Clubfoot Treatment in Children in Turkey

Clubfoot (medically known as Congenital Talipes Equinovarus, or CTEV) is a birth condition in which the foot is twisted inward and downward. Parents or doctors notice it at birth, and sometimes it is detected on an ultrasound scan during pregnancy.

The condition is not painful for a baby, but it does not improve on its own. If left untreated, the child may walk on the outer edge of the foot, develop painful calluses, and have difficulty wearing shoes.

The reassuring news is that clubfoot treatment in children usually begins in the first weeks of life, and that initial treatment is non-surgical for most cases. The Ponseti method is the standard first-line treatment for isolated clubfoot: gradual correction with casts, a small procedure for most children, and then a brace worn for years to maintain the correction.

This article explains how the condition is diagnosed, how treatment proceeds step by step, why the brace is an essential part of treatment, what "successful treatment" actually means and what the studies can and cannot tell us, when surgery is considered, and what families traveling from outside Turkey should know about weekly casting and long-term follow-up. The information is educational and does not replace an assessment of your child by a pediatric orthopedic surgeon.

Quick Summary

• Clubfoot affects about one in every thousand babies and does not improve without treatment.
• The Ponseti method is the standard first-line treatment for isolated clubfoot: gradual casting, then an Achilles tenotomy for most children, then a foot abduction brace for years.
• The brace is an essential part of treatment, not an afterthought. Not wearing it as prescribed is one of the most important factors associated with the deformity coming back.
• Relapse (the deformity returning) is possible. Reported rates range from about 2% to 45% depending on how relapse is defined and how long children are followed. Relapse does not necessarily mean treatment has failed.
• Surgery is not the first option.
• Treatment requires weekly visits for several weeks, followed by regular check-ups until skeletal maturity. This matters for families who travel for treatment.

What Is Clubfoot in Children?

In clubfoot, the tendons that connect the calf muscles to the bones of the foot are short and very tight, so the foot turns inward. In severe cases the sole may face sideways or upward. The deformity has four components: the heel pointing downward (equinus), the heel tilting inward (varus), a high arch in the middle of the foot (cavus), and the front of the foot turning inward (adductus).

According to the American Academy of Orthopaedic Surgeons (AAOS), clubfoot affects about one in every thousand babies, and estimates in studies range from 0.5 to 2 per thousand. In a population study from Tuscany, Italy, the prevalence was 1.56 per thousand, and 78% of cases were isolated. Both feet are affected in about half of cases, and boys are affected about twice as often as girls. The affected foot and leg are usually slightly shorter, and the calf is thinner because the muscles grow less. This is more noticeable when only one side is affected.

Isolated and Non-Isolated Clubfoot

Doctors distinguish between two types, and the distinction affects the course of treatment:

• Isolated (idiopathic) clubfoot: the most common form. The child has no other medical condition.
• Non-isolated clubfoot: occurs together with another condition, such as arthrogryposis or spina bifida. It may be more resistant to treatment, require longer non-surgical treatment, and sometimes need several operations.

This distinction matters when reading the figures in this article. The consensus of the British Society for Children's Orthopaedic Surgery (BSCOS) applies to isolated clubfoot up to walking age; it does not cover non-isolated clubfoot or children who are already walking. Radler notes that the Ponseti method is also used in non-isolated cases, but relapse is more common and closer follow-up is needed, based on small studies. For this reason, we do not generalize figures from isolated cases to others.

Causes and Risk Factors of Clubfoot

There is no single proven cause for all cases. AAOS says the most accepted explanation is a combination of genetic and environmental factors, with a higher risk in families who have a history of the condition. A systematic review concluded that genetics and smoking are strongly associated with the condition, while there is no agreement on one responsible gene and the quality of studies varies.

