Sharing insights from the literature as well as clinical experience, this author discusses key casting principles of the Ponseti technique, the notion of age restrictions with this treatment option, its effectiveness in children with neuromuscular disorders and whether the Ponseti technique can be beneficial for other orthopedic conditions in infants.
Surgical management was the treatment of choice for talipes equinovarus for much of the last half of the 20th century. This is because many surgeons felt that non-operative treatment of clubfoot was either rarely successful or the results were difficult to achieve because of problems adhering to the principles of closed reduction. Since successful outcomes were difficult to achieve, surgeons presumed that investments of time, manpower and supplies were not justified.
In the 1990s, surgeons began to review the long-term results of aggressive surgical management. It became apparent that the results of extensive surgery were not very successful. Surgery did not always achieve the goals of plantigrade, supple, painless and functional feet. Incongruent malformed articulations resulted in stiffness, pain and disability.
This led to renewed interest in non-operative management. Physicians revisited Ponseti’s technique for closed reduction with minimal surgical intervention. By following Ponseti’s instructions, they were able to reproduce the success he claimed was easy to achieve.
When it comes to managing talipes equinovarus with the Ponseti technique, one should simultaneously correct all of the deformity components except for equinus, which the physician would correct last, often with an Achilles tenotomy. In order to correct the cavus forefoot deformity, the physician must supinate the medial column and maintain this via external rotation of the foot around the talar head with stabilization in a long leg cast with the knee flexed. One should perform manipulations weekly.
Step one is to correct the cavus deformity by elevating the first metatarsal and supinating the forefoot relative to the rearfoot. Forefoot adductus and rearfoot varus undergo simultaneous correction. The foot must remain in equinus because premature dorsiflexion prevents the calcaneus from rotating under the talus to its neutral position. One can subsequently treat the equinus by placing pressure on the entire plantar surface of the foot. If this is unsuccessful, perform an Achilles tenotomy with casting in the corrected position. Maintenance in bracing is critical to the success of the procedure.1-6
A Pertinent Overview Of The Types Of Talipes Equinovarus
Talipes equinovarus describes a group of anatomical findings occurring together, making it a syndrome rather than a specific disease. Most cases are idiopathic without any specific identifiable cause. Other forms are parts of specific diseases. One text dealing with human malformations identifies over 70 conditions in which clubfoot (including metatarsus adductus) is a regular or occasionally occurring feature.7
Although there are many classifications for talipes equinovarus, the system proposed by Thompson and Simons is highly useful.8 This system identifies four groups: congenital (idiopathic), teratologic, syndromic and positional.
Congenital talipes equinovarus is an isolated condition without other musculoskeletal findings. There is currently no specific etiology for this group and it is probably not a single entity. The teratological form is associated with underlying neuromuscular disorders, including myelomeningocele, arthrogryposis and other conditions. Syndromic talipes equinovarus is associated with genetic abnormalities and other conditions in which talipes equinovarus occurs regularly or occasionally. Positional (postural) talipes equinovarus is presumably a normal foot held in a deformed position in utero.
What The Literature Reveals About The Ponseti Technique For Complex Idiopathic Clubfoot
Much of the literature on the Ponseti technique describes the management of congenital idiopathic club feet. Ponseti recognized that a small group of club feet did not respond to standard treatment. He labeled such feet complex idiopathic club feet. These feet were characterized by rigid equinus, severe plantarflexion of all of the metatarsals, a deep crease above the heel, a transverse crease in the sole of the foot and a short hyperextended hallux. The tendo-Achilles is very contracted and fibrotic up to the middle of the calf. Some of the complex idiopathic club feet resemble typical idiopathic talipes equinovarus at birth with some response to manipulation and casting.
Physicians modified the Ponseti technique in order to deal with this particular subset.9 Identify the subtalar joint by palpation. Grasp the talar head from side to side and move the anterior calcaneus laterally under the talar head. Dorsiflex the metatarsals as a unit and apply the cast in 110 degrees of knee flexion to prevent slipping. One may follow this with percutaneous tendo-Achilles lengthening as indicated.9
Gerlach and colleagues noted that clubfoot in myelomeningocele is more severe than idiopathic clubfoot. They reported a 68 percent recurrence in the myelomeningocele group in comparison to 26 percent in the idiopathic group.10 Janicki and co-workers studied the use of the Ponseti method in infants with neuromuscular disorders and infants with non-idiopathic club feet.11 The authors concluded that non-idiopathic club feet required more casts and had a higher failure rate and need for additional procedures.11
Although the technique is not as successful in this patient population, one can achieve and maintain clubfoot correction in non-idiopathic club feet. Kowalczyk and Lejman reported their short-term experience with the Ponseti technique in patients with arthrogryposis multiplex congenita.12 They concluded that clubfoot in patients with arthrogryposis multiplex congenita responds to management by the Ponseti technique with improvement or correction. This avoids or decreases the need for extensive surgery.
