The Ponseti method (developed in the 1940s by Ignacio Ponseti, M.D., an orthopedic surgeon) gradually corrects clubfoot through a series of foot manipulations and cast applications, followed by use of a foot brace. Gillette uses the Ponseti method as a first treatment for clubfoot because it can deliver excellent correction without extensive reconstructive surgery. Even if surgery for clubfoot becomes necessary later, the Ponseti method is an effective way to begin improving the appearance, position and function of the foot.
The Ponseti method can benefit infants and children. Typically, the younger a patient is when treatment starts, the better the results are. Ideally, patients should begin treatment within the first few weeks of life. That increases the likelihood that clubfoot will be resolved without extensive surgery. Babies tolerate the Ponseti method very well, with little discomfort.
The Ponseti method begins with a period of casting that usually lasts less than three months. Often, casting is followed by a simple outpatient surgery called an Achilles tenotomy, which lengthens the child’s Achilles tendon. Whether or not we perform that surgery, after casting, the child uses a foot abduction brace. The brace—a pair of adjustable shoes connected by a straight, metal bar—keeps the child’s feet in proper position and helps prevent clubfoot from recurring. The child wears the brace for most of the day at first, then decreases wearing time until stopping use at age 4 or 5 years.
Clubfoot treatment outcomes vary depending on the severity of the condition and the presence of other, associated medical conditions.
When using the Ponseti method, a cast specialist gently exercises and stretches the foot before applying a plaster cast. The cast extends from just above the toes to the top of the thigh, keeping the knee bent at a 90-degree angle. The cast helps limit leg movement and hold the foot in proper position.
After the first cast is applied, your child returns to Gillette for weekly or biweekly cast care appointments, which typically last 30-60 minutes. At these appointments, we remove your child’s casts, stretch the feet, and then apply new holding casts. We continue to change casts for about six or seven weeks. We might need to apply five to nine casts to fully correct the foot. Each cast straightens the foot a little more.
When you come to casting appointments, bring a bottle to soothe your child during the casting. In addition, bring extra diapers and a pacifier (if your child uses one).
During the casting period, you should play with, carry and move your baby as you normally would without the casts.
Your child’s cast might be hard when you leave the clinic, but it takes two to three days for it to completely dry.
The casts must be kept dry, so sponge bathing is advised. Make sure to change your child’s diaper more often than usual to prevent moisture from getting on the cast. You may use a roll of cotton to rewrap the top of the cast when it is soiled. Avoid pulling padding out of the cast.
Check your child’s skin at the top of the cast and on the toes for sores and red marks, indicating chafing from the cast. Do not apply lotions, powder or other substances near the cast.
It’s important to check where your child’s toes are in the cast. You should be able to see the toes. If the cast is slipping or you see less of the toes, the cast needs to be changed right away to alleviate pressure on the skin. Check circulation daily by touching the toes; they should turn pinkish in color within three seconds. If the toes are discolored, try to change their position by lifting your child’s leg. If that doesn’t solve the problem or if your child’s skin becomes irritated, contact Telehealth Nursing at 651-229-3890.
When to Call for Help
Cast problems—especially those that affect the leg or foot’s movement, sensation or circulation—can be very serious. They can cause permanent damage in a short period of time. If you have any questions, don’t hesitate to call Telehealth Nursing or your child’s health care provider.
Contact Telehealth Nursing at 651-229-3890 if you notice:
- Your child acting irritable for no apparent reason
- Change in toe color or temperature
- Increased swelling of toes that is not relieved by elevating the leg
- Skin irritation or rashes
- Toes that appear to have slipped back into the cast
- The cast seems too tight or too loose (moving up or down)
- Cracks in the cast
- The cast is damp or wet
- A foreign object inside the cast that you can’t remove with your fingers
After Final Cast Removal
After removal of the final cast, your child’s feet will be very sensitive to touch for a while. When you touch your child’s feet, a firm touch will feel best until the sensitivity subsides.
Normal changes in blood circulation that occur after the final cast is removed might cause some color changes in your child’s legs.
After the cast removal, it might take a few days for your child’s skin to shed excess dry flakes and return to its normal appearance.
