Non operative 


Ponseti casting


Aims of treatment

1. Correct the deformity early

2. Correct it fully 

3. Hold the corrected position until foot stops growing


- Denis Browne Boots




Start 1 - 3 weeks

- let parents settle and get used to diagnosis

- explain method and length of treatment required




5 - 6 casts applied weekly

- apply SL, then convert to LL

- minimal wool

- someone holds the foot corrected

- tight about foot and ankle, loose calf

- mould about LM /MM / TA

- covert to LL as high up as possible with soft cast

- use soft cast for this




Thumb on navicular, underhand, IF on heel


1.  Correct cavus

- increase supination / elevate first ray

- matching forefoot to midfoot / hindfoot

- pronating foot worsens cavus


2.  Increase abduction serially

- concept is rotation of calcaneus under the talus

- aiming to correct the STJ

- abduction / ER corrects the varus

- use talar head as fulcrum (Kite's mistake - cuboid)

- maintain elevation of first ray - avoid pronation


3.  No attempt to correct equinus til varus / adduction completely corrected

- usually by week 5



- forceful manipulation to correct equinus prior to correction of hindfoot varus

- will result in either a rockerbottom deformity or a flat top talus


Percutaneous tenotomy



- week 5 / 6



- abduction / ER 60o and DF < 10 - 20o

- 85% need tenotomy



- usually performed in OPD

- LA, beaver blade medially

- can go directly posterior


Post op

- ponsetti cast further 3/52 in abduction and DF




Once cast removed

- 23/24 hours

- 3/12


DB Boots


Denis-Browne / Mitchell boots

- worn at night until 4 years 

- shoulder width apart

- clubfoot 70o, normal foot 40o

- also corrects tibial torsion

- critical to success is compliance

- lack of compliance with DB boots strongly linked to recurrence




Successful 90 - 95%

- 5% require PMR / Ilizarov correction

- 7 - 15% need T anterior transfer


Follow up

- until 8



- metatarsus adductus

- dynamic supination


Operative Management


Open clubfoot release



- aged 9/12 to one year

- usually sufficient for child up to three 


Going out of favour

- joint violating surgery

- may increase recurrence

- increase late stiffness


Approach Options




Incomplete circumferential incision

- perform prone

- good exposure and access, especially lateral

- disadvantage heel pad necrosis




Posteromedial incision 

- curved from base of 1st MT above posterior tubercle of calcaneus to the T achilles

- difficult to explore the posterolateral corner

- may need a seperate lateral incision especially in older child




Two incisions

- curved incision from centre of os calcis to talonavicular joint 

- second incision halfway between T achilles & lateral malleolus


Clubfoot Releases




Identify and protect NV bundle

- first thing

- put vessiloop about them


Tendons behind medial malleolus

- T achilles z lengthened

- T posterior z lengthened

- single suture placed


Capsulotomy AKJ / STJ


Identify Knot of Henry above Abductor Hallucis

- reflect Abductor Hallucis downwards

- may be easiest to follow down from ankle

- release plantar fascia

- section / Z lengthen FDL / FHL


Open and reduce TNJ - K wire


K wire up through STJ




Divide CFL

Open and reduce CCJ

- stabilise with K wire


Post op

- plaster for 6/52, then AFO 3/12