What is the recommended treatment for Talipes equinovarus (clubfoot)?

Treatment of Talipes Equinovarus (Clubfoot)

The Ponseti method is the gold standard treatment for talipes equinovarus (clubfoot), consisting of serial manipulation and casting followed by bracing to prevent recurrence.

Initial Management

The Ponseti method involves a specific sequence of interventions:

1. Serial manipulation and casting:

   • Identify the head of the talus by palpation
   • Supinate the forefoot to eliminate cavus deformity
   • Abduct the forefoot while using the lateral head of the talus as fulcrum
   • Apply above-knee cast with foot in corrected position
   • Replace cast every 5-7 days 1

2. Achilles tenotomy:

   • Performed in 60-90% of cases after achieving full abduction
   • Necessary to correct residual ankle equinus
   • Can be performed as outpatient procedure under local anesthesia
   • Final cast applied for 3 weeks after tenotomy 1

3. Bracing protocol:

   • Foot abduction orthosis for 23 hours daily for first 3 months
   • Continued night and nap time bracing until age 4-5 years 1

Timing of Treatment

Treatment should be initiated as early as possible. Research shows that early diagnosis and treatment lead to better outcomes with fewer complications and lower risk of developing foot deformities 1.

Potential Complications and Recurrence

Recurrence occurs in approximately 27% of cases and is primarily associated with:

• Non-compliance with foot abduction brace (FAB): This is the most significant risk factor for recurrence
• Non-compliance typically begins around 11.2±6.5 months of age
• Risk of recurrence increases significantly during the weaning phase when bracing protocol isn't followed 2

Management of Recurrence

If recurrence develops:

• Return to manipulation and casting
• May require additional procedures if recurrence is severe
• Reinforce importance of bracing compliance

Special Considerations

In cases with severe deformities or in patients with epidermolysis bullosa:

• More careful manipulation may be needed
• Surgical release of clawed toes may be considered if they cause pain or difficulty with footwear
• However, surgical procedures should be approached cautiously as contractures almost always recur 3

Follow-up Protocol

• Regular follow-up during casting phase (every 5-7 days)
• After final cast removal, follow-up at 2 weeks, then monthly for 3 months
• Continued monitoring every 3-6 months until age 4-5 years
• Long-term studies show excellent functional outcomes with proper treatment, with clubfeet treated with the Ponseti method functioning as well as normal feet regarding pain and activity level 1

Patient Education

Parents must understand:

• The importance of strict adherence to the bracing protocol
• Techniques for proper brace application
• Signs of complications (skin irritation, brace discomfort)
• The critical role of compliance in preventing recurrence

The Ponseti method has revolutionized clubfoot treatment, allowing complete correction of almost all idiopathic clubfeet in 4-7 sessions with excellent long-term outcomes when the protocol is followed correctly 1.