURE OR RELAPSE
AFTER SURGERY
                                             1. ARTHROGRYPHOTIC FOOT
NEUROVASCULAR COMPROMISE:
                                             2.   INCOMPLETE PRIMARY CORRECTION OF
- AVOID DISSECTION & ISOLATION OF NERVES &
                                                   INVERSION AND EQUINIS
VESSELS – KEEP AS ONE BUNDLE
                                             3. DEFECTIVE POST – OPERATIVE MAINTENANCE
-   EXCISE ITS SHEATH IF NEEDED
                                             4.   ALTERED BONY CONFIGURATION AND
-   LEAVE THE LONG TENDONS INTACT
                                                   ASSOCIATED BONY ANAMALIES PRIOR TO
LOSS OF CORRECTION:                                SURGERY

- FULLY CORRECT THE DEFORMITY BY SURGERY     5.   GROSS INTORTION OF TIBIA GIVES
                                                   IMPRESSION OF FAILURE THOUGH FOOT IS
-   PROPER POST OPERATIVE MANAGEMENT VIZ.
                                                   WELL CORRECTED
1. B.K. POP CAST IN UNDERCORRECTION UNTIL
SKIN HEALS DURING FIRST TWO WEEKS            ADVANTAGES

2. FULLY CORRECTED POSITION CAST FOR         1. TIME PROVEN METHOD WITH OVER 30 YEARS
FURTHER 10 TO 12 WEEKS WITH PERIODIC              OF FOLLOW UP RESULTS AVAILABLE
CHANGES
                                             2. PREDICTABLE CONSTANT RESULTS
3. DYNAMIC SPLINTING POST-CAST PERIOD
                                             3.   USER FRIENDLY – HENCE BETTER PARENTS
UNTIL WEIGHT BEARING IS STARTED
                                                   COMPLIANCE
4. CORRECTIVE FOOTWEAR FOR WEIGHT
                                             4.   NO SPECIAL APPARATUS NEEDED
BEARING

COMPLICATIONS                                5. ONLY ONE TIME SURGERY – BETTER CONTROL
                                                 BY THE SURGEON
    1) SKIN PROBLEMS                2%
    (USUALLY THE POSTERIOR FLAP)             6.    NO CARTILAGE OR BONY DAMAGE, HENCE
                                                   SUPPLE FOOT SUPPORT WITH NO ADVERSE
    2) SERIOUS INFECTION            1%
                                                   EFFECT ON FUTURE GROWTH
    3) TENDONS EXPOSED – 3 CASES –
                                             7.   POTENTIAL TO CORRECT ALL DEFORMITIES
       INDIFFERENT RESULTS WITH SCARRING
                                                   INCLUDING INVERSION OF THE HEEL
    4) NO NEURO-VASCULAR COMPLICATIONS
                                             8.   INCIDENCE OF INFECTION – NEGLIGIBLE NO
RESULTS                                             BONE INFECTION

*   EXCELLENT & GOOD                81%

* FAIR                              14%
                                                                                ww]ww

                                                                                39
                                     MANAGEMENT OF C. T .E .V.

                                                                DR. NAVIN M. SHAH
                                                                CHILDREN’S ORTHOPEDIC HOSPITAL,
                                                                MUMBAI

