High Yield Overview

CLUBFOOT - CONGENITAL TALIPES EQUINOVARUS

CAVE Deformity | Ponseti Method Gold Standard | Tenotomy in 90% | Bracing Critical

1:1000Live births incidence

50%Bilateral cases

2:1Male to female ratio

95%Ponseti success rate

PIRANI SEVERITY SCORING

Mild

PatternScore 0-2

Treatment4-5 casts, possible tenotomy

Moderate

PatternScore 2.5-4

Treatment5-6 casts, tenotomy likely

Severe

PatternScore 4.5-6

Treatment6-7+ casts, tenotomy, possible PTT

Critical Must-Knows

CAVE deformity: Cavus, Adductus, Varus, Equinus - corrected in this specific order
Ponseti method: Gold standard - serial casting corrects all except equinus, then tenotomy
Tenotomy timing: After foot corrected to 60-70 degrees abduction, perform percutaneous Achilles tenotomy
Bracing critical: FAO (foot abduction orthosis) prevents recurrence - 23hrs/day for 3 months then nighttime until age 4-5
Recurrence causes: Non-compliance with bracing is the #1 cause, occurs in 30-40% without proper bracing

Examiner's Pearls

"
Correct cavus FIRST by supinating the forefoot to align with hindfoot
"
Never pronate the forefoot - worsens cavus and creates rocker-bottom deformity
"
Talar head is the fulcrum for correction - thumb pressure over lateral talar head
"
Abduction occurs at calcaneocuboid joint, NOT midfoot

Clinical Imaging

Imaging Gallery

(A) X-ray of right hand demonstrating absence of middle and distal phalanges of digits 4 and 5; (B) x-ray of left hand shows cutaneous syndactyly of digits 2 and 3; (C) split right foot with missing m — (A) X-ray of right hand demonstrating absence of middle and distal phalanges of digits 4 and 5; (B) x-ray of left hand shows cutaneous syndactyly of dCredit: Kruszka P et al. via Mol Genet Genomic Med via Open-i (NIH) (Open Access (CC BY))

Case 2. Postmortem radiography and MRI in a male foetus with congenital high airway obstruction syndrome who was terminated at 24 weeks’ gestation. a Postmortem anteroposterior skeletal radiograph sho — Case 2. Postmortem radiography and MRI in a male foetus with congenital high airway obstruction syndrome who was terminated at 24 weeks’ gestation. a Credit: Arthurs OJ et al. via Pediatr Radiol via Open-i (NIH) (Open Access (CC BY))

Part I. (A–D) Anteroposterior and lateral roentgenograms of the feet of a six-week-old baby boy with severe congenital club feet. In the anteroposterior roentgenograms, the talus and calcaneus are sup — Part I. (A–D) Anteroposterior and lateral roentgenograms of the feet of a six-week-old baby boy with severe congenital club feet. In the anteroposteriCredit: Ponseti IV et al. via Clin. Orthop. Relat. Res. via Open-i (NIH) (Open Access (CC BY))

Critical Clubfoot Exam Points

Ponseti Order of Correction

CAVE order is critical: Correct Cavus first (supinate forefoot), then Adductus and Varus together (abduct around talar head), then Equinus last (Achilles tenotomy). Never dorsiflex before foot is abducted - creates rocker-bottom deformity.

Talar Head Fulcrum

Thumb pressure on lateral talar head is the key to correction. The talar head can be palpated anterolateral to the ankle. All abduction and varus correction occurs by rotating the foot around this fixed point. Do NOT apply countertraction on calcaneus.

Tenotomy Indications

Percutaneous Achilles tenotomy required in 90% of cases. Indications: Foot abducted to 60-70 degrees but cannot dorsiflex past neutral. Perform under local anesthesia as outpatient procedure. Tendon regenerates in 3 weeks in long leg cast.

Bracing Prevents Recurrence

Foot Abduction Orthosis (FAO) is mandatory for 4-5 years. Boots fixed to bar at 70 degrees external rotation (60 degrees for unilateral). Shoulder-width apart. Non-compliance causes 80% of recurrences. Educate parents extensively.

Quick Decision Guide - Clubfoot Management

Clinical Scenario	Findings	Treatment	Key Pearl
Newborn with typical idiopathic clubfoot	CAVE deformity, Pirani 4-6, flexible	Ponseti casting starting week 1-2, tenotomy, FAO	Start early, parents as partners in treatment
Syndromic clubfoot (arthrogryposis, myelomeningocele)	Rigid, associated anomalies, resistant	Extended Ponseti, often surgical release needed	Stiffer feet need more casts, higher recurrence
Relapsed clubfoot after initial Ponseti	Recurrent equinus or varus, loss of abduction	Repeat casting, tenotomy, tibialis anterior transfer if over 2.5 years	Check bracing compliance first
Neglected clubfoot (older child, walking age)	Rigid deformity, callosities, adapted gait	Soft tissue release or osteotomies depending on age/rigidity	Ponseti less effective after walking age

Mnemonic

CAVECAVE - Clubfoot Deformity Components

Cavus

High medial arch from plantar-flexed 1st ray

Adductus

Forefoot adducted (deviated medially) at midfoot

Varus

Hindfoot in varus (heel turned inward)

Equinus

Ankle in plantar flexion (foot points down)

Memory Hook:CAVE - the foot is hiding in a cave, all curled up. Correct in this exact order during Ponseti treatment.