In a meta-analysis of observational studies, the condition was associated with factors including maternal smoking (OR=1.65), paternal smoking (OR=1.72), maternal obesity (OR=1.46), amniocentesis (OR=2.08), and exposure to some SSRI antidepressants (OR=1.78). Family history had the largest effect (OR=7.8). These are statistical associations between groups; they do not prove that any one factor caused the condition in a particular child. It is therefore not appropriate to blame parents for the condition.

What Does Clubfoot Look Like?

Clubfoot ranges from mild to severe, but its general appearance is similar: the foot is turned inward, often with a deep crease in the sole. The condition is not painful in infancy. Because it is a visible deformity at birth, the important step is to have the baby assessed by a specialist as early as possible, rather than looking for symptoms.

Diagnosis of Clubfoot

Before birth: many cases are first detected on a pregnancy ultrasound. But detection before birth remains limited; in the Tuscany study, the rate of prenatal detection of isolated cases rose from 4% to 16% over twenty years. The diagnosis is confirmed by examination after birth.

After birth: diagnosis is clinical, meaning it is based on the doctor's examination. The BSCOS consensus states the following:

• Take a full medical history and examine the child before starting treatment.
• Perform a full neurological examination of the leg to rule out an underlying neurological cause.
• Perform a hip ultrasound for every infant with clubfoot.
• Do not routinely X-ray the foot. StatPearls notes that X-rays are of little use right after birth because many of the foot bones have not yet started to ossify.
• Use the Pirani score at the first assessment and at each stage, and recognize atypical feet or feet associated with a syndrome or neurological disease and refer them to a more suitable team.

The Pirani and Diméglio Scores

These are two tools for estimating the severity of the deformity and monitoring response to treatment:

• Pirani: six signs, three in the hindfoot and three in the midfoot, each scored 0, 0.5 or 1, for a total of 0 to 6.
• Diméglio: a 20-point scale based on four main criteria (downward pointing of the heel, inward tilt, rotation around the ankle, and adduction of the forefoot), with the foot classified into four grades from mild to very severe. References differ on the cut-off points for the grades, so we do not state them here.

An independent study found good agreement between examiners for both scores after a learning phase. Using them to predict whether the deformity will return, however, is disputed. In the Dutch meta-analysis, a higher Diméglio score was associated with a small increase in relapse (OR=1.9), the initial Pirani score showed no association, and the authors question whether the scores are valid for predicting relapse. So they are useful for assessing severity and monitoring treatment, not for predicting the future of the foot.

What Is the Ponseti Method for Treating Clubfoot?

Dr. Ignacio Ponseti described his method and published its results from 1963. It is now the standard first-line treatment for isolated clubfoot: 96.7% of surveyed members of the Pediatric Orthopaedic Society of North America (POSNA) reported using it, AAOS describes it as the most widely used approach in North America and worldwide, and BSCOS guidance names it first-line treatment up to walking age.

The key point: Ponseti is not just "putting a cast on the foot." It is an integrated protocol of manual manipulation and casting, an Achilles tenotomy when needed, then a foot abduction brace to prevent relapse, then regular follow-up. Radler's review stresses that the method includes preventing and treating relapse as well.

Treatment Stages at a Glance

Here is a summary of what the sources say. These are ranges from different sources, not a fixed schedule for every child.

1. Correction with casts: gentle manipulation of the foot, then a cast extending from the toes to the thigh. The cast is changed weekly according to AAOS, or every 4 to 7 days according to BSCOS, and the foot improves in most infants within about 6 to 8 weeks.
2. Achilles tenotomy: a small procedure to release the tight tendon when needed, followed by a cast. The need for it ranges from about 80% to 95% depending on the source, and the cast stays on for about 2 to 3 weeks afterward.
3. Foot abduction brace: two shoes attached to a bar to hold the correction. It is worn 23 hours a day for three months, then during sleep and naps, for 3 to 4 years according to AAOS or until age 5 according to BSCOS.
4. Follow-up: checking the position of the foot and the skin and scoring with Pirani. One week after the brace is fitted, then every 3 months until age two, then every 6 months until age 5, and continuing after that until skeletal maturity.

