Clubfoot (CTEV) — Ponseti Method & Posteromedial Release

First-line — the Ponseti method. Idiopathic congenital talipes equinovarus in the newborn, ideally started within the first 1-2 weeks of life when the connective tissues are most plastic. It applies to all idiopathic structural clubfeet regardless of severity, and is first-line (with modification and a lower success expectation) in syndromic and neuromuscular feet — arthrogryposis, myelomeningocele, diastrophic dysplasia. Late-presenting or neglected clubfoot can still be corrected by Ponseti in walking children up to several years of age, with longer casting and a greater likelihood of adjunctive surgery. When each step is added:

Cautions. Do not force manual dorsiflexion to correct equinus before the midfoot is corrected — it breaks through the midtarsal joint producing a rocker-bottom deformity. Do not perform a tibialis anterior transfer before the lateral cuneiform is ossified (no bony anchor). Treat skin breakdown or active infection before casting. A fully passively correctable positional foot with a normal calf and no rigid equinus or cavus needs only reassurance and stretching — it is not a true structural clubfoot. Consent. Counsel families that the great majority of idiopathic feet are corrected without major surgery, that about 90% need a minor percutaneous tenotomy, and that the foot abduction orthosis is the most important part of treatment — worn 23 hours a day for three months then at night to age four to five years. Relapse is driven far more by brace non-compliance than by initial severity. Setup. The Ponseti method is a clinic technique needing only plaster materials and, for the tenotomy, a fine blade, with a cooperative infant on a parent's lap or a firm surface. Posteromedial release is performed in theatre, supine, with a tourniquet and loupe magnification for the medial neurovascular dissection.

The goal: correct the deformity by gentle weekly manipulation and above-knee casting in the CAVE order, abducting the foot around the lateral talar head in supination, completing most feet with a percutaneous Achilles tenotomy, and reserving formal surgical release (tibialis anterior transfer, posteromedial release) for resistant, neglected, or syndromic feet. The medial exposure for posteromedial release is laid out as the final steps of the sequence below.

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Foot abduction orthosis (boots-and-bar). A Denis Browne-type bar connects two open-toe boots set in external rotation — the affected foot in 60-70 degrees of external rotation (abduction), the normal foot in about 30-40 degrees, the bar shoulder-width. The brace does NOT correct deformity; it maintains the Ponseti correction and prevents relapse. Wear schedule. Full-time 23 hours a day for the first three months after the corrective cast comes off, then night-time and nap-time wear (12-14 hours a day) continued to age 4-5 years. Brace non-compliance is the single leading cause of relapse — Chen and Dobbs reported an odds ratio of about 27 for recurrence with non-compliance, making compliance the strongest modifiable predictor of success. Compliance counselling. Explain at every visit that non-compliance causes relapse far more than initial severity; address fit, skin irritation and socioeconomic barriers; document hours and check fit as the child grows. Recurrence — recognition and management

Spectrum. Congenital talipes equinovarus is idiopathic in the great majority of cases; a smaller group are syndromic or neuromuscular (arthrogryposis, myelomeningocele, diastrophic dysplasia), which are rarer but more rigid and relapse-prone and often bilateral. Severity at presentation, captured by the Pirani and Dimeglio scores, predicts the treatment course. Deformity components (CAVE). Clubfoot is a three-dimensional deformity of the foot and ankle with four interrelated components.

Pathoanatomy. The talus is in fixed equinus with a medially and plantarly deviated neck; its head is uncovered laterally — the palpable fulcrum for correction. The navicular is displaced medially and plantarward, articulating against the medial malleolus rather than the centre of the talar head. The calcaneus is in varus, equinus and medially rotated beneath the talus (it does not simply invert — it rotates as a block with the navicular and cuboid). The cuboid is medially displaced on the calcaneus. Soft-tissue contractures involve the tibialis posterior, Achilles, FHL and FDL, the spring (calcaneonavicular) ligament, the deltoid, the plantar fascia, and the posterior ankle and subtalar capsules. Calf muscle hypoplasia and a smaller foot are intrinsic features that are not correctable. Severity scoring predicts the course. Both the Pirani and Dimeglio scores correlate with the number of casts required and the likelihood of needing a tenotomy or later surgery — a higher initial severity predicts a longer, more relapse-prone course. - Pirani score (0-6): six clinical signs each scored 0, 0.5 or 1 — hindfoot signs (posterior crease, empty heel, rigidity of equinus, 0-3) and midfoot signs (curvature of the lateral border, medial crease, position of the lateral talar head, 0-3). Tracked at each cast visit; a higher hindfoot score predicts the need for tenotomy.

• Dimeglio score (0-20): grades four reducibility parameters (equinus in the sagittal plane, varus in the frontal plane, derotation of the calcaneo-forefoot block around the talus, and forefoot adduction), each 0-4 by range of motion, plus one point each for medial crease, posterior crease, cavus and poor muscle condition. Four grades: I benign (soft-soft, 1-5), II moderate (soft greater than stiff, 5-10), III severe (stiff greater than soft, 10-15), IV very severe (stiff-stiff, 15-20).

Evidence base. The Ponseti method achieves initial correction in about 90-98% of idiopathic feet. The Iowa cohort (Laaveg and Ponseti, 70 patients and 104 feet at 10-27 years) showed durable, functional, supple, largely pain-free feet — the foundation of the method — and was the original basis for tibialis anterior transfer. By contrast, comprehensive posteromedial release produces stiffer, weaker, more painful feet over time with arthritic change: Dobbs et al. (45 patients, 73 feet at a mean 30 years) documented that functional impairment correlated with the extent of soft-tissue release. Non-compliance with the foot abduction orthosis is the dominant predictor of recurrence — Chen and Dobbs reported an odds ratio of about 27 for recurrence with non-compliance.