Review Question - QID 218544

This patient is presenting with congenital talipes equinovarus (idiopathic clubfoot deformity), which is most commonly treated utilizing the Ponseti serial casting followed by Achilles tenotomy and casting for residual equinus.

Ponseti serial casting remains the gold standard treatment for idiopathic clubfoot deformity within the United States. At the conclusion of 4-6 weeks of serial casting, over 90% of patients will continue to display a rigid equinus deformity requiring Achilles tenotomy. This procedure can be performed in-office under local anesthetic or in the operating room with sedation for larger children who cannot safely tolerate the procedure.

Dobbs and Gurnett provided an updated, comprehensive review on the etiology and treatment of idiopathic clubfoot deformity. They discuss the advancement in treatments primarily taking form in recurrence prevention and management. Most patients are treated in a chronologic stepwise manner of Ponseti casting, Achilles tenotomy, and foot ankle orthosis (FAO) wear until the age of 4. Due to incomplete deformity correction or patient compliance with FAO usage, many patients will require some additional treatment such as repeat casting or tibialis anterior transfer. Collectively, the vast majority of patients have successful long-term outcomes without negative sequelae.

Hosseinzadeh and colleagues provided a comprehensive review regarding the management of relapsed clubfoot after being treated with the Ponsetti method. They discuss the high rates of recurrence (between 26-48%) and stress the importance of early recognition and treatment. When detected early, a short series of cast manipulations followed by post-corrective bracing may suffice. However, in older patients, anterior tibial tendon transfers and/or more aggressive osteotomies may be required.

The Pediatric Orthopaedic Society of North America (POSNA) provides physician educational resources in the diagnosis, etiology, and treatment of various pediatric musculoskeletal conditions. The clubfoot deformity overview and treatment guide can be found at: https://posna.org/Physician-Education/Study-Guide/Clubfoot

Figure A shows a newborn infant with congenital talipes equinovarus (clubfoot deformity). Illustration A outlines the general approach to Ponseti casting prior to AFO application.

Answers 1 and 2: When performing serial casting for clubfoot correction using the Ponsetti method, a circumferential plaster cast is typically fabricated. Overall, plaster casts are anecdotally easier to mold and are the standard material used, however, there have been successfully reported use of fiberglass casts as well. However, there is a high failure rate of equinus correction without an Achilles tenotomy.
Answer 3: The application of a foot abduction orthosis (FAO) is highly successful at preventing clubfoot deformity recurrence. It is typically utilized for 23 hours per day for 3 months after the final correction, then worn during naps/nighttime until the age of 4 years. However, an FAO is only applied AFTER final corrections have been obtained.
Answer 5: Even after successful treatment of clubfoot deformity, some residual deformity may remain. Incomplete reduction of the navicular onto the talar head changes the anterior tibialis muscle from predominately a strong dorsiflexing to a strong supinating force. This results in dynamic supination of the foot when the child begins walking/running in which the child’s foot will supinate during the swing phase of gait. If left untreated, this can result in long-term recurrence of hindfoot varus deformity requiring osteotomies to correct. A tibialis tendon transfer to the lateral cuneiform is currently accepted treatment for these patients around age 2-4.