This document summarizes a study on the modified Ponseti technique for treating idiopathic clubfoot. 21 children with 33 clubfeet were treated using a modification of the Ponseti protocol between 2005-2008. The modifications included less frequent cast changes initially, flexibility in timing of cast changes, percutaneous Achilles tenotomy under pediatric supervision, and use of a modified ankle-foot orthosis. Good results were obtained in 16 children, fair results in 3 children, and poor results in 2 children. The study concludes that modifications can be made to the Ponseti protocol as long as the basic principles are followed.

1. Modified Ponseti Technique of Management of Idiopathic Clubfoot

2. Apollo Medicine 2011 December
Review Article
Volume 8, Number 4; pp. 281–286
© 2011, Indraprastha Medical Corporation Ltd
Modified Ponseti technique of management of idiopathic clubfoot
Ramani Narasimhan*, Paras Bhat**
*Senior Consultant, Paediatric Orthopedic Surgery, **Ex-Registrar Orthopedic Surgery, Indraprastha Apollo Hospitals, Sarita Vihar,
New Delhi – 110076, India.
ABSTRACT
Ponseti technique in the nonoperative management of idiopathic clubfoot is being followed worldwide and with good
results.We present our results using a modification in this management to suit our practice.Twenty-one children with
idiopathic clubfoot (33 feet: 12 bilateral, 9 unilateral) were treated at this center following the modified technique,
between 2005 and 2008.The cases included were of Pirani scores 4–6.The patients were prospectively followed up
clinically and radiologically for a minimum follow-up of 24 months (mean 27 months). We obtained good results
(Pirani score 0) in 16 children, fair (Pirani score 1–3) in 3, and poor result (Pirani score >3) in terms of loss of correc-
tion in 2 of the cases. This modified technical protocol ensured good compliance of follow-up and hence mainte-
nance of correction of the deformities. We conclude that as long as the basic principles of Ponseti technique are
followed, any modification according to ones practice can still yield good results.
Keywords: Congenital clubfoot, Ponseti technique, Pirani score
Correspondence: Dr. Ramani Narasimhan, E-mail: ramanirn@hotmail.com
doi: 10.1016/S0976-0016(11)60007-0
INTRODUCTION
Ponseti technique has revolutionized the whole concept
of idiopathic clubfoot management, and has a unanimous
acceptance. Modifications in this management like in terms
of shortening the time of treatment have been described in
order to ensure compliance of the family with treatment.1
Strongly supporting the Ponseti technique for idiopathic
clubfoot treatment, we present the results of our series of
cases with congenital clubfeet treated by our modification
of the original management protocol of Ponseti to suit our
practice.
MATERIALS AND METHODS
We treated 21 children with congenital clubfoot (33 feet: 12
bilateral, 9 unilateral) with the Ponseti technique using a
modified protocol of management at Indraprastha Apollo
Hospitals over a period of 3 years (2005–2008). The cases
included were of Pirani score 4–6 (Figure 1). Of the 21 chil-
dren, 16 were 3 months of age or less (12 newborns, 3 eight
weeks of age and 1 twelve weeks of age) with a bilateral
deformity in 10 and unilateral in 6. Five children (2 bilateral;
3 unilateral) were between 12 and 18 months of age.
In the newborn, we did manipulation and casting weekly
for the first month and thereafter, we were flexible to increase
the interval between the serial castings (between 7–14 days).
In all cases, the previous cast was removed roughly an hour
prior to the application of the next one. In children presenting
>1 month of age, we kept the interval flexibility (7–14 days)
right from the start ensuring better compliance. Syrup tri-
clofos (pedicloryl) was used in all children as advised by the
paediatric intensivist 15–30 min prior to each manipulation
and casting. An average of 6 casts was required until the
foot adduction was sufficiently over-corrected before a per-
cutaneous tendo-achilles release was done. In five (bilateral
1, unilateral 4) feet, we did not achieve >50° of abduction
(no change after 2 consecutive casts) and we proceeded to
perform the tendo-achilles release. Under local/dissociative
anesthesia and under the supervision of a paediatric intensiv-
ist in the minor procedure room, we did step-cuts (distal cut is
medial at the insertion, middle cut is lateral and 1–2cm above
the distal cut, and the proximal one medial just distal to the
musculo-tendinous junction) of the tendo-achilles tendon to
achieve a dorsiflexion of at least 15°. We performed a per-
cutaneous tendo-achilles release in all the patients (Figure 2).

