Professional Documents
Culture Documents
Dr Milind Chaudhary
Hon. Asst. Prof of Orthopaedic Surgery,GMC Akola Director-Centre for Ilizarov Techniques Vice-President, ASAMI India Akola India 444 001. akl_drmmc@sancharnet.in
Clubfoot is the commonest congenital anomaly seen by an Orthopaedic surgeon but has been plagued by ignorance about its Pathoanatomy, misconceptions about manipulative therapy and a plethora of operative techniques, each of which claims excellent results. It is said that the definition of an orthopaedic surgeon is one who modifies a technique the first time he practises it. This trait probably makes any Orthopaedic surgeon believe that his own method of treating clubfoot yields the best of results. While this may show up as good correction of deformity in the short term, the long term may it may manifest as a stiff and painful foot with recurred deformities. The number of operations designed for clubfoot is many, from the minimalist percutaneous TA lengthening, plantar fasciotomies & abductor hallucis resections to small procedures like Posterior Attenborough soft tissue release, going on to extensive Postero-Medial release popularised by Turco. At the other end of the spectrum complete subtalar releases described in the Cincinnati approach probably leave no soft tissues intact around the subtalar joint. Most surgeons believe manipulation to be easy, however they rarely complete the treatment with it and prefer to abandon it and go on to surgery. Recently there is also a big marketing push for external fixation devicesall claiming extreme simplicity and perfect results and are being put on feet of tiny babies leading to much misery. In this Bone & Joint decade we are exposed to a very rapid pace of change where every new
orthopaedic operation is discarded after a few years, and a new prosthesis is touted as the latest advance every few months. However, bones like young plants and saplings grow slowly and it takes many years to see the true results of the procedures we do on growing bones. In this confusing scenario, how does a young and discerning Orthopaedic surgeon decide which method of treatment to adopt for clubfoot? The answer is simple. Choose the technique that 1) 2) 3) 4) 5) has a firm scientific foundation has a clear understanding about the biology of soft tissue behaviour, follows the kinesiology of tarsal joints to achieve correction of foot deformities. uses the simplest and least invasive methods to treat the tiny babies and has proved to give excellent results more than 40 years later.
Only the Ponseti technique fulfils all of these criteria. Hence the old Orthopaedic adage: the oldest orthopaedic surgeon for the youngest babies! is very true when we realize that in the entire galaxy of Orthopaedic surgeons and teachers, only a Dr. Ponseticurrently 91 years of agehas studied, researched and most important, followed up his patients for as long as 40 years. It then becomes a matter of great privilege for us to have a sage amongst us whose experience should guide us in doing the right thing for this ancient and enigmatic deformity. The Ponseti technique is gathering momentum all over the world due to its advantages
of low cost, minimal surgery and good results in trained hands. Parents of young babies are refusing surgery and demanding Ponseti casting. Babies from all over the world are going to Dr Ponseti. At a ripe old age, he is at work, casting babies, talking to their parents and inspecting their braces. My visit to him at the Ponseti Center at Univ of Iowa Hospitals in 2002 was one of the most memorable & inspiring in my Orthopaedic career. His rare wisdom and scientific temper is a heritage that we must cherish and build on. While he had found the solution for Clubfoot in the late 1940s the mainstream Orthopaedic community ignored him and went about operating on most babiesprobably because it was more paying. He never gave in to temptation and persevered with his work. In the 1990s the world started discovering him due to the power of the internet and by now he is a cult figure and rightly acknowledged as the living god of clubfoot treatment.
It is a matter of great pride and luck that we are able to host the first Ponseti Clubfoot Course in India with the Original Technique coming right from the source. It is our privilege to have Dr. Ponsetis assistant, Dr Jose Morcuende, M.D. PhD., to come down to Akola and share the technique with us. On behalf of the Akola Orthopaedic Society I welcome you all to Akola. I am grateful to Maharashtra Orthopaedic Association & Indian Orthopaedic Association for having recognised & supported our academic endevour as an official CME. I am thankful to the Dean, G. M. C. Akola to allow us to host this program in this new Medical College. This program would never have happened except for the help, participation and encouragement from all of my colleagues from the Akola Orthopaedic Society & Department of Orthopaedics at GMC as well as the staff of Center for Ilizarov Technique, Akola. I am sure you will have an academic feast and use this opportunity to help your patients.
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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) UNDERSTANDING TARSAL MOVEMENTS CURRENT UPDATE IN THE MANAGEMENT OF CLUBFOOT IDENTIFICATION AND TREATMENT OF ATYPICAL CASES OF CONGENITAL IDIOPATHIC CLUBFOOT MANAGEMENT OF LATE-RELAPSES OF CLUBFOOT DETAILS OF THE PONSETI TECHNIQUE THE PONSETI METHOD IN BABIES (Akola Expeirence)
OR
Dr Milind Chaudhary Dr Milind Chaudhary Jose A. Morcuende Jose A. Morcuende Jose A. Morcuende Dr. I. V. Ponseti Dr Milind Chaudhary
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PONSETI PRINCIPLES FOR CORRECTION OF RELAPSED UNCORRECTED CLUBFOOT IN OLDER CHILDREN WITH EXTERNAL FIXATION
Dr Milind Chaudhary Dr. Pravin H. Vora Dr. Navin M. Shah Dr. D.K. Taneja Dr. Wilfred DSa. Dr. Milind Chaudhary Dr.V. Thulasiraman
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RADICAL POSTERO - MEDIAL SOFT TISSUE RELEASE MANAGEMENT OF C. T .E .V. EARLY SURGICAL OPTION IN CLUB FOOT AND LONG TERM RESULT PROPERTIES OF LIGAMENTS MANAGEMENT OF IDIOPATHIC CLUBFOOT BY PONSETI TECHNIQUE
UNDERSTANDING
TARSAL MOVEMENTS
Dr Milind Chaudhary
Hon. Asst. Prof of Orthopaedic Surgery,GMC Akola Director-Centre for Ilizarov Techniques Vice-President, ASAMI India Akola India 444 001. akl_drmmc@sancharnet.in
Equinus
Initial
Equinus
Final
Equinus or flexion is defined as movement of the tarsal bone with the distal part moving plantarwards around an axis which runs from side to side.
Calcaneus
Initial
Calcaneus
Final
Calcaneus or extension is defined as movement of the tarsal bone with the distal part moving cephalad around an axis which runs from side to side.
Eversion
Initial
Eversion
Final Position
Eversion is defined as movement of the tarsal bone with the plantar surface moves away from the midline of the body around an axis which runs from back to front.
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
Initial
Adduction
Final
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 Heel varus = Inversion + Adduction Hind foot Pronation = Calcaneus + Eversion + Abduction Heel valgus = Eversion + Abduction
more recent experience, we have re-evaluated the efficacy of the Ponseti method for the correction of congenital idiopathic clubfoot. From October 1992 through December 2003 a total of 230 patients (319 clubfeet) were treated. All patients underwent serial manipulation and casting as described by Ponseti. Main outcome measures included initial correction of the deformity, extensive corrective surgery rate, and relapses. At initial Ponseti casting, 147 patients (67%) were less than 4 months of age, 36 (16%) were between 4 and 6 months, and 36 (16%) were older than 6 months of age. One hundred and sixty-five patients (72%) had some form of treatment before their initial visit to our institution. Eight patients had physical therapy (6%) and 160 (83%) had serial manipulation and casting. The number of casts ranged from 1 to 21, with a median of 10. Thirty-four patients (20%) had a percutaneous tendoachilles tenotomy prior treatment here. Clubfoot
correction was obtained in all but 3 patients (99%). Ninety percent of patients required 5 casts for correction. Average time for full correction of the deformity was 20 days (range, 14 to 24 days). Only 3 patients (1.4%) required extensive corrective surgery. There were 36 relapses (15%). Relapses were unrelated to age at presentation, previous unsuccessful treatment, or severity of the deformity (as measured by the number of Ponseti casts needed for correction). Relapses were related to noncompliance with the foot abduction brace (p=0.0001). Fifteen patients (6.5%) underwent an anterior tibial tendon transfer to prevent further relapses. In conclusion, the Ponseti method is a safe and effective treatment for congenital idiopathic clubfoot and radically decreases the need for extensive corrective surgery. This technique can be used in children up to 2 years of age even after previous unsuccessful non-surgical treatment.
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The Ponseti Center for Clubfoot Treatment Department of Orthopaedic Surgery and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
Background: Congenital idiopathic clubfoot is a complex foot deformity occurring in an otherwise normal child. In the majority of cases, manipulation and serial casting as described by Ponseti result in full correction of the deformity. However, there are some occasional cases that do not respond to this treatment protocol. The purpose of this study was to describe the characteristics of these atypical clubfeet and to discuss their treatment. Methods: We retrospectively reviewed the cases of patients with congenital idiopathic clubfoot treated at our institution from October 1992 to February 2004. There were a total of 242 patients (334 clubfeet). Patients were treated by serial manipulation and casting as described by Ponseti. Patients that did not respond to the standard treatment protocol were considered as atypical. Main outcome measures were the need for extensive corrective surgery and relapses. Results: There were 15 atypical cases (2 %) that required modifications on the treatment protocol. In these cases the foot tends to be short and chubby. The skin is soft and fluffy. The heel is in very severe, rigid equinus and in varus, and a thick fat pad covers the undersurface of the calcaneus. The forefoot is severely adducted. The metatarsals tend to
be markedly plantar flexed to the same degree causing a stiff high arch. There is a deep, transverse skin fold across the sole of the midfoot and another deep fold above the prominent heel. The talus is prominent in front of the ankle. The anterior tuberosity of the calcaneus bulges in front of the lateral malleolus and could be mistaken for the head of the talus. The tendo Achilles is very tight and wide, and appears fibrotic up to the middle third of the calf. The gastrosoleus muscles are small and bunched up in the upper third of the calf. Repeated modified manipulation and serial casting corrected all clubfeet. All required percutaneous Achilles tenotomy. No patient required extensive corrective surgery. There have been not relapses with the use of the new modified foot abduction brace. Conclusions and Clinical Relevance: The Ponseti method is a safe and effective treatment for congenital idiopathic clubfoot, including atypical cases. Identification of these cases and modification of the treatment protocol allows successful correction of the deformity without the need for extensive corrective surgery. Level of Evidence: Therapeutic Study, Level III-2 (Retrospective Cohort Study).
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Background: Congenital idiopathic clubfoot is a complex foot deformity with a high tendency for relapses. Previous studies from our institution have demonstrated that most relapses happen in the first 3 years of life. However, we have observed a few cases of relapses in older children after the brace has been discontinued. The purpose of this study was to describe the characteristics of these cases and to discuss their treatment.
the foot abduction brace 1 year prior to the relapse. The deformity recurr very slowly, with increased impairment to walk. Patients required new manipulation and casting, and underwent anterior tibialis transfer to the 3rd cuneiform. All patients had the deformity corrected without the need of extensive or bony procedures.
