Specific brace-fitting complications in idiopathic congenital talipes equinovarus (CTEV) have been rarely described in published series, and usually focus on non-compliance. Our primary aim was to compare the rate of persistent pressure sores in patients fitted with Markell boots and Mitchell boots. Our additional aims were to describe the frequency of other brace fitting complications and identify age trends in these complications. A retrospective analysis of medical files of 247 idiopathic CTEV patients born between 01/01/2010 - 01/01/2021 was performed. Data was collected using a REDCap database.

Pressure sores of sufficient severity for clinician to recommend time out of brace occurred in 22.9% of Mitchell boot and 12.6% of Markell boot patients (X² =6.9, p=0.009). The overall rate of bracing complications was 51.4%. 33.2% of parents admitted to bracing non-compliance and 31.2% of patients required re-casting during the bracing period for relapse. For patients with a minimum follow-up of age 6 years, 44.2% required tibialis anterior tendon transfer. Parents admitting to non-compliance were significantly more likely to have a child who required tibialis anterior tendon transfer (X²=5.71, p=0.017). Overall rate of capsular release (posteromedial release or posterior release) was 2.0%.

Neither medium nor longterm results of Ponseti treatment in the Australian and New Zealand clubfoot have been published. Globally, few publications describe specific bracing complications in clubfoot, despite this being a notable challenge for clinicians and families. Recurrent pressure sores is a persistent complication with the Mitchell boots for patients in our center. In our population of Australian clubfoot patients, tibialis anterior tendon transfer for relapse is common, consistent with the upper limit of tibialis anterior tendon transfer rates reported globally.

Aims & Background. Congenital Talipes Equinovarus (CTEV) is the most common congenital musculoskeletal birth defect affecting 1 in 1000 births per annum. We have compared our surgical results to the British Society of Children's Orthopaedics (BSCOS) published guidelines. Methods. Between, 2006–16, patients who were referred for treatment of pathological CTEV were audited. Data from a combination of Clinical Portal, Orthotic Patient Administration System and Surgical Elogbook were assessed. In addition, the degree of deformity was classified by the Harrold & Walker method at the time of diagnosis (senior author). Most of this information was recorded prospectively and analysed retrospectively. Ponseti technique was the method of treatment. Results. 96 patients assessed (133 feet). There were 78 males and 18 females, 37 patients were affected bilaterally and 11 had associated syndromes. There were 23 Harrold & Walker (H&W) 1, 28 H&W 2 and 82 H&W 3 classification feet. Average time period in Ponseti boots and bars was 14.4 months (95% CI 12.9–15.9), average time in all types of bracing of was 17.1 months (95% CI 14.8–14.8). Number and rate of surgeries performed were as follows: 77 Tendoachilles release (63.1%), 19 Tibialis Anterior Transfer (5.6%), 15 Radical Release (12.3%), revision 25 Surgery (20.5%) & 5 Abductor Hallucis Release (4.1%). Conclusion. The audit confirms that the unit meets most of the current BSCOS guidelines. All surgical procedures apart from radical release surgery fall within accepted limits. This may be due, in part, to the syndromal cases. We do however demonstrate a significantly reduced average time period in bracing compared to that recommended by BSCOS. There are multiple reasons for this discrepancy including non-compliance and poor splint tolerance (child refusing to use). We feel this work demonstrates a reduced period in bracing can be achieved whilst maintaining standards of treatment

Incidence of Congenital talipes equino varus [CTEV] is 1 to 2 per 1000 birth, Out of all cases 20% cases are Non-idiopathic. The management of non-idiopathic CTEV, however, continues to be challenging due to Rigidity, Poor skin condition, Bony changes, Vascularity and Associated congenital abnormalities. In recent literature, short term results of Ponseti method for correction of non-idiopathic CTEV have been encouraging. As Ponseti method decreases the severity of deformity and hence decreases the need for extensive surgery.