After casting, about 90 percent of children undergoing the Ponseti method still have an abnormally tight Achilles tendon. A pediatric orthopedic surgeon can correct this problem with a quick outpatient surgical procedure called an Achilles tenotomy, which lengthens the tendon.
If your health care provider recommends that your child have an Achilles tenotomy, we perform the procedure in our cast room. After surgery, your child wears an additional cast for three weeks. The tendon heals while in the cast.
Foot Abduction Brace
Immediately after removal of the final cast (whether or not your child had Achilles tenotomy surgery), we fit your child for a foot abduction brace. The brace—a pair of adjustable shoes connected by a straight, metal bar—keeps the child’s feet turned out, in proper position, to help prevent clubfoot from recurring. The shoes and bar work together to maintain the stretching and flexibility that occurred while the foot was in the casts.
It’s important that bracing begin immediately after casting. If you wait to use the brace, corrections achieved during casting can be lost.
At first, your child might be upset by the brace—not because it’s painful, but because it’s unfamiliar. To help your child feel good about wearing the brace, you can try some playful activity and movement. Gently flex and extend your child’s knees by pushing and pulling the bar of the brace.
For the first three months of use, your child wears the brace for 23 hours per day. After that, wearing time gradually decreases. When your child starts walking, the brace is worn for 10-12 hours at night until age 4 or 5 years.
It’s important for your child to wear the brace for the amount of time your health care providers recommend. If your child spends less time in the brace than is recommended, clubfoot might relapse, which might lead to a need for more casting treatments or surgery.
Stretching and Movement
When the brace is off (for one hour a day at first; more often after that), it’s important to stretch your child’s foot and ankle. Stretching helps maintain the ankle’s range of motion achieved during casting and/or after the Achilles tenotomy surgery. Follow stretching exercise instructions provided by your health care provider.
If your child’s feet are fully corrected after 8-9 months of age and your child is ready to crawl or walk at that time, it’s important to allow those activities. Doing so will help develop weak muscles.
Skin and Brace Care
Check your child’s feet for redness, sores and blisters. Such problems can arise when the brace’s shoes don’t fit correctly. If sores or redness don’t go away within 20-30 minutes, stop using the brace and call Telehealth Nursing at 651-229-3890.
When using the brace, your child should wear cotton socks that cover all parts of the foot and leg that touch the shoes. The socks should go higher on your child’s leg than the top buckle on the shoe. Keep the socks pulled taut so they fit smoothly over the foot and leg. Wrinkles in the socks can irritate your child’s skin.
Always keep the shoes, socks, and portions of your child’s skin touching the brace clean and dry.
Your child’s toes should reach the end of the brace’s shoe. If the toes extend past the end of the shoe, make an appointment to have your child fitted for a larger size shoe.
If your child is wiggling out of the brace, you can try several things:
- Tighten the strap.
- Remove the tongue of the shoe. (Using the brace without the tongue will not harm your child).
- Ask your orthotist to check the fit of the shoes. It might be necessary to make modifications, such as adding padding to allow for a better fit.
In some children, clubfoot recurs. That situation might require another round of casting and perhaps another Achilles tenotomy surgery. Some children might need additional surgery when they are 2 to 4 years old. The original condition of the foot and the presence of other underlying conditions can affect whether clubfoot recurs. It’s important that a pediatric orthopedic health care provider monitor the child’s progress and address issues as soon as they’re noticed.
While your child is undergoing Ponseti method treatment, contact Telehealth Nursing at 651-229-3890 if:
- The appearance or position of your child’s foot and ankle seems to be worsening
- Your child’s foot and ankle seem to be losing range of motion
For the vast majority of clubfoot patients, the function and appearance of the foot is nearly normal after treatment with the Ponseti method. Studies show that patients treated with the Ponseti method have a more flexible foot and ankle than do patients treated with only surgery. Long-term studies demonstrate that the benefits of the Ponseti method extend into adulthood.
This information is for educational purposes only. It is not intended to replace the advice of your health care providers. If you have any questions, talk with your doctor or others on your health care team.