Club foot (congenital talipes equinovarus) is a common birth deformity affecting 1-2 per 1,000 live births, with even higher rates in low-income countries. The standard treatment is the Ponseti method using weekly serial casts, but weekly visits for several weeks can be challenging for families in hot climates or with limited resources. This randomized controlled trial compares the standard once-weekly Ponseti casting with an accelerated twice-weekly casting technique. The primary outcome is radiological correction measured by the lateral talocalcaneal angle (target ≥35°) on standardized foot X-rays taken six weeks after brace fitting. Secondary outcomes include the talocalcaneal index (>40) and the tibio-calcaneal (dorsiflexion) angle (60-90°). Babies under six months of age with idiopathic club foot will be randomly assigned to either the standard or accelerated casting group. All other aspects of the Ponseti method (manipulation, number of casts, tenotomy when needed, final cast for three weeks, and foot abduction orthosis) remain identical. Adverse events such as skin problems, swelling, or cast complications will be recorded. The study aims to determine whether accelerated casting achieves better radiographic correction without increasing risks.

This open-label randomized controlled trial will be conducted at the dedicated Ponseti clinic, Department of Orthopedic and Trauma, Khyber Teaching Hospital, Peshawar, Pakistan, over six months. A total of 158 club feet (105 infants) with idiopathic club foot aged <6 months will be enrolled using non-probability consecutive sampling. After informed consent and baseline X-ray, participants are randomly allocated (sealed envelope, odd/even numbers from OpenEpi) to either standard once-weekly casting (every Monday) or accelerated twice-weekly casting (Monday and Friday). All other Ponseti protocol elements (manipulation, number of casts, tendo Achillis tenotomy when indicated, final cast for 3 weeks, and foot abduction orthosis) are identical. The primary outcome is lateral talocalcaneal angle (mean of dorsiflexion and plantar flexion views) ≥35° on standardized X-ray six weeks after bracing. Secondary outcomes are talocalcaneal index >40 and tibio-calcaneal angle 60-90°. Adverse events (skin sores, swelling, cast issues) are recorded. Allocation concealment is blinded to investigator and parents; the outcome assessor (pediatric orthopaedic fellow) is blinded to group assignment. Data will be analyzed using SPSS v20 (intention-to-treat, independent t-test or Mann-Whitney U, adjusted odds ratios, p<0.05 significant). Ethical approval will be obtained from Khyber Medical College, KMU, and ASRB. Treatment is free, but no financial compensation is provided.

Inclusion Criteria:

-Both gender with idiopathic club foot with age less than 6 months

Exclusion Criteria:

• Syndromic club foot (e.g., associated with arthrogryposis, myelomeningocele, or other genetic syndromes)
• Previous treatment for club foot (either serial casting or surgical intervention)
• Any other significant congenital anomaly or medical condition that, in the opinion of the investigator, would interfere with treatment or follow-up

Individual participant data that underlie the results reported in the primary publication (including de-identified radiological measurements, Pirani scores, adverse event data, and baseline demographics) will be shared upon reasonable request for the purpose of meta-analysis or independent verification. No identifiable information (names, contact details, photographs) will be shared.

Data will become available 6 months after publication of the primary results and will remain available for 3 years thereafter.

Access will be granted to researchers who provide a methodologically sound proposal and sign a data access agreement. Requests should be directed to the principal investigator (Dr Sikandar Hayat).

The principal investigator does not perform casting, and the pediatric orthopaedic fellow who measures the radiological outcomes is blinded to treatment group assignment; however, patients, parents, and the personnel applying casts cannot be blinded because of the visibly different casting frequencies (once versus twice per week).