Prof. Anisuddin Bhatti Paediatric Orthopaedic surgeon Dr. Ziauddin University hospital Clifton Karachi Pakistan Presented Principles & practice in Clubfoot at AKU Orthopaedic Review Course. October 2023. Acknowledged for Some text material & Photo taken from Global Health publication on Ponseti Clubfoot treatment & internet media.

1. CFD & VT AKU August 2023

6. Presence of other Congenital
Anomaly, indicates
Syndromic Clubfoot, which
may have treatment
protocols and outcomes that
differ from Idiopathic
clubfeet.
2. Establish the type of CFD
Typical, Atypical, Complex, Syndromic

7. Lime Container
Potters
Surgery
Solar therapy
French
Kites
3. Previous Treatment
The previous treatment
received for clubfoot and
the nature of the prior
treatment, is very
important to further
guide for classification
and treatment.

8. • Non-weight bearing
and weight bearing
clubfeet are subject
to different forces,
which affect growth
and pathology.
• Prognosis, treatment
and outcomes can be
affected by these
differing forces.
6 yrs aged & 10 yrs aged Untreated Walking
4. Walking or Not walking
Untreated Non-Walking

9. • The presence or absence of a
complete, deep, transverse plantar
crease (Plantaris) differentiates
between Untreated Not-walking
Clubfoot -Typical (with only medial crease,
the most common form and Atypical
Clubfoot.
• The Plantaris indicates an underlying
congenital pathology, in contrast to a
classification of Complex Clubfoot, in
which the pathology is acquired
following previous treatment.
Iatrogenic: A complete, deep, transverse
plantar crease (Plantaris) in a Complex CF
following casting
Atypical
Typical
Complex
5. Presence of planter Crease

10. Complex
Syndromic
Untreated Non-walking
Atypical
Diagnosis
&
Classification
Untreated Walking
Summary

11. Misdiagnosed as CFD
Positional CFD
Meta Tarsus Adductus
No Equinus component, More flexible

12. • Ponseti and Smoley 1963
• Harrold & Walker 1983
• Goldner & Fitch, 1994
• Dimeglio et al, 1995
• Pirani 1995
Classification
& Severity

13. Pirani’s severity scoring
It is helpful to use this scoring system and document the results every time the feet
are examined: before the treatment, during the correction phase, during the bracing
phase and at later check ups.
• 6 clinical signs of a Clubfoot are compared to a normal foot.
o3 signs evaluate the Mid Foot Contracture (MFC)
o3 signs evaluate the Hind Foot Contracture (HFC).
• Each sign is scored with:
o 0 = no abnormality
o 0.5 = moderate abnormality
o 1 = severe abnormality
• Higher score indicates a more severe deformity.
• Scoring should be done each visit during treatment.
Pirani s et al.1995
Very good interobserver reliability and reproducibility

15. 3 signs of Hind Foot Contracture (HFC).
1.Posterior crease
2.Empty heel
3.Rigid Equinus

16. 3 signs of Mid Foot Contracture (MFC).
4. Medial crease
5. Curved lateral border
6. Talar head coverage [C]

23. Clubfoot Deformity
Rx
Principles & Practice
Hiram Kite
Bansahel & Masse
Functional / French
Daily Manipulation
& Straping
I.V Ponseti

24. Concept of Coupled Movement
Peri-Talar Joints: TNJ, CCJ & STJ
(1) The movements at Ankle and Sub-Talar
joint are coupled movement and it is almost
impossible to reproduce them independently
without effecting the other joint.

25. CONCEPT OF COUPLED MOVEMENT
TNJ,CCJ & SUBTALAR JOINTS
(2) Owing to interdependence of tarsal joints the
correction of adduction with fulcrum at the head
of talus, simultaneously corrects the varus of the
heel.
(3) Therefore, the heel varus & supination of foot will
automatically get corrected when entire foot is
fully abducted under the talus.
“Ponseti’s Basic Principle” 1948-1963

26. Biological Evidence Supporting
Ponseti technique
Viscoelastic Properties
• THE GENES RESPONSIBLE FOR
CLUBFOOT DEFORMITY ARE
ACTIVE STARTING FROM THE
12TH TO THE 20TH WEEKS OF
FETAL LIFE AND LASTING UNTILL
3-5 YEARS OF AGE
• The Collagen fibers and
cells increases in the
ligaments of neonates.
22 Weeks Fetus

27. Biological Evidence Supporting Ponseti
Technique: Viscoelastic Properties
“Abundant, young collagens in the ligaments of
infants are wavy, very cellular and could be
easily stretched.”
“Displaced navicular, cuboid and calcaneus could
be gradually abducted under the talus without
cutting any of the tarsal ligaments.”
However, Ligaments should never be stretched
beyond their natural amount of give but they can be
stretched periodically to achieve optimum results

28. Biological Evidence Supporting Ponseti Technique:
Viscoelastic Properties
Achilles Tendon
• Unlike, Stretchable tarsal
ligaments Achillis Tendons
is made of non stretchable,
thick tight collagen
bundles with few cells, that
yield less than tarsal
ligaments & capsule.
Hence, Achillis
Tendons often need
P/C Tenotomy
• “67-97 % club feet
need P/C TA, Tnt ”
Bor, Goskar &Moercuendi
• Club feet wth Pirani
score 5 (Dimeglio IV)
very likely require P/C
TA, Tnt ”
Scher et al

