J Orthop Sci (2011) 16:184–189
DOI 10.1007/s00776-011-0027-5
ORIGINAL ARTICLE
Management of idiopathic clubfoot by the Ponseti technique:
our experience at a tertiary referral centre
Aditya Krishna Mootha • Raghav Saini •
Vibhu Krishnan • Kamal Bali • Vishal Kumar •
Mandeep Singh Dhillon
Received: 21 July 2010 / Accepted: 8 November 2010 / Published online: 5 February 2011
Ó The Japanese Orthopaedic Association 2011
Abstract
Background Clubfoot or congenital talipes equinovarus is
a common congenital abnormality of uncertain etiology.
The purpose of this study was to assess the results of the
Ponseti method in India and to investigate the demography
of relapse and resistant cases.
Methods A total of 86 children (146 feet) below 1 year of
age who had presented to the paediatric orthopedic out-
patient department of our institution between June 2003
and January 2007 with unilateral or bilateral idiopathic
clubfoot deformity were included in our study and treated
conservatively by use of the Ponseti technique.
Results 128 feet responded to the Ponseti casting tech-
nique initially and 18 feet were resistant to the conservative
treatment. Of the responsive feet, for 20 feet there was a
relapse of the deformity. Evaluation of the results showed
that poor compliance with splintage was the most common
cause of relapse; delayed presentation and atypical clubfeet
resulted in high resistance to this technique. Correction
achieved at our centre was 82.18%. This is less than in
many recent studies and could be attributed to increased
incidence of delayed presentation, poorer compliance, and
atypical feet in our population.
Conclusion We conclude that the Ponseti technique is
recommended for management of clubfoot and strict
compliance with splintage is essential to prevent relapses.
People of lower socioeconomic status are at high risk of
A. K. Mootha
R. Saini
V. Krishnan
K. Bali
V. Kumar

