Ponseti Clubfoot

Management
Before Correction

Bracing

After

Contents
Organization Management
ForewordMinister of Health...............................2 Screening and Diagnosis....................................20
Project Directors Message..................................3 Clubfoot Assessment..........................................22
Editors Note........................................................4 Overview of Management..................................25
Study Guide Questions.........................................5 Clubfoot Clinics.................................................26
Contributors ........................................................6 Casting Setup and Technique.............................28
Contributing Organizations..................................8 Ponseti Corrective Casts....................................30
Bibliography.........................................................9 Cast Removal.....................................................32
Tenotomy............................................................34
Clubfoot Background Bracing...............................................................36
History of Clubfoot Management......................10 Common Management Errors............................40
Clubfoot Management in Uganda......................12 Relapse...............................................................42
Social and Cultural Barriers...............................14 Anterior Tibialis Tendon Transfer......................44
Anatomy, Physiology, and Pathology................16 Difficult Clubfeet...............................................46
Information for Parents......................................18 Message from Dr. Ponseti..................................48

Teaching Manual for Healthcare Providers in Uganda

2 Message from the Minister of Health
 Project Directors Message 3

Project Directors Message

The congenital clubfoot is the most common serious birth defect of human bones and joints.
More than fifteen hundred children are born with clubfeet in Uganda each year. Left untreat- Quick Find Tabs
ed, the foot remains twisted inwards and becomes painful. The walking child bears weight Your core material
on the thin skin on the top of the foot. Deformity leads to the downward spiral of disability, is identified by the
dependency, and demoralization. Disabled individuals are rarely productive or valued mem- tab color.
bers of society. Their needs add to the burdens of their families and communities and are a
significant cause of poverty.
Professor Ignacio Ponsetis method of nonsurgical treatment of the congenital clubfoot has
been shown by Macharia to be effective in Uganda. It is now the treatment of choice advo-
cated by the Ministry of Health, the Association of Surgeons of Uganda, the Uganda Nurses
and Midwives Council, the Medical Schools at Makerere University and Mbarara University
of Science and Technology, and the Paramedical Schools at Mulago Hospital.
The Uganda Sustainable Clubfoot Care Project (the Uganda Project), is a Canadian
International Development Agency funded collaborative work. Its goal is to make Ponseti
treatment available to all affected infants born in Uganda in a timely, safe, effective, and sus-
tainable manner. The projects methodology is to build capacity in two areas: Everyone
1. In Ugandas schools of healthcare (medical, nursing, and paramedical training schools) to
teach clubfoot detection and Ponseti treatment.
2. In Ugandas healthcare institutions (hospitals and clinics where children are seen) to
detect clubfeet at birth and treat the condition with the Ponseti Method.
The authors intent is to provide one easily digestible source for all core material on
clubfoot detection and treatment by the Ponseti Method for students in Ugandas medi-
cal, nursing and paramedical schools as well as for healthcare workers looking after
infants in Ugandas healthcare institutions.
The Project will print and distribute ten thousand copies of this booklet to Ugandas health-
care schools and institutions. The authors hope that this will lead to increased awareness of
foot deformities by healthcare workers, routine recognition of foot deformities at birth, and
early referral to and effective treatment by trained staff at a network of clubfoot clinics across Parents
Uganda. Effective treatment corrects the deformity. Affected children will be more likely to
grow up following the same life trajectory as any other child in Uganda. Clubfeet will be less
likely to cause disability and poverty in Uganda. Nurses
Even though this teaching manual is by Ugandans and for Ugandans, its message is appro-
priate in many other developing nations facing the same burdens and restraints. The authors
plan to make the guide widely available.
Orthopaedic
This work is the fruit of many people and many organizations working towards a single officers
goal. We would like to thank all. This publication would not have been possible without them.

Medical
Officers
Shafique Pirani, MD Edward Naddumba, MD
2008 2008

Surgeons

Orthopaedic
Technologists
4 Editors Note

Editors Note
This publication is the product of the efforts of many This book is produced by Global-HELP, a not-for-profit
individuals and organizations. It brings together elements organization that produces and distributes free or affordable
of Dr. Piranis manual, Mr. Steenbeeks publication on healthcare education materials worldwide.
clubfoot brace design, the Global HELP Organizations It is a great honor to work on this land-
Ponseti: Clubfoot Management book, and new material mark project and to experience the dedica-
gathered in Uganda and from experience in clubfoot man- tion, passion, skill, and sensitivity of Dr.
agement worldwide. Pirani in originating and managing this
The design of this publication utilizes features developed project. He combines the abilities of a clini-
for other HELP publications that are colorful, graphic, and cian, surgeon, diplomat, and innovator in
engaging, and is presented efficiently and compactly. The achieving the great success of the venture.
publication was created entirely by digital software, simpli- I want to give special thanks to Michelle
fying translations and the addition of new material. Gutierrez and Deborah Cughan for their
We intended that the publication would provide the core professional assistance in producing this book.
information for all healthcare providers who contribute to
clubfoot management. This publication includes elements Lynn Staheli, MD
useful to all providers. Global-HELP Organization
A study guide (opposite page) provides questions to assist Web site: global-help.org
2008
learning. Color tabs identify sections particularly relevant to
different categories of healthcare providers.
Note for Readers
Care has been taken to confirm the accuracy of the informa-
tion presented and to describe generally accepted practices.
However, the authors and publisher are not responsible for
errors or omissions or for any consequences from application of
the information in this book and make no warranty, expressed or
implied, with respect to the currency, completeness, or accuracy
of the contents of the publication. Application of this informa-
tion in a particular situation remains the professional responsi-
bility of the practitioner.
Workshop to develop teaching material in Kampala
 Study Guide Questions 5

Study Guide Questions

Answer these questions to test your understanding of what
you read.
Pages 1011: History of Clubfoot Management Pages 3031: Ponseti Corrective Casts
Outline early writers ideas on clubfeet management. Describe the technique used in manipulating and positioning the foot during
What aspects of clubfoot biology did Dr. Ponseti clarify? cavus correction.
Describe the technique used in cast moulding during cavus correction.
Pages 1213: Clubfoot Management in Uganda Describe the technique used in manipulating and positioning the foot during
adductus and varus correction.
Outline the history of clubfoot management in Uganda.
Describe the technique used in cast moulding during adductus and
Describe the strategy for clubfoot care in Uganda now.
varus correction.
Name key partners in this strategy and their roles.

Pages 1415: Social and Cultural Barriers Pages 3233: Cast Removal
Outline the options technique for removing casts.
What is the usual reason for a child to be a no show for a clubfoot
Describe possible cast-related complications and management.
clinic visit?
What are the common social barriers to care?
What are the common cultural barriers to care?
Pages 3435: Tenotomy
How can healthcare providers help parents overcome barriers? What is the indication for tenotomy?
Describe methods used to evaluate calcaneal abduction and ankle
Pages 1617: Anatomy, Physiology, and dorsiflexion.
How is a tenotomy performed?
Pathology Describe the roles performed by the orthopaedic and medical officers
Name and describe standard foot and ankle movements. during tenotomy.
What causes cavus, adductus, varus, and equinus? What signs indicate successful completion of tenotomy?
How does the subtalar joint move?
What is its clinical relevance? Pages 3637: Bracing
What is a SFAB?
Pages 1819: Information for Parents Where can SFABs be obtained?
What are parents common questions about clubfeet?
What are parents common questions about treatment? Pages 3839: Bracing Technique
What purpose does the SFAB serve?
Pages 2021: Screening and Diagnosis Why is follow-up essential?
Why is screening for clubfoot important? When and how should it be fitted?
What is a visual foot inspection? Who should do it? What helps caregivers use the brace correctly and consistantly?
How do you make a diagnosis of a clubfoot?
Why assess the whole child? Pages 4041: Common Management Errors
Describe six common management errors, and when they occur.
Pages 2223: Clubfoot Assessment Why is it important to identify the head of the talus?
What are the different classes of clubfeet? Why is a below-knee cast ineffective?
What does the Pirani Clubfoot Score measure? Why do braces, apart from SFABs, fail to prevent relapse of deformity?
What are the Total, Hindfoot, and Midfoot Scores?
How does scoring help in managing a clubfoot? Pages 4243: Relapse
What causes relapse?
Pages 2425: Overview of Management Why is it important to recognize relapse early?
What are the four steps in the overall management of a child born How can relapse be recognized?
with clubfeet? What is the treatment of relapse?
Why is follow-up essential?
Pages 4445: Anterior Tibialis Tendon Transfer
Pages 2627: Clubfoot Clinics When is transfer indicated?
Describe a clinics patient volumes and staffing arrangements. What is the standard postoperative care?
What supplies are needed?
How is patient flow organized? Pages 4647: Difficult Clubfeet
Name other possible roles of a clubfoot clinic.
What types of clubfeet can be difficult?
Why is it important to recognize difficult clubfeet?
Pages 2829: Casting Setup and Technique Describe the complex clubfoot and its management.
What materials should be available before starting?
Describe positioning for the manipulator and assistant.
What are the basic steps for each casting?
What instructions are given to the caregivers before leaving the clinic?
6 Contributors

Contributors to this Publication

Kaziba, Benon
The efforts of these contributors have made this publi- Tutor
cation more relevant to Uganda. School for Orthopaedic officers
Trainer Ponseti Method

Amandua, Jacinto
Commissioner of Clinical Services
Kidega, Margaret
Ministry of Health Principal
Project advisor School of Nursing and Midwifery
Kabale

Amone, Jackson Kisombo, David

Assistant Commissioner for Curative Services Tutor
Ministry of Health Orthopaedic Technology Training School
Member, Management Committee Trainer Bracing

Beyeza, Tito Kitemagwa, Diriisa

Head, Department of Orthopaedics Senior Orthopaedic officer
Makerere University Medical School Mulago Hospital Complex
Member, Management Committee Senior Trainer Ponseti Method

Franceschi, Fulvio Konde-Lule, Joseph

Director Professor, School of Public Health
Childrens Orthopaedic Rehabilitation Unit Makerere University
Member, Management Committee Member, Management Committee

Gita, Sheba Madewo, Geoffrey

Lecturer, School of Public Health Orthopaedic Surgeon
Makerere University Mulago Hospital Complex
Project Advisor Orthopaedic Coordinator, USCCP

Jjumba, Sam Mainetti, Sergio

Principal Tutor Head of Orthopaedic Workshop
School for Orthopaedic officers Katalemwa Cheshire Home
Trainer Ponseti Method Senior Trainer Bracing

Kayondo, Sam Mathias, Richard

Acting Principal Tutor Professor, Healthcar Epidemiology
Orthopaedic Technology Training School University of British Columbia
Trainer Bracing Member, Management Committee
 Contributors 7

Mbonye, Ben
Pirani, Shafique
Hon Lecturer, Department of Orthopaedics
Makerere University Medical School Professor, Department of Orthopaedics
Deputy Project Director, Uganda University of British Columbia
Project Director

Sewankambo, Nelson
Mugisa, Didus
Dean, Faculty of Medicine
Lecturer, Department of Surgery Makerere University
Makerere University Medical School
Liaison, Department of Surgery

Musoke, Henry Staheli, Lynn

Senior Orthopaedic officer Professor Emeritus, UW, Seattle
Childrens Orthopaedic Rehabilitation Unit Founder, HELP Organization
Senior Trainer Ponseti Method Editor and Photographer

Mutebi, Issac Steenbeek, Michiel

Tutor CBM Advisor for Orthopaedic Projects
Orthopaedic Technology Training School CORSU
Trainer Bracing Senior Trainer Ponseti Method/Bracing

Naddumba, Edward Steenbeek-Dreise, Marieke

Senior Consultant, Department of Project Administrator
Orthopaedics USCCP
Makerere University Medical School
Project Director, Uganda

Otim, Alfred Waiswa, Gonzaga

Dean of Students Orthopaedic Surgeon
Paramedical Training Schools Mulago Hospital Complex
Trainer Ponseti Method Orthopaedic Coordinator, USCCP

Okello, David Wanaswa, Nathan

Orthopaedic Technician Tutor
Katalemwa Orthopaedic Workshop School for Orthopaedic officers
Trainer Bracing Trainer Ponseti Method

Penny, Norgrove Wangobaya, Milton

Coordinator for Orthopaedic Projects Orthopaedic Technologist
Christian Blind Mission Mulago Orthopaedic Workshop
Member, Management Committee Project Advisor
8 Contributing Organizations

Contributing Organizations Makerere University

Many organizations have contributed to the Uganda Makerere University is Ugandas premier
Sustainable Clubfoot Care Project and this publication. institution of higher learning. With a
student population of more than 30,000,
Association of Universities and Colleges of it ranks as one of the largest in East and Central
Canada Africa. http://www.mak.ac.ug/
The Association of Universities and
Colleges of Canada is the voice of Ministry of Health, Government of Uganda
Canadas universities. It represent 90 Canadian The Ministry of Health provides health
public and private not-for-profit universities and policies, guidance, and standards; facili-
university-degree level colleges. Its mandate is tates district health services; and manages
to facilitate the development of public policy on nationally based health services. It ensures the
higher education and to encourage cooperation attainment of a good standard of health by all
among universities and governments, industry, people in Uganda in order to promote a healthy
communities, and institutions in other countries. and productive life. http://www.health.go.ug/
http://www.aucc.ca/
Mulago Hospital
Canadian International Development Agency
Mulago Hospital is an urban, tertiary care
The Canadian International Development Agency facility located in Kampala, Uganda. It
(CIDA) is Canadas lead development is the largest government referral hos-
agency. It has a mandate to reduce pov- pital, the main teaching hospital of Makerere
erty and to contribute to a more secure, equitable, University, and the site of the main Clubfoot
and prosperous world. CIDA works in partner- Clinic of the Uganda Sustainable Clubfoot Care
ship around the world to support sustainable Project. http://www.mulago.or.ug/
development in developing countries and to offer
humanitarian assistance in areas of need. http:// The Rotary Foundation
www.acdi-cida.gc.ca The Rotary Foundation is a not-for-profit
corporation that supports the efforts of
Childrens Orthopaedic Rehabilitation Unit Rotary International to achieve world
CORU seeks to restore ability in children understanding and peace through international
with physical disabilities. humanitarian, educational, and cultural exchange
programs. It is supported solely by voluntary
contributions from Rotarians and friends of
Christian Blind Mission the Foundation who share its vision of a better
CBM is an international organization world. http://www.rotary.org/foundation/
whose primary purpose is to improve the
The University of British Columbia
quality of life of the worlds poorest people with
disabilities. http://www.cbmi.org The University of British Columbia aspires
to be one of the worlds best universities
by preparing students to become excep-
Global HELP Organization tional global citizens, promoting the values of a
The Global HELP Organization produc- civil and sustainable society, and conducting out-
es free healthcare publications for standing research to serve the people of British
developing countries. Columbia, Canada, and the world.
http://www.global-help.org http://www.ubc.ca/
 Bibliography 9

