Clubfoot:

Overview of Ponseti technique and Operative Management

Andre Yanuar
Dept. of Orthopaedic & Traumatology Hasan Sadikin General Hospital Medical School of Padjadjaran University Bandung

Introduction
One in every 1000 live births Autosomal dominant Bilateral deformities occur in 50% of patients Three basic components : equinus, varus, and adduction deformities

Anatomy

Anatomy

Talonavicular capsule

Anatomy

(Spring lig.)

Anatomy

Anatomy

Biology
Clubfoot is not an embryonic malformation. A normally developing foot turns into a clubfoot during the second trimester of pregnancy. Clubfoot is rarely detected with ultrasonography before the 16th week of gestation Clubfoot is a developmental deformation.

Biology
Thickening of deltoid, tibionavicular ligament, and the tibialis posterior tendon and to merge with the short plantar calcaneonavicular ligament. The interosseous talocalcaneal ligament is normal. Fibers to be wavy and densely packed. The cells are very abundant, and many have spherical nuclei

A 17-week-old male fetus with bilateral clubfoot

Biology
The shape of the tarsal joints is altered relative to the altered positions of the tarsal bones. The forefoot is in some pronation plantar arch more concave (cavus). Increasing flexion of the metatarsal bones is present in a lateromedial direction. Excessive pull of the tibialis posterior abetted by the gastrosoleus, the tibialis anterior, and the long toe flexors.

Increase of connective tissue rich in collagen in the distal end of the gastrosoleus

Biology
The ligaments of the posterior and medial aspect of the ankle and tarsal joints are very thick and taut The size of the leg muscles correlates inversely with the severity of the deformity. Excessive collagen synthesis in the ligaments, tendons, and muscles may persist until the child is 3 or 4 years of age and might be a cause of relapses.

Biology
Increase of collagen fibers and cells in the ligaments of neonates. The bundles of collagen fibers display a wavy appearance known as crimp. This crimp allows the ligaments to be stretched. Gentle stretching of the ligaments in the infant causes no harm. The crimp reappears a few days later, allowing for further stretching. Manual correction of the deformity is feasible.

Kinematics

Kinematics
No single axis of motion exists on which to rotate the tarsus, whether in a normal or a clubfoot. The tarsal joints are functionally interdependent. The movement of each tarsal bone involves simultaneous shifts in the adjacent bones.

Joint motions are determined by the curvature of the joint surfaces and by the orientation and structure of the binding ligaments.

Kinematics
Each joint has its own specific motion pattern. Correction of the extreme medial displacement and inversion of the tarsal bones necessitates a simultaneous gradual lateral shift of the navicular, cuboid, and calcaneus before they can be everted into a neutral position.

These displacements are feasible because the taut tarsal ligaments can be gradually stretched

Kinematics

Talonavicular joint

Calcaneocuboid joint

Roentgenographic Evaluation

Roentgenographic Evaluation
Normal Range of Roentgenographic Angles for Comparison to Clubfoot

Management
Serial manipulation & casting Kite Lovell and Hancock Ponseti

Classification

Steps of clubfoot management (Ponseti)

Details of the Ponseti Technique

Details of the Ponseti Technique

Details of the Ponseti Technique

Details of the Ponseti Technique

Appearance of casts and foot

Foot appearance after the fourth cast

Steps in cast application

Cast removal

Equinus Correction and Fifth Cast

Bracing

Pirani Severity Scoring

Pirani Severity Scoring

Use of Pirani score 1. Every clubfoot under Ponseti management is scored each week for HS, MS, and total score 2. Plotting scores on a graph shows where the foot is on the roadmap of treatment, visually and easily reassuring parents of satisfactory progress. 3. Tenotomy is indicated when HS > 1, MS < 1, and the head of the talus is covered.

