Ponseti method has become the most common and validated initial non-operative and/or minimally invasive treatment modality of idiopathic clubfoot regardless of the severity of the deformity worldwide. Despite hundreds of publications in the literature favoring Ponseti method, the data about secondary procedures performed in the follow-up period of clubfoot and their incidence remains sparse and given as small details in the articles. The objective of this study was to analyse our incidence of secondary procedures performed in the midterm followup period of idiopathic clubfoot patients treated with Ponseti method and review of the relevant literature. For this purpose 86 feet of 60 patients with idiopathic clubfoot who were treated with original Ponseti method were enrolled in this retrospective case control study. Unilateral ankle foot orthosis (AFO) was used rather than standart bar-connected foot abduction orthosis varying from 12 months to 25 months in the follow-up period and 74 of 86 (86%) feet required percutaneous achilles tenotomy. The average age of initial cast treatment was 12.64 days (range 1 to 102 days). The mean follow-up time was 71 months (range 19 to 153 months). Thirty seven feet of 24 patients recieved secondary procedures (43%) consisting of; supramalleolary derotational osteotomy (SMDO) (1 patient/2 feet), complete subtalar release (3 patients/5 feet), medial opening lateral closing osteotomy (double osteotomy) (2 patients/3 feet), double osteotomy with transfer of tibialis anterior tendon (TTAT) (2 patients/3 feet), partial subtalar release (PSTR) (3 patients/5 feet), PSTR with SDO (1 patient/1 foot), posterior release (PR) with repeated achillotomy (1 patient/2 feet), TTAT (6 patients/10 feet), TTAT with PR (2 patients/2 feet), TTAT with Vulpius procedure (1 patient/1 foot) and TTAT with SMDO (2 patients/3 feet) respectively. The amount of percutaneous achilles tenotomy (86%) in our study correlated with the literature which ranged from 80 to 90 %. The transfer of tibialis anterior tendon continued to be the most performed secondary procedure both in our study (51%) and in the literature, but the amount of total secondary procedures in our study (43%) was determined to be higher than the literature data varying from 7 to 27 percent which may be due to unilateral AFO application after Ponseti method for idiopathic clubfoot deformity in our study

We present a systematic review of the results of the Ponseti method of management for congenital talipes equinovarus (CTEV). Our aims were to assess the method, the effects of modifications to the original method, and compare it with other similar methods of treatment. We found 308 relevant citations in the English literature up to 31 May 2010, of which 74 full-text articles met our inclusion criteria. Our results showed that the Ponseti method provides excellent results with an initial correction rate of around 90% in idiopathic feet. Non-compliance with bracing is the most common cause of relapse. The current best practice for the treatment of CTEV is the original Ponseti method, with minimal adjustments being hyperabduction of the foot in the final cast and the need for longer-term bracing up to four years. Larger comparative studies will be required if other methods are to be recommended

Aims. The Ponseti method is an effective evidence-based treatment for clubfoot. It uses gentle manipulation to adjust the position of the foot in serial treatments towards a more physiological position. Casting is used to hold the newly achieved position. At first, the foot resists the new position imposed by the plaster cast, pressing against the cast, but over time the tissues are expected to adapt to the new position and the force decreases. The aim of this study was to test this hypothesis by measuring the forces between a clubfoot and the cast during treatment with the Ponseti method. Patients and Methods. Force measurements were made during the treatment of ten idiopathic clubfeet. The mean age of the patients was seven days (2 to 30); there were nine boys and one girl. Force data were collected for several weeks at the location of the first metatarsal and the talar neck to determine the adaptation rate of the clubfoot. Results. In all measurements, the force decreased over time. The median (interquartile range) half-life time was determined to be at 26 minutes (20 to 53) for the first metatarsal and 22 minutes (9 to 56) for the talar neck, suggesting that the tissues of the clubfoot adapt to the new position within several hours. Conclusion. This is the first study to provide objective force data that support the hypothesis of adaptation of the idiopathic clubfoot to the new position imposed by the cast. We showed that the expected decrease in corrective force over time does indeed exist and adaptation occurs after a relatively short period of time. The rapid reduction in the forces acting on the foot during treatment with the Ponseti method may allow significant reductions in the interval between treatments compared with the generally accepted period of one week

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

We conducted a prospective randomised controlled trial to compare the standard Ponseti plaster method with an accelerated method for the treatment of idiopathic congenital talipes equinovarus. The standard weekly plaster-change method was accelerated to three times per week. We hypothesised that both methods would be equally effective in achieving correction. A total of 40 consecutive patients (61 feet) were entered into the trial. The initial median Pirani score was 5.5 (95% confidence interval 4.5 to 6.0) in the accelerated group and 5.0 (95% confidence interval 4.0 to 5.0) in the standard control group. The scores decreased by an average 4.5 in the accelerated group and 4.0 in the control group. There was no significant difference in the final Pirani score between the two groups (chi-squared test, p = 0.308). The median number of treatment days in plaster was 16 in the accelerated group and 42 in the control group (p < 0.001). Of the 19 patients in the accelerated group, three required plaster treatment for more than 21 days and were then assigned to the standard control method. Of the 40 patients, 36 were followed for a minimum of six months. These results suggest that comparable outcomes can be achieved with an accelerated Ponseti method. The ability to complete all necessary manipulations within a three-week period facilitates treatment where patients have to travel long distances

The Ponseti method of treating club foot has been shown to be effective in children up to two years of age. However, it is not known whether it is successful in older children. We retrospectively reviewed 17 children (24 feet) with congenital idiopathic club foot who presented after walking age and had undergone no previous treatment. All were treated by the method described by Ponseti, with minor modifications. The mean age at presentation was 3.9 years (1.2 to 9.0) and the mean follow-up was for 3.1 years (2.1 to 5.6). The mean time of immobilisation in a cast was 3.9 months (1.5 to 6.0). A painless plantigrade foot was obtained in 16 feet without the need for extensive soft-tissue release and/or bony procedures. Four patients (7 feet) had recurrent equinus which required a second tenotomy. Failure was observed in five patients (8 feet) who required a posterior release for full correction of the equinus deformity. We conclude that the Ponseti method is a safe, effective and low-cost treatment for neglected idiopathic club foot presenting after walking age