Bibliography 1997 Ponseti I.V. Common Errors in the Treatment of

Congenital Clubfoot. Int Orthopaedics 21:137.
1839 Little W.J. A treatise on the nature of club-foot and
1998 Ponseti I.V. Correction of the Talar Neck Angle
analagous distortions. London: W. Jeffs, S. Highley.
in Congenital Clubfoot with Sequential Manipulation and
1891 Phelps A.M. The present status of the open incision Casting. Iowa Orthopaedic J 18:74
method for talipes varo-equinus., New Engl. Med. 10:217.
2000 Ponseti I.V. Clubfoot Management. J Pediatr
1893 Farabeuf L.H. Precis de manual operative. 4th ed. Orthop 20:699.
Masson, Paris. 2001 Pirani S. Zeznik L. Hodges D. Magnetic
1930 Brockman E.P. Congenital club foot: Its causes, Resonance Imaging Study of the Congenital Clubfoot
pathology and treatment. John Wright, Bristol Treated with the Ponseti Method. J Pediatr Orthop 21:719
1930 Kite J.H. Non-operative treatment of congenital 2002 Herzenberg J. Ponseti Versus Traditional Methods
clubfeet. Southern Med. J., 23:337. of Casting for Idiopathic Clubfoot. J Pediatr Orthop 22:517.
1950 Steindler A. Postgraduate lectures on ortho- 2003 Ippolito E. Farsetti P. Caterini R. Tudisco C.
pedic diagnosis and indications, Vol. 1. Springfield, Long-term Comparative Results in Patients with Congenital
Illinois:Thomas. Clubfoot Treated with Two Different Protocols. J Bone Joint
1961 Huson A. Een, ontleedkundig functioneel Surg 85A:1286.
Onderzoekvan de Voetwortel. (An anatomical and functional 2003 Morcuende J. Egbert M. Ponseti I.V. The Effect
study of the tarsus). Ph.D. dissertation, Leiden University. of the Internet in the Treatment of Congenital Idiopathic
1963 Ponseti I.V. Smoley E.N. Congenital Clubfoot: The Clubfoot. Iowa Orthop J 23:83.
Results of Treatment. J Bone Joint Surg. 45A:2261. 2003 Macharia J. The Idiopathic Clubfoot: Short-term
1966 Ponseti I.V. Becker J.R. Congenital Metatarsus Results of Treatment with the Ponseti Method at Mulago
Adductus: The Results of Treatment. J Bone Joint Surg. Hospital. Masters Dissertation. Makerere University.
43A:702. 2004 Dobbs M. Treatment of Idiopathic Clubfeet:
1972 Campos J. Ponseti I.V. Observations on Factors Predictive of Outcome J. Bone Joint Surg. Am. 86:22
Pathogenesis and Treatment of Congenital Clubfoot. Clin 2004 Morcuende J. Dolan L. Dietz F. Ponseti I.V. Radical
Orth and Rel Res. 84:50 Reduction in the Rate of Extensive Corrective Surgery for
1974 Ionasescu V. Maynard J.A. Ponseti I.V. Zellweger Clubfoot Using the Ponseti Method. Pediatrics 113:376
H. The Role of Collagen in the Pathogenesis of Idiopathic 2005 Morcuende J. Results of an Accelerated Ponseti for
Clubfoot: Biochemical and Electron Microscopic Clubfoot. J Pediatr Orthop 25:623
Correlations. Helvetica Paediatrica Acta 29:305.
2005 Tindall A. Results of Manipulation of Idiopathic
1980 Ippolito E. Ponseti I.V. Congenital Clubfoot in Clubfoot Deformity in Malawi by Orthopaedic Clinical
the Human Fetus: A Histological Study. J Bone Joint Surg Officers Using the Ponseti Method: A Realistic Alternative
62A:8. for the Developing World? J Pediatr Orthop 25:627
1980 Laaveg S.J. Ponseti I.V. Long-term Results of 2005 Konde-Lule J. Gitta S. McElroy T and the Uganda
Treatment of Congenital Clubfoot. J Bone Joint Surg 62A:23 Sustainable Clubfoot Care Project. Understanding Clubfoot in
1981 Brand R.A. Laaveg S.J. Crowninshield R.D. Uganda: A Rapid Ethnographic Study. Makerere University
Ponseti I.V. The Center of Pressure Path in Treated Clubfoot. 2006 Dobbs M.B. Long-Term Follow-up of Patients
Clin Orth and Rel Res,160:43. with Clubfeet Treated with Extensive Soft-Tissue Release. J.
1981 Ponseti I.V. El-Khoury G.Y. Ippolito E. Weinstein Bone Joint Surg. Am. 88:986
S.L. A Radiographic Study of Skeletal Deformities in 2006 Ponseti I.V. Treatment of the Complex Idiopathic
Treated Clubfoot. Clin Orth and Rel Res 160:30.
Clubfoot, Clin Orth Rel Res 451:171.
1992 Ponseti I.V. Treatment of Congenital Clubfoot. J 2006 Shack N. Early results of a physiotherapist-
Bone Joint Surg 74A:448.
delivered Ponseti service for the management of idiopathic
1994 Ponseti I.V. The Treatment of Congenital Clubfoot congenital talipes equinovarus foot deformity; J. Bone Joint
Journal of Orthopaedic and Sports Physical Therapy 20:1. Surg 88-B: 1085
1994 Farsetti P. Weinstein S.L. Ponseti I.V. The Long- 2007 McElroy T. Konde-Lule J. Gitta S and the Uganda
term Functional and Radiographic Outcomes of Untreated Sustainable Clubfoot Care Project. Understanding the
and Non-Operatively Treated Metatarsus Adductus. J Bone Barriers to Clubfoot Treatment Adherence in Uganda: A
Joint Surg 76A:257. Rapid Ethnographic Study. Disability and Rehabilitation
1995 Cooper D.M. Dietz F.R. Treatment of Idiopathic 29:845
Clubfoot: A Thirty-Year Follow-up Note J Bone Joint Surg 2008 Ponseti, I.V. Congenital Clubfeet: Fundamentals
77A:1477 of Treatment, 2nd Edition. Department of Orthopaedics,
1996 Ponseti I.V. Congenital Clubfoot: Fundamentals of University of Iowa, Iowa City, IA, 52242
Treatment. Oxford University Press.
10 History of Clubfoot Management

History of Clubfoot Management Clubfeet and the Ponseti Method

Humankind has known of clubfeet since time immemorial. Ponseti a keen clinician and careful scientist
Treatment modalities were always controversial, varying
Ponseti recognized that surgical approaches to clubfeet fail
according to the capabilities of the era. Remarkably, over the
surgery results in stiff and painful feet. He sought to develop
last 10 years, almost all clubfoot experts have migrated to
a more effective nonsurgical solution by returning to basic
using the Ponseti Method.
biology. He advised simultaneous correction of cavus,
Early adductus, and varus followed by correction of equinus [A].
Egyptian tomb paintings show Pharaoh Siptah of the 19th Ponsetis technique of correction took advantage of the syn-
Dynasty to have clubfeet. chronous movements of the tarsal bones making up the sub-
talar joint to unlock the deformity. He found that correction
Hippocrates was the first to write on clubfeet. He recog-
of the deformity could be achieved in just 5 weeks.
nized that treatment should start early, before bony deformity
is established. Biology clarified by Ponseti
Modern medicine (18th century onwards) Abnormal clubfeet anatomy Campos and Ponsetis dis-
The first casts (egg-white-soaked bandages) were applied by sections of stillborns with clubfeet (1966) revealed tarsal
William Cheselden at St. Thomass Hospital, London. The shape abnormalities, abnormal intertarsal relationships, and
first achilles tenotomies were by Delpech, Stomeyer, and abnormalities of the tendons and ligaments posteriorly and
Little in the 1820s. Plaster of paris casts were first used by medially. In particular, the navicular [B, outlined in red] is
M. Guerin (1833). William Adams described pathology after medially displaced on the talus [B, outlined in yellow].
dissecting stillborns. Deformity assessment In infancy, most tarsal bones are
Surgical methods The advent of antisepsis, anaesthesia minimally ossified. Ponseti understood that radiographs would
and the surgical tourniquet allowed a surgical approach. therefore be unhelpful in most cases. He emphasized clinical
Extensive postero-medial releases were developed by Phelps, methods of assessment of deformity in decision making.
Duval, Ogston, and others (1870 and later). Steindler (1950) Kinematic coupling Ponseti clarified tarsal bone move-
recognized poor results in more than 50% of surgical cases, ments in normal and clubfeet by cineradiographic studies
leading to a reappraisal of nonsurgical methods. and understood its importance. Kinematic coupling is a term
Hiram Kite was a leading advocate of nonsurgical man- given by Farabeuf (1893) and Huson (1961) to tarsal bone
agement (1930). He advised a sequential correction of the movement motion coupling.
clubfoot deformity. His technique, however, failed to take Calcaneal adduction is accompanied by inversion and
advantage of the synchronous movements of the tarsal bones flexion of the calcaneus.
making up the subtalar joint. He reported a prolonged period Calcaneal abduction is accompanied by eversion and
of treatment (average 22 months) that was necessary to cor- extension. In other words, calcaneal inversion or varus will
rect the deformity. correct only if it is abducted.
Response to low load Ponseti postulated that young, fast-

A B
A well conducted orthopedic treatment, based on
a sound understanding of the functional anatomy of
the foot, and on the biological response of young
connective tissue and bone to changes in direction
of mechanical stimuli, can gradually reduce or almost
eliminate these deformities in most clubfeet.
(Ponseti 1996)
 History of Clubfoot Management 11

growing connective tissues (tendons and ligaments) and car- Developments and refinements
tilage would show a biologic response to low load tensions Several other investigators have contributed to modern think-
exerted by his manipulation and casting technique that ing about clubfoot.
contractures would stretch and tarsal cartilage abnormalities
Bracing is necessary to prevent relapse (Morcuende 2004).
would remodel [previous page, B].
Piranis MRI studies (2001) confirmed this biologic Long-term outcomes from surgery are poor [C] (Dobbs
response. The MRIs showed that as the foot corrected clini- 2006).
cally [A to B], individual tarsal abnormalities such as a The technique is effective in paramedical hands as
medially inclined talar neck (in yellow) and intertarsal rela- shown in Uganda (Macharia/Pirani 2003), Malawi (Tindall
tionships such as a medially displaced navicular (in red) cor- 2005) and United Kingdom (Shack 2006).
rected [D and E]. The technique is effective in older children The upper
Clinical application age limit remains to be established (Nogueira 2006).
The complex clubfoot variant needs early identification,
Early disinterest Ponseti developed his technique of manip-
as it needs a modification in management. Results remain
ulation and casting. He performed a clinical trial of his
rewarding (Ponseti 2006).
technique on his patients and reported on his findings on
several occasions (1963, 1972, 1980, 1992). However, doc- Syndromic clubfeet respond to the method. Most correct;
tors treating clubfeet were initially slow to change their pat- however, more casts usually are needed and relapse is more
terns of practice and adopt the Ponseti Method. The pathol- common.
ogy and biology remained poorly understood. Ponsetis An accelerated protocol of management with cast chang-
reports were not given due credit, possibly because they es every 4 to 5 days is equally effective and can shorten the
were not read accurately. time needed to obtain correction (Morcuende 2005).
Delayed acceptance Several factors led to the widespread
adoption of Ponsetis technique at the turn of the 21st century.
Very satisfactory long-term outcomes were reported by
independent observers (Cooper and Deitz 1995) [C].
MRI studies were performed and reported (Pirani 2001).
Internet-driven parent demand of nonsurgical option ensued
(Morcuende and Egbert 2003).
Re-emphasis on technical aspects was presented by
Ponsetis monograph on clubfeet (Congenital Clubfoot
Fundamentals of Treatment 1996).
Clarification of Common Errors were addressed (Ponseti A B
1997).
Clinical experience of other investigators documenting
effectiveness of the method prompted a reconsideration of
the need for surgical release (Herzenberg 2002).

