A 2-day-old male neonate born to a 28-year-old primigravida presents with bilateral inversion and plantarflexion of the feet noted at birth. On examination, the feet are held in a fixed position of inversion, adduction, and equinus. The deformity cannot be passively corrected beyond the midline. There is no associated spinal dysraphism or other congenital anomalies. What is the most appropriate initial management?

Explanation

## Initial Management of Congenital Talipes Equinovarus **Key Point:** The Ponseti method is the gold standard first-line treatment for CTEV, with success rates exceeding 95% when initiated early and compliance is maintained. ### Timing and Technique **High-Yield:** Treatment should begin within the first 1–2 weeks of life, ideally before 7 days. Early intervention prevents soft tissue contracture and improves outcomes. 1. **Serial Manipulation** — gentle, progressive stretching of the foot 2. **Weekly Casting** — long-leg plaster casts applied after manipulation, changed weekly 3. **Correction Sequence** — follows the mnemonic **CAVE**: - **C**avus (supination of forefoot) - **A**dductus (medial deviation of midfoot) - **V**arus (inversion of hindfoot) - **E**quinus (plantarflexion of ankle) ### Ponseti Protocol Phases | Phase | Duration | Action | |-------|----------|--------| | **Casting** | 6–8 weeks | Weekly casts; typically 5–7 casts needed | | **Percutaneous Tenotomy** | Single procedure | Achilles tenotomy when equinus persists after 6–8 weeks | | **Maintenance** | 3 months | Abduction brace (Denis Browne splint) 23 hours/day | | **Long-term** | Until age 4–5 years | Night-time brace to prevent relapse | **Clinical Pearl:** Approximately 80–90% of idiopathic CTEV cases achieve full correction with Ponseti casting alone; only 10–20% require additional surgical intervention. ### Why Early Intervention Matters - Neonatal foot tissues are highly malleable - Delayed treatment allows contractures to mature, reducing castability - Compliance with bracing after casting is critical to prevent relapse **Warning:** Aggressive manipulation or forced correction can cause iatrogenic rocker-bottom deformity (convex sole) — the Ponseti method's gentle, progressive approach avoids this catastrophic complication.