Conclusions and Clinical Relevance: The tendencies for clubfoot relapses still persist in a few patients after the age of 4 years. Prompt
Methods: We retrospectively reviewed the cases of patients with congenital idiopathic clubfoot treated at our institution from October 1992 to February 2004. There were a total of 242 patients (334 clubfeet). Patients were treated following the method described by the senior author.
identification and treatment by casting and anterior tibial transfer allows successful correction of the deformity without the need for extensive corrective surgery.
Results: There were 6 cases of late-relapses (2.5%). Most relapses occur at age 5. Patients stopped the use of
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Emeritus Prof. of Orthopaedic Surgery Univ. of Iowa, U.S.A. It is estimated that more than 100,000 babies are born world-wide each year with congenital clubfoot. Eighty percent of the cases occur in developing nations. Most are untreated or poorly treated. Neglected clubfoot causes crushing physical, social, psychological, and financial burdens on the patients, their families, and the society. Glob-ally, neglected clubfoot is the most serious cause of physical disability among congenital musculoskeletal defects. In developed countries, many children with clubfoot undergo extensive corrective surgery, often with disturbing failures and complications. The need for one or more revision surgeries is common. Although the foot looks better after surgery, it is stiff, weak, and often painful. After adolescence, pain increases and often becomes crippling. Clubfoot in an otherwise normal child can be corrected in 2 months or less with our method of manipulations and plaster cast applications, with minimal or no surgery. This was proven by the results of our 35-year follow-up study and confirmed in many clinics around the world. This method is particularly suited for developing countries where there are few orthopaedic surgeons. The technique is easy to learn by allied health professionals, such as therapists and orthopaedic assistants. A well-organized health system is needed to ensure that parents follow the instructions for use of the foot abduction brace to prevent relapses. The treatment is economical and easy on the babies. If well implemented, it will greatly decrease the number of clubfoot cripples.
Anatomical studies
A study of histological sections of ligaments from virgin clubfeet, obtained in the operating room and from fetuses and stillborns, revealed that the abundant young collagen in the ligaments was wavy, was very
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cellular, and could be easily stretched. I conceived, therefore, that the displaced navicular, cuboid, and calcaneus could be gradually abducted under the talus without cutting any of the tarsal ligaments. I discovered that this was so based on cineradiography of clubfeet 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 stillborns, I fully understood the mechanism of the interdependent movements of the tarsal bones and realized that clubfoot deformity was simple to correct. The Huson thesis, An Anatomical and Functional Study of the Tarsal Joints, published in 1961 in Leiden, Holland, corroborated my understanding of the functional anatomy of the foot.
Maintaining correction
The genes responsible for clubfoot deformity are active start-ing from the 12th to the 20th weeks of fetal life and lasting until 3 to 5 years of age. The deformity occurs during the very fast period of growth of the foot. (Such transient gene activity occurs in many other biological events; it is observed in devel-opmental dysplasia of the hip, idiopathic scoliosis, Dupuytrens contracture, and osteoarthritis). With our technique of clubfoot correction, the joint surfaces of the bones reshape congruently in their normal position. It is important to apply the last plaster cast with the foot in an overcorrected position: 75 degrees of abduction and 20 degrees of ankle dorsiflexion.dorsiflexion. While kicking in the foot abduction brace full time for 3 months, the baby strengthens the peroneal muscles and foot extensor muscles that counteract the pull of the tibialis and gastrosoleus muscles. Relapses are rare with the continued use of the foot abduction brace for 14 to 16 hours a day (when the baby sleeps) until 3 to 4 years of age. In a few cases, anterior tibialis tendon transfer to the third cuneiform is necessary to permanently balance the foot.
Casting technique
My casting technique was learned from Bhler and applied during the Spanish Civil War in 19361939 when treating more than 2,000 war- wound fractures with unpadded plaster casts. Precise, gentle molding of the plaster over the reduced sublux-ations of the tarsal bones of a clubfoot is just as basic as the molding of a plaster cast on a well-reduced fracture.
Cavus correction
The cavus, or high arch, is a characteristic deformity of the forefoot that is associated with inversion, or supination, of the hindfoot. It results from a greater flexion of the first metatarsal bone, causing pronation of the forefoot in relation to the hindfoot. Hicks described it in the 1950s as a pronation twist. The surgeons misconception that pronation is necessary to correct clubfoot causes a further increase of the cavus: an iatrogenic deformity. When the functional anatomy of the foot is well understood, it becomes clear that one must correct the cavus first by supinating the forefoot to place it in proper alignment with the hindfoot.
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occurs in one plane. The approach was immediately accepted, and the illustrations were copied in most textbooks. 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 publication of my book a year later, and the posting of Internet support group web sites by parents of babies whose clubfoot I had treated. I have been reprimanded for not pushing the method more forcefully from the beginning. 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 that the tarsal joints move on a fixed axis of motion. Orthopaedists try to correct the severe supination that is associated with clubfoot by forcefully pro-nating the forefoot. This causes an increase of the cavus and a breach in the midfoot. The breach in the midfoot is caused by jamming the anterior tuberosity of the adducted calcaneus against the undersurface of the head of the talus. Clubfoot is easily corrected when the functional anatomy of the foot is well understood. The completely supinated foot is abducted under the talus that is secured against rotation in the ankle mortise by applying counterpressure with the thumb against the lateral aspect of the head of the talus. The varus, inversion, and adduction of the hindfoot are corrected simultaneously, because the tarsal joints are in strict mechanical interdependence and can-not be corrected sequentially. Scientific Basis of Management Our treatment of clubfoot is based on the biology of the defor-mity and of the functional anatomy the foot. Biology Clubfoot is not an embryonic malformation. A normally devel-oping foot turns into a clubfoot during
the second trimester of pregnancy. Clubfoot is rarely detected with ultrasonography before the 16th week of gestation. Therefore, like developmen-tal hip dysplasia and idiopathic scoliosis, clubfoot is a develop-mental deformation. A 17-week-old male fetus with bilateral clubfoot, more severe on the left, is shown [A]. A section in the frontal plane through the malleoli of the right clubfoot [B] shows the deltoid, tibionavicular ligament, and the tibialis posterior tendon to be very thick and to merge with the short plantar calcaneonavicular ligament. The interosseous talocalcaneal ligament is normal. A photomicrograph of the tibionavicular ligament [C] shows the collagen fibers to be wavy and densely packed. The cells are very abundant, and many have spherical nuclei (original magnification, x475). The shape of the tarsal joints is altered relative to the altered positions of the tarsal bones. The forefoot is in some pronation, causing the plantar arch to be more concave (cavus). Increas-ing flexion of the metatarsal bones is present in a lateromedial direction. In the clubfoot, there appears to be excessive pull of the tibialis posterior abetted by the gastrosoleus, the tibialis anterior, and the long toe flexors. These muscles are smaller in size and shorter than in the normal foot. In the distal end of the gastrosoleus, there is an increase of connective tissue rich in collagen, which tends to spread into the tendo Achillis and the deep fasciae. In the clubfoot, the ligaments of the
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posterior and medial aspect of the ankle and tarsal joints are very thick and taut, thereby severely restraining the foot in equinus and the navicu-lar and calcaneus in adduction and inversion. The size of the leg muscles correlates inversely with the severity of the deformity. In the most severe clubfeet, the gastrosoleus is seen as a muscle of small size in the upper third of the calf. Excessive collagen synthesis in the ligaments, tendons, and muscles may persist until the child is 3 or 4 years of age and might be a cause of relapses. Under the microscope, we see an increase of collagen fibers and cells in the ligaments of neonates. The bundles of collagen fibers display a wavy appearance known as crimp. This crimp allows the ligaments to be stretched. Gentle stretching of the ligaments in the infant causes no harm. The crimp reappears a few days later, allowing for further stretching. That is why manual correction of the deformity is feasible. Kinematics The correction of the severe displacements of the tarsal bones in clubfoot requires a clear understanding of the functional anatomy of the tarsus. Unfortunately, most orthopaedists treat-ing clubfoot act on the wrong assumption that the subtalar and Chopart joints have a fixed axis of rotation that runs obliquely from anteromedial superior to posterolateral inferior, passing through the sinus tarsi. They believe that by
pronating the foot on this axis, the heel varus and foot supination can be corrected. This is not so. Pronating the clubfoot on this imaginary fixed axis tilts the forefoot into further pronation, thereby increasing the cavus and pressing the adducted calcaneus against the talus. The result is a breach in the hindfoot, leaving the heel varus uncorrected. In the clubfoot [D], the anterior portion of the calcaneus lies beneath the head of the talus. This position causes varus and equinus deformity of the heel. Attempts to push the calcaneus into eversion without abducting it [E] will press the calcaneus against the talus and will not correct the heel varus. Lateral dis-placement (abduction) of the calcaneus to its normal relation-ship with the talus [F] will correct the heel varus deformity of the clubfoot. The clubfoot deformity occurs mostly in the tarsus. The tar-sal bones, which are mostly made of cartilage, are in the most extreme positions of flexion, adduction, and inversion at birth. The talus is in severe plantar flexion, its neck is medially and plantarly deflected, and its head is wedge shaped. The navicular is severely medially displaced, close to the medial malleolus, and articulates with the medial surface of the head of the talus. The calcaneus is adducted and inverted under the talus. As shown in [A], in a 3-day-old infant, the navicular is medi-ally displaced and articulates only with the medial aspect of the head of the talus. The cuneiforms are seen to the right of the navicular, and the cuboid is underneath it. The calcaneocuboid joint is directed posteromedially. The anterior two-thirds of the calcaneus is seen underneath the talus. The tendons of the tibi-alis anterior, extensor hallucis longus, and extensor digitorum longus are medially displaced.
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No single axis of motion (like a mitered hinge) exists on which to rotate the tarsus, whether in a
improve the degree of correc-tion of the deformity. 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]. Before treatment, the navicular (red outline) is displaced to the medial side of the head of the talus (blue). Note how this relationship normalizes during cast treatment. Similarly, the cuboid (green) becomes aligned with the calcaneus (yellow) during the same 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 regenerates in the proper length with minimal scarring. At that point, the tarsal joints have remodeled in the corrected positions. In summary, most cases of clubfoot are corrected after five to six cast changes and, in many cases, a tendo Achillis tenotomy. This technique results in feet that are strong, flexible, and plantigrade. Maintenance of function without pain has been demonstrated in a 35-year follow-up study. Overview of Ponseti Management Can clubfoot be classified? Yes, classifying clubfoot into categories improves understand-ing for communication and management [A]. Untreated clubfoot: under 2 years of age Neglected clubfoot: untreated after 2 years Corrected clubfoot: corrected by Ponseti management Recurrent clubfoot: supination and equinus develop after initial good correction Resistant clubfoot: Stiff clubfoot seen in association with syn-dromes such as arthrogryposis
normal or a clubfoot. The tarsal joints are functionally interdependent. The move-ment of each tarsal bone involves simultaneous shifts in the adjacent bones. Joint motions are determined by the curvature of the joint surfaces and by the orientation and structure of the binding ligaments. Each joint has its own specific motion pattern. Therefore, correction of the extreme medial displacement and inversion of the tarsal bones in the clubfoot necessitates a simultaneous gradual lateral shift of the navicular, cuboid, and calcaneus before they can be everted into a neutral position. These displacements are feasible because the taut tarsal ligaments can be gradually stretched. Correction of clubfoot is accomplished by abducting the foot in supination while counterpressure is applied over the lateral aspect of the head of the talus to prevent rotation of the talus in the ankle. A wellmolded plaster cast maintains the foot in an improved position. The ligaments should never be stretched beyond their natural amount of give. After 5 days, the ligaments can be stretched again to further
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Complex clubfoot: initially treated by a method other than Ponseti management How does Ponseti management correct the deformity?
