What are the guidelines for managing Congenital Talipes Equinovarus (CTEV) in newborns?

Guidelines for Management of Congenital Talipes Equinovarus (CTEV) in Newborns

The Ponseti method is the gold standard for treating congenital talipes equinovarus (clubfoot) in newborns, with success rates exceeding 95% when properly implemented. This non-surgical approach should be initiated as early as possible after birth to achieve optimal outcomes.

Initial Assessment and Classification

• Use the Pirani Severity Score to classify CTEV deformity (scale 0-6):
  • Midfoot score (0-3): Curved lateral border, medial crease, lateral head of talus
  • Hindfoot score (0-3): Posterior crease, rigid equinus, empty heel
  • Higher scores indicate more severe deformity

Treatment Protocol

Phase 1: Manipulation and Serial Casting

1. Begin treatment within the first few weeks of life (ideally before 3 weeks of age)

2. Manipulation technique:

   • Identify the head of talus as the fulcrum point
   • Gradually correct cavus first by supinating forefoot
   • Then correct adduction and varus while maintaining supination
   • Finally address equinus

3. Casting protocol:

   • Apply well-molded above-knee plaster casts
   • Change casts every 5-7 days
   • Average of 5-7 casts required (range: 3-12 casts) 1, 2
   • Ensure proper molding around malleoli and head of talus

Phase 2: Achilles Tenotomy

• Indicated when midfoot correction is achieved but ankle dorsiflexion remains <15°
• Performed in 80-90% of cases 1, 2
• Procedure:
  • Percutaneous technique under local or general anesthesia
  • Apply final cast post-tenotomy for 3 weeks in 60-70° external rotation

Phase 3: Bracing Protocol

• Foot abduction brace (FAB) is critical to prevent relapse:
  • Initial phase: Full-time wear (23 hours/day) for first 3 months
  • Maintenance phase: Nighttime and nap time wear (12-14 hours/day) until age 4-5 years
  • Affected foot in 60-70° external rotation, unaffected foot in 30-40° external rotation
  • Both feet in 10-15° dorsiflexion

Follow-up Schedule

• Weekly during casting phase
• Every 2 weeks for first month after tenotomy
• Monthly for 3 months after initiating bracing
• Every 3 months until age 3
• Every 6 months until age 5

Complications and Management

Relapse

• Occurs in approximately 4-27% of cases 1, 3

• Primary cause: Non-compliance with bracing protocol 3

• Signs of early relapse:

  • Reappearance of adduction, varus, or equinus deformity
  • Limited dorsiflexion

• Management of relapse:

  • Mild relapse: Repeat manipulation and casting
  • Persistent relapse: May require limited surgical intervention

Skin Complications

• Pressure sores occur in approximately 5-7% of cases 1, 4
• Prevention:
  • Proper cast application technique
  • Adequate padding over bony prominences
  • Close monitoring during early casting phase

Alternative Approaches

• Polyaxial fixation brace may be considered as an alternative to plaster casting in newborns:
  • Similar efficacy to plaster casting (Pirani scores at 3 years: 0.23 vs 0.22)
  • Potentially fewer skin complications (7% vs 21%) 4
  • Allows for easier hygiene and skin monitoring

Key Success Factors

1. Early initiation of treatment (ideally within first month of life)
2. Proper manipulation technique following Ponseti principles
3. Well-molded casts with appropriate positioning
4. Strict adherence to bracing protocol - most critical factor for preventing relapse 3
5. Regular follow-up until skeletal maturity

Special Considerations

• For late-presenting cases (>3 months), the Ponseti method remains effective but may require more casts and has higher relapse rates 5
• Bilateral cases typically require similar treatment approach as unilateral cases
• Tenotomy is required in the majority of cases (80-95%) to achieve full correction 1, 2

The Ponseti method has revolutionized CTEV treatment, dramatically reducing the need for extensive surgical procedures while achieving excellent functional and cosmetic outcomes when properly implemented.