Indian J Pediatr

DOI 10.1007/s12098-015-1860-x

REVIEW ARTICLE

Congenital Clubfoot: Early Recognition and Conservative

Management for Preventing Late Disabilities
Yubin Liu 1 & Dahang Zhao 1,2 & Li Zhao 1 & Hai Li 1 & Xuan Yang 1

Received: 30 April 2015 / Accepted: 22 July 2015

# Dr. K C Chaudhuri Foundation 2015

Abstract Congenital clubfoot is one of the most common
musculoskeletal deformities presenting at birth. Many high risk
factors have been associated with clubfoot such as male gender,
primiparous mothers and maternal smoking. Accurate under-
standing of clubfoot pathoanatomy is supposed to be the basis
for deformity correction. Prenatal ultrasonography is of refer-
ence value in recognizing clubfoot during pregnancy.
Neglected clubfoot can eventually cause a noticeable disability
and severely influence the quality life in adulthood. Early rec-
ognition and treatment are presumed to be the key for preven-
tion of late disabilities. Nowadays, Ponseti method, as one of
the conservative treatment regimen, has been widely accepted
because of the reported good results of long-term follow-up.
However, special attention should be paid to the details in clin-
ical practice for achieving even better correction and a lower
rate of relapse. After the complete correction, brace wearing is
critical for preventing deformity relapse. Non-compliance or
non-adherence with the brace protocol has been considered as
the predominant risk factor predisposing to the relapse of club-
foot, which is still a challenging problem. This paper was pre-
pared to give a general introduction about clubfoot, in terms of
the importance of early recognition and conservative manage-
ment, especially Ponseti method, for preventing late disabilities.
* Li Zhao
orthzl@126.com
1
Department of Pediatric Orthopedics, Xin-Hua Hospital, Shanghai
Jiao Tong University School of Medicine, No. 1665 Kongjiang
Road, Yangpu District, Shanghai 200092, China
2
The Third Department of Orthopedics, The First Affiliated Hospital
of Harbin Medical University, No. 23 Youzheng Street,
Harbin 150001, Heilongjiang Province, China
Keywords Clubfoot . Early recognition . Ponseti method .
Disability prevention
Introduction
Congenital clubfoot, i.e., congenital talipes equinovarus, de-
scribes a range of foot and ankle deformities usually present at
birth, which can be separated into four major components:
forefoot adduction, hindfoot varus, equinus and cavus
(Fig. 1). The term Bclubfoot^ refers to the way the foot is
positioned at a sharp angle to the ankle, like the head of a golf
club. Left untreated, clubfoot can eventually cause discomfort
and become a noticeable disability. Careful physical examina-
tion after birth by an experienced doctor is recommended as
an economical and effective measure for screening. Early rec-
ognition and intervention for clubfoot can help improve treat-
ment results and decrease the risk of late disabilities.
Definition and Epidemiology
Clubfoot could be isolated, which is commonly considered
idiopathic clubfoot [1], or associated with other medical syn-
dromes or neuromuscular disorders such as spina bifida,
myelomeningocele and arthrogryposis, which account for
about 20 % of all cases. Clubfoot can occur all around the
world with an incidence from 0.39 to 8 per 1000 live births
[2, 3]. The ratio of clubfoot between male and female is about
2:1 and up to 50 % of cases are bilateral [4]. Among unilateral
cases, the affected feet are more common in right side [5].
Although numerous hypotheses, such as neuromuscular,
bone, connective tissue and vascular factors, have been report-
ed [6], the precise etiology and pathogenesis of this deformity
remain unclear. However, clubfoot clusters in families suggest

