What is the treatment for bilateral pes equinovarus?

Treatment of Bilateral Pes Equinovarus (Clubfoot)

The Ponseti method is the gold standard first-line treatment for bilateral pes equinovarus (clubfoot), achieving excellent results with initial correction rates of approximately 90% in idiopathic cases.

Initial Assessment and Classification

• Assess severity using the Pirani scoring system (0-6 scale) to document deformity components
• Determine if clubfoot is:
  • Idiopathic (most common)
  • Syndrome-associated/non-idiopathic (associated with conditions like arthrogryposis, trisomy 21, or spina bifida)

Treatment Algorithm

Phase 1: Ponseti Manipulation and Casting

1. Begin treatment as early as possible (ideally within first few weeks of life)

2. Manipulation technique:

   • Locate the head of talus as the fulcrum point
   • Gradually correct cavus by supinating forefoot
   • Abduct the foot while applying counter-pressure at talus
   • Avoid pronation of the foot

3. Casting protocol:

   • Apply long leg casts (toe to upper thigh) after each manipulation
   • Change casts every 5-7 days
   • Typically requires 4-9 casts (average 6) 1
   • Final cast should achieve hyperabduction of the foot

Phase 2: Achilles Tenotomy

• Performed in 75-90% of cases after casting phase 2, 3
• Percutaneous procedure under local anesthesia
• Followed by application of final cast for 3 weeks

Phase 3: Bracing Protocol

• Critical for maintaining correction and preventing relapse
• Foot abduction brace (Denis Browne bar with shoes set at 70° external rotation)
• Wear schedule:
  • Full-time (23 hours/day) for first 3 months
  • Nighttime and nap time (12-14 hours/day) until age 4 years
• Non-compliance with bracing is the most common cause of relapse 1

Special Considerations for Non-idiopathic Cases

• Non-idiopathic clubfoot (associated with syndromes) has higher recurrence rates (44% vs 8% in idiopathic cases) 4
• May require more casts (average 6-9) 2
• Still achieves initial correction in 91% of cases 4
• Consider longer bracing period (up to 4 years) 1

Management of Recurrence

1. Mild recurrence: Repeat casting sequence
2. Moderate recurrence: Repeat casting + possible repeat Achilles tenotomy
3. Severe recurrence or resistant cases:
   • Consider tibialis anterior tendon transfer (for dynamic supination)
   • Extensive surgical release may be necessary in approximately 37% of non-idiopathic cases 4

Accelerated Protocols

For severe cases in young infants (<3 months), an accelerated Ponseti protocol can be considered:

• More frequent cast changes (daily or every other day)
• Complete initial correction within 7-10 days
• Still requires standard 3-week post-tenotomy casting and bracing protocol 5

Monitoring and Follow-up

• Regular follow-up every 3-4 months during first 2 years
• Then every 6 months until age 4
• Annual check-ups until skeletal maturity
• Monitor for:
  • Recurrence of deformity
  • Brace compliance
  • Foot flexibility and function

Outcomes and Prognosis

• Idiopathic clubfoot: Excellent outcomes in 95-98% of cases with proper Ponseti treatment 3
• Non-idiopathic clubfoot: Good outcomes in 63% without extensive surgery 4
• Long-term studies show maintenance of correction and good functional outcomes when protocol is followed

The Ponseti method has revolutionized clubfoot treatment, dramatically reducing the need for extensive surgical releases and their associated complications. The key to success is early intervention, proper technique, and strict adherence to the bracing protocol.