Clubfoot Correction: Mastering the Ponseti Method

Visual Element: An interactive 3D foot model. The user can drag a slider to visualize the sequential correction: Cavus -> Adductus -> Varus -> Equinus.

Congenital Talipes Equinovarus (CTEV), or clubfoot, is one of the most common congenital deformities (1 in 1000 births). Historically, these feet were treated with aggressive "Posteromedial Release" surgery, which resulted in stiff, painful, arthritic feet in adulthood.

The Ponseti Method, developed by Dr. Ignacio Ponseti, revolutionized this. It is a biological, minimally invasive method that relies on the inherent viscoelasticity of the newborn foot. It yields a flexible, plantigrade, pain-free foot in 95% of cases.

However, the method is precise. "Almost Ponseti" is not Ponseti. Deviating from the biomechanical principles leads to the "Complicated Clubfoot" (rocker-bottom deformity).

The Deformity: CAVE

Remember the acronym CAVE for the components of the deformity:

1. Cavus (Midfoot High Arch)
2. Adductus (Forefoot curved in)
3. Varus (Hindfoot turned in)
4. Equinus (Ankle pointed down)

Part 1: The Casting Sequence

The correction must happen in a specific order. You cannot correct everything at once.

Step 1: Correct the Cavus (The First Cast)

• The Pathology: The cavus is caused by the pronation of the forefoot relative to the hindfoot. The first ray is plantarflexed.
• The Maneuver: Supinate the forefoot. Align the forefoot with the hindfoot. This sounds counter-intuitive (as the foot looks supinated already), but "supinating" the forefoot actually elevates the first ray and corrects the cavus.
• Result: The foot looks "worse" (more varus), but the arch is flat.

Step 2: Correct Adductus and Varus (Casts 2-4)

• The Fulcrum: The head of the Talus. This is the key. You must palpate the lateral head of the talus (anterior to the lateral malleolus) and place your thumb there.
• The Maneuver: Abduct the supinated foot around the talar head. The Calcaneus will naturally drift from Varus into Valgus as you abduct (because they are coupled - the "acetabulum pedis").
• The Error (Kite's Error): DO NOT touch the Calcaneocuboid joint. If you block the CC joint, you block the calcaneus from rotating, and you create a midfoot breach (Rocker Bottom Foot).

Step 3: Correct Equinus (Tenotomy)

• Once the foot is abducted to 60-70 degrees and the heel is in valgus, you assess dorsiflexion.
• In 90% of cases, the Achilles is tight. Do not force dorsiflexion (you will break the midfoot).
• Tenotomy: A percutaneous cut of the Achilles tendon. Done under local anaesthetic.
• The Final Cast: Applied in max abduction and dorsiflexion for 3 weeks. The tendon heals in the lengthened position.

Part 2: Maintenance (The Brace)

The casting is the easy part. The bracing is the hard part. The Foot Abduction Brace (FAB) (Boots and Bar) holds the feet in 70 degrees of abduction (external rotation).

Protocol:

• Phase 1: 23 hours/day for 3 months.
• Phase 2: Night and Naps (12-14 hours) until age 4-5.

Compliance: The #1 cause of recurrence is non-compliance with the brace. You must sell this to the parents. "The cast gets the correction; the brace keeps it."

Part 3: Troubleshooting

The Complex/Atypical Clubfoot

Some feet are short, fat, and have a deep transverse crease across the sole.

• Ponseti Modification: Do not abduct to 60 degrees (only 40). Treat the hyperflexion of toes. These are harder to treat and more prone to slipping casts.

Recurrence

If the deformity returns (usually dynamic supination in walking):

• Tibialis Anterior Tendon Transfer (TATT): Transfer the whole TA tendon to the Lateral Cuneiform. This turns the TA from a supinator into a dorsiflexor/pronator.
• Timing: After age 3-4 (when lateral cuneiform ossifies).

Practical Casting Tips

1. Toe to Knee: Apply padding. Minimal padding tight mold.
2. Molding: Mold the arch. Mold around the malleoli.
3. Knee Flexion: 90 degrees. This prevents the cast from slipping off and relaxes the gastrocnemius.
4. Toe Platform: Leave the toes free (dorsal trim) to allow extension, but support the plantar surface.

Conclusion

The Ponseti method is elegant and effective. It requires patience and strict adherence to the biomechanics. Trust the talus.

Ponseti Manual PDF

Download the official 'Global HELP' Ponseti manual.