3. 282 Apollo Medicine 2011 December; Vol. 8, No. 4 Narasimhan and Bhat
© 2011, Indraprastha Medical Corporation Ltd
We applied a thigh length plaster of Paris cast in ≥10°
of dorsiflexion and kept it for 2 weeks. The modified con-
genital talipes equinovarus (CTEV) splint was applied imme-
diately after the last cast was removed 2 weeks after the
tendo-achilles release (Figure 3). The modification of the
CTEV splint was that the angle of splint was fixed at 10°
dorsiflexion. Use of the splint for a minimum of 22h was
encouraged till the child was weight bearing, after which
the use was limited to night and nap times. Thereafter, bare-
foot walking was encouraged and a CTEV shoe was added
to be used 3–4h a day till the age of 3–5 years. The splints
continued till the child was 5 years after which it was
planned to be weaned off. The patients were followed up
clinically and radiologically for a mean of 27 months.
RESULTS
We had good results in 16 children with 28 feet (Pirani
score 0) (Figures 4–7 Case 1, Figures 8–10 Case 2, and
0 .5 1
CLB
0 .5 1
MC
Talar head
None 0
Partial .5
Full 1
LHT
0 .5
1
RE
Empty heel
Easily palpable 0
Palpable deep .5
Not palpable 1
EH
0 .5 1
PC
Figure 1 Pirani’s 6 criteria of scoring for grading clubfoot.
CLB: curvature of the lateral border; MC: medial crease; LHT:
lateral head of the talus; PC: posterior crease; RE: rigidity of
equinus; EH: emptiness of the heel.
(Courtesy: Staheli L. Clubfoot: Ponseti Management 3rd ed.
Global Help).
Figure 2 Healed scars of the step-cutting of tendo-achilles
tendon.
Figure 3 Feet with modified congenital talipes equinovarus
splints.

4. Modified Ponseti technique of management of idiopathic clubfoot Review Article 283
© 2011, Indraprastha Medical Corporation Ltd
Figure 4 Case 1: A 15-month-old child with a unilateral deform-
ity (Pirani score 5).
Figure 5 Case 1: Normal lateral talo-calcaneal angle 3 months
after full correction.
Figure 6 Case 1: Child at 18 months of age.
Figure 7 Case 1: Child at 24 months of age.
Figure 8 Case 2: Bilateral clubfeet, 1 month age.
Figure 9 Case 2: With congenital talipes equinovarus splints
after full correction. Child is seen weight bearing with splints
with rubber soles during the transitional period before congeni-
tal talipes equinovarus shoes were delivered.

5. 284 Apollo Medicine 2011 December; Vol. 8, No. 4 Narasimhan and Bhat
© 2011, Indraprastha Medical Corporation Ltd
Figures 11–13 Case 3), fair results in 2 children with 3 feet
(Pirani score 1–3) and poor results in 1 child with a bilateral
deformity (Pirani score >3).
One child with bilateral clubfeet developed an allergy
to the splints and was out of them without information and
ended up with a fair result (Figure 14). The child needed
to be subjected to manipulations and castings again, till
correction was achieved and that was maintained by splints
made of a different material. The other child with a unilateral
clubfoot with a fair result was from a family background
where the grandfather firmly believed that the cast was the
cause of thin calf. The corrective process ended up to be
very erratic and required a prolonged treatment time. One
child with a bilateral clubfeet had a poor result due to a
practical difficulty of maintaining the casts. The shape of
the limb was conical allowing the casts to slip off time and
again. The correction suffered and hence both feet had to be
operated.
Figure 10 Case 2: At 2 years of age.
Figure 11 Case 3: Newborn with bilateral clubfeet.
Figure 12 Case 3: Second manipulation and casting of right
side shown.
Figure 13 Case 3: At 3 years of age.
Figure 14 Allergy to splints—fair result.