Clubfoot deformity is the most common congenital musculoskeletal disorder (1). Approximately one in one thousand people are born with at least one clubfoot; between 150,000 and 200,000 babies are born with a clubfoot each year (2). Eighty percent of these cases occur in developing countries, and the majority is left untreated. When infants are treated with a non-invasive casting technique pioneered by Ignacio Ponseti M.D., they generally can be “cured” with relative ease. In the United States, 97% of patients given this treatment can walk successfully and are able to live normal lives (3). The Ponseti Method requires several plaster casts but either no or minimal surgery, can be taught fairly easily not only to doctors but also to healthcare workers, nurses, and other people who have some knowledge and training in healthcare. Also, it requires plaster casting, making it an inexpensive treatment. Dr. Ignacio Ponseti first performed his non-invasive treatment in 1949, but didn't publish his results until 1963. Two more papers, published in 1979 and 1995 described the long-term outcomes of treatment. In 1996 Oxford Press published a book detailing his approach. Although the treatment has always had high success rates, a lack of publicity prevented it from becoming more widely used until the late 1990s. Its basic mechanism consists of a series of plaster casts and manipulations that gradually reshape the foot around a fixed talus to obtain correction. Generally, between five and seven casts are required. The casts extend from the toes to the upper thigh and hold the knees at a right angle. One of the most important aspects of this method is timing: infants can be given treatment starting at seven days old and ideally should begin treatment before reaching eight months of age. Brazil, Uganda, Malawi and Chile now have official national programs, which are sponsored by each country's Ministries of Health, in which clinics in each country treat clubfoot disorder using the Ponseti Method. China set up a national program in 2005, but with a population of 1.3 billion people, it will take several years to complete the training. The prevalence of the Ponseti Method varies in the sixty other countries with healthcare workers trained in the treatment. This talk will review the principles of treatment and focus on results of recurrence after initial treatment with the Ponseti Method

Introduction: Clubfoot occurs in approximately 1 in 1,000 live births and is one of the most common congenital birth defects. Although there are multiple reports of successful treatment of idiopathic clubfeet with the Ponseti method, the use of this treatment in nonidiopathic clubfeet has not been reported. This purpose of this study was to evaluate early results of the Ponseti method for the treatment of clubfeet associated with distal arthrogryposis. Methods: Twelve consecutive infants with clubfoot (twenty-four clubfeet) associated with distal arthrogryposis were treated with the Ponseti method and retrospectively reviewed. Four patients had casting treatment prior to referral. The severity of the foot deformity was classified according to the grading system of Dimeglio. The number of casts required to achieve correction was compared to published data for idiopathic clubfeet. Any recurrent clubfoot deformities or complications during treatment were recorded. All patients were followed for a minimum of two years. Results: The clubfeet of all twelve patients (twentyfour clubfeet) were graded as Dimeglio grade IV. Initial correction was achieved in all patients with a mean of 6.75 ± 0.86 casts (range, two to ten casts), which was significantly more compared to the number needed in a published cohort of idiopathic clubfeet treated with the Ponseti method (p< 0.003). Three patients (six clubfeet) had a relapse after initial successful treatment. All relapses were related to non-compliance with brace wear. No relapses occurred in the cohort of patients who were initially treated with the new dynamic foot abduction orthosis (eight patients). Two of the three patients with clubfoot relapse were successfully treated with repeat castings and/or tenotomy; the remaining patient (two clubfeet) was treated with extensive soft-tissue release surgery. Conclusion: Our data supports the use of the Ponseti method in patients with distal arthrogryposis based on success rates approaching that for idiopathic clubfoot. Maintaining correction is perhaps the most difficult aspect of management. Parental teaching and early attention to brace complications are helpful techniques to improve parental compliance

Introduction: The Ponseti method has been adopted by many pediatric orthopaedic centers throughout Europe in the last years. The minimal invasive approach and the short duration of the active treatment phase have been the main reasons to change to the Ponseti method at our institution. We report the short term results of patients treated with the Ponseti method for idiopathic clubfeet and discuss experiences and pitfalls. Material and Methods: From the end of 2002 on we have applied the treatment regime strictly as described by Ponseti himself. For this study we analyzed a group of patients comprising all patients treated for congenital idiopathic clubfoot according to the Ponseti protocol within the first three weeks after births. The need for open release surgery was the main outcome measurement in this group. Results: Between December 2002 and July 2004 we treated a total of 59 clubfeet in 37 patients with the Ponseti method. Our patient population consisted of 14 female and 23 male patients. The mean Dimeglio score was 9.2 points (5–15 points). Using the Pirani score the mean midfoot score was 1.7 points (1–3 points), the mean hindfoot score was 2 points (0.5–3 points) and the mean total score was 3.8 points (2–6 points). Three feet in two patients were treated with Ponseti casting only (5 %) and did not need a percutaneous achilles tenotomy (pAT) or open release surgery. Fifty-two feet in 33 patients (88 %) were successfully treated with Ponseti casting and pAT. Four cases in two patients had to undergo a McKay Simons procedure (7 %). Thereby 93% of all cases were treated without open release surgery. Mean follow-up after the last cast was 7.4 months (3–16 months). A recurrence was seen in one patient representing two cases after about 8 months after pAT. The parents were non compliant with the abduction bar protocol and could not be convinced of the importance of the orthosis; a McKay Simons procedure was performed. No other cases of recurrence were observed during the follow up period. Discussion: The Ponseti method should be applied as originally described, and especially, if more people are involved in the treatment, a standard treatment regime is desirable. As the compliance of the parents is a crucial factor, everything should be done to ensure that the treatment is made as easy for them as possible. Only if a full support for questions or problems with the casts and especially with the braces is available, a good compliance can be ensured. The minimal invasive approach utilized by the percutaneous tenotomy is the lead argument in favor of the Ponseti method. In cases of recurrence or residual deformity when open surgery is necessary, this secondary procedure is in fact primary surgery. Thereby the danger of massive scaring associated with limited range of motion, pain and disability after a second procedures is prevented

