THE PONSETI METHODE

PREPARED BY
DR KHALID AFRIDI

Who was Mr ponseti?

Spainish
Born in 1914
Completed medical education
in 1939
went to France
and finaly to US in 1941 and
settled there
Passed away in 2009

Principles of Ponseti Method

1- All the deformities should
be corrected simultaneously
except equines
2- The caves and adduction are
corrected in supine position
of foot and never probate the
foot

3- The equinus is corrected last

by dorsiflexion or achilles
tenotomy
4- Awell molded plaster cast is
applied above knee in two
sessions

METHODE
The first element of management is
correction of the cavus deformity by
positioning the forefoot in proper alignment
with the hindfoot.

Methode conti

The foot is manipulated next, by

abducting the foot in supination with
the foot stabilized by the thumb over
the head of the talus, and the index of
the same hand behind
the fibula.

Methode conti
The foot is abducted as far as can be done
without causing discomfort to the infant.
. The correction is held
. with gentle pressure
for about 60 seconds
Then above knee cast is applied to be
changed every 5-7days
During this phase of treatment, the
adductus and varus are fully corrected

Methode conti
This manipulation is continued with each
plaster cast until all the deformeties except
equinus are corrected
Finally the equinus checked, if dorsiflexion
of about 15 degrees beyond neutral
position, is possible a final cast in full
dorsiflexion and 70deg abduction is given,
if not percutaneous Achellis tenotomy is
done, and cast for 3weeks applied

Methode conti
After 3weeks the foot is placed in
Brace like Dennis Brawn brace
The brace is worn 24hrs for the 1st
3months and at night only till the
child is 3-4yrs of age
The brace bar lenght is equal to the
shoulders breadth of child with two
adjustable 70degree abducted shoes
at ends

CAST APPLICATION
Before each cast is applied, the foot is
manipulated
Apply only a thin layer of cast padding to
make possible effective molding of the foot.
Maintain the foot in the maximum
corrected position by holding the toes while
the cast is being applied.
First apply the cast below the knee and then
extend the cast to the upper thigh.

Achilles Tendon Tenotomy

INDICATION
Inability to achieve dorsiflexion of 1520degrees

PROCEDURE
Prepare the family by explaining the
procedure
Select a tenotomy blade such as a #11 or
#15 or any other small blade such as an
ophthalmic knife
Prep the foot medially, posteriorly, and
laterally
A small amount of local anesthetic may be
infiltrated near the tendon

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 .

Post-tenotomy cast
Apply the last cast with the foot
abducted 60 to 70 degrees with
respect to the frontal plane of the
tibia.
. The foot is never pronated.

COMPLICATION OF TENOTOMY
There is only one case reported by
M. Changulani (&) N. Garg C. E.
Bruce
Department of Paediatric
Orthopaedics,Royal Liverpool Children
Hospital, Eaton Road,Liverpool L12
2AP, UK
The complication was injury to
post;tibial artery and nerve

Follow up protocol
After applying the brace for the first
time after the tenotomy cast was
removed,
the child returns according to the
following schedule.
Two weeks (to check for compliance
issues)

Follow up protocol conti

Three months (to teach the nightsand-naps protocol)
Every four months until age three
years (to monitorcompliance and
check for relapses)
Every six months until age 4 years
- Every one to two years until
skeletal maturity

EVALUATION OF PONSETI
METHODE
Ponseti methode evaluated by various
methodes but the most widely used in
litrature is the Pirani scoring
It has been proved that using this
scoring with ponseti methode gives
excellent results

PIRANI SCORING
Midfoot score
Three signs comprise the Midfoot
Score (MS), grading the amount of
midfoot deformity between 0 and 3.
Curved lateral border
Medial crease
Talar head coverage

PIRANI SCORING conti

Hindfoot score
Three signs comprise the Hindfoot
Score (HS), grading the amount of
hindfoot deformity between 0 and 3.
Posterior crease
Rigid equinus
Empty heel

MIDFOOT SCORE
LATERAL BORDER

MEDIAL CREASE

TALAR HEAD

HIND FOOT SCORE

POSTERIOR CREASE

RIGID EQUINUS

HEEL EMPTYNESS

OUT COME OF PONSETI METHODE

Various workers have given consistently
better results with this technique.
Lehman et al reported a response rate
of 92%.
Colburn and Williams reported a response
rate
of 94.1%.
Morcuende et al reported a response rate of
98%

Recurrence of CTEV treated by

ponseti methode
Morcuende et al reported a relapse
rate of 11% with the Ponseti
technique.
Herzenberg et al reported a relapse
rate of 3.7% with the Ponseti
technique

Treatment of recurrence
Relapses can be diagnosed by examining
the child walking.
Look for supination of the forefoot,
indicating an overpowering tibialis anterior
muscle and weak peroneals
Look for heel varus
The seated child should be examined for
ankle range of motion and loss of passive
dorsiflexion.

Reasons for relapses

The most common cause of relapse is

noncompliance to the post-tenotomy
bracing program.
Relapses occur in only 6% of compliant
families and more than 80% of
noncompliant families.
In compliant patients, muscle
imbalance of the foot is what causes
relapses.

Treatment of recurrence

Again full protocol of ponseti

If the child has persistent varus and
supination during walking , transfer of
tibialis anterior is indicated

THANKS