A TALE OF TWO PATHOLOGIES : A NEW CASE STUDY ON CONGENITAL TALIPES EQUINOVARUS ( CTEV ) ( PART 1 )
in 2002 , also with a significant manifestation of CTEV . I met Tommy through his mom , who is a nurse at a nursing home I was working in . What started as an evaluation of mom turned into a request that Tommy be seen and possibly helped with pedorthic modalities .
Once Tommy arrived , the CTEV was pretty obvious . His mom said that before Tommy was born , he did not kick as often as her first son did . She also felt discomfort in her lower ribcage during the pregnancy . In some cases of CTEV , the foot can get trapped about the mother ' s ribcage . Many CTEV births have a much lower rate of movement with reference to activity in the uterus than normal births .
Within a short time after birth , Tommy was beginning the serial casting that is standard protocol for management . He went through many months of cast changes and positioning changes as the casts were reapplied . Since the human foot at birth is mainly composed of cartilage , the feet maintained their relatively normal positioning through the process . As he grew out of the protocol for serial casts , he was put into standard straight last shoes attached to a Denis-Browne splint . Again , this is standard treatment protocol .
As a refresher , the Ponseti Method , is a treatment developed by Dr . Ignacio Ponseti in the 1950s , and repopularized in 2000 by Dr . John Herzenberg and NHS surgeon Dr . Steve Mannion . This manipulative treatment of the CTEV deformity is based on the inherent properties of the connective tissue , cartilage , and bone , which respond to the proper mechanical stimuli created by the gradual reduction of the deformity .
The ligaments , joint capsules , and tendons are stretched under gentle manipulations . A plaster cast is applied after each manipulation to retain the degree of correction and soften the ligaments . The displaced bones are thus gradually brought into the correct alignment with their joint surfaces progressively remodeled yet maintaining congruency . After two months of manipulation and casting the foot appears slightly over-corrected .
After a few weeks in splints however , the foot looks normal .
It is important to remember that proper foot manipulations require a thorough understanding of the anatomy and kinematics of the normal foot and of the deviations of the tarsal bones in the clubfoot . Poorly conducted manipulations will further complicate the CTEV deformity . The non-operative treatment will succeed better if it is started a few days or weeks after birth and if the podiatrist and / or pedorthist understand the nature of the deformity and possesses manipulative skill and expertise in plaster-cast applications .
This method was employed in Tommy ’ s course of treatment . Things were looking like Tommy was going to have a normal foot . However , looks can be deceiving , and this proved true here .
The ossification of the bones in the foot as Tommy was in the 3-4 year range spelled the beginning of the problems he would encounter . His feet , never completely in the correct anatomic position , began to lapse back into equinovarus . He was taken to pediatric orthopedic surgeons who charted a course of surgical corrections that were part of the standard protocol . ( The sequella of these procedures will be discussed in future articles ). As the surgeries began piling up , their successes were called into question . Tommy ’ s parents were very concerned that their son would not run , play and grow up with normal gait . Tommy was taken to see Dr . Ponseti prior to his death , where he recommended that Tommy be seen at a Shriner ' s Hospital . His parents did just that where more surgery were performed that transformed the equinovarus into a calcaneovalgus with a very mobile ankle mortise .
Walking became difficult as Tommy tired easily and there was a significant amount of pain and discomfort in the foot and ankle region . His mom was getting worried as Tommy became more and more sedentary . A child ten-years old is far too young to attain couch potato status .
This manipulative treatment of the CTEV deformity is based on the inherent properties of the connective tissue , cartilage , and bone , which respond to the proper mechanical stimuli created by the gradual reduction of the deformity .
16 Pedorthic Footcare Association www . pedorthics . org