Material and Methods

MATERIAL AND METHODS

This is a prospective observational study. The work was under taken at

the Department of Orthopaedics surgery, J.N. Medical College, A.M.U.,

and Aligarh during the period of December 2010 to September 2012.

Inclusion criteria are

All children of less than 1 year of age with idiopathic untreated clubfoot

presenting to JNMCH Aligarh AMU (UP) [Typical clubfoot and delayed

untreated clubfoot].

Exclusion criteria are:

 Child who had taken some form of treatment for clubfoot

 More than 1 year of age

 Clubfoot associated with syndromes

Minimum age was 5 days and the maximum was 10 months.

Thirty three cases, (forty one feet), underwent treatment by the Ponseti

technique (explained later on.

Obstetrical history was recorded with regards to drug intake during first

trimester, any febrile illness during pregnancy, presentation of the baby.

Initial assessment of the patient was done regarding the deformity, any

previous treatment by casts or manipulation, any family history of similar

deformities Following this, complete examination of the patient was done

which included general, systemic and local examination, to rule out

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 Material and Methods

syndromes and other associated anomalies like spina bifida, CDH,

arthrogryposis etc.

Only cases of idiopathic untreated CTEV were included in the study.

In the local examination all components of the deformity were noted.

Scoring of each foot was done according to the Pirani score, photographs

were taken showing the deformity.

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 Material and Methods

Pirani scoring system

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 Material and Methods

Picture showing how to calculate Pirani score

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 Material and Methods

All clubfeet are examined sonographically at start of treatment during the

treatment (before tenotomy if it is required) and after conservative

treatment done as per Ponseti method.

Sonographic machine used has a frequency of 9 MHz (5-9 MHz) is GE-

LOGI Q500 pro series ultrasound machine and all ultrasounds are done

by one person.

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Following evaluations criteria are studied at each time USG was done.

 Medial Malleolus And Navicular Distance

 Medial Soft Tissue Thickness

(it is checked by anteriomedial approach)

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 Calcaneo Cuboid Distance

calculated by lateral projection

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Talar Length

Calculated by dorsal projection.

After this the child was prepared for manipulation and cast application

after sedation with syrup pedichloryl.

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 Material and Methods

PONSETI TECHNIQUE OF MANIPULATION AND

CASTING, (Ponseti, 1996)

In this technique all the components of the deformity except the equinus

are corrected simultaneously. To make the manipulation easy to

understand the correction of the various Components are described

separately. The most essential step is to identify the various bones of the

foot, particularly the dorsolateral surface of the head of the talus. Both the

malleoli are easily identified and the medially displaced navicular lies

almost in contact with the medial malleolus. After identifying the tip of

the lateral malleolus, the finger is slid forward; the first bony prominence

that is palpated is the dorsolateral surface of the head of the talus that is

barely covered by the skin. The anterior end of the calcaneus can be felt

just under the head of the talus laterally.

During manipulation the thumb is used to stabilize the talus and the index

finger of the same hand is put behind the lateral malleolus to further

stabilize the ankle joint.

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Cavus

The cavus is corrected first by elevating the plantar flexed first

metatarsal. This supinates the forefoot, bringing it in proper alignment

with the hind foot so that correction of the adductus and varus can be

achieved. While applying the cast the sole of the foot should be molded

so as to maintain the correction. Along with this counter pressure is

applied over the talus to correct as much adduction as possible. At this

stage it appears as if the deformity has increased. To correct the

supination the foot should never be pronated as this increases the cavus.

Adductus and Varus

Correction of the adduction and varus requires abduction of the foot in

supination and plantar flexion with the head of the talus as the pivot.

Gradual correction should be attempted with the correction maintained

for 60 seconds with gentle pressure. After manipulation for 2-3 minutes a

thin well molded plaster cast is applied to maintain the correction. At this

stage no attempt is made to correct the equinus. At no time is the

calcaneus touched, leaving it free to move out from under the talus.

The casts are changed weekly after gentle manipulation. Care is taken not

to pronate the foot while it is being abducted. The initial cast is applied

up till the knee and maintains the whole

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of the foot in supination, equinus and as much abduction as possible.

After the plaster sets the cast is extended to thigh with the knee in 90°

flexion.

As the foot abducts the calcaneus starts to dorsiflex. The aim is to achieve

about 70° of abduction of the foot under the talus. The foot can be

maintained in external rotation only if the talus, the ankle, and the leg are

stabilized in a toe to groin cast, while the knee is in 90° flexion. A below

knee cast can not immobilize the leg as the leg of the baby is round and

the anterior crest of the tibia is covered with baby fat, the cast can not be

molded, thus the cast rotates inwards with the foot. Further the below

knee cast tends to slip off.

