Ponseti method for treatment of club foot
Last reviewed 01/2018
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
- 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)
- 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)
- an orthotic device that holds the feet in an
abducted, externally rotated, and dorsiflexed position
about a shoulder width apart
- if correction is complete the child then goes into
'boots and bar'
- after removal of this final cast the foot position is
reviewed
- 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
- whilst the foot is in the cast the immature collagen undergoes stress
relaxation (stretches); this then allows greater correction at the next
manipulation
- 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).