Conceptos actuales sobre el tratamiento ortésico en el método Ponseti / Current concepts on bracing in the Ponseti method

El método Ponseti se ha convertido en el patrón de referencia para el tratamiento del pie bot, con excelentes resultados funcionales en el seguimiento a largo plazo. El cumplimiento del protocolo de férula es fundamental para mantener la corrección obtenida y el éxito terapéutico a largo plazo. Existen múltiples férulas para mantener la corrección y prevenir la recurrencia. En este artículo, proporcionamos una revisión de las férulas utilizadas para el pie bot, y analizamos sus ventajas y desventajas, así como la evi-dencia sobre cada una. Nivel de evidencia: V

The Ponseti method has become the gold standard for the treatment of clubfoot, with excellent long-term functional outcomes. Adherence to the bracing protocol is essential for the long-term success of the treatment. Currently, there are multiple braces that can be used to prevent relapse. In this article, we provide a review of clubfoot braces, discussing their advantages and disadvantages, as well as the current evidence on each of them. Level of Evidence: V

Congenital Clubfoot - Is the Ponseti Method the Definitive Solution? / Pé torto congênito - O método Ponseti é a solução definitiva?

Abstract Congenital clubfoot is one of the most common deformities at birth. The inadequacy or absence of treatment causes serious limitations for people with this condition. The initial treatment using the Ponseti method ensures functional results superior to other treatment modalities previously proposed. However, recurrences and neglected feet are still a challenge today. An understanding of the pathophysiology of the disease, as well as of the anatomy and local biomechanics and a thorough clinical and radiological evaluation of patients are essential to understanding the limits of the method and choosing the best treatment.

Resumo O pé torto congênito é uma das deformidades mais comuns ao nascimento. A inadequação ou ausência do tratamento provoca sérias limitações aos portadores desta condição. O tratamento inicial pelo método Ponseti garante resultados funcionais superiores a outras modalidades de tratamento propostas anteriormente, porém as recidivas e os pés negligenciados ainda são um desafio na atualidade. O entendimento da fisiopatologia da doença, da anatomia e biomecânica local e uma minuciosa avaliação clínica e radiológica dos pacientes são imprescindíveis para entendermos o limite do método e escolhermos o melhor tratamento.

Pie bot: conceptos actuales / Clubfoot: current concepts

El pie bot es la deformidad congénita más frecuente de las extremidades inferiores del ser humano, afectando a 1 de cada 1000 recién nacidos vivos. Consiste en la presencia de cuatro deformidades estructurales en el pie y el tobillo: cavo del medio pie, aducto del antepié, varo del retropié y pie en equino.Su registro en la humanidad data del siglo XII A.C. en momias del antiguo Egipto.La fisiopatología de esta deformidad aún no está aclarada. El diagnóstico puede ser prenatal mediante visualización ecográfica, pero la forma más común de diagnóstico es postnatal. La evaluación de estos pacientes se basa en la exploración clínica. Entre las clasificaciones más utilizadas se encuentran: Diméglio, que enfatiza lo reductible ante maniobras manuales de la deformidad; Pirani, que evalúa la gravedad inicial y el progreso del tratamiento; y Ponseti International Association (PIA), que clasifica según etiología.Durante el siglo pasado se describieron numerosos procedimientos quirúrgicos, muchos de los cuales fueron quedando en desuso ante sus resultados insatisfactorios, pies rígidos y dolorosos, con función limitada. Actualmente el método Ponseti es el Gold estándar para su tratamiento, consistiendo en una manipulación y enyesado seriado buscando la corrección sistemática del pie, basado en los fundamentos de la cinemática y la fisiopatología de la deformidad.

Clubfoot is the most frequent congenital deformity of the lower extremities of humans, affecting 1 out of 1000 live newborns. It consists of the presence of four structural deformities in the foot and ankle: midfoot cavus, forefoot adductus, hindfoot varus, and equinus foot.Its records in humanity date from the 12th century B.C., in ancient Egyptian mummies.The pathophysiology of this deformity is still unclear. Prenatal diagnosis by ultrasound imaging is feasible, but most common diagnosis is postnatal. The evaluation of these patients is based on clinical examination. Among the most used classifications are: Diméglio, which emphasizes the reductibility with manual maneuvers; Pirani, who assesses initial severity and progress of treatment; and Ponseti International Association (PIA), which classifies according to etiology.During the last century, numerous surgical procedures were described, many of which were disused due to their unsatisfactory results, stiffness and painful feet, with limited functionality. Currently the Ponseti method is the gold standard for its treatment. It consists of serial manipulation and casting, looking for a systematic correction of the deformity, based on the fundamentals of kinematics and pathophysiology of the deformity.

Does the Presence of Clubfoot delay the Onset of Walking? / A presença do pé torto congênito atrasa o início da marcha?

Abstract Objective Congenital clubfoot (PTC) is a congenital orthopedic condition often requiring intensive treatment; little is known about the impact of such treatment on motor development. The present study assessed whether gait development is later in patients with PTC treated with the Ponseti method in comparison to a control group and analyzed possible related factors. Methods Patients born at term, < 6 months old, not submitted to previous treatment and with a minimum follow-up period of 24 months were included. The control group consisted of patients with no musculoskeletal disorders seen during the present study. Results The study group consisted of 97 patients, whereas the control group had 100 subjects. The mean age at gait start was 14.7 ± 3.2 months in the study group and 12.6 ± 1.5 months in the control group (p< 0.05). Factors related to late gait included age at beginning of treatment > 3 weeks, number of plaster cast changes > 7, recurrence and nonperformance of Achilles tenotomy. Age at beginning of treatment > 3 weeks was related to a greater number of plaster cast changes. Gender and laterality were not related to late gait development. Conclusion Congenital clubfoot patients treated with the Ponseti method show independent walking approximately 2 months later than the control group. Delayed treatment, higher number of plaster cast changes, recurrence and nonperformance of Achilles tenotomy were related to late gait.

