The Ponseti method
In recent years, conservative management has been popularized, developed by Dr. Ignacio Ponseti, as an efficient, simple, low-cost method that produces excellent results (even better than those obtained by surgical methods), in the vast majority of the patients. The Ponseti method has achieved long-term satisfactory results by 89% of the feet. This method involves a series of mild manipulations and corrective plasters, which are changed every week. Most patients can be corrected with about 5-6 plasters. By achieving the correction, a microil tendon microsurgery is usually performed to lengthen it. It continues with plasters until the tendon heals (2-3 weeks more) and then the treatment with orthopedic appliances (shoes with bar) starts. To maintain the correction (from the foot) obtained with the plasters.
When choosing the method, the orthopedist must keep in mind that:
- The goal is to correct all the components of the deformity and get a plane foot (which when walking resting with the foot plant), indolery, with good mobility and that does not require the use of a special footwear
- When there is recurrence of deformity, this tends to be more rigid than the original deformity.
Most orthopedic surgeons agree that the initial treatment of Zambo or Equinavaro must be conservative and should began in the first days after birth, which is when the elastic properties of the connective tissue that form the ligaments, the Articular capsule and tendons are more moldable.
Surgeries performed at this early age induce fibrosis, scars and rigidity of the joints. Surgery must be delayed until the child is at least six months old, in the few cases in which it is necessary. Therefore, the first months of life are the gold period for a skillful surgeon and knowledgeable of the equinovar foot to correct deformity.
When should you start?
The results of the Ponseti method are easier to obtain if you start in the first weeks after birth, although it is also possible to correct zambos feet that have been previously treated up to the age of March (approximately 14 or 16 months ).
What is the Ponseti method based on?
Ponseti method and the corrective plays: It is based on the deep knowledge of the anatomy of the foot and the biological response of human tissues against the changes of position obtained through the manipulations and the plaster.
Treatment, through handling and plastering, is based on the inherent properties of connective tissue, ligaments, tendons, cartilage and bone, which respond to the mechanical stimuli created by the gradual reduction of the deformity. Ligaments, joint capsules and tendons are lengthened by gentle manipulations.
What are the steps of treatment?
These structures are stretched by smooth weekly manipulations. After manipulation, a plastering bandage is placed (with the knee flexed), up to the groin to maintain the degree of correction obtained after each intervention and to soften the tissues (due to immobilization atrophy). In this way, the displaced bones are gradually moved to their normal position at the same time as the joints are remodeled.
Fourth Plaster after handling
After 4-6 plasters, the cavo, the adduct and the varo, are corrected. Achilles tendon microsurgery (tenotomy) must be carried out to lengthen it and thus correct the equine (tenotomy is necessary in approximately 95% of cases). With this simple surgery, the ability to bend the ankle up (dorsiflexion), increases considerably.
The last plaster will be left for three weeks after performing tenotomy until the tendon has fully regenerated. Once the correction is finished, the foot will seem hyper corrected. Do not worry, you will return to the normal position in a few weeks. This correction should be maintained by using a Dennis-Brown splint (Mitchell splint is currently used, approved by Dr. Ponetti) for 24 hours a day, for 2 or 3 months and then during sleep hours until The 4 years. During the day children wear normal shoes.
The splint consists of a bar (length equal to the distance between the shoulders of the baby) to which they are joined in 70 degrees of external rotation some high bootitas on the anterior part that leave the fingers discovered and free for their Dorsiflexion. If the shape of the boot does not carry a heel very well molded, it is necessary to paste a piece of horseshoe-shaped plastic material on the internal upper part of the boot to keep the heel stable and prevent the foot from sliding upwards. The baby may be restless for one or two days until he learns to patate with both feet in unison. In children where only one foot is affected, the corresponding boot on the normal side is placed in external rotation of 30 degrees.
Abduction splint with boots that should be taken throughout the day for 3 months and then in naps and at night until the age of 3-4 years
Prolonged immobilization must be avoided in plaster, since it can be interfered with growth, producing osteoporosis by disuse, muscle atrophy and joint rigidity (of the joints). Six to eight plasters changed weekly must be sufficient to correct deformity.