Timing

AAOS says treatment is best started soon after birth, and that older children have also been treated successfully. BSCOS states that casting should start between the second and sixth week of life, with treatment of premature babies possibly delayed until they reach their expected birth date, taking foot size into account. Radler reports a near-consensus to start within the first month, and a study that found no difference in outcomes between those who started before six months and after. In the Dutch meta-analysis, starting treatment after three months of age was not associated with more relapse (four studies). The difference between sources is small, and the individual decision rests with the treating pediatric orthopedic surgeon.

A Note on the Sources of This Information

The BSCOS consensus is an agreement of British experts reached with the Delphi method, not a clinical trial, and its authors acknowledge that some of its statements lack high-quality evidence. Many of the studies cited below are retrospective or from single centers. Where sources differ on a figure (such as how long the brace is worn), we present the difference rather than picking one number.

Are There Other Methods?

Yes. AAOS describes another non-surgical approach called the French (functional or physiotherapy) method, directed by a trained physical therapist. It involves stretching, moving and taping the foot daily, requires about three visits a week to the therapist, and children often need an Achilles tenotomy as well. But BSCOS guidance considers Ponseti the first-line treatment for isolated clubfoot up to walking age.

Steps of Treatment with Casting

Casting is usually done once a week, or every 4 to 7 days depending on how the clinic is organized. At each session the foot is gently moved to a better position, and the correction is then held with a long cast from the toes to the thigh. Radler's review describes the technique as follows:

• In the first cast, the front of the foot (the first metatarsal) is raised to align it with the heel and reduce the high arch, without pushing the foot into pronation.
• In later casts, the foot is gradually abducted (moved outward) with counter-pressure on the neck of the ankle bone (talus) rather than on the heel, so the heel rotates beneath it and its inward tilt corrects. The target is abduction of about 60 to 70 degrees.
• The foot is not lifted upward (dorsiflexion) before the joint below the ankle is corrected and before the tenotomy; trying to correct the downward pointing before correcting the heel's tilt causes a deformity known as rocker-bottom foot.
• The cast is thin, with little padding and well molded around the foot and heel, and it extends to the upper thigh with the knee bent at least 90 degrees to reduce the chance of it slipping. BSCOS specifies a single layer of padding without a stockinette and the use of plaster of Paris.
• The old cast is removed immediately before the new casting session; removing it the night before was associated with needing more casts. BSCOS recommends removing it in the clinic so the team can check the quality of the previous cast and the skin.

How many casts does a child need? There is no fixed number; it depends on the severity of the deformity and how the foot responds. BSCOS states that skin sores, repeated slipping, the need for more than seven casts, or a stalled Pirani score should prompt a request for help or referral to a more experienced team. In the Dutch meta-analysis, needing more than five casts was associated with a higher chance of relapse (OR=3.5) in three studies, while eight other studies found no association between the number of casts and relapse. It is an inconsistent association and does not predict the outcome for an individual child.

Cast slipping. Parents are taught how to recognize that a cast has slipped and how to contact the team out of hours, and a slipped cast should be removed immediately. Radler notes that cast slippage is a major factor in the development of complex clubfoot.

When Does a Child Need an Achilles Tenotomy?

After the casting sessions, tightness in the Achilles tendon (the heel cord) may remain, preventing the foot from lifting upward enough. It is treated with an Achilles tenotomy. The proportion of children who need it varies by source: about 90% according to AAOS, 85% to 95% according to BSCOS, and 79% in Ponseti's original series and 80% to 90% in many series according to Radler. So it is not needed by every child, but it is needed by most.

When is it done? When the foot is ready. BSCOS defines this clinically: the head of the talus is covered, the heel is neutral or slightly turned outward, and the front part of the heel bone has come out from under the ankle bone.

