THE PONSETI METHOD IS HERE...
(From the Organising Secretarys 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. firstname.lastname@example.org
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. Ponseticurrently 91 years of agehas 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 devicesall 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
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. Ponsetis 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 1940s 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 babiesprobably 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 1990s 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
this opportunity to help your patients.
Dr. Milind Chaudhary with Dr. Ignacio V. Ponseti
at the University of Iowa, U.S.A. circa 2002.
I N D E X
THE PONSETI METHOD IS HERE...
(From the Organising Secretarys 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 DSa.
Dr. Milind Chaudhary 43
MANAGEMENT OF IDIOPATHIC CLUBFOOT
BY PONSETI TECHNIQUE Dr.V. Thulasiraman 46
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. email@example.com
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.
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.
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
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 1940s 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
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.
Jose A. Morcuende, with Dr. Ponseti
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
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
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
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
There were 6 cases of late-relapses (2.5%). Most
relapses occur at age 5. Patients stopped the use of
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.
The treatment is economical and easy on the
Most are untreated or
babies. If well implemented, it will greatly decrease
the number of clubfoot cripples.
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
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.
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
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 19361939 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
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
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
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
Clubfoot is not an embryonic malformation. A In the clubfoot, the
normally devel-oping foot turns into a clubfoot during ligaments of the
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
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
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.
Before applying the last plaster cast, the tendo
Achillis may have to be percutaneously sectioned to
achieve complete cor-rection of the equinus. The
tendo Achillis, unlike the tarsal ligaments that are
stretchable, is made of non-stretchable, thick, tight
collagen bundles with few cells. The last cast is left in
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
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?
stretched. Yes, classifying clubfoot into categories improves
understand-ing for communication and management
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
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
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
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.
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
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.
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.
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.
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
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
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
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
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
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
correction of the navicular. When the clubfoot is
index finger of the
same hand that is
t h a t
stabilizing the talar
head should be
placed behind that
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
Note the changes in the cast sequence [C].
beneath it and avoids any tendency for the posterior
Adductus and varus Note that the first cast shows Steps in cast application
the cor-rection of the cavus and adductus. The foot
remains in marked equinus. Casts 2 through 4 show
Before each cast is applied, the foot is manipulated
correction of adductus and varus.
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.
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.
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
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.
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
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 is typically gained after the tenotomy [E].
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
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
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
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
them into the Ponseti culture. It helps to see the Ponseti
method of management as a lifestyle that demands
must also monitor
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
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
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
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
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
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
that occur after traditional posteromedial release
Varus heel relapses are more common than equinus surgery.
relpases. They can be seen with the child standing
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
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
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
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
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
Expose anterior tibialis tendon
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
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
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
THE PONSETI METHOD IN BABIES
Dr Milind Chaudhary
Hon. Asst. Prof of Orthopaedic Surgery,GMC Akola
Director-Centre for Ilizarov Techniques
Vice-President, ASAMI India
Akola India 444 001. firstname.lastname@example.org
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
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
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!
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. email@example.com
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.
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
wiresone 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
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
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
manipulationposterior 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
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 framethat 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.
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 heelwhich is
the deformity and well retained function in the ankle described as an error in the Ponseti technique.
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 AKOLAtechnique 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
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.
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-
RADICAL POSTERO MEDIAL SOFT TISSUE RELEASE
PROF PRAVIN H. VORA
CHILDRENS ORTHOPAEDIC HOSPITAL
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
A) TIGHT TOUGH FIBROUS CONTRACTURES OF
*2 5 WEEKS : GENTLE MANIPULATION &
1. DEEP FASCEA
* 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
*** 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
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:
· POINTED UPTURNED TRIANGULAR HEEL
· WELL MARKED POSTERIOR AND MEDIAL
CREASE F.H.L & F.D.L. DYNAMIC SPLINTING AND SERIAL
· GROSS INVERSION OF THE HEEL PLASTERING
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
1. LAZY S SKIN INCISION
16. DIVISION OF CALCANEO-FIBULAR LIGAMENT
2. EXPOSURE OF TIBIALIS- POST &
AND SHEATH OF THE PERONEII
17. OPENING OF THE POSTERIOR TALO-
3. EXPOSURE OF INSERTION OF TIBIALIS
18. OPENING TALO-CALCANEAL JOINT
4. OPEN THE CAPSULE OF CUNEO METATARSAL
JT. MEDIALLY, SUPERIORLY AND INFERIORLY
19. EXPOSE AND DIVIDE INTEROSSEOUS TALO-
5. DIVIDE THE ATTACHMENT OF TIBIALIS
ANTERIOR TO MEDIAL CUNEIFORM, IF ANY
20. EXCISE THE SHEATHS OF TIB. POST., F.H.L.
6. DO CAPSULOTOMY OF ALL THE THREE SIDES
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 HENRYS KNOT
VARIOUS TARSAL BONES AND CUT THE SPRING
23. BRING THE FOOT IN FULLY CORRECTED
8. DISSECT NAVICULAR ON PLANTER
24. SUTURE T.A. AND TIB. POST. IN FULLY
ASPECT AND EXPOSE THE BIFURCATE LIGAMENT
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
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
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
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
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
1, 3, & 4 CANNOT BE REMEDIED WITHOUT
RADICAL, MEDIAL, AND PLANTER EXPOSURE - LAZY S CURVED INCISION
OBSERVATIONS - AVOID UNDERMINING OF SKIN
- IMMOBILISE THE FOOT IN SLIGHTLY UNDER * POOR 5%
CORRECTED POSITION FOR FIRST TWO WEEKS
CAUSES OF FAILURE OR RELAPSE
1. ARTHROGRYPHOTIC FOOT
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.
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
2. PREDICTABLE CONSTANT RESULTS
3. DYNAMIC SPLINTING POST-CAST PERIOD
3. USER FRIENDLY HENCE BETTER PARENTS
UNTIL WEIGHT BEARING IS STARTED
4. CORRECTIVE FOOTWEAR FOR WEIGHT
4. NO SPECIAL APPARATUS NEEDED
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%
MANAGEMENT OF C. T .E .V.
DR. NAVIN M. SHAH
CHILDRENS ORTHOPEDIC HOSPITAL,
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
B. When Conservative treatment was not
b) ANKLE AND FOOT CONSISTS OF MULTIPLE
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
Attenbouroughs Posterior release is based on his
PREVANT CORRECTION OF BONY
Infants foot when plantar - flexed goes into
5. SURGICAL PROCEDURE WAS DONE AFTER
THE AGE OF 8 MONTHES AND
He advised Posterior relese, without correction
PROCEDURE WAS INCOMPLET TO
of Fore Foot.
CORRECT THE DEFORMITY. THERE WERE
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
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
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
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
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->
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-
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
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.
PROPERTIES OF LIGAMENTS
Dr. Wilfred DSa.
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
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
Fibroblasts (biological cells) that are arranged in
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
2. Collagen fibrils are slightly less in volume
fraction and organization than tendon
3. Higher percentage of proteoglycan matrix than
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
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
1. Ligaments carry tensile forces from muscle to
2. They carry compressive forces when wrapped
around bone like a pulley
Mechanical proper ties of the ligament
substance are affected by the constituent collagen
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
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
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
The effects of exercise or increased tension are less
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
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,
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 .
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 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
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.
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
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
 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
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.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,
 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.
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 , and the was similar in both groups .
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 .Although radiological
anterior transfer of posteromedial release. Bony
methods of analysis have been described ,they cannot
procedures are almost never indicated . 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 .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.
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  .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