Mnemonic

PIRANIPIRANI - Severity Score Components

Posterior crease

Deep posterior heel crease (0, 0.5, 1)

Inflexible equinus

Rigid equinus deformity (0, 0.5, 1)

Rigid hindfoot

Empty heel - calcaneus not palpable (0, 0.5, 1)

Adduction of forefoot

Curved lateral border (0, 0.5, 1)

No talar head coverage

Lateral talar head palpable (0, 0.5, 1)

Inflexible medial crease

Deep medial crease (0, 0.5, 1)

Memory Hook:PIRANI scores 0-6 total (3 hindfoot + 3 midfoot signs). Higher score = more severe. Guide treatment intensity.

Mnemonic

PONSETIPONSETI - Treatment Steps

Position

Supinate forefoot to correct cavus first

Outward rotation

Abduct foot around talar head (correct varus/adductus)

No countertraction

Do not push on calcaneus or evert foot

Serial casting

5-7 casts, changed weekly

Equinus last

Percutaneous Achilles tenotomy corrects equinus

Tendon regeneration

Cast 3 weeks post-tenotomy in maximum dorsiflexion

Insist on bracing

FAO bracing for 4-5 years prevents recurrence

Memory Hook:PONSETI is the name and the method - follow his exact technique for 95%+ success rate.

Overview and Epidemiology

Clubfoot (Congenital Talipes Equinovarus - CTEV) is one of the most common congenital musculoskeletal deformities. It is a complex three-dimensional deformity of the foot and ankle characterized by equinus, varus, adduction, and cavus (CAVE).

Epidemiology:

Incidence varies by ethnicity: Maori/Polynesian 6-7:1000, Caucasian 1:1000, Asian 0.5:1000
Male to female ratio 2:1
Bilateral in 50% of cases
Positive family history in 25% (multifactorial inheritance)

Idiopathic vs Syndromic

80% of clubfoot is idiopathic (isolated deformity in otherwise normal child). 20% is associated with syndromes (arthrogryposis, myelomeningocele, Larsen syndrome, diastrophic dysplasia) or other anomalies. Syndromic clubfoot is more rigid, has higher recurrence rates, and often requires surgical intervention.

Etiology:

Genetic Factors

Multifactorial inheritance: 25% have affected family member
Concordance: 33% in monozygotic twins, 3% in dizygotic
Genes implicated: PITX1, TBX4, muscle contractile proteins
Risk: 3-4% if one sibling affected, 10-20% if parent affected

Environmental Factors

Intrauterine crowding: Oligohydramnios association
Smoking: Maternal smoking increases risk 1.5-2x
Neuromuscular imbalance: Theory of muscle abnormality
Vascular disruption: Proposed mechanism in some cases

Associated Conditions (screen all patients):

Hip dysplasia (DDH): 3-5% association - clinical hip exam required
Torticollis: 5% association - examine neck
Myelomeningocele: Examine spine for dimple, tuft, lipoma
Syndromes: Look for multiple congenital anomalies

Pathophysiology and Mechanisms

Three-Dimensional Deformity

The clubfoot deformity involves abnormal relationships between the talus, calcaneus, navicular, and cuboid. Understanding the pathoanatomy is essential for correction.

Bones and Their Positions in Clubfoot

Bone	Normal Position	Clubfoot Position	Correction Goal
Talus	90 degrees tibiotalar articulation	Plantar flexed, externally rotated, laterally tilted in mortise	Cannot be directly manipulated - other bones rotate around it
Calcaneus	Below talus, neutral alignment	Inverted (varus), adducted, rotated under talus	Abduct and evert by stretching medial structures
Navicular	Aligned with talar head	Severely medially displaced, may abut medial malleolus	Reduce onto talar head with abduction
Cuboid	Aligned with calcaneus	Medially displaced relative to calcaneus	Follows correction of calcaneus

Talus is the Key

The talus is the fixed point around which all correction occurs. In clubfoot, the talus is plantar flexed in the ankle mortise and externally rotated relative to the leg. You cannot directly manipulate the talus. Instead, the navicular, calcaneus, and cuboid are rotated laterally around the talar head through Ponseti manipulation.

Soft Tissue Contractures

Contracted Structures (Medial/Posterior)

Achilles tendon: Causes equinus - requires tenotomy
Posterior tibial tendon: Contributes to varus and adduction
Toe flexors (FDL, FHL): May contribute to cavus
Tibionavicular ligament: Tethers navicular medially
Plantar fascia: Contributes to cavus
Deltoid ligament: Fibrosed, limits valgus

Attenuated Structures (Lateral)

Peroneal tendons: Stretched over lateral malleolus
Lateral ligaments: Attenuated from varus position
Calcaneofibular ligament: May be lax
Anterior talofibular ligament: Stretched

Muscle and Tendon Abnormalities

Muscle Fiber Abnormalities

Histological studies show increased Type 1 muscle fibers (slow twitch) in clubfoot muscles, with smaller fiber diameter and increased collagen content. This contributes to the stiffness of the deformity. The posterior compartment muscles (gastrocnemius, soleus) are particularly affected.