Pirani Severity Scoring

Operative Treatment
Indication Do not respond to conservative treatment Significant rigid clubfoot deformity

Operative Treatment
What kind of operation ? Posterolateral release Posteromedial release (Turco) - Transverse circumferential (Cincinnati)
- Extensile Posteromedial & Posterolateral Release (Modified McKay) - Tendo Calcaneus Lengthening & Posterior Capsulotomy

Operative Treatment
General principles for any one-stage extensile clubfoot release : Proper hemostasis Careful subcutaneous and skin closure

Operative Treatment
Transverse Circumferential (Cincinnati) Incision

Provide excellent exposure of the subtalar joint Useful for severe internal rotational deformity of the calcaneus

Operative Treatment
Transverse Circumferential (Cincinnati) Incision

Problem : tension on the suture line

HOW TO OVERCOME THIS PROBLEM? Adaptive casting V-Y flaps (Lubicky and Altiok, 2001)

Operative Treatment
Transverse Circumferential (Cincinnati) Incision

Lubicky JP, Altiok H : Regional fasciocutaneous flap closure For clubfoot surgery, J Pediatr Orthop 21:50, 2001

Operative Treatment
Transverse Circumferential (Cincinnati) Incision

Circumferential incision Extend distally either medially or laterally

Operative Treatment
Extensile Posteromedial and Posterolateral Release (Modified Mc Kay Procedure)
Cincinnati incision Preserve Vein & Protect Sural nerve Dissect subcutaneous tissue Lengthen Achilles tendo Separate Calcaneofibular & posterior calcaneotalar ligaments, superior peroneal retinaculum & peroneal tendon sheath Cut off calcaneofibular ligament

Operative Treatment
Extensile Posteromedial and Posterolateral Release (Modified Mc Kay Procedure)

Incise lateral talocalcaneal ligament & lateral capsule Dissect free the neurovascular bundle Enter the compartment of the medial plantar neurovascular bundle Elevate the abductor hallucis muscle & sheath of post. tibial, FHL, FDL tendon

Operative Treatment
Extensile Posteromedial and Posterolateral Release (Modified Mc Kay Procedure)

Section the narrow strip fascia Enter the sheath of the tendon Split the sheath and superficial deltoid lig. Lengthen the posterior tibial tendon Open the talonavicular joint Incise talonavicular joint capsule Incise the remaining medial & posteromedial capsule & sup. deltoid lig.

Operative Treatment
Extensile Posteromedial and Posterolateral Release (Modified Mc Kay Procedure)

Retract lateral plantar nerve Detach the origin of the quadratus plantae muscle Expose long plantar ligament & peroneus longus tendon Roll back the tallus Dividing the interosseus talocalcaneal lig.?

Operative Treatment
Extensile Posteromedial and Posterolateral Release (Modified Mc Kay Procedure)

Pass a 0.062-inch K-wire through the talus from the posterior aspect to the middle of the head. Push the calcaneocuboid joint anterior to the ankle joint Suture all tendon snugly with the foot maximum of 20o of dorsiflexion Pull the sheath of FHL & FDL tendon over

Operative Treatment
Extensile Posteromedial and Posterolateral Release (Modified Mc Kay Procedure)

Reposition the lengthened posterior tibialis tendon Repair the sheath beneath the medial malleolus Keep the peroneal tendons & sheaths from subluxating around the fibula Close the subcutaneous tissue & skin with interrupted sutures Holding the foot in a neutral or slightly plantarflexed position in casting

Operative Treatment
Extensile Posteromedial and Posterolateral Release (Modified Mc Kay Procedure)

Bilateral clubfoot deformities before modified McKay procedure

Operative Treatment
Extensile Posteromedial and Posterolateral Release (Modified Mc Kay Procedure)

Five-year-old child had bilateral modiefied McKay procedure at 6 months of age

Operative Treatment
Tendo Calcaneus Lengthening and Posterior Capsulotomy
Straight longitudinal incision over medial aspect Sharp dissection through the subcutaneous tissue Protect the neurovascular bundle Calcaneus tendon lengthening Perform transverse capsulotomy at the most medial aspect Apply a long leg, bent-knee cast with the foot in 5o of dorsiflexion

Aftertreatment
The cast is removed 6 weeks after surgery Post-op bracing can be used for 6 to 0 months longer