Treatment Plan for Congenital Talipes Equinovarus (CTEV) According to Age
The Ponseti method should be initiated as early as possible after birth, ideally within the first 2 weeks of life, and remains highly effective even when started after 1 month of age, with treatment protocols remaining consistent regardless of age at presentation. 1, 2
Age-Based Treatment Initiation
Newborn to 1 Month of Age
- Begin Ponseti method immediately upon diagnosis, with optimal initiation within the first 14 days of life 1
- Treatment started before 1 month requires an average of 5.9 casts to achieve correction 2
- Mean age at treatment initiation in successful series is 14 days (range 3-81 days) 1
- Early initiation does not significantly reduce the number of casts needed compared to later start, but establishes correction sooner 2
After 1 Month of Age
- The Ponseti method remains equally effective when started after 1 month, with no statistically significant difference in outcomes 2
- Treatment initiated after 1 month requires an average of 5.7 casts 2
- Mean age at presentation in many series is 4.9 months, with successful outcomes still achieved 3
- Late presenters (up to 81 days) can still achieve excellent correction with the same protocol 1
Standard Ponseti Protocol (All Ages)
Serial Casting Phase
- Apply weekly manipulations and long-leg casts, typically requiring 6-7 casts total 1, 3
- Mean duration of casting phase is 2.7 months 3
- Each cast addresses specific deformity components sequentially: cavus first, then adduction, then varus, and finally equinus 4
Achilles Tenotomy
- Perform percutaneous Achilles tenotomy in approximately 83% of cases 1
- Execute tenotomy under general anesthesia in operating room setting 1
- Mean age at tenotomy is 106 days (range 45-213 days) when treatment started early 1
- Tenotomy timing depends on completion of casting phase, not chronological age 1
Bracing Phase (Critical for All Ages)
- Apply Denis Browne boots and bar splint immediately after final cast removal 4
- Wear splint 23 hours daily for first 3 months post-casting 4
- Continue nighttime and naptime wear until age 4-5 years 4
- Non-compliance with bracing is the primary cause of relapse, regardless of age at treatment initiation 1, 4
Expected Outcomes by Age Group
Treatment Started Before 1 Month
- Full correction achieved in 100% of cases 2
- Initial success rate of 91.1% 3
- Relapse rate of approximately 2.5% with good brace compliance 2
- Good to excellent functional scores in 96.3% at mean 4-year follow-up 1
Treatment Started After 1 Month
- Full correction achieved in 100% of cases 2
- Initial success rate remains 91.1% 3
- Relapse rate of approximately 7.5%, but not statistically different from early treatment 2
- All relapses successfully treated with repeat Ponseti casting 3, 2
Management of Treatment Failures
Resistant Clubfoot (8.8% of cases)
- Diagnosed when adequate correction not achieved after 6-7 casts 3
- Requires soft tissue surgical release 3
- Age at presentation does not predict resistance 3
Relapsed Clubfoot
- Occurs in 8.8% of cases, primarily due to brace non-compliance 1, 3
- Treat with repeat Ponseti method casting rather than immediate surgery 3, 2
- Success rate with repeat casting approaches 100% 3, 2
Critical Pitfalls to Avoid
- Do not delay referral if CTEV mistaken for positional talipes at initial examination - urgent referral warranted even if discovered at 6-week check 4
- Do not underestimate importance of bracing compliance - relapse strongly correlated with non-compliance regardless of age at treatment start 1, 4
- Do not proceed directly to extensive surgical releases - the Ponseti method has replaced surgery as first-line treatment across all age groups 4, 5
- Do not assume older infants require different treatment protocols - the same Ponseti technique applies effectively up to several months of age 3, 2