Resumo Objetivo O pé torto congênito (PTC) é uma das alterações ortopédicas congênitas que mais frequentemente necessita tratamento intensivo, e pouco se sabe o impacto desse tratamento no desenvolvimento motor. O presente estudo buscou avaliar se pacientes portadores de PTC tratados pelo método de Ponseti desenvolvem a marcha mais tardiamente comparado a um grupo controle e analisar possíveis fatores relacionados. Métodos Incluídos pacientes nascidos a termo, com < 6 meses de idade, sem tratamento prévio e com seguimento mínimo de 24 meses. O grupo controle foi de pacientes sem alterações musculoesqueléticas, atendidos no mesmo período da realização do presente estudo. Resultados Um total de 97 pacientes formaram o grupo de estudo e 100 o grupo controle. A média de idade no início da marcha no grupo de estudo foi de 14,7 ± 3,2 meses, e 12,6 ± 1,5 meses (p< 0,05) no grupo controle. Fatores relacionados à marcha tardia foram: idade de início do tratamento > 3 semanas, número de trocas gessadas > 7, recidiva e não realização da tenotomia de Aquiles. Idade de início do tratamento > 3 semanas esteve relacionada a maior número de trocas de gessos. Gênero e lateralidade não tiveram relação com a marcha tardia. Conclusão Pacientes com PTC tratados com o método de Ponseti apresentam marcha independente aproximadamente 2 meses mais tarde do que o grupo controle. Início mais tardio do tratamento, maior número de trocas de gessos, recidiva e não realização da tenotomia de Aquiles foram relacionados com atraso da marcha.

Erector spinae plane block in pediatric orthopedic surgery: two case reports / Bloqueio do plano eretor da espinha em cirurgia ortopédica pediátrica: dois relatos de caso

Abstract The erector spinae plane block is a safe and effective regional anesthesia technique, which has earned new indications perioperatively since its description. We introduce two pediatric anesthesia cases in which we performed the erector spinae plane block during intermediate/major orthopedic surgeries. The first patient is a 2 year-old girl submitted to surgical treatment of developmental dysplasia of the hip. The second patient is a 14 year-old boy submitted to surgical treatment of bilateral clubfoot. This last patient is potentially the first published case in which the erector spinae plane block was performed for ankle and foot surgery. Both cases experienced excellent analgesia, avoiding opiate requirement completely.

Resumo O bloqueio do plano eretor da espinha guiado por ultrassonografia é uma técnica segura e eficaz de anestesia regional, que apresenta novas indicações no perioperatório. Apresentamos dois casos de bloqueio do plano eretor da espinha realizados para analgesia de cirurgia ortopédica pediátrica de médio/grande porte. O primeiro: menina de 2 anos submetida a tratamento cirúrgico de displasia do desenvolvimento do quadril. O segundo: menino de 14 anos submetido a correção de pé valgo bilateral. Este último, no melhor do nosso conhecimento, é o primeiro caso de bloqueio do plano eretor da espinha em cirurgia de tornozelo/pé descrito na literatura. Os casos tiveram analgesia pós-operatória adequada, sem necessidade de opioides.

Pé torto congênito: método de Ponseti e sua aplicabilidade pelo fisioterapeuta / Congenital clubfoot: Ponseti method and its applicability by the physiotherapist

O pé torto congênito é uma das deformidades mais frequentes de membro inferior que, por sua complexidade com relação às alterações anatômicas, é alvo de dúvidas e divergência de opinião dos profissionais da área quanto ao tratamento mais eficaz. No entanto, o método mais utilizado atualmente e que vem apresentando resultados positivos é o de Ponseti. O objetivo deste trabalho é analisar a eficácia do método de Ponseti e sua aplicabilidade pelo fisioterapeuta. Tratou-se de pesquisa do tipo revisão, com abordagem qualitativa por meio de consulta a publicações das bases de dados Scielo, Lilacs, Medline e Bireme, preferencialmente dos últimos dez anos, e a coleta de dados no mês de outubro de 2016. Foram encontradas 248 publicações e, após análise, foram selecionados 23 artigos para a pesquisa, distribuídas em duas categorias: Eficácia do método Ponseti e Eficácia das técnicas fisioterapêuticas. Diante do exposto, percebese que o método de Ponseti tem se mostrado o mais eficaz no tratamento do pé torto congênito, e suas técnicas são compatíveis com as utilizadas por fisioterapeutas, sendo possível sua aplicabilidade por este profissional, com exceção da tenotomia do calcâneo. Portanto, este trabalho abre espaço para novas pesquisas que corroborem esta temática. (AU)