How is it done? It is a small procedure: the doctor cuts the tendon with a very fine instrument, without stitches. BSCOS states that it should be a complete percutaneous (through the skin) division of the tendon with the smallest possible blade, in a sterile setting where pediatric resuscitation equipment is available, and performed by a trained pediatric orthopedic surgeon or under their direct supervision. It recommends local anesthesia for the first procedure, with general anesthesia possible after six months of age or at the surgeon's discretion. Radler notes that the procedure can be done under various anesthetic arrangements with relative safety depending on resources and team experience. A new cast is then applied for about three weeks (two to three weeks according to BSCOS), and the brace should be ready to fit when the cast is removed.

Is it major surgery? No, but it is not risk-free. Radler reports significant bleeding in 4 of 200 feet (2%) in one study, and isolated cases of pseudoaneurysm and neurovascular injury. That is why it is performed by a trained team.

The Abduction Brace and Preventing Relapse

This stage maintains what the casts achieved, and it is an essential part of treatment, not a secondary step after it. The brace does not correct the deformity; it prevents loss of the correction, and AAOS notes that clubfoot has a natural tendency to return even after a successful correction.

What does it look like and what is the schedule? Two shoes or sandals attached to a bar. According to BSCOS, the bar is fixed at shoulder width, the shoes are set at 60 to 70 degrees for the affected foot and 30 to 40 degrees for the unaffected foot, and the brace is worn 23 hours a day for the first three months, then during sleep and naps until age five (at least 10 to 12 hours a day). AAOS mentions about 12 to 14 hours a day after the first three months, and stresses that the brace should be used for at least 3 to 4 years. In other words, the duration differs between guidelines, and the treating doctor sets the final duration.

Which type? AAOS says the bar may be rigid or dynamic. BSCOS states that there is not yet evidence supporting unilateral or articulated braces. In small studies cited by Radler, 83% (25 of 30 feet) needed additional treatment for relapse with a unilateral ankle brace versus 31% (12 of 39) with a foot abduction brace, and compliance improved with a dynamic brace in another study. So we do not say one type is better than another; choosing the type is the doctor's decision based on the child's condition.

Why does adherence matter? AAOS says that if the brace is not worn as prescribed, the chance of the deformity returning is high, and that a small percentage of children relapse even with proper bracing. In the Dutch meta-analysis, non-adherence to bracing was among the strongest factors associated with relapse (OR=10, 95% CI 5 to 21, in 17 studies), with large variation between studies (prediction interval 0.56 to 179) and possible bias in all studies. Average reported adherence was 76% (range 0 to 100%) across 21 studies. This is a statistical association and does not mean every non-adherent child will relapse. Radler stresses that educating parents and their partnership with the team matter more than the type of brace itself.

Practical tips from AAOS:

• Play with your child while they are in the brace; this quickly reduces their distress.
• Make wearing it a fixed routine at sleep time.
• The bar can be wrapped in padding, such as a bicycle handlebar pad, to protect the child and the furniture.
• Do not put lotion on the skin; it makes the problem worse. Check both feet several times a day after starting the brace; bright red spots or blisters, especially behind the heel, usually mean the heel is slipping.
• If the child keeps pulling the foot out of the shoe, there are steps the doctor can explain, such as tightening the straps, adding extra socks, and adjusting the straps.

Does the brace affect the child's development? Radler reports a very slight delay in gross motor milestones in children treated with Ponseti and a brace, and that the brace does not cause pathological changes in femoral or tibial torsion.

Relapse and Complex Clubfoot

Relapse: What It Is and What It Means

According to BSCOS, relapse means the return of any component of the deformity in a foot that previously fitted easily into the brace. It does not necessarily mean treatment has failed. AAOS says a foot repeatedly slipping out of the shoe may be the first sign of a mild relapse, and that treating it early usually takes only a few casts and sometimes a minor procedure.