As viewed from behind [B opposite page], note that correc-tion of the heel varus occurs during this manipulation. When should treatment with Ponseti management be undertaken? When possible, start soon after birth (7 to 10 days). When started before 9 months of age, most clubfoot deformities can be corrected by using this management. When treatment is started early, how many cast changes are usually required? Most clubfoot deformities can be corrected in approximately 6 weeks by weekly manipulations followed by plaster cast ap-plications. If the deformity is not corrected after six or seven plaster cast changes, the treatment is most likely faulty. How late can treatment be started and still be helpful? Treatment is most effective if started before 9 months of age. Treatment between 9 and 28 months is still helpful in correcting all or much of the deformity. Is Ponseti management useful for neglected clubfoot? Management that is delayed until early childhood may be start-ed with Ponseti casts. In most cases, operative correction will be required but the magnitude of the procedure may be less than would have been necessary without Ponseti management. What is the expected outcome in adult life for the infant with clubfoot treated by Ponseti management? In all patients with unilateral clubfoot, the affected foot is slightly shorter (mean, 1.3 cm) and narrower (mean, 0.4 cm) than the normal foot. The limb lengths, on the other hand, are the same, but the circumference of the leg on the affected side is smaller (mean, 2.3 cm). The foot should be strong, flexible, and pain free.
Keep in mind the basic clubfoot deformity with the deformed talus and the medially displaced navicular [B]. Ponsetis model shows the mechanism of correction. In the sequence [A opposite page], observe that all
elements are cor-rected when the foot is rotated around the head of the talus. This occurs during cast correction.
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What is the incidence of clubfoot in children with one or two parents who also are affected? When one parent is affected with clubfoot, there is a 3% to 4% chance that the offspring will also be affected. However, when both parents are affected, the offspring have a 15% chance of developing clubfoot. How do the outcomes of surgery and Ponseti management compare? Surgery improves the initial appearance of the foot but does not prevent recurrence. Importantly, no long-term follow-up studies of operated patients have been published to date. Adult foot and ankle surgeons report that these surgically treated feet become weak, stiff, and often painful in adult life. How often does Ponseti management fail and
Is Ponseti management useful for resistant clubfoot? Ponseti management is appropriate for use in children with arthrogryposis, myelomeningocele, and Larsen syndrome. The results may not be as gratifying as they are in the child with idiopathic clubfoot treated from birth, but there are advantages to this approach. The first is that the clubfoot could respond completely to Ponseti management, with or without the need for an Achilles tenotomy. Additionally, even partial preoperative correction of these severe deformities can decrease the extent of surgery and improve the ability to approximate the edges of the contracted skin. Arthrogrypotic clubfoot is perhaps the most challenging. Often, initial percutaneous heel cord tenotomy is required to enable any manipulative 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? The success rate depends on the degree of stiffness of the foot, the experience of the surgeon, and the reliability of the family. In most situations, the success rate can be expected to exceed 90%. Failure is most likely if the foot is stiff with a deep crease on the sole of the foot. Is Ponseti management useful for complex clubfoot? Personal experience, and that of others, has shown that Ponseti management can often be successful when applied to feet that have been manipulated and casted by other practitioners who are not yet skilled in this very exacting management.
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What are the features of recurrent clubfoot? The foot usually develops supination and equinus. What are the usual steps of clubfoot management? Most clubfeet can be corrected by brief manipulation and then casting in maximum correction. After approximately five cast-ing periods [C], the adductus and varus are corrected. A percu-taneous heel cord tenotomy [D] is performed in nearly all feet to complete the correction of the equinus, and the foot is placed in the last cast for 3 weeks. This correction is maintained by night splinting using a foot abduction brace [E], which is con-tinued until approximately 2 to 4 years of age. Feet treated by this management have been shown to be strong, flexible, and pain free [F], allowing a normal life. Details of the Ponseti Technique First four or five casts (more if necessary)
Reduce the cavus The first element of management is correction of the cavus deformity by positioning the forefoot in proper alignment with the hindfoot. The cavus, which is the high medial arch [C, yellow arc] is due to the pronation of the forefoot in relation to the hindfoot. The cavus is always supple in newborns and requires only supinating the forefoot to achieve a normal longitudinal arch of the foot [D and E]. In other words, the forefoot is supinated to the extent that visual inspection of the plantar sur face of the foot reveals a normal appearing archneither 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 the manipulation and casting processes [A]. Casting should be performed by the surgeon when possible [B]. Each step in management is shown for both the right and left feet.
correct the adductus and varus. Manipulation The manipulation consists of abduction of the foot beneath the stabilized talar head. Locate the head of
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the talus. All components of clubfoot deformity, except for the ankle equinus, are corrected simultaneously. To gain this correction, you must locate the head of the talus, which is the fulcrum for correction. Exactly locate the head of the talus This step is essential [F]. First, palpate the malleoli with the thumb and index finger of hand A while the toes and metatarsals are held with hand B. Next, slide your thumb and index finger of hand A forward to palpate the head of the talus (red) in front of the ankle mortis. Because the navicular (yellow) is medially displaced and its tuberosity is almost in contact with the medial malleolus, you can feel the prominent lateral part of the talar head (red) barely covered by the skin in front of the lateral malleolus. The anterior part of the calcaneus (blue) will be felt beneath the talar head. While moving the forefoot laterally in supination with hand B, you will be able to feel the navicular move ever so slightly in front of the head of the talus as the calcaneus moves laterally under the talar head. Stabilize the talus Place the thumb over the head of the talus, as shown by the yellow arrows in the skeletal model [A]. Stabilizing the talus provides a pivot point around which the foot is abducted. The index finger of the same hand that is stabilizing the talar head should be placed behind that lateral malleolus. This fur ther stabilizes the ankle joint while the foot is abducted beneath it and avoids any tendency for the posterior
calcaneal-fibular ligament to pull the fibula posteriorly during manipulation. Manipulate the foot Next, by abducting the foot in supina-tion [A], with the foot stabilized by the thumb over the head of the talus, as shown by the yellow arrow, abduct the foot as far as can be done without causing discomfort to the infant. Hold the correction with gentle pressure for about 60 seconds, then release. The lateral motion of the navicular and of the anterior part of the calcaneus increases as the clubfoot deformity cor-rects [B]. Full correction should be possible after the fourth or fifth cast. For very stiff feet, more casts may be required. The foot is never pronated. Second, third, and fourth casts During this phase of treatment, the adductus and varus are fully corrected. The distance between the medial malleolus and the tuberosity of the navicular when palpated with the fingers tells the degree of correction of the navicular. When the clubfoot is corrected, t h a t distance measures approximately 1.5 to 2 cm and the navicular covers the anterior surface of the head of the talus. Each cast shows improvement Note the changes in the cast sequence [C].
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Adductus and varus Note that the first cast shows the cor-rection of the cavus and adductus. The foot remains in marked equinus. Casts 2 through 4 show correction of adductus and varus. Equinus The equinus deformity gradually improves with correction of adductus and varus. This is part of the correction because the calcaneus dorsiflexes as it abducts under the talus. No direct attempt at equinus correction is made until the heel varus is corrected. Foot appearance after the fourth cast Full correction of the cavus, adductus, and varus are noted [D]. Equinus is im-proved, but this correction is not adequate, necessitating a heel cord tenotomy. In very flexible feet, equinus may be corrected by additional casting without tenotomy. When in doubt, per-form the tenotomy. Cast Application, Molding, and Removal Success in Ponseti management requires good casting tech-nique. Those with previous clubfoot casting experience may find it more difficult than those learning clubfoot casting for the first time.
Steps in cast application Preliminary manipulation Before each cast is applied, the foot is manipulated [A]. Applying the padding Apply only a thin layer of cast pad-ding [B] to make possible effective molding of the foot. Main-tain the foot in the maximum corrected position by holding the toes while the cast is being applied. Applying the cast First apply the cast below the knee and then extend the cast to the upper thigh. Begin with three to four turns around the toes [C], and then work proximally up the leg. Apply the plaster smoothly. Add a little tension [D] to the turns of plaster above the heel. The foot should be held by the toes and plaster wrapped over the holders fingers to provide ample space for the toes. Molding the cast Do not try to force correction with the plaster. Use 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 should be a dynamic process; constantly move the fin-gers to avoid excessive pressure over any single site. Continue molding while the plaster hardens.
We recommend that plaster material be used because the material is less expensive and plaster can be more precisely molded than fiberglass.
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Extend cast to thigh Use much padding at the proximal thigh to avoid skin irritation [F]. The plaster may be layered back and forth over the anterior knee for strength [G] and for avoiding a large amount of plaster in the popliteal fossa area, which makes cast removal more difficult. Trim the cast Leave the plantar plaster to support the toes [H], and trim the cast dorsally to the metatarsal phalangeal joints, as marked on the cast. Use a plaster knife to remove the dorsal plaster by cutting the center of the plaster first and then the medial and lateral plaster. Leave the dorsum free. Note the appearance of the first cast when completed [I]. The foot is in equinus, and the forefoot is fully supinated. Cast removal Remove each cast in clinic just before a new cast is applied. Avoid cast removal before clinic because considerable correction can be lost from the time the cast is removed until the new one is placed. Although a cast saw can be used, use of a plaster cast knife is recommended because it is less frightening to the infant and family and also less likely to cause any accidental injury to the skin. Soak the cast in water for about 20 minutes, and then wrap the cast in wet cloths before removal. Use the plaster knife [A], and cut obliquely [B] to avoid cutting the skin. Remove the above-knee portion of the cast first [C]. Finally, remove the below-knee portion of the cast [D].
Decision to perform tenotomy A major decision point in management is determining when sufficient correction has been obtained to perform a percutane-ous tenotomy to gain dorsiflexion and to complete the treat-ment. This point is reached when the anterior calcaneus can be abducted from underneath the talus. This abduction allows the foot to be safely dorsiflexed without crushing the talus between the calcaneus and tibia [E]. If the adequacy of abduction is un-certain, apply another cast or two to be certain. Characteristics of adequate abduction Confirm that the foot is sufficiently abducted to safely bring the foot into 15 to 20 degrees of dorsiflexion before performing tenotomy. The best sign of sufficient abduction is the ability to palpate the anterior process of the calcaneus as it abducts out from be-neath the talus. Abduction of approximately 60 degrees in relationship to the frontal plane of the tibia is possible. Neutral or slight valgus of os calcis is present. This is deter-mined by palpating the posterior os calcis. Remember that this is a three-dimensional deformity and that these deformities are corrected together. The correction is accomplished by abducting the foot under the head of the talus. The final outcome At the completion of casting, the foot appears to be overcorrected into abduction with respect to normal foot appearance during walking. This is not in fact an overcorrection. It is actually a full correction of the foot into maximum normal abduction. This correction to complete, normal, and full abduction helps prevent recurrence and does not create an over-corrected or pronated foot.