The congenital club foot is one of the most frequent lower limb deformities that, due to its complexity in relation to anatomical changes, is the subject of doubts and divergence of opinion of professionals in the area regarding the most effective treatment. However, the method most used currently and that has presented positive results is that of Ponseti. The aim of this study was to analyze the effectiveness of the Ponseti method and its applicability by the physiotherapist. This research was a literature review, with a qualitative approach, through consultation of publications of Scielo, Lilacs, Medline and Bireme databases, preferably in the last ten years, and data collection in October 2016. We found 248 publications and after analysis, 23 articles were selected for the research, distributed in two categories: Efficacy of the Ponseti method and Efficacy of physiotherapeutic techniques. The Ponseti method has been shown to be the most effective in the treatment of congenital clubfoot, and its techniques are like those used by physiotherapists, being possible its applicability by this professional, except for tenotomy of the calcaneus. Therefore, this work opens space for new research that corroborates this theme. (AU)

Apego al método de Ponseti por parte de los familiares como determinante en el éxito del tratamiento del pie equinovaro / Adherence to the Ponseti method by family members as a determinant in the success of club foot treatment

Resumen: El pie equinovaro aducto congénito (PEVAC) es uno de los padecimientos más comunes en Ortopedia Pediátrica, el cual se compone del equino del retropié, el varo subastragalino, el aducto del antepié y el cavo del mediopié. El método de Ponseti es el tratamiento universalmente aceptado para el PEVAC; éste consta de tres fases: manipulación y enyesado, tenotomía del tendón de Aquiles y una fase de mantenimiento. El mayor porcentaje de las recaídas se presenta en la fase de mantenimiento; en la mayoría de los casos, está asociado el apego familiar deficiente. Presentamos el caso clínico de un paciente con PEVAC típico, tratado en cuatro ocasiones con el método de Ponseti y que no requirió tratamiento quirúrgico.

Abstract: The clubfoot is one of the most common conditions in Pediatric Orthopedics, may affect each part of the foot and ankle, equinus, varus, and internal rotation of the calcaneum, and true equinus of the ankle are common. The Ponseti method is an universally accepted treatment, consisting of three phases: manipulation and plaster, Achilles tendon tenotomy and maintenance phase. The highest percentage of relapses occurs in the maintenance phase and the deficient family member is associated in most cases. We present a clinical case of a patient with typical clubfoot treated with the Ponseti method on four occasions without the need of surgical treatment.

Hemimelia tibial izquierda con pie equino varo aducto bilateral y ausencia del tercer rayo de la mano izquierda. Reporte de Caso / Left tibial hemimelia with bilateral clubfoot and absence of the third ray of the left hand. Case Report

La hemimelia tibial se puede presentar en una gran variedad de espectros, desde la hipoplasia tibial hasta la ausencia completa de la tibia con o sin compromiso adjunto cuadricipital, ligamentario, patelar, fibular y/o femoral; esto ha dado lugar a múltiples clasificaciones con implicaciones anatómicas y terapéuticas. Esta enfermedad se ha descrito desde 1841, sin embargo, es la deficiencia más rara en las extremidades inferiores, siendo la más común la deficiencia fibular. Presentamos un paciente con diagnóstico antenatal de pie equino varo bilateral, agenesia de la tibia izquierda y comunicación aurículo ventricular (CIA) con cariotipo normal. Al nacer presenta fascies normales. Se confirma con radiografías la ausencia del tercer rayo de la mano izquierda y la ausencia de la tibia izquierda con ensanchamiento del peroné, tipo 5C en la clasificación de Paley, y pie equino varo aducto bilateral. Nivel de Evidencia: IV

Tibial hemimelia is a broad spectrum disorder, from tibial hypoplasia to complete absence of the tibia with or without quadricipital, ligament, patellar, fibular and / or femoral attachment. This has led to multiple classifications, with their anatomical and therapeutic implications. Although this disorder has been described since 1841, it is the rarest deficiency in the lower extremities, with the most common being fibular deficiency. The case is presented on a patient with an antenatal diagnosis that included bilateral congenital talipes equinovarus, agenesis of the left tibia, and atrioventricular communication with normal karyotype. The facies were normal at birth. Radiographs confirmed the absence of the third ray of the left hand and the absence of the left tibia, with widening of the fibula, type 5C in Paley classification, and bilateral congenital talipes equinovarus. Evidence Level: IV

Pie bot y FLAP como asociación aislada / Clubfoot and OC as an isolated association

INTRODUCCIÓN: el pie bot y la fisura labio alvéolo-palatina (flap) son malformaciones congénitas relacionadas con síndromes diversos, aunque infrecuentes como entidades aisladas. El pie bot tiene como tratamiento de elección, el método enyesado de Ponseti, mientras que la flap requiere corrección quirúrgica a menudo. Ésta última presenta diferentes variantes: fisura labial, fisura palatina y fisura labio/palatina. OBJETIVO: mostrar 3 pacientes evaluados multidisciplinariamente con asociación pie bot-flap sin formar parte de un síndrome. MATERIAL Y MÉTODOS: estudio retrospectivo descriptivo. Presentamos 3 pacientes atendidos de enero de 2016 a enero de 2017, con pie bot y flap aislados sin otra alteración estudiados por genetista. Se realizó método de Ponseti por ortopedista más tratamiento de la flap por cirujano máxilofacial. RESULTADOS: presentamos 3 pacientes, (2 femeninas). Edad a la consulta: 2 meses promedio con 8.8 Yesos semanales y ferulaje posterior. Una paciente abandonó tratamiento, retomando yesos actualmente. Los 3 necesitaron tenotomía del tendón de Aquiles y cirugía máxilofacial. Seguimiento promedio: 1 año y 5 meses. Se trabajó multidisciplinariamente descartando otras patologías por genetista. CONCLUSIONES: evaluar el paciente de manera multidisciplinar simplifica el tratamiento y favorece el diagnóstico de otras patologías no evidenciadas al momento de la consulta.