How common is it? Figures vary widely depending on the definition and the length of follow-up:

• A systematic review of 84 studies (7,335 patients and 10,535 feet) found relapse ranging from 1.9% to 45%. Only 57% of the studies defined relapse, and the authors call for a standard definition (Gelfer 2019).
• The Dutch meta-analysis (34 studies) found an average relapse of 22% (range 5% to 49%) with an average follow-up of three years, and noted that relapse peaks about five years after the initial correction (van Schelven 2022).
• A systematic review (conference abstract) of 20 studies and 2,782 feet with a mean follow-up of 6.4 years found relapse of 21% (range 5.3% to 68%), and surgery to treat relapse in 9% (range 2.5% to 24%). Relapse was associated with length of follow-up up to about nine years, after which the association faded (Nguyen 2022).

For this reason we do not present a single figure, and no figure should be taken as a promise for an individual child.

How is it treated? BSCOS recommends recasting above the knee after identifying which components have returned, with strong consideration of a second tenotomy under general anesthesia if needed, and then restarting the brace after correction. A foot that has never settled well into the brace calls for a reassessment of whether the correction was adequate. Radler notes that tibialis anterior tendon transfer is recommended for relapse with dynamic inward deviation, and that it does not completely prevent relapse: in a review of 66 patients (102 feet), later relapse after it occurred in 15% of feet.

Complex Clubfoot

A harder type of isolated clubfoot that does not respond easily to the standard protocol. The study by Ponseti and colleagues described it as a foot with a rigid contracture of the heel, severe downward bending of all the metatarsals, a deep crease above the heel and another across the sole, and a short, hyperextended big toe. The study identified 50 patients (75 feet) among 762 consecutive patients at five institutions, and a modified protocol succeeded in correcting them without extensive corrective surgery; three patients needed a second tenotomy. Radler notes that these cases require a learning curve and experience, and that cast slippage is one of the factors in their development. For this reason, difficult cases, or cases referred from other centers, are best treated by a pediatric orthopedic surgeon experienced in these techniques.

When Does a Child Need Surgery?

Surgery is not the first option for treating clubfoot in children, and it is not a necessary step after casting. AAOS says it may be needed if the deformity is not fully corrected by casting, if it comes back after correction (often because it was difficult to follow the program), or if the case is very severe. It adds that surgery usually leaves a stiffer foot, so every effort is made to correct the foot without it.

Operations vary depending on the need:

• Limited surgery targeting the tendons: such as lengthening the Achilles tendon or transferring the tibialis anterior tendon. Tendon transfer was performed in about 20% of feet in medium-term follow-up series.
• Major reconstructive surgery: extensive release of soft tissues with fixation by wires and a cast for four to six weeks, then a short cast for four weeks, and shoes or braces for a year or more. Its common complications include overcorrection, stiffness and pain.

Caution about over-extensive surgical release. BSCOS points out, based on earlier studies, that children treated with soft-tissue release have worse long-term outcomes, with an association between the extent of release and functional impairment, and that surgery rates reached 53.3% where protocol details varied, compared with an average of 10.5% in Europe where Ponseti is followed without deviation. Radler reports that the proportion of infants in the United States who had surgical release fell from 72% in 1996 to 12% in 2006 as Ponseti spread. These are observational data. So if an extensive release operation is proposed as a first step for an infant with isolated clubfoot, it is reasonable to seek a second opinion from a center with Ponseti experience.

Older children and neglected cases. Radler cites small studies: correction without open joint surgery in 35 of 36 feet in older infants after failed casting or late presentation, good correction in 67% of 24 neglected feet in children with a mean age of 3.9 years, and, in a series of 260 feet in children aged one to six years, 79% needed a tenotomy and only 14% needed open joint surgery. The samples are small and results vary, so each child needs an individual assessment.

Treatment Outcomes: What Do We Mean by Success?