The Pirani scoring system, together with the Ponseti method of club foot management, was assessed for its predictive value. The data on 70 idiopathic club feet successfully treated by the Ponseti method and scored by Pirani’s system between February 2002 and May 2004 were analysed. There was a significant positive correlation between the initial Pirani score and number of casts required to correct the deformity. A foot scoring 4 or more is likely to require at least four casts, and one scoring less than 4 will require three or fewer. A foot with a hindfoot score of 2.5 or 3 has a 72% chance of requiring a tenotomy. The Pirani scoring system is reliable, quick, and easy to use, and provides a good forecast about the likely treatment for an individual foot but a low score does not exclude the possibility that a tenotomy may be required

A less invasive surgical treatment of clubfoot is increasingly considered, it aims to limit extensive exposure, to improve the functional and cosmetic outcome and to lower the risk of stiffness and recurrence of the deformity. The Ponseti method consists in an original casting technique followed, only in the most resistant clubfeet, by a percutaneous Achilles tenotomy. Critical decision is the selection of the clubfeet which needs tenotomy. Purpose of this study was to determine if ultrasound assessment of clubfoot may be helpful in making surgical decision. MATERIAL AND Methods: 98 newborns with 122 congenital clubfeet were treated by the Ponseti casting technique from mid-2000 to June 2006. According to Manes classification, there were 20 mild, 47 moderate and 55 severe clubfeet. After 3 to 8 weeks of casting, clubfeet candidate to surgery underwent sonographic assessment according to the original technique previously published by the authors. On the sagittal posterior plane the R.O.M. of the ankle and subtalar joints was stated both in neutral position and under manipulation. No surgery was performed in clubfeet with normal sonographic dorsiflexion, percutaneous tenotomy was done in clubfeet with mild limited sonographic dorsiflexion and more extensive posterior release (tendon Z-lengthening and posterior cut of ankle and subtalar joint) was performed in clubfeet with most evident sonographic persistent equinus and anterior dislodgment of the talus in the ankle mortise. The R.O.M. was checked again by ultrasound at the end of treatment. According to Ponseti method a Denis Browne bar, with clubfoot 60° externally rotated, was worn full time until the walking age. Results: 35/122 clubfeet (28,6%) were treated conservatively (all the 20 mild and 15/47 of moderate deformities), 87/122 (71,4%) surgically (32/47 of moderate deformities and all the 55 severe deformities). On the basis of the dynamic ultrasound evaluation 38 clubfeet underwent simple tenotomy and 49 ones underwent extensive posterior release. At the end of the casting normal dorsiflexion was documented by ultrasound in 72 (82,7%) of the operated feet. Conclusions: The need of surgery in the Ponseti casting technique shows a great variability in Literature. These controversial data are probably due not only to the different confidence in the Ponseti method, but also to the different criteria used in evaluating the correction obtained by casting. Ultrasound assessment of the deformity gives objective qualitative and quantitative information about the restoration of the physiological dorsiflexion and articular biomechanics. On the basis of this simple, non invasive and widely available procedure the surgeon can evaluate the effectiveness of the serial casting and may be able to establish and graduate the need of corrective surgery

We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot. Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30). The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients

The Ponseti method of clubfoot management requires a period of bracing in order to maintain correction. This study compared the effectiveness of ankle foot orthoses and Denis Browne boots and bar in the prevention of recurrence following successful initial management. Between 2001 and 2003, 45 children (69 feet) with idiopathic clubfeet achieved full correction following Ponseti casting with or without a tenotomy, of whom 17 (30 clubfeet) were braced with an ankle foot orthosis while 28 (39 clubfeet) were prescribed with Denis Browne boots and bar. The groups were similar in age, gender, number of casts and tenotomy rates. The mean follow-up was 60 months (50 to 72) in the ankle foot orthosis group and 47 months (36 to 60) in the group with boots and bars. Recurrence requiring additional treatment occurred in 25 of 30 (83%) of the ankle foot orthosis group and 12 of 39 (31%) of the group with boots and bars (p < 0.001). Additional procedures included repeat tenotomy (four in the ankle foot orthosis group and five in the group treated with boot and bars), limited posterior release with or without tendon transfers (seven in the ankle foot orthosis group and two in the group treated with boots and bars), posteromedial releases (nine in the orthosis group) and midfoot osteotomies (five in the orthosis group, p < 0.001). Following initial correction by the Ponseti method, children managed with boots and bars had far fewer recurrences than those managed with ankle foot orthoses. Foot abduction appears to be important to maintain correction of clubfeet treated by the Ponseti method, and this cannot be achieved with an ankle foot orthosis

Objective: The Ponseti method for the treatment of club foot has been shown to be effective in children up to one year of age. However, it is not known whether it is successful in older children. In this prospective study, we used Ponseti method in club foot after walking age; that are neglected or undergone an insufficient previous treatment. Materials and Methods: From 2003 to 2005 we treated and followed-up 37 feet of 30 patients. All the club foot deformities corrected by the method described by Ponseti, with minor modifications. The mean age at presentation was 21 months (12–72 months) and the mean follow-up was 26 months (16–32 months). 21 feet had previous conservative and surgical treatments. The mean applied cast count that used for this method was 5.4 (4 – 8 cast). After cast treatment we performed achilotomyfor 15 feet, achiloplasty for 20 feet and achiloplasty and posterior capsulotomy for 2 feet. All the patients evaluated before and after treatment by the Dimeglio classification. Results: Before treatment 35 feet were grade 3 and 2 feet were grade 4, and after the treatment 11 feet were grade 0, 26 feet were grade 1. All the patients deformities were corrected and the treatment results were statically significant (p=0.0001). Patients distincted in two groups according to their age at the beginning of the treatment. 20 feet were younger than 20 months and 17 feet were older than 20 months. All the patients younger than 20 months had grade 3 deformity before treatment and 19 feet improved grade 1 and 1 foot improved to grade 2 after this method. In patients older than 20 months 15 feet were grade 3 and 2 feet were grade 4. and after this treatment method in this group 13 feet were improved to grade 1 and 4 feet were improved to grade 2. Patients older than 20 months had worse results for the components of varus, medial rotation of calcanopedal block and adductus thant the other group. And difference in these groups were significant. (p> 0.005). Conclusion: We conclude that the Ponseti method is a safe, effective and low-cost treatment for idiopathic club foot presenting after walking age

