SlideShare a Scribd company logo
1 of 45
WHY PONSETI 2022
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
• 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?”
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.
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
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.
Post PMR Outcome
Short, Ugly, Stiff, Pain & Shoe wear
7 yr f u
2 Brothers 1st operated at age of one
month & other at 3 months
Both had Three times Surgeries
5 & 7 yr F U
Ptrpn Turco op at 3
month age
10 Yrs FU
Post PMR, 12 Yr FU
Painful, stiff, flat feet
1997, age 3 yr, now 15 years
Operated at
3 Yr Age
7yr FU
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
Radio-cinematograph with casting:
Talo Navicular
Joint (TNJ):
The bones
and joints
remodel with
each cast
change
Radio-cinematograph with casting:
Calcaneo
Cuboid
Joint (CCJ):
The bones
and joints
remodel
with each
cast
change
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”
Sequential Correction of JH Kite 1930
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.
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
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”
Conservative Rx of CFD
in 20th & 21st Century
• Kite Method
(Conventional)
• Bensahel & Masse
(Functional)
• Ponseti Method
(Gold standard today)
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
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
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
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
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
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
Ponseti Rx examples
Slmn 5 yr fu with Ponseti Teq, LT ft
M AL Ponseti FU 7 Yr FU
Arhm Ponseti 4 yr FU
19 Yr FU.
Ponseti casting initiated
at the age 5 days.
DB Shoe splint for 2 yrs.
19 Yr FU. Ponseti casting at age 5 days. DB Shoe splint for 2 yrs.
c/o Cramps after long walk.
Ponseti 8 yrs FU
Which technique is better?
Evidence based answer
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
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.
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
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
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
Ponseti Technique
• Cooper and Dietz (2009) published the 35 year
excellent follow up results of the Ponseti
technique
• Un matched by any other technique
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
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
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
Thank You for Patience

More Related Content

Similar to Why Ponseti Technique in Clubfoot management MARCH 2022.pptx

Achilles Tendon Lengthening.pptx
Achilles Tendon Lengthening.pptxAchilles Tendon Lengthening.pptx
Achilles Tendon Lengthening.pptxAhmadSyaukat2
 
3a ddh open reduction principles & protocols
3a ddh open reduction principles & protocols3a ddh open reduction principles & protocols
3a ddh open reduction principles & protocolsAnisuddin Bhatti
 
Modified Ponseti Technique of Management of Idiopathic Clubfoot
Modified Ponseti Technique of Management of Idiopathic ClubfootModified Ponseti Technique of Management of Idiopathic Clubfoot
Modified Ponseti Technique of Management of Idiopathic ClubfootApollo Hospitals
 
Dr.ganesh kodaikanal-ppt
Dr.ganesh kodaikanal-pptDr.ganesh kodaikanal-ppt
Dr.ganesh kodaikanal-pptGanesh Puttu
 
Distraction based surgery 30
Distraction based surgery 30Distraction based surgery 30
Distraction based surgery 30amer alkot
 
Community Minimally Invasive Total Hip Replacement Slideshow
Community Minimally Invasive Total Hip Replacement SlideshowCommunity Minimally Invasive Total Hip Replacement Slideshow
Community Minimally Invasive Total Hip Replacement Slideshowscottau
 
CTEV pediatri.pptx
CTEV pediatri.pptxCTEV pediatri.pptx
CTEV pediatri.pptxSyarif M.
 
Hip Arthroscopy in 2013: Inova Annual Sports Medicine Program
Hip Arthroscopy in 2013: Inova Annual Sports Medicine ProgramHip Arthroscopy in 2013: Inova Annual Sports Medicine Program
Hip Arthroscopy in 2013: Inova Annual Sports Medicine Programwashingtonortho
 
Surgical Versus Ponseti Approach for the Management of CTEV - Dr. CHINTAN N. ...
Surgical Versus Ponseti Approach for the Management of CTEV - Dr. CHINTAN N. ...Surgical Versus Ponseti Approach for the Management of CTEV - Dr. CHINTAN N. ...
Surgical Versus Ponseti Approach for the Management of CTEV - Dr. CHINTAN N. ...DrChintan Patel
 
Dottore Marco Spoliti ortopedico, Cellule mesenchimali, difetto condrale Rico...
Dottore Marco Spoliti ortopedico, Cellule mesenchimali, difetto condrale Rico...Dottore Marco Spoliti ortopedico, Cellule mesenchimali, difetto condrale Rico...
Dottore Marco Spoliti ortopedico, Cellule mesenchimali, difetto condrale Rico...Ospedale San Camillo Forlanini Roma
 