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Equinus Correction and Fifth Cast Indications Make certain the indications for equinus correction have been met. Percutaneous heel cord tenotomy Plan to perform the tenotomy in clinic. Preparing the family Prepare the family by explaining the procedure. Sometimes a mild sedative may be given to the infant [A]. Equipment Select a tenotomy blade such as a #11 or #15 or any other small blade such as an ophthalmic knife. Skin preparation Prep the foot medially, posteriorly, and laterally [B]. Anesthesia A small amount of local anesthetic may be infiltrated near the tendon [C]. Be aware that too much local
Post-tenotomy cast Apply the fifth cast [F] with the foot abducted 60 to 70 degrees with respect to the frontal plane of the tibia. Note the extreme abduction of the foot with respect to the leg and the overcor-rected position of foot. The foot is never pronated. This cast is left in place for 3 weeks after complete correction. Cast removal After 3 weeks, the cast is removed. Note the correction [G]. Thirty degrees of dorsiflexion is now possible, the foot is well corrected, and the operative scar is minimal. The foot is ready for bracing. Bracing Bracing protocol The brace is applied immediately after the last cast is removed, 3 weeks after tenotomy. The brace consists of open toe high-top straight last shoes 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 makes the procedure more dangerous. Heel cord tenotomy Perform the tenotomy [D] approximately 1 cm above the calca-neus. Avoid cutting into the cartilage of the calcaneus. A pop is felt as the tendon is released. An additional 10 to 15 degrees of dorsiflexion is typically gained after the tenotomy [E].
external rotation on each side. The bar should be of sufficient length so that the heels of the shoes are at shoulder width. A common error is to prescribe too short a bar, which the child finds uncomfortable [C]. A narrow brace is a common reason for a lack of compli-ance. The bar should be bent 5 to 10 degrees with the convexity away from the child, to hold the feet in dorsiflexion [D].
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The brace should be worn full time (day and night) for the first 3 months after the tenotomy cast is removed. After that, the child should wear the brace for 12 hours at night and 2 to 4 hours in the middle of the day for a total of 14 to16 hours during each 24-hour period. This protocol continues until the child is 3 to 4 years of age. Types of braces Several types of commercially made braces are available. With some designs, the bar is permanently attached to the bottoms of the shoes. With other designs, it is removable. With some designs, the bar length is adjustable, and with others, it is fixed. Most braces cost approximately US $100. In Uganda, Steen-beek designed a brace, which is made at a cost of approximately US $12 (see p. 24). Parents should
calls for a brace to maintain the abduction. This is a bar attached to straight last open toe shoes. This degree of foot abduction is required to maintain the abduction of the calcaneus and forefoot and prevent recurrence. The foot will gradually turn back inward, to a point typically of 10 degrees of external rotation. The medial soft tissues stay stretched out only if the brace is used after the casting. In the brace, the knees are left free, so the child can kick them straight to stretch the gastrosoleus tendon. The abduction of the feet in the brace, combined with the slight bend (convexity away from the child), causes the feet to dorsiflex. This helps maintain the stretch on the gastrocnemius muscle and Achilles tendon [D]. Importance of bracing The Ponseti manipulations combined with the percutaneous tenotomy regularly achieve an excellent result. However, without a diligent follow-up bracing program, recurrence and relapse occur in more than 80% of cases. This is in contrast to a relapse rate of 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 fails. The straight last shoes by themselves do nothing. They function only as an attachment point for the bar. Some braces are no better than the shoes by themselves and, therefore, have no place in the bracing protocol. If well fitted, the knee-ankle-foot braces, such as the Wheaton brace, maintain the foot abducted and externally rotated. However, the kneeankle-foot braces keep the knee bent in 90 degrees of flexion. This position causes the gastrocnemius
be given a prescription for a brace at the time of the tenotomy. This gives them 3 weeks to organize themselves. In the United States, the Markell shoe and brace is most commonly used, but other countries have differ-ent options [E]. Rationale for bracing At the end of casting, the foot is abducted [A] to an exaggerated amount, which should measure 75 degrees (thigh-foot axis). After the tenotomy, the final cast is left in place for 3 weeks. Ponsetis protocol then
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muscle and Achilles tendon to atrophy and shorten, leading to recurrence of the equinus deformity. This
initial casting phase, during which the doctor does all 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 accustomed to moving two legs simultaneously. (If the child tries to kick one leg at a time, the brace bar interferes, and the child may get frustrated). Warn the parents that there may be a few rough nights until the child gets accustomed to the brace [A]. Suggest the analogy of saddle training a horse: it requires a firm but patient hand. There should be no negotiations with the child. Schedule the first return visit in 10 to 14 days. The main pur-pose of that visit is to monitor compliance. If all is well, then the next scheduled visit is in 3 months, when the child advances to the nighttime only protocol (or nights and naps). It is useful to approach brace compliance as a public health issue, similar to tuberculosis treatment. It is not sufficient to prescribe anti-tuberculosis medications; you must also monitor compliance through a public health nurse. We monitor compliance by frequently calling the families of
is particularly a problem if a knee-ankle-foot brace is used during the initial 3 months of bracing, when the braces are worn full time. In summary, only the brace as described by Ponseti is an acceptable brace for Ponseti management and should be worn at night until the child is 3 to 4 years of age. Strategies to increase compliance to bracing protocol The families who are the most compliant to the bracing protocol are those who have read about the Ponseti method of clubfoot management on the Internet and have chosen that method. They come to the office educated and motivated. The least compliant parents are often from families who did no background research on the Ponseti method and need to be sold on it. The best strategy to ensure 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 certain behavior. Take advantage of the face-to-face time that occurs during the weekly casting to talk to the parents and emphasize the importance of bracing. Tell them that the Ponseti management method has two phases: the
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our patients, who are in the brace phase, between office visits. All families are encouraged to call us if 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 tight-ened correctly. Gluing a small pad at the upper rim of the heel counter can help keep the feet captured in the shoes [B]. When to stop bracing Occasionally, a child will develop excessive heel valgus and external tibial torsion while using the brace. In such instances, the physician should dial the external rotation of the shoes on the bar from approximately 70 degrees to 40 degrees. How long should the nighttime bracing protocol continue? There is no scientific answer to this question. Severe feet should be braced until age 4 years, and mild feet can be braced until age 2 years [C]. It is not always easy to distinguish which foot is mild and which is severe, especially when observing them at age 2 years. Therefore, it is recommended that even the mild feet should be braced for up to 3 to 4 years, provided the child still tolerates the nighttime bracing. Most children get used to the bracing, and it becomes part of their life style. However, if compliance becomes very problematic after age 2 years, it may become necessary to discontinue the bracing to ensure that the child and parents get a good nights sleep. This leniency is not tolerable in the younger age groups. Below age 2 years, the children and their families must be encouraged to comply with the bracing protocol at all costs. Managing Relapses Recognizing relapses After applying the brace for the first time after the tenotomy cast is removed, the child returns according to the following suggested schedule.
2 weeks (to troubleshoot compliance issues) 3 months (to graduate to the nights-and-naps protocol) every 4 months until age 3 years (to monitor compliance and check for relapses) every 6 months until age 4 years every 1 to 2 years until skeletal maturity
Early relapses in the infant show loss of foot abduction and/or loss of dorsiflexion correction and/ or recurrence of metatar-sus adductus. Relapses in toddlers can be diagnosed by examining the child walking. As the child walks toward the examiner, look for supination of the forefoot, indicating an overpowering tibialis anterior muscle and weak peroneals [A]. As the child walks away from the examiner, look for heel varus [B]. The seated child should be examined for ankle range of motion and loss of passive dorsiflexion. Reasons for relapses The most common cause of relapse is noncompliance to the post-tenotomy bracing program. Morcuende found that re-lapses occur in only 6% of compliant families and more than 80% of noncompliant families. In brace-compliant patients, the basic underlying muscle imbalance of the foot is what causes relapses. casting for relapses Do not ignore relapses! At the first sign of relapse, consider reapplying one to three casts to stretch the foot out and regain correction. This may appear at first to be a daunting task in a wriggly 14-month-old toddler, but it is important. The casting management is identical to the original Ponseti casting used in
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infancy. Once the foot is re-corrected with the casts, the bracing program is again begun. Equinus relapse Recurrent equinus is a structural deformity that can compli-cate management. Equinus can be assessed clinically, but to illustrate the problem, a radiograph is included to show the deformity [C]. Several plaster casts may be needed to correct the equinus to at least a neutral position of the calcaneus. Sometimes, it may be necessary to repeat the percutaneous tenotomy in children up to 1 or even 2 years of age. They should undergo casting for 4 weeks postoperatively, with the foot abducted in a long leg 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. Varus relapse Varus heel relapses are more common than equinus relpases. They can be seen with the child standing
[D] and should be treated by re-casting in the child between age 12 and 24 months, followed by reinstitution of a strict bracing protocol. Dynamic supination Some children will require anterior tibialis tendon transfer (see page 26) for dynamic supination deformity, typically between ages 2 and 4 years. Anterior tibialis tendon transfer should be considered only when the deformity is dynamic and no structural deformity exists. Transfers should be delayed until radiographs show ossification of the lateral cuneiform that typically occurs at approximately 30 months of age. Normally, bracing is not required after this procedure. One thing is certain: relapses that occur after Ponseti man-agement are easier to deal with than relapses that occur after traditional posteromedial release surgery.
