Congenital Talipes Equinovarus

How is Clubfoot Corrected?

The Ponseti Method

castingThe Ponseti Method is a simple, and in skilled hands, very effective method of treating clubfeet. It requires only skill, patience and plaster. The Doctor takes the baby’s foot in his or her hands and stretches the medial ligaments slightly and holds the foot in place while an assistant applies a cast. After a week, the first cast is cut away. The ligaments are stretched further, and a second cast goes on. Another week, another cast. The cycle typically continues for about four weeks. Then, in most cases, comes a procedure called a tenotomy. The tough and recalcitrant Achilles Tendon is severed. That loosens the foot for positioning before the final cast, which stays on for three weeks to give the Achilles time to heal. The foot abduction brace is used only after the clubfoot has been completely corrected by manipulation, serial casting, and possibly a heel cord tenotomy. The foot abduction brace, which is the only successful method of preventing a relapse, when used consistently as described is effective in > 95% of the patients.

» Read more about The Ponseti Method


Surgery – Posteromedial Release

This surgical method was once the popular standard. My son was born in 1993 and this is the treatment that was recommended to us. We deeply regret that we didn’t know about the Ponseti method. If your Doctor is recommending surgery, find a new Doctor one who is familiar with the Ponseti method. Surgery should only be considered if using the Ponseti method has been ruled out.

Like the Ponseti Method the Surgical Method also begins with serial plaster casting. Casting should be the full-leg cast not just to the knees as was done in Evan’s case. (See a comparison of photos on The Ponseti Method Checklist)

Posteromedial release, consists of releasing all the tight tendons and ligaments in the posterior and medial aspects of the foot, and repairing them in the lengthened position. More recently, it has been recognized that some of the lateral ligaments have to be released as well, to allow a complete release. The incision used may vary. After surgery, the foot needs to be casted followed by the use of splints to hold the correction.

When recurrence occurs, further surgery may be needed. These procedures are called:

  • Osteotomy: involves removing part of the bone, and
  • Arthrodesis: where two or more bones are fused together. The surgeon uses bone from somewhere else in the body.

Although their feet will be functional, some individuals may require 2 different shoe sizes.  There may be a leg-length discrepancy requiring modification of one shoe. It is normal that the calf muscle will be smaller and that there will be some degree of stiffness as scar-tissue builds up following surgery.  Arthritis is a common complaint of patients who were treated surgically.


SPLINTS/BRACES:

Are used as a follow-up after serial casting, or after casts applied at surgery.

    • The Ponseti Foot Aduction Brace – is designed to be more comfortable for the baby making it much easier to accept then the previous DBB. Parents are more able to use it and the baby will sleep through the night. [read more]

 

    • Denis Brown (DBB) type where boots or shoes are attached to a bar which can be adjusted gently daily, until eventually the feet are in the correct position. Dennis Browne Boots and Bar has commonly been used following serial casting to maintain the correction achieved during casting. It is now being replaced with the Ponseti AFO Foot Aduction Brace developed by Dr. Ponseti and John Mitchell pictured above.

 

  • Ankle-foot orthoses (AFO’s), is a hard rigid molded plastic splint held on with velcro worn on the lower leg and foot to support the ankle, hold the foot and ankle in the correct position, and correct foot-drop. This type of AFO was used for clubfoot surgical treatment methods and is not part of the Ponseti Method.

The French Physical Therapy technique

consists of daily visits with the physical therapist. Gentle, painless stretching of the foot is performed. The foot is then taped to maintain the improved position and is held this way until just before the next day’s visit. At night, the taped foot is placed into a continuous passive motion machine at home in order to maximize the amount of stretching. This is tolerated well by the infants. The tape is removed for two hours each day to allow for bathing, airing of the skin, and home exercises. Removable aquaplast splints are also used to reinforce the taped position. The one-hour physical therapy sessions are conducted five days each week for as long as three months (in very stiff feet). Taping is discontinued when the child starts to walk.


Botox

has also been used in conjunction with physical therapy and casting/splinting produced significant improvements in foot flexibility and in some cases surgery was not required. This method involves injecting calf muscles with a purified form of botulinum toxin (a deadly poison if injested).


The Ilizarov technique

has been used in the treatment of complex resistant clubfoot deformities. The Ilizarov technique involves placing tension wires through the bony structures of the clubfoot to realign the joint surfaces and foot anatomy. The Ilizarov external fixator also called the Ilizarov Aparatus is a very powerful tool that may also be used to stabilize fractures, regrow lost bone or correct deformities in the length rotation or angles of bones. [read more]

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