Current Concepts With The Ponseti Technique

Volume 23 - Issue 8 - August 2010
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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.

Author(s):

Edwin Harris, DPM, FACFAS

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.