Biomechanics of Correction:

Cavus is corrected by supinating the forefoot (aligning 1st ray with hindfoot)
This creates a single fulcrum for correction at talar head
Abduction stretches contracted medial structures
Calcaneus derotates and everts beneath talus
Equinus is addressed last via Achilles tenotomy

Classification Systems

Pirani Severity Scoring System

Most widely used clinical scoring system - assesses 6 clinical signs to guide treatment and predict outcomes.

Category	Sign	0 (Normal)	0.5 (Moderate)	1 (Severe)
Hindfoot	Posterior crease	Multiple fine creases	1-2 moderate creases	Single deep crease
Hindfoot	Empty heel	Calcaneus easily palpable	Partially palpable	Calcaneus not palpable
Hindfoot	Rigidity of equinus	Foot dorsiflexes	Slight dorsiflexion	No dorsiflexion possible
Midfoot	Curved lateral border	Straight lateral border	Mild curve	Severe curve/comma shape
Midfoot	Medial crease	Multiple fine creases	1-2 moderate creases	Single deep crease
Midfoot	Talar head coverage	Navicular covers talar head	Partial coverage	Talar head fully palpable laterally

Using Pirani Score

Total score 0-6 (3 hindfoot + 3 midfoot). Score decreases with successful treatment. Use midfoot score to predict number of casts needed. Use hindfoot score (especially empty heel) to predict need for tenotomy. Tenotomy indicated when hindfoot score reaches 0.5-1 but equinus persists.

Clinical Assessment

History:

Prenatal History

Ultrasound diagnosis: Can be seen from 12-16 weeks gestation
Oligohydramnios: Associated with clubfoot
Family history: First-degree relatives with clubfoot
Other anomalies seen: Hip dysplasia, spina bifida

Birth and Neonatal History

Gestational age: Prematurity not protective
Birth trauma: Not a cause of idiopathic clubfoot
Other congenital anomalies: Hands, spine, hips
Syndrome features: Multiple anomalies suggest syndromic

Physical Examination:

Systematic Examination

Clubfoot Examination Sequence

Step 1Inspection

Visual assessment:

Confirm CAVE deformity components present
Compare bilateral (50% bilateral, may be asymmetric)
Look for skin creases (medial and posterior - severity markers)
Assess calf size (smaller on affected side - 1-2cm difference persists)
Examine spine for stigmata of spinal dysraphism (dimple, tuft, lipoma)

Step 2Palpation

Key palpable landmarks:

Talar head: Should be covered by navicular - in clubfoot, palpable laterally
Calcaneus (empty heel sign): Posterior calcaneus difficult to palpate in severe cases
Forefoot-hindfoot alignment: Is forefoot supinated relative to hindfoot?
Muscle bulk: Calf wasting, anterior compartment

Step 3Range of Motion (Reducibility)

Ponseti manipulation test:

Supinate forefoot to correct cavus - does arch flatten?
Abduct forefoot with talar head as fulcrum - how much correction?
DO NOT test dorsiflexion until foot is corrected - will create rocker-bottom
Score flexibility using Pirani or Dimeglio

Step 4Associated Examination

Screen for associated conditions:

Hips: Barlow and Ortolani tests for DDH (3-5% association)
Spine: Midline stigmata - dimple, tuft, lipoma (spinal dysraphism)
Neck: Torticollis (5% association)
Full neurological exam: Syndromic clubfoot may have other findings

Rule Out Syndromic Causes

20% of clubfoot is syndromic. Red flags include: bilateral severe rigid clubfoot, other limb anomalies, facial dysmorphism, multiple joint contractures (arthrogryposis), spine abnormalities (myelomeningocele). Syndromic clubfoot has higher recurrence rates and often requires surgical intervention despite initial Ponseti success.

Investigations

Clinical Diagnosis

Clubfoot is a CLINICAL diagnosis. Imaging is NOT required for diagnosis or routine management. X-rays are reserved for atypical cases, assessment of correction post-treatment, or evaluation of relapse/recurrence.

Imaging Indications:

When to Order X-rays

Atypical clubfoot: Features not consistent with idiopathic
Post-treatment assessment: Confirm correction achieved
Relapse evaluation: Assess bone deformity vs soft tissue recurrence
Pre-operative planning: Before surgical correction
Research purposes: Radiographic outcome measures

X-ray Views

AP foot: Talocalcaneal angle (normally 20-40°, reduced in clubfoot)
Lateral foot: Tibiocalcaneal angle, talus-1st MT alignment
Stress views: Maximal dorsiflexion lateral to assess equinus correction
Kite's angle: Talus-calcaneus parallelism indicates persistent deformity

Radiographic Measurements:

Key Radiographic Angles in Clubfoot

Measurement	Normal Value	Clubfoot Finding	Clinical Significance
AP talocalcaneal angle	20-40 degrees	Less than 20 degrees (parallel)	Hindfoot varus - bones parallel
Lateral talocalcaneal angle	25-50 degrees	Less than 25 degrees	Persistent equinus/varus
AP talo-1st MT angle	0-20 degrees	Negative (overlapping)	Forefoot adduction
Lateral tibiocalcaneal angle	10-40 degrees	Less than 10 degrees	Equinus deformity

Other Investigations:

Genetic testing: If syndromic features present (karyotype, specific gene panels)
Spine MRI: If sacral dimple, tuft, or other spinal dysraphism stigmata
Hip ultrasound: If clinical exam concerning for DDH (routine US not required)

Management Algorithm

Ponseti Technique - Gold Standard

95% success rate when performed correctly and bracing compliance achieved.