M. S. Dhillon
Department of Orthopaedics, Postgraduate Institute of Medical
Education and Research, Sector 12, Chandigarh 160012, India
K. Bali (&)
42, Sec 16, Panchkula, Haryana, India
e-mail: kamalpgi@gmail.com
123
relapse and must be targeted to create awareness among
them about the importance of compliance with splintage.
Introduction
Congenital talipes equinovarus (CTEV) is one of the oldest
and one of the most common congenital anomalies of
mankind, with reported incidence of one to two per thou-
sand live births [1]. The four important components of the
deformity are ankle equinus, heel varus, forefoot adduc-
tion, and cavus [2, 3].
Non-operative treatment of clubfoot has been widely
accepted as the initial standard of care and is started as soon
as possible after birth. Earliest non-operative treatment dates
back to 400 BC when Hippocrates recommended gentle
manipulation of feet followed by splinting. In 1836, Guerin
introduced the plaster-of-Paris cast. Around the turn of the
century, devices such as the Thomas wrench, in which rapid
correction using forceful manipulation was practised, were
introduced [4]. In 1930, Dr Hiram Kite introduced the
technique of gentle manipulation and casting. In 1948, Dr
Ignacio V. Ponseti introduced the most widely followed
system of manipulation and serial casting. The Ponseti
technique has been the most popularly accepted method and
a few studies have established the short and long-term suc-
cess of the technique at different centres [5, 6].
The purpose of this study was to review initial experi-
ence of treating club foot by the Ponseti technique at our
institution and to evaluate the importance of age at pre-
sentation, sex, family history, and socioeconomic status of
Indian patients in the prognosis of clubfoot correction,
incidence of resistance, relapse among these feet after the
Ponseti method, and complications during the course of
treatment.
CTEV management by Ponseti technique
Materials and methods
A total of 86 children below 1 year of age who had pre-
sented to the paediatric orthopedic out-patient department
of our institution between June 2003 and January 2007
with unilateral or bilateral idiopathic clubfoot deformity
were included in our study.
Children with any other significant anomaly or clubfoot
occurring as a component of any known syndromic pre-
sentation or neuromuscular or spinal disorder were exclu-
ded from the study. Children presenting beyond 1 year of
age in whom conservative management has been proved to
be of less benefit were also excluded from the study.
Written informed consent to participation was obtained
from the parents of all the children enrolled in the study.
The parents were asked about socioeconomic status,
monthly income, education level, and any other similar
deformity among close relatives. One of the children had a
sibling with unilateral clubfoot. There was no other family
incidence. There is a practice of issuance of Below Poverty
Line cards in our population. This was used as the criterion
for classification of our patients in the low socioeconomic
status group.
All the children underwent a complete head to toe
examination at initial presentation to rule out any signifi-
cant osseous, neurological, or muscular etiology or any
other syndromic presentation. All the feet were assessed by
Pirani score at presentation (Table 1). The Pirani score is
entirely clinical and commonly used for its simplicity. The
feet were also classified as typical and atypical feet by
clinical examination. Atypical clubfeet were defined by
following the features described by Ponseti [5, 6].
The procedure described by Ponseti was followed.
Correction of the deformity in the Ponseti technique is
accomplished by abducting the foot in supination while
counter pressure is applied over the lateral aspect of the
Table 1 Pirani scoring system
Hind foot score
for assessment of the severity of
clubfoot Look Posterior crease
0: No heel crease
0.5: Mild heel crease
1: Deep heel crease
Feel Empty heel sign
0: Hard heel (calcaneum in normal position)
0.5: Mild softness
1: Very soft heel (calcaneum not palpable)
Move Rigidity of equinus
a
The foot should be moved to 0: Normal dorsiflexion
the position of maximum 0.5: Foot reaches plantigrade with knee extended
correction when assessing the 1: Fixed equinus
medial crease
185
head of the talus to prevent rotation of the talus in the
ankle. A well-moulded plaster cast is applied to maintain
the foot in an improved position. The ligaments should
never be stretched beyond their natural amount of give.
After 5 days, the ligaments can be stretched again to fur-
ther improve the extent of correction of the deformity.
Usually, a total of 5–6 casts is required.
The tendo Achilles tenotomy was performed to correct
the equinus deformity in our patients in whom we had
achieved adequate abduction of 70° at the time of appli-
cation of the last cast. The last cast was, further, maintained
for 3 weeks. The correction was, then, maintained by use
of the Denis Browne splint applied for at least for 16 h a
day until 1 year of age; followed by night time splint for
the first 3 years of age. The orthosis used includes a well-
fitted, open-toed, high-top straight-last shoe attached to a
Denis Browne bar of approximately the length between the
child’s shoulders. The splint maintains the corrected foot in
70° of external rotation to prevent recurrence of the varus
deformity of the heel, adduction of the foot, and toeing-in
[5, 6]. The ankle should be in dorsiflexion, in an attempt to
prevent equinus, and this is accomplished by bending the
bar with the convexity of the bar distally directed. If the
deformity is unilateral, the normal foot is placed in 30° of
external rotation. The children were followed in accor-
dance with the procedure suggested by Ponseti: once at
2 weeks after the bracing started; then at 3 months; once
every 4 months until 3 years of age; every 6 months until
4 years; every 1–2 years until skeletal maturity. The par-
ents were asked about the number of hours of use of the
splint and non-compliant patients were further encouraged
to use the splint. The child’s foot and the splint were
evaluated at each visit. Compliance with the abduction-bar
brace was defined as use of the splint for at least 16 h a
day. Any deviation from this time limit was regarded as
non-compliance.
Mid foot score
Lateral border of foot
0: No deviation from straight line
0.5: Medial deviation distally
1: Severe deviation proximally
Talar head
0: Reduced talo-navicular joint
0.5: Subluxed but reducible
talo-navicular joint
1: Irreducible talo-navicular joint
Medial creasea
0: No medial crease
0.5: Mild medial crease
1: Deep crease altering contour of foot
123
186 A. K. Mootha et al.

