 |
|
CAN
CLUBFOOT BE CLASSIFIED ? |
| |
|
| Yes, classifying clubfoot
into categories improves understanding for communication
and management [A]. |
| |
 |
|
Untreated
Clubfoot : under 2 years of age |
| |
|
|
Neglected Clubfoot
: untreated after 2 years |
| |
|
|
Corrected Clubfoot
: corrected by Ponseti management |
| |
|
|
Recurrent Clubfoot
: supination and equinus develop after
initial good correction |
| |
|
|
Resistant Clubfoot
: Stiff clubfoot seen in association with
syndromes
such as arthrogryposis |
| |
|
|
Complex Clubfoot
: initially treated by a method other than
Ponseti manaagement |
|
| |
 |
HOW
DOES PONSETI MANAGEMENT CORRECT THE DEFORMITY? |
| |
|
| Keep
in mind the basic clubfoot deformity with the deformed
talus and the medially displaced navicular [B]. |
| |
| Ponseti.s
model shows the mechanism of correction. In the sequence
[A opposite page], observe that all elements are corrected
when the foot is rotated around the head of the talus.
This occurs during cast correction. |
| |
| As
viewed from behind [B opposite page], note that correction
of the heel varus occurs during this manipulation. |
| |
|
WHEN
SHOULD TREATMENT WITH PONSETI MANAGEMENT BE UNDERTAKEN
? |
| |
|
| When
possible, start soon after birth (7 to 10 days). When
started before 9 months of age, most clubfoot deformities
can be corrected by using this management. |
| |
|
WHEN
TREATMENT IS STARTED EARLY, HOW MANY CAST CHANGES ARE
USUALLY REQUIRED ? |
| |
|
| Most
clubfoot deformities can be corrected in approximately
6 weeks by weekly manipulations followed by plaster cast
applications. If the deformity is not corrected after
six or seven plaster cast changes, the treatment is most
likely faulty. |
| |
|
HOW
LATE CAN TREATMENT BE STARTED AND STILL BE HELPFUL ? |
| |
|
| Treatment
is most effective if started before 9 months of age. Treatment
between 9 and 28 months is still helpful in correcting
all or much of the deformity. |
| |
|
IS
PONSETI MANAGEMENT USEFUL FOR NEGLECTED CLUBFOOT ? |
| |
|
| Management
that is delayed until early childhood may be started with
Ponseti casts. In most cases, operative correction will
be required but the magnitude of the procedure may be
less than would have been necessary without Ponseti management. |
| |
|
WHAT
IS THE EXPECTED OUTCOME IN ADULT LIFE FOR THE INFANT WITH
CLUBFOOT TREATED BY PONSETI MANAGEMENT ? |
| |
|
| In
all patients with unilateral clubfoot, the affected foot
is slightly shorter (mean, 1.3 cm) and narrower (mean,
0.4 cm) than the normal foot. The limb lengths, on the
other hand, are the same, but the circumference of the
leg on the affected side is smaller (mean, 2.3 cm). The
foot should be strong, .exible, and pain free. |
| |
|
WHAT
IS THE INCIDENCE OF CLUBFOOT IN CHILDREN WITH ONE OR TWO
PARENTS WHO ALSO ARE AFFECTED ? |
| |
|
| When
one parent is affected with clubfoot, there is a 3% to
4% chance that the offspring will also be affected. However,
when both parents are affected, the offspring have a 15%
chance of developing clubfoot. |
| |
|
HOW
DO THE OUTCOMES OF SURGERY AND PONSETI MANAGEMENT COMPARE? |
| |
|
| Surgery
improves the initial appearance of the foot but does not
prevent recurrence. Importantly, no long-term follow-up
studies of operated patients have been published to date.
Adult foot and ankle surgeons report that these surgically
treated feet become weak, stiff, and often painful in
adult life. |
| |
|
|
HOW
OFTEN DOES PONSETI MANAGEMENT FAIL AND OPERATIVE CORRECTION
BECOME NECESSARY ? |
| |
|
|
| |
|
The
success rate depends on the degree of stiffness of the
foot, the experience of the surgeon, and the reliability
of the family. In most situations, the success rate can
be expected to exceed 90%. Failure is most likely if the
foot is stiff with a deep crease on the sole of the foot. |
| |
|
|
|
|
IS
PONSETI MANAGEMENT USEFUL FOR RESISTANT CLUBFOOT? |
| |
|
|
| |
|
Ponseti
management is appropriate for use in children with arthrogryposis,
myelomeningocele, and Larsen syndrome. The results may
not be as gratifying as they are in the child with idiopathic
clubfoot treated from birth, but there are advantages
to this approach. The .rst is that the clubfoot could
respond completely to Ponseti management, with or without
the need for an Achilles tenotomy. Additionally, even
partial preoperative correction of these severe deformities
can decrease the extent of surgery and improve the ability
to approximate the edges of the contracted skin. |
| |
|
|
| |
|
Arthrogrypotic
clubfoot is perhaps the most challenging. Often, initial
percutaneous heel cord tenotomy is required to enable
any manipulative deformity correction. Creating a calcaneocavus
deformity is not a concern because of the severe contracture
of the posterior joint capsules. Anticipate the need for
surgery. |
| |
|
|
|
|
IS
PONSETI MANAGEMENT USEFUL IN MYELODYSPLASIA? |
| |
|
|
| |
|
Concern
has been raised regarding manipulation and casting of
the insensate clubfoot in children with myelomeningocele.
The physician must apply pressure based on his/her experience
with idiopathic clubfoot, in which the child.s comfort
dictates appropriateness. One must be patient during manipulation
and expect that more than the usual number of casts will
be needed. The maneuvers are gentle. Concentrated forceful
molding over bony prominences is avoided, as it is in
all children. |
| |
|
|
|
|
IS
PONSETI MANAGEMENT USEFUL FOR COMPLEX CLUBFOOT? |
| |
|
|
| |
|
Personal
experience, and that of others, has shown that Ponseti
management can often be successful when applied to feet
that have been manipulated and casted by other practitioners
who are not yet skilled in this very exacting management. |
| |
|
|
|
|
WHAT
ARE THE FEATURES OF RECURRENT CLUBFOOT ? |
| |
|
|
| |
|
The
foot usually develops supination and equinus. |
| |
|
|
|
|
WHAT
ARE THE USUAL STEPS OF CLUBFOOT MANAGEMENT ? |
| |
|
|
| |
|
Most
clubfeet can be corrected by brief manipulation and then
casting in maximum correction. After approximately .ve
casting periods [C], the adductus and varus are corrected.
A percutaneous heel cord tenotomy [D] is performed in
nearly all feet to complete the correction of the equinus,
and the foot is placed in the last cast for 3 weeks. This
correction is maintained by night splinting using a foot
abduction brace [E], which is continued until approximately
2 to 4 years of age. Feet treated by this management have
been shown to be strong, .exible, and pain free [F], allowing
a normal life. |