Children with disorders affecting the nervous system required more casts and had a greater risk of recurrence.11 Lovell and Morcuende observed that late relapses in patients who supposedly have idiopathic club feet may represent the onset of a previously undiagnosed neuromuscular disease.13
Are There Age Restrictions With The Ponseti Technique?
Most talipes equinovarus is obvious at or shortly after birth, and physicians usually initiate treatment early. However, authors have commented that delay in the initiation of treatment does not have any significant effect on results.14 Hegazy and colleagues discussed their experience in a group of infants between the ages of 4 and 13 months with a history of failed manipulation.15 Their conclusion was that the Ponseti method in older infants seemed to be effective and reduced the need for extensive surgery.
Alves and co-workers examined two groups of children, those under 6 months old and those more than 6 months old.16 There was no difference between the two groups at the time of the beginning of treatment regarding the number of casts, need for tenotomy, success in initial correction, rate of recurrence and the need for tibialis anterior transfer.
Bor and colleagues noted success with the Ponseti technique even if treatment starts late or begins after failure of other treatment methods.17 Haft and co-workers studied early clubfoot recurrence after the use of Ponseti technique. They noted no significant relationship between recurrence and either the time of presentation or the severity.18 Bor and co-workers noted that older infants with clubfeet can undergo successful treatment without extensive surgery.19
Goksan and colleagues stated that previously unsuccessful treatment attempts by other conservative methods did not adversely affect the results.20 Dobbs and colleagues showed no relationship between risk of recurrence and severity of the deformity, age at the initiation of treatment or previous treatment.21
What You Should Know About Casting
The success of the Ponseti technique depends on gentle stretching of the soft tissues to realign the articular segments. This requires repositioning of the talonavicular joint by moving it from a point on the inferior, proximal and medial aspect of the talar head to a point on its distal surface. At the same time, it requires the calcaneus to rotate both on its long axis and about a vertical axis located in the general direction of the interosseous talocalcaneal ligament.
In order for remodeling to take place, there has to be a mechanism for stabilizing and maintaining this position. This requires an above the knee cast in order to lock the talus in the ankle mortise and externally rotate the foot at the same time. If one uses a below the knee cast, then there is nothing to maintain the foot in external rotation. For this reason, the cast must go above the knee with the knee flexed near 90 degrees. Only one study advocates a below the knee cast.22
Ponseti recommended Plaster of Paris as the material of choice in casting talipes equinovarus.2 It is very easy to manipulate and has superior molding qualities. One can carefully contour the material so there are no pressure points on the skin and deeper tissues. This prevents pressure sores.
The one disadvantage for Plaster of Paris is that the smallest commercially available roll is 2 inches wide. Although an experienced surgeon with a good assistant can apply a 2-inch wide role of Plaster of Paris to a neonate infant, a 1-inch size is preferable. This requires cutting a 2-inch or 3-inch roll in half, leaving a ragged edge on one side that makes smooth rolling difficult.
Soft Cast (3M) is a commercially available 1-inch roll of material. It is very flexible so one can easily apply it to a small infant.22 It has an advantage in that one can remove it without a cast saw by simply unrolling it so in an emergency, parents can easily remove the cast at home. However, this can be a disadvantage as parents can also take the casts off any time they choose. Plaster of Paris still remains the material of choice.23
Manipulation and maintenance of position are equally important for the success of the Ponseti technique. Soaking a cast off is laborious and time consuming. The worry is parental adherence. The concern is when the parents remove the cast at home because there is no way to verify when they removed it. The only purpose for doing so would be to allow the baby a full bath. Sponge bathing can occur at home. In our clinic, the support staff cleans the extremities well after the casts are removed but before the surgeon manipulates the feet and re-applies the casts.
How Safe Is Percutaneous Tendo-Achilles Lengthening?