Pirani scoring was also conducted at each visit. Follow- males and 32 females. There was a much higher inci-
up X-rays were also taken every year during these sub- dence of patients with bilateral involvement. For 38 feet
sequent visits. Standardized weight-bearing plain X-rays in (22 patients) presentation at our hospital was before
the anteroposterior and lateral views were used for radio- 3 months, with more delayed presentation for the
logical assessment. The talocalcaneal angles and talar–first remaining 108 feet. 48 feet had been partially treated
metatarsal angles in the AP and lateral views were mea- elsewhere and the remaining 98 feet were presented to us
sured for all patients. first (Table 2).
The need to perform posteromedial soft tissue release or The mean age at presentation of the patients was
other major surgical procedure was regarded as failure of 15.67 ± 6.57 weeks. Of the 146 feet, 128 feet (87.7%)
treatment. The need to perform a tendo Achilles tenotomy responded to the treatment initially whereas 18 feet
for equines correction was not regarded as a treatment (12.3%) did not respond to casting and needed postero-
failure in our patients. The need for a repeat tendo Achilles medial medial soft tissue release by the Turco procedure or
tenotomy for an equinus relapse or tibialis anterior transfer another major surgical procedure. 8 of our feet were
for dynamic supination were also not regarded as failure of atypical feet at presentation (as per Ponseti’s description)
treatment. All statistical analysis was done using SPSS 12.0 and 5 were resistant to our initial treatment. The mean
software. The chi-squared test was applied for comparison initial Pirani score for the responsive patients was 4.5
of categorical data and the unpaired t test was used to (mean hind foot score 2.5 and mid foot score of 2) whereas
compare numerical data where needed. the mean Pirani score at follow-up for these patients was
0.5 (0–1.0) (mean hind foot score 0.5 and mid foot score of
0). Among the patients who had not responded, the mean
Results Pirani score was 5.5 (mean hind foot score 3 and mid foot
score of 2.5). The mean Pirani score for these patients at
All patients were treated by the Ponseti technique and have follow-up was 1.5 (mean hind foot score 1.0 and mid foot
been followed up at the out-patient pediatric orthopedic score of 0.5). The responsive and resistant feet are com-
department of our hospital up to this date. The average pared in Table 3.
period of follow-up of the patients has been 4 years (range The mean age at presentation for the resistant feet was,
2–7 years). thus, significantly higher than that for the non-responsive
The total number of patients included in the study was feet. Also, a relatively higher number of patients had been
86 (a total of 146 feet were studied). There were 54 partially treated elsewhere among the resistant population
group. The atypical feet were also more resistant to con-
servative treatment, as expected. However, socioeconomic
Table 2 Demography of the study sample status (Below Poverty Line card holders) was not important
Total no. of patients in the study 86 in increased resistance to treatment. Percutaneous tenot-
Total no. of feet studied 146 omy was performed for 90% of the feet.
Age at presentation 22 (\3 months): (25.6%) (38 feet) Of the total 128 feet that initially responded successfully
64 ([3 months): (74.4%) (108 feet) to treatment, 20 (15.6%) feet relapsed after initial success.
Sex Males: 54 Of these, 12 feet (60%) responded to repeat casting and
Females: 32 repeat percutaneous tenotomy. The remaining eight (40%)
Bilateralism Bilateral: 60 relapsed feet required surgical intervention. 2 (25%) of
Unilateral: 26 these feet had presented with dynamic supination that
At presentation Initially treated elsewhere: 48 feet required tibialis anterior transfer. However, the remaining
First presentation: 98 feet 6 (75%) patients required extensive soft tissue release
Atypical feet 8 surgery.
BPL card holders 40 feet Socioeconomic status, family history, age, sex, bilater-
alism and other general features of the population with

Table 3 Comparison of
Responsive feet (128) Resistant feet (18) P value
responsive and resistant feet
Mean age at presentation 14.54 ± 5.54 weeks 23.72 ± 7.72 weeks 0.00*
Partially treated before presenting to us 34 (26.6%) 14 (77.8%) 0.01*
Atypical clubfeet 2 (1.6%) 6 (33.3%) 0.00*
Socio economic status 34 (26.6%) 6 (33.3%) 0.66
* Significant

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CTEV management by Ponseti technique 187

Table 4 Comparison of non-

Non-relapsed feet (108) Relapsed feet (20) P value
relapsed and relapsed feet in the
responsive group Mean age at presentation 14.64 ± 5.61 weeks 15.90 ± 4.61 weeks 0.35
Partially treated before presenting to us 28 (25.9%) 6 (30%) 0.77
Atypical clubfeet 2 (1.8%) 1 (5%) 0.15
Socio economic status 17 (15.8%) 17 (85%) 0.00*
Poor compliance with splint 8 (7.4%) 20 (100%) 0.00*
* Significant