Ponseti Treatment Steps

Cast 1Step 1: Correct Cavus First

Supinate the forefoot relative to hindfoot:

Elevate the 1st ray to align with lesser rays
This flattens the arch and creates a single lever
DO NOT dorsiflex or pronate the forefoot
First cast holds this position

Casts 2-5Step 2: Abduct Around Talar Head

Correct adductus and varus together:

Thumb pressure on lateral talar head (NOT calcaneus)
Abduct forefoot and midfoot as a unit
Calcaneus follows and everts beneath talus
Progressive abduction each cast (60-70 degrees goal)
Casts changed weekly - each gains 10-15 degrees

After 5-7 castsStep 3: Percutaneous Achilles Tenotomy

Required in 90% of cases when:

Foot abducted to 60-70 degrees
Cannot dorsiflex past neutral
Performed under local anesthetic as outpatient
Complete tenotomy 1cm above insertion
Final cast in maximum dorsiflexion for 3 weeks

Post-castingStep 4: Foot Abduction Orthosis (FAO)

Dennis-Browne bar with boots:

70 degrees external rotation (60 degrees unilateral)
Shoulder-width bar
23 hours/day for 3 months
Then nighttime only (12 hours) until age 4-5 years
Non-compliance causes 80% of recurrences

Never Dorsiflex Before Abduction

Dorsiflexing the uncorrected clubfoot creates a rocker-bottom deformity. The talus remains in equinus and the midfoot breaks instead. Always correct cavus first, then abduct to 60-70 degrees, THEN address equinus with tenotomy.

Surgical Technique

Percutaneous Achilles Tenotomy

Indicated in 90% of Ponseti-treated clubfeet after adequate abduction achieved.

Tenotomy Procedure

Step 1Preparation

Outpatient procedure:

Local anesthesia (0.5-1ml 1% lidocaine) or EMLA cream
No sedation typically required
Hold foot in dorsiflexion to identify tight cord
Mark tenotomy site 1cm above calcaneal insertion

Step 2Tenotomy Technique

Technique:

11 or 15 blade scalpel
Enter skin medial to Achilles tendon
Blade parallel to tendon, then rotate 90 degrees
Cut from anterior (deep) to posterior (superficial)
Audible/palpable pop when tendon divides
Foot should immediately dorsiflex 15-20 degrees

Step 3Post-Tenotomy Cast

Final casting:

Long-leg cast in maximum dorsiflexion (aim 15 degrees above neutral)
Maintain 70 degrees abduction
Leave cast 3 weeks for tendon regeneration
Tendon heals in lengthened position

Tenotomy Safety

Posterior tibial artery and nerve are located anteromedial to Achilles tendon. By entering medially with blade parallel to tendon, then rotating, the blade moves away from neurovascular structures. Complete tenotomy is important - incomplete section leads to inadequate correction.

Complications

Complications of Clubfoot Treatment

Complication	Cause	Prevention	Management
Recurrence (30-40%)	Non-compliance with bracing, inadequate initial correction	Parent education, proper bracing protocol, regular follow-up	Repeat Ponseti casting, tenotomy, TATT if over 2.5 years
Rocker-bottom deformity	Dorsiflexion before abduction corrected	Correct CAVE in proper order, never dorsiflex early	Difficult - may need plantar release, casting, or osteotomy
Flat-top talus	Excessive dorsiflexion, repeated aggressive manipulation	Gentle manipulation, proper tenotomy timing	Avoid continued dorsiflexion, may need osteotomy later
Skin complications	Tight casts, pressure sores, slippage	Proper padding, well-molded casts, weekly changes	Cast removal, local wound care, delay recasting if needed
Tibialis anterior weakness post-TATT	Surgical technique, scarring	Careful tendon handling, appropriate rehabilitation	Physiotherapy, usually mild and improves
Overcorrection (calcaneus deformity)	Excessive surgical release	Use Ponseti method, avoid extensive release	Difficult to treat - may need posterior ankle block

Recurrence Timeline

Recurrence typically occurs between 6 months and 4 years of age, corresponding to the period of active bracing. Recurrence after age 5 is rare if proper treatment achieved. Most recurrences are due to bracing non-compliance. First signs: loss of dorsiflexion, returning heel varus, dynamic forefoot supination.

Postoperative Care and Rehabilitation

Post-Treatment Protocol

Week 0-3Immediate Post-Tenotomy

Final long-leg cast:

Maximum dorsiflexion (15+ degrees)
70 degrees abduction
Cast remains 3 weeks for tendon healing
Tendon regenerates in lengthened position

Week 3 - Month 3Initial FAO Phase

Full-time bracing (23 hours/day):

Fit FAO immediately upon cast removal
Remove only for bathing
Check skin daily for pressure areas
Proper sock application prevents blisters

Month 3-6Transition Phase

Gradual weaning:

Reduce to 18-20 hours/day
Allow out of brace for supervised play
Continue night and nap time wear
Regular clinic follow-up every 2-3 months

Month 6 - Age 4-5 yearsLong-Term Maintenance

Nighttime bracing:

12-14 hours overnight (including naps)
Continue until age 4-5 years
Check brace fit as feet grow
Annual or bi-annual follow-up

Parent Education Points:

Bracing is the most important factor for success
Recurrence is preventable with proper compliance
Signs to watch for: tightness, loss of dorsiflexion, in-toeing
Calf size difference is permanent (1-2cm smaller)
Foot size may be 0.5-1.5 sizes smaller on affected side

