Ponseti technique for clubfoot correction is widely accepted treatment method and we think medical professionals who are working in the pediatric orthopedics field should have knowledge.This ponseti cast method is extracted from the global-help website.
Ponseti Cast Correction
Setup
The setup for casting includes calming the child with a bottle or breast feeding. When possible have a trained assistant. Sometimes is necessary for the parent to assist. The treatment setup is important . The assistant holds the foot while the manipulator performs the correction.
Manipulation and casting
Start as soon after birth as possible. Make the infant and family comfortable. Allow the infant to feed during the manipulation and casting processes.
Exactly locate the head of the talus
This step is essential . First, palpate the malleoli with the thumb and index finger of hand(A) while the toes and metatarsals are held with other hand (B). Next , slide your thumb and index finger of hand A forward to palpate the head of the talus in front of the ankle. Because the navicular is medially displaced and its tuberosity is almost in contact with the medial malleolus, you can feel the prominent lateral part of the talar head barely covered by the skin in front of the lateral malleolus. The anterior part of the calcaneus will be felt beneath the talar head.
While moving the forefoot laterally in supination, you will be able to feel the navicular move ever so slightly in front of the head of the talus as the calcaneus moves laterally under the talar head.
Manipulation
The manipulation consists of abduction of the foot beneath the stabilized talar head. Locate the head of the talus. All components of clubfoot deformity, except for the ankle equinus, are corrected simultaneously. To gain this correction, you must locate the head of the talus, which is the fulcrum for correction.
Reduce the cavus
The first element of management is correction of the cavus deformity by positioning the forefoot in proper alignment with the hindfoot. The cavus, which is the high medial arch, is due to the pronation of the forefoot in relation to the hindfoot. The cavus is always supple in newborns and requires only elevating the first ray of the forefoot to achieve a normal longitudinal arch of the foot . The forefoot is supinated to the extent that visual inspection of the plantar surface of
the foot reveals a normal appearing arch—neither too high nor too flat. Alignment of the forefoot with the hindfoot to produce a normal arch is necessary for effective abduction of the foot to
correct the adductus and varus.
Steps in cast application
Dr. Ponseti recommends the use of plaster material because it is less expensive and more precisely molded than fiberglass. Preliminary manipulation Before each cast is applied, the
foot is manipulated. The heel is not touched to allow the calcaneus to abduct with the foot.
Applying the padding Apply only a thin layer of cast padding to allow molding of the foot. Maintain the foot in the maximum corrected position by holding the toes with counterpressure
applied against the head of the talus while the cast is being applied. Applying the cast First apply the cast below the knee and then extend the cast to the upper thigh. Begin with three to four
turns around the toes , and then work proximally up to the knee . Apply the plaster smoothly. Add a little tension to the turns of plaster above the heel. The foot should be held by the
toes and plaster wrapped over the “holder’s” fingers to provide ample space for the toes.
Molding the cast
Do not try to force correction with the plaster. Use light pressure. Do not apply constant pressure with the thumb over the head of the talus; rather, press and release repetitively to avoid pressure sores of the skin. Mold the plaster over the head of the talus while holding the
foot in the corrected position .The thumb of the left hand is molding over the talar head while the right hand is molding the forefoot in supination. The arch is well molded to avoid flatfoot or rocker-bottom deformity. The heel is well molded by countering the plaster above
the posterior tuberosity of the calcaneus. The malleoli are well molded. The calcaneus is never touched during the manipulation or casting. Molding should be a dynamic process; constantly move the fingers to avoid excessive pressure over any single site. Continue molding while
the plaster hardens. Extend cast to thigh Use much padding at the proximal thigh to
avoid skin irritation . The plaster may be layered back and forth over the anterior knee for strength and for avoiding a large amount of plaster in the popliteal fossa area, which makes cast removal more difficult. Trim the cast Leave the plantar plaster to support the toes , and
trim the cast dorsally to the metatarsal phalangeal joints, as marked on the cast. Use a plaster knife to remove the dorsal plaster by cutting the center of the plaster first and then the medial and lateral plaster. Leave the dorsum of all the toes free for full extension. Note the appearance of the first cast when completed . The foot is in equinus, and the forefoot is supinated.
Characteristics of adequate abduction
Confirm that the foot is sufficiently abducted to safely bring the foot into 0 to 5 degrees of dorsiflexion before performing tenotomy. The best sign of sufficient abduction is the ability to palpate the anterior process of the calcaneus as it abducts out from beneath the talus.
Abduction of approximately 60 degrees in relationship to the frontal plane of the tibia is possible. Neutral or slight valgus of os calcis is present. This is determined by palpating the posterior os calcis. Remember that this is a three-dimensional deformity and that these deformities are corrected together. The correction is accomplished by abducting the foot under the head of the talus. The foot is never pronated.
The final outcome
At the completion of casting, the foot appears to be over-corrected into abduction with respect to normal foot appearance during walking. This is not in fact an overcorrection. It is actually a full correction of the foot into maximum normal abduction. This correction to complete, normal,
and full abduction helps prevent recurrence and does not create an overcorrected or pronated foot.
Ponseti Cast Correction
Setup
The setup for casting includes calming the child with a bottle or breast feeding. When possible have a trained assistant. Sometimes is necessary for the parent to assist. The treatment setup is important . The assistant holds the foot while the manipulator performs the correction.