Table 5 Comparison of feet

\3 months (38 feet) [3 months (108 feet) P value
presented before or after 12
weeks Mean Pirani score 4.94 ± 0.57 5.07 ± 0.55 0.24
No. of casts 4.47 ± 0.73 7.12 ± 1.67 0.00*
Relapses 5 (13.1%) 15 (13.9%) 0.92
Resistance 2 (5.3%) 16 (14.8%) 0.27
Partially treated before presenting to us 4 (10.5%) 44 (40.8%) 0.01*
Socio economic status 9 (23.7%) 31 (28.7%) 0.64
Atypical feet 3 (7.9%) 5 (4.6%) 0.76
* Significant

deformity relapse were analysed. Of the 20 feet that had
relapsed, 17 (85%) were of the poorer socioeconomic
group (Below Poverty Line card holders). This was a sig-
nificant difference. All had poor compliance with the
Dennis Browne splint which was noted on further ques-
tioning (Table 4).
64 (74.4%) of our patients presented after 3 months
whereas 22 (25.6%) presented earlier than 3 months. For
patients with early presentation (\3 months) at our hospital
a significantly lower number of casts was required for
correction than for those who had later ([3 months) pre-
sentation. There was also a significantly lower incidence of
resistant cases among the population that presented earlier
than 3 months for conservative treatment (Table 5).
The mean number of casts required for correction of the
responsive feet was 5.7 (4–13). Tendo Achilles tenotomy
was required for 90% of our patients. Early correction at
our centre was, thus, 82.18%. A total of 17.8% feet
underwent extensive surgery either for a resistant or a
relapsed deformity.
The mean initial anteroposterior and lateral talocalca-
neal angles were 13° (range 24°–0°, standard deviation 9°)
and 18° (range 26°–10°, standard deviation 7°), respec-
tively. The mean initial anteroposterior and lateral talar–
first metatarsal angles were 38.6° (range 71°–8°, standard
deviation 20°) and 3.2° (range 8°–0°, standard deviation
2.8°), respectively. The mean anteroposterior and lateral
talocalcaneal angles at last follow-up for the responsive
feet were 24.8° (range 39°–16°, standard deviation 6°) and
27.3° (range 45°–16°, standard deviation 10.8°), respec-
tively. The mean anteroposterior and lateral talar–first
metatarsal angles at the last follow-up were 0° (range 47°
to -32°, standard deviation 28) and 26.4° (range 80°–1°,
standard deviation 30.6°), respectively.
Discussion
The objective of treatment of clubfoot is to achieve a
painless, plantigrade foot with good mobility, without any
need for special orthosis or modified shoes. Current liter-
ature supports the use of primary non-operative techniques
to achieve this. Newer methods of non-operative manage-
ment include manipulation of the foot by a physical ther-
apist [7], continuous passive motion by machine [8], the
French method [9], and Botulinum toxin type A injection
into the gastrosoleus and tibialis posterior muscles [10].
The most popular technique followed today is the serial
casting method devised by Ponseti.
All the feet in our study were assessed by use of Pirani
scoring [11]. Several scoring systems are in use, for
example, the Dimeglio score [12], the Carroll severity scale
[13], and the Pirani score [11]. All of these systems have
been independently validated; inter and intra-observer
reliability is very good and they correlate well with patient-
based assessments of outcome [14].
The incidence of neglected cases of CTEV in our
institution is high. The older patients respond relatively
poorly to the Ponseti technique and also present with a
multitude of soft tissue and skin problems. The socioeco-
nomic status and the education level of the parents in our
country are also poor. These factors may affect the results
of a technique like that of Ponseti in which the parents play
an important role during the treatment and in the