The Ponseti method has been proven to be the gold standard of treatment for clubfoot. The question however remains about the treatment of atypical and complex feet with this method. The Ponseti technique has been used to treat all clubfeet at the our institution for the past 10 years. We interviewed 70 patients (114 affected feet) ages 5–9 regarding the current state of their clubfoot using the 10 item Disease Specific Instrument (DSI) developed by Roye et al. Of these, 16 patients had a complex foot defined by a transverse medial crease. The DSI scores from all patients were transformed onto a 100 point scale and compared based on overall score as well as functional outcome and satisfaction. There was no significant difference in the overall scores with a mean of 76.43 (sd= 21.1) in patients who did not have a complex deformity compared to a mean of 79.17 (sd= 19.4) in those who did have a complex foot (p=0.644). On the functional subscale the mean scores were 74.07 (sd=27.1) and 89.58 (sd=25.9) for patients who had non-complex and complex feet, respectively (p=0.474). Regarding satisfaction, the non-complex group had a mean score of 79.51 (sd=19.7) compared to the mean of 78.75 (sd=16.7) in the complex group (p=0.888). Primary treatment with the Ponseti method achieves very successful correction of the clubfoot deformity with good outcome scores. Furthermore, even in patients with a complex deformity, the Ponseti method still achieves equally successful outcomes

The purpose of the present study is to evaluate the early results of the Ponseti method when used for the treatment of idiopathic clubfoot among the population of the island of Crete. Fourteen consecutive infants (twenty-one feet) with idiopathic clubfoot deformity were managed with the Ponseti method and were retrospectively reviewed at a minimum of six months. The severity of the foot deformity was classified according to the grading system of Pirani et al. The number of casts required to achieve correction was compared with published data for the treatment of idiopathic clubfoot. Recurrent clubfoot deformities or complications during treatment were recorded. Initial correction was achieved with a mean of 5.2 casts. Tenotomy and Dennis-Browne braces followed the cast applications. One foot had a relapse which was then treated by a repeat tenotomy at the age of 8 months. Two children abandoned the protocol because the parents could not comply with bracing. No extensive surgery is needed so far and all feet are flexible and pain free. X-rays when taken showed the talo-calac-neal angle within normal limits. We support the use of the Ponseti method for the treatment of idiopathic clubfoot, since it can deliver flexible physiological feet, in the outpatient environment, thus avoiding the consequences of extensive open surgery

Purpose: To evaluate the effectiveness of the Ponseti method of the treatment i late presentation of clubfeet. Method: Prospective study comprising 91 patients(141 feet) between August 2003 and September 2005. Age range was from 7 dats to 20 months. Majority of patients belonged to Dimeglio grade 3 (75%) and Pirani grade 4(43%) at presentation. All were treated by Ponseti method of serial casting with or wothout tendo-achillis lengthening. Tendon lengthening was required in 79% of patients. The average duration of follow up was 1.5 years. Results: Recurrence of deformity was seen in patients who presented late and had severe deformity at time of presentation. The Ponseti technique failed to achieve correction in 4 patients. Follow up at 2 years showed overall correction rate of 95%. In develpoing countries, delayed presentation could signifucantly affect the final outcomes as the joint deformities progressively become fixed. Our study showed that number of corrective casts, recurrence of deformity and the nned for tendoachillis lengthening was inversly related to the time of presentation. This technique can be relable used to correct clubfeet even in delayed present

Introduction. It has been postulated that a mild clubfoot does better than a severe clubfoot no matter what treatment course is taken. There have been previous efforts to classify clubfoot. For units worldwide that use the Ponseti Method of clubfoot management, the Pirani scoring system is widely used. This scoring system has previously been shown to predict the number of plasters required to gain correction. Our study aimed to investigate whether the Pirani score gave an indication of longer-term outcome using tibialis anterior tendon transfer as an endpoint. Methods. A prospectively collated database was used to identify all patients treated in the Ponseti clinic at the Royal Manchester Children's Hospital between 2002 and 2005 with idiopathic clubfoot who had not received any treatment prior to their referral. Rate of tibialis tendon transfer as well as the patient's presenting Pirani score were noted. Feet were grouped for analytical purposes into a mild clubfoot (Pirani score <4) and a severe clubfoot (Pirani score 4) category depending on initial examination. Clinic records were reviewed retrospectively to identify patients who were poorly compliant at wearing boots and bars and were categorised into having “good” or “bad” compliance with orthosis use. Results. 132 feet in 94 children were included in the study. 30 (23%) tibialis tendon transfers were performed at a mean of 4.2 years (range 2.3–5.5 years). Children with severe clubfoot had a significantly higher rate of tendon transfer compared with those with mild clubfoot (28% vs. 6%; p=0.0001). 81% of patients were classified as being “good” boot wearers. Tibialis tendon transfer rates in those who were poorly compliant with boot usage were significantly higher compared with those with good compliance (52% vs. 16%; p=0.0003). There was a significantly higher tendon transfer rate in those with severe disease and poor compliance compared with good compliance (69% vs. 20%; p=0.0002). There was no association between boot compliance and tendon transfer rates in those with mild disease. Conclusion. This study shows that late recurrences, requiring tibialis anterior tendon transfer, are associated with severity of disease at presentation and compliance with use of orthoses. Tendon transfer rates are higher for those with severe disease. We have confirmed previous reports that compliance with orthotic use is associated with recurrence. However, the novel findings regarding recurrence rates in mild clubfeet may have implications regarding usage of orthoses in the management of mild idiopathic clubfeet after initial manipulation using the Ponseti method

