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

Aim: Congenital Talipes Equinovarus (CTEV) is managed in a variety of ways, with little agreement on how best to assess outcome. Some authors advocate patient based subjective assessments, while others use a variety of objective measures. Without agreement, it is impossible to evaluate different management methods. We have therefore evaluated a number of objective parameters compared to a subjective assessment following management of CTEV. Methods: 216 children and their families consented to participate in the study. The children had been managed in a number of hospitals across Scotland, and in a variety of ways. Outcome was assessed by a researcher not involved in the management of the children. Subjective assessment consisted of a postal questionnaire. Objective assessment consisted of a number of anthropometric measures. Results: A strong correlation was seen between subjective assessment, and several objective outcome measures including foot length discrepancy, calf muscle wasting, and range of movement at the ankle. Conclusions: Objective assessment using several parameters correlates well with subjective assessment. Using these objective measures, it is possible to evaluate and compare different management protocols in CTEV

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

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

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

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

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity.

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.

1. A long-term follow-up of eighty-four patients with talipes equinovarus is reported.

2. A detailed examination was made to ascertain the nature of the residual deformity and assess the function of the deformed foot.

3. Radiographic technique in infants and adults is described.

4. Results showed that: 1) In many cases there was a dysplasia of the whole limb. 2) The dysplasia was no more marked in the patients treated in the early 1930's by multiple forceful under anaesthetic, than in the more recent patients treated by gentler means. 3) Nearly half the cases had only a false correction of the deformity in that the foot was "broken" at the talo-navicular level, leaving the heel in inversion, although the forefoot was plantigrade.

5. The posture of patients with laterally rotated hip joints is related to the fixed inverted heel.

6. Clinical assessment correlated with radiographic appearances shows clearly the near impossibility of a good foot resulting from a false correction.

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.

1. Talipes equinovarus is a specific type of club foot which has a genetic basis. Its occurrence along with certain neurological disorders has been noted.

2. An investigation of its incidence in 1,447 mental defectives, excluding those with cerebral palsy, revealed an incidence of 228 per 1,000, which is about ten times that for the general population.

3. There may be an upset early in embryonic development to account for the co-existence of both mental deficiency and talipes equinovarus.

1. The movements of the talus are described with particular reference to the anatomy of congenital talipes equinovarus.

2. It is suggested that the fundamental deformity in severe club foot is the fixed plantar-flexion of the talus.

3. Early operation is advised whenever serial stretching fails to bring the heel quickly into its normal position.

Aim: This study was carried out in order to clarify the causes that are mainly responsible for the necessity of reoperation after the initial correction of the deformity in congenital talipes equinovarus. The cases, which had been treated surgically with the same method and recurred later, were studied retrospectively in order to be ascertained epidemiological data related to the disease, to be isolated operative findings related to its pathology and to be estimated the surgical results based on clinical and radiological criteria.

Material-Methods: During the 15-year-period from 1990 to 2004, 123 infants (196 feet) with congenital talipes equinovarus have been treated operatively. There were 88 males and 35 females. Seventy three patients (59.3%) had the deformity bilaterally, 20 patients in right foot and 30 in left. Family history was positive in 5 infants. Other congenital anomalies coexisted in 12 infants (9.7%). Preoperative application of successive plasters was started into the first week for 93 infants (75.6%) and its duration was 3 months for 83.7% of cases. All the patients have been operated on with posteromedial approach, extensive ligament division and generous release of soft tissues during the first year of age. Two thirds of cases (67.4%) were treated surgically into the first 6 months of age.

Results: Anatomical variations were revealed during the operation in 14 feet (7.1% of the cases). The clinical results as well as the radiological signs into the first 6 postoperative months were satisfactory, but a reoperation was necessary in 21 feet (in 14 infants) for correction of part of the initial deformity into the following 2–5 years. The clinical criteria were related to the manner of standing and walking, the range of motion of the foot joints and block test. The radiological criteria were related to anteroposterior and lateral talocalcaneal angles and the angle between the longitudinal axis of the talus and that of the first metatarsal in the anteroposterior view as well as the position of the calcaneus in the lateral view. The causes that led to recurrence were related to imperfect correction with the plasters, to incomplete release of soft tissues during the initial operation and to some likely predisposing congenital and environmental factors.

Conclusions: The prevention of recurrence of the initial deformity, in the operative correction of congenital talipes equinovarus, is mainly related to the attentive pre-operative application of plasters, the careful lege artis surgical technique and the early diagnosis and treatment of the predisposing factors.

We present the treatment protocol of congenital clubfoot in different age groups that has been widely used in Bulovka Orthopedic Clinic since 1984. Conservative treatment begins immediately after delivery and corrects all presented deformities on the principle of subtalar derotation of the calcaneus. The correction is applied and an above-knee cast is changed every 48 hours. After five corrections and changes of casts, the casting and correction is then repeated weekly. After achieving reduction of deformities, the cast is changed at intervals of two to three weeks. Cast immobilisation should be continued for two to three months for postural clubfoot, and six to seven months for congenital clubfoot. After retention in the cast, a polypropylene above-knee splint is applied up to the age of two to three years. In addition, passive stretching exercise and stimulation of the lateral part of the foot should be provided in order to achieve muscle balance between the evertors and invertors.