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Common Management Errors Pronation or eversion of the foot This condition worsens the deformity by increasing the cavus. Pronation does nothing to abduct the adducted and inverted cal-caneus, which remains locked under the talus. It also creates a new deformity of eversion through the mid and forefoot, leading to a bean-shaped foot. Thou shall not pronate! External rotation of foot to correct adduction while calcaneus remains in varus This causes a posterior displacement of the lateral malleolus by externally rotating the talus in the ankle mortise. This displace-ment is an iatrogenic deformity. Avoid this problem by abducting the foot in flexion and slight supination to stretch the medial tarsal ligaments, with counter- pressure applied on the lateral aspect of the head of the talus. This allows the calcaneus to abduct under the talus with correc-tion of the heel varus. Kites method of
the calcaneus and interferes with correction of the heel varus. Casting errors 1. The foot should be immobilized with the contracted liga-ments at maximum stretch obtained after each manipulation. In the cast, the ligaments loosen, allowing more stretching at the next session. 2. The cast must extend to the groin. Short leg casts do not hold the calcaneus abducted. 3. Attempts to correct the equinus before the heel varus and foot supination are corrected will result in a rocker-bottom de-formity. Equinus through the subtalar joint can be corrected by calcaneal abduction. Failure to use night brace Failure to use shoes attached to a bar in external rotation full time for 3 months and at night for 2 to 4 years is the most common cause of recurrence. Attempts to obtain per fect anatomical correction It is wrong to assume that early alignment of the displaced skeletal elements will up result in normal show anatomy. Long-term followradiographs abnormalities. However, good long-term function of the clubfoot can be
manipulation Kite believed that the heel varus would correct simply by evert-ing the calcaneus. He did not realize that the calcaneus can evert only when it is abducted (i.e., laterally rotated), under the talus. Abducting the foot at the midtarsal joints with the thumb pressing on the lateral side of the foot near the calca-neocuboid joint (red X) blocks ab-duction of
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expected. correlation
There
is
no the
Transfer the tendon Transfer the tendon to the dorsolateral incision [E]. The tendon remains under the extensor retinaculum and the extensor ten-dons. Free the subcutaneous tissue to allow the tendon a direct course laterally. Option: localize site for insertion Using a needle as a marker, radiography may be useful in ex-actly localizing the site of transfer in the third cuneiform [F]. Note the position of the hole in the radiograph (arrow). Identify site for transfer This should be in the mid-dorsum of the foot and ideally into the body of the third cuneiform. Make a drill hole large enough tendon [G]. Thread sutures Thread a straight needle on each of the securing sutures. Leave the first needle in the hole while passing the second needle to avoid piercing the first suture [H]. Note that the needle pen-etrates the sole of the foot (arrow). to accommodate the
between
radiographic appearance of the foot and long-term function. Anterior Tibialis Transfer Indication Transfer is indicated if the child has persistent varus and supination during walking. The sole shows thickening of the lateral plantar skin. Make certain that any fixed deformity is corrected by two or three casts before performing the transfer. Transfers are best performed when the child is between 3 and 5 years of age. Often, the need for transfer is an indication of poor compli-ance to brace management. Mark the sites for incisions The dorsolateral incision is marked on the mid-dorsum of the foot [A]. Make medial incision The dorsomedial incision is made over the insertion of the an-terior tibialis tendon [B]. Expose anterior tibialis tendon The tendon is exposed and detached at its insertion [C]. Avoid extending the dissection too far distally to avoid injury to the growth plate of the first metatarsal. Place anchoring sutures Place a #0 dissolving anchoring suture [D]. Make multiple passes through the tendon to obtain secure fixation.
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Pass two needles Place the needles through a felt pad and then through different holes in the button to secure the tendon [A]. Secure tendon With the foot held in dorsiflexion, pull the tendon into the drill hole by traction on the fixation sutures and tie the fixation su-tures with multiple knots [B]. Supplemental fixation Supplement the button fixation by suturing the tendon to the periosteum at the site where the tendon enters the cuneiform [C], using a heavy absorbable suture. Neutral position without support Without support, the foot should rest in approximately 10 de-grees of plantar flexion [D] and neutral valgus-varus.
Local anesthetic A long-acting local anesthetic is injected into the wound [E] to reduce immediate postoperative pain. Skin closure Close the incisions with absorbable subcutaneous sutures [F]. Tape strips reinforce the closure. Cast immobilization A sterile dressing is placed [G], and a long leg cast is applied [H]. Postoperative care This patient was discharged on the same day of the procedure. Usually, the patients remain hospitalized overnight. The sutures absorb. Remove the cast at 6 weeks. No bracing is necessary after the procedure. See the child again in 6 months to assess the effect of the transfer.
ww]ww
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Dr Milind Chaudhary
Hon. Asst. Prof of Orthopaedic Surgery,GMC Akola Director-Centre for Ilizarov Techniques Vice-President, ASAMI India Akola India 444 001. akl_drmmc@sancharnet.in
We have been performing casting and manipulation with the Ponseti technique since the last 3 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
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Once the BK portion is hard then AK is applied with hip held in extension No anesthesia is given No cotton padding is used Gentle technique and moulding is the key to success 4 feet required Soft tissue release as they were myelomenigocoele and non-compliance There was recurrence seen in 6 feet early and they needed casting again. Tenotomy was incomplete in two cases the lap must be made small with support to the parents thigh on the head side The childs buttocks must rest at the edge of the lap someone talks to the child or shows toys assistant holds the upper tibia and the toes initial casting is done upto knee thereafter assistant leaves toes. Surgeon moulds the pop around the talar head and the heel. Rocker bottom was seen in 2 feet. We feel that this is indeed a wonderful technique but feel sure that we have a long way to reach the level of perfection of Dr Ponseti. This anecdote should say it all: Dr Ponseti was heard remarking at age 86 at a conference: I think I have only recently started giving a good plaster cast!
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PONSETI PRINCIPLES FOR CORRECTION OF RELAPSED OR UNCORRECTED CLUBFOOT IN OLDER CHILDREN WITH EXTERNAL FIXATION
Dr Milind Chaudhary
Hon Astt Prof of Orthopaedic Surgery,GMC Akola Director-Centre for Ilizarov Techniques Akola India 444 001. akl_drmmc@sancharnet.in
Recurrent & Untreated Clubfoot at ages of 4 and above present specific difficulties. These may be due to neglect, improper treatment or inadequate bracing ( in which case the deformties are likely to be soft) or they may follow soft tissue releases & are stiff & have severe deformities of cavus-adductus & equino-varus. The treatment algorithm is decided by age, stiffness of the ankle and sphericity of the Talar dome. If the talar dome is significantly flattened and movement in the ankle joint is reduced, it is best to 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 using Ponseti principles with a versatile external fixation system like the Ilizarov. Casting and Ilizarov in relatively supple feet In children of ages between 4 to 8 years when the foot deformities are not very stiff, repeat casting is still a choice. The casts are applied without anesthesia using all the Ponseti principles for correcting the forefoot deformities. 6 to 9 casts may be needed at larger intervals of 2 to 3 weeks. The casting itself can allow some softening of the foot and almost full correction of the forefoot can be achieved along with the abduction of the calcaneum. At the end of this period of casting,
hindfoot equinus persists. Hindfoot deformities are stiff due to previous soft tissue releases and offer no leverage to bring the heel down . At this stage the Ilizaorv apparatus may be applied with the sole aim of correcting the hindfoot equinus and perhaps some inversion. The fixator duration is therefore short and full correction of the hindfoot equinus may be achieved. The description of this technique is at end of the next section. Ilizarov Correction using Ponseti principles in Stiff Feet.
5 Yrs. old with previous PSTR with rigid and stiff feet. Initial 4 casts at fortnightly intervals corrected the forefoot. Next Ilizarov was applied only to correct hindfoot equinus.
In older children or in those with very stiff feet, the Ilizarov external fixator offers significant advantages due to modularity & flexibility in application. The Ponseti principles can be incorporated in the construction of the Ilizarov frame to ensure that the correction is accurate & follows the kinematics of the ankle and hindfoot joints.
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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 half pins. (TR) The forefoot is fixed with a half ring (FR) with two wiresone of them being an olive from the medial side. The hindfoot is fixed with two wires and if possible a half pin.(HR) Forefoot Supination Initially the FR is connected to the anterior part of TR by two parallel connections with multiplane hinges.(Fig1) Supination is achieved by pulling up on
the medial side and pushing down on the lateral side.(Fig2) Correction of the forefoot initially into supination is important as it aligns it with the hindfoot supination. This would prevent the occurance of cavus at the mid-foot and also allow the forefoot to transmit forces congruently to push the calcaneum into abduction. Forefoot abduction For the forefoot to be able to abduct we need a counter-pressure on the head of the talus. We insert an olive wire passing through the lateral side of the talar head. This is attached to the TR with long dropped
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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 corrective forces and natural constraints of the joints ( articular shape, joint capsule and ligaments & the Instant Centre of Rotation) to achieve correction. Non-Constrained correction of equinus with any external fixation hardware is fraught with risk of anterior subluxation of the ankle joint. Typically the TR are perpendicular to the lower tibia and the HR is in as much equinus as the calcaneum. If the MR for correction of equinus are brought straight down perpendicular to the TR, its resultant force will push the talus anteriorly out of the ankle mortice. It is recommended to place the MR angled at about 7 degrees posteriorly to prevent anterior subluxation. Computer simulation & dynamics and kinesiology of the ankle teach us that 7 degrees is inadequate. When the talus moves from plantarflexion into dorsifexion, it not only rolls but also glides a little posteriorly. Hence our motor rods must be able to help in this normal motion and should be placed almost tangential to the curvature of the talar dome. In practice, it is essential to maintain an acute angle between the motor rod and the long axis of the calcaneum anteriorly to about 75 to 80 degrees at all times.(Fig6) When we start the treatment with the heel in 30 to 40 degrees of equinus, (Fig7)this usually means the MR needs to come from way anterior angling
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.
posts. On the medial side it may be attached to a screw traction mechansim to pull the talus medially as well. This wire gives counter pressure on the talar head to allow the forefoot to abduct and the calcaneum be pushed into abduction. Absence of this wire causes the same effect as seen in faulty manipulationposterior displacement of the fibula, which is an iatrogenic deformity. The HR is kept free and is not attached to the TR at the this stage(Fig3). There is a medial projection from the TR and this attaches a motor rod(MR) to the medial side of the FR. (Fig4).This is distracted apart at 1 mm per day. The origin of this MR needs to be changed at least once to adapt to the more abducted forefoot.(Fig5) On the lateral side, the FR and HR may be connected with loose connections. Hindfoot eversion At the end of this stage of correction, the calcaneum is palpated and we can ensure that the distance between the lateral malleolus and the posterior tuberosity of the calcaneum has increased. This is proof that abduction of the calcaneum is adequate.
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posteriorly, attached to the hindfoot ring with multiplanar hinges. As the correction proceeds, the angle between the calcaneum and the motor rod anteriorly becomes more acute and hence the motor rod now has to be anchored on the lower tibial ring at a more posterior level.(Fig8) Using Computer simulation we can determine the position of the Center of rotation of the ankle joint. The wire is inserted thru this point in the talus and is attached to the lower tibial rings with long dropped posts. This wire itself may act as the hinge around which ankle is brought out of equinus. The other way to achieve this would be to have a Constrained correction, with accurate placements of hinges at the level of instant centre of rotation of the ankle and a single motor rod posteriorly. The anterior rods may be kept loose and adjust to the changing position of the forefoot. The ankle is pulled out of equinus into mild overcorrection within a few weeks. The apparatus is now retained for at a further 4 to 6 weeks. Upon removal a cast retains the overcorrection and thereafter foot abduction orthoses & shoes need to be worn. The first stage is performed similar to that described in the previous section. It cannot be emphasized that the two MR are placed with a significant angulation from anterior to posterior to ensure that they are almost tangential to the shape of the talar dome. The talus wire can be distracted to help adjust the position of the talus and also give an anterior part of the force couple to achieve good correction of equinus. Complications Wires in the calcaneum need careful insertion and tensioning as the hindfoot is frequently osteoporotic. The hindfoot fixation must be stable and be able to last the duration of the treatment.
