Ponseti Technique

 

Maintenance and Recurrence Prevention
Upon removal of the final cast, the infant is placed into an orthosis or brace which maintains the foot in its corrected position. The purpose of this splinting, after the casting phase in the Ponseti method, is to maintain the foot in the proper position, with the forefeet set apart and pointed upward. This is accomplished with a brace consisting of shoes mounted to a bar. (Figure 7)
Image of the foot orthotic.
Figure 7: Image of the foot orthotic.
The brace is worn 23 hours per day for the first 3 months following casting and then while sleeping for several years to follow, usually until around age three or four. Two recent studies have demonstrated the high risk for recurrence if the brace is not worn according to these guidelines. The reasons for recurrence in feet that appear to be fully corrected have not yet been clearly proven, but regardless of the cause, recurrence appears to be close to zero when the bracing regimen is followed accurately. In one study, researchers reported no recurrences among patients compliant with the foot abduction orthosis compared with 57% recurrence among non-compliant patients when studied at short-term follow-up. (Thacker MM, Scher DM, Sala DA, et al: Use of the foot abduction orthosis following Ponseti casts: Is it essential? J Pediatric Orthop 25:225-228, 2005)

Management of Recurrence
The risk of recurrence persists for several years after the casting is completed. Ponseti reported a recurrence rate of approximately 50% in his early series, but noted a decrease with greater emphasis placed on the use of the foot orthotic. Early recurrences are best treated with several long-leg plaster casts applied at two-week intervals. The first cast may require correction of recurrent foot deformity, with subsequent casts to correct ankle tightness. An Achilles tendon lengthening may be necessary if there is insufficient correction at the ankle, and a tendon transfer (of the tibialis anterior tendon) may be performed in older children to help maintain the correction. Following this additional surgery, the child is then placed in a long-leg cast for four weeks with the foot in neutral position.
Conclusion: The Treatment of Choice for Children with Clubfeet
The Ponseti technique is gaining widespread acceptance as the treatment of choice for infants with clubfeet. It is now even implemented in several third-world countries, where it is supported by their national health systems and administered by casting specialists and technicians. If a child's physician meticulously follows the details of this technique and applies all of the elements without modification, parents can expect optimal results in the short and long term for children with clubfeet.

 
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