Surgical treatment: When conservative treatment is unsatisfactory, the goal of operative treatment is to reduce all deformities in a one-step procedure. Posterior capsulotomy at the age of three to six months is indicated when the forefoot has been corrected by conservative treatment but the hindfoot remains fixed in the equinus and mild varus, or at the age of six to 12 months for residual hindfoot equinus.

Complete subtalar release according to McKay is required at the age of over six months to three years. Post-operative treatment is the same as for the abovementioned conservative treatment.

Treatment between the age of three and seven: The choice of surgical procedure must be individual according to the deformity, but surgical correction of severe deformity principally includes extensive subtalar release, and lateral column shortening by cuboid enucleation.

Treatment between the age of seven and ten: Individual procedures (Ilizarov method; Dwyer osteotomy of the calcaneus, or osteotomy of the mid-tarsal bones) are chosen to treat deformities. These procedures are usually combined with soft tissue release, but not with complete subtalar release.

Treatment after the age of ten (skeletal maturity of the foot): The same methods as in the previous group are used. When severe or unsatisfactory results after previous surgical treatment are obvious, a triple subtalar arthrodesis is the appropriate salvage method of correction.

Treatment of residual deformities: For treatment of dynamic deformities due to muscle imbalance after the age of four, a temporary lateral transfer of the whole tendon of the anterior tibial muscle is performed. For the same age group, forefoot adduction and supination are corrected with a ball and socket osteotomy of the base of metatarsals I-V.

This therapeutic concept was applied to 397 operated feet. 60% of the cases were primary surgical corrections, and 40% were repeated surgical corrections. 95% of primary surgical procedures and 75% of secondary surgical procedures were classified as satisfactory, indicating that the foot was sufficiently mobile, with plantigrade weight bearing.

1. The indications for talectomy in the treatment of equinovarus deformity in arthrogryposis multiplex congenita and spina bifida are discussed.

2. The technique of the operation is described, with variations which may be necessary in special circumstances.

3. The results of forty-one operations are analysed.

4. It is concluded that the operation has a useful place in the management of equinovarus deformity in arthrogryposis multiplex congenita and spina bifida, especially between the ages of one and five years.

From mid-1992 to 2000 and in conjunction with our paediatric department, we have run a screening program to detect congenital orthopaedic abnormalities. Over this period, we have been referred 245 patients with a provisional diagnosis of clubfeet, of these 54 or 22% were true CTEV (78 feet) giving an incidence in the general population of 0.18% while the rest were diagnosed as having simple postural clubfoot (0.6%).

Each patient was assessed clinically and classified according to the Harrold and Walker scale as well as being checked for other congenital/neurological abnormalities. 83% of patients were seen within two weeks of referral. Initial management entailed strapping for 6 weeks with further periods of plaster immobilization (required by 46%). Those who failed to respond or who deteriorated underwent surgical correction with sub-talar release. A small percentage required secondary procedures such as Tibialis Anterior transfer, Tendoachillis release and revision.

Patients were continued in the program until at least 6 years of age. While there was a wide variation of other abnormalities in those with type 2 CTEV, those with type 3 had a high incidence of neurological conditions and in particular, arthrogryphosis (59%). These patients did worse and 55% required further surgery after the initial sub-talar release.

We would like to present the findings of an 8.5 year prospective study looking at the incidence of the condition, the frequency of other abnormalities and the results of conservative and surgical treatment for each grade.

Aim: To compare the rate of relapse of Ponseti treatment method with a historical cohort who underwent conventional surgery.

Method and Results: From June 2002 to December 2004, 70 patients presented with 107 clubfeet and started the Ponseti treatment method. 15 feet in 9 patients were excluded due to teratologic deformity. 50 patients with 75 clubfeet were studied (41 boys and 9 girls). There was at least a two-year follow up period, or failure of the Ponseti method within this time frame. Data was compiled from clinic assessment forms and patient notes. All cases resulting in recasting or further surgical procedures were regarded as failure of conservative treatment. This was compared to published data from the same centre, regarding relapse for the two-stage surgical method. From 1988 to 1995, 86 patients presented with 120 clubfeet and had surgical treatment. 68 patients with 91 clubfeet (48 boys 20 girls) had the two-stage surgical procedure and were followed up at a mean age of 5.7 years (2.2 to 9.6). The mean age for surgery was 8.9 months.

Relapse rate of both treatment methods was compared for all feet in all Dimeglio grades. Relapse rates for Ponseti and surgery respectively were: grade 2, 18.2% vs 0%; grade 3, 36.2% vs 20.4%; grade 4, 35.3% vs 65.4%. The differences were not statistically significant

Conclusions: The Ponseti method is as valid as the two-stage surgical method for the treatment of clubfoot. Functional outcomes of the two treatment methods need to be compared.

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.

It is difficult to predict the outcome or likely treatment that will be required for an individual child with a rigid clubfoot deformity at an early stage.

32 Dimeglio grade II, III or IV CTEV feet in 24 infants were treated with weekly serial casts according to Ponseti method. Graphical plots of the improvement obtained in Dimeglio scores during serial cast treatment of CTEV were subsequently analysed to identify characteristic features that would help predict the likely success of casting or the need and extent of surgical release. The rate of change in global Dimeglio score, hindfoot (equinus / heel varus) and midfoot (adduction / derotation) components were specifically studied.