Fig. 1 Four components of
clubfoot deformity: a Forefoot
adduction; b Hindfoot varus;
c Equinus; d Cavus
that genetic heredity may be an important causation for the
deformity. The increased risk was also observed in first-degree
relative of an affected person than in the general population
[2]. Unaffected parents with a clubfoot child have a chance of
1 in 40 that another son has clubfoot [3]. The evidence of
environmental factors for clubfoot etiology is scant and
often derived from poorly designed investigations. The
issue of environmental factor was firstly proposed in
1970s based on the work by Dunn [7]. Nowadays, many
high risk factors have been reported to be associated with the
occurrence of clubfoot such as male gender, primiparous
mothers, maternal smoking, high-intensity of alcohol
and coffee intake [8–11]. Other risk factors, such as
marital status, maternal diabetes, maternal age and level of
education, are still controversial and need further researches
[4, 9, 10, 12–14].
Pathoanatomy
Clubfoot is a three dimensional deformity of the foot and
ankle with the major pathologies at the tarsal bones. The de-
formity has four components: equinus, varus of hindfoot,
cavus and forefoot adductus. The talus is in severe plantar
flexion and its neck is medial and plantar deflection. The an-
terior portion of calcaneus lies directly beneath the head of the
talus, which is responsible for varus and equinus of the heel.
The navicular turns inward and articulates with the medial
surface of the talar head. The medial displacements of the
navicular, cuboid, cuneiforms and together with the metatar-
sals contribute to the adduction deformity. The cavus defor-
mity is produced by the slight downward displacement of the
Indian J Pediatr
cuneiforms and plantar flexion of the first metatarsal greater
than the fifth one (Fig. 2) [15].
The ligaments of the posterior and medial aspects of the
foot are thickened and shortened, severely restricting the foot
in the position of equinus and adduction. The severity of club-
foot deformity has a positive correlation with leg muscle sizes.
The muscles of tibialis posterior, gastrosoleus and toe flexors
are smaller in size and shorter. Excessive collagen synthesis is
observed in ligaments and tendons, and this progress may
persist until the child is 3 or 4-y-old [16]. The inherent prop-
erties of connective tissue, cartilage and bone can be remolded
by the changes of mechanical stimuli regularly, resulting in a
normal looking foot [17]. This may be the basis of manual
correction of the deformity.
Prenatal Examination
Birth defect is one of the leading causes of infant mortality and
disability. Early detection could lead to early treatment and
eventually improve the life quality of the patients. With the
widespread use of ultrasonography and improved techniques,
an increased detection of clubfoot has been made prenatally.
Because it is difficult to detect clubfoot deformity by means of
ultrasonography before the 16th wk of gestation [18], prenatal
detection of musculoskeletal disorders by means of obstetric
ultrasonography is performed usually around 20 wk of gesta-
tion. However, prenatal ultrasonography diagnosis of clubfoot
had a false positive (FP) rate between 0 and 29 % [19].
Glotzbecker et al. designed a novel sonographic scoring sys-
tem to improve detection of a true clubfoot and reduced the FP
rate to 7 % eventually as reported [20].
Indian J Pediatr

Fig. 2 Skeletal model showing

the pathologies in tarsal bones:
a Head (TH) and neck of talus are
plantarflexed and medially
deviated. Navicular (N) is
medially displaced on the talus;
b Cavus resulted from a greater
flexion of the first metatarsal bone