The correction is monitored carefully by taking frequent xrays. This allows us to focus on the ankle joint at all times and ensure that the cartilage is neither getting crushed nor the ankle is undergoing excessive distraction. The biggest risk is the anterior subluxation or dislocation of the talus. Asymmetric distraction of the joint is also possible if the hinges are placed inaccurately. If MR are placed inaccurately, there can be posterior subluxation of the ankle or the lower growth plate may separate posteriorly ( seen in one foot in our series).This was corrected by modifying the apparatus and after one year a valgus and external rotation deformity has developed. Towards the end of the hindfoot equinus correction, it is observed that the MR tend to push the calcaneum without bringing the talus along with it and a talo-calcaneal separation results. This can be prevented by attaching the talar wire now to the HR assembly and also converting the equinus correction into a Constrained type. The other way to prevent this from happening would be to gradually pull up on the talar wire( pulling up the anterior part of the talus out of equinus) and simultaneously pushing the calcaneum. Rate of complications using this protocol is significantly lower as compared to previous method of correction using the Ilizarov framethat we have used in more than 60 feet in the first 11 years of Ilizarov usage. Results We have finished treatment in 22 feet in 18 children with this method in the last 2 years. (Fig 9 to 12)Inadquate correction was seen in three feet. In one this was because of flattening of the talar dome & he should have been treated with a v osteotomy. In another child inadequate follow-up caused the incomplete correction in both his feet. Mild persistent cavus remained in the forefoot and varus in the heel.
34
The parents are not unhappy as he got at least 90% improvement. There are compatibility issues with post-operative bracing in older children, who do not tolerate both feet tied together in a Foot Abduction Orthosis. This leads to partial recurrence in some children. Just wearing corrective shoes is not enough to retain the correction in some children. We have tried the Dimeglio method of taping a footruler to the shoes which forces the foot into external rotation; without too much success. We are pleased with the quality of early post-operative results with this method. We seem to be getting consistent results with better correction of the deformity and well retained function in the ankle joint. Modularity of the Ilizarov fixator permits us to conform to the Ponseti principles which allows us to have a kinesiological correction with fewer complications. The salient features of this technique are novel and have been described for the first time. It has become possible to translate the principles of Ponseti accurately. This AKOLAtechnique has now spread to the USA as well as Europe. Ilizarov vs Simpler Fixators : Simpler Fixators using half pins have been propogated since the last 12 yrs. as the perfect answer to clubfeet at all ages. This marketing hype has totally ignored the scientific realities of the situation. These fixators offer no control over the talus at all. 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-
constrained correction that is being offered is also inadequate, as it is impossible to alter the direction of forces that are applied to various parts of the foot at various times. Lastly the lack of modularity of the JESS and UMEX fixators do not permit the correction of any complications if and when they may arise. It is also seen that the motor rods are easily manipulated by older children who will frequently reverse the turning and hence jeopardise the treatment. The basic flaw lies in the scientific basis or the lack of it. It was propogated for many years by these marketing teams that one has to correct the varus first that was done by everting the heelwhich is described as an error in the Ponseti technique. There is a strong tendency to cause anterior subluxation of the talus due to the direction of the motor rods and inability to change the directions. Finally the half life of half pins in fixation of the foot is very poor and the pins tend to become loose very soon as opposed to the thin wires of the Ilizarov system. The discerning surgeon should not be worried about the seeming complexity of the Ilizarov fixator and should try to master it as it gives total control and better results. It is quite possible that the simplicity of the fixators is more for the sake of the surgeon and is makes life more difficult for the patients.
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PHILOSOPHY OF MANAGEMENT OF C.T.E.V. EITHER CORRECT BY GENTLE REPEATED MANIPULATIONS OR DO ONE TIME SOFT TISSUE SURGERY OF ALL THE TIGHT CONTRACTED AND FIBROUS SOFT STRUCTURES & DO THE DYNAMIC CORRECTION OF TIGHT MUSCULATURE AND ALTER BONE SHAPES BY CORRECTIVE SPLINTAGE AND FOOTWEAR USUAL PROTOCOL MANAGEMENT
ST
ROUNDED OUTER BORDER OF THE FOOT WITH PROMINENCE OF CUBO METATARSAL AREA CLINICAL FINDINGS FURTHER COROBORATED BY FOOT PRINTS AND X-RAYS INDICATIONS FOR SURGERY II 3. FAILED PREVIOUS SURGERY INCOMPLETE CORRECTION RECURRENCE 4. OLDER AGE GROUP PATIENTS
FOR
C.T.E.V.
* 1 WEEK : GENTLE MANIPULATION BY MOTHER *2 5 WEEKS STRAPING * 6 WEEKS TO : MANIPULATION UNDER G.A. & POP 4 MONTHS B.K. CAST CHANGED EVERY 4 WEEKS *AFTER 4 MTHS: SOFT TISSUE RADICAL POSTERO MEDIAL RELEASE : GENTLE MANIPULATION
1.
2. TENDON SHEATHS 3. LIGAMENTS 4. JOINT CAPSULES *** PRIMARY SURGICAL CORRECTION NEEDED FACTORS RESISTING CORRECTION II B) MUSCLES & TENDONS:
*LATE CHILDHOOD : SOFT TISSUE SURGERY WITH BONY SURGERY INDICATIONS FOR SURGERY I 1. WHERE CONSERVATIVE TREATMENT OF THE FEW MONTHS HAVE FAILED 2. SEVERE DEFORMITY CHARACTERISED BY: POINTED UPTURNED TRIANGULAR HEEL WELL MARKED POSTERIOR AND MEDIAL CREASE GROSS INVERSION OF THE HEEL
TENDONS DO NOT NEED LENGTHENING EXCEPT 1. 2. INTERSTITIAL MUSCLE FIBROSIS TO EXPOSE DEEPER STRUCTURES
(E.G. TENDO-ACHILIS & TIBIALIS POSTERIOR TENDONS) C) OTHERS: F.H.L & F.D.L. DYNAMIC SPLINTING AND SERIAL PLASTERING
36
11. LENGTHENING OF TENDO ACHILIS 12. DIVISION OF TOUGH FIBROUS THICKENING OF DEEP FASCIA DEEP TO T.A. 13. ISOLATION AND RETRACTION OF F.H.L 14. OPENING OF POSTERIOR CAPSULE OF ANKLE 15. DIVISION OF POSTERIOR TIBIO-FIBULAR LIGAMENT
- DYNAMIC SPLINTING IN MILD ABERATION IN EARLY CASES - DEFINITIVE BONY SURGERY IN LATE CASES SURGERY UNDER TOURNIQUET 1. LAZY S SKIN INCISION OF TIBIALISPOST &
2. EXPOSURE LENGTHENING
16. DIVISION OF CALCANEO-FIBULAR LIGAMENT AND SHEATH OF THE PERONEII 17. OPENING OF THE POSTERIOR TALOCALCANEAL JOINT 18. OPENING TALO-CALCANEAL COMPLETELY MEDIALLY JOINT
3. EXPOSURE OF INSERTION OF TIBIALIS ANTERIOR 4. OPEN THE CAPSULE OF CUNEO METATARSAL JT. MEDIALLY, SUPERIORLY AND INFERIORLY 5. DIVIDE THE ATTACHMENT OF TIBIALIS ANTERIOR TO MEDIAL CUNEIFORM, IF ANY 6. DO CAPSULOTOMY OF ALL THE THREE SIDES OF NAVICULO- CUNEIFORM JOINT & SEPARATE TIGHT PLANTAR STRUCTURES FROM UNDERNEATH THIS AREA 7. DO CAPSULOTOMY OF TALONAVICULAR JOINT AND DIVIDE ALL EXTENSIONS OF TIB. POST. TO VARIOUS TARSAL BONES AND CUT THE SPRING LIGAMENT 8. DISSECT NAVICULAR ON PLANTER ASPECT AND EXPOSE THE BIFURCATE LIGAMENT AND DIVIDE IT, AND OPEN CALCANEO-NAVICULAR JOINT AND CALCANEO-CUBOID JOINT 9. OPEN ANTERIOR TALO-CALCANEAL JT. PART OF
19. EXPOSE AND DIVIDE INTEROSSEOUS TALOCALCANEAL LIGAMENT 20. EXCISE THE SHEATHS OF TIB. POST., F.H.L. AND F.D.L. 21. EXCISE ARCH OR ORIGIN OF FLEXOR AND ADDUCTOR HALLUCIS 22. DIVIDE FIBROUS CONTRACTURE OVER HENRYS KNOT 23. BRING THE FOOT IN FULLY CORRECTED POSITION 24. SUTURE T.A. AND TIB. POST. IN FULLY CORRECTED POSITION 25. CLOSE SUBCUTANEOUS TISSUE & SKIN 26. APPLY B.K. CAST IN UNDERCORRECTED POSITION AND RELASE THE TOURNIQUET POST - OP MANAGEMENT . 1. B.K. CAST IN SLIGHT UNDER CORRECTION FOR FIRST TWO WEEKS UNTIL SKIN HEALS
10. DIVIDE SUPERFICIAL PART OF DELTOID, SPANNING MEDIAL ASPECT OF TALO- CALCANEAL JOINT, BUT SPARING TIBIO-TALAR PART
37
2. TOTAL CAST IMMOBILISIATION 10 12 WEEKS WITH PERIODIC CHANGES 3 4 WEEKS 3. DYNAMIC SPLINTAGE POST CAST PERIOD TILL WEIGHT BEARING IS STARTED 4. CORRECTIVE FOOTWEAR ON WEIGHT BEARING RESISTANT STRUCTURES OF IMPORTANCE 1. DEEP FASCEA OF LEG UNDER TENDO ACHILIS 2. FIBROUS FLEXOR SHEATHS OF LONG FLEXOR TENDONS AND NOT THE TENDONS THEMSELVES 3. TALO CALCANEAL PART OF DELTOID LIGAMENT SOMETIMES REPLACED BY CARTILAGENOUS MASS OVER THE SUSTANTACULUM TALI 4. INTEROSSEOUS LIGAMENT TALO CALCANEAL
1. 2.
SKIN Z PLASTY NOT NEEDED PLANTER TENOTOMY AND TENDON LENGTHENING OF F.H.L. & F.D.L. NOT NEEDED POST-OP ONLY B.K. CAST IS NEEDED A.K. CAST NOT REQUIRED RESIDUAL FOREFOOT ADDUCTION CORRECTS BY SERIAL CASTING, DYNAMIC SPLINTING & CORRECTIVE FOOTWEAR AS CHILD GROWS CORRECTIVE BONY SURGERY NEEDED ONLY IN OLDER CHILDREN WITH BONY CHANGES PERSISTANT INTORTION OF TIBIA CORRECTS AS CHILD GROWS WITH DYNAMIC SPLINTING AND CORRECTIVE FOOTWEAR
3. 4.