During casting the rate of change over 4 weeks and a “plateauing” of the global Dimeglio score after 4–6 weeks of casting separated those feet that responded to casting alone from those that required additional surgery. Those with “plateauing” and minimal midfoot deformity by 4 weeks (adduction /derotation score < =2) required a posterior release. Failure to correct the mid-foot deformity by 4 weeks (adduction /derotation score > = 3) predicted the need for a combined plantar medial and posterolateral release. These parameters were clearly demonstrated by graphical plots that can be easily obtained in a busy clinic setting.

Graphical representation of the rate of change in Dimeglio parameters can predict the likely treatment needed for children with CTEV. A graphical algorithm has been developed that can be used during the first 6 weeks of treatment to guide Ponseti method casting and early surgical intervention.

Purpose: We report a retrospective consecutive series of 57 hemiplegic patients (32 men and 25 women) who underwent surgery between 1995 and 2000 for spastic talipes equinovarus associating fascicular neurotomy of the tibial nerve and tendon release in order to recover sole to floor walking capacity.

Material and methods: Mean patient age was 47 years (16–75). The hemiplegia resulted from stroke (n=41), trauma (n=8), and other causes (n=8). All patients had spastic talipes equinovarus and 46 required a walking aid. Triceps force and spasticity were scored 2.1 (MRC) and 3.66 (Ashworth) respectively. Pedial hypoaesthesia was present in 23 patients. The mean functional ambulation classification (FAC) score was 3.3, with severe disability (FAC 1 or 2) in 13 patients. Surgery was performed three years (average) after the causal event. After identification by electrical stimulation, we performed microsurgical section of 4/5 nerve fibres of the terminal branches of the tibial nerve in 55 patients. After physical exploration of musculotendon retraction (triceps and toes flexors) and dorsiflesion palsy, we released tendons as needed. The Achilles tendon was lengthened percutaneously in 13 patients, Bardot tenodesis or transfer of the anterior hemi-tibial anterior tendon was performed in 29, and tenotomy of the toe flexors in 12.

Results: Mean follow-up was three years (1–6). Triceps force and foot sensitivity were not modified by the surgery. Spasticity was scored 1.08 and 1.19 (Ashworth) postoperatively and at last follow-up respectively. The FAC walking score was 4.13 and 4.15 postoperatively and at last follow-up respectively. The walking aid was no longer necessary or was improved in 52 patients. Tibiotalal arthrodesis was necessary for recurrent spasticity in three patients.

Discussion: The preoperative assessment of foot deformity and gait is an essential element. Correct preoperative assessment enables microsurgery for fascicular neurotomy of the posterior tibial nerve and tendon lengthening or tenodesis during the same operation. These procedures are indicated for severe deformity and should be used as the first intention treatment before arthrodesis which involves greater morbidity.

Background: The Ilizarov external fixator has theoretical advantages over conventional revision surgery for the treatment of recurrent clubfoot deformity where scarred tissue planes, abnormal anatomy and impairment of local blood supply are common.

Objective: To assess the outcome of treatment of recurrent club-foot deformity using this device.

Patients/Methods: The study evaluated Ilizarov external fixator correction of 40 feet in 31 patients. Deformity was idiopathic in 29 patients, associated with constriction bands in 6 patients and was syndromic or associated with a defined neuromuscular disorder in 6 patients.

Patients were reviewed clinically and completed questionnaires documenting pain, function and satisfaction before and after treatment at a mean follow-up of 44 months (range 14–131). All patient’s notes and radiographs were examined.

Results: Pain and function scores after treatment improved in 67% and 72% of cases respectively. A subjective increase in stiffness was noted in 46%. Patient satisfaction with outcome was 61%, correlating with improved pain and function scores. Pain and function scores were not significantly different in stiff versus non-stiff feet. The overall recurrence rate was 44%, and was highest in the idiopathic group (59%) compared with the constriction band group (17%) and the neuromuscular/syndromic group (0%). Feet with recurrent deformity had been treated with the Ilizarov fixator at a younger mean age (7.8 years) than those feet which did not recur (mean age 12.6 years). 71% of recurrences experienced significant pain post treatment, compared with only 36% of those feet where deformity did not recur. Functional ability was, however, similar in the two groups. Further surgical treatment has been necessary in 6 patients, including 4 further Ilizarov frames.

Complications included almost universal minor pin-site infections, flexion contractures of the toes in 5 feet and skin ulceration in 2 feet, 1 requiring a muscle flap.

Conclusions: Treatment of relapsed clubfoot with the Ilizarov fixator can improve the appearance of the foot, correlating with improvement in pain, function and patient satisfaction. This must be balanced however against a high recurrence rate, particularly in young idiopathic feet, an increase in stiffness of the ankle, which has implications for future surgery, and the risk of complications inherent in the technique.

From a cohort of 110 idiopathic clubfeet, 26 feet in 18 children requiring surgery for severe relapse have been studied. Surgery was comprised of a lateral column shortening procedure (Lichtblau) plus or minus a plantarmedial release. Surgery was staged to avoid wound complications.