INTRODUCTION: Clubfoot and orofacial cleft (OC) are congenital malformations related to different syndromes, although uncommon as isolated entities. The treatment of choice for the clubfoot is the Ponseti method with casting while the OC often requires surgical correction. The latter presents different variants: lip cleft, palate cleft or both. OBJECTIVE: to show 3 patients with non syndromic associated clubfoot-OC who were evaluated with a multidisciplinary approach. MATERIALS AND METHODS: a descriptive retrospective study. We present 3 patients with isolated clubfoot and orofacial cleft and no other alteration, treated from January 2016 to January 2017 and examined by a genetist. Ponseti method was applied by an orthopedist and the orofacial cleft was treated by an oro-maxillo-facial surgeon. RESULTS: we presented 3 patients (2 female). Age at evaluation: average 2 months with 8.8 weekly casts and subsequent splinting. One patient dropped the treatment and now has resumed casting. The 3 of them needed tenotomy of the Achilles tendon and oromaxillo-facial surgery. Average follow-up: 1 year 5 months. The approach was multidisciplinary and other pathologies were ruled out by a genetist. CONCLUSIONS: Evaluating the patient by using a multidisciplinary approach simplifies the treatment and favors the diagnosing of other pathologies not presented at the office visit.

Resultados del tratamiento de pie equinovaro congénito con el método de Ponseti / Outcomes of congenital clubfoot treatment using the Ponseti method

Introducción El pie equinovaro congénito es la deformidad congénita más frecuente del pie. Actualmente, el método Ponseti es el método de referencia para el tratamiento de esta anomalía, pues provee de una corrección completa de las deformidades con buena movilidad y función del pie. Existen muchos estudios en el mundo que muestran resultados funcionales del método. Sin embargo, en Colombia no hay publicaciones de este tipo con el método Ponseti. Materiales y métodos Este es un estudio descriptivo, retrospectivo, de tipo serie de casos en pacientes entre 0 y 12 años diagnosticados con pie equinovaro congénito, tratados con el método Ponseti entre julio de 2002 y diciembre de 2015. Con un seguimiento mínimo de menos 6 meses, se midió la gravedad según la escala de Dimeglio y la funcionalidad según la escala de Laaveg-Ponseti. Resultados 123 pacientes (183 pies) con un seguimiento medio de 8 años. Edad de inicio del tratamiento: entre 0 y 24 meses. Según la clasificación del grado de gravedad de Dimeglio, el 6,5% eran leves, el 74% moderados, el 13% graves y el 6,5%, muy graves. La mayoría de los pies estudiados era de origen idiopático (96%). El 20% presentaron recidiva. Los resultados funcionales según la escala de Laaveg-Ponseti fueron excelentes (71%), buenos (23%) o regulares (6%). Discusión Nuestros resultados con desenlaces buenos y excelentes del 94% son similares a reportes previos. Con una recidiva del 17,8%, en la bibliografía se reportan el 20 y el 40%, respectivamente. Este estudio, a diferencia de los demás, no encontró relación directa entre el uso del aparato de abducción y la recidiva. No hubo sobrecorrecciones y ningún paciente tuvo un resultado malo según la escala de Laaveg-Ponseti. Nivel de evidencia clínica Nivel IV.

Background Congenital clubfoot is the most common congenital deformity of the foot. The Ponseti method is currently the gold standard for the treatment of this anomaly, as it provides a complete correction of the deformities with good foot mobility and function. There are many studies from all over the world that present the functional results of the method. However, in Colombia there are no publications of this type using the Ponseti method. Materials and methods This is a descriptive, retrospective, case series-type study in patients between 0 and 12 years old diagnosed with clubfoot, and treated using the Ponseti method between July 2002 and December 2015, and with a minimum follow-up of at least 6 months. Severity was measured according to the Dimeglio scale, and functionality with the Laaveg-Ponseti scale. Results The study included a total of 123 patients (183 feet) with a mean follow-up of 8 years. Treatment was started between 0 and 24 months. According to Dimeglio severity rating, 6.5% were mild, 74% moderate, 13% severe, and 6.5% very severe. Most (96%) of the studied feet were of idiopathic origin. There was a relapse in 17.8%. The functional results, according to the Laaveg-Ponseti scale were excellent in 71%, good in 23%, and average in 6%. Discussion The results with good and excellent outcomes of 94% are similar to previous studies. With a relapse rate of 17.8%, compared to the 20% and 40%, respectively, reported in the literature. This study, unlike the others, found no direct relationship between the use of the abduction apparatus and relapse. There were no over-corrections and no patient had a poor outcome according to the Laaveg-Ponseti scale. Evidence level IV.

