BUGANDO MEDICAL CENTER DEPARTMENT OF PHYSIOTHERAPY CONTINUOUS MEDICAL EDUCATION (CME) THE PONSETI METHOD OF CLUBFOOT MANAGEMENT 26 May 2016 Phenias Mashahu. BSc. PT(TU), Dip.PT. Elias Pallangyo. BSc.PT

CLUBFOOT  Congenital deformity of the foot that is characterized by cavus, adductus, varus and equinous.  Synonymous→ Congenital tallipes equinovarus  Abbrev→ CTEV

CLUBFOOT AETIOLOGY  Most often idiopathic,  Less commonly secondary,  Not understood clearly,  Most likely a genetic disorder, When one parent has clubfoot- 3% to 4% chance for offspring to be affected, when both parents have clubfoot- 30% chance for offspring to be born with clubfoot (Lynn Staheli MD, Global Help 2009)

BUGANDO STATISTICS NEW CASES

IDIOPATHIC  Isolated  Smaller calf

SECONDARY  Neuropathic- S. bifida, hydrocephalus etc.

 Arthrogryposis,  Amniotic band syndrome. SYNDROMIC

ATYPICAL  Severe,  casts fall off,  short cocked great toe  Transverse crease/plantaris

UNTREATED  Before 2years of age TREATED  With the Ponseti method

RESISTANT  Difficult to fully correct  Foot scores persist  Often part of Syndromic

RECCURENT  Recurrence after treatment  Walk on lateral border  Equinous foot  Varus on hind foot.

COMPLEX  Treated with method other than Ponseti  May have other deformities

NEGLECTED  Never been corrected before the child walks  Severe contractures and deformity

Pathoanatomy of Clubfoot Involves calcaneus and navicular rotating around talus (Gosselin R.A et al. 2014) Congenital clubfoot is a complex deformity with four components: (CAVE).  Cavus,  Adductus,  Varus and  Equinus

Anatomy of foot and ankle

Ankle and foot Movements

Cavus  Increase in the height of the medial arch of the foot  Forefoot in relation to the mid foot is in Pronation.  Mid foot strong Supination

Adductus The distal foot is deviated towards the median body plane. Talo-navicular joint  The navicular is severely medially displaced.  The lateral part of the talar head remains uncovered.  The medial pole of the navicular approaches the medial malleolus.

Adductus.. Calcaneo-cuboid joint  The cuboid is medially displaced and adducted in front of the calcaneus.  Only the medial part of the anterior tuberosity of the calcaneus articulates with the cuboid.

Heel in Varus  Supination and Adduction of the Calcaneus.  Calcaneus is locked under the Talus.

Hind foot Equinus  Severe Plantar flexion in the ankle joint.  High Calcaneus (not in the heel pad)  Talus in severe Flexion.

ASSESSMENT  History  General- head-toe PIRANI scoring system.  There are, hind and mid foot scores,  Hind foot~ equinus rigidity, posterior crease, empty heal.  Mid foot~ lateral Curvature, medial crease, lat head of talus.  Each score range~ 0-1  0-normal, 0.5-moderate & 1- Severe Total of 6 score

THE PONSETI METHOD

 Gold standard for clubfoot management  Dr. Ponseti Spanish, worked in Spain, Mexico and USA, Prof. of Orth surgery at the university of IOWA.

TWO PHASES  Corrective and maintenance phases, Corrective phase  Manipulation & Casting (M&C)- 4-8wks  Tenotomy

MANIPULATION AND CASTING  Soon after birth  C avus  A dductus  V arus  E quinus  Precautions → sensation, crying, color on toes, cast wetting  Cast removed at clinic with water

 Tenotomy.  Scores must be; ˂ 1 mid foot and, ˃ 1 hind foot Approx. 1.5cm above the insertion

Maintenance phase  Brace- 23hrs for 3months  Night&nap time for 4 years

ADVANTAGES  Effective  Faster  Less casts  No extensive surgery  Good ankle mvts.

CHALLENGES  Neglected/Untreated clubfoot  Dropouts  Relapses

WAY FORWARD  Doctors  Midwives  Other staff  Conducting health education to health centers  Posters  Advocacy  World clubfoot day

 References;  Lynn Staheli MD, Clubfoot: Ponseti Management: Global- HEL  Pirani S, Maddumba E, Mathias R, Konde-Lule J, Penny N, Beyeza T, Mbonye B, Amoni J, Franceschi F (2009) Towards effective Ponseti clubfoot care:  The Uganda Sustainable Clubfoot Care Project. Clinical Orthopaedics and Related Research 467: P Publication p14