Method of Ponseti

Contents :

Principles of the method
Duration and calendar of the phase of reduction (plasters)
Realization of the first plaster
Monitoring of the plaster in the residence
Second plaster
Third plaster
Fourth platser
Fifth plaster
Sixth plaster
Seventh plaster
Installation of the American sandals and the splint
Monitoring and kinesitherapy

Results
The place of the surgery

 

 

Principles of the method of Ponseti :

The correction of the deformations of the club-foot calls upon the realization of plasters which follow a very precise procedure.
These plasters are known as cruro-pedal bus they extend from the root of the thigh to the toes.
They are made out of plaster of Paris (and not out of resin), easy to model.
They are carried out when the baby is calmest possible, the ideal being to benefit from the moment from têtée (with the feeding-bottle or the centre).
They require the presence of 2 people accustomed to this technique: 1 person to maintain the foot in good position, 1 person to make the plaster.
Each plaster is left in place during 1 week (except the 2 last which is left during 10 days).
Throughout all plaster, it is impossible to bathe the children.
Before and after each plaster, the club-foot is evaluated by using the classification of Diméglio, and receives a note from 1 to 20.
The note of 20 corresponds to a very severe and very stiff club-foot.
The note of 1 corresponds to a very moderate and very flexible club-foot.
This note makes it possible to follow the evolution of the club-foot week after week.

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Duration and calendar of the phase of reduction (plasters) :

   
Old
Realization and duration of the plaster
1st plaster
1 day
Realized in consultation, ideally at the 1st day of life.
Duration = 1 week
2nd plaster
1 week
Realized in consultation.
Duration = 1 week
3rd plaster
2 weeks
Realized in consultation.
Duration = 1 week
4th plaster
3 weeks
Realized in consultation.
Duration = 1 week
5th plaster
1 month
Realized in consultation.
Duration = 1 week
6th plaster
5 weeks

Percutaneous section (through the skin) of the tendon of Achilles
Realized with the operating theatre suite under general anaesthesia
Duration = 10 days

7th plaster
1 month1/2

Catch of prints for the manufacture of the American sandals.
Realized in consultation.
Duration = 10 days

   
2 months
Put in American sandals and splint of Denis-Browne (UNI-BAR splint)

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Réalisation du premier plâtre :

The operator holds the foot in good position and prevents the baby from moving
The assistance unrolls without tightening a band
of cotton, since the toes to the root of the thigh
Cotton goes up largely on the top of the thigh to protect the skin.
The baby is calmed by the catch of the feeding-bottle

The plaster band of Paris is soaked in the water then unrolled since the toes to the knee.

The plaster is very often smoothed in the course of application.

The operator places the foot in the typical position of correction of the 1st plaster, which gives distorts it impression to exaggerate the deformation.
Image of right foot with beginning of correction by the 1st plaster of Ponseti: the correction does not force the foot towards outside, but it prepares the foot for the following plasters.
The left foot is not plastered yet.
When the first part of the plaster is solid, the plaster is finished by taking the knee then the thigh.
1st plaster of Ponseti at the end of the realization.
The toes are released with the scissors to allow the monitoring.

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Monitoring of the plaster in the residence :

The plaster of Paris used for the clothes industry of the plasters of Ponseti requires a time of drying (by evaporation of water) approximately 48 hours. During the first 24 hours, it is necessary to avoid equipping the plaster (sock, pyjamas) to enable him to dry. It is usual that the toes are a little more cold during this phase of drying.
It is useless to dry the plaster with the séche-hair.
On the other hand, during the first two nights, it is necessary to place a small cushion (or a cuddly toy) under the plaster to keep the foot a little higher, and to allow the circulation blood to adapt to the presence of the plaster.
The plaster is well tolerated when:
the baby does not cry
the toes are quite pink (they can be slightly purple)
the toes are recolorent easily (the toes become white when one supports above, but turn pink quickly as soon as the pressure is slackened).

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Second plaster :
One week later, the first plaster is removed with the saw with plaster with much of precautions.
The second plaster is carried out immediately. This second plaster, like all the others, also goes up on the thigh.

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Third plaster :
The third plaster places the plant of the foot in direction of the ground, and gives a “normal” aspect more to the foot.

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Fourth plaster :
The plant of the foot is well directed. The foot starts to be turned towards outside.

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Fifth platser :
The fifth plaster continues the rotation movement of the foot towards outside.