Propuesta de un nuevo diseño de órtesis post-tratamiento de pie equino varo congénito / Proposal for a new design of post-treatment congenital club foot orthosis

La investigación tuvo como objetivo rediseñar la órtesis utilizada post-tratamiento Ponseti, en niños con pie equino varo congénito, de forma tal que permita la reducción de rechazo a su uso. Método: Se identificaron las necesidades de los niños con pie equino varo congénito, para verificar los inconvenientes con respecto a la funcionalidad, diseño y adaptabilidad a la órtesis dado que si la férula no se usa adecuadamente el riesgo de recidiva es de 80 %, por el contrario con el uso de la férula el riesgo es de 4 %. Se realizó un estudio biomecánico del movimiento de un paciente durante el gateo, con y sin la órtesis. Resultados: Se elaboró un modelo 3D de la propuesta, para simular el diseño sometido a las fuerzas generadas por los bebés durante el pataleo en posición supina. Se evaluó experimentalmente el desempeño del prototipo alfa, para determinar si cumplía con la meta prevista. Se obtuvo la fabricación y pruebas de la órtesis en plataforma virtual y físico. Acorde al alcance del proyecto, se determinó que es probable que se reduzca el rechazo al uso y por consiguiente la formación de recidiva, al reducir los factores determinantes propios de la férula del mercado, que propiciaban el mal uso de esta en el tratamiento. La velocidad promedio de gateo es de 0.48 m/s y con la férula se reduce a 0.37 m/s. Discusión: La férula del mercado pesa 304.07 g y la propuesta pesa 209.26 g. Se sugiere que se continúe la investigación en el estudio biomecánico.

This research was developed with the objective of redesigning the orthosis used in the post- Ponseti treatment in children with clubfoot, with the intention of reducing the rejection to its use. Method: A research on the needs of children with congenital clubfoot was conducted to identify the disadvantages on functionality, design and adaptability of the orthosis if the splint is not used appropriately, the risk of relapse is 80 %, whereas using the splint, the risk is 4 %. A biomechanical study of a patient's movement during the crawl was performed with and without the orthosis. Results: A 3D model of the design was developed to simulate computationally its performance under the forces generated by the babies during the kick in supine position. Finally, an experimental evaluation of the alpha prototype performance was made to determine whether it met the intended goal. Thus, the manufacturing and testing of the orthosis on virtual and in physical platform took place. Taking in account the goal of this project, it 3 was determined that it is possible to reduce the reject to the use and therefore the formation of relapse by reducing the determinant factors of the common market splint, which promotes its incorrect use of this in the treatment. The average crawl speed is 0.48 m/s and with the splint, it decreases to 0.37 m/s. Discussion: The weight of the common market splint is 304.07 g and the weight of the one designed in the study is 209.26 g. Further biomechanical research is suggested to get conclusive results

Nivel de evidencia y grado de recomendación del uso del método de Ponseti en el pie equino varo sindromático por artrogriposis y síndrome de Moebius: una revisión sistemática / Evidence level and grade of recommendation of the Ponseti method for arthrogryposis-related syndromic talipes equinovarus and Moebius syndrome: a systematic review

Resumen: Antecedentes: El pie equino varo aducto congénito (PEVAC) es una malformación musculoesquelética común que afecta de uno a 4.5 de cada 1,000 nacidos vivos; se asocia de manera común a artrogriposis y síndrome de Moebius; éstos son más difíciles de tratar y requieren de tratamientos quirúrgicos agresivos para lograr un pie plantígrado; por lo tanto, ¿cuál es el nivel de evidencia y grado de recomendación del uso del método de Ponseti en el pie equino varo sindromático por artrogriposis y síndrome de Moebius? Métodos: Estudio de diseño de revisión sistemática de acuerdo a las recomendaciones del grupo Cochrane por medio de la identificación de Medical Subject Headings (MeSH) y del método booleano para ubicar artículos que cumplieran con los criterios de selección mediante búsqueda de fuentes primarias como OVID, Cochrane, EBSCOhost, Elsevier, Medigraphic. Resultados: En total, seis artículos cumplieron con los criterios de selección a través de la búsqueda de fuentes primarias: cinco de ellos sobre el tratamiento del PEVAC con método de Ponseti en pacientes con artrogriposis y uno para pacientes con Moebius. Se encontraron artículos con niveles de evidencia y grado de recomendación: IV-D (3), III-D (1) y II (B). Conclusiones: El método de Ponseti es un tratamiento inicial en artrogriposis y síndrome de Moebius; es barato, no invasivo y no requiere de un médico para poderse realizar (pero sí un personal capacitado); se recomienda su uso para evitar cirugías extensas y complicaciones médicas que trascienden al orden económico intrahospitalario.

Abstract: Background: Adduct congenital talipes equinovarus (CTE) or clubfoot is a common musculoskeletal malformation affecting between 1 and 4.5 out of every 1000 live births. It is usually associated with arthrogryposis and Moebius syndrome with the latter two being more difficult to treat as they require aggressive surgery to achieve a plantigrade foot. We therefore ask what is the evidence level and grade of recommendation of the Ponseti method to treat syndromic talipes equinovarus resulting from arthrogryposis and Moebius syndrome. Methods: Systematic review according to the recommendations of the Cochrane group identifying medical subheadings (MeSH) and of the Boolean method to identify the articles that met the selection criteria through the search of primary sources such as OVID, Cochrane, EBSCOhost, Elsevier, Medigraphic. Results: A total of six papers met the selection criteria through the search in the primary sources. Five of them address the treatment of adduct CTE with the Ponseti method in patients with arthrogryposis, and one in patients with Moebius. Evidence levels and grades of recommendation of these papers were: IV-D (3), III-D (1) y II (B). Conclusions: The Ponseti method is an first-line treatment for arthrogryposis and Moebius syndrome. It is unexpensive, non-invasive and does not require a physician to perform it (however, it does require trained staff). Its use is recommended as it avoids extensive surgeries and medical complications that go beyond the hospitals' economic possibilities.

