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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
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CLUBFOOT Congenital deformity of the foot that is characterized by cavus, adductus, varus and equinous. Synonymous→ Congenital tallipes equinovarus Abbrev→ CTEV
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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)
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BUGANDO STATISTICS NEW CASES
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IDIOPATHIC Isolated Smaller calf
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SECONDARY Neuropathic- S. bifida, hydrocephalus etc.
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Arthrogryposis, Amniotic band syndrome. SYNDROMIC
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ATYPICAL Severe, casts fall off, short cocked great toe Transverse crease/plantaris
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UNTREATED Before 2years of age TREATED With the Ponseti method
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RESISTANT Difficult to fully correct Foot scores persist Often part of Syndromic
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RECCURENT Recurrence after treatment Walk on lateral border Equinous foot Varus on hind foot.
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COMPLEX Treated with method other than Ponseti May have other deformities
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NEGLECTED Never been corrected before the child walks Severe contractures and deformity
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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
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Anatomy of foot and ankle
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Ankle and foot Movements
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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
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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.
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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.
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Heel in Varus Supination and Adduction of the Calcaneus. Calcaneus is locked under the Talus.
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Hind foot Equinus Severe Plantar flexion in the ankle joint. High Calcaneus (not in the heel pad) Talus in severe Flexion.
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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
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THE PONSETI METHOD
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Gold standard for clubfoot management Dr. Ponseti 1914-2009 Spanish, worked in Spain, Mexico and USA, Prof. of Orth surgery at the university of IOWA.
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TWO PHASES Corrective and maintenance phases, Corrective phase Manipulation & Casting (M&C)- 4-8wks Tenotomy
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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
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Tenotomy. Scores must be; ˂ 1 mid foot and, ˃ 1 hind foot Approx. 1.5cm above the insertion
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Maintenance phase Brace- 23hrs for 3months Night&nap time for 4 years
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ADVANTAGES Effective Faster Less casts No extensive surgery Good ankle mvts.
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CHALLENGES Neglected/Untreated clubfoot Dropouts Relapses
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WAY FORWARD Doctors Midwives Other staff Conducting health education to health centers Posters Advocacy World clubfoot day
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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: 1154-1163 P Publication p14
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