Purpose: The aim of this study is to analyze objectively pathoanatomical changes of clubfoot treated with Ponseti method. Introduction: In the treatment of clubfoot, regardless of the grade and severity of the disease, first conservative treatment and serial casting should be chosen. The follow up period for surgery performed group ranges usually from 2 to 8 years (not longer than 10–15 years). Thirty years results of Ponseti’s idiopathic clubfoot treatment is with 78% success. In some recent series 95% success rate was reported. Standard conservative treatment (Kite’s) success rates are only 11% to 58% for idiopathic group. Material and Methods: Seventy patients, 115 feet (45 Bilateral, F/M 15/55) were included in the study. 28 of these patients were neurogenic group (20 Spina Bifida and 8 Artrogripotic). Since 1997, we strove Ponseti’s strict casting protocol. Bensahel’s a la carte PMR surgery was performed in 2 cases. Downey’s MRI evaluation criterias were used. In statistical analysis of the idiopathic, neurogenic and normal groups, ANOVA test was used. Results: The Navicular angle assessment was statistically significant (p< 0.05). Assessment of the results of idiopathic group was in normal range. Pathological components of Clubfoot were significantly reduced in the neurogenic group. Conclusions: Ponseti method is the effective treatment way of both the idiopathic clubfoot and the neurogenic foot. It is concluded that sound understanding of the anatomy of the foot, the biological response of young connective tissue and bone to changes in direction of mechanical stimuli, can gradually reduce or almost eliminate these deformities in most clubfeet

Non-operative treatment methods of idiopathic clubfoot have become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular due to published short and long term success rates in North America. The purpose of the current study was to examine the early rate of relapse in a New Zealand population and analyze patient characteristics for factors predictive of relapse. Fifty-one consecutive babies with seventy-eight club-feet treated by the Ponseti technique were followed prospectively for a minimum of two years from the start of treatment. Recurrence, defined as the need for any operative intervention, was analyzed with respect to severity at presentation, timing of presentation, the number of casts needed to obtain correction, family history of clubfoot, ethnicity, and compliance with abduction bracing. Recurrence was subdivided into minor recurrences, defined as a tendon transfer or Achilles lengthening, and major recurrences, defined as a full posterior or posteromedial release. Twenty patients (39%) had a recurrence. Eleven patients (22%) had a major recurrence and nine patients (17%) had a minor recurrence. Only three of twenty-five patients (12%) who were compliant with bracing had a major recurrence. Twenty-five of fifty-one patients (49%) were compliant with bracing. The greatest risk factor for recurrence was non compliance with abduction bracing, with an odds ration of 5 (p = 0.009). Although not quite statistically significant (p = .07), ethnicity was also related to recurrence, with Polynesian patients being three times less likely than white Europeans to recur. No statistically significant relationships were found between recurrence and severity at presentation, timing of presentation, the number of casts needed to obtain correction, or family history of clubfoot. Compliance with abduction bracing is crucial to avoiding recurrence of clubfoot. The Polynesian club-foot seems more amenable to Ponseti technique and less likely to recur than the white European clubfoot. In those patients who are compliant, the Ponseti method is very effective at maintaining a correction, with minimal need for major surgery. However, even among the compliant patients, minor recurrences are common, and among the noncompliant patients, many major and minor recurrences should be expected

Aim: To evaluate our initial experience using the Ponseti method for the treatment of clubfoot. Materials and Methods: 85 feet in 56 patients treated at Alder Hey Hospital, Liverpool between Nov 2002 – Dec 2004 were included in the study. The standard protocol described by Ponseti was used for treatment. Mean period of follow up was 12 months (6– 30 months). Evaluation was by the Pirani club foot score. Results: Results were evaluated in terms of the number of casts applied, the need for tenotomy and the recurrence of deformity. Average number of casts required were 6. Tenotomy was required in 80% of feet. At the latest follow up approximately 15% of feet recurred following treatment and were managed surgically. Poor compliance was noted to be the main cause of failure in these patients. We have recently modified our splint and hope this will address some of the reasons for poor compliance. There was also a smaller subgroup of patients (approximately 5%) which failed to respond to the treatment regime and could not be brought to the point were tenotomy would be appropriate. Conclusion: In our hands the ponseti technique has proved to be a very effective treatment method for the management of CTEV but like all treatment methods does have some limitations

Aim : To evaluate our initial experience using the Ponseti method for the treatment of clubfoot . Materials and Methods: 85 feet in 56 patients treated at Alder Hey Hospital, Liverpool between Nov 2002 – Dec 2004 were included in the study. The standard protocol described by Ponseti was used for treatment. Mean period of follow up was 12 months (6– 30 months). Evaluation was by the Pirani club foot score. Results : Results were evaluated in terms of the number of casts applied, the need for tenotomy and the recurrence of deformity. Average nuber of casts required were 6. Tenotomy was required in 80% of feet. At the latest follow up approximately 15% of feet recurred following treatment and were managed surgically. Poor compliance was noted to be the main cause of failure in these patients. We have recently modified our splint and hope this will address some of the reasons for poor compliance. There was also a smaller subgroup of patients (approximately 5%) which failed to respond to the treatment regime and could not be brought to the point were tenotomy would be appropriate. Conclusion: In our hands the ponseti technique has proved to be a very effective treatment method for the management of CTEV but like all treatment methods does have some limitations

Purpose: The purpose of this paper was to determine how to predict the need for a percutaneous tenotomy at the initiation of the Ponseti method for treatment of a clubfoot. Methods: Fifty clubfeet in 35 patients were treated with serial casting performed at weekly intervals and were rated according to the Pirani and Dimeglio clubfoot scoring systems. Scores for each foot were obtained at each visit, prior to cast application and following removal of the final cast. The final cast was applied with the foot in 15 degrees of dorsiflextion. A percutaneous Achilles tenotomy was performed if the foot could not be dorsiflexed to 15 prior to application of the final cast. Tenotomies were performed as an office procedure under local anesthesia in 36 to 50 feet (72%). Results: The patients that underwent tenotomy required significantly more casts. Of 27 feet with initial Pirani scores of ≥5.0, 85.2% required a tenotomy and 14.8% did not; and 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and those that did not have a tenotomy. Conclusion: Children with clubfeet who have an initial score of ≥5.0 by the Pirani system or who are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy

