Clubfoot: Ponseti Management Second Edition Preface Ignacio Ponseti Contributors Ignacio Ponseti Jose Morcuende Vincent Mosca Shafique Pirani Fred Dietz John Herzenberg Stuart Weinstein Norgrove Penny Michiel Steenbeek Editor Lynn Staheli Effect of weekly Ponseti cast treatment Contents Contents ..............................................................1 Managing Relapse .............................................19 Preface .................................................................2 Transfer of Anterior Tibial Tendon ...................20 Contributors ........................................................3 Reference Foreword ............................................................4 Pirani Scoring ....................................................22 Management Common Management Errors ...........................23 Scientific Basis of Management .........................6 Public Health Approach to Management ..........24 Overview of Management ...................................8 For Parents Details of Technique ..........................................10 General Information ..........................................26 Cast Technique ..................................................12 Instructions for Brace Use .................................27 Equinus Correction ...........................................14 Common Questions ...........................................28 Atypical clubfoot ...............................................15 Contacts .............................................................29 Bracing Principles ............................................16 Global-HELP Organization Bracing Options ................................................18 HELP Team .......................................................30 HELP P ublications ...........................................31 Global-HELP Publication 2 Preface Preface Sponsors Dr. Ignacio Ponseti developed a method of clubfoot manage- Susan Elliott and her husband, Travis Burgeson, sponsored ment that is inexpensive and effective. Long-term follow- the printing this sec- up studies show that feet treated ond edition. Susan by Ponseti management are strong, Elliott is organiza- flexible, and pain free. These stud- tional consultant ies prove that Ponseti management who has worked in of clubfoot is best for all countries private, public and and cultures. non-profit sectors. We produced this book to pro- She is the Chair of vide an affordable, authoritative, the Development easy-to-follow guide for health care Program for global- professionals to learn the Ponseti HELP organiza- method of clubfoot management. tion and a Founding This book is designed to be engag- Member of the Board ing and colorful, with sufficient of Directors. Ms. Elliott has a long-standing interest in innova- detail to help newcomers master the tive projects and believes global-HELP.org will have a positive method. impact on the health of men, women and children throughout This is the second edition of the world. this book. The first edition was published in November of 2003 and Translation Project Manager translated into 4 languages, 10,000 Floret Khosa-Richardson graduated with a copies were printed and distributed degree in computer science from George in over 50 countries. Mason University in Virginia. She worked In this second edition we have as a software designer/programmer for 10 shortened some sections while add- years. In 2004 she decided to dedicate her ing others to make the book more complete and up-to-date. time to our Global-HELP Organizations. Guided by feedback from the authors and readers the book has been reorganized. Each of the authors has contributed their material and experience. This second edition is being Publisher translated into multiple additional languages for even broader Global-HELP Organization distribution. This book is produced by the Global-HELP organization Copyright (HELP), a not-for-profit organization that produces and distrib- utes free or affordable health care education materials world- Copyright, Global-HELP.Organization, 2003 wide through our web site at global-help.org. Financial support for printing of this second edition in Note to the Reader English was provided by Susan Elliott and Travis Burgeson. Every effort has been made to confirm the accuracy of the pre- We appreciate the donation of professional text editing by Ms. sented information. The authors, editors, and publisher cannot Dori Kelly and translation management by Ms. Floret Khosa- accept legal responsibility for any errors, omissions or resulting Richardson and Jack Foster and the McCallum Print Group of consequences, and make no warranty, expressed or implied, Seattle for the high quality printing. with respect to the