Many infants with talipes equinovarus have a considerable amount of subcutaneous fat in the foot and lower leg that makes palpation of the soft tissue difficult. One can identify the tendo-Achilles as a tight soft tissue structure when attempting to dorsiflex the ankle. A small incision usually allows the physician to isolate the tendon and section it while avoiding vital structures. Often, physicians perform the procedure with the child under local anesthesia in an outpatient setting.
Changulani and co-workers concluded that percutaneous tendo-Achilles tenotomy is safe. However, there are potential complications.24 Significant bleeding has been reported following percutaneous tendo-Achilles lengthening. This can be caused by laceration of the small saphenous vein, the peroneal artery or even the posterior tibial artery. Burghardt and colleagues described a pseudoaneurysm following percutaneous tendo-Achilles lengthening.25
Other neurovascular complications may occur.24 Dobbs and colleagues reported four cases of serious bleeding complications following percutaneous tendo-Achilles tenotomy.26 One must take great care to avoid injury to the superior and posterior portion of the calcaneus.
General anesthesia in the operating room offers several advantages. First, the infant does not struggle. Second, there is no worry about the parents. Third, there is better pain control postoperatively and easier cast application. The disadvantages are the need for general anesthesia and the additional cost factor.
Some authors have suggested that surgeons could perform a tenotomy with a large gauge needle.27 The easiest way to avoid complication is to visualize the tendon while sectioning it.28,29 The physician can do this easily by making a small incision, delivering the tendon into the wound over a small right angle instrument and sectioning the tendon under direct vision.
Addressing Potential Failure Of The Ponseti Technique
Some feet are so rigid that they are unlikely to reduce fully. This is particularly true for the teratologic and syndromic forms. Talipes equinovarus associated with myelomeningocele is particularly difficult to manage. Although some semblance of closed reduction can occur, many of these patients have dynamic muscle imbalance, resulting in early recurrence of the deformity. Prognosis is guarded because of high recurrence rates.18
Maintenance with bracing is very difficult and even radical surgical reduction often does not achieve a satisfactory result. This is problematic because these children need plantigrade feet so they can seat well in bracing on wheelchair platforms. Since the feet are insensate, imbalance makes them liable to pressure ulcerations. Syndromic variations are equally difficult to manage and success depends on the underlying disease.
Adherence with casting principles is very important. Cast application must occur under the supervision of a podiatric physician who understands both the anatomy and the technique. It is strongly recommended that one remove the cast in the office on the day of the cast change.30 Allowing the parents to remove the cast at home gives them the opportunity to remove the cast at any time. Most parents will take the casts off on the morning of the appointment to allow bathing. Other parents may take the cast off two or three days beforehand, sometimes even on the day of cast application.
A frequently raised question is whether more frequent cast applications would result in more rapid correction, fewer tendo-Achilles tenotomies and less recurrence. One study evaluated two protocols, casting changes in five days and seven days respectively.31 There was no difference in outcome.
Maintenance of position following successful cast reduction is the key to long-term success. The Fillauer bar (Fillauer, LLC) and shoe apparatus or some similar foot abduction brace are critical.32 There have been a number of modifications of this device to improve patient acceptance and adherence.33,34 Failure to utilize some form of abduction brace is the most common cause for failure of the Ponseti technique.10,14,17,33-38
How many children need extensive surgery after failure of the Ponseti technique? Park and co-workers discussed selective soft tissue release for recurrence of residual deformity after conservative treatment of idiopathic clubfoot.39 Patients had a 40 percent recurrence. The most common procedures were tibial osteotomy, split anterior tendon transfer, split posterior tibial tendon transfer and combinations of these for recurrent deformity.
In a study by Willis and colleagues, they found that 7 percent of patients failed to improve after treatment with the Ponseti technique and all of these patients required extensive surgery.38 Haft and co-workers reported a recurrence rate of 41 percent following the Ponseti technique.18 A significant number had major recurrence, which required a posterior or posteromedial release.
Relapses of the deformity can occur at any time but become problematic when they happen over the age of 2½ years. This usually means that the navicular is still medially displaced and the heel is still in some degree of varus.
Treatment consists of manipulation and serial casting for about six weeks followed by transfer of the tibialis anterior to the third cuneiform in one of two ways. One can free the tendon from its insertion, route it above the superior extensor retinaculum and then tunnel under the retinaculae, and secure the tendon to the third cuneiform.
A second equally effective technique is to free the tendon from its insertion, incise the inferior extensor retinaculum along its course and then pass the tendon subcutaneously to a drill hole in the third cuneiform. One may recognize an imbalance between the peroneals and the tibialis before the recurrence becomes fixed. I have transferred the tendon in several patients and the deformity did not recur.