Evaluación ultrasonográfica del tendón de Aquiles en niños con pie equino varo aducto congénito posterior a tenotomía de Aquiles con el método de Ponseti. Seguimiento a 12 semanas / Sonographic evaluation of Achilles tendon healing in tenotomies for congenital clubfoot and Ponseti's treatment. A 12-week follow-up

Resumen: Objetivo: Determinar el tiempo de curación del tendón de Aquiles en pacientes pediátricos tratados mediante tenotomía de Aquiles con método Ponseti en el Hospital Shriners para Niños de México, AC. Material y métodos: Estudio experimental, analítico, prospectivo, longitudinal de pacientes con diagnóstico de pie equino varo aducto congénito idiopático en tratamiento con método Ponseti con evaluación estática y dinámica mediante ecógrafo en tiempo real Siemens Diagnostic Ultrasound System Sonoline 650 con transductor lineal de 10.5 mHz seriada del tendón de Aquiles previa a la tenotomía y a las tres, seis, nueve y 12 semanas tras el tratamiento quirúrgico. Resultados: Se obtuvo una muestra de 23 pacientes, 16 masculinos y siete femeninos, 16 con patología bilateral y siete unilateral, para un total de 39 pies, 18 derechos y 21 izquierdos, con una media de edad de 8.3 ± 2.3 meses. Previamente a la tenotomía, la anchura en corte longitudinal ultrasonográfico media fue de 2.7 ± 0.42 mm; en la semana tres, la media fue 3 ± 0.39 mm; a las seis semanas, 2.92 ± 0.36 mm; el ultrasonido de las nueve semanas reportó media de 2.84 ± 0.38 mm y a las 12 semanas, 2.82 ± 0.39 mm. Se compararon mediante t de Student el ancho prequirúrgico y a las 12 semanas, sin encontrarse diferencia p > 0.03. Conclusiones: La valoración ecográfica muestra integridad a las tres semanas posteriores a la tenotomía de Aquiles. Sin embargo, la reparación completa se logra a las 12 semanas.

Abstract: Objective: The aim of this study was to determine the healing time of Achilles tendon in pediatric patients treated with Achilles tenotomy with the Ponseti method in Shriners Children's Hospital of Mexico, AC. Material and methods: Experimental, analytical, prospective, longitudinal study of patients with a diagnosis of idiopathic congenital clubfoot treated with the Ponseti method with serial static and dynamic evaluation by ultrasound in real time with a Siemens Diagnostic Ultrasound System Sonoline 650, linear transducer 10.5 MHz of Achilles tendon before tenotomy and at three, six, nine and 12 weeks after the surgical treatment. Results: A sample of 23 patients, 16 male and seven female, 16 with unilateral and seven with bilateral pathology was obtained, for a total of 39 feet, 18 right and 21 left, with a mean age of 8.3 ± 2.3 months. Before tenotomy, the width was 2.7 ± 0.42 mm; in week three, the average was 3 ± 0.39 mm; at six weeks, 2.92 ± 0.36 mm; ultrasound at nine weeks reported an average of 0.38 ± 2.84 mm, and 2.82 ± 0.39 mm at twelve weeks. They were compared using Student's t presurgical width and at twelve weeks, without finding difference p > 0.03. Conclusions: Although there is integrity at three weeks after Achilles tenotomy, complete repair is achieved at 12 weeks.

Transposición tendinosa del tibial posterior al centro del pie en lesiones neuromusculares. Experiencia en pacientes adultos / Adult experience with the tibialis posterior transposition to the center of the foot in neuromuscular disease

Resumen: La transferencia del tibial posterior al centro del dorso del pie es un método que se utiliza para lograr la dorsiflexión en parálisis flácida de la musculatura anteroexterna de la pierna o para contrarrestar el desequilibrio muscular del pie equino varo. Objetivo: Describir los resultados funcionales después del procedimiento quirúrgico de transposición del tibial posterior al centro del pie. Material y métodos: Estudio observacional, descriptivo, transversal y ambispectivo con una descripción del universo de trabajo en pacientes con deficiencia de la musculatura dorsiflexora del pie y afectación de la marcha en el período de Enero de 2008 a Diciembre de 2014. Resultados: Se obtuvo un total de 18 pacientes. Discusión: Creemos que este estudio podría considerarse como generador de hipótesis sobre si representa una alternativa superior a la artrodesis. Para ello proponemos continuar estudios en esta rama con mayor cantidad de evaluaciones en el preoperatorio y postoperatorio para obtener resultados más objetivos y con un grupo más amplio de individuos.

Abstract: The transfer of the posterior tibial tendon to the center of the dorsum of the foot is a method used to achieve dorsiflexion in flaccid paralysis of the anterolateral leg muscles or muscular imbalance of clubfoot. Objective: To describe functional results back to the surgical procedure for transposition of posterior tibial the center of the foot. Material and methods: The study design was observational, descriptive, transversal, ambispective with a description of the world of work patients with impaired dorsiflexora foot muscles and impaired gait in the period January 2008 to December 2014. Results: A total of 18 patients who were candidates for what this type of treatment was obtained. Discussion: We believe that this study can be estimated as generating hypotheses about whether it is a superior alternative to arthrodesis. For this plan to continue studies in this field, with an increased number of assessments both before and after surgery to have more objective results and a greater number of individuals.