This paper evaluates the ability to predict the need for a tenotomy prior to beginning the Ponseti method. The purpose of this study was to determine how one might predict the need for tenotomy at the initiation of the Ponseti treatment for clubfeet. Fifty clubfeet in thirty-five patients were treated with serial casting. The feet were prospectively rated according to two different scoring systems (Pirani, et. al. and Dimeglio, et. al.). The decision to perform a tenotomy was made when the foot could not be easily dorsiflexed 15 degrees prior to application of the final cast. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required a significantly greater number of casts (p< 0.05). Of 27 feet with an initial Pirani score 5.0, 85.2% required a tenotomy and 14.8% did not. 94.7% of the Dimeglio Type III feet required tenotomies. At the time of the initial evaluation there was a significant difference between those that did and did not require a tenotomy for multiple components of the Pirani hind-foot score. Following removal of the last cast there was no significant difference between those that did and did not have a tenotomy. In conclusion, children with clubfeet who have an initial score of 5.0 by the Pirani system or are rated as Type III feet by the Dimeglio system are very likely to need a tenotomy. Those that needed a tenotomy were more severely deformed with regard to all components of the hindfoot deformity, not just equinus. At the end of treatment feet were equally well corrected whether or not they needed a tenotomy

Aim: To evaluate the initial experience of using the Ponseti Method in the management of idiopathic clubfoot and to identify learning curve problems. Materials and Methods: A retrospective analysis undertaken of 57 feet in 39 patients with CTEV treated by the Ponseti method. The standard protocol described by Ponseti was followed. Pirani’s clubfoot score was used to assess the deformity and the results of treatment. The follow-up in the study ranged from 3 months to 35 months. Denis Brown splints were used full-time for 3 months and at night for 1 year. Results: 47 out of 57 feet had good results with no evidence of recurrence. 10 feet had recurrence and underwent further surgery. If compliance was poor with the Denis Brown splints or if there was a severe initial deformity there was an increased risk of recurrence. 20% had problems with the plaster of Paris cast and the foot slipped out of the Denis Brown splint in 14%. It was noted there were 2 cases of bruising and swelling associated with the removal of the cast and the application of Denis Brown boots which had not previously been reported. Conclusion: This is only a preliminary study and therefore the long-term outcome cannot be assessed. It was noted that attention to detail and appropriate regular follow-up is important in achieving satisfactory results

Purpose: Congenital idiopathic clubfoot is the most common congenital deformity in children and can be a major cause of disability for the child as well as an emotional stress for the parents. The Ponseti method of club-foot correction, consisting of serial manipulations and casting, is now the gold standard of treatment. It has traditionally been described using plaster of Paris (POP) above-knee casts, which are affordable, stiff, and easily moldable. Recently, semi-rigid fiberglass softcast (FSC, 3M Scotchcast) has grown in popularity due to ease of removal, durability, lighter weight, better appearance, ease of cleaning, and water resistance. There are currently no randomized controlled trials to prove its efficacy with respect to POP. The purpose of this study was to determine the influence of choice of cast material on the correction of congenital idiopathic clubfeet using the Ponseti method. Method: A prospective, randomized controlled trial. Based on the results of a pilot study performed at our centre, a sample size of 30 patients was determined to be appropriate. Thirty consecutive patients presenting with congenital idiopathic clubfoot were randomized into POP and FSC groups prior to commencement of treatment with the Ponseti Method. Clubfeet secondary to non-idiopathic diagnoses were excluded. The Pirani classification was used to determine clubfoot severity (less severe, < =4; severe > 4), and for surveillance during casting. The primary outcome measure was the number of casts required to correct the clubfoot deformities to the point where the foot was ready for a percutaneous tendo-achilles tenotomy (TAL) or when the foot was completely corrected (Pirani=0). Secondary outcome measures include: number of casts by clubfoot severity, ease of cast removal, number of methods needed to remove casts, need for percutaneous tendo-achilles tenotomy. Results: Of the 30 patients enrolled, 13 (40%) were randomized to POP and 18 (60%) to FSC. No patients were lost to follow-up. In the POP and FSC groups, eight (67%) and 11 patients (61%) underwent a TAL, respectively. In general, there were no differences in the mean number of casts required for clubfoot correction between the two groups (p=0.13). When analyzed by clubfoot severity, the mean number of casts for each material in the less severe group was equal (3 casts). In the severe group, the mean number of casts in the FSC group (6.4 casts) was considerably higher than for the POP group (4.7 casts) but our study was underpowered to verify this result. According to parents, POP was harder to remove than FSC (p< 0.001). Conclusion: In general, FSC was found to be as efficacious as POP in the correction of idiopathic clubfeet by the Ponseti Method and was the preferred cast material by parents. For stiffer, more severe feet, POP seemed to show a faster correction time than FSC

Actually conservative treatment and/or minimal invasive surgical approach is considered the gold standard in the treatment of CF all around the world. Two main italian pediatric hospitals (Bambino Gesù in Rome and Meyer in Florence) will present own series in order to realize how the two methods (Ponseti in Rome and Seringe in Florence) can be used, the right indications for each method and sharp limits as well. The aim of this study is to compare two methods for evaluating their effectiveness and their applicability. Patients, Methods and Results. Rome series: from 1998 to 2009 pediatric hospital Bambino Gesù in Rome had treated 1350 patients with the Ponseti method (1980 feet). All feet had been scored according to Pirani classification. At age of 3–4 months, the 72% of feet treated had minimal surgery consisted in transversal tenotomy of achille's tendon. Casting for further 3 weeks and Denis-Brown splint wore full time until walking age and during the night only for 3 years after walking age. Surgery had been performed in 72% of case and surgery has been directly related to CF severity. Florence series: the Unit of Pediatric Orthopaedics Meyer Children's Hospital of Florence was born in January 2004 and therefore the series includes patients from January 2004 to December 2009. 173 patients (239 feet) were treated. Dimeglio's classification was used. At the age of 4–5 months were treated with tenotomy of Achille's tendon 51,9% of patients, mainly stage 3, and immobilization in long leg cast was used only for three weeks after surgery. Discussion. Minimally invasive treatment for CF is universally considered one of the best way to correct the deformity without using the extensive surgery that often causes stiffness, pain and shoes discomfort in adulthood. The long-term results of two series are similar and this enhance our mind that not invasive method for CF treatment is effective, low-cost, with very low rate of recurrence, only if applied following strictly the protocol. In our series in fact the highest rate of recurrence concerns the missing of Denis-Brown device or early dismission of Denis-Brown as well. The adherence to the protocol is chiefly recommended by the authors when surgery is not performed and therefore the risk of recurrence is higher. The French method especially needs a skill panel of physical therapist that are in confidence with the bandage manoeuvres. Only medical operators in confidence with the methods are able to guarantee good results and a low rate of recurrence as well. For this reason the method recommended by Dr. Seringe is easy exported in geographic areas where health service and health support are well represented