5.
OBSERVATIONS 1. 2. 3. SKIN Z PLASTY NOT NEEDED PLANTER TENOTOMY AND TENDON LENGTHENING OF F.H.L & F.D.L NOT NEEDED POST OP ONLY B.K. CAST IS NEEDED A.K. CAST NOT REQUIRED
5. FIBROCARTILAGENOUS MASS DEVELOPING IN CALCANEO NAVICULAR PART OF BIFURCATED Y LIGAMENT 6. SPRING LIGAMENT ANAMALOUS OBSERVATIONS AT SURGERY. 1. TIB. ANT. : THICK BIFID, INSERTED IN MEDIAL CUNEIFORM ALSO 2. TIB. POST. : VERY THICK AND SOMETIMES MUSCULAR UNTIL LOWER END : SOMETIMES REPLACED BY FIBROUS TISSUE 3. TALOCALCANEAL SYNOSTOSIS 4. TALONVICULAR SYNOSTOSIS : : SYNDESMOSIS SYNDESMOSIS OR OR
4. RESIDUAL FOREFOOT ADDUCTION CORRECTS BY SERIAL CASTING, DYNAMIC SPLINTING & CORRECTIVE FOOTWEAR AS CHILD GROWS CORRECTIVE BONY SURGERY NEEDED ONLY IN OLDER CHILDREN WITH BONY CHANGES 5. PERSISTANT INTORTION OF TIBIA CORRECTS AS CHILD GROWS WITH DYNAMIC SPLINTING AND CORRECTIVE FOOTWEAR
HOW TO AVOID PROBLEMS SKIN: LAZY S CURVED INCISION AVOID UNDERMINING OF SKIN
1, 3, & 4 CANNOT BE REMEDIED WITHOUT RADICAL, MEDIAL, AND PLANTER EXPOSURE OBSERVATIONS
38
- IMMOBILISE THE FOOT IN SLIGHTLY UNDER CORRECTED POSITION FOR FIRST TWO WEEKS AFTER SURGERY NEUROVASCULAR COMPROMISE: - AVOID DISSECTION & ISOLATION OF NERVES & VESSELS KEEP AS ONE BUNDLE EXCISE ITS SHEATH IF NEEDED LEAVE THE LONG TENDONS INTACT
5%
3. DEFECTIVE POST OPERATIVE MAINTENANCE 4. ALTERED BONY CONFIGURATION AND ASSOCIATED BONY ANAMALIES PRIOR TO SURGERY GROSS INTORTION OF TIBIA GIVES IMPRESSION OF FAILURE THOUGH FOOT IS WELL CORRECTED
LOSS OF CORRECTION: - FULLY CORRECT THE DEFORMITY BY SURGERY PROPER POST OPERATIVE MANAGEMENT VIZ. 5.
1. B.K. POP CAST IN UNDERCORRECTION UNTIL SKIN HEALS DURING FIRST TWO WEEKS 2. FULLY CORRECTED POSITION CAST FOR FURTHER 10 TO 12 WEEKS WITH PERIODIC CHANGES 3. DYNAMIC SPLINTING POST-CAST PERIOD UNTIL WEIGHT BEARING IS STARTED 4. CORRECTIVE FOOTWEAR FOR WEIGHT BEARING COMPLICATIONS 1) SKIN PROBLEMS (USUALLY THE POSTERIOR FLAP) 2) SERIOUS INFECTION 2% 1%
ADVANTAGES 1. TIME PROVEN METHOD WITH OVER 30 YEARS OF FOLLOW UP RESULTS AVAILABLE 2. PREDICTABLE CONSTANT RESULTS 3. 4. USER FRIENDLY HENCE BETTER PARENTS COMPLIANCE NO SPECIAL APPARATUS NEEDED
5. ONLY ONE TIME SURGERY BETTER CONTROL BY THE SURGEON 6. NO CARTILAGE OR BONY DAMAGE, HENCE SUPPLE FOOT SUPPORT WITH NO ADVERSE EFFECT ON FUTURE GROWTH POTENTIAL TO CORRECT ALL DEFORMITIES INCLUDING INVERSION OF THE HEEL INCIDENCE OF INFECTION NEGLIGIBLE NO BONE INFECTION
3) TENDONS EXPOSED 3 CASES INDIFFERENT RESULTS WITH SCARRING 4) NO NEURO-VASCULAR COMPLICATIONS RESULTS * EXCELLENT & GOOD 81% 14%
7. 8.
* FAIR
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MANAGEMENT OF C. T .E .V.
DR. NAVIN M. SHAH
When I joined in1970, consisted of : A. Conservative Treatment M.U.A. & Plaster Cast Kite Serial Plaster Cast B. When Conservative treatment was not successful Radical Soft Tissue (Brokman, Turco), was carried out usually after the age of 8 Months. Review of the Results - in 1974: There was almost no correction of Deformative by conservative method. Almost all had Pseudocorrection and recurrence of Deformity. With Surgical Management : 50% Correction of Deformaty 50% Under Correction Attenbouroughs Posterior release is based on his observation that... Infants foot when plantar - flexed goes into inversion. He advised Posterior relese, without correction of Fore Foot. Deformity. UNFORTUNATLY OUR RESULTS OF THIS APPROACH WERE POOR. ANALYSIS OF FAILURES: 1. VARIED EXPRESSION OF SEVERITY DEFORMITY MANAGEMENT HAS TO BE CUSTOMISED. 2. CAVUS DEFORMITY WAS NOT GIVEN PROPER ATTENTION. THIS RESULTED IN FAILURE OF DEROTATION OF CALCANEUM
3. a)
b)
4.
5.
CONTRACTED SOFT TISSUES WHEN STRETCHED ELONGATES. UNPROPER TECHNIQUE OF CORRECTION CAN LEAD TO PSEUDO CORRECTION LIKE HORIZONTAL BREACH. ANKLE AND FOOT CONSISTS OF MULTIPLE JOINTS. STRETCHING OF UNYIELDING SOFT TISSUE MAY STRETCH NEAR BY JOINT LIGAMENT AND PRODUCE SPURIOUS CORRECTION e.g. ROCKER-BOTTOM DEFORMITY WHEN CORRECTING EQUINUS. AGE AT SURGERY: THERE IS A RAPID PROGRESS OF OSSIFICATION OF TARSAL BONES IN INFANCY. SURGERY DELAYED CANS PREVANT CORRECTION OF BONY DEFORMITY. SURGICAL PROCEDURE WAS DONE AFTER THE AGE OF 8 MONTHES AND PROCEDURE WAS INCOMPLET TO CORRECT THE DEFORMITY. THERE WERE PROBLEMS WITH BREAK DOWN OF WOUND, RESULTING IN SEVERE UNYIELDING SCAR TISSUE.
C.T.E.V. DEFORMITY CONSISTS OF: TALUS EQUINUS AND LATERALLY ROTATED CALCANEUS ROTATED UNDER TALUS MID FOOT IS IN CAVUS FOREFOOT ADDUCTED AND SUPINAPED CONCEPT OF TETHERS PREVENTING CORRECTION OF DEFORMITY
40
FOLLOWING SOFT TISSUES CONTRACTURE PREVENTS CORRECTION OF C.T.E.V... 1. PLANTAR FASCIA. 2. POSTERIOR CAPSULE OF ANKLE JOINT. 3. POSTERIOR TALO-FIBULAR LIGAMENT. 4. INFERIOR TIBIO- FIBULAR LIGAMENTS & LOWER INTEROSSEOUS MEMBRANE RAB (1994) IN A STUDY OF MECHANICAL MODEL OF C.T.E.V. CONFIRM ABOVE MENTION FINDINGS. HE ALSO STRETSSED IMPORTANCE OF: CALCANEOFIBULAR LIGAMENT, SPRING LIGAMENT TALONAVICULAR PART OF DELTOID LIGAMENT BASED ON THE CONCEPT OF TETHERS, FOLLOWING PROTOCOL WAS ESTABLISHED. POSTURAL CLUBFOOT -> EASILY CORRECTED BY 2/3 PLASER CAST TRUE CLUBFOOT -> SURGICAL TRETMENT FIRST 3 WEEKS OF AGE -. PASSIVE MANIPULATION BY MOTHER AS DEMONSTRATED. AT 3 WEEKS OF AGE -.> SUBCUTANEOUS PLANTAR TENOTOMY IS PERFORMED. CORRECTION OF CAVUS, FOREFOOT ADDUCTION AND SUPINATION, DEROTATION OF TALUS. X-RAY DONE TO CHECK THE CORRECTION BELOW KNEE PLASTER CAST APPLIED. AT 6 WEEKSOF AGE-> WHEN ABOVE MENTION CORRECTION ACHIVED, POSTERIOR SOFT TISSUE RELEASE WAS DONE .IT CONSISTED OF Z-LENGTHENING OF TENDO ACHILES POSTERIOR CAPSULOTOMY OF ANKLE JOINT RELEASE OF LIGAMENTS OF INFERIOR TIBIO-
FIBULAR - JOINT WITH LOWER INTEROSSEOUS MEMBRANE RELEASE OF POSTRIOR TALO-FIBULAR LIGAMENT FRACTIONAL LENGTHENING OF TENDONS OF TIBIALIS POSTERIOR, FLEXOR DIGITAL LONGUS AND FLEXOR HALLUCIS LONGUS FIXATATION WITH 3 K WIRES CHECK X-RAYS ABOVE KNEE PLASTER IS APPLIED 3 WEEKS POST OPERATIVE-> CHANGE OF PLASTER CAST UNDER G.A. 6 WEEKS POST OPERATIVE -> REMOVAL OF K-WIRES, SUTURES CHECK X-RAYS PAIR OF BOOTS WITH STRAIGHT AND STIFF INSTEP NO HEELS , DEMONSTRATE PASSIVE MOBILISATION OF FOOT TO MOTHER REGULAR POST OPERATIVE FOLLOW UP CLINICAL AND RADIOLOGICAL WHEN DEROTATION OF TALUS DID NOT TAKE PLACE AFTER PLANTAR TENOTOMY, IT WAS NECESSARY TO PERFORM TOTAL SUBTALAR RELEASE. THIS WAS USUALLY NECESSARY WHEN DEFORMITY WAS SEVERE OR SURGERY WAS DELAYED. IN CONCLUSION: C.T.E.V. is complex Deformity with multipal Pathogenesis & varied expression of severity. Single method of management is not sufficient to correctall cases. I have presanted a simple plan of management when applied in early infancy this method corrects the Deformity in 90% of cases. Correction is maintained as observed in long term Follow up.
