The late Dr Ignacio Ponseti from Iowa, developed the Ponseti method, a minimally invasive treatment for clubfoot. The Ponseti Method involves weekly sessions in which a specialist manipulates your baby’s foot with their hands, gradually correcting the position of the foot. A plaster cast is then applied from your baby’s toes to their groin to hold the foot in its new position.
The casts will be changed weekly at each appointment and your baby’s foot is corrected a little more each time. A minor operation, known as a tenotomy, is also usually required to release your baby’s Achilles tendon.
When the foot is fully corrected, your child has to wear special boots attached to a bar (brace) to hold their feet in the most effective position. The boots are worn for 23 hours a day for the first 3 months and then just at night and nap times for up to the age of 4/5years. Regular footwear may then be worn at all other times.
Ponseti Method: Casting Stage
Casting should ideally begin in the first week or two of life in order to take advantage of the elasticity of the ligaments, tendons (soft tissues) and joint capsules. The casting stage which takes a couple of months, involves weekly sessions in which a specialist (usually a physiotherapist) manipulates your baby’s foot, gradually correcting the bend in the foot.
A plaster cast is then applied from your baby’s toes to their groin to hold the foot in its new position. The toes should be exposed and clearly visible.
The cast is changed at each session and your baby’s foot is corrected a little more each time.
On average five to six casts are required. Your baby may need to have a few more or a few less, depending on the severity of the condition.
Manipulation and casting of the foot are done very gently so should not hurt your baby.
Most hospitals will allow you to bottle/breast feed your baby while casting is being done. This helps as the baby is then more relaxed. You may be allowed to bathe your baby at the hospital when they take the cast off and before they apply the new one
Ponseti Method: Tenotomy
Following the casting stage, your specialist will decide whether your baby needs to have a small operation (Tenotomy) to release the tight tendon at the back of their heel (the Achilles tendon).
A tenotomy is often recommended when the heel has not stretched down fully (usually after the fourth or fifth cast) and this procedure allows this to happen.
The procedure is usually carried out under a local anaesthetic on an outpatient basis, which means that your baby will not have to stay in hospital overnight. In some cases, a general anaesthetic may be used (useful for wriggling babies!).
During the procedure, the surgeon will make a small cut in your baby’s heelcord to release their foot into a more natural position. Your baby’s foot and leg will be put in a plaster cast for about 2 to 3 weeks.
Your baby may cry before, during or after the procedure, but be assured that this will not be due to pain, but probably because he/she objects to being held! Don’t be alarmed if there is some bleeding at the back of the heel – the cast will act as a sponge to the tiny amount of blood and will look worse than it is. Bleeding up to the size of a 20 pence piece is acceptable, more than this should be checked by the hospital
One in 3 children will require further surgery when they are between 2 and 7 years of age. This may involve moving a tendon in front of the ankle to a different position to improve the foot’s function. (Tendon Transfer). It is not possible to predict if a tendon transfer is needed until after the child has started walking.
Ponseti Method: Boots and Bars
When the foot is fully corrected, your child must wear special boots attached to a bar (brace) to hold their feet in the corrected position. These must be fitted as soon as the cast is removed – a wait of only a few days might result in a relapse.
There are mainly two types of boots supplied by the hospital:-
Mitchell boots which are soft suede boots with buckles.
Markell boots which are white leather boots with laces.
Either type of boot works eaqually well in the majority of cases.
The boots are worn for 23 hours a day for the first 3 months and then just at night and nap times for up to the age of 4/5years. Regular footwear may be worn at all other times.
This is a crucial part of the treatment and relies entirely on the parents’ compliance. Taking the boots and bars off for only a few hours, or overnight can result in a relapse and may involve reverting to the plastering stage. Remember that the casting will correct the feet but it is the boots and bar that maintain the correction long term.
Important note: When wearing the boots and bars at nights and nap time parents should aim for a minimum of 12 hours overnight and set up an evening routine, for example: bath, boots, bottle, bed.