Current Concepts With The Ponseti Technique

Author(s): 
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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