C
Long-Term Outcomes of Clubfoot Treatment Adapted
from Treatment of Idiopathic Clubfoot: A Thirty Year
Follow-up Note, (JBJS 77A, 1477) and Long-Term Follow-up
of Patients with Clubfeet Treated with Extensive Soft Tissue D E
Release (JBJS 88A,986)
Surgical Ponseti Treatment
Treatment
Good and Excellent 33% 78%
Fair and Poor 67% 22%

Operative patients had less physical function, more bodily pain, less
general health, and less social function than Ponseti-treated patients.
(Dobbs 2006)
12 Clubfoot Management in Uganda

Clubfoot Management in Uganda Ponseti Method Introduction to Uganda

Before Ponseti management, clubfoot management in In 1999, with evidence that the Ponseti Method was effec-
Uganda mirrored management elsewhere in developing tive in correcting deformity in clubfeet, stakeholders reached
nations with scarce surgical resources. consensus to introduce the Ponseti Method to Uganda as a
potential solution to preventing the consequences of neglect-
Clubfoot A surgical diagnosis ed clubfeet.
Surgery was considered necessary in most cases to correct
Early experience
the deformity.
Detection at birth The importance of this was not empha-
A trial of the Ponseti Method was conducted at the
sized, as casting was considered ineffective and surgery Mulago Hospital Clubfoot Clinic on infants presenting
largely unavailable. with congenital clubfeet. The model of care advocated:
Management Where available, treatment was with the Kite Manipulation and casting by orthopaedic officers under
method by paramedical staff (orthopaedic officers) with the supervision of a medical officer.
biweekly below-knee plaster of paris casts. Only 10% of Tenotomy by a medical officer.
deformities corrected after 6 months of casting. Steenbeek foot abduction bracing to prevent relapse of
Outcome Most caregivers abandoned treatment, exhausted deformity.
by repeated clinic visits with little or no improvement. Most Results Macharia (2003) confirmed clubfeet in Uganda
children grew up burdened by their neglected clubfeet. could be successfully corrected by orthopaedic officers.
Consequences Barriers
Atria estimated there were 10,000 children with neglected Macharias work suggested that barriers prevented success-
clubfeet in Uganda in 1994. Neglected clubfeet have several ful outcomes in all.
negative consequences.
Barriers for caregivers Many children present late, or
On the Individual In an agrarian society, pain with walk- not at all, for treatment for many reasons, including lack of
ing results in disability, decreased opportunity for gainful awareness of the deformity or concerns about cost of care.
employment, and social marginalization. Females are particu-
Barriers for healthcare providers Inconsistency of sup-
larly vulnerable mothers carry the burden of care for chil-
plies at many clinics and variable quality of support and
dren, and afflicted girls are less likely to marry. Each affected
supervision of orthopaedic officers reduced the effectiveness
individual faces a downward spiral of deformity, disability,
of the treatment method.
dependency, demoralization, despair, and depression.
On the family The family carries the burden of providing
for the disabled and are financially poorer.
On society Ill health is the leading cause and consequence
of poverty in developing nations.

A
Uganda: Population
Density and
Clubfoot Clinics
 Clubfoot Management in Uganda 13

A Sustainable Clubfoot Care Program workers such as midwives. Inform all healthcare provid-
Healthcare initiatives that are economically and socially ers seeing babies and children of the opportunities for
feasible for society are more likely to be sustainable. The screening for foot deformities during early life by a visual
Uganda Project is expanding on early experience in Uganda foot inspection and to refer if positive. A failure to detect a
with the Ponseti Method by building capacity throughout foot deformity will deprive the child of the opportunity to
Uganda for sustainable care of the child born with a clubfoot. have it corrected.
Multiple partners, each playing an important role, have col- Midwives and nurses The examination of the newborn
laborated to develop a common national strategy. A concerted is the best time to perform a visual foot inspection.
effort is needed to reduce barriers for patients and healthcare Immunization workers In many areas immunization
providers. rates exceed 90% and continue at regular intervals. A visual
foot inspection should be performed at every immunization.
Ugandas strategy to manage clubfeet
These visits provide an excellent opportunity for trained
Screening, diagnosis, and treatment Healthcare work- immunization workers to screen for foot deformities in chil-
ers attending births should screen for foot deformities at the dren born in the village.
examination of the newborn. Babies with suspected foot The Child Health Card will have a reminder to screen
deformity are to be referred early to one of a network of club- for foot deformities.
foot clinics across the country. Trained orthopaedic officers Referral Midwives, nurses, immunization workers and
will confirm the diagnosis and treat with the Ponseti Method. others suspecting a foot abnormality on visual foot inspection
Training in clubfoot screening, diagnosis, and treat- are to refer the infant to the nearest clubfoot clinic.
ment is to become routine for healthcare professionals that A network of clubfoot clinics staffed by trained
regularly come into contact with infants and children. orthopaedic officers and doctors continues to grow at many
Policy and advocacy consist of standardized careplans regional and general hospitals across the country [previous
for clubfeet and advocacy for resources for care of children page, A].
with clubfeet. Orthopaedic officers are specially trained in the
Partners and roles Ponseti Method. They are most suited to making the diagno-
sis of a clubfoot and treating it.
The Ministry of Health The Commissioner of Clinical
Tenotomies are performed by a surgeon or medical officer.
Services coordinates clubfoot activities of the Ministry.
Steenbeek foot abduction braces are made by ortho-
Policy is created to guide the care of children born
paedic technicians and technologists at government and NGO
with clubfeet. All children born in Uganda with clubfeet
orthopaedic workshops.
should be managed by the Ponseti Method.
School of Public Health The schools role is to research
Standards for screening, treatment, and support/super-
issues surrounding this initiative (e.g., an incidence survey of
vision are created and monitored.
clubfeet at birth in Uganda, an ethnocultural survey of club-
Create awareness in Ugandan society and healthcare
feet in Uganda) and advising on public health aspects.
workers for the need to detect clubfeet at birth and start
Makerere University and University of British Columbia
early treatment.
The updated curriculum content and teaching materials for
Resource allocation Incidence and census data allow
clubfoot detection and treatment by the Ponseti Method are
the Ministry to estimate births of children with clubfeet by
a collaborative effort of the University of British Columbia,
district and to allocate resources. The materials necessary for
Makerere University Medical School, and other Ugandan
treatment are on a credit line with the National Medical Stores.
Schools of Healthcare.
Ugandas healthcare schools All medical, nursing and
Christian Blind Mission Through CORU, the role of the
midwifery, and paramedical schools (for orthopaedic officers
Christian Blind Mission includes providing expertise and facili-
and technologists) will include in their curricula, as appropri-
ties for the activities of the project.
ate, screening for foot deformities at birth, congenital club-
foot diagnosis, and its management by the Ponseti Method.
New modules The Project has produced new mod-
ules for clubfoot detection and treatment for all cadres of
healthcare students.
This teaching manual provides specific teaching mate-
rials for each core group of healthcare students.
Ugandas healthcare institutions Only 35% of births in
Uganda occur under the supervision of trained healthcare
14 Social and Cultural Barriers

Social and Cultural Barriers Barriers Social

To understand what Ugandans know, feel, and believe about Poverty
clubfeet, the Project commissioned an ethnocultural survey
Uganda continues to make economic progress. Yet one-
of clubfeet in Uganda. This highlighted the issues of barriers
third still live below the poverty line (DFID 2007). Despite
to care as an important problem. Contact the Department of
parents wishes to have their child treated, they may not be
Orthopaedics at Makerere for a copy of the survey for com-
able to cope financially and drop out. In one survey, 60% of
plete details.
caregivers said they had difficulty meeting the costs, having
Most parents want their children to be healthy. A no
to borrow or sacrifice other basic needs. Even though care at
show child at the clinic usually means that the parent or
Ugandas hospitals is free of charge, constraints in supplies
caregiver met a barrier to attending the clinic they were
can mean that caregivers have to buy materials. This burden
unable to overcome. The child therefore suffers. If healthcare
is aggravated if careproviders also charge.
workers understand these barriers, they can work with care-
givers to develop strategies to overcome them [B]. Conflict with other maternal responsibilities
Most Ugandans live in rural areas and are subsistence farmers.
A Observations about Barriers by The average household is seven people. Traditionally, females
Dean Nathan Wanaswa are responsible for household tasks such as cooking and child-
1. Some parents believe clubfoot is a curse by a relative or a
care. The mother may become overwhelmed and feel unable
supernatural power and often blame their ancestors. to take on the additional burden of the childs treatment. She
2. If a clubfoot runs in the family, the father may decline treatment as may start treatment but drop out due to the difficulties.
the deformity identifies the family line.
Travel to clinic
3. The mother of the child may be divorced because the father cannot
accept that he is the father and considers his wife was unfaithful. Simply getting to the clinic is usually a long and costly effort.
4. Untreated, a girl with clubfoot may become pregnant without Once at the clinic, the parent and child may face long lines [A].
marriage; if she has a child with a clubfoot, the father is angry as
the child is a disgrace to the family. The girl cannot marry as she is Challenges of treatment process
considered cursed. Mother will not bring the child for treatment. Parents worry about whether their child will have pain, or
5. Some believe that the condition will resolve with time. It does not. how to bathe and carry the child. They may feel shame. The
There can be considerable delay before treatment is sought.
prospect of endless visits to the clinic can be daunting [A].
6. Some fear a plaster cast. They believe it acquires lice.
7. Many believe the deformity cannot be corrected. Lack of paternal involvement and support
8. Most fear the hospital. Doctors and nurses abuse and harass them. Whereas the father is usually the breadwinner (and therefore
They fear surgery, and are concerned that the doctor may cut off the
controller of family finances), the mother is the primary
childs foot. They fear seeing strange diseases and deformities.
caregiver for children. Mothers need the fathers understand-
9. Many feel small and just do not want to be with better educated
people because they feel inferior. They are embarrassed to show their
ing and financial support to follow the treatment protocol.
child in public. The poor cannot afford clothing that they feel necessary However, only one out of ten children at the clinic come with
to appear in public so they stay home. Husbands consider the wife the their fathers. Fathers do not always have the opportunity to
cause of the problem and refuse to bring the child to the hospital. completely understand that the clubfoot is a completely cor-
10. Long distances to hospitals and expensive transport makes rectable condition, provided treatment is followed.
management difficult.
11. Sickness, either in the child or some other family member (AIDS), B
may interfere with treatment.
12. Relatives may not be supportive. They may disown the child, When we fail to recognize these macro level issues, we are at risk of
feeling that it is from another family line and suggest that the child is blaming parents and their families for non-compliance.
cursed. (USCCP Ethnocultural Survey)

C
 Social and Cultural Barriers 15

Barriers Cultural Barriers How to Help

Many healthcare approaches Help parents overcome barriers by the following measures.
People all over the world use both modern and alternative Establish clubfoot clinics
medicines. Uganda is no exception. Parents often seek care A network of clubfoot clinics across Uganda encourages the
from traditional healthcare practitioners, as they are easily same standards of free, quality, and effective care. You can
available in their communities. However, these treatments are help by establishing a clinic and advocating for clinic space,
ineffective for clubfoot, and delay the parent from seeking materials, and personnel with your healthcare administrators.
effective care from the medical system [A]. Delayed presen-
tation complicates management and can compromise out- Involve fathers
comes, especially if the child has already started walking. Encourage fathers to attend the clubfoot clinic with the moth-
ers and to become involved in treatment. Fathers who feel
Beliefs involved and understand are more likely to support the moth-
In some Ugandan communities there are beliefs that clubfoot ers in following treatment for the child [B].
is caused by evil spirits, witchcraft, a curse, or the mothers
misdeeds, and that treatments are ineffective. This results in Discuss management and plan follow-up
a delay in seeking care with consequences as indicated above Inform caregivers of the entire treatment plan (20 visits over
[previous page, A]. 4 years). Discussing and planning the entire treatment at the
start encourages families to plan how to gather necessary
Stigma funds. Inform parents that the cost of care will be covered by
Often a child with a disability is a source of shame and is the hospital.
hidden by the family [previous page, A].
Partnerships
Village birth Encourage care-sharing partnerships to manage barriers.
Infants born in the village pose a special problem. They will Parents and other caregivers share the financial burden and
not normally have the benefit of an examination of the new- other family responsibilities. Healthcare workers (orthopae-
born by a trained healthcare worker. The families may have dic officers, orthopaedic technicians, nurses and doctors)
no awareness of the diagnosis or management options. share health delivery responsibilities. Consider asking local
churches, mosques, service clubs, and NGOs to assist the
very poor by facilitating transport or offering other services.
Education, respect, reassurance
A
You talk to the parents and advise them it can be fixed. it is Educate parents and the community [C] by informing
important to listen to the parents beliefs and then to discuss about clubfeet, its causes, and that the medical system can
your beliefs. You can then reach a compromise that will
manage these problems. This will help make the condition
allow the parents to adhere to treatment. If you respect them
and their beliefs, they will come back. (Practitioner treating more acceptable. Educate those in birthing and immunization
clubfoot, Uganda) clinics to screen for foot deformities with a visual foot inspec-
tion and refer if positive. Posters help [opposite page, C].
Respect mothers needs to return quickly to their other
B duties at home by avoiding excessive waiting in clinics.
Reassure that the cause is not the parents fault and
treatment is highly effective but takes time.

