1. Learning the Ponseti Technique of Treatment For Clubfoot Deformity
Or can you teach this old dog new tricks?
Mitchell Goldflies, MD

2. Old School Kite technique I began using Kite technique in 1976
Limited success in complete correction of deformity
Weekly casting for up to 6 months
First stage in posterior medial release (PMR)
Allows for the soft tissue to better tolerate PMR
Labor, time and resource intensive

3. Old School Kite technique
Heel varus will correct by everting the calcaneus
Each weekly visit you stretch thefoot and then cast
Long leg plaster casts
Soak off cast and remove day prior to clinic visit
Parents stated that foot would look better when the cast came off than in clinic the following day
Problems with patients that did not have the cast removed prior to clinic

4. Old School Kite technique
Correct each deformity in sequence before addressing next deformity
First correct forefoot adductus
Second correct hindfoot varus
Third correct equinus
Wheaton Brace to maintain reduction while continuing stretching program

5. Ponseti Technique The foot is a bag of wet clay that can be molded
Works in newborns and delayed treatment cases
No force needed to correct deformities
Correct deformities in sequence
Recurrences happen
Expect to perform TAL
Splinting for 3 to 4 years
Requires good parent compliance

6. Ponseti Technique Developed by Ignacio Ponseti, MD over 50 years ago
More that 100,000 children born world-wide with congenital clubfoot
Clubfoot in an otherwise normal child can be corrected with the Ponseti method of manipulation and plaster cast application in 2 months or less

7. Ponseti Technique
Avoids the posteromedial surgical release that results in a scarred and stiff foot with misshapen joints
Since the collagen in the newborns is easily stretched the displaced navicular, cuboid and calcaneus can be gradually abducted under the talus without cutting any of the tarsal ligaments

8. Ponseti Technique Clubfoot classification
Untreated-under 8 years of age
Corrected-using Ponseti technique
Recurrent- Supination and equinus develop after good initial correction
Resistant-Stiff foot associated with conditions such as arthrogryposis
Atypical-short, chubby, stiff feet with a deep crease in the sole of the foot behind the ankle, shortening of the first metatarsal with hyperextension of the MTP joint

9. Ponseti Technique
Basic clubfoot deformity is a foot with a deformed talus and a medially displaced navicular
Begin treatment soon after birth, 7 to 10 days
Most clubfoot deformities can be corrected with the Ponseti technique if treatment is begun before 9 months of age

10. Ponseti Technique Gentle manipulation followed by casting
Precise, gentle molding of plaster casts over the reduced subluxations of the tarsal bones of a clubfoot results in correction of the deformities

11. Ponseti Technique Plaster casting technique
Soak off cast in waiting room
Treat skin with lotion
Do not apply benzoin to skin prior to padding
Limit use of cast padding
Apply short leg portion of cast first while molding cast
Then extend to long leg cast

12. Ponseti Technique
Fiberglass Soft Cast avoids many of the problems with plaster casting
Does not allow for molding as was as plaster
Costs more
Less mess
Contact dermatitis
Easier to use with possible poorer results

13. Ponseti Technique Sequence of correction
Correct midfoot cavus as a result of flexion of the first metatarsal by supinating the forefoot
Correct forefoot varus, inversion and adductus by abducting the foot beneath the stabilized head of the talus
Apply lateral pressure to talus just distal to fibular malleolus
Apply medial pressure to first metatarsal head
Corrects rear foot varus
Progressively bring forefoot into 70 deg. of external rotation relative to the frontal plane of the tibia

14. Ponseti Technique Sequence of correction Correct equinus
Casting in 20 deg. of dorsiflexion
Percutaneous TAL
Performed in clinic under local anesthesia
1.5 cm above calcaneus with the foot held in maximum dorsiflexion
Cast for additional 3 weeks in 30 deg. of dorsiflexion and the forefoot abducted deg.

15. Ponseti Technique Casting tips Do not feed child in waiting room
Start feeding when foot stretching begins
2 person cast application
Most experience person holds foot in corrected position
Good cast application technique required
Trim cast around toes dorsally

16. Ponseti Technique Sequence of correction Dennis Brown (Markell) splint
External rotation of affected leg 70 deg.
Reduce to 40 deg. if excessive heel valgus
External rotation of unaffected leg 30 deg.
Use 23 hours/day until walking
Continue night splinting for at least 3-4 years
Change splint and shoes as child grows
Straight last or tarso-pronator shoes
High top lace up straight last shoes with Thomas heels for ambulation

17. Ponseti Technique Family compliance issues with splinting program
Family does not like 70 deg. external rotation because foot looks deformed
Expect recurrences that respond to recasting
Some feet are supple and correct well in 6 weeks
Some feet are more rigid and require longer treatment and surgery

18. Ponseti Technique Relapses Evaluate parent compliance Recast 1-3 times
Surgical equinus release-repeat TAL
Anterior Tibial Tendon transfer to lateral cuneiform for dynamic supination

19. Ponseti Technique Pirani Severity Scoring
Clinical assessment of the amount of deformity in an unoperated clubfoot
Scores 6 clinical signs
0=normal
0.5=moderately abnormal
1=severely abnormal

20. Ponseti Technique Pirani Severity Scoring Midfoot score (MS) 0-3
Curved lateral border [A]
Medial crease [B]
Talar head coverage [C]
Hindfoot score (HS) 0-3
Posterior crease [D]
Rigid equinus [E]
Empty heel [F]

21. Ponseti Technique Pirani Severity Scoring
Score every foot weekly for HS, MS and total score
Plot scores on graph
Tenotomy is indicated when HS>1, MS>1 and the head of the talus is covered

22. Ponseti Technique Management errors Pronation or eversion of foot
External rotation of the foot to correct adduction while the calcaneus remains in varus
Failure to manipulate foot
Short leg cast
Premature equinus correction
Failure to night brace
Attempts to obtain perfect anatomical correction

23. Ponseti Technique Questions?
Is it worth the time to switch techniques?
Is it hard to learn the Ponseti technique?
Do I consider going back to the Kite technique?
Do I need a team to treat children with the Ponseti technique.
When do I bail out of the Ponseti technique early?
Is there more family participation required of the Ponseti technique?

24. Clubfoot: Ponseti Management
Ponseti Technique
Reference:
Clubfoot: Ponseti Management
Second Edition
Lynn Staheli, editor
Global-HELP Organization
2003

25. Thank You