Pre-operatively, feet were prospectively categorised into one of four grades according to a system reported by Dimeglio. Children were reviewed on two subsequent occasions. At review, feet were again graded. In addition, appearance and functional outcome was analysed and included an assessment of gait, activity and functional limitation.

Three children were lost to follow-up, leaving 22 feet in seven male and eight female patients available for review. The mean age at surgery was 43 months (23–82). The mean time from surgery to first and second reviews was 35 and 56 months, respectively.

There was a significant improvement in grading at first review compared to pre-operative grading (Wilcoxon signed ranks test). Although there remained a significant improvement in grading at second review compared to the preoperative grading, there was a significant reduction in the number of feet in which grading had improved when compared to first review.

There was no significant change in function between the two post-operative reviews (Chi-square tests), with the majority of children experiencing little functional limitation. There were no wound complications.

Relapse surgery, involving a lateral column shortening procedure for severe clubfoot, results in a significant initial improvement when assessed using a grading system. This improvement in grading subsequently decreases over time. However, the functional outcome in such cases remains favourable.

The equinovarus hind foot deformity is one of the most common deformities in children with spastic paralysis and is usually secondary to cerebral palsy. Split posterior tibialis tendon transfer is performed to balance the flexible spastic varus foot and is preferable to posterior tibialis lengthening, as the muscle does not loose its power and therefore the possibility of a valgus or calcaneovalgus deformity is diminished. The cohort of the study consisted of 50 children with cerebral palsy who underwent split posterior tibial lengthening to manage spastic equinovarus hind foot deformity. Our inclusion criteria were: ambulatory patients with cerebral palsy, age less than 6 years at the time of the operation, varus deformity of the hind foot during gait, flexible varus hind foot deformity, and the follow-up at least 4 years. We retrospectively evaluated 33 ambulant patients with flexible spastic varus hind foot deformity. Twenty-eight patients presented unilateral and 5 bilateral involvement. The mean age at the time of the operation was 10,8 years (6–17) and the mean follow-up was 10 years (4–14). Eighteen feet presented also equinus hind foot deformity, requiring concomitant Achilles cord lengthening. Clinical evaluation was based on the inspection of the patients while standing and walking, the range of motion of the foot and ankle, callus formation and the foot appearance using the clinical criteria of Kling et al. Anteroposterior and lateral weight-bearing radiographs of the talo-first metatarsal angle were measured. The position of the hind foot was evaluated according to the criteria of Chang et al for the surgical outcome. 20 feet were graded excellent, 14 were graded good and 4 were graded poor. Feet with recurrent equinovarus deformity or overcorrection into valgus or calcaneovalgus deformity were considered as poor results. There were 23 feet presenting concomitant cavus foot component that underwent supplementary operations performed at the same time with the index operation. None of the feet presented mild or severe valgus postoperatively, while 4 feet presented severe varus deformity and underwent calcaneocuboid fusion sixteen and eighteen months after the index operation. On the anteroposterior and lateral weight-bearing radiographs the feet with severe varus had a negative talo-first metatarsal angle (mean −26,8 ± 18,4), those with mild varus had a mean of −14,5 ± 12,2. In feet with the hind foot in neutral position the mean value was 5.0 ± 7.4. The results of the feet in patients with hemiplegic pattern were better and significantly different than the diplegic and quadriplegic ones (p = 0.005). The results in our cases were in general satisfactory as 34 out of 38 feet were graded excellent and good. The feet with poor results presented a residual varus deformity due to intraoperative technical errors.

Introduction: The Ilizarov external fixator has theoretical advantages over conventional revision surgery for the treatment of recurrent clubfoot deformity. The aim of this study was to assess the outcome of such treatment.

Materials & Methods: Patients were reviewed clinically and completed extensive questionnaires documenting pain, function and satisfaction before and after the frame at a mean follow-up of 44 months (range 14–131). All patient notes and radiographs were reviewed.

Results: There were 42 frames applied to 40 feet in 31 patients. Deformity was idiopathic in 29 cases. Pain and function scores after treatment improved in 67% and 72% of cases respectively. A subjective increase in stiffness was noted in 46%. Patient satisfaction with outcome was 61%. Pain and function scores were not significantly different in stiff versus non-stiff feet. The overall recurrence rate was 44%; these feet had been treated with the Ilizarov fixator at a younger mean age (7.8 years) than those feet which did not recur (12.6 years). Recurrence was highest in the idiopathic group (59%) compared with the constriction band group (17%) and the neuromuscular/syndromic group (0%), despite the fact that the idiopathic group were older overall. 71% of recurrences experienced significant pain post treatment, compared with only 36% of non-recurrent feet. Functional ability was, however, similar in the two groups. Further surgical treatment has currently been necessary in 6 patients, including 4 repeat Ilizarov frames. Complications included almost universal minor pin-site infections, flexion contractures of the toes in 5 feet and skin ulceration in 2 feet, 1 requiring a muscle flap.

Conclusions: Treatment of the relapsed clubfoot with the Ilizarov fixator can improve the appearance of the foot, correlating with improvement in pain and function. Risks include recurrence, particularly in young, idiopathic feet, an increase in stiffness of the ankle, which has implications for future surgery, and other complications.

Pes equinovarus is a multi-factorial congenital disease that involves 1/1000 births, is bilateral in half of the cases and affects usually male children.