C
Education For Parents of Children with Clubfeet
Inform parents about clubfeet and the appropriate management. This
information explains the cause of the problem and averts common
misconceptions. Include a description of the appearance of the
clubfoot, the importance of early treatment, and reassurance that
treatment can fully correct the deformity. Emphasize that clubfeet can
occur in any family and is not caused by any behaviors of the parents
or curse. It is simply a medical condition that can be corrected.
16 Anatomy, Physiology, and Pathology

A Ankle and Foot Movements Anatomy, Physiology, and Pathology

Ankle Extension Foot moves in a dorsal direction [B] The bones of the newborns foot are largely formed in carti-
Ankle Flexion Foot moves in a plantar direction [B] lage, which is less rigid and more easily moulded by external
Foot Adduction Distal part of foot moves towards median forces than bone. With growth, the cartilage is gradually
body plane [C] replaced by bone except for joint surfaces.
Foot Abduction Distal part of foot moves away from
median body plane [C]
Movements
Foot Inversion Plantar aspect of foot moves towards The joints of the foot move in many directions. Terminology
median body plane [D] can be confusing. Its useful to consider a standard nomencla-
Foot Eversion Plantar aspect of foot moves away from ture for ankle and foot movements [A].
median body plane [D]
Foot Supination Combined Inversion, adduction and
Joints
flexion of foot [E]
Ankle joint This lies between the tibia, fibula and talus.
Foot Pronation Combined eversion, abduction, and Ankle movements [B] are dorsiflexion and plantarflexion.
extension of foot [F]
Subtalar and midtarsal joints The subtalar joint lies
between the talus and calcaneus. The midtarsal joints include
B C the talonavicular and calcaneocuboid joints. Subtalar, ankle
and midtarsal joints move together and result in foot supina-
tion [E] and pronation [F].
Muscles
Muscles provide the power to make the foot joints move:
Gastrosoleus flexes the ankle.
Tibialis anterior extends the ankle and supinates the foot.
Tibialis posterior flexes the ankle and supinates the foot.
Long toe flexors flex the ankle and toes.
Long toe extensors extend the ankle and toes.
D Peroneals flex the ankle and pronate the foot.

Ligaments
Stability of the foot is provided by ligaments. Ligaments
are strong fibrous bands that connect bones and allow lim-
ited motion.

E F
 Anatomy, Physiology and Pathology 17

Clubfoot Pathology Functional Anatomy

Muscles of the foot and leg are smaller than normal espe- It is important to understand the movements of the subtalar
cially the gastrocnemius. The more severe the deformity, joint. This helps explain the nature of the clubfoot deformity
the greater the discrepancy. Medial and posterior ligaments and the foot movements necessary in the Ponseti Method of
are thick and taut and hold the foot in a deformed position. correcting deformity.
They prevent the foot from passively being put through a full
Movements of the subtalar joint
range of motion.
Congenital clubfoot is a complex deformity with four Joint movements are determined by the curvatures of the
components: cavus, adductus, varus, and equinus. joint surfaces and their restraining ligaments. Movements of
the subtalar joint are complex; however, the following inter-
Cavus dependecies are useful to remember.
The foots medial longitudinal arch is increased by plantar- In foot supination, the calcaneus adducts, inverts, and
flexion of the first ray [page 21,B]. plantar flexes under the talus [previous page, E].
Adductus In foot pronation the calcaneus abducts, everts, and dorsi-
The distal foot is deviated towards the median body plane. flexes under the talus [previous page, F].
Talo-navicular joint The navicular is severely medially Nature of the deformity
displaced [A and B]. It articulates only with the medial part In a clubfoot, consider the tarsal bones to be in the most
of the talar head. The lateral part of the talar head remains extreme position caused by excessive pull of the gastroso-
uncovered. The medial pole of the navicular approaches leus, tibialis anterior and tibialis posterior [A and B] giving
the medial malleolus. The talar neck is deviated medially rise to the adducted, flexed and supinated position of the cal-
and plantarward. caneus under the talus.
Calcaneo-cuboid joint The cuboid is medially displaced
Clinical relevance
and adducted in front of the calcaneus [A and B]. Only the
medial part of the anterior tuberosity of the calcaneus articu- This calcaneal malposition needs to be corrected. To do so,
lates with the cuboid. The calcaneocuboid joint is oblique in abduct the forefoot with counterpressure against the head
orientation instead of transverse. of the talus. This causes the calcaneus to abduct. Subtalar
motion interdependencies ensure that as the calaneus abducts,
Varus it simultaneously everts and dorsiflexes. The clinical deformi-
The hindfoot is deviated towards the midline. This is best ties of midfoot adduction, heel varus and equinus arising from
appreciated by looking at the heel from behind [page 21, C]. calcaneal plantarflexion are therefore corrected together.
The calcaneus is adducted and inverted under the talus. It is very important not to touch the heel or block the
The anterior tuberosity of the calcaneus lies under the head cuboid from abducting because this blocks normal sub-
of the talus rather than lateral to it [A and B]. talar motion. Remember that the normal infants foot
abducts 7080 degrees [C]. Calcaneal dorsiflexion occurs
Equinus mainly during terminal abduction. Therefore, a clubfoot is
The foot points down [page 21, E]. not adequately corrected until full abduction is obtained.
The ankle joint is severely plantarflexed [A and B]. Abducting the foot only to neutral position is not adequate.
Calcaneal varus and extension do not correct fully, and
The subtalar joint is flexed as part of foot supination.
relapse is inevitable.

A
Normal Clubfoot
T T
B C
Talus
Navicular
Cuboid
Calcaneus
18 Information for Parents

Information for Parents About Treatment

Take a few moments to answer the questions of parents and What is the best treatment for clubfeet?
caregivers. Informed parents are more likely to cope with the
Most experts everywhere now agree that the best treatment
demands placed on them by the treatment protocol [A]. Here
for clubfeet regardless of cost is the Ponseti Method. The
are some standard questions and answers.
outcomes are most gratifying for both the patient and the
Are there different types of clubfeet? healthcare provider.
Yes. There are three kinds. A few (positional clubfeet) are What is the Ponseti Method?
due to a lack of room in the womb for the baby, for example
At birth, the childs foot is soft and supple like a green shoot
if the baby is large or if there are twins. The foot is pushed or
of a young plant. Just as you can bend a green shoot without
squeezed on one side. These clubfeet get better quite quickly
hurting it, you can straighten a clubfoot in an infant without
after birth. With the most common type (congenital idio-
hurting the foot or the infant. The Ponseti Method is a way of
pathic clubfeet), only the feet are affected, whereas with the
straightening a clubfoot by gently pushing the foot towards
third type (syndromic clubfeet), other parts of the body may
the correct position and then applying a holding cast. The
also be affected.
time in cast loosens the foot a little more, so that at the next
What causes clubfeet? visit, it can be further corrected. Correction is completed by a
Science is trying to find the exact cause. Most experts feel small cut just above the heel before the final cast. To prevent
that clubfeet are caused by a combination of genetic pre- the clubfoot from coming back, a brace is worn until 4 years
disposition and as yet unidentified environmental factors. of age.
Clubfeet are not anyones fault. They are not due to witch- When should the treatment start?
craft or curses.
The foot is most receptive to treatment at or within a few
Do clubfeet run in families? weeks after birth [C]. Treatment is still effective if started
In the community at large, the rate of clubfeet is about one later, but it can be more complicated and take longer. Start
baby in a thousand. However, if clubfoot is already in the treatment as early as family circumstances permit enough
family, there is a higher rate. For example, if a parent has a visits for the treatment to be fully effective.
clubfoot, there is a 3% to 4% chance that the offspring will When treatment is started early, how many cast
also be affected [B, white arrows]. If both parents have club- changes are usually required?
feet, the offspring have a 30% chance of developing clubfoot.
Most clubfeet are corrected in approximately five to seven
Are Ugandans more affected than others? casts. Usually they are changed either weekly or twice a
Surveys have shown that the incidence of clubfeet in Uganda week. If the deformity is not corrected after eight or nine
is 1.2 affected babies per one thousand live births. This is the casts, the treatment may be faulty.
same as most other places in the world. How late can treatment be started and still be
helpful?
Treatment is less effective if started after the child starts to
walk. After walking age, treatment still helps, but there is a
higher chance that up to 12 casts or perhaps surgery may be
A necessary to achieve full correction.

B C
 Information for Parents 19

Is surgery needed? About Outcomes

In the past, most doctors believed extensive surgery under a
general anaesthetic was necessary for correction. This is no
Expected outcome of Ponseti Management
longer the case. Most cases now need only a small cut just Feet treated by this management have been shown to be
above the heel before the final cast. This is done in the clinic strong, flexible, and pain free, allowing a normal life [C].
under local anaesthetic. Extensive surgery for most patients If only one foot is affected, it is slightly shorter and nar-
is not necessary nowadays. rower than the normal foot. The affected leg may be a little
shorter than the normal leg. In most situations, all of this
How often does Ponseti Management fail? makes no difference.
Correctly applied, the method is successful in correcting the
deformity in the vast majority of cases [A]. The success rate
A
depends on the experience of the treating team, the reliability
of the family, and the degree of stiffness of the foot. Some
clubfeet (called syndromic clubfeet), such as those seen with
arthrogryposis or myelomeningocoele, can be more stiff and
difficult to correct. However, the most common causes of
failure are either difficulty in the child getting to the clinic
for all visits during the casting phase, or difficulties with the
child wearing the brace until 4 years of age.
I am worried I will not be able to cope with
bracing my child what will help me cope?
Remember that all parents at sometime feel as if they will
not be able to cope with the problems their children bring.
And yet almost all parents, after some consideration and
planning, manage. It helps to remind the parent of a few
things. First, a properly fitting brace should not be painful
for the child [B]. If the child cries, they should check for sore
areas and have the brace adjusted to fit properly. Second,
make putting the brace on a regular part of the family rou-
tine. Do not even skip one day. Third, the parents should
remember that they are not alone. If they are having prob-
lems, they should ask the clinic staff for advice.

C
20 Screening and Diagnosis

Screening and Diagnosis Visual Foot Inspection

The strategy for early diagnosis of the clubfoot in Uganda Be aware that foot abnormalities [B] occur in about 13% of
depends on nurses, midwives, immunization staff, and others newborns. Many are benign and may resolve without treat-
screening for foot deformities at birth or initial immunization ment. Some, such as clubfoot, are not benign and require
with a visual foot inspection. early treatment to avoid a lifetime disability.
Perform the visual foot inspection [A] as part of the
Screening examination of the newborn. This is a critically important
Screening is a public health service in which newborns and step in clubfoot management in Uganda. This means that all
infants are offered a test, the visual foot inspection [A]. infants should be screened for foot deformities at birth. Any
This identifies those with a suspected foot abnormality [B]. infant with a foot deformity should be referred for assess-
Encourage all healthcare workers to perform the visual foot ment and treatment by an orthopaedic officer at a clubfoot
inspection whenever newborns or young infants contact the clinic. Seeing a real clubfoot in an orthopaedic clinic is the
healthcare system, such as at birth, postnatal clinics, and best preparation for becoming a skilled screener.
immunization visits. Those identified with a possible foot Counseling of parents Reassuring parents that most foot
deformity can then be referred to the nearest clubfoot clinic. deformities are easily corrected if treatment is begun early
In-hospital births About 40% of deliveries occur in health helps to build confidence. Involve the whole family, espe-
facilities. Nurses and midwives routinely do an examination cially the father. Encourage both parents to go to the clubfoot
of the newborn, ideally about an hour after a normal delivery. clinic with their child, allowing both to participate in deci-
Home births These are attended by traditional birth sion making. Posters with this message can be helpful [C].
attendants. Encourage the attendants to routinely perform
screening exams.
Immunization All infants should receive immunization. In
some areas immunization rates exceed 90%. Immunization is
an ideal opportunity to screen for foot deformities.

A B

C
 Screening and Diagnosis 21

Diagnosis of Clubfoot Assessing the Whole Child

At the first consultation in the clubfoot clinic, the orthopae- The orthopaedic officer (as the primary healthcare provider)
dic officer performs a complete history and physical exam. is responsible for the care of the whole child. This includes a
Diagnosis of the clubfoot The finding of the four classic full assessment to make certain no other conditions are pres-
features of cavus, adductus, varus and equinus confirms the ent. Examine the infant by performing the following steps.
diagnosis of clubfoot. The pneumonic CAVE describes these General and musculoskeletal physical exam
features:
Examine the cardiovascular, respiratory, gastro-intestinal,
Cavus is an increase in the height of the medial arch of
genito-urinary, and central nervous systems. Examine the
the foot [B]. spine, upper extremities, hips, and feet. Finding other con-
Adductus is medial deviation of the distal part of the genital abnormalities, such as spina bifida (an open spinal
foot [D]. cord) [A], or arthrogryposis (multiple joint contractures) [F]
Varus is a medially deviated heel and is best observed suggest a syndrome. Refer to a pediatrician as appropriate.
from behind [C]. Syndromic clubfeet can be more difficult to correct. The long
Equinus is downward pointing of the foot at the ankle [E]. -term outcome is more determined by the syndrome than the
Clubfoot type and score Once a diagnosis of clubfoot is foot deformity.
made, classify its type and determine the amount of defor- The management of other deformities may complicate club-
mity (score) present in the foot (page 22). This information foot management. For instance, should hip instability be found,
helps to guide treatment and reassure parents about the it should be managed before starting clubfoot management.
treatment plans. Forms
Incidence Project data indicate the incidence of clubfoot The Project suggests using a standard form [page 24, A and
in Uganda is 1.2 per thousand live births. Boys are affected B] in all clubfoot clinics. This facilitates capturing all neces-
three times more than girls. Clubfoot is bilateral in about half sary data regarding the child and the deformity and its treat-
of the cases. ment.
Etiology Clubfoot occurs due to a combination of genetic
and environmental factors. Clubfoot sometimes runs in fami- A
lies. Emphasize to caregivers that clubfeet are not caused by
evil spirits, witchcraft, curses, or the mothers misdeeds. If a
family has one child with a clubfoot, the risk in subsequent
siblings is about 30 times higher than average.

