Ponseti Treatment for Clubfoot in Infants (non-op and operative)

Ponseti treatment is a nonsurgical method employed in the treatment of clubfoot in newborn infants.  Clubfoot is a congenital foot deformity that can affect one or both feet. The condition is commonly characterized by inward turning of the foot with the bottom of the foot facing sideways or even upward. Male infants are twice as likely to develop this deformity than female infants.

The Ponseti method of treatment involves gentle stretching, manipulation, and casting of the affected foot to gradually correct the foot deformity. However, a small number of infants may still continue to have structural abnormalities in the foot despite Ponseti treatment. In such circumstances, your pediatric orthopedic surgeon may recommend undergoing operative procedures such as Achilles tendon lengthening or tendon transfer surgery to completely correct the foot deformity.

Indications

Typical indications of clubfoot deformities that warrant Ponseti treatment in infants include:

• Foot turned inward and downward
• Front of the foot twisted toward the other foot
• Affected foot slightly smaller than normal
• Abnormal walking pattern in which the ankle or side of the foot meets the ground instead of the sole of the foot
• The leg and foot may be smaller and the calves less developed than normal

Treatment

Non-operative

Non-operative treatment with the Ponseti method will involve the following elements:

Manipulation and casting: In this phase, your infant’s foot is carefully stretched, manipulated, and re-positioned to bring it into a correct position. The corrected position is then held with a long leg cast that covers from the thigh to the toes. Every week this process of stretching, manipulating, repositioning, and casting is repeated till the affected foot is largely corrected. It may take 5 plaster casts and 6 to 8 weeks for this to be accomplished.

Achilles tenotomy: Before applying the final cast, around 90 percent of infants may need a small, quick procedure called a tenotomy to release stiffness in the heel cord or Achilles tendon. During a tenotomy, your surgeon will use a very slender instrument to cut the tendon to relieve the stiffness. The cut is too small to require any stitches. The final cast is then applied to the limb to safeguard the tendon while it heals, which typically takes about three weeks. By the time the final cast is removed, the heel cord will have regrown to its full length and the clubfoot fully corrected.

Bracing: Bracing is employed to maintain the successful correction and prevent any relapses of the clubfoot deformity. To ensure that the foot remains permanently in the correct position, your child is placed in a brace called a "boots and bar" brace for a few years. The brace maintains the correction by holding the foot at the right angle throughout this period. For the first three months, your child will need to wear the brace for 23 hours a day, with 1 hour set aside for foot stretching and bathing. After 3 months, your child will have to wear the brace just overnight and at nap time for about 12 hours a day for the next 3 to 4 years.

Operative Procedures

Sometimes, the clubfoot may not be fully corrected or may relapse. In such instances, your orthopedist may recommend one of the following surgeries:

Achilles tendon lengthening: If an infant’s clubfoot has not been responsive to treatment because the Achilles tendon has not stretched or grown back as anticipated following the Achilles tenotomy, your surgeon may advise a surgery called Achilles tendon lengthening. This surgery enables your infant’s foot to stretch and grow into proper position. The surgery involves the following steps:

• General anesthesia is administered to your infant.
• Your surgeon makes small surgical cuts behind your infant’s foot to access the Achilles tendon.
• Your surgeon then gently stretches and cuts the tendon, lengthens it, and moves it into proper position.
• The surgical cuts are then closed with dissolvable sutures.
• Immediately after surgery, a long-leg cast is applied to be worn for a minimum of 4 weeks to facilitate tendon healing.

After 4 weeks, the long-leg cast is removed, and a new walking cast is applied that your infant will need to wear for 2 weeks. In some cases, your doctor may recommend a leg brace for your infant to be worn for many weeks after removing the walking cast.

Tendon transfer surgery: Some children treated with the Ponseti method as infants may have a slight recurrence or relapse of clubfoot when they are 3 to 5 years old. During this relapse, you may notice a slight in-turning of your child’s foot. This is attributed to an overactive tendon, not the Achilles tendon, which has not stretched adequately to enable full repositioning of the foot. To correct this abnormality, your pediatric surgeon may recommend surgery to transfer a tendon from one side of the foot to the other to enable the foot to have better flexibility and complete range of motion. In general, the surgery involves:

• General anesthesia is administered to your child.

• Your surgeon makes an incision to access the anterior tibialis tendon found along the inner arch of the foot and cuts it.
• The cut tendon is then transferred to the other side of the foot, where it is reconnected to the bones utilizing a tiny surgical button, which holds the tendon in place.
• This new tendon position prevents the in-turning of your child’s foot.

• The surgical cuts are closed with dissolvable sutures.
• Post procedure, a long-leg cast is applied to be worn for 6 weeks to facilitate the tendon healing in its new position.

The long-leg cast is removed after 6 weeks, and during that time, a quick procedure is performed to remove the surgical button.

Summary

Ponseti treatment is a gold standard for correction of clubfoot deformity. Most cases of clubfeet can be rectified in infancy in about 6 to 8 weeks with correct manipulations and plaster casts. Ideally, treatment for clubfoot with the Ponseti method should start when an infant is 2 weeks of age to take advantage of the elasticity of the tissues forming the muscles, tendons, and ligaments, although older infants have also been successfully treated.