A 2-day-old male neonate born to non-consanguineous parents presents with bilateral rigid foot deformities characterized by equinus, varus, and cavus. On examination, the feet cannot be passively dorsiflexed beyond midline. The parents are counseled about the condition and wish to begin treatment immediately. What is the most appropriate next step in management?

Explanation

## Management of Neonatal CTEV: The Ponseti Method **Key Point:** The Ponseti casting method is the gold standard first-line treatment for congenital talipes equinovarus and should be initiated as early as possible—ideally within the first 1–2 weeks of life. ### Why Early Intervention Matters **High-Yield:** Early casting (within days to weeks of birth) exploits the plasticity of neonatal cartilage and ligaments, making the deformity more amenable to gradual correction. Delaying treatment hardens the deformity and reduces success rates. ### Ponseti Casting Protocol | Phase | Duration | Key Features | |-------|----------|---------------| | **Abduction phase** | 4–6 weeks | Weekly casts; foot gradually abducted from varus to 40–50° external rotation | | **Dorsiflexion phase** | 2–3 weeks | Foot dorsiflexed from equinus toward neutral position | | **Maintenance phase** | Until age 4–5 years | Bracing (Denis Browne splint or AFO) to prevent relapse | **Clinical Pearl:** Most cases (85–90%) achieve full correction with conservative casting alone; only 10–15% require surgical intervention (usually Achilles tenotomy during the dorsiflexion phase). ### Why the Other Options Are Incorrect - **Immediate surgery** is premature; the Ponseti method succeeds in the vast majority without surgery. - **MRI at age 2 days** is not routine unless there are red flags (e.g., spinal dysraphism signs); isolated CTEV does not mandate spinal imaging. - **Delaying to 6 weeks** allows the deformity to stiffen, reducing the success rate of conservative treatment. **Mnemonic:** **PONSETI = Progressive, Outpatient, Non-surgical, Serial casting, Early intervention, Tenotomy (if needed), Imaging (selective)** [cite:Campbell's Operative Orthopaedics 13e Ch 32]