club foot ponseti
DESCRIPTION
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Club footClub foot
Muhammad RizalMuhammad Rizal
Surgery is the wrong approach for the treatment of the club foot
Ponseti
Surgery is the wrong approach for the treatment of the club foot
Ponseti
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Ponseti
menulis di :
• JBJS 1963
• dan banyak majalah orthopaedi
• 1996 Text book : Congenital Club foot Fundamentals of treatment. Oxford University Press
• Pengalaman & evaluasi 35 tahun
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Ignatius V. Ponseti
• Professor, Dept. of Orthopaedic Surgery the University of IOWA, IOWA City, IOWA
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Implementasi cara Ponseti dilakukan banyak center :
• USA,Canada, Inggris, Jerman, Australia, Brazil, India, Afrika dan lain-lain
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Keberhasilan tinggi dengan cara konservatif + TAL SubkutanKeberhasilan tinggi dengan cara konservatif + TAL Subkutan
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Pato anatomi
Kaki :– Pilar medial– Pilar lateral
(Grant)
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Bone of the foot, dorsal aspect
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Bone of the foot, plantar aspect
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Pato anatomi
Pilar medial : – talus, naviculare, cuneiforme 1,2,3,mt 1,2,3– corpus tali dl mortise
Pilar lateral– calcaneus, cuboid, mt 4,5– calcaneus letak subtalar
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Pato anatomi
Kelainan CTEV
a. Equinus : ankle-arah kaki kebawah
b. Varus : calcaneus inversi subtalar
c. Aduksi : – Pilar medial kecuali talus bersama pilar
lateral rotasi horizontal ke medial– Naviculare subluksasi ke medial dari caput
tali
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Pato anatomi
d. Cavus :– Aduksi disertai dengan gerakan rotasi
vertikal kedua pilar– Calcaneus inversi (varus, supinasi)– Fore foot supinasi + aduksi– Kedudukan fore foot terhadap tumit adalah
pronasi– mt fleksi : cavus bertambah
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Pato anatomi
Talus– Collum dan caput tali
deviasi kemedial dan inferior
– Corpus tali didalam mortise, berputar kelateral fibula terdorong keposterior (horizontal breach)
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Pato anatomi
Calcaneus– Varus dan aduksi– Calc.posterior –
mendekati malleolus lateralis
Posterolateral viev (N)
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Pato anatomiKoreksi CTEV
– Kedua pilar di re-align (ditata kembali)
Talo calcaneal– Calcaneus bergerak ke medial (aduksi) dan inversi
(varus)
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Pato anatomi
Soft tissue– Semua otot, tendon, ligamen bagian
posterior dan medial memendek
CTEV– Developmental deformation bukan
embryonic malformation– Awal embrio tumbuh normal.
trimester II (mg 12-20), faktor genetik pembentukan kolagen berlebihan pada ligamen
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Pato anatomiCTEV
– Serat-serat kolagen tersusun bergelombang (wavy), padat, banyak sel-sel
– Ligamen tidak mengalami kontraktur, tetapi serat-serat memendek dengan “wavy” mudah diregangkan
– Pengaruh genetik : sampai umur (3-4) tahun serupa dengan DDH, scoliosis
– Rekurensi – bracing (3-4) tahun
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KinematikDasar pikiran Ponseti :
– Kinematik sendi subtalar yang membuat efektifnya metode koreksi CTEV
– Gerakan sendi subtalar ditentukan oleh pergeseran tuberositas anterior calcaneus
Konsep I– Seluruh kaki bergerak dibawah talus
“calcaneo-pedis block”Konsep II– Fore foot dan hind foot terkoreksi secara
simultan dengan abduksi
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Kinematik
– Sendi-sendi tarsalia secara fungsional inter-dependent
– Semua elemen akan terkoreksi pada saat kaki dirotasi sekitar caput tali
– Koreksi equinus (dorsofleksi) kebanyakan mengalami kesulitan karena tendo Achilles non stretchable collagen, tebal dan kaku
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Management club foot
– Semua unsur varus, cavus, aduksi akan terkoreksi bersamaan (simultan) bila kaki dirotasi sekitar caput tali
– Equinus : 95% TAL subkutan (Ponseti)– Hasil terbaik : bayi umur beberapa hari– Umur 3 bl, 5bl, 9 bl masih bisa dikoreksi
konservatif– Malahan umur 25 bulan
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Koreksi club footstretching sebelum plaster correction
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Koreksi club foot
a. Realign cavus : forefoot supinasi (3,4)
b. Fulcrum : caput tali : stabilisator (5)
c. Forefoot dalam supinasi abduksi (6)
d. Abduksi forefoot maksimal (7)
e. Dorsofleksi (+ TAL)
Proses a,b,c,d (5-6)x tiap (5-7) hari
Plaster sampai diatas lutut, lutut fleksi 900
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– TAL • Setelah plaster ke 6• Plaster 3minggu• Bracing :
– 3 bulan (24 jam)
– (2-4) jam siang, 12 jam malam– (3-4) tahun night splint
• Jalan dengan sepatu khusus
– Keberhasilan Ponseti =90%– Bila protokol (tidak pakai brace) rekurensi
80%
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Kegagalan Koreksi CTEV
– CTEV yang berat (severe), rigid sejak dilahirkan
Ponseti : alasan diatas tidak selalu betul– Kegagalan adalah karena :
1. Kesalahan cara koreksi manipulasi dan plastering
2. hanya + 10% resistent, bentuk kaki CTEV yang berat, pendek,gemuk, ligamen kaku indikasi surgery
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Kesalahan-kesalahan koreksi CTEV pada umumnya
1. Abduksi forefoot dalam pronasi cavus bertambah berat dengan kata lain : cavus tidak dikoreksi saat abduksiCalcaneus locked (jammed) dibawah caput tali, midfoot dan forefoot twisted eversi
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Kesalahan-kesalahan koreksi CTEV pada umumnya
2. Fulcrum : tidak mempergunakan caput tali
Kite : fulcrum calcaneo-cuboid : calcaneus tidak terkoreksi, hanya naviculare dan forefoot yang bergerak ke lateral
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Kesalahan-kesalahan koreksi CTEV pada umumnya
3. Manipulasi, stetching tanpa plaster imobilisasi
4. Plaster immobilisasi BK – harus AK agar• tidak terjadi sliding• ankle dan talus tidak rotasi• mempertahankan kaki abduksi subtalar
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Kesalahan-kesalahan koreksi CTEV pada umumnya
5. Equinus dikoreksi sebelum cavus, varus, abduksi terkoreksi Rocker bottom foot
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Kesalahan-kesalahan koreksi CTEV pada umumnya
6. Pemakaian Bar sesuai protokol (Ponseti)
7. Kadang-kadang perlu tibialis anterior transfer
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Club foot deformity
Infant < 2 years
UNTREATED CTEV
child < 2 years
Ponseti Tx Non-Ponseti Tx No Tx
Complex CTEV Neglected CTEV
Resistant CTEV
Foot corrects
Does not correctwith Tx
Recurrent CTEV
correctwith Ponseti Tx
Treated CTEV
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