The aim of current study is to evaluate the results of Ponseti method in Non-idiopathic CTEV. Total 7 children below the age of one year with Non idiopathic clubfoot presented to us in the duration of 2013 to 2015 who were treated by us. The cases included are Streeters Dysplasia with congenital constriction rings 3, Arthrogryposis multiplex congenita with Developmental dysplasia of hip 2, Arthrogryposis multiple congenita spina Bifida 1, Pierre Robinson Syndrome with Ichthiosis 1. Initially all the patients treated with Ponseti casting technique and scoring was done using modified pirani scoring. At an average we could correct the foot from Pirani 7 to 2.5 with a relapse in 4 patients. 2 patients were treated again by Ponseti's method with success while treatment was discontinued in 2 feet.

We recommended Ponseti's technique in Syndromic clubfoot as an non-surgical initial modality with good results given. The final outcome may depend more on the underlying condition than the CTEV.

Congenital talipes equinovarus (CTEV), also known as club foot or talipes is a common congenital disorder. Parents are using the Internet more and more as a source of information about health care. Unfortunately, the quality of health care information on the Internet varies. This study looked at information available to parents using two instruments for judging the equality of information on the internet. The top five search engines were searched on Google. Three of these were also included in the top 50 sites in Ireland so these 3 sites were used. The phrases CTEV and club foot were searched from all 3 platforms. Websites were then scrutinized using the HON code and the DISCERN tool. 54 organic sites were found for the 3 search engines using the key word club foot. For the key word CTEV 55 matches were returned for the three search engines. 4 websites displayed the HON code. Using the discern tool CTEV websites had a mean score of 60 with a standard deviation of 17. While club foot had a mean score of 56.8 with a standard deviation of 13. Max score 80. Large volumes of information are available to parents on the Internet. Often parents find comfort in sharing experiences and feel empowered by learning about their children's illnesses. However, information provided on the interned can also be ambiguous and disingenuous. Practitioners should be aware of a number of key websites that parents can be directed towards.

This is the first study in the Ponseti-era to compare severity and outcomes in cases of idiopathic congenital talipes equinovarus (CTEV) diagnosed antenatally versus those diagnosed at birth. Small pre-Ponseti studies showed antenatal diagnosis to be a predictor of severity and poor prognosis.

Prospective data collection was used to compare indicators of severity and outcomes for idiopathic CTEV between these two groups. These include Pirani score, number of casts, follow-up Roye score and need for surgery.

68 children with 106 affected feet were included. Antenatal diagnosis (AD) was made in 45 children (71 feet), with birth diagnosis (BD) in 23 children (35 feet). Mean follow-up age was 4.8 years (AD = 4.9, BD = 4.7), male:female ratio 2:1 (AD=BD) with bilateral CTEV in 55% (AD = 58%, BD=52%). Mean initial Pirani scores were 5.25 in the AD group vs 4.86 in the BD group (p=0.06). Mean Roye score at follow-up was 1.39/4 in the AD group vs 1.26/4 in the BD group (p=0.33) with 33% vs 30% complaining of pain respectively (p=0.80). Surgery was needed in 11/71 (15.5%) in the AD group vs 1/35 (2.9%) in the BD group (p=0.06))

There is no significant difference in severity between antenatal and birth diagnoses of idiopathic CTEV and no difference in outcomes between these groups when treated with the Ponseti regime. Although small, our sample size is greater than the largest published comparable study.

Complex congenital foot deformities pose a challenge to the surgeon due to poor results after extensive surgery. We report the clinical outcomes of children with complex congenital foot deformities treated with UMEX® (Universal mini-external fixator System) frames. This is a prospective review of our experience in patients treated in this way, from 2004 to 2011. The indications for treatment included resistant/recurrent Congenital Talipes Equino Varus (CTEV), cavo-varus deformity secondary to Charcot-Marie-Tooth disease, arthrogryposis, fibular hemimelia and other congenital abnormalities. A total of 32 children (35 feet) have been treated, out of which 22 were male and 10 were female patients. Age at surgery ranged from 3 to 15 years (median age – 7 years). Three patients underwent bilateral procedures; the reminder (29 patients) underwent unilateral foot operations. Twenty-eight patients had undergone previous surgery including soft-tissue and/or bony corrective procedures. The frames were removed at an average of 69 days after application, and the patients spent a further 6 weeks in a walking cast. Good functional outcomes were noted in 26 patients in the first postoperative year and in 19 patients in the fifth postoperative year. Further operations were needed in 10 patients. Complications occurred in 10 patients, predominantly pin-site infections and 1 case of bony overgrowth at pin-site and 1 of proximal tibio-fibular diastasis. This is a simple fixator to use with a short learning curve. In groups of patients with complex congenital abnormalities, we achieved good functional outcome with low-complication rates