Outcomes

Clinical Outcomes After Ponseti Treatment

Bilateral clubfoot after Ponseti treatment - anterior view at 5-year follow-up — Anterior view of bilateral feet at 5-year follow-up after Ponseti method treatment. Both feet are well-corrected with plantigrade position, normal foot alignment, and no residual forefoot adductus. This demonstrates the excellent long-term outcomes achievable with the Ponseti method and proper bracing compliance.Credit: Porecha MM et al., J Orthop Surg Res (PMC3031260) - CC-BY

Bilateral clubfoot after Ponseti treatment - posterior view showing gait — Posterior view during walking at 5-year follow-up showing bilateral heels in neutral alignment with no residual varus deformity. Note the symmetric heel position and good functional gait pattern. Calf size asymmetry (1-2cm smaller on affected side) is a permanent finding that does not affect function.Credit: Porecha MM et al., J Orthop Surg Res (PMC3031260) - CC-BY

Long-Term Outcomes:

Ponseti-treated feet have better function, motion, and strength than surgically released feet
Most patients achieve plantigrade, pain-free, functional feet
Calf size difference persists (smaller on affected side)
Foot size difference may persist (0.5-1.5 sizes smaller)
Full sports participation usually possible

Predictors of Poor Outcome:

Syndromic clubfoot (arthrogryposis, myelomeningocele)
Severe initial Pirani score with rigid deformity
Non-compliance with bracing
Delayed treatment initiation (after 6 months of age)
Extensive surgical release

Ponseti vs Surgical Release

Long-term studies show Ponseti-treated feet are stronger, more flexible, and have less pain than surgically released feet. Surgery should be reserved for failed Ponseti treatment only. The "French functional method" (physiotherapy-based) is an alternative but requires more resources and has similar outcomes to Ponseti.

Evidence Base

Ponseti Method Original Outcomes

Ponseti IV, Smoley EN • J Bone Joint Surg Am (1963)

Key Findings:

35-year follow-up of manipulation and casting technique for clubfoot
89% good or excellent results with proper technique
Recurrence rate 30-40% without bracing, less than 10% with bracing
Tenotomy required in 85-90% of cases for residual equinus

Clinical Implication: Established the Ponseti method as an effective, reproducible treatment for idiopathic clubfoot.

Limitation: Case series without control group, early era without standardized bracing protocols.

Long-Term Follow-Up Ponseti vs Surgical Release

Zionts LE et al • Clin Orthop Relat Res (2010)

Key Findings:

Comparative study of Ponseti method vs comprehensive surgical release
Ponseti group had significantly better ankle range of motion
Ponseti group had stronger calf muscles on isokinetic testing
Surgical release group had more stiffness and pain

Clinical Implication: Confirms superiority of Ponseti method over surgical release for functional outcomes.

Limitation: Retrospective comparison, different eras of treatment.

Importance of Bracing Compliance

Dobbs MB et al • J Bone Joint Surg Am (2004)

Key Findings:

Prospective study of bracing compliance in 257 patients
Recurrence rate 6% in compliant families vs 47% in non-compliant
Bracing continued until age 4 years was most protective
Parent education and socioeconomic support improved compliance

Clinical Implication: Bracing compliance is the single most important factor preventing recurrence. Resources should focus on parent education and support.

Limitation: Self-reported compliance may be inaccurate.

Tibialis Anterior Transfer for Relapse

Ponseti IV • Clin Orthop Relat Res (2009)

Key Findings:

TATT indicated for dynamic supination in children over 2.5 years
Success rate over 85% in preventing further recurrence
Best results when foot is passively correctable
Combined with additional Ponseti casting before and after surgery

Clinical Implication: TATT is an effective treatment for recurrent dynamic supination but requires proper patient selection.

Limitation: Case series, no randomized comparison.

Ponseti Method in Low-Resource Settings

Pirani S et al • East Afr Med J (2009)

Key Findings:

Large-scale implementation of Ponseti method in Uganda
Over 2000 children treated with 95% initial correction rate
Local healthcare workers trained successfully
Bracing compliance was the main challenge

Clinical Implication: Ponseti method is universally applicable and can be taught to non-specialist healthcare workers.

Limitation: Follow-up rates lower in low-resource settings.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 2-week-old baby boy is referred with bilateral clubfeet diagnosed on prenatal ultrasound. Describe your assessment and management plan."

VIVA Q&A

Q1:How would you assess this baby?

I would confirm the diagnosis of bilateral idiopathic clubfoot by examining for the CAVE deformity: Cavus (high arch), Adductus (forefoot deviated medially), Varus (heel turned inward), Equinus (ankle plantarflexed). I would assess severity using the Pirani score, evaluating 3 midfoot signs (curved lateral border, medial crease, talar head coverage) and 3 hindfoot signs (posterior crease, empty heel, rigid equinus), each scored 0, 0.5, or 1 for a total of 0-6. I would examine the hips for developmental dysplasia (5% association), the spine for midline stigmata suggesting spinal dysraphism, and the neck for torticollis.

Q2:What is your management plan?

