Club Foot Management
The Ponseti method is the recommended standard of care for clubfoot treatment, consisting of specific manipulation techniques, serial casting, percutaneous Achilles tenotomy when needed, and bracing with a foot abduction orthosis to prevent relapse. 1
Understanding Clubfoot
Clubfoot (congenital talipes equinovarus) is a complex pediatric foot deformity with four components:
- Forefoot adductus
- Midfoot cavus
- Hindfoot varus
- Ankle equinus
The Ponseti Method Protocol
The Ponseti method involves a sequential approach:
Initial Assessment and Manipulation
- Identify the head of the talus by palpation
- Supinate the forefoot to eliminate cavus deformity
- Abduct the forefoot using the lateral head of the talus as fulcrum
- Maintain reduction of cavus deformity during manipulation
Serial Casting
- Apply above-the-knee cast with foot in corrected position
- Replace casts every 5-7 days
- Continue until foot is abducted approximately 50° from the frontal plane of the tibia
- Most cases require 4-7 casting sessions for complete correction 1
Achilles Tenotomy
- Required in 60% to >90% of patients to correct residual ankle equinus
- Performed as an outpatient procedure under local anesthetic
- Can be done without sedation
- Not needed if foot can be dorsiflexed to >15° without midfoot breach 1
Final Casting
- Applied after tenotomy
- Worn for three weeks 1
Bracing Protocol
- Foot abduction orthosis for 23 hours daily for first 3 months
- Then night and nap time bracing until age 4-5 years 1
Timing of Treatment
- Treatment should begin as early as medically possible
- Even premature babies in NICU can successfully undergo Ponseti treatment
- First cast can be applied within the first week of life in most cases 2
- Early initiation of treatment has shown successful outcomes with minimal complications 2
Provider Considerations
Recent evidence shows that both orthopedic surgeons and properly trained physical therapists can effectively perform the Ponseti method with equivalent outcomes and no significant difference in complications 3. This provides flexibility in treatment delivery options.
Special Populations
Premature Infants and NICU Patients
- Treatment can begin in the NICU setting
- Only 4% of casts require removal due to complications like leg edema or need for venous access 2
- For syndromic clubfoot, treatment follows the same principles but may require more attention to underlying conditions 4
Non-idiopathic Clubfoot
- The Ponseti method is also effective for teratologic, residual, and neurogenic clubfoot
- Good functional outcomes with reduced need for extensive surgical procedures 4
Long-term Outcomes
Long-term follow-up (25-42 years) has demonstrated that clubfeet treated with the Ponseti method function as well as normal feet with respect to pain and level of activity 1.
Surgical Considerations
While the Ponseti method has dramatically reduced the need for extensive surgical intervention, surgery may be considered in cases of:
- Recurrent deformity despite proper bracing
- Resistant cases not responding to casting
- Older children with neglected clubfoot
Potential Pitfalls and Complications
- Inadequate correction of cavus deformity
- Improper manipulation technique
- Poor cast application
- Non-compliance with bracing protocol (most common cause of relapse)
- Premature discontinuation of bracing
The Ponseti method has revolutionized clubfoot treatment by providing excellent outcomes while avoiding extensive surgical procedures and their associated complications such as soft tissue contractures, neurovascular complications, infections, and limb shortening 5.