From 1995 – 2008 we have treated in total 172 children with pes equinovarus, 116 male and 56 female with age from 1 week to 4 years-old. There was bilateral pes equinovarus in 36 children whereas unilateral disease revealed equal rate of incidence. All children were treated initially with corrective casts and sequentially 122 children had surgery consisting of Achilles tendon lengthening and posterior capsulotomy, whereas in the rest of the cases was necessary medial hind foot structures and tendons release.

Final correction with only one operation were achieved in 108 children, there were pes equinovarus recurrence in 18 children that was treated with new soft tissue operation whereas 3 children had to undergo some kind of osteotomy in a later time. The recurrence time varied from 30 months to 13 years. The treatment was successful in 70% of the cases and 30% of them needed more than one operation for achieving a satisfactory functional result.

Pes equinovarus is a severe condition that now-a-days can be early diagnosed even in fetal life, but leads to significant handicap if left without treatment. In our department there were successful rates similar to international reports. The importance of an established long-term follow up of children that were operated for pes equinovarus is the keystone of a successful outcome and the early treatment is mandatory.

Introduction and Aims: To illustrate complete, single chance correction, of congenital clubfoot in 89 cases in the Pacific Islands, from a humanitarian, scientific, and surgical perspective. To identify the unique Polynesian clubfoot gene, its particular characteristics, and the environmental factor suspected to trigger its activation.

Method: A rolling surgical procedure commencing with Turco operation and progressing as far as lateral border decancellation, is used. Tripple arthrodesis is not done, obsessive and meticulous after care is required for two weeks.

Results: Return clinic visits through inter-islands hospitals, aid post and villages, have revealed excellent long-term corrections. There have been no reoccurences and the surgical team have received no negative feedback.

Genetic studies suggest a single dominant gene of variable penetrants. Seventeen comfirmed perterdries from Vanawatu indicate a recessive inheritance in the population. The frequency varies from Island to Island, eg. Efate 0.26, Tanna 0.13. Seven cases gave a history of at least one other family member being affected. However, there was no vertical transmission in any degrees we conclude in a recessive mode of inheritance for ITEV in South Pacific Polynesian people. The desired surgical protocol is determined by an incremental combination of current surgical procedures with careful placement of incisions. Associated bone procedures are carefully selected. A rigorous and disciplined post-operative protocol has avoided known complications to date.

Conclusion: Single stage ITEV correction in adverse surgical conditions is successful and straightforward. The recipient is given a chance to avoid life-long degradation.

Genetic studies indicate a simple environmental cause activating a single dominant gene with 33% penetrants.

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

Purpose of the study: The purpose of this work was to study outcome at the end of grow after surgical treatment for idiopathic congenital equinovarus club foot.

Material and methods: From 1983 to 1991, 63 children (85 club feet) given functional treatment underwent surgery because of insufficient results. At birth, the Dimeglio classification was II:11.7%; III:40%; IV:25.8%. Surgery was performed before the age of 2 years for 52 fee (61%) and after 2 years for 33. The indication for surgery was a triple deformity: equin (8.1±15.2, varus (8.2±13.1, adductus (32.5±13.8). Surgery was associated as needed with posterolateral release (94.1%), anteromedial release (92.9%), plantar release (61.1%) and Lichtblau shortening of the lateral column (42%). The tendon of the tibialis anterior was lengthened for 86% of the feet. Functional, clinical, and radiographic outcomes were noted at last follow-up.

Results: Mean follow-up was 15 years (8–22). Fifteen feet (17.6%) had a second operation: 13 for recurrence (repeat release), one for over correction (lengthening of the calcaneum) and one for metatarsus adductus (metatarsal osteotomies). One foot had a third operation for recurrence (repeat release). Three feet (3.5%) did not have surgery; a double arthrodesis followed progressive aggravation during growth. In the first group (surgery before 2 years), outcome was very good, good or fair for 76.9, 17.3 and 5.8% of the feet. The “fair” outcomes concerned three children who had more than one operation. In the second group (surgery after 2 years), the outcomes were 78.8%, 18.2% and 3% (n=1) respectively. The “fair” result concerned the double arthrodesis. There was no significant difference for the final outcome as a regards age at surgery (p=0.07). Among the four feet with a “fair” outcome, two were initially Dimeglio III and two Dimeglio IV.

Discussion: Soft tissue release enables correct results at the end of growth for the majority of these club feet. While the Dimeglio score is an element predictive of an indication for surgery, it is not a prognostic element for the final outcome. Age at surgery does not have a significant impact on the final outcome.

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.

Introduction: To review the medium term outcome of staged surgery for treating recalcitrant idiopathic talipes equinovarus.

Methods: Between 1988 and 1995, we studied 91 club feet from a series of 120 recalcitrant feet in 86 patients requiring surgical treatment. The initial results have been reported previously and this cohort has been subsequently followed up for between 7 and 15years. The mean age at initial operation was 8.9 months. Surgery consisted of an initial plantar medial release followed two weeks later by a posterolateral release. This strategy was used specifically to address the problems of wound healing associated with single-stage surgery and to ascertain the rate of relapse after a two-stage procedure. The feet were classified preoperatively and prospectively into four grades according to the system suggested by Dimeglio et al. Reported relapse at last review was 0.0% in grade 2, 20.4% in grade 3 and 65.4% in grade 4 feet. The rate of overall relapse was 30.8%. At 7 to 15 year review an additional 9.1% in grade 2, 7.4% in grade 3, 11.5% in grade 4 had relapsed. Overall a further 8.8% had relapsed and were treated with further surgery. Functional outcome of the group remains good with 95.6% overall finding no restrictions to activities.

