Journal of Orthopaedic Nursing (2004) 8, 160–163

Journal ofOrthopaedic Nursing

www.elsevierhealth.com/journals/joon

Congenital talipes equino varus – evidencefor using the Ponseti method of treatment

Julia Judd, RGN, RSCN, ENB 219 (Paediatric OrthopaedicNurse Practitioner)*

C/o Ward G3, Southampton University Hospitals NHS Trust, Tremona Road, Southampton SO16 6YD, UK

Summary This article reviews current literature on the Ponseti method forcongenital talipes equino varus (clubfoot) correction in children. A case is made forthe method and argues that demand from parents indicates that this is becoming theintervention of choice above that of more radical surgery.

�c 2004 Elsevier Ltd. All rights reserved.

KEYWORDSPonseti method;Congenital talipes

equino varus;Clubfoot;Paediatric orthopaedics

Editor’s commentThis readable article about congenital talipes equino varus (CTEV) makes a case for a more long-term conservative interventionabove that of the immediacy of more radical surgery. Much of the argument is based on the subjective but powerful choice ofparents themselves. PD

Background

Traditional surgical methods of treating the infan-tile clubfoot deformity are being challenged, pri-marily due to a combination of research results andpublic pressure. In particular Ponseti’s publishedresearch results of a 40 year follow up of his pa-tients (Cooper and Dietz, 1995), treated by a non-surgical approach has opened the floodgate tochanges in practice.

Weinstein (2000) informs us that the treatmentof any medical condition is an attempt to alter thenatural history of that condition. Research studiesgive us the opportunity to assess the outcomes ofthose treatments and to base changes in practiceon the research results.

* Tel.: +44-023-80-794991.E-mail address: julia.judd@suht.swest.nhs.uk.

1361-3111/$ - see front matter �c 2004 Elsevier Ltd. All rights reserdoi:10.1016/j.joon.2004.06.010

Clubfoot research

An accepted method of treatment for clubfoot isinitial serial casting followed by surgical correctionfor resistant deformity (Herzenberg et al., 2002;Ponseti, 1997). However, the age of the child whentreatment is initiated and agreement on an as-sessment and evaluation tool, remains controver-sial (Anguelov, 2000; Craig, 1995; Wainwrightet al., 2002; Dimeglio et al., 1995; Kyzer andStarck, 1995; Dobbs et al., 2000; Cummings et al.,2002). Long-term results of surgical methods arenot readily available nor are they comparable (VanCampenhout et al., 2001). Anguelov (2000) sug-gests this is due to lack of agreement for evaluatingfunctional outcomes and the limited number ofreported long-term results for surgically treatedfeet (Cooper and Dietz, 1995).

It is notable that in comparing studies of currentand past methods of treatment, a main problem isthe criteria set for each study. Whilst some studies

ved.

Congenital talipes equino varus 161161

report radiological and functional outcomes(Ponseti et al., 1981; Sterling et al., 1980), othersinclude a focus on patient satisfaction (Cooper andDietz, 1995). The initial baseline assessment anduse of different evaluation tools has been recog-nised as problematic when comparing final results(Roye et al., 2001) and similarly the varyingmethods and age for surgery (Van Mulken et al.,2001).

It is suggested that by classifying the severity ofthe foot deformity using a recognised tool, theoutcomes can be better evaluated and meaning-fully reported. Flynn et al. (1998) reviewed theclassification systems of Pirani and Dimeglio findingthat both were quick and easy to use and could beused to form the basis of an outcome study of in-fants treated for clubfoot. More recently Wain-wright et al.’s (2002) comparison of fourclassification systems found Dimeglio et al.’s(1995) to have the greatest reliability. The impor-tance of producing comparable results is advocatedby Sackett et al. (2000), in the drive to supportpractice with evidence. This ultimately providesmeaningful choices for the parents when decidingbetween surgical or non-surgical methods of club-foot treatment.

Literature review

The main aim of correcting the clubfoot is to pro-vide a functional pain-free foot (Ponseti, 1992).Research has produced objective results thatcompare radiological appearances and range ofmovement of the corrected clubfoot (Cooper andDietz, 1995; Sobel et al., 2000). However, it isperhaps more important for the patient at the endof treatment to have a foot that is functional, ableto wear normal shoes and is pain-free for dailyactivities and working life (Ponseti, 1992). Sterlinget al. (1980) report a 10–27 year follow up of sci-entific objective results with a reassuring focusstrong on subjective reporting of overall satisfac-tion from patients. Kyzer and Starck (1995) informof Kite’s description in 1939 of a conservativecasting method for correcting the clubfoot. Themain problem of his method was the overall lengthof treatment (Dobbs et al., 2000) due to incorrectmanipulation and the requirement of the child toundergo three years of plaster cast treatment.Turco (1979) proposed a single operative correc-tion for congenital clubfoot to produce a flexible,pain-free foot, and although this method continuesto be used, long-term results of surgical methodsare not available (Herzenberg et al., 2002).