There is controversy whether congenital foot abnormalities are true risk factors for pathological dysplasia of the hip. Previous United Kingdom screening guidelines considered congenital talipes equinovarus (CTEV) to be a risk factor for hip dysplasia, but present guidelines do not. We assessed the potential relationship between pathological dysplasia of the hip and fixed idiopathic CTEV.

We present a single-centre 21-year prospective longitudinal observational study. All fixed idiopathic CTEV cases were classified (Harrold and Walker Types 1 to 3) and the hips clinically and sonographically assessed. Sonographic Graf Type III, IV and radiological irreducible hip dislocation were considered to be pathological hip dysplasia.

Over 21 years there were 139 children with 199 cases of fixed idiopathic CTEV feet. Sonographically, there were 259 normal hips, 18 Graf Type II hips, 1 Graf Type III hip and 0 Graf Type IV hip. There were no cases of radiological or sonographic irreducible hip dislocation.

Fixed idiopathic CTEV should not be considered as a significant risk factor for pathological hip dysplasia. This conclusion is in keeping with the current newborn and infant physical examination guidelines in which the only risk factors routinely screened are family history and breech presentation. Our findings suggest CTEV should not be considered a significant risk factor in pathological dysplasia of the hip.

Cite this article: Bone Joint J 2014;96-B:1553–5.

The October 2014 Children’s orthopaedics Roundup³⁶⁰ looks at: spondylolisthesis management strategies; not all cervical collars are even; quality of life with Legg-Calve-Perthe’s disease; femoral shaft fractures in children; percutaneous trigger thumb release – avoid at all costs in children; predicting repeat surgical intervention in acute osteomyelitis; and C-Arm position inconsequential in radiation exposure

Congenital Talipes Equinovarus (CTEV) is one of the most common congenital limb deformities. We reviewed the records of infants who had received treatment for structural CTEV between 1 January 2007 and 30 November 2012. This was cross-referenced with the prenatal scans of mothers over a corresponding period of time. We investigated the sensitivity, specificity, and positive and negative predictive values of the fetal anomaly scan for the detection of CTEV and explored whether the publication of Fetal Anomaly Screening Programme guidelines in 2010 affected the rate of detection. During the study period there were 95 532 prenatal scans and 34 373 live births at our hospital. A total of 37 fetuses with findings suggestive of CTEV were included in the study, of whom 30 were found to have structural CTEV at birth. The sensitivity of screening for CTEV was 71.4% and the positive predictive value was 81.1%. The negative predictive value and specificity were more than 99.5%. There was no significant difference between the rates of detection before and after publication of the guidelines (p = 0.5). We conclude that a prenatal fetal anomaly ultrasound screening diagnosis of CTEV has a good positive predictive value enabling prenatal counselling. The change in screening guidance has not affected the proportion of missed cases. This information will aid counselling parents about the effectiveness and accuracy of prenatal ultrasound in diagnosing CTEV. Cite this article: Bone Joint J 2014;96-B:984–8

The purpose of this study was to describe the clinical course of patients with Down's syndrome (DS) and congentital talipes equinovarus (CTEV) treated with the Ponseti regimen.

The members of the United Kingdom Ponseti Users Group were contacted to provide details of patients with DS and CTEV, whom they had treated using the Ponseti regimen. Nine patients (13 feet: 7 right, 6 left) were identified, and the case notes were reviewed. Six patients were male, 3 female. In all but one case, the DS was diagnosed postnatally. Co-morbidites included atrioventricular septal defect, hearing deficiencies and plagiocephaly. The initial mean Pirani score was 4.5 (range 3.0 to 6.0). Casting was commenced at a mean of 25 days (range 12–84 days). The mean number of casts required was 7 (range 3 to 12), taking a mean of 6.5 weeks (range 3–12) to achieve correction. 6 of the 13 feet (46%) required a tendoachilles tenotomy, and 2 of 13 (15%) required re-casting. No patients have required a tibialis anterior transfer, soft tissue releases or bony procedures, at a mean follow up of 44 months (9–65 months).