The feet treated by this method are flexible, strong, not painful and without calluses giving rise to a normal life.
It is important that parents know:
- The plasters should always be placed up to the thigh and with the knee flexed 90 degrees.
- The initial plasses must be changed every week, since the newborn grows and gains weight and body volume with great speed, which exposes the extremity to vascular complications if the gypsum is not changed in a timely manner.
- The plaster should be applied to the thigh, since the plasters below the knee, can not control all the components of the deformity and also tend to slide and lose the original correction position.
- It is essential that parents learn about the correct cleaning and conservation of such plasters so that the baby is as comfortable as possible.
- The baby should be calm at the time they are going to put the plaster, this is usually achieved by giving it a bottle with milk.
- Achilles tendon surgery will be done until the rest of the deformities are corrected.
The initial period of correction with plasters should not be extended beyond 2 to 3 months of age, since from that moment it is advisable to stimulate the perception of its body scheme and allow the musculature to be developed in the Affected extremity, which would be impossible with prolonged immobility.
With adequate supervision and parent cooperation you can avoid returning to approximately 50% of patients. Most of these recurrences (the feet have been again turned after treatment with plasters) can be managed satisfactorily with new manipulations and plasters in external rotation for a period of 4 to 8 weeks.
The advantages of this method against other conservative methods are:
- is faster (average 6 weeks of treatment with plasters).
- is more effective
- decreases the time of immobilization in plaster,
- is cheaper
Care to the baby with the corrector plaster
- Keep the plaster dry and clean. Avoid staining with urine or excrement
- Check that the plaster does not present coders or is broken.
- The edges must be covered and padded so that the baby's skin does not hurt.
- no scrapes the baby bass from the plaster, introducing objects
- Do not apply the baby cream or talc lotions, under plaster.
- covers the plaster while you give it to eat the baby, to avoid food or lumps of bread inside the plaster
- keep the plaster raised to decrease the edema (swelling) on his legs, during the first day after the application.
How to swim my baby with plaster?
If you are newborn you can bathe it by parts, loading it and protecting your plasters. If it is larger, it wraps the upper edge of the plaster and part of the leg with a plastic and then places a plastic sleeve knotted in each plaster and seal it with micropore (this does not hurt the skin when removing it) and in this way it will not be filtered the Water. Try that the bathroom is fast to avoid leakage of water.
When calling the doctor
If your baby presents the following symptoms you must notify the doctor
- Temperature above 37. 5º C
- pain that is increasing
- Edema (swelling) on the edges of the plaster
- Tingling or feeling of numbness
- Output of some liquid or bad smell.
- cold and bluish fingers or very pale. His fingers must be comfortable (not mounted one on another), his fingers should not be purple, at the top he should not tighten the plaster.
Plaster post tenotomy
According to the child's age, this plaster is maintained between 3 to 4 weeks to allow the Achilles tendon to regenerate and stretch.
Second stage: the abduction splint
As deformity has a great tendency to recurrence (return from deformity), the splint (abduction or dennis-browne splint) is immediately after removing the last plaster, about 3 weeks after tenotomy. The splint consists of a pair of open-straight moor boots ahead that are joined in a bar. In unilateral cases, the boot has more rotation than the healthy side.
The important thing about this split is the abduction and only fulfills its purpose of maintaining the correction of the foot when the boots are attached to the bar. It should be maintained all the time (day and night) except an hour for the bathroom and toilet, until the child starts to walk. After this period the splint is used about 14-16 hours a day (at night and during naps) until the age of 3-4 years. The decision to remove it will depend on the severity of the malformation and the evolution of the child.
The combination of abduction of the boot and slight curvature of the bar (up), makes possible the nozzle dorsiflexion, which also helps to stretch the muscles and tendon of Achilles. With this type of iron the knees are free so the child is free to kick and stretch his legs and thus helps to stretch and strengthen the muscles.
Abduction splint
What is the responsibility of parents in the use of the splint?
It can be said that the Ponseti method has two phases: the initial phase of the plaster during which it is the doctor who does the work and the phase of the splint during which the parents who perform the work are. The day that is removed by the gypsum of tenotomy, & ldquo; it is passed ” Responsibility to parents.