   When I joined in1970, consisted of :                 3.   CONTRACTED SOFT TISSUES WHEN
A.     Conservative Treatment                                STRETCHED – ELONGATES.
       M.U.A. & Plaster Cast                            a)   UNPROPER TECHNIQUE OF CORRECTION
       Kite Serial Plaster Cast                              CAN LEAD TO PSEUDO CORRECTION LIKE
                                                             HORIZONTAL BREACH.
B.       When Conservative treatment was not
                                                        b)   ANKLE AND FOOT CONSISTS OF MULTIPLE
successful –
                                                             JOINTS.
         Radical Soft Tissue (Brokman, Turco), was
                                                             STRETCHING OF UNYIELDING SOFT
carried out usually after the age of 8 Months.
                                                             TISSUE MAY STRETCH NEAR BY JOINT
Review of the Results - in 1974:                             LIGAMENT AND PRODUCE SPURIOUS
     There was almost no correction of Deformative           CORRECTION e.g. ROCKER-BOTTOM
by conservative method. Almost all had Pseudo-               DEFORMITY WHEN CORRECTING
correction and recurrence of Deformity.                      EQUINUS.
With Surgical Management :                              4.   AGE AT SURGERY:
       50% Correction of Deformaty                           THERE IS A RAPID PROGRESS OF
       50% Under Correction                                  OSSIFICATION OF TARSAL BONES IN
                                                             INFANCY. SURGERY DELAYED CANS
   Attenbourough’s Posterior release is based on his
                                                             PREVANT CORRECTION OF BONY
observation that...
                                                             DEFORMITY.
       Infant’s foot when plantar - flexed goes into
                                                        5.   SURGICAL PROCEDURE WAS DONE AFTER
inversion.
                                                             THE AGE OF 8 MONTHES AND
      He advised Posterior relese, without correction
                                                             PROCEDURE WAS INCOMPLET TO
of Fore Foot.
                                                             CORRECT THE DEFORMITY. THERE WERE
     Deformity.
                                                             PROBLEMS WITH BREAK DOWN OF
       UNFORTUNATLY OUR RESULTS OF THIS
                                                             WOUND, RESULTING IN SEVERE
APPROACH WERE POOR.
                                                             UNYIELDING SCAR TISSUE.

ANALYSIS OF FAILURES:                                    C.T.E.V. DEFORMITY CONSISTS OF:
1. VARIED EXPRESSION OF SEVERITY                         TALUS – EQUINUS AND LATERALLY ROTATED
   DEFORMITY – MANAGEMENT HAS TO BE                      CALCANEUS ROTATED UNDER TALUS
   CUSTOMISED.                                            MID FOOT IS IN CAVUS
2. CAVUS DEFORMITY WAS NOT GIVEN                         FOREFOOT ADDUCTED AND SUPINAPED
   PROPER ATTENTION. THIS RESULTED IN                   CONCEPT OF ‘TETHERS’ PREVENTING
   FAILURE OF DEROTATION OF CALCANEUM                   CORRECTION OF DEFORMITY


