Management of Clubfoot by Ponseti Technique Sureshwar Pandey, RA Agrawal
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IntroductionChapter 1

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The high incidence of clubfoot makes it a common congenital deformity. Clubfoot has been derived from the word club meaning a heavy tapering stick with knobby end. Worldwide incidence is about one to two per thousand live births with higher incidence reported in Maori, Polynesians and Hawaiians. The ratio of male to female is 3:1 and around 40% cases are bilateral.
The earliest evidence of clubfoot dates back to the Egyptian period and drawing of clubfoot has been found on the walls of tombs, a statue of distrophic dwarf with clubfoot is among the collections of Tutankhamen.
The archeological experts of Mexico have reported that Azetecs knew about clubfoot and treated it with splints made from cactus leaves. The Indian surgeon Sushrut 500 BC recommended correction of such deformity by massage in infancy, splinting in early childhood and adaptive foot-wear in adults. It is mentioned in Corpus Hippocrates that gentle repeated manipulation could effectively correct the clubfoot deformity, this basic principle still holds well.
Earliest account of surgical intervention for correction was subcutaneous tendo-Achilles tenotomy performed by Lorenz in Frankford in 1782. Talectomy was first performed by Lund in 1872. With the modern era of orthopedics equipped with superior antisepsis, anaesthesia, tourniquet, etc. evolved, the better operative treatment. Phelp (1890), an orthopaedist from New York, described a single stage medial plantar soft tissue release with lengthening of tendons. He also 3performed an osteotomy of the neck of talus with wedge resection of calcaneum. During 1900-1930 many surgical methods evolved including correction of clubfoot by soft tissue release at an early age of three years by Codvilla from Italy. Few orthopaedists advocated nonsurgical management after poor long-term results of operative treatment.
Thus, the whole century was spent in exploring, planning, and modifying those treatments, which produced unsatisfactory results. This period enhanced the knowledge of pathoanatomy of the clubfoot. In 1866, Adams differentiated congenital clubfoot from acquired clubfoot variety due to neurological and other causes.
Till few years the most accepted method of nonoperative treatment of clubfoot was that advocated by Hiram Kite in 1930 through serial manipulation and immobilization in plaster cast.
 
 
Ponseti's Principle
Method of Kite was studied by Ignacio V. Ponseti, who had an opportunity to observe his method in 1960. Ponseti concluded that the method was lengthy and short of satisfactory results. After an extensive study and reviewing, he came to the conclusion that the major flaw of Kite's method was the attempt to correct the components of the deformity one by one instead of simultaneously correcting them. The movements at ankle and subtalar joints are coupled movement and it 4is almost impossible to reproduce them independently without affecting the other joint. Ponseti studied these movements extensively by dissection and radiocinematography and developed a non-operative method to correct the clubfoot deformity.
Based on his studies he developed and refined a uniform type of treatment schedule in the late forties. In forty years of his follow-up experience, he found the method optimum. The method is very easy to master and surgery can be avoided by this method. The method requires lesser duration and produces superior results in comparison to extensive manipulation and surgery by other methods. In 1948, he proposed following guidelines for treatment of the clubfoot:
  1. All the components of clubfoot deformity should be corrected simultaneously except obviously the equinus, which is finally corrected at the last.
  2. The cavus is the result of pronation of forefoot in relation to the hindfoot—it is corrected as the foot is abducted in supinated position of forefoot and thereby placing it in proper alignment with the hindfoot.
  3. While the whole foot is held in supination, it is gradually and gently abducted under the talus which is held secured against rotation in the ankle mortise by applying counter-pressure with the thumb over the lateral aspect of the head of the talus.
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  4. The heel varus and supination of foot will automatically get corrected when the entire foot is fully abducted under the talus. The foot should never be everted.
  5. Finally, the equinus is corrected by dorsiflexing the foot. The tendo-Achilles subcutaneous tenotomy may be required to facilitate this correction.
This method is being used by us and has produced better result than previously adopted method for the treatment of clubfoot. Assimilating the principles of the technique, we at our centre implemented this method of gradual manipulation in older neglected cases with the help of Ilizarov ring fixators and are happy to get expected results.
This book is a step towards providing a simplified method along with other information regarding clubfoot deformity so that it can be easily mastered and implemented.