Clubfoot Management in Newborns
The Ponseti method of serial casting is the recommended initial treatment for clubfoot in newborns, beginning as early as the first week of life when medically feasible. 1, 2
The Ponseti Method: Core Principles
The Ponseti technique corrects clubfoot deformity through sequential manipulation and casting, following these specific steps 1:
- Simultaneous correction of all deformity components except equinus, which is addressed last after other components are corrected 1
- External foot rotation around the talar head to maintain correction 1
- Supination of the first ray to correct the cavus deformity 1
- Weekly cast changes for 4-5 weeks, with each cast holding the progressive correction 1
Timing of Treatment Initiation
Begin casting within the first week of life whenever possible 2. Studies demonstrate that:
- Treatment is feasible and effective when started in the first week, even in premature infants requiring neonatal intensive care 2
- Casting can be successfully performed in sick neonates with respiratory support, including those on ventilators 2
- Fourteen of 16 surviving infants in one NICU study had their first cast applied within the first week of life 2
However, there is conflicting evidence regarding optimal timing:
- One study suggests waiting until after 30 days of age or until foot length reaches ≥8 cm may yield better Diméglio scores 3
- Despite this, the overwhelming consensus supports early treatment initiation, as older infants (even up to 6 months) can still be successfully treated without extensive surgery 4
In practice, begin treatment as soon as the infant is medically stable, prioritizing early intervention while ensuring the baby can tolerate casting 2.
Treatment Protocol
Serial Casting Phase
- Apply long-leg casts weekly for approximately 4-6 weeks 1, 4
- Each cast progressively corrects the deformity through gentle manipulation 1
- Monitor for complications requiring cast removal: leg edema or need for venous access (occurred in only 4% of casts in NICU patients) 2
- Casts should be routinely replaced every 4-7 days 2
Achilles Tenotomy
- Percutaneous Achilles tenotomy is required in approximately 97% of cases to correct residual equinus 4
- Perform under local or general anesthesia after 4-5 weeks of casting 1
- Can be safely performed in the NICU setting for premature or sick infants 2
Bracing Phase
- After tenotomy, apply a cast for 3 weeks to allow healing 1
- Dennis Brown brace (foot abduction orthosis) must be worn continuously (23 hours/day initially, then nights and naps) until age 4-5 years 1
- Bracing compliance is critical: failure to maintain bracing is the primary cause of relapse 5
Expected Outcomes and Complications
Success Rates
- Only 2.8-2.9% of feet require extensive posteromedial release surgery when Ponseti method is properly applied 4
- Plantigrade, functional feet are achieved in the vast majority of cases 5
Relapse Management
Relapses occur in approximately 47% of patients on long-term follow-up 5:
- Most relapses are managed with repeat casting 4
- Anterior tibialis tendon transfer may be needed for dynamic supination deformity 4
- Only 14% of patients requiring additional surgery need intra-articular procedures 5
Common Pitfalls to Avoid
- Do not delay treatment waiting for "optimal" timing—begin as soon as medically feasible 2
- Do not proceed directly to surgical release—even older infants and those with failed previous casting can be successfully treated with Ponseti method 4
- Ensure proper bracing compliance—this is the most critical factor in preventing relapse 5
- In sick neonates, casting is still feasible—only 4% of casts required early removal for medical reasons 2
Special Populations
Premature and Sick Neonates
- Treatment can begin safely in the NICU, even with gestational age as low as 27 weeks 2
- Casting is compatible with respiratory support, including mechanical ventilation 2
- Remove casts only for true medical necessity: significant edema or urgent need for venous access 2