Parents may be extremely stressful about the immediate Conservative Treatment Methods
diagnosis after baby birth, especially when there is lack of
detailed information of clubfoot and explanations of progno- Owing to the fact that the etiology of clubfoot remains
sis. With a prenatal diagnosis of clubfoot, parents may be unknown, we can hardly treat this condition at the
more active to counsel for knowledge of clubfoot and prepare levels of ligament, tendon and muscle pathology, which
the families for the arrival of their babies. Prenatal detection may be the main causation [23]. The treatment goal of
avoids a surprise of clubfoot, and most mothers seem to ap- clubfoot is acquisition of a pain-free, functional and planti-
preciate having a prenatal diagnosis [21]. grade foot without the need to wear modified shoes.
Neglected clubfoot deformity can deter the development of a
normal gait, lead to a lifetime disability for the patient, limit
Diagnosis and Classification employment opportunities and socialization, and often result
in the problems at the family level. Besides, ostracism or
Although prenatal obstetric ultrasonography plays an impor-
tant part in clubfoot screening, a definite diagnosis of the
Table 1 Clubfoot incidence in association with various syndromes
clubfoot depends on typical clinical examination after birth,
which can be easily made by pediatrician, pediatric orthope- Syndromes Abnormalities except for clubfoot deformity
dist and even physical therapist. Classification of clubfoot can
be divided into four types based on the cause and response to Arthrogryposis Limited range of motion in the involved joints;
A firm, inelastic end point;
treatment as follows: idiopathic, postural, neurogenic and Lack of normal skin creases
syndromic clubfoot [22]. The idiopathic clubfoot, accounting Stickler syndrome Eye problems;
for most cases, occurs in an otherwise normal child. This Hearing difficulties;
deformity does not resolve spontaneously and the treatment Overly flexible joints;
should be started soon after the birth. The long-term follow-up Scoliosis and Osteoarthritis in adolescence
outcome with the Ponseti method is usually good or excellent. BTARP^ syndrome Atrial septal defect;
Robin sequence;
Postural clubfoot is a deformity secondary to intrauterine Persistence of the left superior vena cava
crowding. This type of foot deformity is flexible and usually Ampola syndrome Mental retardation;
becomes normal along with the time. Follow-up is mostly Facial anomalies;
recommended for the clinical observation. However, this type Short stature;
of deformity can occur at an early stage of a true clubfoot in Seizures and finger and toe abnormalities
preterm babies with the gestational age of 24 to 30 wk. Bruck syndrome Osteoporosis and bone fragility;
Progressive joint contractures
Neurogenic clubfoot is often associated with other neurolog-
De Grouchy syndrome A short stature;
ical disorders such as spina bifida and meningomyelocele, for
Hypotonia (Lack of muscle tone);
which correction is usually more difficult. Syndromic clubfoot Hearing impairment;
is one of the manifestations in the patient with a syndrome Distal hypoplastic tapering of lower legs;
such as multiarthrogryposis, Stickler syndrome and so on Vertical talus
(Table 1). Conservative treatment remains the first choice, Potter syndrome Limb contractures;
Sacral agenesis;
but may be more difficult. The prognosis of this type
Pulmonary hypoplasia;
may depend much more on underlying conditions than the Cranial anomalies
clubfoot.

