JOURNAL CLUB Orthopaedic Unit, MMC Orthopaedic Unit, MMC Chairperson: Chairperson: Asst. Prof. Dr. Humayun Kabir Asst. Prof. Dr. Humayun Kabir Department.

JOURNAL CLUBJOURNAL CLUB

Orthopaedic Unit, MMCOrthopaedic Unit, MMC

Chairperson:Chairperson: Asst. Prof. Dr. Humayun KabirAsst. Prof. Dr. Humayun Kabir

Department of Department of

Orthopedic Surgery, MMC.Orthopedic Surgery, MMC.

Speaker:Speaker: Dr. Md. Tariqul Islam Dr. Md. Tariqul Islam

(D-Ortho Resident)(D-Ortho Resident)

The Ponseti Technique for the The Ponseti Technique for the Treatment of Congenital Club FootTreatment of Congenital Club Foot

By Md. Jahangir Alam, Kh. Abdul Awal By Md. Jahangir Alam, Kh. Abdul Awal Rizvi, Md. Sajjad Husain, Sk. Nurul Rizvi, Md. Sajjad Husain, Sk. Nurul Alam, A.F.M Ruhul Haque.Alam, A.F.M Ruhul Haque.

NITOR, Dhaka, Bangladesh.NITOR, Dhaka, Bangladesh.

Published in thePublished in the “The Journal of “The Journal of Bangladesh Orthopaedic Society”Bangladesh Orthopaedic Society”

Volume: 24 Number 1 January 2009Volume: 24 Number 1 January 2009

Introduction:Introduction:

- Congenital club foot or congenital Congenital club foot or congenital talepes equinovarous (CTEV) is the talepes equinovarous (CTEV) is the commonest congenital deformity is commonest congenital deformity is seen in orthopaedic practice. seen in orthopaedic practice.

- It is the complex deformity that is It is the complex deformity that is difficult to correct. It has a tendency difficult to correct. It has a tendency to recur until the age of 3 or 4. to recur until the age of 3 or 4.

- The recurrence in an adolescent is The recurrence in an adolescent is usually associated with incomplete usually associated with incomplete correction & inadequate follow up correction & inadequate follow up rather than being secondary to rather than being secondary to growth alone. growth alone.

- The deformity has four components, - The deformity has four components, Equinus, Varus, Adductus & Cavus.Equinus, Varus, Adductus & Cavus.

- The goal of treatment is to reduce or The goal of treatment is to reduce or eliminate these four deformities, so eliminate these four deformities, so that the patient has a functional, that the patient has a functional, pain free, plantigrade foot, with good pain free, plantigrade foot, with good mobility and without calluses and mobility and without calluses and does not needed to wear modified does not needed to wear modified shoes.shoes.

- The success of manipulation and serial The success of manipulation and serial application of plaster cast varies with application of plaster cast varies with the age of the patient, severity of the age of the patient, severity of deformity, skilness of the orthopaedic deformity, skilness of the orthopaedic surgeon and understanding of the surgeon and understanding of the deformity by the orthopaedic surgeon. deformity by the orthopaedic surgeon. It is much easier to correct a club foot It is much easier to correct a club foot deformity in the first days of life than deformity in the first days of life than after even a few weeks.after even a few weeks.

- Manipulation and serial application of Manipulation and serial application of plaster casts supported by limited plaster casts supported by limited operative intervention (Percutaneous operative intervention (Percutaneous tenotomy) Yielded satisfactory tenotomy) Yielded satisfactory functional results in 94% of the foot in functional results in 94% of the foot in ponseti clinic by ponseti technique. ponseti clinic by ponseti technique.

- In some centre early and even primary In some centre early and even primary operative treatment of club foot is operative treatment of club foot is practiced but often some failure practiced but often some failure complication are common such as complication are common such as wound infection, necrosis of the skin, wound infection, necrosis of the skin, severe scarring, stiffness of the joint, severe scarring, stiffness of the joint, overcorrection and under correction, overcorrection and under correction, dislocation of navicular, flattening and dislocation of navicular, flattening and breaking of talar head, talar necrosis, breaking of talar head, talar necrosis, weakness of planter flexor or ankle with weakness of planter flexor or ankle with major disturbance of gait.major disturbance of gait.

Some people believe as ponseti does Some people believe as ponseti does that “The successful non operative or that “The successful non operative or limited operative treated foot is much limited operative treated foot is much better than the successful surgically better than the successful surgically treated foot.treated foot.

