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Ponseti Technique in the Treatment of Clubfoot

Planning

B

Preoperative Plan

1

Radiographic templating

2

Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • casting materials
  • #6900 beaver plade

2

Room setup and equipment

  • OR table

3

Patient positioning

  • supine

Technique

D

Cavus Deformity Correction

1

Supinate the pronated foot

2

Elevate the first metatarsal

3

Place a well molded plaster cast with the forefoot supinated and a mold under the first metatarsal

  • this will maintain all the metatarsal heads in a row
E

Forefoot Adductus and Hindroot Varus Correction

1

Manipulate the forefoot

  • abduct the forefoot against counterpressure on the head of the talus
  • make sure the counterpressure is not on the fibula or the calcaneocuboid joint
  • this will correct the metatarsus adductus by reduction of the metatarsals and the navicular on the head of the talus and the cuboid on the calcaneus
  • with further casting the calcaneus will begin to evert and abduct under the talus
  • the hindfoot will then begin to convert from varus to neutral or valgus
  • it is critical to perform abduction with the foot in with the forefoot in supination and the foot in equinus so that the calcaneus can evert and abduct underneath the talus

2

Perform serial maniulations and casting

  • perform weekly manipulations and castings with the forefoot in supination and with the foot in equinus until full correction of forefoot adduction and hindfoot varus is obtained
F

Equinus Correction

1

Prepare for the tenotomy

  • prepare the area with Betadine prep
  • if performing in the office, place topical anesthetic to the area of the tenotomy 45 minutes before the procedure

2

Position the extremity

  • have an assistant hold the knee
  • position the foot to avoid excessive dorsiflexion
  • be aware of the location of the medial neurovascular bundle and remember the elevated calcaneal pitch

3

Perform a heel cord tenotomy

  • perform the tenotomy about 1.5 cm above the palpable tuberosity of the calcaneus
  • insert a #6900 beaver blade or # 11 blade medial to the tendon edge
  • rotate the blade laterally so that is lies partially anterior to the Achilles tendon
  • use a the contralateral finger to push the Achilles tendon against the blade to complete the tenotomy

4

Confirm that complete tenotomy has been performed

  • complete tenotomy is confirmed when there is an audible pop and there is an increase in dorsiflexion of approximately 20 degrees
G

Casting of the Tenotomy

1

Prepare the surgical site for casting

2

Place the cast

  • place a well molded plaster cast over a sterile cotton roll over the tenotomy site
  • apply the cast with maximum dorsiflexion and abduction of the foot
  • place mold over talar head for counter pressure

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • check range of motion

2

Screen medical studies to identify and contraindications for surgery

3

Orders appropriate initial imaging and laboratory studies

4

Perform operative consent

  • describe complications of surgery including
  • residual deformity
  • recurrence
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain control
  • schedule follow 3 weeks
  • wound care
M

Intermediate Evaluation and Management

1

Obtains focused history and physical

  • history
  • symptoms
  • physical exam
  • recognizes factors that could predict complications or poor outcome

2

Orders and interprets required diagnostic studies

  • radiographs

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Postop: 3 Week Postoperative Visit

  • diagnose and management of early complications
  • place the child in a foot abduction orthosis after correction
  • this consists of two shoes that are attached to a bar that maintains the foot in external rotation
  • keep the feet at shoulder width
  • the shoes are placed in the degree of external rotation that was achieved in the last cast
  • if this is unilateral correction, the unaffected foot is placed into 35 degrees of external rotation
  • return to the clinic at intervals of 1 month, 3 months 6 months and 12 months from final cast removal
  • maintain patient in FAO full time x3 months, followed by nighttime/naptime until 3 years old
N

Advanced Evaluation and Management

1

Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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