Management of Congenital Talipes Equinovarus (CTEV) in Newborns
The Ponseti method should be initiated immediately upon diagnosis in newborns with CTEV, consisting of serial manipulation and casting performed weekly, followed by percutaneous Achilles tenotomy when needed and long-term bracing to prevent relapse.
Initial Assessment and Diagnosis
When evaluating a newborn with suspected CTEV, you must differentiate true structural CTEV from positional talipes, which occurs five times more commonly and requires no treatment 1.
Key examination findings that confirm structural CTEV include:
- Fixed cavus deformity of the midfoot 1
- Fixed forefoot adductus 1
- Fixed hindfoot varus 1
- Fixed ankle equinus 1
Additional mandatory examinations:
- Hip stability, leg length equivalence, and symmetry of hip abduction 1
- Spine examination for peripheral stigmata of spina bifida 1
- Assessment for syndromic features (present in 27.7% of CTEV cases) 1
Document the initial severity using the Pirani Severity Score, which typically ranges from 4.3-6 points in structural CTEV 2.
The Ponseti Method Protocol
Timing of Initiation
Treatment should begin as early as possible, ideally within the first few weeks of life 2, 3. Studies demonstrate that starting treatment before versus after one month of age shows no significant difference in outcomes, with both groups requiring similar numbers of casts (5.9 vs 5.7) and achieving 100% correction rates 4. However, urgent referral is warranted when diagnosed to avoid delays 1.
Serial Casting Technique
The standard Ponseti protocol involves:
- Weekly manipulations followed by above-knee plaster casts 1, 2
- Average of 5-7 casts required per foot (range 2-6 casts) 2, 3
- Each cast maintained for approximately one week 2
- Progressive correction of cavus first, then adductus, then varus, and finally equinus 1
The mean treatment duration to achieve good appearance is approximately 1.6-1.7 months 5.
Percutaneous Achilles Tenotomy
Tenotomy is required in 82-86% of cases 2, 5. This procedure should be:
- Performed percutaneously under general anesthesia in an operating room 2
- Done at a mean age of 106 days (range 45-213 days) after serial casting 2
- Followed by a final cast for 3 weeks 2
Post-Correction Bracing
The Denis Browne boots-and-bar splint is mandatory and represents the most critical phase for preventing relapse 1. The bracing protocol requires:
- Full-time wear (23 hours/day) for the first 3 months after cast removal 1
- Nighttime and naptime wear until age 4-5 years 1
- Strict compliance, as relapse is strongly correlated with non-compliance 1
Expected Outcomes
Success rates with proper Ponseti technique are excellent:
- 96-100% achieve good to excellent functional outcomes 2, 4, 3
- Mean post-treatment Pirani scores of 0.22-0.36 5, 3
- Relapse rates of 3.7-5.2% when compliance is maintained 2, 3
The primary cause of treatment failure is poor compliance with the bracing protocol 2. All relapses can typically be successfully treated with repeated Ponseti casting 4.
Alternative to Traditional Casting
A polyaxial fixation brace has been studied as an alternative to plaster casts during the manipulation phase 5. This approach showed:
- Similar correction rates and Pirani scores compared to traditional casting 5
- Significantly lower rates of percutaneous tenotomy needed (4.6% vs 12.8%) 5
- Fewer skin complications with scarring (0% vs 3.5%) 5
However, traditional plaster casting remains the gold standard with the most extensive evidence base 1, 2.
Common Pitfalls to Avoid
Critical errors that compromise outcomes:
- Mistaking structural CTEV for positional talipes and delaying referral 1
- Inadequate parent education about bracing compliance 1, 2
- Premature discontinuation of nighttime bracing before age 4-5 years 1
- Improper cast application causing skin sores (occurs in 5-15% of cases) 5, 3
When skin complications develop:
- Most sores heal without scarring with timely treatment 5
- Temporary cast removal and wound care prevent permanent scarring 5
When to Consider Surgical Release
Extensive surgical releases are now rarely indicated, representing a dramatic shift over the past 25 years away from surgical approaches 1. Surgery should only be considered after failed conservative management with documented poor compliance or in rare syndromic cases with severe rigidity 1.