The word "success" can mean several things, and mixing them up gives parents the wrong impression of the numbers. The following four concepts are different, and each has figures that vary from study to study:

Initial correction: the foot reaching a corrected position after casting (with a tenotomy when needed). A systematic review of the method (Jowett 2011) reported about 90%, Radler reports more than 98% in high-experience series, and the figure was 97% (range 86.6% to 100%) in Nguyen's review of 20 studies.

Functional outcome: how the foot works for walking and activity, according to a scale each study chose. Nguyen's review found a "satisfactory" result in 90% (range 63.4% to 100%) with a mean follow-up of 6.4 years and with scales that differ between studies. Radler reports excellent or good results in 74% of 104 feet after 10 to 27 years, and in 78% of 71 feet at a mean age of 34 years, both from series at the center where the method originated.

Relapse: return of a component of the deformity after correction, with no single definition. It ranged from 1.9% to 45% across 84 studies (Gelfer 2019), averaged 21% (range 5.3% to 68%) in Nguyen's review, and 22% (range 5% to 49%) in the Dutch meta-analysis.

Need for additional surgery: a surgical intervention after initial treatment. It was 9% (range 2.5% to 24%) to treat relapse in Nguyen's review, and tendon transfer was performed in about 20% of feet in some series reported by Radler.

There is therefore no single general success rate. Each figure above is tied to its definition, its length of follow-up, and the kind of cases studied, mostly isolated ones. Nguyen's review notes that long-term studies are few. We have not used figures from single-center studies as if they represented Turkey, and in the references we reviewed we found no documented national Turkish data.

Cosmetic correction is not the same as functional outcome. According to AAOS, most children after treatment can run, play and wear regular shoes, but the treated foot is usually smaller by one to one and a half sizes and less mobile, the calf is thinner, the child may complain of "sore legs" or tire faster, and the leg may be slightly shorter with usually no major practical effect. For this reason we do not use the phrase "permanent cure"; follow-up continues until skeletal maturity.

Complications and Risks

Each stage of treatment has its risks, and most can be detected early with regular follow-up:

• Casting: skin sores and cast slippage, which are reasons to seek help or referral. BSCOS recommends checking the skin at every session and removing a slipped cast immediately.
• Achilles tenotomy: rare bleeding or neurovascular injury (figures in the tenotomy section above). Radler warns against forceful lifting of the foot after the procedure because it may damage the dome of the talus.
• Brace: blisters on the skin behind the heel when the middle strap is loose or the shoe is too big, and bruising on the front of the foot when it is tightened too much. When skin problems appear, BSCOS suggests long close-fitting socks, trying a different make of shoe, a short rest out of the brace, or a period of recasting. The biggest risk here is non-adherence and the possible relapse that follows.
• Corrective surgery: overcorrection, stiffness and pain.
• Long term: a smaller foot, a thinner calf, and faster tiring.

Rates of other complications (such as infection or muscle weakness) vary between studies, and we do not present figures for them because we did not find a documented source that gives these rates for the Ponseti method.

Recovery and Long-Term Follow-Up

The child's movement and development. Radler reports a very slight delay in gross motor milestones, and that the brace does not cause pathological changes in femoral or tibial torsion. We have no standard timetable for when each child starts to walk; it differs from child to child and is determined by the treating team.

Physical therapy and stretching exercises. There is no standard recommendation for physical therapy after Ponseti. Data from only two studies suggest that extra stretching exercises done by parents during the brace period may be promising (OR=31 for not doing them), but the evidence is limited, the two studies have moderate bias, and the authors call for stronger trials before any recommendation.

Follow-up. BSCOS recommends a check one week after the brace is fitted, then every three months until age two, then every six months until age five, then continued follow-up until skeletal maturity. At each visit the foot's correction, the skin and the Pirani score are checked.