                                                                                        40
   FOLLOWING SOFT TISSUES CONTRACTURE         FIBULAR - JOINT WITH LOWER INTEROSSEOUS
PREVENTS CORRECTION OF C.T.E.V...             MEMBRANE
1.    PLANTAR FASCIA.                           RELEASE OF POSTRIOR TALO-FIBULAR
2.    POSTERIOR CAPSULE OF ANKLE JOINT.       LIGAMENT
3.    POSTERIOR TALO-FIBULAR LIGAMENT.          FRACTIONAL LENGTHENING OF TENDONS OF
4.    INFERIOR TIBIO- FIBULAR LIGAMENTS       TIBIALIS POSTERIOR,      FLEXOR DIGITAL
      & LOWER INTEROSSEOUS MEMBRANE           LONGUS AND FLEXOR HALLUCIS LONGUS
                                                      FIXATATION WITH 3 K – WIRES
RAB (1994) IN A STUDY OF MECHANICAL MODEL
                                                      CHECK X-RAYS
OF C.T.E.V. CONFIRM ABOVE MENTION FINDINGS.
                                                      ABOVE KNEE PLASTER IS APPLIED
HE ALSO STRETSSED IMPORTANCE OF:
  CALCANEOFIBULAR LIGAMENT,                     3 WEEKS POST OPERATIVE-> CHANGE OF
  SPRING LIGAMENT                             PLASTER CAST UNDER G.A.
    TALONAVICULAR PART OF DELTOID
                                                 6 WEEKS POST OPERATIVE -> REMOVAL OF
LIGAMENT
                                              K-WIRES, SUTURES
BASED ON THE CONCEPT OF TETHERS,                CHECK X-RAYS
FOLLOWING PROTOCOL WAS ESTABLISHED.             PAIR OF BOOTS WITH STRAIGHT AND STIFF
                                                    ,
                                              INSTEP NO HEELS
POSTURAL CLUBFOOT -> EASILY CORRECTED
                                                 DEMONSTRATE PASSIVE MOBILISATION OF
BY 2/3 PLASER CAST
                                              FOOT TO MOTHER
TRUE CLUBFOOT -> SURGICAL TRETMENT
                                                REGULAR POST OPERATIVE FOLLOW UP –
FIRST 3 WEEKS OF AGE -. PASSIVE
                                              CLINICAL AND RADIOLOGICAL
MANIPULATION BY MOTHER
                                              WHEN DEROTATION OF TALUS DID NOT TAKE
     AS DEMONSTRATED.
                                              PLACE AFTER PLANTAR TENOTOMY,
     AT 3 WEEKS OF AGE -.>
  SUBCUTANEOUS PLANTAR TENOTOMY IS             IT WAS NECESSARY TO PERFORM TOTAL
PERFORMED.                                    SUBTALAR RELEASE. THIS WAS USUALLY
                                              NECESSARY WHEN DEFORMITY WAS SEVERE
CORRECTION OF CAVUS, FOREFOOT
                                              OR SURGERY WAS DELAYED.
ADDUCTION AND SUPINATION,
  DEROTATION OF TALUS.                        IN CONCLUSION:
   X-RAY DONE TO CHECK THE CORRECTION           C.T.E.V. is complex Deformity with multipal
  BELOW KNEE PLASTER CAST APPLIED.            Pathogenesis & varied expression of severity. Single
                                              method of management is not sufficient to correctall
AT 6 WEEKSOF AGE->
                                              cases.
     WHEN ABOVE MENTION CORRECTION
                                                I have presanted a simple plan of management -
ACHIVED, POSTERIOR SOFT TISSUE RELEASE
                                              when applied in early infancy this method corrects
WAS DONE .IT CONSISTED OF
                                              the Deformity in 90% of cases. Correction is
   Z-LENGTHENING OF TENDO ACHILES
                                              maintained as observed in long term Follow up.
  POSTERIOR CAPSULOTOMY OF ANKLE JOINT
 RELEASE OF LIGAMENTS OF INFERIOR TIBIO-
                                                                                        ww]ww

                                                                                       41
                                     “EARLY SURGICAL OPTION IN
                                  CLUB FOOT AND LONG TERM RESULT”

                                                                                             Dr. D.K. Taneja


AIM OF TREATMENT                                          TIBIALIS ANTERIOR LENGTHENING

    1. Various sublutation and dislocation in the club           As a routine (Limited Experience)
       foot must be fully reduced.                               It decreases the rate of recurrence (wicart 2002)
    2. This realignment should be made early in life.
                                                          FINAL GOAL OF TREATMENT
OPERATION IS THE ONLY OPTION IN-
                                                                   Corrected foot must be fully mobile, be
  1. Severe form of club foot.
                                                          developing normally and be capable of painless,
  2. After 8 weeks of treatment of manipulation if
                                                          unrestricted use (silk 1976)
     radiographs show, that osseous inter relation
     has not been achieved.                                      What we need is normally functioning foot.
  3. Recurrent and relapsed club foot.                    Cosmetic acceptability is a different thing.
  4. Persistent Mid tarsal displacement.                  IMPORTANT TIPS
         Perseverance with conservative treatment in       1. Complete reduction of displacement of the triple
above condition – lead to cartilage damage, this will         joint of Tarsus is indispensable or else the result
lead to altered growth of foot or even it may cease.          will be no better than that of any other
SURGICAL OPTIONS AVAIABLE ARE                                 incomplete or false correction.
    - Minor procedure – like tenotomy                      2. Very Extensive operation carries the danger of
    - or open TA lengthening with or without                  over correction.
        posterior capsulotomy.                             3. Integrity of Lateral Calcaneo – cuboid tie is
    - Steinlers – specially in persistent cavaes.             essential for the stability of mid tarsal joint,
    - Soft tissue operations-                                 therefore it needs to be preserved.
    A) Posterio – Medial                                   LONG TERM RESULTS
        i.Conventional – Brockmann Patna Procedure
                                                           1. Some degree of wasting of calf muscles will persist.
    B) More Extensive – silk
                                                           2. Some residual deformity persists.
    C) Global release Simons
                                                           3. Difficulty in running.
    D) Talo Meta tarsal release for persistent – FF
                                                           4. Difficulty in squatting
        Adduction
                                                           5. There is some lack of motion at Ankle.
Incision – conventional post-medical or Cincinnati
                                                           6. Limping – may not be perceptible. (Cumming
TENDON SURGERY                                                2001)
         Tibiais Anterior Transfer - only when there is    7. Occasional pain.
active fore foot adduction, occurring in swing phase       8. Some case will show flat top talus & hypoplasia
with weak peroneal muscles.                                   of Talar Head & neck.