Do We Make Taping More Complicated Than It Needs ToBe?
Do We Make Taping More Complicated Than It Needs ToBe?Do We Make Taping More Complicated Than It Needs ToBe?
Do We Make Taping More Complicated Than It Needs ToBe?RockTape
 
Free fibula flap OMFS 2021 journal club presentation
Free fibula flap OMFS 2021 journal club  presentationFree fibula flap OMFS 2021 journal club  presentation
Free fibula flap OMFS 2021 journal club presentationRobertMbaluka
 

Similar to Why Ponseti Technique in Clubfoot management MARCH 2022.pptx (20)

Knee Cartilage surgery in India
Knee Cartilage surgery in IndiaKnee Cartilage surgery in India
Knee Cartilage surgery in India
 
Blount disease
Blount diseaseBlount disease
Blount disease
 
Achilles Tendon Lengthening.pptx
Achilles Tendon Lengthening.pptxAchilles Tendon Lengthening.pptx
Achilles Tendon Lengthening.pptx
 
ctev seminar
 ctev seminar ctev seminar
ctev seminar
 
Lecture 11 parekh pilon
Lecture 11 parekh pilonLecture 11 parekh pilon
Lecture 11 parekh pilon
 
3a ddh open reduction principles & protocols
3a ddh open reduction principles & protocols3a ddh open reduction principles & protocols
3a ddh open reduction principles & protocols
 
Modified Ponseti Technique of Management of Idiopathic Clubfoot
Modified Ponseti Technique of Management of Idiopathic ClubfootModified Ponseti Technique of Management of Idiopathic Clubfoot
Modified Ponseti Technique of Management of Idiopathic Clubfoot
 
Dr.ganesh kodaikanal-ppt
Dr.ganesh kodaikanal-pptDr.ganesh kodaikanal-ppt
Dr.ganesh kodaikanal-ppt
 
Distraction based surgery 30
Distraction based surgery 30Distraction based surgery 30
Distraction based surgery 30
 
Community Minimally Invasive Total Hip Replacement Slideshow
Community Minimally Invasive Total Hip Replacement SlideshowCommunity Minimally Invasive Total Hip Replacement Slideshow
Community Minimally Invasive Total Hip Replacement Slideshow
 
CTEV pediatri.pptx
CTEV pediatri.pptxCTEV pediatri.pptx
CTEV pediatri.pptx
 
Hip Arthroscopy in 2013: Inova Annual Sports Medicine Program
Hip Arthroscopy in 2013: Inova Annual Sports Medicine ProgramHip Arthroscopy in 2013: Inova Annual Sports Medicine Program
Hip Arthroscopy in 2013: Inova Annual Sports Medicine Program
 
Surgical Versus Ponseti Approach for the Management of CTEV - Dr. CHINTAN N. ...
Surgical Versus Ponseti Approach for the Management of CTEV - Dr. CHINTAN N. ...Surgical Versus Ponseti Approach for the Management of CTEV - Dr. CHINTAN N. ...
Surgical Versus Ponseti Approach for the Management of CTEV - Dr. CHINTAN N. ...
 
Dottore Marco Spoliti ortopedico, Cellule mesenchimali, difetto condrale Rico...
Dottore Marco Spoliti ortopedico, Cellule mesenchimali, difetto condrale Rico...Dottore Marco Spoliti ortopedico, Cellule mesenchimali, difetto condrale Rico...
Dottore Marco Spoliti ortopedico, Cellule mesenchimali, difetto condrale Rico...
 
Recurrent clubfoot CTEV
Recurrent clubfoot CTEVRecurrent clubfoot CTEV
Recurrent clubfoot CTEV
 
Ctev
CtevCtev
Ctev
 
Jess
JessJess
Jess
 
Do We Make Taping More Complicated Than It Needs ToBe?
Do We Make Taping More Complicated Than It Needs ToBe?Do We Make Taping More Complicated Than It Needs ToBe?
Do We Make Taping More Complicated Than It Needs ToBe?
 