B C

D E F
22 Clubfoot Assessment

Clubfoot Assessment The Pirani Clubfoot Score

It is useful to classify a clubfoot when first seen to determine Definition
prognosis. Once classified, a clubfoot does not change its clas- The Pirani Clubfoot Score measures the amount of defor-
sification. Three classes of clubfeet can be determined at birth. mity in the clubfoot. Six clinical signs seen in all clubfeet
Congenital idiopathic clubfoot is the typical clubfoot. No that change in severity as the foot deformity changes are
other major abnormalities are present. It generally corrects in each scored 0 (normal), 0.5 (mildly abnormal) or 1 (severely
five casts [C]. With treatment, long-term outcomes are usu- abnormal). They create a simple scoring system [opposite
ally good or excellent. page]. Score each clubfoot every visit and record the finding
Syndromic clubfoot Other congenital abnormalities are on the form [page 24]. Scoring the foot at every visit helps
present. The clubfoot is part of a syndrome. Ponseti manage- tell the treating practitioner if deformity is correcting satis-
ment remains the standard care, but may be more difficult, factorily and when achilles tenotomy is indicated.
and response may be less predictable. The final outcome may Interpretation
depend more on the syndrome (such as arthrogryposis) than
the clubfoot. Scores and graphs are part of the patients notes. Clinicians
and parents can readily monitor the progress of treatment,
Positional clubfoot At birth, the foot looks like a clubfoot,
and attend to specific areas of concern as the need arises.
but is much more flexible. It occurs because of intrauterine
Examples
crowding. The prognosis is excellent. It corrects with one
Typical clubfoot [C]
or two casts. Braces, if used, can usually be discarded much
sooner, as relapse is hardly ever a problem. At week 1, the foot had a HS (in green) of 3, a MS (in
blue) of 3, and a TS (in red) of 6.
At weeks 2, 3, and 4, HS remained 3, MS improved
A week by week to 1, and TS improved to 4.
At week 5 before tenotomy, midfoot pathology is cor-
rected (MS 1 or less) and hindfoot pathology persists (HS
greater than 1). Achilles tendon tenotomy is performed to
correct the hindfoot pathology. After tenotomy HS improved
to 0.5, MS remained at 0.5, and TS improved to 1.
Resistant clubfoot [A] All scores drop very slowly.
Cast removal early [B] Scores rebound up during cast
treatment if cases are removed before the clinic visit
Early relapse [D] Scores rebound up during brace
B treatment if bracing is inconsistent.

D
 Clubfoot Assessment 23

Scoring The Midfoot Score (MS)

The Midfoot Score measures midfoot deformity and is the
The Total Score (TS)
sum of three signs (medial crease, curved lateral border, and
This is the sum of the HS and MS and indicates the amount lateral head of talus). Values can range from 0 or (no defor-
of deformity overall. Values can range from 0 (no deformity), mity), to 3 (severe deformity).
to 6 (severe deformity).
The Hindfoot Score (HS)
The amount of hindfoot deformity is measured as the
Hindfoot Score and is the sum of three signs (posterior
crease, rigid equinus, and empty heel). Values can range
from 0 (no deformity), to 3 (severe deformity).

1 0 .5 1

Curved lateral border (CLB) A normal foot has a straight

lateral border and scores 0. Adductus causes a curved lateral
0 .5 border. A mild curve, where the lateral border curves at the
metatarsals, scores 0.5. A lateral border that curves at the
Rigid Equinus (RE) Gently extend the ankle with the knee level of the calcaneo-cuboid joint scores 1.
extended. The normal ankle extends at least 15 degrees
beyond neutral and scores 0. With posterior contracture,
ankle extension is limited. Extension only to neutral scores
0.5. Extension short of neutral scores 1. 0 .5 1

Empty Heel
Medial Crease (MC) A normal arch displays multiple fine
Easily Palpable 0
skin lines and scores 0. Mild medial contracture causing one
Palpable Deep .5
or two deeper creases that do not alter the archs contour scores
Not Palpable 1 0.5. A single deep crease indenting the archs contour suggests
severe medial/plantar contracture and scores 1.

Empty Heel (EH) Gently extend the ankle without hurting

the child. Place a finger at the corner of the heel and feel the
fat over the calcaneal tuberosity. The calcaneus is normally
immediately palpable [score 0]. With posterior contracture, Talar Head Palpability
the calcaneus is drawn up and out of the heel pad, and the None 0
fat feels soft on palpation. A calcaneus that is palpable only Partial .5
deeply within the heel pad scores 0.5. A calcaneus that is not Full 1
palpable scores 1.

0 .5 1 Lateral Head of Talus (LHT) Estimate the amount of

uncovered talar head laterally [page 17, B] as an indicator of
midfoot pathology. Hold the foot deformed and palpate the
head of the talus with the thumb. Abduct the foot with the
other hand. Note if the navicular reduces onto the head of the
talus. Normally, abduction reduces the navicular completely
to the talar head which is no longer palpable and scores 0.
Posterior Crease (PC) The normal posterior ankle skin With medial contracture, the navicular does not fully cover
shows multiple fine creases and scores 0. Deeper creases over the talar head. A talar head that partially covers but
imply more posterior contracture. A posterior heel with one remains somewhat palpable scores 0.5. A talar head that does
or two deeper creases scores 0.5. The presence of a single not cover at all and remains easily palpable scores 1.
deep crease that changes the contour of the heel scores 1.
24 Clubfoot Assessment

Clubfoot Assessment
B

Clubfoot Patient Record

The Clubfoot Patient Record is a convenient way of chart-
ing all necessary information in a compact yet concise
manner for each patient on two pages [A and B]. Start a
new Clubfoot Patient Record for every child seen with club-
feet. Blank forms can be obtained from the Department of
Orthopaedics at Mulago Hospital and should be available in
the clubfoot clinic.
Record on page 1
Record the demographics, history, examination, additional
notes as necessary and a diagnosis [A].
Record on page 2
Record in table form the Pirani Clubfoot Scores each week
(Midfoot, Hindfoot, and Total Scores), the treatment rendered
(manipulation and casting, tenotomy and bracing), the effect
of treatment (cast position achieved, such as 1st, 2nd, 3rd
cast, etc.), and follow-up data [B].
Record on the lower part of page 2, data from follow up
examinations, and reatment given

A
 Overview of Management 25

Overview of Management A
There are four steps in the overall management of the child
with a clubfoot.
Step 1 Screen for foot deformities
Encourage all healthcare workers [A] at birthing and immu-
nization centers to screen all newborns and infants for foot
deformities and then to refer those with possible abnormality
for assessment and treatment by an orthopaedic officer at a
clubfoot clinic. This lessens the risk of those born with club-
feet escaping early diagnosis.
Step 2 Confirm diagnosis of clubfoot
The orthopaedic officer makes or refutes the diagnosis of
clubfoot at the first visit to the clubfoot clinic.
Step 3 Correct by casting and tenotomy B
Once diagnosed, treat with the Ponseti Method usually five
casts are sufficient [B].
Correct cavus by holding the supinated forefoot in
proper alignment with the hindfoot. Start abducting the foot
often the foot comes into some abduction. Cast 1 corrects
cavus and can correct some adduction.
Correct adduction and heel varus by holding the entire
foot in gradually increasing abduction under the talus with
casts 2, 3 and 4. Heel varus will correct when the entire foot
is fully abducted. C
Correct equinus with percutaneous tenotomy of the
tendo achilles as needed and then holding the foot dorsi-
flexed and in full abduction with cast 5.
Step 4 Prevent relapse of deformity by bracing
The purpose of the Steenbeek foot abduction brace [C] is to
prevent relapse of deformity by holding the foot in the cor-
rected position. Its use full time for 3 months and at night-
time until 4 years of age is critical for the success of the
treatment program.
Follow-up is essential, as management extends over sev-
eral years [D]. See the infant and family at regular intervals
to identify problems with the use of the brace to prevent
problems that might lead to noncompliance.

D
Optimal Ponseti Management Timeline

0 6 12 24 36 48 60
Months of age
Clubfoot detection by screening

Correct deformity by casting

Maintain correction by bracing

26 Clubfoot Clinics

Clubfoot Clinics Maintenance phase See the patient every 3 months

up to walking age, and then every 6 months until the fourth
A network of clubfoot clinics are the focal points of care of
birthday. At each visit, assess for relapse and fitting of the
the child with a clubfoot. The typical clubfoot clinic will be
brace. Determine if the brace is being worn. Children with
in a general hospital or regional referral hospital for a half
muscle imbalance will need longer follow-up and more visits.
day each week in the plaster room.
Volume Patient flow
Expect about one to three new infants a week referred Clubfoot management involves many steps. At many club-
with foot deformities. Many will have positional foot defor- foot clinics, staff organize stations, where clinic activities
mities not requiring any more than reassurance. Twenty-five are performed. Teaching posters outline the nature of activi-
to 50 infants born each year will need care for clubfeet half ties at each station [opposite page].
will have both feet affected. Therefore plan corrective casts Assessment At the first visit confirm or refute a diagnosis
for between 40 to 70 feet per year. Adjust numbers according of clubfoot. Children with other orthopaedic problems should
to experience. be directed to the general orthopaedic clinic.
At each weekly clinic 5 to 10 patients will be there for Classify the type of clubfoot at the first visit and exam-
consultation, manipulation and casting, tenotomy, or first- ine for other congenital anomalies. If present, refer also to
time brace application (2030 minutes each), and 10 to 20 other appropriate clinics (such as the spina bifida clinic).
patients will be there for brace check and review for relapse Measure Pirani Score for every clubfoot at every visit.
of deformity (1015 minutes each). Clinic numbers will It guides the treatment plan for the visit.
grow for four years before reaching a steady state, as each Manipulation and casting Correct the cavus, adductus, and
child will be seen for at least four years. varus components of the deformity with manipulation and
Staffing casts 1 to 4.
There will be enough work for two orthopaedic officers. Tenotomy When indicated by the Pirani Score, call the
They should have quick access to a medical officer or a sur- doctor to correct the equinus component of the deformity by
geon for tenotomies. achilles tenotomy.
Bracing Prevent relapse by fitting and ensuring continuing
Typical materials/supplies for 70 feet per year
use of a well-fitting Steenbeek foot abduction brace. Watch
Cotton padding Order 1500 six-inch rolls of padding. for relapse and manage nonoperatively if it occurs. Refer
Plaster Order 1200 six-inch plaster rolls. Each foot relapse not responding to nonoperative methods to an ortho-
will require 3 six-inch rolls for each cast. paedic surgeon for re-evaluation.
Recurrent clubfeet About 10% of clubfeet will recur. Visit checkout Check the foot and cast or brace at the visit
Each recurrent clubfoot will need between 15 and 30 rolls for checkout. Arrange follow-up.
correction, depending of foot size and severity of relapse.
Tenotomy supplies Most feet will come to achilles teno- Clubfoot Clinic Roles
tomy. Use a new set on each foot (unless performing bilateral Clubfoot clinics may also have teaching and research roles.
tenotomies at the same sitting). Occasionally tenotomies are
Educational role
needed for relapse. Prepare 70 sets annually.
All nursing, midwifery, and (para)medical students who
Steenbeek foot abduction splints Each child will need up
come into contact with newborns and infants will benefit
to 8 braces (sizes 6 to 13) during treatment. Reuse braces
from a rotation in their training by attending a local clubfoot
when possible. Order 30 complete sets the first year. Then
clinic to learn about clubfeet and their management.
adjust according to patient volume and experience.
Teaching posters detail the treatment at all stations
Patient visit protocol [opposite page]. Following infants through each treatment
Advise caregivers that about 20 visits over four years leads station allows healthcare workers to understand the theory
to optimal outcomes. and practice of each step in treatment.
Corrective phase usually requires 7 visits 5 weekly Research role
visits for five casts, a 6th visit 3 weeks later for removal of
Clinics collect data for clinical care. These data can also be
cast and fitting of a SFAB, and a 7th visit 2 to 4 weeks later
used for program administration and research.
for a brace-wearing compliance check.
 Clubfoot Clinics 27

Patient Flow

Assessment Station Casting Station

Bracing Station Visit Checkout

Tenotomy Station
28 Casting Setup and Technique

Casting Setup and Technique Communication with parents

These two pages show the general steps in cast application Take a moment to teach the parents about foot and cast care
common to all casts. Pages 3031 describe the specific steps before they leave the clinic. Reassuring and encouraging
for each individual cast. We suggest using these steps every words help the caregivers to feel that the treatment will have
time. The process will soon become second nature, and better a beneficial outcome. Ask the parents to regularly observe
results will be achieved. for signs of trouble.
Toes change color/swell and baby cries Caregivers
Materials
should soak the cast, remove it, and bring the infant back to
Preparing and setting up before the clinic starts makes mate- the clinic.
rials easily available during casting. The clinic will thus run
Cast gets wet This irritates the skin. The cast becomes too
more smoothly.
weak to maintain the foot in good position. Caregiver should
Cast cart A mobile cast cart, available from the orthopaedic bring the infant back to the clinic as soon as feasible.
workshop at Katalemwa, holds all supplies and a low plat-
form for a bucket of water [A]. It is on wheels and can be Positioning
moved as needed. Supplies can be easily reached throughout Manipulator and assistant Both sit facing the affected foot
the casting procedure. [C]. With respect to the affected foot, the manipulator sits
Supplies The supplies needed during manipulations and laterally and the assistant sits medially.
casting are listed in the table of materials for casting [B]. Infant in mothers lap Position the infant across the moth-
Attitude ers lap to allow the infant to breast-feed before and during
the casting [C]. When casting the right foot, the infants head
Be kind, sensitive, and reassuring to the family and infant.
should be near the mothers right breast. Reverse the position
Emphasize that treatment will be successful and the infants
when casting the left foot.
deformity will be corrected. Use the casting time to explore
problems the parents might have or to answer questions.
Help the family to understand the overview of management
and the importance of each step. Allow the mother to breast-
feed, which calms the infant during the procedure. Everyone
will be more at ease if the child is happy. Watch the childs
face for signs of discomfort. If the infant appears distressed,
encourage breastfeeding. If this is not successful, slow down,
reduce the pressure, and allow the infant to become calm. Do
not hurt the infant. This should be a painless procedure.