Parents have to learn to put and remove the splint. At first they are recommended to remove it and put it several times a day until the baby is getting used to use.
It is possible that the first nights are difficult and the baby can cry and be restless. This is not because they have pain but that they can not move their legs individually. It is important to explain that they should teach their baby, with games, to kick with both legs at the same time since once they learn this, tolerance is guaranteed. Do not be due & ldquo; Ceder ” Because the risk of recurrence is almost safe. The use of the night splint does not delay the development of the child: sit, crawl or walk. The almost single cause of recurrences (that the treated feet turn back) is the lack of commitment in the use of the Ferula and its early retirement.
When the child starts to walk she can wear normal shoes or walk barefoot.
A tip for the splint
For the splint they can make FOAM or fabric protections with sponge that close with Velcro and place them in the bar that joins the two shoes. These coverages, more to protect you from the blows of the bar and the furniture and damage fabrics, are one more accessory that can be combined with your baby's clothes.
How old should the night use of the boot be recommended?
Each case is different, however, it has been seen that the possibility of a recurrence is 60% if they stop using it at 2 years of age, 20% if they leave it at 3 years of age and from 10% if left it at 4 years.
How long will the child have to be guarded by the specialist?
Children should be monitored for several years, with any of the two treatments (plasters or surgery) to ensure that the deformity does not come back.
Recurrence (the return) can be early, from weeks or months after achieving the correction, a year or two after treatment, or even a while after. That is why the specialists recommend that the person be monitored until he turns 18, which is when growth ends.
Once the child achieves the standing (start of the march), which occurs between 10 and 12 months in most cases, the way to place foot for support will be what determines the Need for greater treatment. If the standing foot with the outer edge or tips (the heel does not touch ELFLAT), this means a recurrence of the deformity and it is necessary to restart the treatment.
A second series of plasters can be recommended for approximately 2 to 4 weeks, in a few cases (less than 10% of cases, if the conservative handling is carried out appropriately) surgery is required.
Regarding extensive corrective surgeries, these, although they produce a rapid correction of the deformities, also entail an extensive healing around and within the joint, as well as the risk of direct injury to articular cartilage during surgery. These factors lead to pain and limitation of the mobility of the foot and ankle, which translates into a severe functional limitation of the child in late adolescence and adulthood at a large percentage of patients.
Forecast
Can you leave sequels (permanent injuries)?
If the treatment is applied from the beginning by specialists in these lesions, most children with equinovaro foot cases (even serious) can use normal shoes by growing, participating in sports activities and leading a full and active life. However, the affected foot and leg do not usually develop as well as healthy ones. Usually, the difference between the length of the legs is 1 to 1.5 cm and the size of the shoes of one and another varies in stocking or one size.
If it is not treated, a seriously affected foot remains twisted and grows that way.
If the baby has the two feet affected, the feet and legs will be similar (but will not have strength and mobility completely normal), but if she has only deformity on one foot, a slight asymmetry will be perceived.
Treatment may be less effective if the equinovar foot is associated with other congenital disorders.
What is the prognosis of the Children treated from Equinovaro, when they are adults?
Deitz and Cooper have recently published a follow-up study for 30 years to the people treated with the Poneti method
These people, did not report foot pain. Faced with this evidence, Dr. Ponseti's method that is a new current, acquires greater acceptance in many hospitals of the American Union, in which specialization centers are being developed to teach this technique.
of the people who were monitored (followed in the evolution of their treatment) that were overweight and those who developed their work being standing many hours, it was found that they were more predisposed to suffer from pain in their feet, Like other people in the same circumstances.
Prevention
While it is possible to prevent in many cases the resulting disabilities from the equine foot Varo, by early treatment, there is still no method to prevent this defect. However, women are recommended to avoid smoking, as this can reduce the risk of having a baby affected, especially if they have a family history. (Smoking also increases the risk of having a low weight or premature baby and other complications during pregnancy).
A genetic specialized advisor can help parents determine the odds that exist in every pregnancy of having a child with equine foot. Usually, if the only defect that the child has at birth is is equal foot various, the chances that it is happening again in another pregnancy are low (around 3 percent).
