Prof Anisuddin Bhatti. Paediatric Orthopaedic surgeon presented talk on Why Ponseti Technique, Concept Evolution in Clubfoot treatment. Presented in AKUH Orthopaedic Review course. March 2022. Acknowledged for some text material & photo taken from published literature

1. WHY PONSETI 2022

2. WHY PONSETI’s Technique
Concept Building
Anisuddin Bhatti
President (Rtd) Paediatric Orthopaedic Society Pakistan
Focal Person Ponseti International Pakistan
Founding Director PORP registry
Consultant Ziuaddin University Hospital, Clifton, Karachi
RMU March 2022

3. • Most common MSK birth deformity,
1:800 live births.
• Affecting >200,000 newborns each year.
• 80 % CFD children in developing world.
• Clubfoot load in Pakistan 6000-7000/ yr
• > 100,000 children and young adults are
living with Clubfoot Disability worldwide.
Clubfoot Deformity
“Borne with Deformity! Why to live with disability?”

4. Biology
• CFD is not an embryonic
malformation buta
developmental.
• A normally developing foot
turns into a clubfoot during
the second trimester of
pregnancy.
• Rarely detected with U/S
before the 16th week of
gestation.
17wk old fetus,
bilateral clubfoot.

5. Evolution of
Ponseti’s Technique
“In the mid 1940 I examined
22 patients with clubfoot
that had been surgically
treated in the 1920s by
Arther Stendler, the feet
had become rigid, rigid,
weak and painful.”
“After a few years of this
experience I was convinced
that surgery was the wrong
approach for treatment of
club foot”
Ref. Ignacio V Ponseti 1945

6. Outcome of PMR Surgery
Ponseti’s study findings revealed that PMR &
other Surgeries invariably followed by:
• Deep Scarring
• Unhealthy cosmetic look
• Exact anatomical re-alignment not
possible even after capsulotomy &
ligamentous release.
• T.C.J & C.C.J surfaces not matching
even after surgery and attempt to
realign makes joint surfaces
incongruous.

7. Post PMR Outcome
Short, Ugly, Stiff, Pain & Shoe wear
7 yr f u

8. 2 Brothers 1st operated at age of one
month & other at 3 months
Both had Three times Surgeries
5 & 7 yr F U

9. Ptrpn Turco op at 3
month age
10 Yrs FU

10. Post PMR, 12 Yr FU
Painful, stiff, flat feet
1997, age 3 yr, now 15 years

11. Operated at
3 Yr Age
7yr FU

12. Evolution of Ponseti Technique:
• Ponseti worked on clubfoot from 1945 to 1960.
• He studied ankle and subtalar Joint movements
extensively to know the functional anatomy, by:
(a) Cadaver dissections
(b) Radio-Cinematography

13. Radio-cinematograph with casting:
Talo Navicular
Joint (TNJ):
The bones
and joints
remodel with
each cast
change

14. Radio-cinematograph with casting:
Calcaneo
Cuboid
Joint (CCJ):
The bones
and joints
remodel
with each
cast
change

15. Outcome Of Hiram Kite Sequential 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”
Kite’s Error.. Breaking
medial Capsular structures
Hiram Kite method is
“a lengthy and short of
satisfactory results”

16. Sequential Correction of JH Kite 1930

17. Ponseti’s Basic Principle:
of Simultaneous Correction
“COUPLED MOVEMENT OF TNJ,CCJ & SUBTALAR JOINTS”
Owing to interdependence of tarsal joints the correction
of adduction with fulcrum at the head of talus,
simultaneously corrects Varus of the heel.
Therefore, the heel varus & supination of foot will
automatically get corrected when entire foot is fully
abducted under the talus.

