1. Ponseti Casting and Technique for Pediatric Clubfoot Management Mitchell Goldflies, MD Saint Joseph Hospital/Chicago, IL PM&S-36 Seminar Series October 19, 2011

2. Old School Kite technique –I began using Kite technique in 1976 –Limited success in complete correction of deformity –Weekly casting for up to 6 months –First stage in posterior medial release (PMR) –Allows for the soft tissue to better tolerate PMR –Labor, time and resource intensive

3. Old School Kite technique –Heel varus will correct by everting the calcaneus –Each weekly visit you stretch the foot and then cast –Long leg plaster casts –Soak off cast and remove day prior to clinic visit –Parents stated that foot would look better when the cast came off than in clinic the following day –Problems with patients that did not have the cast removed prior to clinic

4. Old School Kite technique –Correct each deformity in sequence before addressing next deformity First correct forefoot adductus Second correct hindfoot varus Third correct equinus –Wheaton Brace to maintain reduction while continuing stretching program

5. Kite Technique

6. Wheaton Brace

7. Ponseti Technique Developed by Ignacio Ponseti, MD over 50 years ago More that 100,000 children born world- wide with congenital clubfoot Clubfoot in an otherwise normal child can be corrected with the Ponseti method of manipulation and plaster cast application in 2 months or less

8. Ignacio Ponseti, MD

9. Ponseti Technique The foot is a bag of wet clay that can be molded Works in newborns and delayed treatment cases No force needed to correct deformities Correct deformities in sequence Recurrences happen Expect to perform TAL Splinting for 3 to 4 years Requires good parent compliance

10. Ignacio Ponseti, MD

11. Ponseti Technique Avoids the posteromedial surgical release that results in a scarred and stiff foot with misshapen joints Since the collagen in the newborn is easily stretched the displaced navicular, cuboid and calcaneus can be gradually abducted under the talus without cutting any of the tarsal ligaments

12. Clubfoot

13. Ponseti Technique Clubfoot classification –Untreated-under 8 years of age –Corrected-using Ponseti technique –Recurrent- Supination and equinus develop after good initial correction –Resistant-Stiff foot associated with conditions such as arthrogryposis –Atypical-short, chubby, stiff feet with a deep crease in the sole of the foot, shortening of the first metatarsal with hyperextension of the MTP joint

14. Ponseti Technique Basic clubfoot deformity is a foot with a deformed talus and a medially displaced navicular Begin treatment soon after birth, 7 to 10 days Most clubfoot deformities can be corrected with the Ponseti technique if treatment is begun before 9 months of age

16. Ponseti Technique Gentle manipulation followed by casting Precise, gentle molding of plaster casts over the reduced subluxations of the tarsal bones of a clubfoot results in correction of the deformities

17. Correct Cavus

18. Correct forefoot varus, inversion and adductus

19. Ponseti Technique Plaster casting technique –Soak off cast in waiting room –Treat skin with lotion –Do not apply benzoin to skin prior to padding –Limit use of cast padding –Apply short leg portion of cast first while molding cast –Then extend to long leg cast

21. Ponseti Technique Fiberglass Soft Cast avoids many of the problems with plaster casting –Does not allow for molding as well as plaster –Costs more –Less mess –Contact dermatitis –Easier to use with possible poorer results

22. Ponseti Technique Sequence of correction –Correct midfoot cavus as a result of flexion of the first metatarsal by supinating the forefoot

23. Ponseti Technique Sequence of correction –Correct forefoot varus, inversion and adductus by abducting the foot beneath the stabilized head of the talus Apply lateral pressure to talus just distal to fibular malleolus Apply medial pressure to first metatarsal head Corrects rear foot varus Progressively bring forefoot into 70 deg. of external rotation relative to the frontal plane of the tibia

25. Ponseti Technique Sequence of correction –Correct equinus Casting in 20 deg. of dorsiflexion Percutaneous TAL –Performed in clinic under local anesthesia –1.5 cm above calcaneus with the foot held in maximum dorsiflexion –Cast for additional 3 weeks in 30 deg. of dorsiflexion and the forefoot abducted 60-70 deg.

27. Ponseti Technique Casting tips –Do not feed child in waiting room Start feeding when foot stretching begins –2 person cast application Most experience person holds foot in corrected position Good cast application technique required Trim cast around toes dorsally

28. Ponseti Technique Sequence of correction –Dennis Brown (Markell) splint External rotation of affected leg 70 deg. –Reduce to 40 deg. if excessive heel valgus External rotation of unaffected leg 30 deg. Use 23 hours/day until walking Continue night splinting for at least 3-4 years Change splint and shoes as child grows –Straight last or tarso-pronator shoes –High top lace up straight last shoes with Thomas heels for ambulation

29. Dennis Brown Splint

30. Ponseti Technique Family compliance issues with splinting program Family does not like 70 deg. external rotation because foot looks deformed Expect recurrences that respond to recasting Some feet are supple and correct well in 6 weeks Some feet are more rigid and require longer treatment and surgery

31. Ponseti Technique Relapses –Evaluate parent compliance –Recast 1-3 times –Surgical equinus release-repeat TAL –Anterior Tibial Tendon transfer to lateral cuneiform for dynamic supination

32. Surgical Correction

33. Ponseti Technique Pirani Severity Scoring –Clinical assessment of the amount of deformity in an unoperated clubfoot –Scores 6 clinical signs 0=normal 0.5=moderately abnormal 1=severely abnormal

34. Ponseti Technique Pirani Severity Scoring –Midfoot score (MS) 0-3 Curved lateral border [A] Medial crease [B] Talar head coverage [C] –Hindfoot score (HS) 0-3 Posterior crease [D] Rigid equinus [E] Empty heel [F]

35. Ponseti Technique Pirani Severity Scoring –Score every foot weekly for HS, MS and total score –Plot scores on graph –Tenotomy is indicated when HS>1, MS>1 and the head of the talus is covered

36. Ponseti Technique Management errors –Pronation or eversion of foot –External rotation of the foot to correct adduction while the calcaneus remains in varus –Failure to manipulate foot –Short leg cast –Premature equinus correction –Failure to night brace –Attempts to obtain perfect anatomical correction

37. Ponseti Technique Questions? Is it worth the time to switch techniques? Is it hard to learn the Ponseti technique? Do I consider going back to the Kite technique? Do I need a team to treat children with the Ponseti technique. When do I bail out of the Ponseti technique early? Is there more family participation required of the Ponseti technique?

38. After Treatment

39. Practice Technique

40. Ponseti Technique Reference: Clubfoot: Ponseti Management Second Edition Lynn Staheli, editor Global-HELP Organization 2003 www.global-help.org

41. Thank You