Between 1980 and 2003, 600 patients with idiopathic clubfoot attended our clinic. Until 1989, we manipulated the feet according to the Robert Jones method. After that we changed to the Ponseti method. Depending on the residual deformity at age 3 months, patients underwent either percutaneous Achilles tenotomy or full posteromedial release, as described by McKay, and were supplied with a thermoplastic splint until walking age. Minor changes to the surgical technique were made over the years. At follow-up, a minimum of 2 years postoperatively, the feet were evaluated both according to the McKay scoring method and by a simpler method that correlated well with it. Although our results compare unfavourably with those of Ponseti (80% non-surgical correction), we had excellent overall outcomes, with low revision and complication rates

Clubfoot is one of the commonest congenital abnormalities and is 2–3 times commoner in African populations than Caucasian. From December 2000 in Lilongwe, Malawi, the Ponseti method was used for treatment of this condition combined with the Colombian Clubfoot Score. Over the study period 150 patients were treated, with an average age on presentation of 5.5 months. 43% of cases had completed the manipulation and casting part of treatment and 5.5 months. 43% of cases had completed the manipulation and casting part of treatment and had been braced, but 75% of these were no longer attending regular follow up. We believe that the method is useful for treating CTEV in Africa, but that the intensive nature of the therapeutic regime leads to compliance difficulties

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. Methods. We retrospectively identified patients treated for idiopathic CTEV between 1997 and 2007 under a single surgeon. Two cohorts with a minimum 4 years' follow-up were treated with Kite (1997–2001) and Ponseti (2002–2007) manipulation and casting. The entire Kite cohort (14 patients) and none of the Ponseti cohort (16 patients) required PMR. All patients were assessed by clinical and functional examination, questionnaire and medical notes review. There was a total of 40 feet (10 bilateral and 20 unilateral) with 20 feet in each cohort. Results. 7 feet (35%) in each cohort required further surgical procedures. Of these, 6 feet in the Kite/PMR group required bony surgical correction compared with none in the Ponseti group. There was a significant difference between the Kite/PMR and Ponseti groups in; calf circumference difference (mean 24mm vs 13mm p<0.05), subtalar movement (mean 15° vs 25° p<0.05), and ankle plantar flexion (mean 20° vs 45° p<0.05). There were also functional differences between the two cohorts (Kite/PMR vs Ponseti) with regard to; being very satisfied with the outcome (55% vs 95%), never limiting activities (50% vs 95%), never painful (60% vs 95%), and the ability to toe walk (35% vs 100%). Conclusions. Since the introduction of the Ponseti method for treating CTEV in our unit, the outcome for children with this condition has improved significantly with regard to function, cosmesis and a greatly reduced risk of further surgical intervention

Introduction: A growing number of pediatric orthopaedic surgeons have adopted the Ponseti method for the treatment of idiopathic congenital clubfeet. Ponseti himself does not recommend the standard use of radiographs but suggests that palpation alone should be used to assess the correction in infant clubfeet. Although ultrasound diagnostic techniques for evaluating the infant foot are on the rise, most orthpaedic surgeon still rely on native radiographs to objectify the course of treatment. The aim of our study was to elucidate the role of radiographs in Ponseti clubfoot treatment. Material and Methods: From the end of 2002 on we have used the treatment regime as originally described by Ponseti. Only infants with idiopathic clubfeet treated within the first three weeks of life were included. Radiographs of infant clubfeet are taken in ap.- view and lateral view in maximum dorsiflexion. Radiographs were taken at presentation mostly for legal documentation, before tenotomy at about 6 to 15 weeks of age, and 1 week after the percutaneous Achilles tenotomy (pAT). The tibiocalcaneal angle (Tib.C.-angle), the ap.- talo-calcaneal angle (TC-angle) and the lateral talo-calcaneal angle (lat. TC- angle) were evaluated. The maximum dorsiflexion was evaluated clinically. Results: Forty-seven feet met the inclusion criteria. The mean gain of the tibiocalcaneal angle after tenotomy was 15,08 degrees. The ap.- talo-calcaneal angle only showed a mean change of 2,57 degrees and the lateral talo-calcaneal angle changed 0,44 degrees. The dorsi-flexion was found to have gained 13,85 degrees after tenotomy. The values of the tibiocalcaneal angle (Tib. C.-angle) and the values for dorsiflexion (DF) before and after pAT showed a significant difference (p< 0.05). No significant difference was found for the ap.- talo-calcaneal angle (TC-angle) and the lateral talo-calcaneal angle (lat. TC- angle) before and after tenotomy. Discussion: The results of our series indicate that the tib-iocalcaneal angle changes about the same amount as the clinical dorsiflexion does. The ap.- talo-calcaneal angle (TC-angle) and the lateral talo-calcaneal angle (lat. TC- angle) were not influenced much by the Achilles tenotomy in our series. This seems reasonable as cutting of the Achilles tendon mostly influences the calcaneous which is the endpoint of the tendon. The dorsal opening of the talocalcaneal joint is coupled with derotation of the talus and calcaneous in the ap.-view and is hardly influenced by pAT. Although the position of the calcaneous in the heel can be palpated and even quantified by the empty heel sign according to Pirani, radiographs are the only way to objectify the true anatomy

Our goal was to evaluate the use of Ponseti’s method, with minor adaptations, in the treatment of idiopathic clubfeet presenting in children between five and ten years of age. A retrospective review was performed in 36 children (55 feet) with a mean age of 7.4 years (5 to 10), supplemented by digital images and video recordings of gait. There were 19 males and 17 females. The mean follow-up was 31.5 months (24 to 40). The mean number of casts was 9.5 (6 to 11), and all children required surgery, including a percutaneous tenotomy or open tendo Achillis lengthening (49%), posterior release (34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue release combined with an osteotomy (2%). The mean dorsiflexion of the ankle was 9° (0° to 15°). Forefoot alignment was neutral in 28 feet (51%) or adducted (< 10°) in 20 feet (36%), > 10° in seven feet (13%). Hindfoot alignment was neutral or mild valgus in 26 feet (47%), mild varus (< 10°) in 19 feet (35%), and varus (> 10°) in ten feet (18%). Heel–toe gait was present in 38 feet (86%), and 12 (28%) exhibited weight-bearing on the lateral border (out of a total of 44 feet with gait videos available for analysis). Overt relapse was identified in nine feet (16%, six children). The parents of 27 children (75%) were completely satisfied.

