Ponseti technique for Clubfoot

Courtesy: Hitesh Shah, Paediatric Orthopaedic Surgeon, Manipal, India

 

Ponseti Method of Clubfoot Management

Introduction

• Manipulation and casting provide superior, simpler, and faster outcomes compared to surgical intervention in the management of clubfoot.

• The Ponseti method is:

  • Easy to learn

  • Cost-effective

  • Minimally invasive

  • Highly effective when performed correctly

• It is currently considered the gold standard for the treatment of idiopathic clubfoot.

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Topics Covered

• Objectives of treatment

• Types of clubfoot

• Deformities in clubfoot

• Aims of treatment

• Ponseti manipulation technique

• Atypical clubfoot

• Common errors

• Limitations of manipulation

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Types of Clubfoot

1. Primary idiopathic clubfoot

2. Secondary clubfoot

   • Neurogenic causes such as spina bifida

   • Multiple congenital contractures

   • Associated syndromes including:

     • Larsen syndrome

     • Diastrophic dysplasia

     • Möbius syndrome

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Deformities in Clubfoot

Hindfoot Equinus

• The heel is elevated and does not touch the ground.

• On lateral view, the angle between the tibial axis and foot axis is greater than 90 degrees.

• Normally, the plantar foot makes a right angle with the table surface.

Hindfoot Varus

• The heel is deviated medially.

• In a normal foot, the heel bisects the calcaneum.

• In clubfoot, medial deviation occurs due to subtalar joint deformity.

• Hindfoot varus results from adduction, inversion, and plantar flexion at the subtalar joint.

Cavus

• The medial longitudinal arch is accentuated.

• The first ray is plantar flexed.

• The lateral border of the foot contacts the ground.

Forefoot Adduction

• The medial and lateral borders of the foot are curved.

• The foot cannot be aligned in a straight axis.

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Findings in Dissected Specimens

Equinus

• Severe plantar flexion at the tibiotalar and talocalcaneal joints.

Adduction

• Medial inclination of the talar neck.

• Medial displacement of the navicular and cuboid.

• Calcaneus is adducted.

• Forefoot is adducted relative to the hindfoot.

Varus

• Calcaneus is adducted, plantar flexed, and inverted.

Cavus

• Plantar flexion of the first metatarsal.

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Pirani Scoring System

Hindfoot Score

Posterior Crease

• 0: Absent

• 0.5: Faint

• 1: Deep

Empty Heel

• 0: Calcaneum palpable

• 1: Calcaneum not palpable

Rigid Equinus

• 0: Passive dorsiflexion beyond neutral

• 0.5: Passive dorsiflexion to neutral

• 1: No dorsiflexion, fixed at 90 degrees

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Midfoot Score

Medial Crease

• 0: Absent

• 0.5: Faint

• 1: Deep

Lateral Head of Talus

• 0: Not palpable

• 0.5: Palpable but not prominent

• 1: Prominent and palpable

Curved Lateral Border

• 0: Forefoot touches straight line

• 0.5: Forefoot partially touches straight line

• 1: Forefoot does not touch straight line

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Interpretation of Pirani Score

• Score ranges from 0 to 6

• 0 indicates complete correction

• 6 indicates severe deformity

• Forefoot deformity should be corrected first

• Midfoot score should be 0 or 0.5 before addressing hindfoot equinus

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Goals of Treatment

• Functional foot

• Pain-free foot

• Plantigrade foot

• Mobile foot

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Ponseti Technique

• A specific method of serial manipulation and casting

• Uses the head of the talus as a fulcrum

• Followed by tendo-Achilles tenotomy in most cases

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Goals of Plaster Manipulation

• Begin treatment as early as possible, ideally within 1 week of birth

• Change casts every 5 to 7 days

• Endpoint is complete correction of all deformities

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Order of Deformity Correction

• Cavus

• Adduction

• Varus

• Equinus

Rationale

• Attempting to correct equinus first can lead to rocker-bottom deformity

• Following the correct sequence prevents secondary deformities

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Stages of Correction

Step 1: Cavus Correction

• Achieved by elevating the first metatarsal

• First and fifth metatarsals are brought into the same plane

• This corrects forefoot pronation and is termed supination of the forefoot

• Thumb is placed over the head of the talus to provide counter-pressure

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Step 2: Correction of Adduction and Varus

• The head of the talus is used as a fulcrum

• Forefoot is gradually abducted while maintaining supination

• Navicular shifts laterally

• Gradual abduction up to 70 degrees is required

• Hindfoot varus corrects automatically with forefoot abduction

• Pronation of the foot should never be performed

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Casting Technique

• Manipulation is maintained for 30 to 40 seconds

• Casting is applied immediately after manipulation

• Above-knee cast is applied with:

  • Knee flexed to 90 degrees in children under 1 year

  • Knee flexed to 40 to 60 degrees in older children

• All casts are applied without anesthesia or sedation

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Step 3: Correction of Hindfoot Equinus

• Most children require tendo-Achilles tenotomy

• Forceful manipulation of equinus should be avoided

• Incorrect manipulation may cause rocker-bottom deformity

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Tendo-Achilles Tenotomy

Indications

• Midfoot score less than 1

• Hindfoot score greater than 1

Goals

• Achieve at least 15 degrees of ankle dorsiflexion

Technique

• Performed under local or general anesthesia

• Tendon is completely transected

• Dorsiflexion should occur at the tibiotalar joint, not the midtarsal joint

• Performed using a needle or blade

• Care is required due to medial neurovascular structures

Post-Procedure Care

• Foot is maintained for 3 weeks

• Position:

  • 15 degrees dorsiflexion

  • 70 degrees abduction

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Foot Abduction Orthosis

Usage

• Worn 23 hours per day until walking age, minimum 3 months

• Daytime wear continued until 4 years of age

Measurements

• Bar length equals the distance between the child’s shoulders

Care

• Ensure heel is seated properly in the shoe

• Ankle strap must be secured firmly

• Hindfoot equinus correction must be maintained

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Discontinuation of Orthosis

• When the child can actively abduct and invert the foot

• Some children may develop dynamic supination due to tibialis anterior overactivity

• These cases may require tibialis anterior tendon transfer

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Number of Casts Required

• Depends on:

  • Age of the patient

  • Severity of deformity

  • Degree of soft tissue tightness

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Atypical Clubfoot

• Short first metatarsal

• Dorsiflexed first metatarsophalangeal joint

• Deep plantar creases

• All metatarsals plantar flexed

Treatment

• Apply targeted pressure to correct plantar flexed metatarsals

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Limitations of Ponseti Method

• Approximately 95 percent achieve complete correction

• Limitations occur when:

  • Navicular is fixed with false correction

  • Subtalar joint is fixed, commonly in secondary clubfoot

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Common Errors

• Failure to correct cavus by elevating first metatarsal

• Pronation or eversion of the foot

• Premature attempt to correct equinus

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Follow-Up

• Long-term follow-up is mandatory for all children

• Relapses can occur if bracing protocol is not followed

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Age Limit for Ponseti Method

• Initially used up to 2 or 3 years of age

• Currently, no upper age limit is defined

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Key Principles of Ponseti Method

• Correct sequence of deformity correction is essential

• Elevation of first metatarsal is critical

• Counter-pressure must be applied on the lateral aspect of the talar head

• Heel varus corrects with abduction

• Tendo-Achilles tenotomy is required in most cases