I would initiate the Ponseti method, which is the gold standard treatment with 95% success rate. This involves serial above-knee casting with weekly changes. The key is correcting deformities in the correct order: first correct cavus by supinating the forefoot, then correct adductus and varus simultaneously by abducting the foot around the talar head as the fulcrum. After achieving 60-70 degrees abduction (typically 5-7 casts), I would assess equinus. In 90% of cases, percutaneous Achilles tenotomy is required, followed by 3 weeks of casting in dorsiflexion. Finally, foot abduction orthosis bracing is critical for 4-5 years.

Q3:What advice would you give the parents about bracing?

I would emphasize that bracing is the most important factor in preventing recurrence. Without proper bracing, recurrence rates are 30-40%; with proper bracing, they drop to 5-10%. The bracing protocol is: boots attached to a bar at 70 degrees external rotation, shoulder-width apart. Full-time wear (23 hours/day) for the first 3 months, then nighttime only (12 hours) until age 4-5 years. The boots should be checked for fit every 3 months. I would see them regularly to monitor compliance and early signs of recurrence.

KEY POINTS TO SCORE

CAVE order of correction is critical - cavus first, equinus last

Pirani scoring assesses severity and guides treatment

Tenotomy indicated after abduction achieved but equinus persists

Bracing compliance is the key to preventing recurrence

COMMON TRAPS

✗Dorsiflexing before abduction causes rocker-bottom deformity

✗Pushing on calcaneus blocks correction

✗Incomplete tenotomy leads to inadequate correction

LIKELY FOLLOW-UPS

"What is the role of tibialis anterior transfer?"

"How would you manage recurrence at age 3?"

"What features suggest syndromic rather than idiopathic clubfoot?"

VIVA SCENARIOChallenging

EXAMINER

"A 3-year-old child presents with recurrent clubfoot deformity 2 years after initially successful Ponseti treatment. The parents report they stopped using the brace at 18 months because the child refused to wear it."

VIVA Q&A

Q1:How would you assess this child?

I would assess the degree and nature of recurrence. This includes examining for return of CAVE components: Does the hindfoot sit in varus? Is there forefoot adduction? Can I dorsiflex past neutral? Is there dynamic supination during gait? I would determine if the deformity is flexible (passively correctable) or fixed (rigid). I would also assess calf size, foot size, and overall function. The Pirani score can be used again to quantify severity.

Q2:What are your management options?

For a 3-year-old with recurrence, I would consider: (1) Repeat Ponseti casting - still effective up to walking age and sometimes beyond for flexible feet, (2) Repeat percutaneous Achilles tenotomy if equinus is the main issue, (3) Tibialis anterior transfer (TATT) - indicated for dynamic supination in children over 2.5 years, transferred from medial cuneiform to lateral cuneiform to balance the foot. For fixed bony deformity, soft tissue release or osteotomies may be needed, though I would try conservative measures first.

Q3:How would you counsel the parents about bracing going forward?

I would explain that non-compliance with bracing caused this recurrence and emphasize that proper bracing going forward is critical to prevent further relapses. After repeat treatment, the FAO must be worn nighttime (12-14 hours) until age 4-5 years. I would address any barriers to compliance - discomfort, fit issues, or child resistance - and offer solutions like proper sock liners or different brace styles. I would see them more frequently to monitor compliance and catch early recurrence.

KEY POINTS TO SCORE

Non-compliance with bracing is the commonest cause of recurrence

TATT is indicated for dynamic supination in children over 2.5 years

Repeat Ponseti casting often effective for flexible recurrence

Fixed deformity may require surgical correction

COMMON TRAPS

✗TATT does not address fixed bony deformity

✗Extensive surgical release has poor long-term outcomes

LIKELY FOLLOW-UPS

"How would you counsel the parents?"

"What is the technique for tibialis anterior transfer?"

VIVA SCENARIOCritical

EXAMINER

"You are performing a percutaneous Achilles tenotomy on a 6-week-old infant with clubfoot. Describe your technique and how you would manage a complication."

VIVA Q&A

Q1:Describe your tenotomy technique.

I perform this as an outpatient procedure under local anesthesia. I apply EMLA cream or inject 0.5ml of 1% lidocaine around the Achilles tendon. With the foot held in dorsiflexion to identify the tight tendon, I mark a point 1cm above the calcaneal insertion. Using an 11 or 15 blade, I enter the skin medial to the tendon with the blade parallel to the tendon fibers. I then rotate the blade 90 degrees to face anteriorly and cut from deep to superficial through the tendon. I expect an audible or palpable pop when the tendon divides. The foot should immediately dorsiflex 15-20 degrees. I apply pressure briefly for hemostasis, then apply the final cast in maximum dorsiflexion and 70 degrees abduction for 3 weeks.

Q2:What complications can occur and how would you manage them?

Potential complications include: (1) Bleeding - apply direct pressure, usually self-limiting; (2) Incomplete tenotomy - if foot doesn't dorsiflex after attempt, I would re-enter and complete the section; (3) Pseudoaneurysm of posterior tibial artery - rare but serious, presents as pulsatile mass, requires ultrasound and vascular surgery referral; (4) Nerve injury - very rare with proper technique entering medially; (5) Wound infection - clean technique minimizes this, treat with antibiotics if occurs. The most common issue is incomplete tenotomy, which requires repeat procedure.

Q3:What is the post-tenotomy protocol?