B Material for Casting

1. Cotton undercast padding
2. Plaster of Paris bandages cut to 2 3-inch size
3. Bucket of water
4. Plastic apron
5. Plaster scissors for trimming edges of the cast
Manipulator Assistant
6. Surgical blade #24
7. Cloth for clean up
8. Disposable gloves
 Casting Setup and Technique 29

Cast Technique E
Casting requires two skilled persons a manipulator and an
assistant and preferably the mother to hold the infant in her
lap. All should be seated. People and hands in the pictures
are identified by a red dot for the manipulator and a smaller
blue dot for the assistant. Differentiating the roles helps in
learning positioning and hand technique. The manipulator
manipulates the foot to correct the deformity as much as pos-
sible without hurting the infant [A and B], and then holds the
foot in the improved position while the assistant applies the
padding [C] and then the cast [D]. Once applied, mould the
cast as it sets to maintain the foot in the correct position [E].
Extend above the flexed knee [F and G] and trim [H]. These
techniques are fully described on pages 30 and 31.

A B
Mould cast The maniplator stabilizes the knee while the
assistant moulds the cast to hold the foot in the corrected
position [E]. The assistants hands and fingers move con-
tinuously to reduce the risk of pressure sores while the
plaster sets.

F G

Manipulate foot and hold The manipulator gently corrects

the deformity as much as possible (without hurting the child)
to stretch medial and plantar soft tissues [A and B]. A mental
note is made regarding the position achieved.

C D Extended cast above knee The cast is extended above the

D
flexed knee (90 degrees) to avoid the possibility of the cast
slipping off the leg [F and G].

Apply below-knee padding and cast The manipulator

holds the foot in position. The assistant applies thin (about
0.5 cm thick) padding over foot and leg from the tips of the
toes to just below the knee [C]. Beginning with the toes, the Trim cast The cast is then trimmed to remove excess plaster
assistant applies 4-5 layers of plaster distal to the knee [D]. to leave the toes uncrowded and yet supported [H]. Clean
Excessive layers make moulding difficult. the child.
30 Ponseti Corrective Casts

Ponseti Corrective Casts Apply cotton wool and plaster

Most clubfeet correct with about five casts. The first cast cor- With the foot in the corrected position, the manipulators
rects the cavus. Subsequent casts correct the adduction and left hand moves up the leg to be out of the way of the cotton
varus by progressively abducting the foot. The last cast in wool. Correction is maintained by gentle left thumb pressure
combination with tenotomy corrects the equinus. over the upper leg. The manipulators right hand continues
There are three phases to applying each cast: manipula- holding the forefoot in the corrected position while the assis-
tion, applying padding and plaster, and moulding after the tant applies the cotton wool [B]. As the padding and then the
cast is applied. Different hand positions are required for each cast is applied, the first few wraps go over the manipulators
phase. An effective method is shown. Use this method until fingers. As the wrapping/cast moves proximally, the manipu-
experience is gained. Once you are experienced, you may lators right thumb comes out from under the wrap and helps
prefer to consider using one of several alternative hand posi- to hold the foot in good position by applying some pressure
tions as shown on page 47 [E, bottom picure]. to the talar head laterally [C]. The assistant applies a below-
the-knee cast [D] as the manipulator continues holding the
Correction of Cavus First Cast foot in the corrected position in the same fashion as for
The text and pictures describe the technique for a right club-
wrapping the cotton wool.
foot. Reverse hands for a left clubfoot. Cavus is due to the
pronation of the forefoot in relation to the hindfoot, which Mould cast
is supple in newborns. Elevating the first metatarsal usually The assistant uses the left hand to hold the foot. The left
restores a normal longitudinal arch to the foot. Therefore, thumb elevates the first metatarsal and moulds the arch. The
correct cavus by elevating the first metatarsal to position the left index finger (constantly moving to avoid creating a dent
forefoot in proper alignment with the hindfoot and apply cast in the cast) applies pressure over the head of the talus. The
1. Correct alignment of the forefoot with the hindfoot is nec- right index finger moulds above the calcaneus and around the
essary before correcting the adductus and varus. malleoli [E].
Manipulation Extend above knee
The manipulator uses both hands to position the foot. Once the lower section is set, the upper part of the cast is
Exactly locate the head of the talus Palpate the right lat- applied with the knee in 90 degrees of flexion. Take care not
eral malleolus with the thumb of the left hand while the toes to externally rotate the lower extremity through the knee. The
and metatarsals are held with the other hand. Next, slide the cast is applied up to the groin.
left thumb forward about 1 to 1.5 cm to palpate the head of
the talus. The lateral part of the talar head is barely covered Cast appearance
by the skin in front and is easily felt. The first cast corrects the cavus deformity. A gentle depres-
Elevate the first metatarsal The manipulators right hand
sion is seen just above the heel posteriorly. This prevents the
gently grasps the foot at the first metatarsal head and elevates heel from moving proximally in the cast. The plantar surface
it for about 30 seconds to stretch the plantar tissues [A]. Start is moulded flat. The ankle remains in marked equinus. The
abducting the foot often the foot comes into some abduc- foot is supinated [F]. Compare to the model of the first cast
tion. Cast 1 corrects cavus and can correct some adduction. [next page, D].

A B C D E F
 Ponseti Corrective Casts 31

Correction of Adduction and Varus Mould cast

The Second, Third, and Fourth Casts The assistant uses the left hand to hold the position of the foot
The text and pictures on this page describe the technique while the right hand moulds around the malleoli and achil-
for a right clubfoot. Reverse hands for a left clubfoot. les tendon. The left thumb applies pressure over the plantar
Forefoot adduction is due to medial displacement of the and medial sides of the first metatarsal, gently supinating and
navicular on the head of the talus and cuboid on the cal- abducting the forefoot. The left index finger gently moves over
caneus. Heel varus is due to an adducted and inverted the head of the talus laterally, providing counterpressure. It is
calcaneus under the talus. Both deformities are corrected very important for the right index finger to mould carefully
by manipulating and casting the supinated foot gradu- around the malleoli and above the calcaneus [G]. These casts
ally into full abduction. This correction usually requires should fit snugly and have the appearance of the foot. If the
three to four casts applied at weekly intervals [A, B, C cast is not well moulded, the foot can slip upward causing pres-
and D]. Adduction and varus correct simultaneously. sure sores or a secondary deformity. Extend the cast above the
Manipulation knee, as with the first cast [H].
For a right clubfoot, the manipulator locates the head of Cast appearance
the talus using the left thumb [E]. The manipulators right
Each cast shows improvement. The foot progressively abducts
hand gently grasps the first metatarsal head and abducts
about 20 degrees each time. After the fourth cast, full correc-
the first metatarsal (and therefore the entire foot) while
tion of the cavus, adductus, and varus are noted [C and D]. The
maintaining supination. The left thumb continues to apply
equinus deformity also gradually improves because the calca-
counterpressure at the head of the talus. The medial tissues
neus dorsiflexes as it abducts under the talus. No direct attempt
are stretched for about 30 seconds [E]. The left thumb then
at equinus correction is made. Attempting to dorsiflex the foot
moves up the leg to be out of the way. It applies counter-
against a tight tendo achilles causes a rocker bottom deformity
pressure at the upper leg [F].
of the foot. Final correction of ankle equinus is effected by per-
Apply cotton wool and cast cutaneous tenotomy of the achilles tendon.
The manipulator holds the corrected position while the
assistant applies the padding and cast. As with the first
cast, the padding is thin and precise about the foot and
thicker on the leg. The padding is wrapped over the
fingers holding the forefoot. A below-the-knee cast is
applied [G].
A B C

DAppearance of casts
1st 2nd 3rd 4th

E F G H
32 Cast Removal

Cast Removal Unrolling the plaster This is the most simple method but
requires that the end of the plaster roll be found [D]. Finding
Inform parents that all casts are removed in the clinic just
this end may be facilitated by including it in a plaster nob
before a new cast is applied. Correction can be lost from the
when the cast is applied.
time the cast is removed until the new one is placed.
Plaster shears This method utilizes shears to remove a
Soaking cast segment of plaster [next page, A, B and C]. As the shears
Soak the cast in water provided at the clinic for about 20 encompass the cast, injury to the skin is minimized. Insertion
minutes in preparation for cast removal. This can be sim- of the shear blades is easy in the thigh but more difficult in
ply performed with buckets provided in the clinic [A and the leg portion because of insufficient space between the cast
B]. Further softening of the cast may be done manually [C] and the skin to allow inserting the blades.
to make removal easier [D]. Plaster knife Plaster knives should be kept sharp and are
Options for removal an inexpensive and effective method for cast removal [next
page, D, E and F]. Use the blade to cut obliquely to reduce
The softened cast may be removed in a number of ways. the risk of cutting too deeply.
Scalpel blade Blades are often available in the clinic and
convenient to use [next page, G and H]. Because they are
very sharp, they must be used with caution. Hold the blade
A with just a small amount of the blade exposed to avoid cut-
ting deeper than the plaster.
Electrical cast saw These are noisy, and often frighten the
infant and family, and therefore are not recommended.

C D
 Cast Removal 33

Technique of removal Complications of Casting

Remove the cast in steps: Using careful technique, as described, complications
Cut the cast from the anterior or lateral aspect beginning at are uncommon.
the groin and moving downward [A, B, and C]. Pressure sores are due to poor technique. Common sites
Monitor the depth of the cutting edge of the blade to avoid include the head of the talus or over the heel.
cutting too deeply [G]. Superficial sores are managed by applying a dressing and a
Cut only the cast, not the padding with the cast knife to new cast with additional padding.
avoid skin injury [G]. Deep sores are dressed and left out of the cast for one week
Remove the above-knee portion of the cast first [C]. to allow healing. Casting is then resumed with special care to
Remove the soft padding gently to expose the skin [F]. avoid relapse.
Remove the below-knee portion of the cast last [H].
Clean the skin with water.

A B C

D E F

G H
34 Tenotomy

A B Tenotomy
Indication for tenotomy
In the Ugandan system the orthopaedic officer sees each
child, examines every clubfoot and measures the Pirani
Score on every visit, especially during the first year of
treatment. When the examination or the Pirani Score sug-
gest that a tenotomy is indicated, the medical officer or sur-
geon supporting the clinic should be called to confirm the
findings and perform a tenotomy.
Tenotomy is indicated to correct equinus when cavus,
adductus, and varus are fully corrected but ankle dorsiflexion
remains less than 10 degrees above neutral. There are two
ways to tell if tenotomy is indicated.
Evaluate calcaneal abuction and ankle dorsiflexion The
clubfoot is sufficiently corrected to proceed with tenotomy
when the anterior calcaneus is abducted away from under
the anterior talus. With sufficient abduction, the anterior
C process of the calcaneus becomes palpable laterally just
plantar to the head of the talus, which becomes less pal-
pable as it is covered by the navicular. The foot appears
Tenotomy abducted approximately 60 or 70 degrees in relationship to
Indicated the frontal plane of the tibia [A]. The heel is in neutral or
slight valgus. Proceed with tenotomy if ankle dorsiflexion
is less than 10 degrees above neutral [B].
The Pirani Score is a measure of midfoot and hindfoot
deformity [C]. As correction progresses, the Midfoot Score
(blue line in graph) corrects first whereas the Hindfoot Score
(green line in graph) remains high. Tenotomy is indicated
(red arrow) when the Midfoot Score is one or less and the
Hindfoot Score is more than one (the Lateral Head of Talus
Sign should be zero).
Preparing the family and equipment
Prepare the family by explaining the procedure. Explain that
tenotomy is a minor procedure performed under local anaes-
thetic in the outpatient clinic. Prepare a blade. A cataract
D Triceps knife is best as the incision is then very small. If unavailable,
Sheath other blades such as an #11 or #15 blade will work. Prepare
other supplies as shown in the equipment list [E].
Equinus Skin incision
correction

N-V structures

Sequence of tenotomy E Equipment List

Insulin or tb syringe
25# needle
gloves
gauze
#11 or #15 blade

local anaesthetic
prep solution

Divide tendon within sheath After healing

 Tenotomy 35

Tenotomy Technique A small amount of bleeding is normal. A piece of clean

gauze is placed over the incision and the orthopaedic officer
Positioning and roles applies a new above-knee plaster cast [E].
Place the baby at the end of the examination table with the
Post-tenotomy cast
medical officer at the feet, and the orthopaedic officer to the
ipsilateral side [F]. The diagram [previous page, D] shows After correction of equinus by tenotomy, apply the fifth
what needs to be achieved. This is a complete section of the cast [E and F] with the foot abducted 60 to 70 degrees with
tendon, not a tendon lengthening. In infants, the tendon rap- respect to the frontal plane of the ankle, and 15 degrees dor-
idly heals. siflexion. The foot looks overcorrected with respect to the
thigh. This cast holds the foot for 3 weeks after complete
The medical officer is postioned looking at the tendon from
correction. It should be replaced if it softens or becomes
the medial aspect and performs the tenotomy.
soiled before 3 weeks. The baby and mother may go home
The orthopaedic officer acts as an assistant. With one hand, immediately. Usually no analgesic is necessary. This is usu-
the assistant holds the limb firmly at the knee, holding the ally the last cast required in the treatment program.
knee straight. The other hand dorsiflexes the foot to stretch
the achilles tendon [A]. Cast removal
After 3 weeks, the cast is removed. Twenty degrees of dorsi-
Skin preparation and anesthesia
flexion is now possible. The operative scar is minimal. The
The medical officer preps the foot thoroughly from midcalf foot is ready for bracing. The foot appears to be overcorrect-
to midfoot with an antiseptic [A]. ed into abduction. This is often a concern to the caregiver.
The medical officer then palpates the spot where the ten- Explain that this is not an overcorrection, only full abduction.
don feels most prominent, usually about one to one and a
half centimeters above the calcaneus. Plan on tenotomy at
this point. Infiltrate a small amount of local anesthetic just
medial to the tendon where it is most easily palpated [B]. Be F Parent
aware that too much local anesthetic makes palpation of the
tendon difficult and the procedure more complicated.
Right Foot Surgeon
Heel cord tenotomy Infant
Insert the tip of the scalpel blade from the medial side,
directed immediately anterior to the tendon. Keep the flat Orthopaedic
part of the blade parallel to the tendon. The initial entry Officer
causes a small longitudinal incision [C]. Care must be taken
to be gentle so as not to accidentally make a large skin
incision. The blade is then rotated, so that its sharp edge is Orthopaedic
directed posteriorly towards the tendon. The blade is then Officer
moved a little posteriorly. A pop is felt as the sharp edge
releases the tendon. The tendon is not cut completely unless Surgeon
Left Foot
a pop is appreciated. An additional 15 to 20 degrees of
dorsiflexion is typically gained after the tenotomy [D]. Infant
Parent