                                                                                                      42
                                               PROPERTIES OF LIGAMENTS

                                                                             Dr. Wilfred D’Sa.
                                                                             Dr. Milind Chaudhary
                                                                             Centre For Ilizarov Technique, Akola

Introduction                                               the actual ligament and merges into the periosteum
                                                           of the bone around the attachment sites of the
                                                           ligament.
                                                                The cells are responsible for matrix synthesis and
                                                           they are relatively few in number and represent a small
                                                           percentage of the total ligament.The crimp is the
                                                           waviness of the fibril; we will see that this
                                                           contributes significantly to the nonlinear stress strain
                                                           relationship for ligaments and tendons and indeed for
                                                           basically all soft collagenous tissues.Ligament
       The Vikings,of course, knew the importance of
                stretching before an attack                un-crimping, allowing the ligament to elongate
Structure                                                  without sustaining damage12.
  Composed of closely packed collagen fiber bundles
organized mostly in a parallel configuration along              The solid components of ligaments are
the length of the tissue to resist tensile loads. Their    principally collagen (type I collagen accounting for
nonlinear tensile properties enable them to                85% of the collagen and the rest made up of types III,
maintain smooth movement of joints and help to             VI, V, XI and XIV) which accounts for approximately
restrain excessive joint displacements under high loads.   75% of the dry weight with the balance being made
                                                           up by proteoglycans (<1%), elastin and finally other
                                                           proteins and glycoproteins such as actin, laminin and
                                                           the integrins.


                                                                Fibroblasts (biological cells) that are arranged in
                                                           parallel rows


                                                           LIGAMENTS
  Ligaments often have a more vascular
overlying layer termed the "epiligament" covering their    Anatomy COMPARED TO TENDON.
surface6 and this layer is often indistinguishable from    1.      Similar to tendon in hierarchical structure



                                                                                                        43
2.     Collagen fibrils are slightly less in volume
       fraction and organization than tendon
3.     Higher percentage of proteoglycan matrix than
       tendon
4.     Fibroblasts.


Blood Supply
                                                            fiber organization and orientation, elastin. and other
                                                            ground substances such as proteoglycans but are
       1. Microvascularity from insertion sites
                                                            neither affected by the size and shape nor the
       2. Nutrition for cell population; necessary for
                                                            contribution of the ligament insertion site to bones.
       matrix synthesis and repair molecules. Crosslink
formation is the critical step that gives collagen fibres
                                                            1.Nonlinear Elasticity 
such incredible strength. During growth and
development, crosslinks are relatively immature and
soluble but with age they mature and become insoluble
and increase in strength..




                                                              The toe-in region represents "un-crimping" of the
                                                            crimp in the collagen fibrils. Since it is easier to stretch




Function

Basic Functions
1.     Ligaments carry tensile forces from muscle to
       bone
2.     They carry compressive forces when wrapped
       around bone like a pulley
3.     proprioception.

