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| Patient's
Information |
| Clubfoot |
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| DETAILS OF THE PONSETI TECHNIQUE |
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| FIRST FOUR OR FIVE CASTS
(MORE IF NECESSARY) |
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| Start as soon after birth as possible.
Make the infant and family comfortable. Allow the infant
to feed during the manipulation and casting processes
[A]. Casting should be performed by the surgeon when possible
[B]. Each step in management is shown for both the right
and left feet. |
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| REDUCE THE
CAVUS |
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| The .rst 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 [C, yellow arc] is due to
the pronation of the forefoot in relation to the hindfoot.
The cavus is always supple in newborns and requires only
supinating the forefoot to achieve a normal longitudinal
arch of the foot [D and E]. In other words, 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 .at. 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. |
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| MANIPULATION |
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| 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. |
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EXACTLY
LOCATE THE HEAD OF THE TALUS |
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This step is essential [F]. First,
palpate the malleoli with the thumb and index .nger of
hand A while the toes and metatarsals are held with hand
B. Next, slide your thumb and index .nger of hand A forward
to palpate the head of the talus (red) in front of the
ankle mortis. Because the navicular (yellow) 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 (red) barely covered by the skin
in front of the lateral malleolus. The anterior part of
the calcaneus (blue) will be felt beneath the talar head. |
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| While moving the forefoot laterally
in supination with hand B, 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. |
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STABILIZE
THE TALUS |
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Place the thumb over the head
of the talus, as shown by the yellow arrows in the skeletal
model [A]. Stabilizing the talus provides a pivot point
around which the foot is abducted. The index .nger of
the same hand that is stabilizing the talar head should
be placed behind that lateral malleolus. This further
stabilizes the ankle joint while the foot is abducted
beneath it and avoids any tendency for the posterior calcaneal-.bular
ligament to pull the .bula posteriorly during manipulation. |
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MANIPULATE
THE FOOT |
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Next, by abducting the foot in
supination [A], with the foot stabilized by the thumb
over the head of the talus, as shown by the yellow arrow,
abduct the foot as far as can be done without causing
discomfort to the infant. Hold the correction with gentle
pressure for about 60 seconds, then release. The lateral
motion of the navicular and of the anterior part of the
calcaneus increases as the clubfoot deformity corrects
[B]. Full correction should be possible after the fourth
or .fth cast. For very stiff feet, more casts may be required.
The foot is never pronated. |
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SECOND,
THIRD, AND FOURTH CASTS |
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During this phase of treatment,
the adductus and varus are fully corrected. The distance
between the medial malleolus and the tuberosity of the
navicular when palpated with the .ngers tells the degree
of correction of the navicular. When the clubfoot is corrected,
that distance measures approximately 1.5 to 2 cm and the
navicular covers the anterior surface of the head of the
talus. |
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EACH
CAST SHOWS IMPROVEMENT |
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Note the changes in the cast sequence
[C]. Adductus and varus Note that the .rst cast shows
the correction of the cavus and adductus. The foot remains
in marked equinus. Casts 2 through 4 show correction of
adductus and varus. |
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| Equinus The equinus deformity
gradually improves with correction of adductus and varus.
This is part of the correction because the calcaneus dorsi.exes
as it abducts under the talus. No direct attempt at equinus
correction is made until the heel varus is corrected. |
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FOOT
APPEARANCE AFTER THE FOURTH CAST |
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Full correction of the cavus,
adductus, and varus are noted [D]. Equinus is improved,
but this correction is not adequate, necessitating a heel
cord tenotomy. In very .exible feet, equinus may be corrected
by additional casting without tenotomy. When in doubt,
perform the tenotomy. |
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