Final 123 presentation
Final 123 presentationFinal 123 presentation
Final 123 presentation
 
Free fibula flap OMFS 2021 journal club presentation
Free fibula flap OMFS 2021 journal club  presentationFree fibula flap OMFS 2021 journal club  presentation
Free fibula flap OMFS 2021 journal club presentation
 

More from Anisuddin Bhatti

Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptxPrinciples, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptxAnisuddin Bhatti
 
VERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptxVERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptxAnisuddin Bhatti
 
Principles of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptxPrinciples of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptxAnisuddin Bhatti
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxAnisuddin Bhatti
 
Mock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptxMock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptxAnisuddin Bhatti
 
Mock ExaminationLong case Cerebral Palsy .pptx
Mock ExaminationLong case Cerebral Palsy  .pptxMock ExaminationLong case Cerebral Palsy  .pptx
Mock ExaminationLong case Cerebral Palsy .pptxAnisuddin Bhatti
 
Mock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptxMock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptxAnisuddin Bhatti
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxAnisuddin Bhatti
 
Mock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptxMock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptxAnisuddin Bhatti
 
Mock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptxMock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptxAnisuddin Bhatti
 
Bhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic HipsBhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic HipsAnisuddin Bhatti
 
Congenital vertical talus Pes Plano Valgus
Congenital vertical talus Pes Plano ValgusCongenital vertical talus Pes Plano Valgus
Congenital vertical talus Pes Plano ValgusAnisuddin Bhatti
 
Pakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention programPakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention programAnisuddin Bhatti
 
Post Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limbPost Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limbAnisuddin Bhatti
 
PostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limbPostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limbAnisuddin Bhatti
 
Post Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of RxPost Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of RxAnisuddin Bhatti
 
1 perthese diagnosis & classification
1 perthese diagnosis & classification1 perthese diagnosis & classification
1 perthese diagnosis & classificationAnisuddin Bhatti
 
4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & aboveAnisuddin Bhatti
 
2 ddh principles & protocols of rx. 0 12 m age
2 ddh principles & protocols of rx. 0 12 m age 2 ddh principles & protocols of rx. 0 12 m age
2 ddh principles & protocols of rx. 0 12 m age Anisuddin Bhatti
 

More from Anisuddin Bhatti (20)

Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptxPrinciples, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
 
VERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptxVERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptx
 
Principles of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptxPrinciples of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptx
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptx
 
Mock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptxMock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptx
 
Mock ExaminationLong case Cerebral Palsy .pptx
Mock ExaminationLong case Cerebral Palsy  .pptxMock ExaminationLong case Cerebral Palsy  .pptx
Mock ExaminationLong case Cerebral Palsy .pptx
 
Mock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptxMock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptx
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptx
 
Mock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptxMock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptx
 
Mock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptxMock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptx
 
Bhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic HipsBhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic Hips
 
Congenital vertical talus Pes Plano Valgus
Congenital vertical talus Pes Plano ValgusCongenital vertical talus Pes Plano Valgus
Congenital vertical talus Pes Plano Valgus
 
Pakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention programPakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention program
 
Post Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limbPost Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limb
 
PostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limbPostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limb
 
Post Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of RxPost Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of Rx
 
LCPD Perthes'_ management
LCPD Perthes'_ managementLCPD Perthes'_ management
LCPD Perthes'_ management
 
1 perthese diagnosis & classification
1 perthese diagnosis & classification1 perthese diagnosis & classification
1 perthese diagnosis & classification
 
4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above
 
2 ddh principles & protocols of rx. 0 12 m age
2 ddh principles & protocols of rx. 0 12 m age 2 ddh principles & protocols of rx. 0 12 m age
2 ddh principles & protocols of rx. 0 12 m age
 

Recently uploaded

Hi Fi * Surat ℂall Girls Surat Dumas Road 8527049040 WhatsApp AnyTime Best Su...
Hi Fi * Surat ℂall Girls Surat Dumas Road 8527049040 WhatsApp AnyTime Best Su...Hi Fi * Surat ℂall Girls Surat Dumas Road 8527049040 WhatsApp AnyTime Best Su...
Hi Fi * Surat ℂall Girls Surat Dumas Road 8527049040 WhatsApp AnyTime Best Su...Neelam SharmaI11
 
ESC HF 2024 Spotlights Day-2.pptx heart failure
ESC HF 2024 Spotlights Day-2.pptx heart failureESC HF 2024 Spotlights Day-2.pptx heart failure
ESC HF 2024 Spotlights Day-2.pptx heart failuremahiavy26
 
