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Ponseti treatment diagram

The Ponseti method is named for Ignacio Ponseti, M.D., who perfected the three-phase method over many years. Courtesy of Shafique Pirani, M.B.B.S.

Clubfoot treatment with Ponseti method relies on teamwork, family support

January 31, 2022

The Ponseti method is now considered the gold standard of care for the treatment of idiopathic congenital clubfoot, the most common serious musculoskeletal birth defect in the world.

In the U.S., about one in 1,000 infants is born with an idiopathic clubfoot (or clubfeet, as approximately 40% are bilateral). A true idiopathic clubfoot is quite stiff. It should not be confused with foot and lower leg deformities resulting from intrauterine crowding, which are flexible, often self-correcting and much more common.

Prior to the general acceptance of the Ponseti technique, orthopedic surgeons had been frustrated by the long-term outcomes of clubfoot treatment. Previous surgical and nonsurgical treatments and combinations of the two often looked promising in the short term, only to be followed by recurrent deformity with pain and stiffness as the child reached skeletal maturity.

A new AAP clinical report can guide medical practitioners in caring for these children. The report, Diagnosis and Treatment of Idiopathic Congenital Clubfoot, from the Section on Orthopaedics, is available at and will be published in the February issue of Pediatrics.

Treatment regimen

The Ponseti method is named for lgnacio Ponseti, M.D. (1914-2009), who was born in Spain, immigrated to the U.S. and became a professor of orthopedic surgery at the University of Iowa. There, he perfected his three-phase method over many years.

Phase 1 is a specific casting technique that should be started soon after the baby leaves the newborn nursery around 1-3 weeks of age. The casts are changed weekly until all elements of the deformity are corrected except for a tight Achilles tendon.

Phase 2, required in 90% of cases, is an Achilles tenotomy done under local anesthesia followed by a final cast for three weeks.

Phase 3 is a prolonged period of bracing full time for three months following casting and then night time only until the child is 4 to 5 years old. The brace is a bar with shoes or splints attached at shoulder width. The shoe or splint is turned out 60-70 degrees on the clubfoot side and 30-40 degrees on the normal side.

Phases 1 and 2 should be performed by a physician experienced with the technique, often a pediatric orthopedic surgeon. If no local physician is experienced with the Ponseti technique, the family should travel for care.

Phase 3 is most important because without prolonged night-time bracing until age 4 to 5, the clubfoot deformity will recur.

Compliance, teamwork, communication

It is not easy for a family to keep a child in a brace every night for four years, especially when the foot looks and functions normally. Fortunately, significant improvements in brace design have made them much easier for parents to apply and for children to tolerate. The old stiff shoes that were rigidly fixed to the bar have been replaced by detachable shoes or splints with soft linings.

The child's pediatrician and pediatric orthopedic surgeon need to work as a team in helping families comply with the bracing phase.

Barriers to compliance should be explored and corrected. However, even with perfect compliance, the clubfoot deformity may recur. When this happens, casting is repeated and bracing resumed.

In a small percentage of cases, the deformity recurs again despite repeated casting and bracing. When this happens, the pediatric orthopedic surgeon may recommend an anterior tibial tendon transfer, which is part of the Ponseti technique. It is different from the joint release surgeries done in the past. It should be extremely rare for a child treated with the Ponseti method to require joint release surgery.

Clubfoot deformity may be discovered during prenatal ultrasonography usually at 20 weeks’ gestation. Although no prenatal treatment is available, appropriate prenatal counseling is important. Pediatric orthopedic surgeons often are willing to meet with parents in the prenatal period to review the ultrasound findings and discuss treatment options.

It is important for parents to know that idiopathic clubfoot is an isolated finding, and children who undergo Ponseti treatment and are successful with bracing can be expected to wear normal shoes, participate in sports and have every opportunity for a happy and productive life.

Eighty percent of babies born with clubfoot live in countries with limited resources where adults with untreated clubfoot face a life of poverty and isolation. The Ponseti method requires minimal resources and can be performed by physician extenders taught the method by Ponseti experts. Ponseti programs have been started in many countries with limited resources with the goal of eliminating from the world the disability caused by untreated clubfoot.

Drs. Cady, Hennessey and Schwend are lead authors of the report. Dr. Cady is a former member and Dr. Schwend is a former chair of the AAP Section on Orthopaedics Executive Committee.


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