• First correct cavus with forefoot SUPINATED (NOT pronated) by aligning the less varus forefoot with the more varus hindfoot (pronation would increase cavus deformity) • Secondly correct adduction and heel varus by rotating calcaneus and forefoot around talus (head of talus acts as a fulcrum) into forefoot ABDUCTION
• Equinus correction last with tendinoachilles tenotomy • Perform when foot is at least 60° abducted, heel is in valgus and equinus persists • Cast in maximal dorsiflexion for 3 weeks after tenotomy
• With FAO holding affected feet at least 60°external rotation and 30° in normal foot for unilateral cases
• Feet are measured prior to tenotomy so FAO is available on the day of post-tenotomy cast removal
• 30-50% will need TA transfer with or without repeat TAL or gastrocnemius recession for recurrent deformity• Indicated if the patient demonstrates supination during gait
• Daily corrective manipulations of the clubfoot are performed by an experienced physical therapist and the correction is held with elastic taping and splints until the next day's session.
• Family participation is integral to the success of this treatment program as the family must be able to bring the infant to therapy during the week for 1-3 months
• Each session lasts approximately 30 mins per foot and manipulations are performed in a progressive gentle pattern
• Begin with derotation of the calcaneopedal block and correction of forefoot adduction through massage of the Achilles tendon and gastrocnemius muscle
• Next, medial soft tissues are stretched to allow the navicular to move away from the medial malleolus and its medial position on the head of the talus . Distraction of the forefoot and midfoot helps to loosen the tightened structures, and derotation of the foot facilitates reduction of the talus
• To maintain the gain achieved in passive range of motion, the toe extensors and peroneals are recruited by stimulating (tickling) the lateral border of the foot and leg and the tops of the toes
• Once the talonavicular joint has been reduced, attention is directed toward the correction of varus and equinus. With the valgus maneuver, the calcaneus gradually moves to a neutral and eventually valgus position . The ankle is externally rotated at the same time that the calcaneus is being mobilized into valgus. The knee should be kept at 90° during these maneuvers
• Equinus is corrected with gradual dorsiflexion of the foot. Correction of equinus can be augmented with a percutaneous heel cord tenotomy
• Fewer visits to the therapist are needed as the parents assume the daily treatment exercises and taping
• Periodic follow-up is needed to monitor the range of motion of the foot and the development of the infant and to fabricate new splints
• Once the patient is walking, taping is discontinued and a resting ankle-foot orthosis is used during nighttime and naps until the age of two years.
• Throughout this treatment program, the patient visits the physician every two to three months for evaluation of the foot
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Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A tibialis anterior transfer is appropriate for which of the following patients with clubfoot?
Newborn with forefoot adduction
3-year-old with a foot that supinates when he dorsiflexes
6-month-old residual equinus after casting
5-year-old boy with a fixed hindfoot varus
2-year-old with a foot that pronates when he plantarflexes
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Which of the following photographs is most consistent with pediatric clubfoot deformity?
A 3-week-old infant presents with the unilateral foot deformity displayed in Figure A. All of the following are key concepts for treatment of this deformity with manipulation and serial casting EXCEPT:
Forefoot is supinated and not pronated during correction
Forefoot abduction with lateral pressure on the talus
Percutaneous achilles tenotomy done before final cast application for residual equinus
Weekly cast changes
The last cast is applied with the foot in 30 degrees of abduction
A 3-year-old boy has been treated in the past with Ponseti casting now presents with dynamic supination during gait. You're planning to perform an anterior tibialis transfer to the lateral cuneiform. All of the following are true EXCEPT:
This transfer is required in 10-20% of children who undergo the Ponseti treatment
Weak peroneals are counteracted by overpull of the anterior tibialis
Grade 4 or 5 strength of the anterior tibialis is needed prior to transfer
Subtalar rigidity supplements the transfer
Dynamic supination includes foot supination during swing phase and landing on the lateral foot border during stance phase
A 19-year-old female presents with metatarsalgia and difficulty with wearing closed-toe shoes on her left foot. She is found to have a muscular strength imbalance between the anterior tibialis and peroneus longus on the left side. A clinical image and lateral foot radiograph are shown in Figures A and B, respectively. Which congenital condition most likely contributed to the development of the current foot deformity?
Congenital calcaneonavicular coalition
Congenital vertical talus
Congenital oblique talus
Congenital talipes equinovarus
Which of the following components of the clubfoot deformity should be addressed first when using the Ponseti method?
Residual cavus after surgical correction of a clubfoot deformity with comprehensive clubfoot release and pinning is caused by what technical error?
Inadequate Achilles tendon lengthening
Failure to correct hindfoot valgus
Failure to perform a posteromedial imbrication
Placement of the navicular in a dorsally subluxated position
Failure to perform a lateral column lengthening
In patients with clubfeet treated with soft-tissue release, which of the following variables shows the greatest correlation with long-term functional impairment.
Extent of soft-tissue release
Subtalar joint function
Ankle joint function
Peroneal muscle function
Duration of cast treatment
A 6-week-old boy presents with bilateral lower extremity deformities shown in Figure A. All of the following are true regarding the Ponseti technique for correction of this congenital deformity EXCEPT:
Weekly manipulation and application of long leg casts
Achilles tenotomy is indicated for residual equinus before final cast application
Pronation of the foot during initial cast correction
Abduction of the foot with counterpressure at the talus
Correction of adduction deformity prior to equinus
Figure A shows a lateral radiograph of an 9-month old's dorsiflexed foot. What is the first line treatment for this condition?
Manipulation under anesthesia followed by a single casting
Serial manipulation and casting followed by surgical release and talonavicular reduction with pinning
A 4-year-old boy demonstrates excessive supination occuring during the swing phase of gait following Ponseti casting for an isolated right clubfoot. Which of the following sites identified in Figure A shows the correct destination for the transferred tendon in order to balance the foot and eliminate the supination?
A 5-year-old boy has a history of being treated with the Ponseti technique for a unilateral clubfoot. What muscle most commonly causes a dynamic deformity in the swing phase of gait following Ponseti casting?
A 16-year-old female complains of foot pain with ambulation. She previously underwent clubfoot soft tissue releases at 5 months of age. Each of the following are complications or late deformities associated with clubfoot surgery EXCEPT:
Osteonecrosis of the talus
Rigid pes planus
Tarsal tunnel syndrome
HPI - neglected clubfoot treatment in childhood
How would you treat this patient