Information on Relapsing from Global HELP Booklet

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Information from the Global HELP Booklet on the Ponseti method on

Relapses in the Ponseti method.

Managing Relapses

Recognizing relapses

" After applying the brace for the first time after the tenotomy cast

is removed, the child returns according to the following suggested

schedule.

• 2 weeks (to troubleshoot compliance issues)

• 3 months (to graduate to the nights-and-naps protocol)

• every 4 months until age 3 years (to monitor compliance and check

for relapses)

• every 6 months until age 4 years

• every 1 to 2 years until skeletal maturity

Early relapses in the infant show loss of foot abduction and/or loss

of dorsiflexion correction and/or recurrence of metatarsus

adductus. Relapses in toddlers can be diagnosed by examining the

child walking. As the child walks toward the examiner, look for

supination of the forefoot, indicating an overpowering tibialis

anterior muscle and weak peroneals [A]. As the child walks away from

the examiner, look for heel varus . The seated child should be

examined for ankle range of motion and loss of passive dorsiflexion.

Reasons for relapses

The most common cause of relapse is noncompliance to the post-

tenotomy bracing program. Morcuende found that relapses

occur in only 6% of compliant families and more than 80% of

noncompliant families. In brace-compliant patients, the basic

underlying muscle imbalance of the foot is what causes relapses.

Casting for relapses

Do not ignore relapses! At the first sign of relapse, consider

reapplying one to three casts to stretch the foot out and regain

correction. This may appear at first to be a daunting task in a

wriggly 14-month-old toddler, but it is important. The casting

management is identical to the original Ponseti casting used in

infancy. Once the foot is re-corrected with the casts, the bracing

program is again begun.

Equinus relapse

Recurrent equinus is a structural deformity that can complicate

management. Equinus can be assessed clinically, but to illustrate

the problem, a radiograph is included to show the deformity [C].

Several plaster casts may be needed to correct the equinus to at

least a neutral position of the calcaneus. Sometimes, it may be

necessary to repeat the percutaneous tenotomy in children up to 1 or

even 2 years of age. They should undergo casting for 4 weeks

postoperatively, with the foot abducted in a long leg bent knee

cast, and then go back into the brace at night. In rare situations,

open Achilles lengthening may be necessary in the older child.

Varus relapse

Varus heel relapses are more common than equinus relpases. They can

be seen with the child standing [D] and should be treated by re-

casting in the child between age 12 and 24 months, followed by

reinstitution of a strict bracing protocol.

Dynamic supination

Some children will require anterior tibialis tendon transfer (see

page 26) for dynamic supination deformity, typically between ages 2

and 4 years. Anterior tibialis tendon transfer should be considered

only when the deformity is dynamic and no structural deformity

exists. Transfers should be delayed until radiographs show

ossification of the lateral cuneiform that typically occurs at

approximately 30 months of age. Normally, bracing is not required

after this procedure.One thing is certain: relapses that occur after

Ponseti management are easier to deal with than relapses that occur

after traditional posteromedial release surgery. "

http://www.global-help.org/publications/pdfs/PonsetiBook.pdf