A 3-month-old male infant from rural Maharashtra presents with bilateral clubfeet. On examination, the feet are in equinus, varus, and adduction with medial rotation. Regarding the management principles of CTEV, all of the following are correct EXCEPT:

Explanation

## Management of CTEV: Current Evidence-Based Approach **Key Point:** The Ponseti method is the gold standard first-line treatment for CTEV worldwide, including in India. Surgery is reserved for resistant cases or those presenting late. ### Treatment Hierarchy **High-Yield:** The modern management paradigm has shifted from early surgery to conservative treatment with the Ponseti method as the primary approach. This has dramatically improved outcomes and reduced the need for extensive surgical intervention. ### Ponseti Method: The Gold Standard 1. **Timing**: Start as early as possible, ideally within the first 2 weeks of life (while tissues are most malleable) 2. **Technique**: Serial gentle manipulation and plaster casting 3. **Sequence**: Correct deformities in a specific order: - Adduction (first) - Varus (second) - Equinus (last, often requires percutaneous Achilles tenotomy) 4. **Duration**: Weekly cast changes for 4–6 weeks until correction is achieved 5. **Success Rate**: 90–95% of cases achieve full correction with Ponseti method alone ### Post-Correction Bracing | Phase | Duration | Orthosis | Purpose | | --- | --- | --- | --- | | Immediate post-casting | 3 months | Foot Abduction Orthosis (FAO) at 70° abduction | Maintain correction | | Long-term | 3–5 years | FAO part-time (nights and naps) | Prevent relapse | **Clinical Pearl:** The FAO is crucial — relapse occurs in up to 40% of cases if bracing is discontinued prematurely. Compliance with bracing is the most common reason for treatment failure. ### Why Option 2 Is Incorrect Surgery is **NOT** first-line treatment. It is reserved for: - Cases resistant to Ponseti method (10–15%) - Late presentation (>6 months) where soft tissues are less malleable - Recurrent deformities despite adequate bracing - Complex or syndromic clubfoot Early surgical intervention (before 6 months) is outdated and associated with worse long-term functional outcomes, including stiffness and pain. **Warning:** A common trap in NEET PG is confusing "early intervention" with "early surgery." Early intervention means starting Ponseti method early, not performing surgery early. ### Treatment Goals The ultimate goal is to achieve: - **Painless** foot (no chronic pain or pressure areas) - **Plantigrade** foot (heel and forefoot in contact with ground) - **Mobile** foot (good ankle and subtalar joint mobility) - **Functional** foot (able to wear normal shoes, walk normally) **Mnemonic:** **PPM** — Painless, Plantigrade, Mobile. These are the three pillars of successful CTEV management. ### Evidence Base The Ponseti method has become the standard of care globally because: - Excellent long-term outcomes (>90% success) - Minimal invasiveness - Lower cost - Reduced need for multiple surgeries - Better functional and cosmetic results - Applicable even in resource-limited settings (as in rural India)