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Sixième plâtre :

CAUTION
the sixth plaster is carried out under general anaesthesia
(except in the event of counter-indication)

The 5th plaster is removed with the operating theatre suite.
The tendon of Achilles complétement is complétement divided (tenotomy) with the point of the lancet by an incision of 3 mm which do not leave any scar.

A video of tenotomy is accessible to the Images page.

The 6th plaster is carried out at the end of the intervention.
It is left in place during 10 days.

Operating view of tenotomy

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Seventh plaster :
The seventh plaster keeps overall the foot in the same position as the precedent.

   
Moulding of the first 5 plasters.
The progression of the correction from left to right is seen.
Moulding of the first 5 plasters

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Installation of the American sandals and the splint :
After the last plaster (seventh or eighth), one sets up the American sandals and the splint of Denis-Browne.
The splint is règlée by the surgeon in order to maintain the club-foot strongly turned towards outside (60°).

Américan sandal
American sandal and the splint of Denis-Browne
Système d'attache de la sandale sur l'attelle


The sandals and the splint of Denis-Browne are left in place day and night for 6 months (with 1 hour of freedom the morning and the afternoon).
From 6 months, this freedom is increased to 2 a.m. the morning and the afternoon.
The splint is generally well tolerated the night, provided that its installation becomes a kind of “ritual of sleeping”.

Quentin with his splint during the night Sleeping position
 
When the treatment
is quite carried out, one often sees appearing a furrow cutaneous and greasy in extreme cases of let us botillons, related to the distribution of grease.
This furrow disappears spontaneously with the growth.

After acquisition of walk, harnesses and shoes are carried only the night.


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Monitoring and kinesitherapy :

After the age of walk, the children can be fitted normally in the majority of the cases.
If need be, one can set up therapeutic shoes of prolonged use (CH.U.P.), intended to maintain the part before foot in position of correction.

The role of kinesitherapy in the method of Ponseti is very limited: kinesitherapy is especially indicated to mobilize the calacaneum (bone of the heel) to the bottom when there remains placed too high.
The risk to see the deformations reappearing (repetition) is important in the event of abandonment of the port of the sandals and the splint (in the 2 to 4 months which follow).

After the installation of the American splint and sandals, an appointment of control is carried out to 1 month. Then clinical controls are carried out every 3 months until the age of walk.
After acquisition of an autonomous walk, a precise radiographic assessment is carried out.
The rate/rhythm of monitoring is then of 1 control every 4 months.
After the stop of the splint (towards the age of 3 or 4 years), the ryhtme of monitoring is of 2 controls per annum.

After the 6 years age, the rate/rhythm of monitoring is of 1 control per annum until the end of the growth of the feet.
The repetition of the deformation does not lead automatically to an operation, but can be treated by another correct plaster cycle.

 

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Results :


Left club-foot
treaty by the method of Ponseti


At birth
At the 4 years age
Left club-foot at birth
Result at the 4 years age
Left club-foot at birth

Result at the 4 years age
Left club-foot at birth
Result at the 4 years age


A recent study published in Journal of Pediatric Orthopaedics (Vol.22, N°4, 2002) realized in Baltimore compared the evolution of 34 club-feet treaties by the method of Dr. Ponseti and of 34 other club-feet treated by another correct plaster technique: 1 only club-foot (either 3%) treated according to the technique of Ponseti required an surgical operation, whereas 32 club-feet (or 97%) treated by the other method have being operated.
Still should it be announced that the only club-foot treated by plasters of Ponseti and operated corresponds to a case where the family had not followed the treatment correctly, by abandonment of the splint of Denis-Browne…

Despite everything, a club-foot NEVER becomes a completely normal foot (with the eyes of the surgeons), but it can have the aspect (with the eyes of the parents), and allow a normal life of it.


Even in the event of excellent result, it keeps always certain more or less visible defects.



Almost constant defects after treatment

Excess of skin on the external face of the foot
The amyotrophie of the calf is always present, more visible so only one east coast reached
The difference in size between the two feet is quasi constant for the unilateral shapes of club-foot.
The difference in length of the member carrying the club-foot remains often moderate.

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The place of the surgery :
The surgery should not be regarded as the last of the solutions, when all failed. It intervenes as a “surgery of improvement of the result” when the treatment by plaster as well as walk do not make it possible any more to improve the foot.

Many procedures can be proposed, according to the aspect of the foot (with the examination and on radiographies).

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