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42
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 ligament. The cells are responsible for matrix synthesis and they are relatively few in number and represent a small percentage of the total ligament.The crimp is the waviness of the fibril; we will see that this contributes significantly to the nonlinear stress strain relationship for ligaments and tendons and indeed for
The Vikings,of course, knew the importance of stretching before an attack
basically all soft collagenous tissues.Ligament un-crimping, allowing the ligament to elongate without sustaining damage12. The solid components of ligaments are principally collagen (type I collagen accounting for 85% of the collagen and the rest made up of types III, VI, V, XI and XIV) which accounts for approximately 75% of the dry weight with the balance being made up by proteoglycans (<1%), elastin and finally other proteins and glycoproteins such as actin, laminin and the integrins. Fibroblasts (biological cells) that are arranged in parallel rows LIGAMENTS
Structure Composed of closely packed collagen fiber bundles organized mostly in a parallel configuration along the length of the tissue to resist tensile loads. Their nonlinear tensile properties enable them to maintain smooth movement of joints and help to restrain excessive joint displacements under high loads.
Ligaments often have a more vascular overlying layer termed the "epiligament" covering their surface6 and this layer is often indistinguishable from Anatomy COMPARED TO TENDON. 1. Similar to tendon in hierarchical structure
43
2. 3. 4.
Collagen fibrils are slightly less in volume fraction and organization than tendon Higher percentage of proteoglycan matrix than tendon Fibroblasts.
Blood Supply 1. Microvascularity from insertion sites 2. Nutrition for cell population; necessary for 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..
fiber organization and orientation, elastin. and other ground substances such as proteoglycans but are neither affected by the size and shape nor the contribution of the ligament insertion site to bones. 1.Nonlinear Elasticity
The toe-in region represents "un-crimping" of the crimp in the collagen fibrils. Since it is easier to stretch
Function Basic Functions 1. 2. 3. Ligaments carry tensile forces from muscle to bone They carry compressive forces when wrapped around bone like a pulley proprioception.
44
out the crimp of the collagen fibrils, this part of the stress strain curve shows a relatively low stiffness. Thus a key concept is that the overall behavior of ligaments and tendons depends on the individual crimp structure and failure of the collagen fibrils. 2.Viscoelasticity Two major types of behavior characteristic of viscoelasticity. The first is creep. Creep is increasing deformation under constant load. The second significant behavior is stress relaxation. This means that the stress will be reduced or will relax under a constant deformation 3.Hysteresis The other major characteristic of a viscoelastic material is hysteresis or energy dissipation. This means that if a viscoelastic material is loaded and unloaded, the unloading curve will not follow the loading curve. Ligaments also exhibit time- and historydependent viscoelastic properties owing to interactions among the collagen, proteoglycans, water, and other constituents of the tissue. Therefore, a hysteresis loop is usually formed between the loading and unloading 1) 2) mechanical properties can be expected to vary with moisture content Experimental variables including temperature, strain rate, and dehydration can also significantly affect ligament properties
2.Exercise The changes in ligaments and tendons generally occur more slowly than adaptation in bone, because ligaments and tendons have less vascular supply 3.Immobilization: During immobilization, the cross sectional area of the ACL is reduced. This implies a loss of collagen fibrils as well as a loss of glycosaminoglycans that form the ground substance of the ligament. In addition, the may be alterations in collagen fibril orientation that reduce properties. Immobilization has a more rapid and substantial affect on mechanical properties than does increased load from exercise 4.Trauma In the case of tendons, which glide within a sheath, the introduction of passive motion for healing and repaired tendons is believed to be important because it prevents adhesion between the sheath and tendons that restricts motion. In one study, the flexor tendons of skeletally mature dogs were lacerated and then repaired The MCL can heal spontaneously and therefore is an ideal ligament with which to study the healing process of such tissue. On the other hand, the ACL is more complex and does not heal. Immobilization can significantly compromise both the structural properties of the bone-ligament-bone complex and the mechanical properties of the ligament, with weakening more pronounced at the insertion sites. The effects of exercise or increased tension are less pronounced than the effects of immobilization. Even with a substantial duration of exercise, enhancement is only moderate.
Effects of : exercise, immobilization, surgery and trauma 1.Age In rat tail tendons, the diameter of collagen fibrils increase during age from skeletally immature to mature animals
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45
Introduction It is a complex deformity that is difficult to correct .This deformity has been treated in the past by several methods with variable success. The early treatment of this disorder were manipulative [6, 10].Several surgical options were tried later, but the results have not proven to be superior and more complications have been reported after the use of surgical treatment [ 1,3,7 ]. Ponseti has been the pioneer of the manipulation and casting technique for the management of this problem and has practiced and perfected his technique for over 50 years [9, 10]. We present here our experience in the treatment of this disorder by using the ponseti technique. Material and methods 77 patients (102 feet) with CTEV presented to our department Out of these 77 pateints[78] feet were found suitable for ponseti method of management and were included in the study. Patients already treated elsewhere with plasters, Patients older than 3 months with rigid feet, postural varus deformities and arthrogypotic children were not included in the study. The ages of the patient ranged from 2 days to 2 weeks averaging 11days. Late presentation beyond 3 weeks is 7 case 10 feet. 46%patients had bilateral deformity and of which the right side predominated in 54%. 14%of the patients had associated congenital
anomalies (constriction ring in two cases, pulmonary anomaly, ileal atresia, cleft lip, syndactyly, undescended testis, microcephaly in one case each). Familial involvement was found in two patients. The age of the mother ranged from 18to 37 averaging 24 years .history of consanguinity was present 47% of the children, majority of three children (48%) were of first order birth. On examination the deformity was found to be flexible in 56%. And rigid in the remaining case. The severity of the deformity was classified according to the classification method of Dimigleo et al [3]. Stage-1 Correction of cavus. The cause of the cavus deformity is the relative pronation of the forefoot in comparison to the hind foot due to drop of, I and II metatarsals. The aim of stage I correction is to align the forefoot of the hind foot by supinating the forefoot. This is done by elevating the, I and II metatarsal heads and applying a groin to toe cast. Stage II Correction of forefoot adduction. After achieving the correction of cavus the entire foot distal to talus, which is fixed inside the ankle mortise. A thumb placed on the head of the talus is used as a fulcrum while the outward pressure is exerted over the first metatarsal and cuniform. Above
46
knee cast was applied. This was repeated for 2 times with the interval of one week. Stage III Correction of varus. Correction of the heel varus deformity is done by abduction and external rotation of the forefoot, while maintaining the thumb pressure over the lateral aspect of the head of the talus as fulcrum. During this manure, the navicular and cuboids is displaced lateral and the calcanium will be displaced outwards and upward from its initial position, thus correcting the varus deformity of the heel. Above knee cast was applied after correcting the Varus deformity. This was repeated for 2-3 times. Stage 1V- Correction of Equinus Dorsiflexion of the ankle is done to correct Equinus deformity while simultaneous maintaining the foot in abduction and external, rotation, closed tendoachilles tenotomy nay be needed to correct the residual deformity. We have done tenotomy of tendoachilles in 30 patients under general anesthesia 10 patients under local anesthesia .Following the tenotomy a groin to toe cast as applied for 2- 3 weeks. MAINTENECE Corrective cast were applied until dorsiflexion and aversion of 10 deg were achieved .fur ther maintenance cast were continued with the foot in 10 deg dorsiflexion and abduction and aversion of 60deg for 3 months. After this period the correction was maintained by using Equinus own splint and AK foot orthosis. During the period of manipulative correction patients were seen a week, during the maintenance period twice a month and after achieving correction, once a month.
RESULTS Out of 77 patients 10 were last follow up, 3 during the corrective period and 7 during the maintenance period. The results were analyzed in the remaining 78 patients . A good correction of the deformity was achieved in 57 patints(77%) ,an acceptable result in 15(19)% and a poor result in 5 patients (4%)all of who under went posteromedial release.Tenotomy was done in 42 patients (68%of the feet).Three patients needed posterior release only and re tenotomy was needed in two patients, In three patients with bilateral deformity, one side respond to manipulative correction while the other side require surgical intervention. COMPLICTIONS Major complications were encountered in two patients, one child developed pressure necrosis of the dorsum of both feet, which healed well following debridgement and dressing.Minor complications encountered were plaster ulceration in the thigh in four cases, leg in one case and over the first metatarsal head in one patient .These cases were managed by removal of the plaster and reapplication after a week. 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 deformity developed in four cases, which was managed by reapplication of the plasters. Discussion. The Ponseti method of manipulation has been proven to achieve a good correction of the deformity in majority of the patients[ 6,9,10,11] .Ippolito et al [6] have compared the results after treatment of congenital CTEV by two different Protocols .One group of patients was treated by the technique of Marino Zuco,in which the forefoot was initially
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pronated and abducted and later corrections of the heel varus and Equinus was done .The second group of patients was, managed by the Ponseti and Smoley [10] technique. The results were excellent were good in 43 % of the first group compared to the 78% by using the Ponseti technique. The first group of patients needed surgery in the form of posteromedial release to correct residual deformities and had a higher rate of complication like pain, flatfoot deformity and late osteoarthritis [6 ]. We have achieved a good correction of the deformity in 77% of the patients which is comparable to the 78% reported by Ippolito et al [6], and the 71% good results reported originally by Ponseti [10,11] . The analysis of the degree of correction of the deformity can be done by palpation ,by observing the talonavicular and calcaneocuboid relationship, the relation of the heel to the forefoot and the movements of the ankle[11] .Although radiological methods of analysis have been described ,they cannot be relied upon until 2-3 yrs, because of small and eccentric ossification centers of the tarsal bone[2] .The yardstick for assessing successful treatment is therefore a clinically satisfactory alignment of the tarsal bones and ankle motion[11]. The lack of correlation between radiological and functional results has also been outlined by Herbsthofer etal [5] .By strict adherence to the protocol advocated by Ponseti, good results can be obtained in majority of the patients in our series .But the treatment must be started as early as possible .Time is never more precious than in the management of CTEV .In the first few months after birth, the muscles, ligaments and tendons are more pliable ,and the cartilaginous bones are less prone to deformation ,and therefore every attempt must be made to early
correction of the deformity in the shortest possible duration[11].Age is however not an absolute criteria and good results have been obtained in older children, late presentations and after failed previous casting, by employing the ponseti technique, thus sparing these patients the trauma of unnecessary surgery[9]. The correction of Equinus deformity by ponseti method requires a percutaneous tenotomy in majority of patients .Ippoloto et al compared, the amount of dorsiflexion achieved after closed tenotomy and open tendoachilles lengthening with posterior capsulotomy and concluded that the range of ankle dorsiflexion was similar in both groups [6]. Recurrence of the deformity is very common and several author have reported a recurrence rate of up to 50% [6,11].However majority of the recurrences respond to conservative measure of soft tissue soft procedures like tendoachilles lengthening, tibialis anterior transfer of posteromedial release. Bony procedures are almost never indicated [11]. As with any method there are several potential complication with the ponseti method of manipulation .The complication encountered by us were all avoidable and were seen in the early part of the series, emphasizing the need for gentleness of manipulation in these patients, The ponseti methods of manipulation has proved to be a time tested method of management of idiopathic club foot ,with strict adherence to the protocol .good results have been achieved in majority of the patients. However a very vigilant follow up is necessary to detect recurrence and mange it appropriately .no new born with ctev should be denied this method of manipulation.
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