18. Based on this concept of “Coupled movement of
TNJ,CCJ & Sub-talar joints”: Ponseti
Recommended (1948), a uniform type of
treatment schedule of: Gentle massage and
manipulation of the clubfoot deformity
to stretch the contracted ligaments &
muscles, then casting to prevent relapse, that is
well known today as “Ponseti’s method”.
Ponseti’s Basic Principle:
Simultaneous Correction

19. In forty years of his follow-up
work, he found his
technique:
 An optimum method
 Very easy to master
 Require lesser duration
and produce superior
results in comparison to
other methods.
4 yr FU
“90-98% Successful results.. Bor, Goksani & Morcuende”

20. Conservative Rx of CFD
in 20th & 21st Century
• Kite Method
(Conventional)
• Bensahel & Masse
(Functional)
• Ponseti Method
(Gold standard today)

21. PONSETI’s GOALS OF TREATMENT
Aims & Objectives
• 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

22. When should start CFD Rx
• Ponseti’s concentrations have been mainly cover
to manage the neoantes clubfoot or clubfoot in
early infancy.
• Most of the Orthpodist agree to begin treatment
just after birth to take advantage of
VISCOELASTIC PROPERTIES of connective tissue
forming ligaments, joint capsules and tendons.
Attlee 1968

23. When should start CFD Rx
• “Ponseti casting can be used in pt. upto 2 yrs age , even after unsuccessful previous
non-operative treatment” . Bor, Goskan &Moercuendi
• 15 centres, 7 countries. 492 feet. Age 2 yr to>8yrs.
• Conclusion: Ponseti method is effective to correct neglected CFD. Relapses occurred in
younger than 4 yrs and in noncompliance with brace. Our study reinforces the
recommendation for Ponseti method with no major modification to treat neglected CF
in patient with walking Age.
IOWA Orthop J 42(!). 2020

24. Biology (Ponseti’s study)
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

25. Biology
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

26. Biology:
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

27. Ponseti Rx examples

28. Slmn 5 yr fu with Ponseti Teq, LT ft

29. M AL Ponseti FU 7 Yr FU

30. Arhm Ponseti 4 yr FU

31. 19 Yr FU.
Ponseti casting initiated
at the age 5 days.
DB Shoe splint for 2 yrs.

32. 19 Yr FU. Ponseti casting at age 5 days. DB Shoe splint for 2 yrs.
c/o Cramps after long walk.

33. Ponseti 8 yrs FU

34. Which technique is better?
Evidence based answer

35. Generalized Concept
…… all except Ponseti’s methods failed
to achieve
(95-100%) results
due to poor understanding of the
functional anatomy of normal &
Clubfoot.
that’s only true in his hand

37. Which technique is better?
Cochrane review on Clubfoot treatment
Searched CENTRAL (2011, Issue 2), NHSEED (2011, Issue 2), MEDLINE (January
1966 to April 2011), EMBASE (January
1980 to April 2011), CINAHL Plus (January 1937 to April 2011), AMED (1985 to
April 2011) and the Physiotherapy Evidence
Database (PEDro to April 2011). We checked the references of included studies.

38. Ponseti versus Kite technique
• Three studies compared Ponseti versus Kite
techniques
(Sanghvi 2009; Sud 2008; Rijal 2010)
• All strata found the Ponseti technique to be
superior to the Kite technique.
Cochrane review on Clubfoot treatment

39. Surgery Vs Ponseti
• One trial compared Ponseti to traditional
surgical treatment in idiopathic CTEV
(Zwick 2009).
• Ponseti technique was found to be superior
Cochrane review on Clubfoot treatment

40. Surgery for Clubfoot
• Dobbs(2007) found poor results at 30 years of
post surgical patients
• All feet were stiff, painful and arthritic
Cochrane review on Clubfoot treatment

41. Ponseti Technique
• Cooper and Dietz (2009) published the 35 year
excellent follow up results of the Ponseti
technique
• Un matched by any other technique

42. Ponseti Technique
• Gupta (2007) found that the apparently low
tech.
• Ponseti technique was ideally suited for
developing countries as compared to surgery
Cochrane review on Clubfoot treatment

43. Ponseti Technique
• Lorenco and Morcuende (2007) found that
patients presenting after walking age (avg
3.9years) had good outcome treated non
operatively with Ponseti technique

44. Cost of treatment
• Surgical treatment entails bigger direct and
indirect costs to patient
• Ponseti Technique has significantly lesser costs
(Hussain. Iowa Orthop. Journal 2013. Indus
Hospital)
• Cost of treatment usually below $250

45. Thank You for Patience