Conclusion: This review confirms that the strategy of staged surgery is supported in the medium term when considering rates of relapse and functional outcome.

The Cincinnati incision is widely utilized in clubfoot surgery and allows excellent access to the medial, lateral and posterior structures involved. Closure of the skin at the end of the procedure without undue tension may be difficult. Wound necrosis and excessive scarring may occur and may lead to inadequate correction. One alternative is to splint the foot in an initial equines position post-operatively with repeat cast changes to achieve optimal position once soft tissue swelling has decreased. A further method is to leave the wound open and allow it to granulate.

The healing and final cosmetic appearance of wounds allowed to heal by granulation following the Cincinnati incision were reviewed.

We reviewed 14 feet in 10 patients who had undergone partial closure of the Cincinnati incision following peritalar release. The majority of the children were male and the average age at surgery was 28 weeks. All corrections were performed as primary procedures on patients with idiopathic CTEV. At the end of the procedure an above-knee plaster was applied. The plaster was changed weekly in the outpatients department until the wound had healed. Patients were maintained in plaster for 12 weeks.

All final wounds were cosmetically acceptable both to the surgeon and the parents. The widest scar was 3 mm and the average time to heal four weeks. No infection had occurred although two wounds were treated for overgranulation.

Partial wound closure of the Cincinnati incision avoids undue tissue tension and allows a fully corrected position of the foot to be maintained at the end of the initial procedure. A second anaesthetic to obtain further correction is therefore avoided. Partial wound closure leaves cosmetically acceptable scarring with minimal complications. Parents should be warned about the initial appearance of the wound but may be reassured regarding final outcome.

Purpose of the study: The aim of this study was to evaluate the results of the repeated soft tissue release for recurrent postoperative idiopathic congenital talipes equinovarus. There is no real consensus on the appropriate therapeutic option.

Materials and Methods: Fifty two patients (74 feet) underwent revision surgery performed by our senior surgeon between 1974 and 2001. One, two or three soft tissue release procedures were performed on 59, 12 and 3 feet respectively. Mean age at the time of the revision surgery was 5.7 years (range 15m-14y). Triple deformity (varus, equinus, adductus) was found in 46 feet, while 28 feet had one dominant deformity. The operation consisted of complete release of the soft tissues in 26 feet and partial release in 48. Subtalar release was indicated in 21 feet. Lichtblau osteotomy was performed in 48 feet. The clinical and radiological outcome was assessed using the Ghanem and Seringe scores recorded before surgery and at last follow-up.

Results: Mean follow-up was 11 years (range 4–30). Complications included overcorrection in valgus (n=6) and recurrence (n=8). The anatomic correction was highly significant. Dorsoplantar X-rays show the improvements in the mean talocalcaneal divergence (18–21°), the mean talus-first metatarsal angle (reduced from 28° to 4°), and the calcaneus-fifth metatarsal angle (reduced from 20° to 2°). The average of tibiocalcaneal angle in lateral view increased from 1° to 10° and the average of calcaneal incidence from 6° to 9°. At last follow-up, outcome was considered as ‘excellent’ in 29% and ‘good’ in 42% of the cases. We had ‘fair’ results in 14 feet (19%) because of poor functional results in one third and anatomical defects in two-thirds of them. The outcome was considered ‘poor’ in seven feet (10%), which was due to significant anatomical defects. Triple arthrodesis was needed in seven feet after skeletal maturity.

Discussion and Conclusion. Repeated soft tissue release provides an effective means for correcting anatomical anomalies caused by recurrent postoperative talipes equinovarus. The mid-term results are however affected by functional limitations characterised by decreased range of motion and joint pain, particularly in ankle joint. Excessive subtalar release raises the risk of valgus overcorrection. A splint worn at night may be helpful for preventing the recurrence.

It is difficult to predict the outcome or likely treatment that will be required for an individual child with a rigid clubfoot deformity at an early stage.

32 Dimeglio grade II, III or IV CTEV feet in 24 infants were treated with weekly serial casts according to Ponseti method. Graphical plots of the improvement obtained in Dimeglio scores during serial cast treatment of CTEV were subsequently analysed to identify characteristic features that would help predict the likely success of casting or the need and extent of surgical release. The rate of change in global Dimeglio score, hindfoot (equinus/heel varus) and midfoot (adduction/derotation) components were specifically studied.

During casting the rate of change over 4 weeks and a “plateauing” of the global Dimeglio score after 4–6 weeks of casting separated those feet that responded to casting alone from those that required additional surgery. Those with “plateauing” and minimal midfoot deformity by 4 weeks (adduction/derotation score < =2) required a posterior release. Failure to correct the mid-foot deformity by 4 weeks (adduction/derotation score > = 3) predicted the need for a combined plantarme-dial and posterolateral release. These parameters were clearly demonstrated by graphical plots that can be easily obtained in a busy clinic setting.

