JOURNAL CLUB Orthopaedic Unit, MMC Chairperson: Asst. Prof. Dr. Humayun Kabir Department of Orthopedic Surgery, MMC.

Speaker: Dr. Md. Tariqul Islam (D-Ortho Resident)

The Ponseti Technique for the Treatment of Congenital Club Foot By Md. Jahangir Alam, Kh. Abdul Awal Rizvi, Md. Sajjad Husain, Sk. Nurul Alam, A.F.M Ruhul Haque. NITOR, Dhaka, Bangladesh. Published in the “The Journal of Bangladesh Orthopaedic Society” Volume: 24 Number 1 January 2009

Introduction: Congenital club foot or congenital talepes equinovarous (CTEV) is the commonest congenital deformity is seen in orthopaedic practice. It is the complex deformity that is difficult to correct. It has a tendency to recur until the age of 3 or 4.

The recurrence in an adolescent is usually associated with incomplete correction & inadequate follow up rather than being secondary to growth alone. - The deformity has four components, Equinus, Varus, Adductus & Cavus.

The goal of treatment is to reduce or eliminate these four deformities, so that the patient has a functional, pain free, plantigrade foot, with good mobility and without calluses and does not needed to wear modified shoes.

The success of manipulation and serial application of plaster cast varies with the age of the patient, severity of deformity, skilness of the orthopaedic surgeon and understanding of the deformity by the orthopaedic surgeon. It is much easier to correct a club foot deformity in the first days of life than after even a few weeks.

Manipulation and serial application of plaster casts supported by limited operative intervention (Percutaneous tenotomy) Yielded satisfactory functional results in 94% of the foot in ponseti clinic by ponseti technique.

In some centre early and even primary operative treatment of club foot is practiced but often some failure complication are common such as wound infection, necrosis of the skin, severe scarring, stiffness of the joint, overcorrection and under correction, dislocation of navicular, flattening and breaking of talar head, talar necrosis, weakness of planter flexor or ankle with major disturbance of gait.

Some people believe as ponseti does that “The successful non operative or limited operative treated foot is much better than the successful surgically treated foot.

Ponseti Seminars 2007 August 17th and 18th September 28th and 29 May 25th and 26th December 7th and 8th February 2nd and 3rd July 6th and 7th March 23rd and 24th November 23rd and 24th June 15th and 16th Brazilian States with training in Ponseti technique

Patho-anatomy: John Herzenberg stated three dimensional C.T. of club foot deformities these are comprises of – Navicular bone is severely medially displaced. Talus is in severe planter flexed, its neck is medially and planterly deflected and head is wedge shaped. Body of talus is externally rotated within the ankle mortes. Calcaneus is adducted and inverted under the talus. Calcanocuboid joint is distorted and cuboid is under beneath of navicular bone

Biology of soft tissue: - Under the microscope, there found increase of collagen fibers and cells in the ligaments of neonates. The bundle of collagen fibers display a wavy appearance known as crimp. The crimp allows the ligaments to be stretched. Gentle stretching of the ligaments in the infant causes no harm. The crimp reappears a few days latter, allowing for further stretching. That is why manual correction of the deformity is feasible.

Fig: A photomicrograph of the tibionavicular ligament showing the collagen fibers to be wavy and densely packed.

Materials and Method: Type of study: This was prospective clinical study. Place of the study: NITOR, Sher-e- Bangla Nagar, Dhaka – 1207. Duration of study: From January 2005 to December 2008. Study Population: Patient with CTEV attending at OPD of NITOR. Age group: 07 days to 20 months of age. Sex Group: Both male and female. Sample size: 175 ft of 100 patients.

Details of the patient Ponseti technique: The corrective process utilizing can be divided into two phases – The treatment phase The maintaining phase

A. The treatment Phase:- The initial manipulation for 60 sec. Plaster cast application 4 to 6 times for correction of cavus, addactus ,varus and corrective equines. Residual equines correction by percutaneus hell cord tenotomy.

Fig: Manipulation of Club foot.

Fig: Gradual correction of club foot by serial plaster cast.

Percutaneous Tenotomy: After proper positioning, knife (BP Blade-15/11 size) was placed parallel to tense tendoachillis approximately 1 cm above the insertion at calcaneus. Then blade is turn 90 degree, perpendicular to tendon. Then tendon is cut from medial to lateral direction. A “POP” is felt as the tendon is released. An additional 10 to 15 degree of dorsiflexion is typically gained after tenotomy.

B. Maintenance Phase: It is maintained by Danis browne splint. Splinting started after the removal of final cast or tenotomy cast, 3 weeks after tenotomy. Splint wear initial 3 months for at least 23 hours of a day and then 12 to 14 hours of a day up to 3 to 4 years of the patient

Result: Age of the patient ranges from 07 days to 20 months, sex were both male and female, bilateral – 75 and unilateral – 25, no. of plaster ranges from 4 to 6 ( 4 plaster- 20 patients, 5 plaster - 30 patient and 6 plaster – 50 patient), Patients were treated by only plaster cast – 70 feet ( 40%) along with tenotomy 105 feet (60%).

The result is regarded as Dr The result is regarded as Dr. Shafiq Pirani score by six clinical sign which is either 0 (normal), 0.5 (moderately abnormal) and 1 (severely abnormal). Final result – 140 feet were excellent with pirani score- 0, 30feet were good with pirani score- 0.5 and 05 feet were satisfactory with pirani score – 1.

Discussion: The goal of treatment is to reduce or eliminate this deformity. So that patient has a functional, pain free, plantigrade foot, with good mobility without callucess, and does not need to wear modified shoes.

The conventional treatment of club foot (CTEV) is serial plaster, two weekly or three weekly up to seven or eight plaster or surgery (PMR) in different methods or approaches. All the procedures have different complications like inadequate correction, stiffness, and weak, sever scar and often painful foot. On the other hand ponseti technique yielded satisfactory anatomical and functional result, with simple, effective, minimally invasive, inexpensive and ideally suited for all countries cultures

The difficult part of the study is maintenance of bracing protocol The difficult part of the study is maintenance of bracing protocol. The patients reported that initial 2 or3 days were the critical period, during which patients were restless and tried to remove the splint. After that the patients were adjusted with the splint.

Author agree with the most of the author that correction of foot also depend on the brace protocol. To make it complaints, parents should be tought about the advantage and disadvantage to gain the more success rate during the maintain phase of the ponseti technique.

Conclusion: The treatment of congenital club foot (CTEV) by ponseti technique is very effective method with excellent result and negligible morbidity. The method is simple, effective, minimally invasive, inexpensive, ideally suited for all countries and culture and usually performed at out patient department.