What is the initial treatment for clubfoot?

Initial Treatment for Clubfoot

The Ponseti method of serial casting is the initial treatment of choice for clubfoot, ideally started within the first week of life, and has proven highly effective even in older infants, complex cases, and premature babies in the NICU. 1, 2, 3

The Ponseti Method: Core Principles

The Ponseti technique corrects clubfoot through a specific sequence of manipulations and casting 2:

• All deformity components are corrected simultaneously except equinus, which is addressed last 2
• Correction is achieved by external foot rotation around the head of the talus 2
• Cavus (excavatus) is corrected by supinating the first ray of the foot 2
• Serial casts are applied weekly, typically requiring 4-7 casts before tenotomy 1, 2, 3
• Percutaneous Achilles tenotomy is performed after 4-5 weeks of casting in approximately 90% of cases to correct residual equinus 2, 3
• Post-tenotomy immobilization continues for 3 weeks, followed by Dennis Brown bracing until age 4-5 years 2

Timing of Treatment Initiation

Treatment should begin as early as medically possible, with compelling evidence supporting very early intervention 1:

• First cast can be applied within the first week of life in most cases, including premature infants 1
• Treatment is feasible even in sick neonates requiring intensive care, including those on respiratory support 1
• Older infants (>3 months) can still be treated successfully with the Ponseti method, achieving similar outcomes to newborns 3
• In one study of older infants, only 2.8% required open surgical release, comparable to the 2.9% rate in newborns 3

Special Populations

The Ponseti method is effective across diverse patient populations 1, 4:

• Premature babies in the NICU: Treatment achieved successful correction in all surviving infants, with casts applied as early as the first week despite gestational ages as low as 27 weeks 1
• Arthrogryposis-associated clubfoot: Initial correction obtained in 94% of cases (31/32 feet), though more casts are typically required (average 7 vs. 5-6 for idiopathic) 4
• Syndromic clubfoot: Treatment is feasible and effective, though these patients may have higher medical complexity 1

Practical Implementation

Cast application follows a specific protocol 1, 2:

• Casts are routinely replaced every 4-7 days 1
• Average of 6 casts required before tenotomy in most series 3
• Casts may need removal (4% rate) for leg edema or venous access needs in medically complex infants 1
• Percutaneous Achilles tenotomy is performed under local or general anesthesia after adequate forefoot correction is achieved 2

Expected Outcomes and Relapse Management

Initial correction rates are excellent, but relapse is common 5:

• Relapse rates range from 26% to 48% even with proper initial treatment 5
• Early relapse detection allows treatment with repeat casting and bracing resumption 5
• For children >2.5 years with relapse, anterior tibial tendon transfer to the third cuneiform is the preferred option after preoperative casting 5
• More extensive surgical procedures (cuboid-cuneiform osteotomy, posterior releases) are reserved for select refractory cases 5

Critical Success Factors

Bracing compliance is essential for maintaining correction 2, 5:

• Dennis Brown brace must be worn continuously (23 hours/day initially, then nights/naps) until age 4-5 years 2
• Poor brace compliance is the primary cause of relapse 5
• Early relapse responds well to repeat casting if detected promptly 5

Avoiding Extensive Surgery

The Ponseti method dramatically reduces the need for posteromedial release surgery 3, 4:

• Only 2.8% of older infants required open surgical release versus the 18 patients (78%) who were originally advised to undergo posteromedial release 3
• Even in arthrogryposis, only 1 of 32 feet required posteromedial release for insufficient initial correction 4
• No talectomies were required in the arthrogryposis series 4