Ponseti Method for atypical club foot

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.

Treatment by Ponseti method

Start with manipulation and casting. Be aware that treatment will be prolonged and the risk of relapse is increased.
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

Reduce abduction on the affected side to 30 degrees in the foot abduction brace. The follow-up management remains the same

Ponseti Technique for Doctors and Physiotherapists

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.

CHAIR DISEASE

Why sitting hurts your back??

Where are you right now? Lounging on an overstuffed couch with the newspaper and a cup of coffee? Sitting on a kitchen chair taking in the news online? Well, here's some news you should sit down for. (Or maybe you should stand.) Your chair is slowly killing you.

Most of the people feel pain but many don't think why shitting hurts your back, some might think and change the chair, some try to spend as much as money to get most comfortable and ergomically designed chair to get releif of pain. which might able to keep themseld busy at work.BUT BUT everyone should stop for a while and think?????

Actually It's not really a chair's fault. The problem is that most of us sit wrong—slouched forward with our earlobes in front of our shoulders—and for hours without moving, as you can see here. The result?

Avoidable chair-related ailments, including flabby butts, an increased risk of blood clots, and back pain.

"Sitting all day is the worst thing in the world you can do for your back, " Sitting puts nearly twice the stress on the spine as standing; slouching while you sit increases the pressure even more. That's because hunching forward pushes the back into a convex or C shape.This shape while slouching fatigues and overstretches the ligaments, causing back pain.
To make matters worse, we stay in this bad C position for hours, barely moving, even when nature calls.

Now at this situation , movement is key because the discs in our vertebrae are important shock absorbers.When individuals are locked at one position, the discs are starving.
Sitting also tightens and shortens the psoas—the strong hip flexor—which can affect how the pelvis rotates and increase the load on the low back.