Current Concepts With The Ponseti Technique

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What You Should Know About Other Techniques For Talipes Equinovarus

At the turn of the 20th century, treatment for talipes equinovarus consisted of forceful manipulation of the foot under general anesthesia with devices such as the Thomas wrench. The result was destructive pressure on bone and cartilage with stiffness and fibrosis. With more advanced surgery, operations on fascia, tendon, bone and joint became fashionable. The goal of these procedures was to reduce the deformity quickly. Relapses were frequent and many patients had unacceptable rigidity and stiffness. Some were worse off than had they not been treated.

   Kite’s technique. Kite studied the anatomy and treatment of talipes equinovarus under Hoke and achieved success with manipulative reduction in the 1920s.57,58 Kite divided the abnormal anatomy into three parts. These were adduction of the forefoot, inversion of the heel and equinus of the ankle. He believed the forefoot was adducted in comparison to the rearfoot and the calcaneus rotated inward under the talus, causing the entire foot to assume an inverted position. The equinus deformity had two components. The forefoot was plantarflexed on the rearfoot, resulting in forefoot equinus. The entire foot was plantarflexed at the ankle, resulting in ankle equinus.

   Kite isolated treatment into three sections.57,58 First, he corrected the adduction of the forefoot and subsequently corrected the inversion of the calcaneus. Once he had completely corrected both deformities, he treated the ankle equinus. The first part of the correction occurred by bringing the forefoot out of abduction until the cuboid was in line with the calcaneus and the navicular was anatomically seated on the talar head. Kite accomplished this with lateral cuboid pressure. Once he achieved this, the ankle equinus reduced.57,58

   The French technique. The French physiotherapy method developed in the late 1970s and is more popular in Europe.59-61 The theory behind this method is that clubfoot results from a contracted posterior tibial tendon, malpositioned joints and weakness of the peroneal muscle group. It involves daily manipulation by a physiotherapist, splinting with elastic tape, stimulation of muscles by activating tonic cutaneous reflexes to excite the toe extensors and the peroneals, and continuous passive motion while the baby sleeps. It is very labor intensive for both the therapist and family members. This approach is not very popular in the United States although some centers use it.

   Correction begins with the rotation of the entire foot around the talus and one augments this with massage of the calf muscles and tendo-Achilles. The first step is to stretch the medial soft tissue to allow the navicular to move away from the medial malleolus and its medial position on the talar head. The second step is to correct forefoot adduction. The third step is to progressively reduce the hindfoot varus. One can only do this after reducing the talonavicular joint. The last step is to correct the equinus deformity.

   The technique underwent further modification in the 1990s with the introduction of continuous passive movement.61 Most of the improvement occurs during the first three months of treatment.

Edwin Harris, DPM, FACFAS

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.

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