Manipulation and casting
Start as soon after birth as possible. Make the infant and family comfortable. Allow the infant to feed during the manipulation and casting processes.
Exactly locate the head of the talus
This step is essential . First, palpate the malleoli with the thumb and index finger of hand(A) while the toes and metatarsals are held with other hand (B). Next , slide your thumb and index finger of hand A forward to palpate the head of the talus in front of the ankle. Because the navicular is medially displaced and its tuberosity is almost in contact with the medial malleolus, you can feel the prominent lateral part of the talar head barely covered by the skin in front of the lateral malleolus. The anterior part of the calcaneus will be felt beneath the talar head.
While moving the forefoot laterally in supination, you will be able to feel the navicular move ever so slightly in front of the head of the talus as the calcaneus moves laterally under the talar head.
Manipulation
The manipulation consists of abduction of the foot beneath the stabilized talar head. Locate the head of the talus. All components of clubfoot deformity, except for the ankle equinus, are corrected simultaneously. To gain this correction, you must locate the head of the talus, which is the fulcrum for correction.
Reduce the cavus
The first element of management is correction of the cavus deformity by positioning the forefoot in proper alignment with the hindfoot. The cavus, which is the high medial arch, is due to the pronation of the forefoot in relation to the hindfoot. The cavus is always supple in newborns and requires only elevating the first ray of the forefoot to achieve a normal longitudinal arch of the foot . The forefoot is supinated to the extent that visual inspection of the plantar surface of
the foot reveals a normal appearing arch—neither too high nor too flat. Alignment of the forefoot with the hindfoot to produce a normal arch is necessary for effective abduction of the foot to
correct the adductus and varus.
Steps in cast application
Dr. Ponseti recommends the use of plaster material because it is less expensive and more precisely molded than fiberglass. Preliminary manipulation Before each cast is applied, the
foot is manipulated. The heel is not touched to allow the calcaneus to abduct with the foot.
Applying the padding Apply only a thin layer of cast padding to allow molding of the foot. Maintain the foot in the maximum corrected position by holding the toes with counterpressure
applied against the head of the talus while the cast is being applied. Applying the cast First apply the cast below the knee and then extend the cast to the upper thigh. Begin with three to four
turns around the toes , and then work proximally up to the knee . Apply the plaster smoothly. Add a little tension to the turns of plaster above the heel. The foot should be held by the
toes and plaster wrapped over the “holder’s” fingers to provide ample space for the toes.
Molding the cast
Do not try to force correction with the plaster. Use light pressure. Do not apply constant pressure with the thumb over the head of the talus; rather, press and release repetitively to avoid pressure sores of the skin. Mold the plaster over the head of the talus while holding the
foot in the corrected position .The thumb of the left hand is molding over the talar head while the right hand is molding the forefoot in supination. The arch is well molded to avoid flatfoot or rocker-bottom deformity. The heel is well molded by countering the plaster above
the posterior tuberosity of the calcaneus. The malleoli are well molded. The calcaneus is never touched during the manipulation or casting. Molding should be a dynamic process; constantly move the fingers to avoid excessive pressure over any single site. Continue molding while
the plaster hardens. Extend cast to thigh Use much padding at the proximal thigh to
avoid skin irritation . The plaster may be layered back and forth over the anterior knee for strength and for avoiding a large amount of plaster in the popliteal fossa area, which makes cast removal more difficult. Trim the cast Leave the plantar plaster to support the toes , and
trim the cast dorsally to the metatarsal phalangeal joints, as marked on the cast. Use a plaster knife to remove the dorsal plaster by cutting the center of the plaster first and then the medial and lateral plaster. Leave the dorsum of all the toes free for full extension. Note the appearance of the first cast when completed . The foot is in equinus, and the forefoot is supinated.
Characteristics of adequate abduction
Confirm that the foot is sufficiently abducted to safely bring the foot into 0 to 5 degrees of dorsiflexion before performing tenotomy. The best sign of sufficient abduction is the ability to palpate the anterior process of the calcaneus as it abducts out from beneath the talus.
Abduction of approximately 60 degrees in relationship to the frontal plane of the tibia is possible. Neutral or slight valgus of os calcis is present. This is determined by palpating the posterior os calcis. Remember that this is a three-dimensional deformity and that these deformities are corrected together. The correction is accomplished by abducting the foot under the head of the talus. The foot is never pronated.
The final outcome
At the completion of casting, the foot appears to be over-corrected into abduction with respect to normal foot appearance during walking. This is not in fact an overcorrection. It is actually a full correction of the foot into maximum normal abduction. This correction to complete, normal,
and full abduction helps prevent recurrence and does not create an overcorrected or pronated foot.
This is great that you published this information for others! Thank you! I would also recommend publishing the details about how to recognize and treat atypical clubfoot since many doctors who have success with most cases using the method still do not have the understanding needed to adequately treat these short, stiff feet without major surgery.
ReplyDeleteDetails can be found in the article "Treatment of the Complex Idiopathic Clubfoot" by Ponseti et al published in 2006.
Dear,
ReplyDeleteThanks a lot for your suggestion. We will definatly see your recommended article.