derision derived from the deformed appearance of the foot and
ankle can also be a source of psychological harm. So, wide-
spread concern should be aroused to initiate a positive action
for clubfoot treatment at an early stage.
Treatment protocol has been shifted from a standard surgical
management to the conservative treatment over the past 2 de-
cades [24] because the extensive soft-tissue release was report-
ed to result in a scarred, stiff, weak and painful foot, and to
impair the quality of life significantly in the long-term follow-
up [25]. However, children with stunted, rigid feet or those with
a very severe deformity may still require a surgical procedure of
soft tissue release. Nowadays, most orthopedists have agreed
that the initial treatment of clubfoot should be non-operative,
meanwhile the prior choice is that including serial manipula-
tions and casts applied soon after the birth [26, 27]. The success
rate of clubfoot management mainly depends on the severity
and stiffness of the deformity. However, it is still difficult to
foresee how a clubfoot will respond to the treatment. For ex-
ample, some severe clubfeet may be easily corrected, while
some others may be corrected with great difficulties by means
of the same procedure of manipulation and casting.
Three conservative approaches for correction of clubfoot
named Kite, French and Ponseti methods were introduced as
follows:
Kite Method
According to the Kite method, the thumb in manipulating
should be located on the lateral side of the calcaneocuboid
joint, which may block the abduction of the calcaneus. As it
is reported, the incomplete or defective correction rate is up to
95 % [28]. Besides, the complications of Kite method include
the rocker-bottom deformity, fracture of metaphysis and stiff-
ness of the joint.
French Method
The French method, also known as Bfunctional method^, was
developed by Dr. Masse in 1970s [26]. It consists of daily
manipulation, muscles stimulation and correction mainte-
nance of the foot using non-elastic straps and splints. The
encouraging result was reported; almost 86.6 % of the cases
were excellent and good using this method [29]. However,
this method is very time consuming and difficult to master,
with a success rate depending on the skills of individual phys-
ical therapists [26, 29].
Ponseti Method
Nowadays, Ponseti method has become the most popular ap-
proach for the clubfoot management and its safety and
Indian J Pediatr
efficacy has been extensively demonstrated around the world
[30]. Great advantages of the Ponseti method have been found
in that it is easy to learn for spreading and affordable for
ordinary families with the initial correction rate even as high
as 100 % and excellent long-term follow-up outcomes [25, 31,
32]. Despite of the great popularity of the Ponseti method, the
regimen should be intensive and special attention should be
paid to the details for a higher success rate [33].
Practical Issues Relating to Ponseti Method
The Ponseti method, developed by Ignacio Ponseti in the late
1940s, is based on adequate understanding of the functional
anatomy of the foot and ankle. The outlines are as follows: 1)
all the deformities are corrected simultaneously; 2) cavus is
corrected at the first maneuver of manipulation to elevate the
first ray of foot; 3) to abduct the forefoot while applying
counter-pressure against the lateral aspect of the head of the
talus; 4) heel varus is corrected when the entire foot is fully
abducted, but the heel is never touched; 5) abduction of the
forefoot is increased progressively; 6) in the last cast, the foot
should be markedly abducted to 60° to 70° without pronation;
7) residual equinus is usually corrected by means of percuta-
neous Achilles tenotomy (PAT) with the indication when 15°
of ankle dorsiflexion is not obtained; 8) post PAT long-leg cast
is applied and left in place for 3 wk to allow for healing of the
Achilles tendon; 9) for maintaining the correction obtained by
manipulation with or without PAT, a well-molded plaster cast
is applied in 2 sections with knee flexed at 90° or more and the
cast is changed weekly; 10) when the full correction is
achieved, brace is used to maintain the foot at 60° to 70°
external rotation on the affected side and 30° to 40° on the
normal side.
The initial correction rate of this method can be achieved
reportedly in more than 95 % [25] and satisfactory clinical and
functional results have been demonstrated by long-term fol-
low-up of the patients [16, 23]. However, some practical is-
sues of the Ponseti method should be raised in clinical aspects.
According to the Ponseti method, treatment should be started
soon (7 to 10 d) after birth. However, Iltar et al. reported that
casting with the Ponseti method in infants older than 1 mo of
age or with an affected foot ≥8 cm in length had a better final
Dimeglio score [34]. In authors’ institute, they start the treat-
ment at 4 to 5 d after birth. The deformity could be corrected in
most cases with no more than five long-leg Ponseti casts (av-
erage 4.1 casts). The initial correction rate in the case of un-
treated idiopathic clubfoot is 100 % (Data not yet published).
To demonstrate the association between clubfoot and DDH
(developmental dysplasia of the hip) in the neonates so that
both conditions can be treated simultaneously at the possible
early stage, hip sonography is recommended in authors’
Indian J Pediatr

institute. According to Graf classification, the incidence of

Fig. 3 A boy, 6-wk-old, with clubfoot and DDH: a & b An Otto Bock
splint is worn after the fourth Ponseti cast; c An Otto Bock splint is worn
during the phase of foot abduction orthosis (reproduced with permission
from Zhao D, 2013 [35])
DDH is greater (2.7 %) in the neonates with idiopathic club-
feet [35]. These findings in authors’ institute help the early
recognition of DDH, which also requires the early interven-
tion for the better outcome (Fig. 3).
Clubfoot can be diagnosed immediately by first looking at
the foot. The question is raised as to how to accurately assess
the severity of the deformity at birth. Several assessment sys-
tems have been established to monitor and document the se-
verity of the deformity. Currently, Pirani and Dimeglio Score
systems have been widely used and a good correlation has
been demonstrated between these two systems [36]. Pirani
score is more commonly used to recognize the severity of each
component of the deformity, scored as 0 (normal), 0.5 (mild)
and 1 (severe). Besides, Pirani score can also help decide
when to perform a PAT procedure.
Successful management needs an adequate understanding of
pathoanatomy of clubfoot. Kite method was developed to cor-
rect foot equinus, varus and adductus deformities respectively
in a gradual fashion. As requested in this technique, the thumb
should be located on the lateral side of the calcaneocuboid joint,
which eventually leads to the failure of clubfoot correction. The
first element in the manipulation of Ponseti method is to correct
the cavus deformity by elevating the first ray of the forefoot
(Fig. 4). Elevation of the first metatarsal and supination of the
forefoot seems to be Bcounterintuitive^ for increasing the ap-
pearance of foot inversion. However, it is the most critical step
to position the forefoot in proper alignment with the hindfoot.
The cavus deformity is often corrected with the first plaster
cast. Then, the foot is abducted to correct adductus and varus