Properties

     Mechanical       proper ties   of   the   ligament
substance are affected by the constituent collagen


                                                                                                            44
out the crimp of the collagen fibrils, this part of the       2.Exercise
stress strain curve shows a relatively low stiffness.           The changes in ligaments and tendons
     Thus a key concept is that the overall behavior of       generally occur more slowly than adaptation in bone,
ligaments and tendons depends on the individual               because ligaments and tendons have less vascular
crimp structure and failure of the collagen fibrils.          supply
                                                              3.Immobilization:
2.Viscoelasticity
                                                                During immobilization, the cross sectional area of
     Two major types of behavior characteristic of
                                                              the ACL is reduced. This implies a loss of
viscoelasticity. The first is creep. Creep is increasing
                                                              collagen fibrils as well as a loss of glycosaminoglycans
deformation under constant load.                              that form the ground substance of the ligament. In
     The second significant behavior is stress relaxation.    addition, the may be alterations in collagen fibril
This means that the stress will be reduced or will relax      orientation that reduce properties.

under a constant deformation                                    Immobilization has a more rapid and
                                                              substantial affect on mechanical properties than does
3.Hysteresis                                                  increased load from exercise
     The    other     major     characteristic      of   a    4.Trauma
viscoelastic material is hysteresis or energy dissipation.      In the case of tendons, which glide within a sheath,
This means that if a viscoelastic material is loaded and      the introduction of passive motion for healing and
unloaded, the unloading curve will not follow the             repaired tendons is believed to be important
loading curve.                                                because it prevents adhesion between the sheath and
                                                              tendons that restricts motion. In one study, the flexor
   Ligaments also exhibit time- and history-
                                                              tendons of skeletally mature dogs were lacerated and
dependent viscoelastic properties owing to interactions
                                                              then repaired
among the collagen, proteoglycans, water, and other
constituents of the tissue. Therefore, a hysteresis loop        The MCL can heal spontaneously and
is usually formed between the loading and unloading           therefore is an ideal ligament with which to study the
                                                              healing process of such tissue. On the other hand, the
1)      mechanical properties can be expected to vary
                                                              ACL is more complex and does not heal.
        with moisture content
2)      Experimental variables including temperature,            Immobilization can significantly compromise both
        strain rate, and dehydration can also significantly   the structural properties of the bone-ligament-bone
        affect ligament properties                            complex and the mechanical properties of the
                                                              ligament, with weakening more pronounced at the
Effects of : exercise, immobilization, surgery and
                                                              insertion sites.
trauma
                                                                 The effects of exercise or increased tension are less
1.Age
                                                              pronounced than the effects of immobilization. Even
  In rat tail tendons, the diameter of collagen fibrils       with a substantial duration of exercise, enhancement
increase during age from skeletally immature to               is only moderate.
mature animals                                                                                              ww]ww

                                                                                                          45
                 MANAGEMENT OF IDIOPATHIC CLUB FOOT BY PONSETI TECHNIQUE
                                                            Dr.V. Thulasiraman, Dr.S. Shanmugam,
                                                            Dr .Dharmaraj. Dr. B .Suresh Gandhi, Dr R.H. Govardhan,
                                                            Institute of child health and hospitals for children
                                                            Egmore, Chennai 600008.
                                                            And Chengulpattu medical college and hospital chengalpattu,
                                                            Tamilnadu.