Vesu + ℂall Girls Serviℂe Surat (Adult Only) 8849756361 Esℂort Serviℂe 24x7 C...
Vesu + ℂall Girls Serviℂe Surat (Adult Only) 8849756361 Esℂort Serviℂe 24x7 C...Vesu + ℂall Girls Serviℂe Surat (Adult Only) 8849756361 Esℂort Serviℂe 24x7 C...
Vesu + ℂall Girls Serviℂe Surat (Adult Only) 8849756361 Esℂort Serviℂe 24x7 C...anushka vermaI11
 
The Clean Living Project Episode 24 - Subconscious
The Clean Living Project Episode 24 - SubconsciousThe Clean Living Project Episode 24 - Subconscious
The Clean Living Project Episode 24 - SubconsciousThe Clean Living Project
 
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptxANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptxDr. Sohan Biswas
 
Gallbladder Double-Diverticular: A Case Report المرارة مزدوجة التج: تقرير حالة
Gallbladder Double-Diverticular: A Case Report  المرارة مزدوجة التج: تقرير حالةGallbladder Double-Diverticular: A Case Report  المرارة مزدوجة التج: تقرير حالة
Gallbladder Double-Diverticular: A Case Report المرارة مزدوجة التج: تقرير حالةMohamad محمد Al-Gailani الكيلاني
 
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose AcademicsCytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose AcademicsMedicoseAcademics
 
Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?bkling
 
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptxGross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptxDr. Rabia Inam Gandapore
 
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUELCONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUELMKARTHIKEMMANUEL
 
Charbagh { ℂall Girls Serviℂe Lucknow ₹7.5k Pick Up & Drop With Cash Payment ...
Charbagh { ℂall Girls Serviℂe Lucknow ₹7.5k Pick Up & Drop With Cash Payment ...Charbagh { ℂall Girls Serviℂe Lucknow ₹7.5k Pick Up & Drop With Cash Payment ...
Charbagh { ℂall Girls Serviℂe Lucknow ₹7.5k Pick Up & Drop With Cash Payment ...jamal khanI11
 
How to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw materialHow to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw materialSherrylee83
 
NDCT Rules, 2019: An Overview | New Drugs and Clinical Trial Rules 2019
NDCT Rules, 2019: An Overview | New Drugs and Clinical Trial Rules 2019NDCT Rules, 2019: An Overview | New Drugs and Clinical Trial Rules 2019
NDCT Rules, 2019: An Overview | New Drugs and Clinical Trial Rules 2019Akash Agnihotri
 
Young & Hot Surat ℂall Girls Dindoli 8527049040 WhatsApp AnyTime Best Surat ℂ...
Young & Hot Surat ℂall Girls Dindoli 8527049040 WhatsApp AnyTime Best Surat ℂ...Young & Hot Surat ℂall Girls Dindoli 8527049040 WhatsApp AnyTime Best Surat ℂ...
Young & Hot Surat ℂall Girls Dindoli 8527049040 WhatsApp AnyTime Best Surat ℂ...Neelam SharmaI11
 
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose AcademicsConnective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose AcademicsMedicoseAcademics
 
Failure to thrive in neonates and infants + pediatric case.pptx
Failure to thrive in neonates and infants  + pediatric case.pptxFailure to thrive in neonates and infants  + pediatric case.pptx
Failure to thrive in neonates and infants + pediatric case.pptxclaviclebrown44
 
Stereochemistry & Asymmetric Synthesis.pptx
Stereochemistry & Asymmetric Synthesis.pptxStereochemistry & Asymmetric Synthesis.pptx
Stereochemistry & Asymmetric Synthesis.pptxAkanshaBhatnagar7
 
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...marcuskenyatta275
 
Quality control tests of suppository ...
Quality control tests  of suppository ...Quality control tests  of suppository ...
Quality control tests of suppository ...Hasnat Tariq
 

Recently uploaded (20)

Hi Fi * Surat ℂall Girls Surat Dumas Road 8527049040 WhatsApp AnyTime Best Su...
Hi Fi * Surat ℂall Girls Surat Dumas Road 8527049040 WhatsApp AnyTime Best Su...Hi Fi * Surat ℂall Girls Surat Dumas Road 8527049040 WhatsApp AnyTime Best Su...
Hi Fi * Surat ℂall Girls Surat Dumas Road 8527049040 WhatsApp AnyTime Best Su...
 