Biomechanical Parameters in Children with Unilateral and Bilateral Clubfoot during Vertical Jumps

Abstract Gait analysis may offer information to choose the best exercise-based clinical intervention for the children with clubfoot. However, other motor abilities are not commonly investigated. The aim of this research was to analyze the biomechanics of countermovement vertical jumping in clubfooted children who had undergone surgery. Fourteen children with idiopathic clubfoot were selected and the control group consisted of 11 children. Clubfooted children showed less dorsiflexion in the jump preparation phase. In the impulse phase, this group showed more knee flexion and less plantarflexion associated with less magnitude of vertical reaction force and less muscular activity in the gastrocnemius medialis. In the landing phase, for clubfoot group, we found high loading rate for the first peak of vertical force, less plantarflexion and more knee flexion. Understanding the biomechanical changes of vertical jump landing should assist in better targeting of physical and sporting activities of this population.(AU)

Síndrome de Moebius: manifestaciones neurológicas, musculoesqueléticas y del lenguaje / Moebius syndrome: Neurological, musculoskeletal and speech anomalies

El síndrome de Moebius es una enfermedad congénita caracterizada por parálisis facial no progresiva y alteración de la abducción ocular de uno o ambos ojos por compromiso del VI par, pudiendo extenderse a otros pares oculomotores, así como al IX, X y XII. Se ha asociado con manifestaciones musculoesqueléticas y epilepsia. Presentamos el caso de un preescolar con antecedente de intento fallido de la madre de interrupción voluntaria del embarazo en el primer trimestre. Al nacimiento se evidencia diplejía facial, parálisis bilateral del VI par y pie equino varo. A los 17 días de vida presenta crisis tónico-clónicas y se diagnostica síndrome de Moebius y epilepsia de difícil control. Durante el seguimiento presenta retardo global del desarrollo, con predominio en el área del lenguaje y alteración de la deglución...(AU)

Moebius syndrome consists of congenital non-progressive facial nerve palsy and unilateral or bilateral paralysis of the sixth cranial nerve with inability to abduct the eye. The oculomotor cranial nerves, as well as, cranial nerves IX, X and XII, may also be affected. This syndrome has also been associated with anomalies of the musculoskeletal system and epilepsy. A case is presented in a preschool boy whose mother tried to voluntarily interrupt pregnancy in the first trimester but failed to abort. Facial diplegia, bilateral sixth cranial nerve palsy and bilateral equinovarus deformity of the feet were evidenced at birth. At 17 days of life he presented a tonic-clonic seizure and was diagnosed with Moebius syndrome and difficult to treat epilepsy. Delayed overall development, predominantly swallowing and speech difficulties, were evidenced upon follow up...(AU)

Functional and clinical results achieved in congenital clubfoot patients treated by Ponseti's technique / Resultados funcionais e clínicos alcançados em pacientes com pé torto congênito tratados pela técnica de Ponseti

ABSTRACT OBJECTIVES: To analyze and evaluate functional and clinical results in patients with congenital clubfoot treated with Ponseti's technique. METHODS: This study evaluated 31 patients diagnosed with 51 congenital clubfeet, treated between April 2006 and September 2011 with Ponseti's technique. The patients who did not achieve an equinus correction with manipulation were treated with Achilles tenotomy. An anterior tibial tendon transfer was performed in patients who maintained residual adduction. All plasters were made by fellows and supervised by Ankle and Foot Chiefs. The technique was performed without the need for physical therapists, orthotics, and plaster technicians. Patients were submitted to pre- and post-treatment examination and evaluated under Pirani's classification. RESULTS: Male patients had an increased incidence and the right side was more affected, while bilateral involvement was observed in 64.5% of the cases. The mean number of cast changes was 5.8, and Achilles tenotomy was necessary in 26 patients. There were significant deformity improvements in 46 of the 51 treated feet (90.2%); Pirani's mean score improved from 5.5 to 3.6 after treatment. CONCLUSION: The Ponseti method was effective in both functional and clinical evaluation of patients, with significant statistical relevance (p = 0.0001), with a success rate of 90.2% and mean improvement in the Pirani's index of 65.5%.

RESUMO OBJETIVOS: Analisar e avaliar os resultados funcionais e clínicos em pacientes com pé torto congênito tratados pela técnica de Ponseti. MÉTODOS: O estudo incluiu 31 pacientes diagnosticados com 51 pés tortos congênitos, tratados entre abril de 2006 a setembro de 2011 pela técnica de Ponseti. Os pacientes que não alcançaram a correção do estado equino com manipulação foram tratados com tenotomia do Aquiles. Uma transposição do tendão tibial anterior foi feita nos pacientes que mantiveram uma adução residual. Todos os gessos foram feitos por residentes e supervisionados pelos chefes de Tornozelo e Pé. A técnica foi aplicada sem a necessidade de fisioterapeutas ou técnicos de gesso. Os pacientes foram submetidos a exame antes e depois do tratamento e avaliados de acordo com a escala de Pirani. RESULTADOS: Os pacientes do sexo masculino apresentaram um aumento de incidência e o lado direito foi o mais afetado, enquanto que o acometimento bilateral foi observado em 64,5% dos casos. A média de mudanças de gesso foi de 5,8 e a tenotomia do tendão de Aquiles foi necessária em 26 pacientes. Houve melhorias significativas das deformidades em 46 dos 51 dos pés tratados (90,2%), a escala de Pirani pontuou um avanço na média de 5,5 para 3,6 após o tratamento. CONCLUSÃO: O método de Ponseti foi eficaz nas avaliações funcionais e clínicas dos pacientes, com uma relevância estatística significante (p = 0,0001), com uma taxa de sucesso de 90,2% e um avanço na escala de Pirani de 65,5%.