Fig. 4 Manipulative procedure:

a Supinate forefoot to correct
cavus; b Lateral head of talus is
the fulcrum; c Abduct forefoot to
correct adductus and varus;
d Before each cast is applied, the
foot is manipulated
 Indian J Pediatr

Fig. 5 Well-molded plaster cast:

a a long leg cast from toes to
groin; b the cast with knee at
flexion of 90° from lateral view

deformity simultaneously with counterpressure applied on the
lateral aspect of the head of the talus. Long leg plaster casts
(Fig. 5) from toes to groin are applied immediately to maintain
the position achieved by manipulation. This progress is repeat-
ed weekly until the full correction is completely obtained. The
total number of cast changes may be five or six. Cautions of
cast care should be informed by the practicing doctor, especial-
ly of poor circulation of toes end and cast slipping off.
When the talar head is covered, heel is in valgus, forefoot is
abducted 60° to 70° and the dorsiflexion is less than 15°, the
PAT procedure is required to correct the residual equinus un-
der local anaesthesia or sedation (Fig. 6). As reported in the
published studies, up to 70 to 75 % of patients underwent a
procedure of percutaneous Achilles tenotomy [37]. The suc-
cessful indication is that an additional 15 to 20° of dorsiflexion
at the ankle is gained after tenotomy. Then, a long leg cast
should be applied for 3 wk with the foot dorsiflexion at
15~20° and abducted at 70°. After removal of the final cast, a
foot abduction orthosis (Fig. 7) is prescribed immediately to
prevent the relapse of deformity. The brace consists of a pair
of straight high-top shoes and a connected bar. The shoes
should be placed at the position of abduction with 60 to 70°
for the affected foot and 30 to 40° for the normal foot. The
connected bar should be at shoulder length and bent at 5 to 10°
with the convexity away from the baby. The brace should be
worn at least 23 h per day for the first 3 mo, then a total of 14
to 16 h per day until the patient is 3 to 4-y-old [37]. In authors’
institute, they have slightly modified the brace protocol as:
full-time use for the first 3 mo, then 16 to 18 h until the age
of 2-y-old, and then 14 to 16 h until the end of 4-y-old. Long
term follow-up of this brace protocol has shown excellent
results of foot morphology and function (Data not yet pub-
lished). Skin irritation caused by brace wearing is often a big
problem in infants. So the feet should be examined several
times a day for the first week, and comfortable shoes with
application of soft liners are very necessary. The expected
outcome for the patients treated with the Ponseti method is
that the affected foot should be strong, flexible and pain free,

Fig. 6 Percutaneous Achilles

tenotomy (PAT): a When the talar
head is covered, heel is in valgus,
forefoot is abducted 60° to 70°
and the dorsiflexion is less than
15°, PAT is indicated; b The blade
is inserted at the level 1 to 1.5 cm
proximal to the heel tuberosity
where the Achilles tendon is
attached; c The dorsiflexion of
ankle reaches to 20° to 25° after
PAT with moderate compression
for 1 to 2 min on the cutting site to
control bleeding; d Dressing the
incision
Indian J Pediatr

Fig. 7 Brace and diagram for

FAO brace design: a The α angle
is 60° to 70° external rotation on
the affected side and 30° to 40° on
the normal side, The length
between two shoes (L) is equal to
the shoulder length; b The β
angle is 5° to 10° to hold the feet
at the valgus position; c The γ
angle is more than 15° to keep the
foot at the dorsiflexion;
d Mitchell-Ponseti Brace

but slightly shorter and narrower than the normal foot. Ponseti method soon after birth. Difficulties of the Ponseti
Figure 8 shows the appearance at the pre-treatment and method involve perineum hygiene, skin irritations and anxiety
follow-up in a case, who underwent the management using from Achilles tenotomy.