After tenotomy, I apply the final long-leg cast in maximum dorsiflexion (15+ degrees above neutral) and 70 degrees abduction. This cast remains for 3 weeks to allow the Achilles tendon to regenerate in its lengthened position. After cast removal, the foot abduction orthosis is fitted immediately - the same day. FAO is then worn 23 hours per day for the first 3 months, then nighttime only (12-14 hours) until age 4-5 years. Parents are educated extensively about bracing importance.

KEY POINTS TO SCORE

Enter medial to tendon with blade parallel, then rotate 90 degrees

Posterior tibial artery is anteromedial - technique moves blade away

Complete tenotomy is essential - foot should dorsiflex immediately

Cast in dorsiflexion for 3 weeks allows tendon regeneration

COMMON TRAPS

✗Incomplete tenotomy leads to persistent equinus

✗Entering laterally risks sural nerve injury

LIKELY FOLLOW-UPS

"How do you manage a wound infection?"

"What if the foot still won't dorsiflex after tenotomy?"

MCQ Practice Points

Pirani Score Interpretation

Q: What does a Pirani hindfoot score of 2.5 indicate? A: Moderate-severe hindfoot involvement with at least two of three signs significantly present (posterior crease, empty heel, rigid equinus). This predicts need for percutaneous Achilles tenotomy. A hindfoot score approaching 0 with persistent equinus is the classic indication for tenotomy.

Order of Correction

Q: Why must cavus be corrected before other components in Ponseti method? A: Correcting cavus first (by supinating the forefoot) creates a single lever arm for correction. If cavus is not corrected, the forefoot and hindfoot are misaligned, and attempting abduction will increase midfoot deformity. Supinating the forefoot aligns the 1st ray with the hindfoot, allowing the entire foot to rotate as a unit around the talar head.

Rocker-Bottom Prevention

Q: What causes iatrogenic rocker-bottom deformity in clubfoot treatment? A: Dorsiflexing the foot before adequate abduction is achieved. The talus is fixed in equinus in the ankle mortise. If you dorsiflex without first abducting and derotating the calcaneus, the midfoot breaks dorsally while the talus remains plantarflexed, creating a convex plantar surface (rocker-bottom). This is why equinus is corrected LAST via tenotomy.

Bracing Non-Compliance

Q: A 2-year-old with prior Ponseti treatment presents with returning varus and loss of dorsiflexion. What is the most likely cause? A: Non-compliance with foot abduction orthosis (FAO) bracing. This is responsible for 80% of recurrences. Management includes repeat Ponseti casting and emphasizing bracing importance. For children over 2.5 years with dynamic supination, tibialis anterior transfer should be considered.

Syndromic Clubfoot

Q: What features distinguish syndromic from idiopathic clubfoot? A: Syndromic clubfoot is associated with other congenital anomalies, tends to be more rigid, has higher recurrence rates, and often requires surgical intervention despite initial Ponseti success. Look for: bilateral severe rigid feet, other limb anomalies, facial dysmorphism, joint contractures (arthrogryposis), spine abnormalities (myelomeningocele).

Medicolegal Considerations

Consent Points for Clubfoot Treatment:

Recurrence risk: 5-10% with proper bracing, 30-40% without
Calf size difference: Affected side remains smaller (1-2cm)
Foot size difference: May be 0.5-1.5 sizes smaller
Need for prolonged bracing: 4-5 years commitment
Possible need for further procedures: Tenotomy, TATT, other surgery

Documentation Requirements:

Initial assessment including Pirani score
Cast number and position achieved at each change
Tenotomy performed and outcome
Bracing prescription and compliance documentation
Evidence of screening for associated conditions (hips, spine)

Bracing Compliance Documentation

Document bracing compliance and any non-compliance at each visit. If recurrence occurs, documentation of counseling about bracing importance protects against litigation. Photograph feet in brace showing proper fit.

Australian Context

Epidemiology in Australia:

Incidence approximately 1:1000 live births
Higher incidence in Indigenous Australian populations
Ponseti method is standard of care across all states
Treatment typically provided through public pediatric orthopaedic services

Access to Care:

Metropolitan centers have dedicated pediatric orthopaedic services
Regional and remote areas may have limited access - telehealth and visiting services help
Foot Abduction Orthoses (FAOs) available through public hospitals and private orthotists
Aboriginal and Torres Strait Islander children may face additional barriers to consistent follow-up

Bracing Support:

Equipment Programme provides financial support for FAOs in some states
Private health insurance typically covers orthotics with appropriate referral
Ponseti International Association provides resources and training

High-Yield Exam Summary

CAVE Deformity Order

•Cavus first: supinate forefoot to flatten arch
•Adductus + Varus: abduct around talar head
•Equinus last: percutaneous Achilles tenotomy
•NEVER dorsiflex before abduction - causes rocker-bottom

Ponseti Key Numbers

•5-7 casts: typical number for initial correction
•60-70 degrees: target abduction before tenotomy
•90%: percentage requiring tenotomy
•3 weeks: final cast duration post-tenotomy
•4-5 years: bracing duration

FAO Bracing Protocol

•70 degrees external rotation (60 degrees unilateral)
•23 hours/day for first 3 months
•Nighttime only (12 hours) until age 4-5
•Non-compliance causes 80% of recurrences

Recurrence Management

•First: repeat Ponseti casting
•Tenotomy if equinus persists
•TATT if over 2.5 years with dynamic supination
•Surgical release reserved for failures only