February 2nd and 3rd

Ponseti Seminars 2007Ponseti Seminars 2007

March 23rd and 24th

May 25th and 26th

June 15th and 16th

July 6th and 7th

August 17th and 18th

September 28th and 29

December 7th and 8th

November 23rd and 24th

Brazilian States with training in Ponseti technique

Patho-anatomy:Patho-anatomy:

John Herzenberg stated three dimensional C.T. of John Herzenberg stated three dimensional C.T. of club foot deformities these are comprises of –club foot deformities these are comprises of –

1.1. Navicular bone is severely medially displaced.Navicular bone is severely medially displaced.

2.2. Talus is in severe planter flexed, its neck is Talus is in severe planter flexed, its neck is medially and planterly deflected and head is medially and planterly deflected and head is wedge shaped. Body of talus is externally rotated wedge shaped. Body of talus is externally rotated within the ankle mortes.within the ankle mortes.

3.3. Calcaneus is adducted and inverted under the Calcaneus is adducted and inverted under the talus.talus.

4.4. Calcanocuboid joint is distorted and cuboid is Calcanocuboid joint is distorted and cuboid is under beneath of navicular boneunder beneath of navicular bone

Biology of soft tissue:Biology of soft tissue:

- Under the microscope, there found increase of - Under the microscope, there found increase of collagen fibers and cells in the ligaments of collagen fibers and cells in the ligaments of neonates. neonates.

- The bundle of collagen fibers display a wavy The bundle of collagen fibers display a wavy appearance known as crimp. appearance known as crimp.

- The crimp allows the ligaments to be stretched.The crimp allows the ligaments to be stretched.- Gentle stretching of the ligaments in the infant Gentle stretching of the ligaments in the infant

causes no harm. causes no harm. - The crimp reappears a few days latter, allowing for The crimp reappears a few days latter, allowing for

further stretching. further stretching. - That is why manual correction of the deformity is That is why manual correction of the deformity is

feasible.feasible.

Fig: A photomicrograph of the tibionavicular Fig: A photomicrograph of the tibionavicular ligament showing the collagen fibers to be ligament showing the collagen fibers to be wavy and densely packed.wavy and densely packed.

Materials and Method:Materials and Method: Type of study: This was prospective Type of study: This was prospective

clinical study.clinical study. Place of the study: NITOR, Sher-e- Bangla Place of the study: NITOR, Sher-e- Bangla

Nagar, Dhaka – 1207.Nagar, Dhaka – 1207. Duration of study: From January 2005 to Duration of study: From January 2005 to

December 2008.December 2008. Study Population: Patient with CTEV Study Population: Patient with CTEV

attending at OPD of NITOR. attending at OPD of NITOR. Age group: 07 days to 20 months of age.Age group: 07 days to 20 months of age. Sex Group: Both male and female.Sex Group: Both male and female. Sample size: 175 ft of 100 patients.Sample size: 175 ft of 100 patients.

Details of the patient Ponseti technique:Details of the patient Ponseti technique:

The corrective process utilizing can The corrective process utilizing can be divided into two phases –be divided into two phases –

1.1. The treatment phaseThe treatment phase

2.2. The maintaining phase The maintaining phase

A. The treatment Phase:-A. The treatment Phase:-

The initial manipulation for 60 sec.The initial manipulation for 60 sec. Plaster cast application 4 to 6 times Plaster cast application 4 to 6 times

for correction of cavus, for correction of cavus, addactus ,varus and corrective addactus ,varus and corrective equines.equines.

Residual equines correction by Residual equines correction by percutaneus hell cord tenotomy. percutaneus hell cord tenotomy.

Fig: Manipulation of Club foot.Fig: Manipulation of Club foot.

Fig: Gradual correction of club foot by Fig: Gradual correction of club foot by serial plaster cast.serial plaster cast.

Percutaneous Tenotomy: Percutaneous Tenotomy:

After proper positioning, knife (BP Blade-After proper positioning, knife (BP Blade-15/11 size) was placed parallel to tense 15/11 size) was placed parallel to tense tendoachillis approximately 1 cm above tendoachillis approximately 1 cm above the insertion at calcaneus. the insertion at calcaneus.

Then blade is turn 90 degree, Then blade is turn 90 degree, perpendicular to tendon. perpendicular to tendon.

Then tendon is cut from medial to lateral Then tendon is cut from medial to lateral direction. direction.