ESC HF 2024 Spotlights Day-2.pptx heart failure
ESC HF 2024 Spotlights Day-2.pptx heart failureESC HF 2024 Spotlights Day-2.pptx heart failure
ESC HF 2024 Spotlights Day-2.pptx heart failure
 
Vesu + ℂall Girls Serviℂe Surat (Adult Only) 8849756361 Esℂort Serviℂe 24x7 C...
Vesu + ℂall Girls Serviℂe Surat (Adult Only) 8849756361 Esℂort Serviℂe 24x7 C...Vesu + ℂall Girls Serviℂe Surat (Adult Only) 8849756361 Esℂort Serviℂe 24x7 C...
Vesu + ℂall Girls Serviℂe Surat (Adult Only) 8849756361 Esℂort Serviℂe 24x7 C...
 
The Clean Living Project Episode 24 - Subconscious
The Clean Living Project Episode 24 - SubconsciousThe Clean Living Project Episode 24 - Subconscious
The Clean Living Project Episode 24 - Subconscious
 
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptxANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
 
Gallbladder Double-Diverticular: A Case Report المرارة مزدوجة التج: تقرير حالة
Gallbladder Double-Diverticular: A Case Report  المرارة مزدوجة التج: تقرير حالةGallbladder Double-Diverticular: A Case Report  المرارة مزدوجة التج: تقرير حالة
Gallbladder Double-Diverticular: A Case Report المرارة مزدوجة التج: تقرير حالة
 
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose AcademicsCytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
 
Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?Report Back from SGO: What’s the Latest in Ovarian Cancer?
Report Back from SGO: What’s the Latest in Ovarian Cancer?
 
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptxGross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
Gross Anatomy and Histology of Tongue by Dr. Rabia Inam Gandapore.pptx
 
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUELCONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUEL
 
Charbagh { ℂall Girls Serviℂe Lucknow ₹7.5k Pick Up & Drop With Cash Payment ...
Charbagh { ℂall Girls Serviℂe Lucknow ₹7.5k Pick Up & Drop With Cash Payment ...Charbagh { ℂall Girls Serviℂe Lucknow ₹7.5k Pick Up & Drop With Cash Payment ...
Charbagh { ℂall Girls Serviℂe Lucknow ₹7.5k Pick Up & Drop With Cash Payment ...
 
Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...
Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...
Best medicine 100% Effective&Safe Mifepristion ௵+918133066128௹Abortion pills ...
 
How to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw materialHow to buy 5cladba precursor raw 5cl-adb-a raw material
How to buy 5cladba precursor raw 5cl-adb-a raw material
 
NDCT Rules, 2019: An Overview | New Drugs and Clinical Trial Rules 2019
NDCT Rules, 2019: An Overview | New Drugs and Clinical Trial Rules 2019NDCT Rules, 2019: An Overview | New Drugs and Clinical Trial Rules 2019
NDCT Rules, 2019: An Overview | New Drugs and Clinical Trial Rules 2019
 
Young & Hot Surat ℂall Girls Dindoli 8527049040 WhatsApp AnyTime Best Surat ℂ...
Young & Hot Surat ℂall Girls Dindoli 8527049040 WhatsApp AnyTime Best Surat ℂ...Young & Hot Surat ℂall Girls Dindoli 8527049040 WhatsApp AnyTime Best Surat ℂ...
Young & Hot Surat ℂall Girls Dindoli 8527049040 WhatsApp AnyTime Best Surat ℂ...
 
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose AcademicsConnective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
 
Failure to thrive in neonates and infants + pediatric case.pptx
Failure to thrive in neonates and infants  + pediatric case.pptxFailure to thrive in neonates and infants  + pediatric case.pptx
Failure to thrive in neonates and infants + pediatric case.pptx
 
Stereochemistry & Asymmetric Synthesis.pptx
Stereochemistry & Asymmetric Synthesis.pptxStereochemistry & Asymmetric Synthesis.pptx
Stereochemistry & Asymmetric Synthesis.pptx
 
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
 
Quality control tests of suppository ...
Quality control tests  of suppository ...Quality control tests  of suppository ...
Quality control tests of suppository ...
 

Why Ponseti Technique in Clubfoot management MARCH 2022.pptx

  • 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
  • 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.
  • 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
  • 36.
  • 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