Graphical representation of the rate of change in Dimeglio parameters can predict the likely treatment needed for children with CTEV. A graphical algorithm has been developed that can be used during the first 6 weeks of treatment to guide Ponseti method casting and early surgical intervention.

Background: Congenital talipes equinovarus (CTEV) is a common developmental disorder of the foot, affecting between 1 and 4.5 babies per 1000 live births. The etiology is not well elucidated. While both genetic and environmental factors are implicated, no specific genes have been identified and little is known about environmental risk factors.

Methods: We conducted a case-control study of idiopathic congenital talipes equinovarus (ICTEV) in the United Kingdom. 194 cases and 60 controls were recruited. Pedigrees were obtained for 162 cases.

Results: The rank of the index pregnancy, maternal education and cesarean delivery were significantly associated with ICTEV risk in a multivariate model. There were suggestions that maternal use of folic acid supplements in the three months before the pregnancy decreased ICTEV risk, and that parental smoking during the pregnancy increased risk. One quarter of pedigrees showed a family history of CTEV, and autosomal dominant inheritance was suggested in some of these.

Conclusion: Uterine restriction did not appear to have a strong influence on ICTEV development in our study. Large population-based studies are needed to clarify the etiology of this common developmental disorder.

CTEV is a difficult condition to treat with chances of recurrence, re-operation rate and over correction. Recent literature based on evidence is favourable with the Ponseti management. The aim of the study was to review our surgical results over a 5-year period using the Cincinnati approach.

Children with failure of conservative serial stretching and casting for 6 months underwent open release. The records and radiographs were reviewed retrospectively from 1997–2002. 60 patients were identified with 92 feet undergoing primary sub radical releases using the Cincinnati approach in 40 male and 20 female children. The mean age at surgery was 10 months. 55 patients were idiopathic with 3 syndromal and 2 teratological.

Consultants performed > 75% of operations, with k-wire stabilisation done in 46 patients and primary wound closure in 25; the majority of wounds were left open. The timing of plaster change varied, with the majority at 2 weeks. Wound problems occurred in 4 patients (significant in 2). All patients but one wore splints for an average length of 13 months. Complication rate was 20% comprising infection, over- correction and recurrence. Re-operation rate for early recurrence was 12%. Further surgery in the form of tibialis anterior transfer and derotation osteotomy was performed on 15% and 10% of feet respectively. 6 feet in 4 patients showed signs of significant over correction.

Wound healing by secondary intention of the Cin-cinnati approach is safe. Results and complications are comparable to other series, but not to the Ponseti non-operative management. Practice is now changed to the latter based on evidence.

Aim of study: To assess ankle dorsiflexion of operated pedes equinovari congenitales in both clinical examination and gait analysis.

Introduction: Mac Kay subtalar release corrects mostly perfectly deformed feet. Operated feet show however stiffness not only in subtalar but as well as in ankle joint. The range of motion in ankle joint was not yet studied systematically at all. Gait analysis offers the possibility to follow the motion in ankle joint dynamically.

Material: Thirty six consecutively operated feet were examined by clinical as well as by gait analysis examination. All were operated by Mac Kay procedure at least one year before examination (range 1–7 years). Feet were examined in lying and stance positions. Gait analysis was based on use of Oxford foot model (8 cameras motion capture system).

Results: Dorsiflexion/plantiflexion of the foot estimated by clinical examination was compared with maximum dorsiflexion in phase of mid-stance (second rocker)/maximum plantiflexion in pre-swing phase (third rocker). Differences individually for each patients in dorsiflexion/plantiflexion were calculated. Mean of difference between dorsiflexion in clinical examination and dorsiflexion in gait analysis x = 14.3°. Mean of diference between plantiflexion in clinical examination and plantiflexion in gait analysis x= 5,4°. Using T-paired test these differences were found statistically significant (p=0,01). Normal maximum dorsiflexion of the children’ foot in gait analysis is about 20°. From this point 14 operated feet out from 36 did not fulfill this criterion. On the other hand only 4 operated feet showed in gait analysis dorsiflexion less than 10°.

Discussion: Dorsiflexion of the foot is important for smooth gait. The diference between dates from clinical examination and dates from gait lab can be explained by weight - bearing force pushing the foot into dorsiflexion during second rocker or by secondary adaptive intrinsic bending of the foot

Conclusion: Operated feet showed moderate/severe stiffnes of ankle joint. Despite of it, the gait cycle was not significantly impaired.

Purpose of the study: Among the causes of secondary congenital equinovarus club foot, neurological disorders predominate. The entity we examine here corresponds to irreversible pure motor paralysis with no sensorial disorder affecting the lateral compartment predominantly and sometimes associated with involvement of the anterior compartment. There is no literature on this entity. Beyond the question of the aetiology, the demonstration of this pathological condition can modify therapeutic strategy in order to prevent recurrence.