Equinus

The equinus is corrected actively last of all. As the calcaneus abducts, it

also dorsiflexes. Residual equinus is corrected by dorsiflexion of the

whole foot after adduction and varus have been corrected with the palm

under the sole of the foot. The heel is pulled down with the thumb and the

index finger of the other hand. The index finger of the other hand can be

used to exert downward pressure on the calcaneal tuberosity. The aim is

to get at least 15° of dorsiflexion at the ankle joint. The heel should be

well molded. 2-3 such casts should be applied. When

the desired dorsiflexion is achieved a final cast is applied for

three weeks with the foot in 70° of abduction and 15-20° of dorsiflexion.
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 Material and Methods

If the tendoachilles feels tight and dorsiflexion is not achieved by

manipulation a simple percutaneous tenotomy of the tendoachilles is done

without any local anaesthesia on the

sedated child, using a #15 blade under aseptic precautions. Immediately

after the tenotomy dorsiflexion of about 15-20° is achieved. Dorsiflexion

beyond this is usually not possible

because of talar and calcaneal malformation, and tight ligaments. After

tenotomy, the puncture wound is covered with a sterile gauze piece and a

cast is given for three weeks. The mother is told that there will be some

soakage of blood on the cast and the child is advised a broad spectrum

oral antibiotic for a week. If full dorsiflexion is not possible after the

tenotomy, the patient is called again after one week, for remanipulation to

achieve the full amount of dorsiflexion

Tibial Torsion

Internal tibial torsion is defined as one of the components of the

deformity. Actually it’s a relative medial torsion, as children with

clubfeet have half the amount of external tibial torsion as that in normal

children. Tibial torsion, varus deformity of the heel and adduction

deformity of the heel can be gradually corrected by toe to groin casts with

the knee in 90° of flexion with the foot externally rotated under the talus.

Splints worn after the cast maintain the correction

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 Material and Methods

Cast Application

During the cast application an assistant holds the thigh with one hand and

the toes with the other. A soft roll is applied snugly over the foot

extending from the toes to the upper thigh. A two

inch plaster cast is applied from the toes to just below the knee. Molding

of the cast is the most important. The foot is abducted with counter

pressure applied over the dorsolateral surface of the head of the talus,

with the forefoot in supination. The pressure should not be maintained for

so long as to create an indent on the setting cast. The heel should be well

molded taking care not to push it into valgus. During setting of the cast

the limb is supported by the leg and heel is not touched at all. The plaster

should be trimmed so that the nail beds are visible however a platform of

a cast should extend under the toes to prevent the flexion of the toes.

Plaster should be trimmed to expose the great toe, with the force being

exerted on\ the metatarsal heads. The cast is changed every week till the

last one which is worn for three weeks after which patient is put on a

brace.

Pirani scoring of the foot was done each week and decision of tenotomy

was taken once midfoot score was less than 1 and hind foot score

continued to be more than 1.

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BRACING

After the 3 week cast was removed the patient was shifted to an

abduction brace. The brace that we used was the Steenbeek foot

abduction brace, which comprises of open toe leather shoes with lace

closure and a strap. A round metal bar (6mm) connects the shoes which

are kept at 70° of external rotation in bilateral cases and 70°(affected

side) and 45°(normal side) in unilateral cases. The approximate length of

the connecting bar is about the distance between the shoulders of the

child. There is an inspection hole on the medial side of the heel to inspect

that the heel is properly placed in the shoe. The bar is bent with a

convexity away from the child to maintain a dorsiflexion of 10°-15°. In

the brace the knees are left free so that the child can do the kicking

movements to stretch the gastrosoleus and the Achilles tendon.

Bracing has to worn for 23 hrs a day and it should continues until the age

child starts crawling , after which the child is shifted to nap time bracing

in which the brace is worn during the night and during any day time naps.

Total time of bracing is 12-16 hrs a day. This is to be followed till the age

of 4 yrs. Care is taken to look for external tibial torsion and heel valgus

while the child is on the brace, and if this occurs the rotation of the foot

should be decreased to 40° from 70°.

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After application of the brace the patient was called up for follow up

visits as follows.

At 2 weeks to troubleshoot compliance issues

At 3 months to shift to nap and night time bracing

Every 4 months to check for relapses and compliance, until 3 years

Every 6 months until 4 years

Every 1-2 years until skeletal maturity

RECOGNITION AND MANAGEMENT OF RELAPSES

Relapse in infants is recognized by the loss of abduction, loss of

dorsiflexion, recurrence of metatarsus adductus.

Relapse in toddler is recognized while the child is walking. From the

front one should look for forefoot supination and from behind look for

heel varus. Loss of dorsiflexion at ankle should be looked for.

Management of relapses requires early recognition and reapplication of

corrective cast by the Ponseti technique after which strict bracing is

started again. This is sufficient for varus relapse.

Apart from reapplication of casts equinus relapse may require a repeat

percutaneous tenotomy in children less than 2 years of age and an open

tendoachilles lengthening in older children.

The treatment protocol after a repeat tenotomy remains the same as that

after the primary procedure. A repeat percutaneous tendoachilles

tenotomy should be done at a site away from the first site.

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