The results of the Ponseti regimen have not been described in patients with DS. From this small series, we can conclude that all patients responded to the regime. A tendoachilles tenotomy was required in just under half, and further casting was required in only 15% of the treated feet. No patient has required further surgery. The tenotomy rate is lower than in most series, but otherwise, the results are comparable to those for idiopathic CTEV for which the Ponseti regimen has become the gold standard. Parents of children with DS can be reassured that in the short term their feet will respond well to Ponseti treatment

Aim:. An assessment of the relationship between pathological Developmental Dysplasia of the Hip (DDH) and Congenital Talipes Equinovarus (CTEV). Introduction:. Traditional UK guidelines consider abnormalities of the foot to be a risk factor for DDH. 1,2. Currently, there is controversy whether congenital foot abnormalities are true risk factors for pathological DDH. 3,4. There is a relationship between CTCV and hip dysplasia though the relationship between CTEV and pathological DDH is less clear. 5. In a previous 11 year prospective longitudinal study no case of Graf Types III, IV or irreducible hip dislocation were associated with CTEV. 5. Subsequent correspondence and case histories have challenged this view. 6. Methods:. In order to clarify this issue, a 20-year prospective longitudinal observational study was undertaken. All cases of fixed CTEV (Harold & Walker types 1 to 3) referred to the sub-regional Paediatric Orthopaedic clinic at the Royal Blackburn Hospital were evaluated, the feet and hips clinically assessed (Ortolani & Barlow manoeuvres) and the hips ultra-sounded by the senior author (RWP). Modified Graf and Harcke hip ultrasound classification systems were employed. Graf Type III, IV and irreducible hip dislocation were considered pathological. Results:. The incidence of CTEV was 1.46 per 1000 live births (nationally quoted incidence of 1 to 2 per 1000 live births. 7. ). There was one case of Graf Type III dysplasia with no cases of clinical hip instability. Currently, the clinical significance of this type of dysplasia is uncertain. There were no cases of Graf Type IV dislocations or radiological irreducible hip dislocation. Conclusion:. Fixed CTEV should not be considered as a risk factor for pathological DDH and routine sonographic hip screening of CTEV should not be advocated. This is supportive evidence for the current English NIPE guidelines in which the only risk factors screened are family history and breech presentation. Level of evidence: II

We undertook a randomised clinical trial to compare treatment times and failure rates between above- and below-knee Ponseti casting groups. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below- or above-knee plaster of Paris casting. Outcome measures were total treatment time and the occurrence of failure, defined as two slippages or a treatment time above eight weeks.

A total of 26 children (33 feet) were entered into the trial. The above-knee group comprised 17 feet in 13 children (ten boys and three girls, median age 13 days (1 to 40)) and the below-knee group comprised 16 feet in 13 children (ten boys and three girls, median age 13 days (5 to 20)). Because of six failures (37.5%) in the below-knee group, the trial was stopped early for ethical reasons. The rate of failure was significantly higher in the below-knee group (p = 0.039). The median treatment times of six weeks in the below-knee and four weeks in the above-knee group differed significantly (p = 0.01).

This study demonstrates that the use of a below-knee plaster of Paris cast in conjunction with the Ponseti technique leads to unacceptably high failure rates and significantly longer treatment times. Therefore, this technique is not recommended.

Cite this article: Bone Joint J 2013;95-B:1570–4.