Material and methods: We examined 42 congenital equinovarus club feet with persistent pure motor paralysis involving the lateral compartment and sometimes the anterior compartment with a mean 10 years follow-up. The Dimeglio classification was used and an analytical muscle score was noted for each patient. Complementary tests included an electromyogramme when possible. Conservative treatment was the rule either using a functional method or the Ponseti method; surgery was then proposed when necessary for posteromedial release with or without palliative muscle transfer. The following procedures were performed: posteromedial release (n=33) and muscle transfer (n=26): tibialis posterior (n=22), tibialis anterior (n=3); hemisoleus (,n=1); tibialis posterior associated with flexor digitorum longus (n=3).

Results: Conservative treatment was used for all feet but all presented recurrence and required secondary surgery (33 posteromedial releases and 26 muscle transfers).

Discussion: This study opens the discussion on the similarity between idiopathic and arthrogryoposis club foot since the electromyography sometimes reveals an anomaly of the anterior horn. Thus club foot with pure motor and persistent paralysis involving the lateral and/or anterior compartment will not respond sufficiently to nocturnal contention if an adapted muscle transfer is not associated.

Conclusion: Muscle transfer to reactivate dorsal flexion of the foot enables a better functional outcome. First intention conservative treatment can be instituted while waiting for potential recovery. If the paralysis persists beyond one year, muscle transfer is indicated before the deformity recurs and requires an associated posteromedial release.

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

We report the results of transfer of the long toe flexors and lengthening of the calcaneal tendon in 33 patients with equinovarus deformity requiring orthoses after a stroke. Review of 29 patients more than two years after surgery showed that 21 were able to walk without an orthosis. Equinovarus deformity had recurred in six patients and hammer toe in 11, but walking ability without bracing was still better in seven of these. Results are improved by the release of the short toe flexors

Aims: To assess the long term results of correction of recalcitrant club feet in syndromes such as Arthrogryposis and Spina Biþda after combining talectomy with the application of Ilizarov frame. Methods: 8 patients (10feet) with syndromes including Arthrogryposis, Spina Biþda and Diastrophic Dysplasia were followed up at 7.25 years (1 Ð 10) years following application of Ilizarov frame. The mean age was 19.5 (10– 29) years at follow up and there were equal number of males and females. These patients presented with recurrent and resistant clubfeet with 3.8 (1–6) procedures per foot, done prior to Ilizarov frame application. Talectomy was done before frame application in 5 feet, simultaneously in 4 feet and following frame in 1 foot. All 10 feet were talipes Equinovarus. Results: 8 excellent, 1 good and 1 fair result. All patients are now pain free, none require more than daytime AFO splints (with a much improved tolerance), none have major skin problems, All patients/parents described their feet as Ôfar betterñ or Ôbetterñ and would readily submit to the same procedure again if necessary. Conclusion: In properly selected complex cases with syndromes, talectomy combined with frame can produce more excellent and good results with long lasting correction

Aims

To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle.

Charcot osteoarthropathy of the foot is a chronic and progressive disease of bone and joint associated with a risk of amputation. The main problems encountered in this process are osteopenia, fragmentation of the bones of the foot and ankle, joint subluxation or even dislocation, ulceration of the skin and the development of deep sepsis. We report our experience of a series of 20 patients with Charcot osteoarthropathy of the foot and ankle treated with an Ilizarov external fixator. The mean age of the group was 30 years (21 to 50). Diabetes mellitus was the underlying cause in 18 patients. Five had chronic ulcers involving the foot and ankle. Each patient had an open lengthening of the tendo Achillis with excision of all necrotic and loose bone from the ankle, subtalar and midtarsal joints when needed. The resulting defect was packed with corticocancellous bone graft harvested from the iliac crest and an Ilizarov external fixator was applied. Arthrodesis was achieved after a mean of 18 weeks (15 to 20), with healing of the skin ulcers. Pin track infection was not uncommon, but no frame had to be removed before the arthrodesis was sound.

Every patient was able to resume wearing regular shoes after a mean of 26.5 weeks (20 to 45).

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

Our aim was to evaluate the results of triple arthrodesis, performed without the use of supplementary bone graft. We carried out a retrospective review of 100 consecutive triple arthrodeses. All the operations had been performed by the senior author (TSS) using a standard technique. Only local bone graft from the excised joint surfaces had been used, thereby avoiding complications at the donor site.

The mean age of the patients at surgery was 58 years (18 to 84). The mean time to union was 5.1 months (3 to 17). There were 75 good, 20 fair and five poor results. There were four cases of nonunion.

Our study has shown that comparable rates of union are achieved without the need for supplementary bone graft from the iliac crest or other donor site.

Most children with spastic hemiplegia have high levels of function and independence but fixed deformities and gait abnormalities are common. The classification proposed by Winters et al is widely used to interpret hemiplegic gait patterns and plan intervention. However, this classification is based on sagittal kinematics and fails to consider important abnormalities in the transverse plane. Using three-dimensional gait analysis, we studied the incidence of transverse-plane deformity and gait abnormality in 17 children with group IV hemiplegia according to Winters et al before and after multilevel orthopaedic surgery.

We found that internal rotation of the hip and pelvic retraction were consistent abnormalities of gait in group-IV hemiplegia. A programme of multilevel surgery resulted in predictable improvement in gait and posture, including pelvic retraction. In group IV hemiplegia pelvic retraction appeared in part to be a compensating mechanism to control foot progression in the presence of medial femoral torsion. Correction of this torsion can improve gait symmetry and function.