Ponseti method for treatment of club foot

The preferred treatment for clubfoot is the Ponseti method which is a detailed method of manipulation and casting without major surgical releases:

• method has become the standard of care and completely eliminates the need for extensive operative correction in over 98% of patients if applied correctly
• treatment involves manipulation, a series of castings, percutaneous achilles tenotomy and foot bracing
• with correct application of the procedure and appropriate patient adherence, complete correction can be achieved in as little as 16 days with an accelerated casting protocol (1)
  
  
• treatment should commence as soon as possible after birth
  • a precise sequence of manipulations of the clubfoot that lead to correction of the deformity
  • Ponseti emphasised that the cavus should be corrected by raising the first metatarsal, which initially makes the deformity look 'worse'
    • correction should occur around the head of the talus without the heel being touched
      
      
  • at weekly intervals the foot is manipulated into the maximum position of correction and then held in a plaster of Paris cast
    • whilst the foot is in the cast the immature collagen undergoes stress relaxation (stretches); this then allows greater correction at the next manipulation
      
      
    • after about six weeks of weekly cast changes the deformity of the midfoot and forefoot is generally corrected
      • often the foot is still in the equinus position at this stage (pointing down at the ankle), and in most cases this will not correct further with manipulation
        • thus about 90% of children have an Achilles tenotomy undertaken at this stage (2)
        • child then goes into a final cast for three weeks
          • after removal of this final cast the foot position is reviewed
            • if correction is complete the child then goes into 'boots and bar'
              • an orthotic device that holds the feet in an abducted, externally rotated, and dorsiflexed position about a shoulder width apart
                • child wears this device all the time for three months and then at night time and during naps until 4 years of age
                • importantly, adherence to the bracing protocol is critical for the long-term success of the treatment as demonstrated by the high relapse rate in non-adherent parents (10 times greater)
                  • adherence to bracing is a better predictor for relapse than severity of the deformity at birth, which is not a reliable indicator of the odds of relapse (1)
                    
                    
  • if treatment is successful the child will be left with a supple well corrected foot
    • will look similar to the unaffected foot but may be slightly smaller (around one shoe size)
    • calf may also be smaller than on the unaffected side

Reference:

• Desai L et al. Bracing in the treatment of children with clubfoot: past, present, and future. Iowa Orthop J. 2010;30:15-25
• Royal Berkshire NHS Foundation Trust. Foot: Clubfoot - Ponseti treatment (Accessed 11/2/14).