DAWN CLABON CLINICAL LEAD PHYSIOTHERAPIST

ANEURIN BEVAN UNIVERSITY HEALTHBOARD

What is CTEV?

What is Ponseti treatment?

Potted history of Ponseti

Challenges getting started

How is it going now?

Clubfoot (CTEV) is not an embryonic malformation. It becomes evident during the 2nd trimester Equinovarus refers to the downwards & inwards position of the foot

INCIDENCE – 1 -2 per 1,000 births 2.5 males:1 female 50% are bilateral

Malformation seen from around 15 weeks gestation

CLASSIFICATION

Positional – not clubfoot. No bony abnormality

Structural – misshapen, mal-aligned bones. Histological changes in soft tissue

Idiopathic

Non-idiopathic (eg arthrogryposis, spina bifida)

PIRANI CLASSIFICATION

2 distinct sections

Weekly plastering (abduct the supinated foot with the talus stabilised). Full leg casts.

Achilles tenotomy

3 wk post-op plasters

Boots & bar (23 & half hours per day) for 3 months

Boots & bar (night time only) until 5 yrs old

Performed under local anaestetic

Tendon completely severed

Neither tendon nor skin are sutured

Cast reapplied with foot dorsiflexed & very abducted

3 weeks in post op cast – changed once

Only about 3% require invasive surgery

Foot looks normal & functions normally

Feet tend to be; Resulting in; Short Poor balance Stiff Inefficient gait Painful Repeated surgery Relapsing Problems with footwear Poor fitness Problems with other joints

Long-term follow-up study (Cooper 1995). Ponseti Rx gradually spread through Britain in late 1990s & early 2000s

Many successful Clubfoot projects around the world. Well suited to developing countries

In early 1990s, many babies & children were undergoing extensive surgery, in line with most of the country

I attended training course in Manchester 1996.

Surgeon unconvinced

Discussed Rx with Neonatologists & presented evidence. They started to refer pts for Ponseti.

Began Ponseti Rx (tenotomies done in Bristol)

Surgeon retired. New appointee soon convinced

Visit to Ponseti in Iowa 2006

Began annual meetings with BCH to share experience & Audit results

Now have S Wales & S West regional Ponseti group which meets annually to discuss & feed data into joint audit

Have treated ~150 children (~225 feet)

400 doctors in Belarus have now been trained

Cooper D. Treatment of Idiopathic Clubfoot – a 30yr follow-up note. J Bone & Joint Surgery 77-a 10 Oct 1995 1477-89

Morcuuende J. Radical Reduction in the rate of Extensive Corrective Surgery for Clubfoot using the Ponseti Method. Pediatrics Feb 2004 vol 113 Issue 2

Laaveg S, Ponseti I Long-term results of treatment of congenital clubfoot J Bone & Joint Surgery Jan 1980 62 (1) 23-31

Herzenburg J, Ponseti versus Traditional Methods of Casting for Idiopathic Clubfoot Journal of Pediatric Orthopaedics July/Aug 2002 Vol 22 4 517-521