29. Sequential Correction of JH Kite 1930

30. Hiram Kite vs Ponseti Manipulative Correction
Ponseti’s Observation:
A. Major flaw of Kite method
was the attempt to correct
the components of
deformity one by one
(Sequential) instead of
simultaneously correcting
them.
B. The movements at ankle and
sub-talar joint are coupled
movement and it is almost
impossible to reproduce them
independently without
effecting the other joint:
“Ponseti’s Basic Principle”

31. Outcome of Hiram Kite Sequential Correction
•Breaking medial
Capsular structures:
Kite’s error.
•a lengthy and short
of satisfactory
results
•Significant number
of relapses.

32. Ponseti’s manipulations cause
Simultaneous / synchronous
correction all three level
deformities.
 An optimum method
 Very easy to master
 Require lesser duration and
produce superior results in
comparison to other methods.
 90-98% Successful results.. ,,,,,,,,
Bor, Goksani & Morcuende”
4 yr FU
Outcome of Ponseti’s Manipulation

33. PONSETI’s GOALS OF TREATMENT
• Achieve “Normal Functional”, pain free,
normal looking, Planti-grade & weight
bearing foot.
• Achieve Supple foot with good mobility which
can fit into a normal shoe.
• Establish muscle balance

34. PONSETI’s Technique
“Principles”

35. PONSETI’S PRINCIPLES (1948)
COUPLED MOVEMENT OF TNJ, CCJ & SUBTALAR JOINTS:
Mid foot movement is always coupled
with its heel movement

36. Ponseti’s Principle: 1
Coupled movement of Peri-talar jts
With corrective
manipulation of
forefoot, all the
components of
clubfoot deformity
(Varus, inversion and
adduction) are
corrected
simultaneously,
Except Equinous, which is
corrected at the last.
Inversion and Adduction
Forefoot
Pronation
+
Heel
equinus
Varus and Equinus

37. Ponseti’s Principle: 2
The Cavus is the result of
excessive planter flexion
of 1st Metatarsus leading
to pronation of fore foot
in relation to the hind
foot.
Cavs is corrected as the foot is
abducted in supination of
fore foot, by lifting the head
of 1st metatarsus and
thereby placing it in proper
alignment with the hind foot.
“Pronation twist”.
Hicks(1950)

38. Ponseti’s Principles:3
While the Forefoot is held in
supination it is gradually
and gently abducted
under the talus.
B. Be careful, Not to place
thumb over the
Calcaneum, it will obstruct
rotation of the Calcaneum
…. Leading to failure to
achieve results
Be careful, Not to do this

39. Ponseti’s Principles:4
Finally, the Equinous is
corrected by dorsiflexing the
whole foot.
“T. A. S/C tenotomy only be required
to facilitate this correction.”
• The foot should never be everted,
nor the heel be over corrected to
valgus.
• It is mandatory to achieve 60-70-
degree abduction before correction
of Equinous with PC -TA lengthening.

40. Ponseti’s Technique
“Manipulation Technique”
Implementation of Ponseti Principles,
Concept of Simultaneous correction

41. Ponseti’s Technique Steps: Manipulations
Manipulate the foot for 1-2 minutes
Step 1: Localize Talus Head
Step 2: Stabilize Talus Head
Step 3: Supinate the fore foot by raising 1st Metatarsus
Step 4: Supinate & Abduct the foot beneath the stabilized Talus
head
Step 5: Assess for Adequate Abduction
Step 6: Correct Equinus
Concept of Simultaneous Correction

42. Step-1: Locate head of Talus
Localize talus by sliding finger over tip of
lateral Malleolus down to foot 1st bony
prominence is Talus.

43. Step -2: Stabilize the Talus
• Stablize head of the Talus
by thumb
•Stablize ankle Mortise by
index & middle finger of
same thumb
•The talus is held secured
against rotation in ankle
mortise by applying
counter pressure with
thumb over the lateral
aspect of the head of the
talus.

44. Stabilize talus
lift head of 1st MT by grasping
forefoot with Index & thumb
of other hand
Correction of Cavus is
achieved by positioning the
forefoot in proper alignment
with the hindfoot by
Supinating the forefoot.
Step 3:
Supinate Forefoot

45. Step 3+4: Correction of Cavus & Adduction
Supination + Abduction & more Abduction of
the foot beneath the stabilized Talar head
Don’t
place
your
thumb
on
Calcan

46. Step 5: Assessment of Abduction
Methods:
 Unable to palpate Talar head
(coverage)
 Ability to palpate anterior process
of calcanium
 Foot in abduction of 60 – 700 in
relation to frontal plane of Tibia.
“Adquate abduction (60-700 ) is essential before embarking on TA tenotomy”

47. Ability to palpate anterior process of calcaneum
• In clubfoot anterior process of calcanum is not palpable due to internal
rotation of calcanium under the Talus.
• With abduction calcaneum rotate externally and anterior process is easily
felt if abduction achieved is >600