Introduction                                                anomalies (constriction ring in two cases, pulmonary
                                                            anomaly, ileal atresia, cleft lip, syndactyly,
   It is a complex deformity that is difficult to correct
                                                            undescended testis, microcephaly in one case each).
.This deformity has been treated in the past by several
                                                            Familial involvement was found in two patients. The
methods with variable success. The early treatment
                                                            age of the mother ranged from 18to 37 averaging 24
of this disorder were manipulative [6, 10].Several
                                                            years .history of consanguinity was present 47% of
surgical options were tried later, but the results have
                                                            the children, majority of three children (48%) were of
not proven to be superior and more complications
                                                            first order birth.
have been reported after the use of surgical treatment
[ 1,3,7 ].
                                                              On examination the deformity was found to be
  Ponseti has been the pioneer of the manipulation          flexible in 56%. And rigid in the remaining case. The
and casting technique for the management of this            severity of the deformity was classified according to
problem and has practiced and perfected his                 the classification method of Dimigleo et al [3].
technique for over 50 years [9, 10]. We present here
our experience in the treatment of this disorder by         Stage-1 Correction of cavus.
using the ponseti technique.
                                                              The cause of the cavus deformity is the relative
                                                            pronation of the forefoot in comparison to the hind
Material and methods
                                                            foot due to drop of, I and II metatarsals. The aim of
  77 patients (102 feet) with CTEV presented to our         stage I correction is to align the forefoot of the hind
department Out of these 77 pateints[78] feet were           foot by supinating the forefoot. This is done by
found suitable for ponseti method of management             elevating the, I and II metatarsal heads and applying
and were included in the study. Patients already            a groin to toe cast.
treated elsewhere with plasters, Patients older than 3
months with rigid feet, postural varus deformities and      Stage II – Correction of forefoot adduction.
arthrogypotic children were not included in the study.
                                                              After achieving the correction of cavus the entire
The ages of the patient ranged from 2 days to 2 weeks
                                                            foot distal to talus, which is fixed inside the ankle
averaging 11days. Late presentation beyond 3 weeks
                                                            mortise. A thumb placed on the head of the talus is
is 7 case 10 feet. 46%patients had bilateral deformity
                                                            used as a fulcrum while the outward pressure is
and of which the right side predominated in 54%.
                                                            exerted over the first metatarsal and cuniform. Above
14%of the patients had associated congenital


                                                                                                            46
knee cast was applied. This was repeated for 2 times       RESULTS
with the interval of one week.
                                                              Out of 77 patients 10 were last follow up, 3 during
Stage III – Correction of varus.                           the corrective period and 7 during the maintenance
                                                           period. The results were analyzed in the remaining
  Correction of the heel varus deformity is done by
                                                           78 patients . A good correction of the deformity was
abduction and external rotation of the forefoot, while
                                                           achieved in 57 patints(77%) ,an acceptable result in
maintaining the thumb pressure over the lateral aspect
                                                           15(19)% and a poor result in 5 patients (4%)all of
of the head of the talus as fulcrum. During this manure,
                                                           who under went posteromedial release.Tenotomy was
the navicular and cuboids is displaced lateral and the
                                                           done in 42 patients (68%of the feet).Three patients
calcanium will be displaced outwards and upward            needed posterior release only and re –tenotomy was
from its initial position, thus correcting the varus       needed in two patients, In three patients with bilateral
deformity of the heel. Above knee cast was applied         deformity, one side respond to manipulative correction
after correcting the Varus deformity. This was repeated    while the other side require surgical intervention.
for 2-3 times.
                                                           COMPLICTIONS
Stage 1V- Correction of Equinus
                                                             Major complications were encountered in two
  Dorsiflexion of the ankle is done to correct Equinus     patients, one child developed pressure necrosis of the
deformity while simultaneous maintaining the foot in       dorsum of both feet, which healed well following
abduction and external, rotation, closed tendoachilles     debridgement and dressing.Minor complications
tenotomy nay be needed to correct the residual             encountered were plaster ulceration in the thigh in
deformity. We have done tenotomy of tendoachilles          four cases, leg in one case and over the first metatarsal
in 30 patients under general anesthesia 10 patients        head in one patient .These cases were managed by
under local anesthesia .Following the tenotomy a groin     removal of the plaster and reapplication after a week.
to toe cast as applied for 2- 3 weeks.                     Edema of the foot occurred in four children and
                                                           sustained in two days with out plasters .One child
MAINTENECE
                                                           developed rocker bottom foot .Recurrence of the
  Corrective cast were applied until dorsiflexion and      deformity developed in four cases, which was
aversion of 10 deg were achieved .fur ther                 managed by reapplication of the plasters.
maintenance cast were continued with the foot in 10        Discussion.
deg dorsiflexion and abduction and aversion of 60deg
                                                             The Ponseti method of manipulation has been
for 3 months. After this period the correction was
                                                           proven to achieve a good correction of the deformity
maintained by using Equinus own splint and AK foot
                                                           in majority of the patients[ 6,9,10,11] .Ippolito et al
orthosis. During the period of manipulative correction
                                                           [6] have compared the results after treatment of
patients were seen a week, during the maintenance
                                                           congenital CTEV by two different Protocols .One
period twice a month and after achieving correction,
                                                           group of patients was treated by the technique of
once a month.
                                                           Marino –Zuco,in which the forefoot was initially