Signs that call for contacting the treating team immediately:

• A slipped cast.
• The foot repeatedly coming out of the brace shoe, which may be the first sign of a mild relapse.
• Bright redness or blisters on the skin, especially behind the heel.
• A component of the deformity appearing in a foot that used to fit easily in the brace, or a foot that never settled well in the brace.
• Any concern after the tenotomy; parents should have an out-of-hours emergency number.

Cost of Clubfoot Treatment in Children in Turkey

The cost of clubfoot treatment in children in Turkey, according to an estimate from O9 Medical, ranges from a lower amount for correction with casting alone to an estimated average of about USD 4,400. This figure is an estimate provided by O9 Medical, not a proven national average for prices in Turkey, and it should not be assumed to include any particular services; what the price includes is determined after the case is assessed and a treatment plan is made.

The figure does not mean every child needs an operation costing this amount. Most children are treated with casting, an Achilles tenotomy for the majority, and a long-term brace, and major corrective surgery is not the first option.

The cost varies depending on the treatment method and the child's age when it starts, the severity of the deformity and the number of casting sessions the response requires, the need for an Achilles tenotomy and the type of anesthesia, the need for a special brace, a relapse requiring recasting or a limited procedure, the need for corrective surgery in a few cases, and the length of follow-up after treatment.

We advise families to ask any center exactly what the price includes: casting sessions, the tenotomy and anesthesia, the brace, follow-up, accommodation, and how additional visits are handled if the case calls for them.

Travel and Follow-Up for Families from Outside Turkey

Treatment with the Ponseti method requires frequent attendance, and families should know this before deciding to travel:

• Casting phase: the cast is changed about every week, or every 4 to 7 days, and the foot improves in most infants within about 6 to 8 weeks.
• After the tenotomy: the cast stays on for about two to three weeks, and the brace is fitted when it is removed; it may be measured before the procedure.
• Follow-up: a check one week after the brace is fitted, then every 3 months until age two, then every 6 months until age 5, continuing until skeletal maturity.

This logically means that a family coming from abroad needs to plan ahead. Will they stay in Turkey for the weeks of the casting phase, or will some sessions be done near home in coordination with the treating team? Who will follow the child in their own country during the years of bracing? Where can the child be recast or the brace adjusted if signs of relapse appear, given that early relapse is treated by recasting? This is a decision the treating team makes with the parents according to the child's condition, and this article does not describe arrangements specific to any particular center.

Useful questions for a family to ask any center before traveling:

• Who will perform the manipulation, casting and tenotomy, and are they a pediatric orthopedic surgeon trained in the method, or working under such a surgeon's supervision?
• How can the team be reached out of hours if a cast slips or there is a concern after the tenotomy?
• Who will supply the brace and set its size and angle, and what happens when the size has to change as the child grows?
• What is the plan for dealing with relapse if it appears after returning home?
• What follow-up schedule is proposed, and can some check-ups be done near the family's home?
• Can we get a written summary of the treatment (cast dates, tenotomy, brace settings), with a copy handed to the doctor in your country?

Why Choose a Pediatric Orthopedic Specialist?

The outcome of Ponseti depends on skill and experience at every stage. A well-made cast requires precise technique, and cast slippage or an error in the order of correction can lead to a harder deformity. AAOS advises seeking referral to a surgeon with experience in the non-surgical treatment of clubfoot. The BSCOS consensus states that Ponseti clinics should be overseen by a named consultant pediatric orthopedic surgeon, that the clinical lead should have received formal hands-on training in the method, that the clinic's results should be audited annually (number of casts, rates of tenotomy and repeat tenotomy), that the team should have a clear referral pathway to greater expertise when there are difficulties, and that tenotomy should be performed by a trained surgeon or under their supervision.

When looking for a center, it is better for a family to ask specifically about the team's experience in treating clubfoot in children with the Ponseti method, and whether its results are reviewed regularly, rather than asking only about the hospital's reputation.

Medical note: this information is for general education. It does not replace consultation with a specialist doctor and is not a diagnosis or a prescription.