15 the Ponseti Methode

8/10/2019 15 the Ponseti Methode

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THE PONSETI METHODE

PREPARED BY

DR KHALID AFRIDI


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Who was Mr ponseti?


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Spainish

Born in 1914Completed medical education

in 1939

went to Franceand finaly to US in 1941 and

settled there

Passed away in 2009


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Principles of Ponseti Method1- All the deformities should

be corrected simultaneously

except equines

2- The caves and adduction are

corrected in supine positionof foot and never probate the

foot


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3- The equinus is corrected last

by dorsiflexion or achilles

tenotomy4- Awell molded plaster cast is

applied above knee in twosessions


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METHODE

The first element of management is

correction of the cavus deformity by

positioning the forefoot in proper alignment

with the hindfoot.


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Methode conti The foot is manipulated next, by

abducting the foot in supination with

the foot stabilized by the thumb overthe head of the talus, and the index ofthe same hand behind

the fibula.


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Methode conti

The foot is abducted as far as can be done

without causing discomfort to the infant.

. The correction is held with gentle pressurefor about 60 seconds

Then above knee cast is applied to be

changed every 5-7daysDuring this phase of treatment, the

adductus and varus are fully corrected

.


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Methode conti

This manipulation is continued with eachplaster cast until all the deformeties exceptequinus are corrected

Finally the equinus checked, if dorsiflexionof about 15 degrees beyond neutralposition, is possible a final cast in fulldorsiflexion and 70deg abduction is given,if not percutaneous Achellis tenotomy isdone, and cast for 3weeks applied


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Methode conti

After 3weeks the foot is placed inBrace like Dennis Brawn brace

The brace is worn 24hrs for the 1st3months and at night only till thechild is 3-4yrs of age

The brace bar lenght is equal to theshoulders breadth of child with twoadjustable 70degree abducted shoesat ends


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CAST APPLICATION

Before each cast is applied, the foot is

manipulated

Apply only a thin layer of cast padding tomake possible effective molding of the foot.

Maintain the foot in the maximum

corrected position by holding the toes whilethe cast is being applied.

First apply the cast below the knee and then

extend the cast to the upper thigh.


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Achilles Tendon Tenotomy

INDICATION

Inability to achieve dorsiflexion of 15-

20degrees


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PROCEDURE

Prepare the family by explaining theprocedure

Select a tenotomy blade such as a #11 or

#15 or any other small blade such as anophthalmic knife

Prep the foot medially, posteriorly, andlaterally

A small amount of local anesthetic may beinfiltrated near the tendon


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PROCEDURE Conti

Perform the tenotomy approximately 1 cm

above the calcaneus. Avoid cutting into

the cartilage of the calcaneus

A pop is felt as the tendon is released

An additional 10 to 15 degrees of

dorsiflexion is typically gained after the

tenotomy .


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Post-tenotomy cast

Apply the last cast with the footabducted 60 to 70 degrees withrespect to the frontal plane of thetibia.

. The foot is never pronated.


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COMPLICATION OF TENOTOMY

There is only one case reported by

M. Changulani (&) N. Garg C. E.Bruce

Department of PaediatricOrthopaedics,Royal Liverpool ChildrenHospital, Eaton Road,Liverpool L122AP, UK

The complication was injury topost;tibial artery and nerve


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Follow up protocol

After applying the brace for the firsttime after the tenotomy cast wasremoved,

the child returns according to thefollowing schedule.

Two weeks (to check for compliance

issues)


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Follow up protocol conti

Three months (to teach the nights-and-naps protocol)

Every four months until age three

years (to monitorcompliance andcheck for relapses)

Every six months until age 4 years

- Every one to two years untilskeletal maturity


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EVALUATION OF PONSETIMETHODE

Ponseti methode evaluated by variousmethodes but the most widely used inlitrature is the Pirani scoring

It has been proved that using thisscoring with ponseti methode givesexcellent results


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PIRANI SCORING

Midfoot score

Three signs comprise the MidfootScore (MS), grading the amount ofmidfoot deformity between 0 and 3.

Curved lateral border

Medial crease

Talar head coverage


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PIRANI SCORING conti

Hindfoot score

Three signs comprise the HindfootScore (HS), grading the amount ofhindfoot deformity between 0 and 3.

Posterior crease

Rigid equinus

Empty heel


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MIDFOOT SCORELATERAL BORDER


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MEDIAL CREASE


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TALAR HEAD


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HIND FOOT SCOREPOSTERIOR CREASE


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RIGID EQUINUS


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HEEL EMPTYNESS


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OUT COME OF PONSETI METHODE

Various workers have given consistentlybetter results with this technique.

Lehman et al reported a response rate

of 92%.

Colburn and Williams reported a responserate

of 94.1%.

Morcuende et al reported a response rate of

98%


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Recurrence of CTEV treated byponseti methode

Morcuende et al reported a relapserate of 11% with the Ponsetitechnique.

Herzenberg et al reported a relapserate of 3.7% with the Ponsetitechnique


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Treatment of recurrence

Relapses can be diagnosed by examiningthe child walking.

Look for supination of the forefoot,

indicating an overpowering tibialis anteriormuscle and weak peroneals

Look for heel varus

The seated child should be examined for

ankle range of motion and loss of passivedorsiflexion.


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Reasons for relapses

The most common cause of relapse isnoncompliance to the post-tenotomy

bracing program. Relapses occur in only 6% of compliant

families and more than 80% ofnoncompliant families.

In compliant patients, muscleimbalance of the foot is what causesrelapses.


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Treatment of recurrence

Again full protocol of ponseti

If the child has persistent varus and

supination during walking , transfer oftibialis anterior is indicated


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THANKS

15 the Ponseti Methode

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