Guest Blog: Rich Griffin
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3 year old boy born with unilateral talipes, from birth patient was treated with ponseti method. However surgeon was considering a tibialis anterior transfer at time of assessment due to over activity of tibialis anterior plus lack of peroneal activity/action. Surgeon also mentioned peroneal nerve innovation may be lost thus peroneals can not perform their action. A tibialis transfer is a common procedure for patients with talipes and those demonstrating excessive supination in the gait cycle.
The parents of the child/patient wanted to avoid any more surgery to the right limb, a tendo-achilles subcutaneously had been preformed to increase dorsiflexion and foot position in line with Ponseti protocol.
What is Talipes: Clubfoot? How many does it effect?
Congenital talipes equinovarus (CTEV) often know as “clubfoot” is a common but little studied developmental disorder of the lower limb. It is defined as fixation of the foot in abduction, in supination and in varus ie. Inclined inwards, axially rotated outwards and pointing downwards.1
About 1 in 1,000 babies born in the UK has talipes equinovarus.2
What Is The Ponseti Method Of Treatment?
Based on early concepts, Ponseti3 developed his treatment guidelines:
All the components of the clubfoot deformity have to be corrected simultaneously with the exception of the equinus which should be corrected last.
The cavus results from a pronation of the forefoot in relation to the hindfoot, and is corrected as the foot is abducted by supinating the forefoot and thereby placing it in proper alignment with the midfoot.
While the whole foot is held in supination and in flexion, it can be gently and gradually abducted under the talus, and secured against rotation in the ankle mortise by applying counter-pressure with the thumb against the lateral aspect of the head of the talus.
The heel varus and foot supination will correct when the entire foot is fully abducted in maximum external rotation under the talus. The foot should never be everted.
After the above is accomplished, the equinus can be corrected by dorsiflexing the foot. The tendo-Achilles may need to be subcutaneously sectioned to facilitate this correction.
When proper treatment of clubfoot with manipulation and plaster casts has been started shortly after birth, a good clinical correction can be obtained in the vast majority of cases. A plaster cast is applied after each weekly session to retain the degree of correction and soften the ligaments. After two months of manipulation and casting the foot often appears slightly overcorrected. As mentioned, the percutaneous tenotomy of the Achilles tendon is an office procedure and is done in 85% of Ponseti’s patients to correct the equinus deformity. Open lengthening of the tendo Achilles is indicated for children over one year of age. This is done under general anesthesia. Excessive lengthening of the tendon must be avoided since it may permanently weaken the gastrocsoleus. Transfer of the tibialis anterior tendon to the third cuneiform is done after the first or second relapse in children older than two-and-a-half years of age, when the tibialis anterior has a strong supinatory action. The relapsed clubfoot deformity must be well corrected with manipulations and two or three plaster casts left on for two weeks each before transfer of the tendon. With appropriate early manipulations and plaster casts, surgery of the ligaments and joints should only be rarely necessary.4
Treatment design is to provide patients with a functional, pain-free, normal- looking foot, with good mobility, without calluses, and requiring no special shoes, and to obtain this in a cost-effective way, further research will be needed to fully understand the pathogenesis of clubfoot and the effects of treatment, not only in terms of foot correction, but also of long-term results and quality of life. One thing that is definitely missing in the literature is a long term follow up study on surgically treated clubfeet. The authors of this paper are currently involved in a multi-center retrospective study to look at this group of patients.4
Figure 1 shows the use of serial plastering to manipulate the symptomatic limb.
- Miedzybrodzka Z, Congenital talipes equinovarus (clubfoot): a disorder of the foot but not the hand. 2003
- Morcuende J, Lori A, At El, Radical Reduction in the rate of extensive corrective surgery for clubfoot using the ponseti method. Pediatrics Vol.113. 2004.
- Dobbs M, Nunley R, Schoenecker M, Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. 2006.
- Critchley J, Taylor R, Transfer of the tibialis anterior tendon for relapsed club-foot. 1952.
- Haasbeek JF, Wright IG, A comparision of the long term results of posterior and comprehensive release in the treatment of club foot. J Pediatr Orthop, 17: 29-35. 1997
- Templeton P, Flowers M, Et Al, Factors predicting the outcome of primary clubfoot surgery. 2005.