A B C D E
36 Bracing

Bracing SFAB Design Features

Bracing is indispensible in preventing relapse. Even after full The SFAB has open toe leather shoes with lace closures
initial correction of the clubfoot, relapse is common. Relapse [B]. A round iron bar connects the shoes. A hole in the heel
leads to disability. Prevent relapse by bracing the foot in the allows checking the position of the heel [C]. Shoe abduction
fully corrected position achieved in the last cast (foot abduct- and dorsiflexion can be changed by bending the bar [E].
ed 70 degrees and dorsiflexed 15 degrees). Many braces have Standard sizes
been tried. No brace works unless the foot is held abducted
and dorsiflexed hence the term foot abduction brace. SFABs come in eight standard sizes. Mass production [next
page, A] means off-the-shelf availability. Each standard size
has an appropriate length of bar between the shoes [A].
Steenbeek Foot Abduction Brace The length of the foot abduction bar is such that the dis-
Commercially available foot abduction braces (such as the tance from the inside of one shoe-heel to the other shoe-heel
Markell or Mitchell Brace) are expensive and difficult to equals the width of the childs shoulders (measured at the
access. In Uganda, use the Steenbeek foot abduction brace lateral side of both deltoid muscles).
(SFAB). Developed by Michiel Steenbeek, working for the
Christoffel Blinden Mission at the Katalemwa Cheshire Inspection hole
Home in Kampala, the SFAB can be made from simple, eas- The medial side of each shoe has an inspection hole to check
ily available materials in Uganda. It is designed to be effec- the position of the heel in the shoe [C].
tive in maintaining correction, easy to use, easy to fabricate,
inexpensive, and ideally suited for widespread use. SFABs Deep heel cup
are manufactured in standard sizes to fit all feet needing The SFAB has a deep heel cup [C] designed to prevent the
braces [A]. Standardized patterns allow prefabrication and foot from slipping out of the shoe. It also promotes the soft
bulk production. This enables the clinician to fit braces off tissues of the heel to develop into a normal shape.
the shelf [D].
Low heel cut design
The heel leather has a low posterior cut design [C] to pre-
vent the heel from slipping out of the shoe.
A B If the heel leather of the shoe is low (at the level or below
the level of the anatomical ankle joint) in plantar flexion, the
heel of the foot remains well positioned on the sole of the
shoe [F].
In contrast, if the heel leather is increased in size and it
reaches above the anatomical ankle joint, a point of contact
between the posterior side of the leg and the heel leather will
now act as a fulcrum proximal to the anatomical ankle joint.
C The fulcrum causes the heel to lift up from the shoe when
the child attempts to plantarflex the ankle [G].

F G
 Bracing 37

SFAB Manufacture Sources of Braces

The SFAB is critical for the success of a Ponseti treatment Michiel Steenbeek at Katalemwa Cheshire Home
program in Uganda. and Rehabilitation Centre, Gayaza Rd, Mpererwe Market,
Materials and tools Kampala or CBM [B].
Mulago Orthopaedic Workshop, Kampala [A].
Brace manufacture requires only local materials (leather,
Kumi General Hospital, Kumi.
lining, plywood, and mild steel rod stock), ordinary shoe-
making tools (a leather-sewing machine), and tools for met- The Steenbeek brace production manual, in full color
alworking and welding [C,E, and F]. with patterns for all brace sizes, is available on www. global-
help.org or by contacting michiel.steenbeek@lycos.nl or
Sustainability m.steenbeek@africaonline.co.ug.
Affordable local manufacture promotes sustainable brace
supplies in Uganda.
Training The Orthopedic Technology School in Kampala
includes fabrication of this brace in its curriculum. Each stu-
dent is required to create 15 braces during training. Samuel
Kayondo and David Kisombo tutor at the school [D].
Cost The SFAB is inexpensive when made in Uganda
(about US $7 in 2006).

D E F
38 Bracing

SFAB Availability First Bracing Visit

Stock SFABs in the clubfoot clinic so that they are avail- Apply the SFAB immediately after the last cast is removed,
able for immediate initial fitting and replacement. This will three weeks after tenotomy. Instruct caregivers that the brace
reduce relapse rates, and transport costs for the families of is to be worn full time (except for bathing) for 3 months.
children with treated clubfeet. Then it should be worn at night and nap time until the child
is 4 years old [A].
Check shoe abduction and extension
SFABs are made with both shoes abducted 70 degrees and
extended 15 degrees. Check this is so, especially if reusing a
A SFAB. Adjust as necessary.
Unilateral deformity
With a unilateral deformity, bend the bar next to the shoe for
the normal foot back to 3040 degrees abduction only.
Sizing
Measure the length of the sole of the childs clubfoot once
corrected in centimeters from the heel to the tip of the big
toe. In general this length in centimeters corresponds with
the size of the SFAB needed. Do not add an allowance for
growth. Select the correct size of the brace [B and C] from a
full stock of all brace sizes kept in the clinic.
Fitting technique
Steenbeek has listed the important steps when first applying
the brace to the infants foot. These steps should be taught to
B the mother and family members [D]. It is important to have
the mother demonstrate in the clinic that she can apply the
brace correctly before leaving.
Make sure the ankle has at least 10 degrees dorsiflexion.
Without enough dorsiflexion, the heel will tend to pull away
from the heel cup, increasing the probability of the foot pull-
ing out of the SFAB.

D Steps in Brace Fitting [Facing page A, B, C]

Foot Size [cm] Brace Size C
1. Loosen and remove the laces from the shoes.
6.5 to 7.5 cm 6
2. Fit the most difficult foot first. In unilateral cases, this is the involved
7.5 to 8 cm 7
foot; in bilateral cases it is the most rigid foot.
8 cm 8
3. Gently push the foot up in dorsiflexion with one hand and hold that
9 cm 9 position, then push the foot, heel first, into the brace.
10 cm 10 4. Close the tongue of the shoe and check through the inspection
11 cm 11 window to be certain that the heel is down in the brace.

12 cm 12 5. While maintaining this position with one hand, lace the shoe with the
other hand.
13 cm 13
6. Fit the other foot in the brace the same way.
7. If the child cries more than usual, check the feet for red spots or
blisters. In such a case, the brace might be too small for the child.
8. When the child is about to outgrow the SFAB, have the parents go
back to the clinic or workshop for a larger size.
 Bracing 39

Follow-up Bracing Visits Improving SFAB Compliance

Follow-up at regular intervals is essential to minimize brac- Frequently, caregivers will want to stop putting the SFAB on
ing problems and to detect relapse early. the childs feet because the feet look corrected and the child
fusses. Failure to comply with bracing protocols is the most
Visit schedule
common cause of relapse. Explain to the parents making the
At 2 weeks check for fitting problems and compliance. following points:
At 3 months advance to nighttime use if no evidence of
Parent education
relapse. A new brace may be necessary.
Explain the importance of the brace to the parents. Remind
Every 3 months until age 2 years and then every 6 months
them often of the almost universal tendency for deformity to
until 4 years of age. recur if the brace is not worn. Teach parents to exercise the
Check SFAB fit and progress to a larger size as needed. childs knees together as a unit (flex and extend) in the brace,
Inquire about home situation and brace use problems so that the child gets accustomed to moving two legs simul-
to identify problems that might lead to noncompliance. taneously. (If the child tries to kick one leg at a time, the
Check for relapse as shown on page 42. brace bar interferes, and the child may get frustrated.)

When to discontinue bracing Fit the SFAB immediately

The SFAB can be discontinued after age of 4 years if there is The child will not have a chance to get used to having the
no sign of relapse. See the child again after 6 to 12 months to feet free and will cry less if braces are fitted on the day the
be certain there is no relapse (about 5% of feet may relapse last casts are removed.
after 4 years of age).
Demonstrate brace use
If you notice any signs of relapse, reapply a series of
corrective casts. Ask the parent to apply the brace during the first visit to
make certain the parents understand its use and application.
Reassure parents
Reassure parents that although there may be a few rough
nights at first, the child will get accustomed to the brace. If
the child cries more than usual, the parents can check the feet
for red spots or blisters in case the brace might be getting
too small for the child. If the foot appears satisfactory, the
parents can reapply the brace and should check the child for
other causes of pain such as earache.
A B Plan for growth
When the child is about to outgrow the brace, the parents and
child should go back to the clinic/workshop for a bigger size.
Encourage consistentcy
Inform parents that regular brace use (every day) will make
for a compliant child. Intermittent usage will make for a
child who fights the brace.

C
40 Common Management Errors

Common Management Errors Errors during casting

The following are common management errors. Understand Failure to cast Performing frequent manipulations and not
and avoid them. Your patients will have less trouble. casting is an error. The foot should be casted with the con-
tracted ligaments at the maximum stretch obtained after each
Errors before manipulation manipulation. The stretched ligaments loosen sufficiently to
Failure to recognize clubfoot, or refer to the clinic is a facilitate further stretching at the next manipulation.
result of healthcare workers lack of awareness of the clini- Using below-knee casts Below-knee casts do not hold the
cal features of clubfoot or knowledge that it can be treated. calcaneus abducted [D]. Above-knee casts are needed to pre-
Encourage healthcare workers to take all opportunities to vent the ankle and talus from rotating within the cast; other-
perform a visual foot inspection, and if concerned, refer to wise, the correction obtained by manipulation is lost.
the clubfoot clinic. Attempting to apply the cast alone without help Large
Failure to provide a holistic approach to the child and clinics and limited personnel make it tempting to try casting
family Continually monitor how the family is dealing with without help. This only jeopardizes the correction by intro-
the extra demands placed on them. Emphasize that the condi- ducing the possibility of immobilizing the foot in an incor-
tion is totally correctable but requires the ongoing effort of rect position. It is preferable to have a parent instructed
the whole family. This helps families overcome the barriers how to hold the foot during the application than to apply
they face in adhering to treatment protocols. the cast alone.
Starting casting without the family understanding the
overall management plan Make certain the family under-
stands the overall plan of management so they can plan.
Explain that bracing is just as important as casting for suc-
cess and that a common reason for failure is the premature
discontinuation of bracing. Inform the family that the best
way to prevent relapse is to use the SFAB as instructed until
age 4 years. Families who understand the whole manage-
ment sequence can avoid many problems. A
Changing the management protocol described by
Ponseti Avoid the common tendency to change treatment.
Dr. Ponseti has carefully developed the technique over a B
period of 50 years.
Errors during manipulation
Failure to manipulate Manipulate the foot to place contract-
ed ligaments at maximum stretch in the cast. In the cast, the
ligaments loosen, allowing more stretching at the next session.
Manipulating without accurately identifying the head of
the talus This error is commonly due to inexperience. To
identify the head of the talus, palpate the lateral malleolus
with the thumb [A]. Then move the thumb just forward to
identify the next bony prominence the head of the talus
[B]. Successful correction of deformity depends of abduc- C D
tion of the calcaneus under the talus. This is impeded without
counterpressure on the head of the talus.
Pronation of the foot This worsens the deformity by
increasing the cavus. Pronation [C] does nothing to abduct
the adducted and inverted calcaneus, which remains locked
under the talus. Thou shalt not pronate!
 Common Management Errors 41

Errors during tenotomy Failure to examine the foot for relapse during follow-up
visits for bracing Identify relapse early by observing the
Premature equinus correction Attempts to correct the
childs gait. In the stance phase of the normal gait cycle, the
equinus before the heel varus and foot supination are cor-
foot contacts the ground with the heel first (heelstrike), fol-
rected will result in a rocker-bottom deformity. Equinus
lowed by the whole foot (flatfoot) and finally the toe leaves
through the subtalar joint can be corrected only if the calca-
the ground (toe off).
neus abducts. Tenotomy is indicated after cavus, adductus,
Signs of early relapse are early heel rise (child walk-
and varus are fully corrected.
ing away from examiner), swing phase dynamic supination
Failure to perform a complete tenotomy The sudden
(child walking towards examiner) and loss of ankle dorsi-
lengthening with a pop or snap signals a complete tenoto- flexion to less than ten degrees [B].
my. Failure to achieve this may indicate an incomplete teno-
Manage relapses by repeated corrective casting.
tomy. Repeat the tenotomy maneuver to ensure a complete
tenotomy if there is no pop or snap. Management without bracing Avoiding the brace entirely
is tempting as bracing can be difficult for the caregiver.
Errors during bracing However, studies have shown 90% relapse rates at 12
Ponseti management calls for bracing into foot abduction months of age if the brace is omitted. Bracing until 4 years
and ankle extension the foot is placed in the fully corrected of age is necessary to reduce risk for relapse. Relapse is rare
position, similar to the last cast. Bracing into pronation, ever- after age four.
sion or external rotation does not do this. These were com- Attempts to obtain perfect anatomical correction
mon errors before Ponseti management was taught. It is wrong to assume that Ponseti treatment will result in
Using braces other than the SFAB completely normal anatomy. For example, complete reduc-
An ankle foot orthosis (AFO) is like a below-knee cast tion of the extreme medial displacement of the navicular
[A]. It controls ankle extension but cannot maintain the cal- may not be possible. Long-term follow-up radiographs show
caneus abducted under the talus, and the foot is not placed some abnormalities. There is no correlation between the
into the fully corrected position. In an AFO, the deformity is radiographic and clinical appearance of the foot. Good long-
likely to recur. term function of the Ponseti-treated clubfoot can be expect-
The knee-ankle-foot-orthosis controls for foot abduc- ed, as long as the foot is supple and plantigrade. A well treat-
tion, but is inefficient at controlling for ankle extension. ed right clubfoot and a normal left foot are shown [C, D, and
Because it keeps the knee in a permanent 90-degree flexion E]. Note the small differences between the feet. Although
position, it does not stretch the gastrocnemius muscle satis- anatomically imperfect, correction will provide good func-
factorily. When the child starts standing with the knee extend- tional and cosmetic results for at least five decades. This
ed and then walking, the foot will have an equinus contracture. avoids many of the complications of operative tarsal release,
such as stiffness and pain.