123
188
maintenance of correction after completion of treatment. A
previous study conducted in India reported 95% correction
after treatment for idiopathic club foot (CTEV) by the
Ponseti method [15]. There was a statistically significant
difference between pre and postcorrection Pirani scores
and mean footprint angle (FPA) in their patients.
This study was planned to follow the results of correc-
tion by the Ponseti technique in our patients, to analyse the
demographic and other features of the populations of
responders and non-responders and to identify the factors
that resulted in relapse in these patients after initial cor-
rection. The general profile of our group of patients was
quite different from the usual reported population of CTEV
patients. There was a relatively higher incidence of male
patients in our population (62.8%). The incidence of
bilateral cases was 60 compared with 26 unilateral cases.
This was much higher than the figure reported in the lit-
erature (50% bilateralism). This could be attributed to
selection bias, because our institution was a referral centre
and the more severe manifestations were usually received
at our outpatient department. There was a 5.4% incidence
of atypical clubfoot in our population. The mean age at
presentation of the patients was 15.67 ± 6.57 weeks. This
was a significant deviation from the population of patients
who presented in the developed countries at birth. There
are, still, a large number of deliveries that are conducted at
home without proper trained attendants in our country. As a
result, a large number of CTEV cases are missed at the
neonatal period. Our sample could have also been biassed
for reasons stated earlier (because most of the neglected
patients are referred to our institution). The later age at
presentation and the atypical clubfeet were significantly
more resistant in our study. Ponseti had described inci-
dence of 2–3% of atypical clubfeet. He stated that these
feet were more resistant to the usual corrective technique,
and he described a different technique to correct these feet.
The pre-moulded foot–ankle brace developed to improve
compliance with bracing was also recommended for these
patients. We used the conventional correction technique for
all our feet irrespective of the nature of the deformity. This
could have been the reason for the higher incidence of
resistance to Ponseti correction of these feet by our
patients. The socio economic status of our patients did not
significantly affect correction of their deformity. However,
this factor had a significant bearing on relapse of the
deformity. The parents of patients belonging to lower socio
economic strata had a poor educational status and, there-
fore, poorer understanding of the need for continued
splintage. Parents from the poorer socio economic strata
also had difficulty in travelling long distances for regular
follow-up for a period of 3–4 years and changing the splint
as the children’s feet grew with age (most probably
because of economic constraints).
123
A. K. Mootha et al.
Non-compliance with regular splintage was revealed by
Ponseti as the most common cause of recurrence of the
deformity. Our study also confirmed this observation of
Ponseti. One limitation of our study, which was also noted
in a similar study reported in the literature, was the diffi-
culty of accurately assessing compliance. Objective mea-
sures of compliance were not available; therefore, verbal
reports of parents with regard to the use of the brace were
used as the primary means of assessing compliance. We
deviated a little from Ponseti’s procedure for splintage in
that Ponseti recommended splintage for 23 h a day for
3 months or the age of 1 year whichever is earlier and then
at night times till the age of 3 years. However we recom-
mended to all the parents in our study to continue bracing
for at least 16 h a day until the age of 1 year considering
the delayed age of presentation and willingness of the
parents. We arrived at an arbitrary value of 16 h per day
from our previous survey of parents whose children had
good response to the Ponseti technique without any relapse
(unpublished). The incidence of poor compliance in our
patients was 21.8%, which was quite high. We had a high
incidence of poor compliance despite having advised the
parents of the importance of regular long term splintage.
Some parents had also been reluctant in attending the fol-
low-up OPDs. With the Ponseti technique, we were able to
avoid posteromedial soft tissue release surgery in 82% of
our cases. The Ponseti technique has been a successful non-
operative modality of treatment for clubfoot. Many studies
have proved the efficacy of this technique for this condi-
tion. However, most of these studies have been in the
developed world. Our study was conducted at an apex
institute in India.
The age, presentation of the clubfeet, and the socio-
economic profile of our patients were quite different from
those in the developed world. The technique was equally
effective in Indian patients in achieving correction despite
these differences. Our study showed that the Ponseti
method should be the initial mode of treatment in our
patients also. However, there is a great need to identify
cases at a much earlier age for improved results. Our
study also showed a need to identify the atypical clubfeet
more effectively and use of greater care to correct these
feet. The major problem in our patients was the poorer
education level and socioeconomic status. These were
major hurdles in maintaining the correction once it was
achieved.
There is a need to concentrate especially on these high-
risk parents and to impress upon them the need for greater
conviction and commitment. It may also be suggested that
these parents need to be educated specially by the treating
doctors, with possible involvement of special NGOs, health
care workers, and community health personnel at the pri-
mary health care level.
CTEV management by Ponseti technique
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