                                                                                                        47
pronated and abducted and later corrections of the          correction of the deformity in the shortest possible
heel varus and Equinus was done .The second group           duration[11].Age is however not an absolute criteria
of patients was, managed by the Ponseti and Smoley          and good results have been obtained in older children,
[10] technique. The results were excellent were good        late presentations and after failed previous casting,
in 43 % of the first group compared to the 78% by           by employing the ponseti technique, thus sparing
using the Ponseti technique. The first group of patients    these patients the trauma of unnecessary surgery[9].
needed surgery in the form of posteromedial release
                                                              The correction of Equinus deformity by ponseti
to correct residual deformities and had a higher rate
                                                            method requires a percutaneous tenotomy in majority
of complication like pain, flatfoot deformity and late
                                                            of patients .Ippoloto et al compared, the amount of
osteoarthritis [6 ].
                                                            dorsiflexion achieved after closed tenotomy and open
         We have achieved a good correction of the          tendoachilles lengthening with posterior capsulotomy
deformity in 77% of the patients which is comparable        and concluded that the range of ankle dorsiflexion
to the 78% reported by Ippolito et al [6], and the          was similar in both groups [6].
71% good results reported originally by Ponseti
                                                              Recurrence of the deformity is very common and
[10,11] . The analysis of the degree of correction of
                                                            several author have reported a recurrence rate of up
the deformity can be done by palpation ,by observing
                                                            to 50% [6,11].However majority of the recurrences
the talonavicular and calcaneocuboid relationship,
                                                            respond to conservative measure of soft tissue soft
the relation of the heel to the forefoot and the
                                                            procedures like tendoachilles lengthening, tibialis
movements of the ankle[11] .Although radiological
                                                            anterior transfer of posteromedial release. Bony
methods of analysis have been described ,they cannot
                                                            procedures are almost never indicated [11]. As with
be relied upon until 2-3 yrs, because of small and
                                                            any method there are several potential complication
eccentric ossification centers of the tarsal bone[2] .The
                                                            with the ponseti method of manipulation .The
yardstick for assessing successful treatment is therefore
                                                            complication encountered by us were all –avoidable
a clinically satisfactory alignment of the tarsal bones
                                                            and were seen in the early part of the series,
and ankle motion[11].
                                                            emphasizing the need for gentleness of manipulation
  The lack of correlation between radiological and          in these patients,
functional results has also been outlined by
Herbsthofer etal [5] .By strict adherence to the                     The ponseti methods of manipulation has
protocol advocated by Ponseti, good results can be          proved to be a time tested method of management
obtained in majority of the patients in our series .But     of idiopathic club foot ,with strict adherence to the
the treatment must be started as early as possible          protocol .good results have been achieved in majority
.Time is never more precious than in the management         of the patients. However a very vigilant follow up is
of CTEV .In the first few months after birth, the           necessary to detect recurrence and mange it
muscles, ligaments and tendons are more pliable ,and        appropriately .no new born with ctev should be denied
the cartilaginous bones are less prone to deformation       this method of manipulation.
,and therefore every attempt must be made to early
                                                                                                        ww]ww

                                                                                                       48

				
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