Aim. Congenital Talipes Equinovarus (CTEV) has been excluded from the standards set by the NHS fetal anomaly screening programme (NHS FASP) for the 18. +0. –20. +6. week fetal ultrasound scan (USS). Whilst adhering to NHS FASP guidelines, the antenatal ultrasound department at our centre performs “incidental screening” for CTEV; parents are informed if CTEV is noted incidentally during the scan and referral made to the fetal medicine department. Our aim was to investigate the effectiveness of incidental antenatal screening for structural CTEV. Method. The database of the antenatal ultrasound department was interrogated for all suspected cases of CTEV on the 18. +0. –20. +6. week USS, between August 2006 and June 2012. Terminations, stillbirths and outside referrals were excluded. Our Ponseti-service database was searched to identify all patients treated for structural CTEV between January 2007 and November 2012. Cases were excluded if the mother did not receive antenatal-care at our centre. Results from the two searches were cross-referenced, and statistical analysis performed. Results. 30077 18. +0. –20. +6. week USS were performed on 24282 patients, with CTEV diagnosed in 74 patients. After exclusions, there were 39 patients. 54 patients were treated for structural CTEV with 37 patients (54 feet, CTEV-incidence 0.001) after exclusions; 25 (67.5%) diagnosed pre-natally (15 unilateral, 10 bilateral), and 12 (32.5%) diagnosed post-natally (5 unilateral, 7 bilateral). Sensitivity of screening for CTEV was 67.5%, specificity 99.8%, positive predictive value (PPV) 64.1% and negative predictive value 99.9%. The proportion of cases detected antenatally has reduced since introduction of NHS-FASP. Conclusion. This data is important and necessary to comprehensively counsel our patients. We are unable to find similar contemporary data from other units within the NHS for comparison. NHS-FASP guidelines seem to have reduced the efficacy of antenatal detection of CTEV at our unit, and further prospective study is required to determine the value of screening for patients

Aim

Kite manipulation and casting for congenital talipes equinovarus (CTEV) was noted to require a subsequent posteromedial release (PMR) in almost all of the children treated, with variable outcomes including overcorrection and stiffness. Introduction of the Ponseti serial manipulation and casting technique dramatically reduced the need for PMR. This study assesses the medium term outcomes in these two treatment groups.

The April 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: improving stress distribution in dysplastic hips; the dangers of fashion; the natural history of supracondylar fractures; ankles that perform well as knees; intra-articular hip pathology at osteotomy; the safe removal of flexible nails; supracondylar fracture fixation; and talipes.

Introduction

The Ponseti regime was introduced in Swansea in 2003 for the treatment of congenital talipes equinovarus (CTEV). The aim of this retrospective cohort study was to compare children treated with this regime with a historical group treated traditionally before then.

Ponseti first advocated his treatment for idiopathic clubfoot in the early 1950's. The method has only gained popularity and widespread use since the 1990's. Despite publications showing favourable results, there is little published data scrutinising the change in modes of talipes treatment. This study sought to define the trends in treatment for Idiopathic Clubfoot in Scotland over a twelve-year period (1997 – 2008).

(i) A review was performed to identify the number of publications referencing the Ponseti method over the past 40 years. (ii) A structured questionnaire was sent to all Paediatric Orthopaedic practitioners in Scotland to ascertain the treatment methods used and over the time period. (iii) Data from the National Census for number of live births were combined with that obtained from the Scottish Morbidity Record (SMR01) for number of peritalar clubfoot surgeries performed over the study period. (iv) Similar data was also obtained for non-Talipes related peritalar surgeries, and data colleceted for the number of Tibialis Anterior transfer operations for this period. Clubfoot incidence data was measured indirectly by means of sample from the database of a tertiary referral Paediatric Orthopaedic Unit. Regression analysis was used to evaluate the trends over time.

Review of the literature referencing the Ponseti method over the past 40 years showed an exponential increase from the late 1990's. The survey of Clubfoot management of Paediatric Orthopaedic Surgeons in Scotland showed a marked increase in use of the method over with this period. Over this period, the number of operations for clubfoot dropped substantially, from 55 releases in 1997 to 1 release in 2008. The linear equation estimated a decrease of approximately 5 surgical releases per year (R²= 0.87, p<0.05). In Scotland, most Tibialis Anterior transfers are performed at age 3years, the frequency of the procedure has increased in the latter half of the study period.

In Scotland between 1997 and 2008, the number of peritalar (posterior, medial, posteromedial release) operations used in the primary treatment of idiopathic clubfoot has dropped substantially. This correlates with a marked increase in reference to the method within the literature and increased usage of the Ponseti technique by Paediatric Orthopaedic Consultants.