Surgical treatment of neglected clubfoot using external fixator / Tratamento cirúrgico do pé torto inveterado com fixador externo

ABSTRACT The definition of neglected clubfoot (NC) includes a variable range of complex deformities of the foot that are refractory to conventional treatments or are treated inappropriately. Several etiologies may be related to this. The Ilizarov method has become established as a tool for treating these deformities. It minimizes soft-tissue damage through gradual correction of the deformity, with a high success rate in relation to achieving a plantigrade foot, with low incidence of recurrence. The indications for treatment include severe rigid deformities (Dimeglio III and IV), or adverse skin conditions. Careful clinical and radiological examination is fundamental for proper planning and installation of the external fixator. The techniques used include selection of external fixation assemblies, which can be closed when there is a connection between the leg, hindfoot and forefoot. This closed assembly may or may not be constricted, according to whether hinges are provided or whether use of the natural anatomical hinges during correction of the deformity is envisaged. An open assembly makes it possible to add flexibility to the foot through histogenesis, while allowing closed corrections of greater precision later on. Hexapod fixators are an innovation with high potential for accuracy in correcting deformities. Procedures associated with external fixation include soft-tissue release and bone procedures. These procedures enable corrections that are more anatomical, for different degrees of severity and stiffness of deformity. It can be concluded from analyzing this case series that treatment of neglected clubfoot using an external fixator has a high rate of good and excellent results, with low frequency of complications.

RESUMO O pé torto inveterado (PTI) inclui em sua definição uma gama variável de deformidades complexas do pé refratário a tratamentos convencionais ou tratados de forma inadequada. Diversas etiologias podem estar relacionadas. O método de Ilizarov é consagrado como uma ferramenta de tratamento dessas deformidades, minimiza danos a partes moles, através de correção gradual da deformidade, com alto índice de sucesso em relação à obtenção de um pé plantígrado com incidência baixa de recidiva. As indicações do tratamento incluem deformidades graves e rígidas (Dimeglio III e IV) ou em condições de pele desfavoraveis. O exame clínico e radiológico criterioso é fundamental para um planejamento adequado e a montagem do fixador externo. As técnicas empregadas incluem a seleção das montagens do fixador externo, que pode ser fechada, quando há conexão entre perna, retro e antepé. Essa montagem fechada pode ser constrita ou não, quando se oferecem as dobradiças ou quando se espera usar dobradiças anatômicas naturais durante a correção da deformidade. A montagem aberta permite flexibilizar o pé através da histogênese, permite correções fechadas mais precisas posteriormente. Os fixadores hexapodais representam inovações com alto potencial de precisão na correção de deformidades. Os procedimentos associados à fixação externa incluem as liberações miotendíneas e os procedimentos ósseos. Esses procedimentos permitem correções mais anatômicas para graus diferentes de gravidade e rigidez de deformidade. Conclui-se, na análise das séries de casos, que o tratamento do pé torto inveterado com fixador externo apresenta um alto índice de bons e excelentes resultados, com baixa frequência de complicações.

Valoración y seguimiento en el tratamiento del pie equinovaro congénito con el método de Ponseti en pacientes del HNNBB en los años 2008, 2009, 2010 / Assessment and follow-up in the treatment of congenital clubfoot with the Ponseti method at the HNNBB patients in 2008, 2009, 2010

El pie zambo es una deformidad evidente desde el nacimiento. Si no se le corrige, cuando el niño comienza a caminar, lo hace sobre el borde externo del pie desarrollando callosidades en dicha zona y con el tiempo la marcha se hace dolorosa. Se estima que anualmente nacen unos 120,000 niños con pie zambo congénito. Actualmente se puede corregir el pie zambo fácilmente mediante el método de Ponseti. Se realizó un estudio descriptivo, de corte retrospectivo, que incluyó a todos los niños con diagnóstico de pie equinovaro congénito, atendidos en la consulta externa de ortopedia del Hospital Nacional de Niños Benjamín Bloom durante los años 2008-2010. Los datos fueron recolectados a partir de revisión de expedientes clínicos, en base a un cuestionario previamente diseñado. Se realizó el análisis de información y determinación de resultados por medio del programa EXCEL. Este trabajo fue sometido a evaluación por el comité de ética en investigación clínica, siendo aprobado y autorizando su realización. De los 55 pacientes que se incluyeron en el estudio, la edad más frecuente para consulta e inicio de tratamiento fue entre 1-2 meses de edad (27%), se observó que el pie equinovaro bilateral (47%) era más frecuente. En la evaluación inicial con la escala de Dimeglio se encontró que el 64% de los pacientes presentaban pie equinovaro congénito moderado, el 29% benigno, y el 7% grave, y ninguno grave. En la evaluación posterior al tratamiento con técnica de Ponseti se observó que 91% de los pacientes incluidos en el estudio presento un pie equinovaro benigno o ya corregido, un 9% fue moderado y ninguno grave o muy grave