Pirani Score Components

•Midfoot (3): curved border, medial crease, talar head
•Hindfoot (3): posterior crease, empty heel, rigid equinus
•Total 0-6: higher = more severe
•Guides cast number and tenotomy timing

Clinical Scenario

Findings

Treatment

Key Pearl

Newborn with typical idiopathic clubfoot

CAVE deformity, Pirani 4-6, flexible

Ponseti casting starting week 1-2, tenotomy, FAO

Start early, parents as partners in treatment

Syndromic clubfoot (arthrogryposis, myelomeningocele)

Rigid, associated anomalies, resistant

Extended Ponseti, often surgical release needed

Stiffer feet need more casts, higher recurrence

Relapsed clubfoot after initial Ponseti

Recurrent equinus or varus, loss of abduction

Repeat casting, tenotomy, tibialis anterior transfer if over 2.5 years

Check bracing compliance first

Neglected clubfoot (older child, walking age)

Rigid deformity, callosities, adapted gait

Soft tissue release or osteotomies depending on age/rigidity

Ponseti less effective after walking age

Bone

Normal Position

Clubfoot Position

Correction Goal

Talus

90 degrees tibiotalar articulation

Plantar flexed, externally rotated, laterally tilted in mortise

Cannot be directly manipulated - other bones rotate around it

Calcaneus

Below talus, neutral alignment

Inverted (varus), adducted, rotated under talus

Abduct and evert by stretching medial structures

Navicular

Aligned with talar head

Severely medially displaced, may abut medial malleolus

Reduce onto talar head with abduction

Cuboid

Aligned with calcaneus

Medially displaced relative to calcaneus

Follows correction of calcaneus

Ponseti Technique - Gold Standard

95% success rate when performed correctly and bracing compliance achieved.

Ponseti Treatment Steps

Cast 1Step 1: Correct Cavus First

Supinate the forefoot relative to hindfoot:

Elevate the 1st ray to align with lesser rays
This flattens the arch and creates a single lever
DO NOT dorsiflex or pronate the forefoot
First cast holds this position

Casts 2-5Step 2: Abduct Around Talar Head

Correct adductus and varus together:

Thumb pressure on lateral talar head (NOT calcaneus)
Abduct forefoot and midfoot as a unit
Calcaneus follows and everts beneath talus
Progressive abduction each cast (60-70 degrees goal)
Casts changed weekly - each gains 10-15 degrees

After 5-7 castsStep 3: Percutaneous Achilles Tenotomy

Required in 90% of cases when:

Foot abducted to 60-70 degrees
Cannot dorsiflex past neutral
Performed under local anesthetic as outpatient
Complete tenotomy 1cm above insertion
Final cast in maximum dorsiflexion for 3 weeks

Post-castingStep 4: Foot Abduction Orthosis (FAO)

Dennis-Browne bar with boots:

70 degrees external rotation (60 degrees unilateral)
Shoulder-width bar
23 hours/day for 3 months
Then nighttime only (12 hours) until age 4-5 years
Non-compliance causes 80% of recurrences

Never Dorsiflex Before Abduction

Complication

Cause

Prevention

Management

Recurrence (30-40%)

Non-compliance with bracing, inadequate initial correction

Parent education, proper bracing protocol, regular follow-up

Repeat Ponseti casting, tenotomy, TATT if over 2.5 years

Rocker-bottom deformity

Dorsiflexion before abduction corrected

Correct CAVE in proper order, never dorsiflex early

Difficult - may need plantar release, casting, or osteotomy

Flat-top talus

Excessive dorsiflexion, repeated aggressive manipulation

Gentle manipulation, proper tenotomy timing

Avoid continued dorsiflexion, may need osteotomy later

Skin complications

Tight casts, pressure sores, slippage

Proper padding, well-molded casts, weekly changes

Cast removal, local wound care, delay recasting if needed

Tibialis anterior weakness post-TATT

Surgical technique, scarring

Careful tendon handling, appropriate rehabilitation

Physiotherapy, usually mild and improves

Overcorrection (calcaneus deformity)

Excessive surgical release

Use Ponseti method, avoid extensive release

Difficult to treat - may need posterior ankle block

Grade	Score	Description	Treatment
I (Benign)	Less than 5	Soft, reducible	Minimal casting
II (Moderate)	5-10	Partially reducible	Standard Ponseti
III (Severe)	10-15	Resistant	Extended Ponseti
IV (Very Severe)	15-20	Rigid	Surgical release likely

Phase	Duration	Wear Time	Bar Setting
Initial (full-time)	3 months post-casting	23 hours/day	70° ER bilateral, 60° ER unilateral
Transition	Month 4-6	18-20 hours/day	Same settings
Nighttime only	Age 6 months to 4-5 years	12-14 hours (naps + night)	Same settings

Grade	Score	Description	Treatment
I (Benign)	Less than 5	Soft, reducible	Minimal casting
II (Moderate)	5-10	Partially reducible	Standard Ponseti
III (Severe)	10-15	Resistant	Extended Ponseti
IV (Very Severe)	15-20	Rigid	Surgical release likely

Phase	Duration	Wear Time	Bar Setting
Initial (full-time)	3 months post-casting	23 hours/day	70° ER bilateral, 60° ER unilateral
Transition	Month 4-6	18-20 hours/day	Same settings
Nighttime only	Age 6 months to 4-5 years	12-14 hours (naps + night)	Same settings