B C E
42 Relapse

Relapse Signs Before Walking Age

Examine the child seated on the mothers lap look for:

Relapse Brace usage

Ponseti management corrects deformity, but it does not The brace should look well used. Check the angle of abduc-
remove the cause of clubfoot. It has a stubborn tendency tion and dorsiflexion parents sometimes bend the bar into
to recur. an ineffective angle.

Causes Loss of passive ankle dorsiflexion

Relapse is almost always due to failure or incorrect brace This should be at least 10 degrees above neutral with the
wear. Morcuende (2003) found that relapses occur in only knee extended [A]. Recognize early relapse if dorsiflexion is
6% of compliant families but more than 80% of noncompli- any less, even in the presence of full subtalar motion [B].
ant families. The importance of the brace must be explained Palpable head of talus
to the parents.
With growth, the tendency for relapse lessens consider- Abduct the foot with counterpressure on the head of the talus
ably: 91% of relapses occur before 5 years of age. Relapse [C]. The navicular should cover the talar head completely.
after age 7 is very rare. It may be an indicator of an underly- Recognize late relapse if the talar head remains palpable with
ing neuromuscular disorder. the foot in maximal available abduction [D]. The navicular
and anterior tuberosity of the calcaneous cannot be abducted.
Sequence and early identification
Loss of calcaneal abduction and extension
Relapse has a charactersitic sequence. Early relapse pre-
sents as a loss of dorsiflexion. Later, heel varus and adductus With late relapse, foot abduction is insufficient. Therefore,
develop. Rarely is significant cavus a feature. Early relapse is the heel will not go into valgus and the calcaneus will not
therefore easier to correct than late relapse. Detection of early extend [E and F].
relapse is important. At every clinic visit, look for relapse. Supination
History Involuntary supination of the foot during active ankle dorsi-
Ask parents about bracing difficulties (pain, inconsolable flexion often represents tibialis anterior activity unopposed
crying, sore areas,) that may have led to inconsistent use. by weak peroneals.
Parents may have noted the heel not touching down on the
footplate of the shoe.
Age
The signs of relapse before walking and after walking age
are different.

A B

C D E F
 Relapse 43

Signs After Walking Age Treatment of Relapse

Observe the childs feet standing. Then ask the child to walk Do not ignore relapse. Treat at the first sign. Delaying treat-
towards and away from you. Repeat as needed. Observe what ment only results in more relapse. Early relapse is much
the foot does in swing and stance phases of gait. Then exam- easier and less complicated to deal with than late relapse.
ine the childs foot with the child on mothers lap.
Relapse before 30 months of age
Standing and walking Treat with repeat manipulation and casting, adding tenotomy
Standing Look at how the foot weight-bears or if needed.
touches the ground. In early relapse, the foot appears plan- Manipulate and cast one to three times at 2-week inter-
tigrade. However, the heel may not touch the ground [C]. vals [H and I] until the foot is completely corrected. Use the
Additionally, in late relapse, the medial forefoot is raised off technique as shown on pages 28 to 31.
the ground [A, left foot], or the foot bears weight on the lat- Tenotomy can be repeated if ankle dorsiflexion is less
eral border [B]. than 10 degrees above neutral after the third cast. Apply a
Walking Early relapse is most easily appreciated as the fourth cast for 3 weeks. No significant problems have been
child walks away from you as early heel rise. Late relapse is associated with repeat tenotomies.
seen as the foot tending to supinate in swing phase (dynamic Bracing remains critical to prevent further relapse. Restart
supination), and as weight bearing on the lateral rays of the bracing after understanding the caregivers barriers to brac-
foot (child walking towards you) [A, left foot; B]. Heel-strike ing. Come up with a strategy that will resolve the problem.
is absent, and there is fixed stance-phase heel varus (child
walking away from you) [D]. Relapse after 30 months of age
Treat a childs first relapse after 30 months of age as above.
Examine the child seated on the mothers lap A second or subsequent relapse is an indication for transfer
Passively test ankle and subtalar joint range of motion. of the tibialis anterior to the lateral cuneiform. Its ossifica-
Recognize early relapse if ankle dorsiflexion is less than 10 tion center usually appears at 30 months of age and can act
degrees above neutral with the knee extended [E]. Subtalar as a suitable attachment site for a tendon transfer. Changing
jont involvement (seen as a loss of full calcaneal abduction the attachment point from the medial side of the foot to the
or incomplete talar head coverage by the navicular) indicates dorsum turns the deforming force of the tibialis anterior into
late relapse [F and G]. a corrective force. First manipulate and cast to correct defor-
Active ankle dorsiflexion may be accompanied by supi- mity [H and I]. Then refer to the surgeon for anterior tibialis
nation of the foot from tibialis anterior overactivity. tendon transfer.
Sole of foot may show thickening of the skin under the
lateral rays.

A B C D

E F G H I
44 Anterior Tibialis Tendon Transfer

Anterior Tibialis Tendon Transfer Place anchoring sutures

Indication Place a #0 dissolving anchoring suture [D]. Make multiple
passes through the tendon to obtain secure fixation.
Transfer is indicated if the child is more than 30 months of
age and has a second relapse. Indications include persistent Transfer the tendon
heel varus and forefoot supination during walking; the sole Transfer the tendon to the dorsolateral incision [E]. The ten-
shows thickening of the lateral plantar skin. don remains under the extensor retinaculum and the extensor
Correct deformity tendons. Free the subcutaneous tissue to allow the tendon a
direct course laterally.
Make certain that any fixed deformity is corrected by two
or three casts before performing the transfer [next page, Localize lateral cuneiform
G and H]. Usually cavus, adductus, and varus corrects. If available, use x-ray [F]. Note the position of the hole in
Equinus may be resistant. If the foot easily dorsiflexes to the radiograph [F, inset arrow]. Otherwise identify by delin-
10 degrees, only the transfer is needed. Otherwise add teno- eating the joint between it and the third metatarsal.
tomy of the heelcord.
Identify site for transfer
Anaesthesia, positioning and incisions
Make a drill hole in the middle of the lateral cuneiform large
Put the patient under a general anaesthetic, positioned supine. enough to accommodate the tendon [G].
Use a high-thigh tourniquet. Make a dorsolateral incision
centered on the lateral cuneiform. Its surface marking is Thread sutures
the intersection of two lines (base of the fifth metatarsal to Thread a straight needle on each of the securing sutures. Pass
cunieformfirst metatarsal joint and proximal projection of one needle into the hole. Leave the first needle in the hole
third metatarsal) [A]. The dorsomedial incision is made over while passing the second needle to avoid piercing the first
the insertion of the anterior tibialis tendon [B]. suture [H]. Note that the needle penetrates the sole of the
foot [H, arrow].
Expose anterior tibialis tendon
Expose the tendon and detach at its insertion [C]. Avoid
extending the dissection too far distally to avoid injury to the E
growth plate of the first metatarsal.

A B

G H

C D
 Anterior Tibialis Tendon Transfer 45

Pass two needles Skin closure

Place the needles through a felt pad and then through differ- Close the incisions with absorbable subcutaneous sutures [F].
ent holes in the button to secure the tendon [A]. Tape strips reinforce the closure.
Secure tendon Cast immobilization
With the foot held in dorsiflexion, pull the tendon into the Place a sterile dressing [G], and apply a long-leg cast [H].
drill hole [B, arrow] by traction on the fixation sutures and Keep the foot abducted and dorsiflexed.
tie the fixation suture with multiple knots [D, arrow].
Postoperative care
Supplemental fixation Usually, the patient remains hospitalized overnight. The
Supplement the button fixation by suturing the tendon to the sutures absorb. Remove the cast and button at 6 weeks. The
periosteum at the site where the tendon enters the cuneiform child may mobilize weight-bearing as tolerated.
[C, arrow], using a heavy absorbable suture.
Bracing and follow-up
Neutral position without support No bracing is necessary after the procedure. See the child
Without support, the foot should rest in neutral plantar flex- again in 6 months to assess the effect of the transfer.
ion [D] and neutral valgus-varus.
Local anesthetic
Inject a long-acting local anesthetic into the wound [E] to
reduce immediate postoperative pain.

A B E

G H

D
46 Difficult Clubfeet

A Difficult Clubfeet
Most idiopathic congenital clubfeet correct with about five
well-applied Ponseti casts. Some clubfeet, however, can be
considered difficult as they have some unique characteris-
tics that demand a modified approach for management.
The untreated clubfoot in the older child
Treatment This 3-year-old with severe deformity [A] and
x-rays [B] had no prior treatment. The feet were managed
with six manipulations [C] and casts [D]. This was followed
by a tenotomy and a holding cast maintained for 6 weeks.
Following treatment, the foot was clinically well corrected
B [E]. Radiographs [F and G] showed marked improvement.
Results In Nepal, 79 clubfeet in children aged 15 years
were treated as described above. Treatment resulted in plant-
egrade feet in all cases.
Upper age limit Experience from the developing world
suggests that the Ponseti Method continues to be effective
well after walking age. However it is likely that beyond
C 3 years of age there will be increasing residual deformity.
Further treatment may be necessary for residual deformity,
such as a calcaneo-cuboid fusion for residual calcaneo-
cuboid subluxation.

E
G
 Difficult Clubfoot 47

The complex congenital clubfoot Experience with the Ponseti Method Many if not most
The complex congenital clubfoot, a recently described syndromic clubfeet do correct. Therefore manage syndro-
variant of congenital clubfoot, is important to recognize. mic clubfeet initially with the standard Ponseti technique;
Treatment needs to be modified. There is an increased risk however, be aware that correction may require more casts
of relapse. than usual. Usually a plantigrade foot can be obtained with-
out surgery.
History There is often a history of casts slipping so that toes
slowly disappear inside the plaster. Long-term functional outcome usually depends
more on the underlying syndrome than the clubfoot.
Exam The signs of the complex clubfoot are rigid equinus,
plantaris (severe plantarflexion of all metatarsals), a deep Resistant clubfoot Rarely, idiopathic congenital clubfeet
crease just above the heel, a deep transverse crease across the do not correct completely with accurately applied Ponseti
sole of the midfoot, a short hyperextended big toe, abnormal treatment. Sometimes there is co-existing pathology such
flattened shape to heel [A, B] and an edematous dorsum of as tarsal coalition. A posterior or posteromedial release may
the foot. If present, consider modifying the treatment. be necessary.
Modify treatment Using the classic Ponseti Method results A B
in development of a secondary deformity. (The forefoot
adduction corrects with first or second cast. Cavus however
persists. Further attempts to abduct the forefoot cause an
increase in plantaris and abduction of metatarsals at the liz-
franc joint rather than abduction of calcaneus.) A modifica-
tion of the management technique is needed to prevent this.
Manipulation Carefully identify the talar head later-
ally. It is not as prominent as the anterior process of the
calcaneus. When manipulating, the index finger should rest
over the posterior aspect of the lateral malleolus while the
thumb of the same hand applies counterpressure over the lat-
C D
eral aspect of the talar head [E, lower picture]. Do not abduct
more than 40 degrees. After 40-degree abduction is achieved,
change emphasis to correction of plantaris. All metatarsals are
extended simultaneously with both thumbs [E, upper picture].
Casting Always apply casts with the above-knee por-
tion in 110 degrees flexion to prevent slippage. Up to ten
casts can be needed to correct deformity.
Tenotomy A tenotomy is necessary in all cases.
Perform the tenotomy when plantaris is corrected. At least 10
degrees dorsiflexion is necessary. Sometimes it is necessary
to change casts at weekly intervals after the tenotomy to gain
more dorsiflexion, if sufficient dorsiflexion is not achieved
E
immediately after the tenotomy.
Bracing Reduce abduction on the affected side to 40
degrees in the foot abduction brace. The follow-up protocol
remains the same.
The clubfoot in a child with a syndrome F
Children with clubfeet seen in the presence of other congeni-
tal abnormalities, such as arthrogryposis [C and D], myelo-
meningocoel [F], and other syndromes, often have abnormal
collagen forming their ligaments, capsules, and other soft
tissues. Syndromic clubfeet have been difficult to treat in the
past, and often have required surgery.