This portion is extracted from "Treatment of Complex idiopathic clubfoot" by I.ponseti CORR, Number 451,171-176,2006 and Help manual for ponseti method.We hope this information could be beneficial who are dealing with clubfoot management.
Orthopaedists familiar with the treatment of congenital clubfoot know a small percentage of clubfeet are stiff and resistant to manipulation.These clubfeet could be variant of stiff feet or non-ponseti method has made additional deformity which is difficult to managae. However, the tissues usually soften after three to four casts, and the feet eventually are corrected with five or six more casts.
Examination:
The complex clubfoot is short and stubby. The calf muscles are small and the tendo Achillis is long, wide, and tight. The hindfoot is in severe equinus and varus. The forefoot is adducted and all metatarsals are in severe plantar flexion. There is a deep crease across the sole of the
foot and another above the heel. The severe equinus is concurrent with severe plantar flexion of the metatarsals and apparent shortening of the foot and toes. Such deformity may be attributable to shortening and tightness of the deep plantar intrinsic muscles of a similar nature to the changes observed in the calf muscles. Severe fibrosis in the quadratus plantae inserted into the long toe flexors explains the persistent hyperabduction of the metatarsals after faulty manipulations. In most clubfeet there is increased fibrous tissue in the muscles, fasciae, and ligaments,mainly in the gastrosoleus, posterior tibial, long toe flexors, and the posterior ankle and medial tarsal ligaments. In the complex clubfoot, it is the gastrosoleus and the plantar intrinsic muscles and ligaments that are more severely involved. The medial ligaments and tendons of the foot can be stretched easily, but the cavus and the equinus strongly resist correction. The grotesque deformity results from attempts to hyperabduct the midfoot and forefoot, as is done in typical clubfeet.
foot and another above the heel. The severe equinus is concurrent with severe plantar flexion of the metatarsals and apparent shortening of the foot and toes. Such deformity may be attributable to shortening and tightness of the deep plantar intrinsic muscles of a similar nature to the changes observed in the calf muscles. Severe fibrosis in the quadratus plantae inserted into the long toe flexors explains the persistent hyperabduction of the metatarsals after faulty manipulations. In most clubfeet there is increased fibrous tissue in the muscles, fasciae, and ligaments,mainly in the gastrosoleus, posterior tibial, long toe flexors, and the posterior ankle and medial tarsal ligaments. In the complex clubfoot, it is the gastrosoleus and the plantar intrinsic muscles and ligaments that are more severely involved. The medial ligaments and tendons of the foot can be stretched easily, but the cavus and the equinus strongly resist correction. The grotesque deformity results from attempts to hyperabduct the midfoot and forefoot, as is done in typical clubfeet.
Treatment by Ponseti method
Start with manipulation and casting. Be aware that treatment will be prolonged and the risk of relapse is increased.
Manipulation
Manipulation
Carefully identify the talar head laterally. It is not as prominent as the anterior process of the calcaneus. When manipulating, the index finger should rest over the posterior aspect of the lateral malleolus while the thumb of the same hand applies counterpressure over the lateral aspect of the talar head. Do not abduct more than 30 degrees. After 30 degrees abduction is achieved, change emphasis to correction of the cavus and equinus. All metatarsals are extended simultaneously with both thumb.
The deformity is difficult to treat because although the forefoot adduction is corrected easily after the first or second manipulation and casting, the metatarsals remain in stiff plantar flexion and the calcaneus remains fixed in equinus. Additional attempts to correct the heel varus by abducting the foot causes hyperabduction of the severely plantar-flexed metatarsals. Because of the rigid flexion of the heel and metatarsals, the plaster cast easily slips off,making the deformity worse and damaging the edematous skin of the dorsum of the foot. To correct heel varus in complex clubfeet, the hindfoot is abducted with counter pressure applied not only to the talar head but also to the lateral malleolus. The forefoot should not be abducted beyond its normal alignment. Once the heel varus is corrected,the flexed forefoot and the equinus are corrected simultaneously by forcefully dorsiflexing the metatarsals with both thumbs while applying a plaster cast reinforced by a posterior slab.
Casting
To prevent the plaster cast from slipping,the knee is immobilized in at least 110° flexion.Upto 6-8 casts were needed to correct deformity.
Tenotomy
A tenotomy is necessary in most cases. Perform the tenotomy when eqinus is corrected. At least 10 degrees dorsiflexion is necessary. Sometimes it is necessary to change casts at weekly intervals after the tenotomy to gain more dorsiflexion,if sufficient dorsiflexion is not achieved immediately after the tenotomy.
Bracing
Bracing
Reduce abduction on the affected side to 30 degrees in the foot abduction brace. The follow-up management remains the same
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