Review Question - QID 906

Cavus should be addressed first when using the Ponseti method to treat clubfoot.

Idiopathic clubfoot is characterized by forefoot adductus, hindfoot varus, ankle and subtalar equinus, and supination of entire foot. The forefoot is pronated relative to hindfoot. Correction of clubfoot requires an organized and sequential methodology. The helpful acronym is CAVE which describes both the clinical position and the general order of deformity correction in the Ponseti method. Cavus is first corrected with forefoot supination via dorsiflexion of the first metatarsal. Some practitioners will add a small degree of abduction to the first cast as well. Metatarsus adductus and hindfoot varus are then simultaneously corrected by abducting the foot and applying counter pressure laterally at the talar head. Meanwhile, foot supination is slowly decreased during each successive casting. Equinus is corrected last and should only be attempted when the hindfoot is in neutral to slight valgus position. This can be done through progressive stretching and casting or by a percutaneous heel cord tenotomy as is done in a large majority of patients.

Noonan et al review the nonoperative management of clubfeet using several techniques. They note that the Ponseti method consists of manipulation and casting of idiopathic clubfeet while the French method consists of physiotherapy, taping, and continuous passive motion.

Illustration A shows a series of casts from the Ponseti method, revealing the progressive changes obtained with each cast.