6. Modified Ponseti technique of management of idiopathic clubfoot Review Article 285
© 2011, Indraprastha Medical Corporation Ltd
The differences between our management protocol and
the conventional Ponseti treatment protocol were mainly in
• the frequency of manipulations and castings,
• the number of castings before tendo-achilles release,
• the procedure of percutaneous release of tendo-achilles
(under monitoring and supervision of a paediatric
intensivist),
• the orthosis for maintenance of correction, and
• the follow-up protocol during the maintenance of
correction.
DISCUSSION
Clubfoot is a developmental deformation like developmental
dysplasia of the hip (DDH) or idiopathic scoliosis.2
Ponseti’s
nonoperative technique has revolutionalized the treatment of
idiopathic clubfoot. Principles of its correction as laid down
by Ponseti are time-tested, widely accepted and show excellent
results.3–10
Modifications in the protocol of Ponseti technique have
been described in the past.1,11,12
In clinical set-ups across
the world, especially in the developing countries, the treat-
ing orthopedic surgeon needs to be acutely aware of gaining
confidence and trust of the family in the long treatment of
their child’s clubfoot and take it to a successful completion.
One does not have an extra help from any allied medical
personnel to educate and counsel families on a regular
short-term basis like one does in the developed countries of
in the west.
We felt that a minimum period of 7 days/1 week is nec-
essary for the re-formation of the ‘crimp’ as described by
Ponseti,2
in order to achieve further correction. We changed
plasters between 7 and 14 days (average 10) which helped
the family to plan their arrival in advance. An average of 6
cast changes was found to be needed before the tendo-Achilles
release. Once the complete management protocol was dis-
cussed in detail on their first visit, no family had any problem
with the time required to achieve full correction.
We feel that it is impossible to achieve the recommended
single incision full tenotomy of tendo-achilles percutane-
ously, ensuring that the sheath is intact, as an outpatient
department (OPD) procedure using local anesthesia. Hence,
the step correction of tendo-achilles under the supervision
of a paediatric intensivist and proper monitoring (not as an
OPD procedure),11,12
is just playing safe in this day and age
of multiple lawsuits.
Although the efficacy of foot-abduction brace as a
dynamic orthosis for the maintenance of correction is well
established, it is only based on the assumption that all families
are comfortable using it and are thoroughly compliant, espe-
cially immediately after full correction. Sadly, compliance
was a huge issue with foot abduction orthosis (FAO) in
most families coming to us.11,13
There is a lack of social
workers and other allied medical personnel (as mentioned
earlier) in our set-up to constantly counsel families, espe-
cially to convince them regarding the importance of using
the FAO. In fact, it was more difficult to convince them
that an FAO will not be an obstacle in the motor develop-
ment of their child. Although not an orthosis preferred for
correction maintenance and not considered by majority as
‘effective’, we feel that a CTEV splint with a small modifica-
tion of 10° in dorsiflexion maintained our corrections rea-
sonably well. No family had problems in using this orthosis
even for a longer period of time. We preferred a less accept-
able but more compliant orthosis to the more acceptable and
more effective but much less compliant one and achieved
good results.
Barefoot walking mainly, along with the usage of CTEV
shoe in the initial years, helped us to maintain correction
dynamically. We feel that it is imperative to keep a regular
follow-up during the period of growth, even after the best of
achieved corrections.
Finally, as long as one strongly adheres to the principles
of Ponseti2,4–6,8
to achieve full correction of clubfoot and are
conscious of maintaining the same, any modification of the
management protocol in one’s practice especially in terms
of correction maintenance, can still yield good results.
REFERENCES
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