material contained herein. Responsibility for any application of the information in this book to a particular Lynn Staheli, MD situation remains solely with the practitioner. Editor and Producer, 2005 Visit our web site at global-help.org Contributors 3 Translators Authors This booklet has been translated into the following languages. Ignacio Ponseti, MD Arabic Dr. Ponseti developed his method of man- Alaa Azmi Ahmad agement more than 50 years ago and has Gaza city, Palestine treated hundreds of infants using this method. [email protected] Currently Professor Emeritus at the University of Iowa, he provided guidance throughout the Chinese production of the book and wrote the forward Jack Cheng and scientific basis of management. Hong Kong, China [email protected] Jose A. Morcuende, MD, PhD Christian and Brian Trower Guilin, China A colleague of Dr. Ponseti, Dr. Morcuende [email protected] provided the text for management and advice throughout the process of preparing the mate- French rial for production. Dr. Franck Launay Marseille, France Vincent Mosca, MD [email protected] Dr. Mosca provided the section on information for parents and demonstrated the anterior tibi- German alis transfer procedure. Dr. Marc Sinclair Hamberg, Germany Shafique Pirani, MD [email protected] A major contributor skilled in Ponseti manage- ment, Dr. Pirani is an advocate and early user Hindi of the method in Canada. He has created a suc- Dr. Dhiren Ganjwala cessful model for using Ponseti management in Ahmedabad, Gujarat, India undeveloped countries. [email protected] Fred Dietz, MD Japanese Dr. Natsuo Yasui A colleague of Dr. Ponseti, Dr. Dietz contrib- Tokushima Japan uted the images and text for the management [email protected] section. Portuguese John E. Herzenberg, MD Dr. Monica Paschoal Nogueira One of the first physicians to adopt the Ponseti Sao Paulo, Brazil method of clubfoot management outside of [email protected] Iowa. Dr. Herzenberg contributed the text and illustrations for the sections on bracing and Russian management of relapses. Jolanta Kavaliauskiene Kaunas, Lithuania, [email protected] Stuart Weinstein, MD A long-term colleague of Dr. Ponseti and early Spanish advocate of his management, Dr. Weinstein Dr. Jose Morcuende contributed suggestions and support . Iowa City, Iowa, USA [email protected]. Norgrove Penny, MD Swedish Dr. Penny is a major contributor to the Uganda Dr. Bertil Romanus project. He has made many contributions for Goteborg, Sweden health care delivery in developing countries. [email protected] Michiel Steenbeek Turkish Dr. Selim Yalcin Mr. Steenbeek is an orthotist and physiothera- Istanbul, Turkey pist who designed a brace that is constructed [email protected]. by using widely available tools and materials, making it useful in developing countries. 4 Foreword Foreword Anatomical studies A study of histological sections of ligaments from virgin It is estimated that more than 100,000 babies are born world- clubfeet, obtained in the operating room and from fetuses and wide each year with congenital clubfoot. Eighty percent of stillborns, revealed that the abundant young collagen in the the cases occur in developing ligaments was wavy, was very cellular, and could be easily nations. Most are untreated or stretched. I conceived, therefore, that the displaced navicular, poorly treated. Neglected club- cuboid, and calcaneus could be gradually abducted under the foot causes crushing physical, talus without cutting any of the tarsal ligaments. I discovered social, psychological, and finan- that this was so based on cineradiography of clubfeet I had cial burdens on the patients, partially or fully reduced without surgery. their families, and the society. From dissections of normal feet of children and adults in the Globally, neglected clubfoot is anatomy department and of clubfeet of stillborns, I fully under- the most serious cause of physi- stood the mechanism of the interdependent movements of the cal disability among congenital tarsal bones and realized that clubfoot deformity was simple musculoskeletal defects. to correct. The Huson thesis, An Anatomical and Functional In developed countries, many Study of the Tarsal Joints, published in 1961 in Leiden, children with clubfoot undergo Holland, corroborated my understanding of the functional extensive corrective surgery, anatomy of the foot. often with disturbing failures and complications. The need for one or more revision surgeries Casting technique Dr. Ponseti is common. Although the foot My casting technique was learned from Böhler and applied looks better after surgery, it is during the Spanish Civil War in 1936–1939 when treating stiff, weak, and often painful. more than 2,000 war-wound fractures with unpadded plaster After