Can The Ponseti Technique Be Effective For Other Orthopedic Conditions In Infants?
Talipes calcaneovalgus (calcaneovalgus deformity) is characterized by dorsiflexion of the foot at the ankle, abduction of the forefoot and pronation of the subtalar joint complex. Anterior ankle joint soft tissue contractions maintain the foot in dorsiflexion. The dorsum of the foot may rest against the anterior tibia. Plantarflexion is limited to neutral or just below neutral. The forefoot is abducted and the talocalcaneonavicular joint complex is pronated.
Unlike with talipes equinovarus, the bony structures are presumably normal with talipes calcaneovalgus. It is a common condition mentioned by a number of authors discussing neonatal screening and the incidence of foot deformities.40-48 Many of the same authors feel that this deformity spontaneously corrects. It may occur in isolation but is frequently associated with breech presentation and in babies large for gestational age.49 It may be associated with hip dysplasia and dislocation.44 The differential diagnosis includes paralytic calcaneus deformity and congenital convex pes valgus.
Treatment is nonoperative and consists of the Ponseti technique in reverse. Manipulate the foot and ankle into an equinus and varus position. Apply an above the knee cast to maintain the plantarflexed position and stabilize the medial rotation of the foot, which is necessary to reduce the talonavicular joint subluxation. In most cases, it is possible to place the foot and ankle in an anatomical position without any ankle equinus once one reduces the talocalcaneonavicular joint complex. If ankle equinus is present, place the foot in supination of the subtalar joint complex and gradually bring the ankle out of equinus until the patient achieves at least 15 degrees of ankle dorsiflexion.
Congenital convex pes valgus (congenital vertical talus deformity) is known to result in long-term adult disability if it is left untreated.50 There are two forms of this disorder. Most are secondary to some other condition and only a few are primary disorders without underlying etiology. Since the infants with secondary diagnoses are more likely to present initially in tertiary centers, it is the primary form which physicians are more likely to see in community practices.
Early diagnosis and institution of treatment is needed to achieve a functional result.51,52 Historically, initial treatment has involved the use of manipulation and serial casting, and a subsequent extensive soft tissue release.53 Even under the best circumstances, treatment is difficult and often not completely successful. Surgical management often leads to stiffness, under-correction or over-correction.54
Dobbs and associates described a conservative method to treat congenital vertical talus, consisting of weekly stretching and manipulation followed by the application of long leg casts.55 One would plantarflex and adduct the foot, and apply pressure to the medial talar head. This corrects all of the components except the equinus.
Schedule surgery when the talonavicular joint is reduced. Make an incision on the medial aspect of the talonavicular joint. If the joint is reduced, it is pinned under direct vision. If the joint is not reduced, perform a dorsal capsulotomy and assess the anterolateral soft tissues for possible release. After stabilization of the talonavicular joint, perform a percutaneous Achilles tenotomy. Follow this with casting for six weeks and subsequent bracing.53,55,56
When it comes to the Ponseti technique, the most important points are the understanding of the pathoanatomy and the method of reversing the abnormal anatomy. The type of talipes equinovarus determines the overall success but one should initially treat all forms with Ponseti’s technique.
The complex idiopathic clubfoot presents a challenge and requires modification of the technique. Older infants and those who have failed previous attempts at closed reduction are still candidates for Ponseti’s technique. The prognosis for success in the response of neuromuscular talipes equinovarus to Ponseti’s technique is guarded.
Casting is critical. The cast must be an above the knee cast. Plaster of Paris is still preferred over synthetic cast material. The surgeon should remove the cast in clinic. Post-cast bracing is critical to success. Some infants can be expected to fail and may need extensive surgery. One can modify the Ponseti technique to treat talipes calcaneovalgus and congenital convex pes valgus (congenital vertical talus).
Dr. Harris is a Clinical Associate Professor in the Department of Orthopaedics and Rehabilitation at the Loyola Medical Center in Maywood, Ill. He is a Fellow of the American College of Foot and Ankle Surgeons.
For related articles, see “Key Insights To Treating Talipes Equinovarus” in the April 2004 issue of Podiatry Today, “How To Master The Ponseti Technique For Clubfoot” in the December 2008 issue or “Congenital Foot Deformities: A Guide To Conservative Care” in the August 2007 issue.
To access the archives, visit www.podiatrytoday.com.
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