A “POP” is felt as the tendon is released. A “POP” is felt as the tendon is released. An additional 10 to 15 degree of An additional 10 to 15 degree of

dorsiflexion is typically gained after dorsiflexion is typically gained after tenotomy. tenotomy.

B. Maintenance Phase:B. Maintenance Phase:

It is maintained by Danis browne It is maintained by Danis browne splint. Splinting started after the splint. Splinting started after the removal of final cast or tenotomy removal of final cast or tenotomy cast, 3 weeks after tenotomy. cast, 3 weeks after tenotomy.

Splint wear initial 3 months for at Splint wear initial 3 months for at least 23 hours of a day and then 12 least 23 hours of a day and then 12 to 14 hours of a day up to 3 to 4 to 14 hours of a day up to 3 to 4 years of the patient years of the patient

Result:Result:

Age of the patient ranges from 07 days Age of the patient ranges from 07 days to 20 months, sex were both male and to 20 months, sex were both male and female, bilateral – 75 and unilateral – female, bilateral – 75 and unilateral – 25, no. of plaster ranges from 4 to 6 ( 4 25, no. of plaster ranges from 4 to 6 ( 4 plaster- 20 patients, 5 plaster - 30 plaster- 20 patients, 5 plaster - 30 patient and 6 plaster – 50 patient), patient and 6 plaster – 50 patient), Patients were treated by only plaster Patients were treated by only plaster cast – 70 feet ( 40%) along with cast – 70 feet ( 40%) along with tenotomy 105 feet (60%).tenotomy 105 feet (60%).

The result is regarded as Dr. Shafiq The result is regarded as Dr. Shafiq Pirani score by six clinical sign which is Pirani score by six clinical sign which is either 0 (normal), 0.5 (moderately either 0 (normal), 0.5 (moderately abnormal) and 1 (severely abnormal). abnormal) and 1 (severely abnormal). Final result – 140 feet were excellent Final result – 140 feet were excellent with pirani score- 0, 30feet were good with pirani score- 0, 30feet were good with pirani score- 0.5 and 05 feet were with pirani score- 0.5 and 05 feet were satisfactory with pirani score – 1.satisfactory with pirani score – 1.

Discussion:Discussion:

The goal of treatment is to reduce or The goal of treatment is to reduce or eliminate this deformity. So that patient eliminate this deformity. So that patient has a functional, pain free, plantigrade has a functional, pain free, plantigrade foot, with good mobility without foot, with good mobility without callucess, and does not need to wear callucess, and does not need to wear modified shoes. modified shoes.

The conventional treatment of club foot The conventional treatment of club foot (CTEV) is serial plaster, two weekly or three (CTEV) is serial plaster, two weekly or three weekly up to seven or eight plaster or surgery weekly up to seven or eight plaster or surgery (PMR) in different methods or approaches. All (PMR) in different methods or approaches. All the procedures have different complications the procedures have different complications like inadequate correction, stiffness, and like inadequate correction, stiffness, and weak, sever scar and often painful foot. On weak, sever scar and often painful foot. On the other hand ponseti technique yielded the other hand ponseti technique yielded satisfactory anatomical and functional result, satisfactory anatomical and functional result, with simple, effective, minimally invasive, with simple, effective, minimally invasive, inexpensive and ideally suited for all inexpensive and ideally suited for all countries culturescountries cultures

The difficult part of the study is The difficult part of the study is maintenance of bracing protocol. The maintenance of bracing protocol. The patients reported that initial 2 or3 patients reported that initial 2 or3 days were the critical period, during days were the critical period, during which patients were restless and tried which patients were restless and tried to remove the splint. After that the to remove the splint. After that the patients were adjusted with the splint. patients were adjusted with the splint.

Author agree with the most of the Author agree with the most of the author that correction of foot also author that correction of foot also depend on the brace protocol. To make depend on the brace protocol. To make it complaints, parents should be tought it complaints, parents should be tought about the advantage and disadvantage about the advantage and disadvantage to gain the more success rate during to gain the more success rate during the maintain phase of the ponseti the maintain phase of the ponseti technique.technique.

Conclusion:Conclusion:

The treatment of congenital club foot The treatment of congenital club foot (CTEV) by ponseti technique is very (CTEV) by ponseti technique is very effective method with excellent result effective method with excellent result and negligible morbidity.and negligible morbidity.

The method is simple, effective, The method is simple, effective, minimally invasive, inexpensive, ideally minimally invasive, inexpensive, ideally suited for all countries and culture and suited for all countries and culture and usually performed at out patient usually performed at out patient department. department.