While I was evaluating mom's condition, she began talking
about her son and his travails with doctors and orthotics. He
has had plenty of devices over his young life, most of which
were unable to restore stability, function and comfort to his feet.
We have all had the experience of the "bag of orthotics" being
dumped out on the floor when we see a patient who has been
through it all. I had to visualize Tommy's devices as his mom
described them. Needless to say, my pedorthic juices began
flowing and I was very anxious to meet this remarkable boy who
wanted to walk. My chance would come about a week later. shoe. At present, he is in fourth grade and is the tallest boy in his
class, and in most of the school. Because of his current height,
people assume that Tommy is older. While he is very mature for
his age, he still acts like a ten year old. It will be challenging for
him to be in junior high and to be a child trapped into an adult
sized body.
My anticipation was of a very strange looking foot and an equally
strange gait. Tommy’s look was nearly normal and the gait was
really strange compared to others with CTEV. I was bound and
determined to help this child out, especially to reach his goal to
play soccer and do what every ten year old wants to do. No ten-
year old should want to sit more than get out and play. In the next installment, we will cover the similarities and
differences in management from 1950 and 2002, as well as the
technical details about surgery and management modalities.
Stay tuned as we go through the year with Albert and Tommy
and what pedorthics has done to improve their lives.
Some additional background information on Tommy needs
to be mentioned. Tommy's doctors have predicted that when
he reaches adulthood, he will be six foot seven to six foot nine
inches tall. Both mom and dad are very tall, and height runs in
the dad's family. His uncle is six foot seven with a size sixteen Research sources: Neale's Common Foot Disorders, Fifth Edition, 1997.
Churchill-Livingstone publishers.
This is Tommy's future. It is imperative that a suitable solution
is found.
Nand, Satya: "A Study of Congenital Talipes Equinovarus” Singapore
Medical Journal, Vol. 5 No. 4, December 1964. pp 212-215
How The Ponseti Method is Applied to CTEV
Step 1:
The calcaneal internal rotation (adduction) and plantar
flexion is the key deformity in CTEV. The foot is adducted
and planter-flexed at the subtalar joint, and the goal is
to abduct the foot and dorsiflex it. In order to achieve
correction of the CTEV, the calcaneum should be allowed
to rotate freely under the talus, which also is free to rotate
in the ankle mortise. The correction takes place through
the normal arc of the subtalar joint. This is achieved by
placing the index finger of the operator on the medial
malleolus to stabilize the leg and levering on the thumb
placed on the lateral aspect head of the talus while
abducting the forefoot in supination. Forcible attempts at
correcting the heel varus by abducting the forefoot while
applying counter pressure at the calcaneocuboid joint
prevents the calcaneum from abducting and therefore
everting.
Step 2:
Foot cavus increases when the forefoot is pronated. If
cavus is present, the first step in the manipulation process
is to supinate the forefoot by gently lifting the dropped
first metatarsal to correct the cavus. Once the cavus is
corrected, the forefoot can be abducted as outlined in step
1.
Step 3:
Pronation of the foot also causes the calcaneum to jam
under the talus. The calcaneum cannot rotate and stays
in varus. The cavus increases as outlined in step 2. This
results in a bean-shaped foot. At the end of step 1, the foot
is maximally abducted but never pronated.
Step 4:
The manipulation is carried out in the cast room, with the
baby having been fed just prior to the treatment or even
during the treatment. After the foot is manipulated, a long
leg cast is applied to hold the correction. Initially, the short
leg component is applied. The cast should be snug with
minimal but adequate padding. The person doing this
procedure should paint or spray the limb with tincture of
benzoin to allow adherence of the padding to the limb,
or if preferred, apply additional padding strips along the
medial and lateral borders to facilitate safe removal of the
cast with a cast saw. The cast must incorporate the toes
right up to the tips but not squeeze the toes or obliterate
the transverse arch. The cast is molded to contour around
the heel while abducting the forefoot against counter
pressure on the lateral aspect of the head of the talus. The
knee is flexed to 90° for the long leg component of the cast.
The parents can soak these casts for 30–45 minutes prior
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Current Pedorthics
January/February 2013
17