Reviewing the literature it becomes apparentthat changes in clubfoot treatment have turned fullcircle. Early methods included Hippocrates in 400BC (Cummings et al., 2002) using manipulation andbandaging. Various surgical methods that haveevolved demonstrate initial good results, but oftenwith further problems of components of the de-formity relapsing and additional surgery being re-quired (Uglow and Clarke, 2000). It is known thatsurgery often results in scarring and stiffness of thefoot (Ponseti, 1992, 1997).

In comparing outcomes of treatment there arefew studies of surgical long-term results in com-parison to Ponseti who has produced a 40 yearfollow up study of his patients. It becomes cleartherefore that in making decisions regardingtreatment for their child, parents when given theinformation are likely to opt for non-operativemethods.

From the parents’ perspective, managementtechniques vary dependent on the child’s residencyand locality of treatment. Although true of manymedical domains, variety in treatment elicits con-cern, doubt and questions. This is evident whenaccessing information from parent support net-works on the World Wide Web. It is importanttherefore for the practitioner to be knowledgeable,and up to date regarding best available evidence tobe able to supply parents with the information theyneed to make their decision for treatment.

Recently, in the United Kingdom (UK) somecentres have adopted the Ponseti method (Ponseti,1996) of treating clubfoot. This non-operative orconservative method of treatment is rapidly gain-ing popularity, not least for the parents who preferto avoid surgical correction.

Ponseti’s method

Ponseti’s conservative method of treating infantileclubfoot involves gradual correction of the club-foot deformity through weekly casting for approx-imately five to seven weeks. The plaster castsextend from the toes to the thigh to prevent thebaby kicking the casts off. A minor surgical proce-dure to release the tight tendo-achilles is per-formed under a local or general anaesthetic tocorrect the equinus. The last plaster cast is wornfor three weeks followed by the wearing of orthoticboots for up to two years to maintain the correctedposition (Ponseti, 1996) (see Fig. 1). The boots on abar need to be worn by the baby for 23 out of 24 hfor three months. They are then worn for two yearsat night and nap times only.

Outline of the Ponseti Method

Week 1 Week 2 Week 3

Moulded cast to correct foot cavus deformity, bysupinating the foot and dorsi-flexing the firstmetatarsal

Correct varus andadduction -obtained byabducting the supinated foot with counter-pressure to lateral aspect of head oftalus

Continue abduction,stretching the medial tarsalligaments

Week 4 Week 5 Week 6

Abduction continues of the midfoot and forefoot. Footis not pronated. Medial tarsal ligaments stretched by abducting foot to 70 degrees

Abduction continues.

N.B. All casts applied above knee, with knee at 90 degrees flexion and tibia externally rotated

Further manipulation ifrequired

Minor Surgical Procedure Achilles tenotomy performed to correct equinus.

Performed under local or general anaesthetic. Plaster cast for further 3 weeks.

Boots on a bar for 23 hours a day for 3-4 months. A unilateral clubfoot deformity is positioned at 70 degrees,

with the normal foot at 40 degrees.Bilateral clubfeet are both positioned at 70 degrees.

Bar bent in 15 degrees of dorsi-flexion

AFO’s (Ankle foot orthosis) and Piedro Boots (daytime) Boots on bar (night-time) for 2 years

Figure 1 Outline of the Ponseti method.

162 J. Judd

The treating practitioner requires an in-depthknowledge and understanding of the normal footanatomy and kinematics, and of the pathophysi-ology and disease management process to ensuresuccessful treatment (Ponseti, 1996). The parentsmeanwhile need to be committed to the treat-ment. Weekly visits for up to seven weeks arerequired for the gradual process of manipulatingthe foot and application of moulded plaster caststo bring the feet round to a corrected position.They need to know how to care for their baby inplaster casts and for the last part of the treat-ment in particular, they require great commit-

ment and compliance. Ponseti suggests that oneof the main reasons for a poor outcome using hismethod is a failure of the boots on a bar beingworn by the baby (Ponseti, 1992). They are asignificant part of the treatment used to preventtightening of the stretched ligaments. Parentsshould be made aware of the importance of en-suring the boots are worn for the recommendedperiod of time to avoid the foot position relaps-ing. Information is paramount at the beginning oftreatment with on going telephone support beingavailable to sort out problems the parents arecoming across when at home.

Congenital talipes equino varus 163163

Conclusion

This conservative method of treatment is on theverge of replacing more traditional surgical meth-ods, with public demand outstripping resources.Information regarding the success of the Ponsetimethod is spreading rapidly both verbally and viathe World Wide Web. As yet few centres in the UKoffer this management strategy for clubfoot.However, parents are wishing to not only avoidsurgery, but by also having access to informationand to the success stories, are willing to travel longdistances to obtain their treatment of choice. Thisin itself is proof of the importance of publishingresearch results and making sure the evidence oftreatment outcomes is made widely available.

References

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Cooper, D.M., Dietz, F.R., 1995. Treatment of idiopathicclubfoot. Journal of Bone and Joint Surgery 77-A (10),1477–1489.

Craig, C., 1995. Congenital talipes equinovarus. ProfessionalNurse 11 (1), 30–32.

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Kite, J.H., 1939. Principles involved in the treatment ofcongenital clubfoot. The Journal of Bone and Joint Surgery21 (3), 606.

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