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Weekly manipulation and application of long leg casts
3%
38/1232
Achilles tenotomy is indicated for residual equinus before final cast application
7%
88/1232
Pronation of the foot during initial cast correction
77%
953/1232
Abduction of the foot with counterpressure at the talus
6%
71/1232
Correction of adduction deformity prior to equinus
69/1232
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Clubfoot is chrarcterized by hindfoot equinus and varus along with midfoot and forefoot adduction and cavus. A helpful acronym is "CAVE" which describes both the clinical position and the general order of deformity correction. The Ponseti casting technique as described in the articles by both Ponseti and Cummings et al has markedly impacted the way clubfoot patients are treated. Cavus is first corrected with forefoot supination (NOT pronation) and aligning the plantar-flexed first ray with the remaining metatarsals. An attempt to correct the inversion of the foot by forcible pronation of the forefoot increases the cavus deformity as the first metatarsal is plantar-flexed further. Metatarsus adductus and hindfoot varus are then simultaneously corrected by abducting the foot and applying counter pressure laterally at the talar head. Meanwhile, foot supination is slowly decreased during each successive casting. Equinus is corrected last and should only be attempted when the hindfoot is in neutral to slight valgus position. This can be done through progressive stretching and casting or by a cutaneous heel cord tenotomy as is done in 70 to 75% of patients. Level 3 evidence from Herzenberg et al showed that with the Ponseti technique, only 1 (3%) of 34 feet required open posteromedial release(PMR). In the control group of traditional casting, 32 (94%) of 34 feet required PMR within the first year of life, despite a longer casting period.
4.2
(20)
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