Fig. 8 A boy with bilateral

clubfeet before and after the
management using Ponseti
method: a & b the prominent
deformities were observed in
bilateral feet before treatment;
c–f good morphology and
function of bilateral feet after
treatment, c dorsal appearance,
d lateral view of ankle at dorsal
flexion, e and f posterior view of
the heels in neutral position with
white arrows indicating the tiny
incision scar from PAT

Fig. 9 Clinical tips for recognizing brace compliance: White arrows
indicate the slightly narrowing appearance above the ankles. This was
one of our patients, who had worn the brace by 23 hours per day
adherently for about 2 mo
Bracing Compliance
The bracing phase of the method, which is the only effective
way for relapse prevention, requires the efforts from not only
providers but also patients and parents. General education on
brace compliance is therefore, necessary. The patient educa-
tion is very important to ensure the bracing compliance and/or
adherence to the primary requisite of the Ponseti method,
because brace phase is critical in maintaining correction
and preventing relapse despite of a number of variables
reported to be associated with the occurrence of relapse.
Nowadays, it is suggested in a number of published
studies that non-compliance with the brace regime is
closely associated with the relapse of deformity [25,
31, 32]. The importance of brace-wearing should be stressed
to the parents at the beginning of treatment and an internet-
based platform created by the physicians to introduce the
Ponseti method is of great necessity for parents' education.
The parents or caregivers should be encouraged to call or visit
the clinic if they experience any problems during the
brace phase. At each visit to the clinic, the physician
should ask how many average hours the child keeps
wearing the brace each day and discuss with the parents
the difficulties of brace wearing. Encouraging calls and
shorter interval for follow-up are helpful for brace com-
pliance to address any problems that the parents may
encounter. A useful clinical tip for recognizing brace
compliance is the slightly narrowing appearance above
the ankles (Fig. 9). The most important factor for brace
wearing is to confirm proper seating of the heel in the
brace.
There are many reasons for brace non-compliance such as
physician’s poor training in the Ponseti method, poor commu-
nication between physician and parents, low educational level
of caregivers, annual family income, physical distance and
transport [31, 38–40]. The most common reason for non-
Indian J Pediatr
compliance is the discomfort in brace wearing. Several novel
types of newly designed foot abduction orthosis (FAO), such
as dynamic foot abduction orthoses [41, 42], unilateral foot
abduction orthoses [43] and comfortable shoe braces, have
been reported with their expectation to improve compliance
or adherence. Furthermore, education of the Ponseti method
and the efforts in encouraging calls and regular patient’s visit
are also very helpful for brace compliance. It is still uncertain
whether the intensified education on bracing compliance
or adherence is required in a certain group of patients
with potential risks for relapsing. Early relapse of defor-
mity, characterized by the loss of foot abduction and
dorsiflexion, is still a challenging problem for orthope-
dists to manage. Repeated treatment of serial manipula-
tion and casting is the prior choice to correct the relapsed
deformity. Transfer of anterior tibialis is indicated in some
of the cases presenting with dynamic supination during
the swing phase of gait, which is usually evaluated after
walking.
Conclusions
Early recognition of congenital clubfoot is critical for
family education and appropriate referral to the pediatric
orthopedic specialist. Early and proper treatment can
lead to a good long-term result. Ponseti method of club-
foot management, one of the conservative, suitable and
currently worldwide-accepted regimens, has a good out-
come with radical reduction of extensive surgery [24] in
most cases of clubfoot according to the published stud-
ies for the treatment as early as 4 or 5 d after birth and
is of significant value in preventing late disabilities in
terms of safety, efficiency, effectiveness and economical
healthcare resource. Ponseti method requires not only metic-
ulous attention to the technical details, but also dedicated
care to the post-correction phase of brace wearing,
whose value in preventing relapse of deformity seems
to be not often stressed enough. The education of brace
importance in patients and parents is the elementary part
in implementing this method.
Contributions YL was responsible for searching the literature and
drafting the manuscript, DZ did the data collection and drafted the part
of the manuscript, LZ planned this review and formatted the manuscript,
HL did literature reading and analysis, and XY did data collection and
interpretated the clinical relevance. YL and DZ contributed equally to this
article.
Conflict of Interest None.
Source of Funding None.
Indian J Pediatr
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