Congenital Talipes Equinovarus (CTEV) occurs in approximately 1 in 1000 live births. Most cases occur as an isolated birth defect and are considered idiopathic. The widespread adoption of the Ponseti technique of serial casting followed by Achilles tenotomy and long term bracing has revolutionised the outcomes in CTEV. In most cases, plantigrade, flexible, pain-free feet may be produced without the need for extensive surgery. It is estimated that about 10% of cases of CTEV are not idiopathic. These feet are stiffer and more challenging to treat. In particular, there is little evidence in the literature concerning the efficacy of the Ponseti method in these cases. In our institution, a dedicated weekly Ponseti clinic has operated since 2005. To date 140 patients have been treated. We prospectively enter all details regarding their management onto an independent international database. The aim of this study was to audit the non-idiopathic cases of CTEV and to assess the effectiveness of the Ponseti technique in these challenging cases. Outcome measures included the Pirani score and eventual need for surgical intervention. We identified 29 cases (46 feet) with non-idiopathic CTEV. This comprises 21% of our workload. Seventeen were bilateral. The commonest diagnoses were neuromuscular conditions such as spina bifida (5 cases) and cerebral palsy (3 cases). There were 4 cases of Trisomy 21. Other causes included Nail Patella syndrome, Moebius syndrome, Larsen syndrome and Ito syndrome. In approximately 12% of cases, the underlying disorder remained undiagnosed despite thorough medical and genetic testing. In cases of non-idiopathic CTEV, the mean starting Pirani score was 5.5 (out of 6). After serial casting and Achilles tenotomy, the average score was 2.0. Twenty-one of 46 feet (46%) ultimately required further surgical intervention (mostly posteromedial release). We found that certain conditions were more likely to be successfully treated with the Ponseti method – these included conditions characterised by ligamentous laxity such as Trisomy 21 and Ehlers Danlos syndrome. All patients showed some improvement in Pirani score after serial casting. We believe that it is essential to attempt the Ponseti method of serial casting in all cases of CTEV. More than half of all non-idiopathic cases will not require further surgical intervention – and those that do are not as stiff thanks to the effects of serial casting. Thus, the surgery required is not as complex as it might otherwise have been. This is the largest series of its kind in the current medical literature

Background and aims of the study: Identifying risk factors for poor outcome, is an important issue in the management of idiopathic congenital talipes equino varus foot deformity using Ponsetti Method.

Material & Methods: 198 feet of idiopathic congenital talipes equino varus foot deformity in 126 children, were treated using the Ponseti technique. They were followed up for a maximum of 36 months.

Patient prenatal, natal and family history were documented. Pre and post intervention morphologic measures were recorded. All cases had thorough clinical examination to exclude cases other than idiopathic congenital talipes equino varus, identified syndromes were excluded. Serial weekly plaster casting to correct cavus adducts and varus, followed by heel cord tenotomy if needed. Then foot abduction brace was used. results were graded as fully plantigrade(good), not fully plantigrade (fair) and relapsed (poor).

Results: The mean follow up was 19.9 + 5 months, 14 children 22 (11.1%) feet failed to show up at last follow up. Mean age at presentation was 56 + 143.6 days (1 day to 4 years). 112 children with 176 feet showed up at last follow up. 84 (75%)were males and 28 were females 12.5% had a similar condition in the family, positive consanguinity was in 35.7%. 31.2% were delivered by Caesarian section. The average number of casts was 8.2 for each foot, 14 (7.9%) had no tenotomy, all feet were corrected. 22 (12.5%) relapsed and recasted, 11 (6.2%) feet had retenotomies. In 18 (10.2%) feet (13 children) the parents refused the Ponseti management and under went open surgical releases else were. 21.4% of parents were compliant with abduction splint. In the surgical group 3 feet (16.6%) had a good result, 11 (61.1%) fair and 4 feet (22.2%) poor, 1 (5.5%) foot had residual metatarsus adducts. In the Ponseti managed group of (158 feet), 95 feet (60.1%) were good, 54 feet (34.2%) were fair and 9 feet (5.7%) poor, 21 (13.3%) feet had residual metatarsus adducts. Caesarian section (p=0.71), consanguinity (p=0.864), positive family history (p=0.12), sidedness (p=0.12) and age at presentation (p=0.52) had no bearing on results.

Conclusion: Parents’ compliance and devotion is a key factor for the successes of the technique.