48. Step 6: Correction of Equinus
• Manipulate foot in dorsi-flexion
with one hand under the sole,
grasping heel with thumb and
index finger of other had and
pulling heel downward.
 While dorsi-flexion the
pressure should be applied on
the entire sole of foot to avoid
development of Rocker Bottom
deformity

49. Ponseti’s Technique
“Casting”
Asistatant Manipulator
Overal Objective to Achive:
• 15—300 Dorsiflexion
• 60-700 Abduction
• Slight heel valgus

50. A: Positioning & Comfort
 Feed Baby at the Casting
 Provide Comfort & Sense of
Security by placing Mother
on one side
 Technician on other side
 Technician to hold toes with
one hand & thigh with other
hand.
 Surgeon himself to correct
deformity, apply and
mold the cast

52. B: Pre-cast Manipulation
 Manipulate & Hold the foot for 30-40 seconds
 Manipulation for 2-3 times
 = 2 minutes per foot

53. B: Pre-cast Manipulation
Positions of Fingers

54. C: Casting Protocol
• Maintain knee at 900 flexion
• Lightly encircle 2-3 inches
Soft Cotton roll doubled
over the half, from foot
upward
• Avoid extra cotton rather to
mold plaster cast properly
over to be bony
prominences to avoid
loosening
• Cotton should be applied
snugly over foot and ankle,
loose over calf & thigh

55. D: Casting
Plaster bandage to cover the
fingers of assistant holding
toes to avoid crumbling of
toes.
Plaster to start from toes,
initially extended up to
below the knee.
Apply cast evenly, properly by
avoiding extra pressure.

56. C:Molding
• Mold cast specially
over the
oArch of foot,
oHeel and
oAnkle &
oFlattening the cast on
sole
oCovering the toes to
achieve anatomical
precision.

57. Molding & Snug Fitting technique

58. Manipulation, Cast application & Molding

59. Casting above Knee & trimming
• Cast in extended above knee
just below groin, once molding
and setting of cast below knee
in achieved.
Change cast every 7th day

60. Shape after 1st cast

61. 2nd 3rd and 4th Post cast Appearance
Full correction of the cavus,adductus,and varus
noted. equinus is improved

62. 2nd 3rd and 4th casts : appearance

63. PC A Tenotomy
Technical details in next Lecture
“67-97 % club feet need P/C TA, Tnt ” Bor, Goskar &Moercuendi
Club feet with Pirani score 5 (Dimeglio IV) very likely require P/C TA, Tnt ” Scher et al

64. Pre & Post PCT cast appearance

65. Cast Care
Give simple, very clear instruction to
Parents that:
• Watch for circulation in toe every hour for
first 6 hours, then 4 times a day.
• Train them to gently press the toes and
watch for return of blood flow, White to
Pink phenomenon (Blanching)
• Give them Contact numbers in case poor
Blanching, they shall contact U & follow
the instruction, may be removal of Cast

66. Cast removal
• Remove cast by shear
• Do not use electric saw
but use sheer for cast
removal
• The Best is to Train them
for easy removal of
cast:……
• we use…Uganda method
of Soak, Wet, Soften
Deroll & Remove the cast

67. Cast Removal
Train mothers to Remove Cast by:
Soak, Wet, Soften, Deroll & Remove

68. Parents Guide Materials: Posters

70. PONSETI’s Technique
Physiotherapy:
Massage, Manipulation &
Exercises

71. Post Cast Removal Exercises:
• Taught mother to
administer massage &
exercises, every time for
few minutes while baby
is out of brace
• Squatting with knees
together, heel touching
ground for 5 minutes
• Abduction exercises
• Dorsiflexion exercises to
stretch TA

72. OVERVIEW:
Ideopathic
Typical CFD
• Gradual Correction &
Maintenance to prevent
relapse.
• Varus, inversion and
adduction corrected
simultaneously, except
equinus, which is corrected
at the last.
• Correction of Equinus often
need facilitation with P/C
tenotomy of TA

73. OVERVIEW:
Ideopathic
Typical CFD
Younger age.. Non-
Walker
• Methodology as
already described
• PC AT in most cases
• Prevent relapse by
Bracing &
Physiotherap ..
Training to squat

74. OVERVIEW:
Ideopathic,Typical
Older age.. Walker
• Gradual correction
sessions required as much
as per age and severity.
• Mid foot inversion, varus
heel and rigid equinous
needs patience and good
attention.
• PC AT in most cases
• Bracing & Physiotherapy,
manipulation and squat
• May further need second
PCAT +/- TAntT

75. Overview
• Early intervention yields good results
• Start Treatment as early as possible;
within few days after birth.
• Weekly manipulations & casting yields
well, due to Viscoelastic properties of
soft tissues during very early infancy.
However:
odo not over stretch, that may lead to
pressure necrosis (Flat Talus, Crush
Cuboid) , poor long-term results.
oNever pronate
oAlways check for comfort in cast &
brace

77. CFC #140, inaugurated July 2023

78. Picture: Cortesy google.com
AFO / KFO
No role in CFD Rx