SITEMAP | FEEDBACK | DISCLAIMER  
     
Dr. Taral Nagda
Paediatric Orthopaedic Surgeon

 
     
Home
Patient's Information
Clinic Network
Pediatrician's Section
Orthopaedic's Surgeons Section
Calcium and Bone Health
Links
Contact
 
Patient's Information
Clubfoot
 
ARTICLES
 
Details of the the Ponseti Technique
Cast Application, Molding, and Removal
Equinus Correction and Fifth Cast
Bracing
Managing Relapses
Instructions for Brace Use
Overview of Ponseti Management
Common Questions
LINKS
CASE DISCUSSIONS
PATIENT'S REVIEW
 
MANAGING RELAPSES
 
RECOGNIZING RELAPSES
 
After applying the brace for the .rst time after the-tenotomy cast is removed, the child returns according to the following suggested schedule.
 
2 weeks (to troubleshoot compliance issues)
 
3 months (to graduate to the nights-and-naps protocol)
 
every 4 months until age 3 years (to monitor compliance and check for relapses)
 
every 6 months until age 4 years
 
every 1 to 2 years until skeletal maturity
 
Early relapses in the infant show loss of foot abduction and/ or loss of dorsi.exion correction and/or recurrence of metatarsus Relapses in toddlers can be diagnosed by examining the child walking. As the child walks toward the examiner, look for supination of the forefoot, indicating an overpowering tibialis anterior muscle and weak peroneals [A]. As the child walks away from the examiner, look for heel varus [B]. The seated child should be examined for ankle range of motion and loss of passive dorsi.exion.
 
REASONS FOR RELAPSES
 
The most common cause of relapse is noncompliance to the post-tenotomy bracing program. Morcuende found that relapses occur in only 6% of compliant families and more than 80% of noncompliant families. In brace-compliant patients, the basic underlying muscle imbalance of the foot is what causes
 
CASTING FOR RELAPSES
 
Do not ignore relapses! At the .rst sign of relapse, consider reapplying one to three casts to stretch the foot out and regain correction. This may appear at .rst to be a daunting task in a wriggly 14-month-old toddler, but it is important. The casting management is identical to the original Ponseti casting used in infancy. Once the foot is re-corrected with the casts, the bracing program is again begun.
 
EQUINUS RELAPSE
 
Recurrent equinus is a structural deformity that can complicate management. Equinus can be assessed clinically, but to illustrate the problem, a radiograph is included to show the deformity [C].
 

Several plaster casts may be needed to correct the equinus to at least a neutral position of the calcaneus. Sometimes, it may be necessary to repeat the percutaneous tenotomy in children up to 1 or even 2 years of age. They should undergo casting for 4 weeks postoperatively, with the foot abducted in a long leg bent knee cast, and then go back into the brace at night. In rare situations, open Achilles lengthening may be necessary in the older child.
 
VARUS RELAPSE
 
Varus heel relapses are more common than equinus relpases. They can be seen with the child standing [D] and should be treated by re-casting in the child between age 12 and 24 months, followed by reinstitution of a strict bracing protocol.
 
DYNAMIC SUPINATION
 
Some children will require anterior tibialis tendon transfer (see page 26) for dynamic supination deformity, typically between ages 2 and 4 years. Anterior tibialis tendon transfer should be considered only when the deformity is dynamic and no structural deformity exists. Transfers should be delayed until radiographs show ossi.cation of the lateral cuneiform that typically occurs at approximately 30 months of age. Normally, bracing is not required after this procedure. One thing is certain: relapses that occur after Ponseti management are easier to deal with than relapses that occur after traditional posteromedial release surgery.
 
top
 
Copyrights 2006 Children's Bone & Spine Clinic. All Rights Reserved. Design & Maintained by : Hitesh Brahmbhatt