A plantigrade foot was achieved in 46 feet (84%) without an extensive soft-tissue release or bony procedure, although under-correction was common, and longer-term follow-up will be required to assess the outcome.

Cite this article: Bone Joint J 2013;95-B:1721–5.

Traditionally clubfoot in South Africa is treated by manipulation, serial casting and, at the age of 3 to 4 months, posteromedial release. Revision surgery, with its attendant problems, is often necessary.

In November 2003 we started using the Ponseti technique. To date we have treated 61 feet, most of which are type-III according to the Harold and Walker classification. Serial castings are done according to Ponseti technique. Initially the forefoot is manipulated into supination to align it with the hindfoot. The talonavicular joint is gradually reduced until 75° of abduction is achieved. Then percutaneous tenotomy is done to correct hindfoot equinus. Manipulation is done weekly and an above-knee cast is applied. Following tenotomy, the cast remains in place for 3 weeks, after which a Denis Brown splint is worn continually (except at bath time) for 3 months and then at night for 3 years. Parent compliance has been good.

We have had six failures to date. One foot was found to have tarsal coalition and another was an arthrogrypotic foot, which was successfully corrected.

Our results suggest that most operations for clubfoot are avoidable. The Ponseti manipulation technique is simple and can easily be taught to the staff of peripheral hospitals, making it ideal for treatment of clubfoot in Africa.

Aim

10 years after the introduction of the Ponseti casting regimen as standard treatment for idiopathic clubfoot at Alder Hey Children's Hospital, we reviewed the mid-term outcomes of the initial 2-year cohort (treated from 2002–2004)

Aims. The Ponseti method is the gold standard treatment for congenital talipes equinovarus (CTEV), with the British Consensus Statement providing a benchmark for standard of care. Meeting these standards and providing expert care while maintaining geographical accessibility can pose a service delivery challenge. A novel ‘Hub and Spoke’ Shared Care model was initiated to deliver Ponseti treatment for CTEV, while addressing standard of care and resource allocation. The aim of this study was to assess feasibility and outcomes of the corrective phase of Ponseti service delivery using this model. Methods. Patients with idiopathic CTEV were seen in their local hospitals (‘Spokes’) for initial diagnosis and casting, followed by referral to the tertiary hospital (‘Hub’) for tenotomy. Non-idiopathic CTEV was managed solely by the Hub. Primary and secondary outcomes were achieving primary correction, and complication rates resulting in early transfer to the Hub, respectively. Consecutive data were prospectively collected and compared between patients allocated to Hub or Spokes. Mann-Whitney U test, Wilcoxon signed-rank test, or chi-squared tests were used for analysis (alpha-priori = 0.05, two-tailed significance). Results. Between 1 March 2020 and 31 March 2023, 92 patients (139 feet) were treated at the service (Hub 50%, n = 46; Spokes 50%, n = 46), of whom nine were non-idiopathic. All patients (n = 92), regardless of allocation, ultimately achieved primary correction, with idiopathic patients at the Hub requiring fewer casts than the Spokes (mean 4.0 (SD 1.4) vs 6.9 (SD 4.4); p < 0.001). Overall, 60.9% of Spokes’ patients (n = 28/46) required transfer to the Hub due to complications (cast slips Hub n = 2; Spokes n = 17; p < 0.001). These patients ultimately achieved full correction at the Hub. Conclusion. The Shared Care model was found to be feasible in terms of providing primary correction to all patients, with results comparable to other published services. Complication rates were higher at the Spokes, although these were correctable. Future research is needed to assess long-term outcomes, parents’ satisfaction, and cost-effectiveness. Cite this article: Bone Jt Open 2023;4(11):865–872

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.

Aims. Our aim was to describe the mid-term appearances of the repair process of the Achilles tendon after tenotomy in children with a clubfoot treated using the Ponseti method. Patients and Methods. A total of 15 children (ten boys, five girls) with idiopathic clubfoot were evaluated at a mean of 6.8 years (5.4 to 8.1) after complete percutaneous division of the Achilles tendon. The contour and subjective thickness of the tendon were recorded, and superficial defects and its strength were assessed clinically. The echogenicity, texture, thickness, peritendinous irregularities and potential for deformation of the tendon were evaluated by ultrasonography. Results. The appearance of the Achilles tendon was slightly abnormal, with more thickening and less conspicuous contours than a normal tendon. Its strength was grossly normal, with no insufficiency of the triceps surae. Ultrasonographic findings revealed a mild fusiform thickening in 12 children (80%). The tissue at the site of the repair had a slightly hypoechoic, fibrillar quality with hyperechoic striation and the anterior contour was irregular and blurred. There was a focal narrowing within the healing tissue in two children. Conclusion. This mid-term evaluation of the ability of the Achilles tendon to repair after division suggests a combination of intrinsic and extrinsic mechanisms. There were minor abnormalities which did not appear to affect function. Cite this article: Bone Joint J 2017;99-B:139–44

The initial treatment of the congenital clubfoot is still a debated subject among different schools. We report our current experience with Ponseti method. Materials and Methods: From April 1999 to May 2001 we have consecutively treated with this method 80 idiopathic clubfeet of 57 children put under treatment at neo-natal period. Progressive correction of the deformity has been obtained with 7 toe-to-groin plaster casts changed weekly. When complete derotation of the hind-foot and forefoot has been reached, subcutaneus tenotomy of the tendon Achilles has been performed. At the end of this first period, the feet have been adapted in Denis Browne splint, worn full time for four months and thereafter just at night. The feet have been evaluated clinically (score of Dimeglio and Bensahel), radiologically and some with MRI. Results: Whole correction of the deformity at the end of treatment with plaster casts, has been achieved for 71 times. When the plaster casts are removed, the talocalcaneal divergence, on antero-posterior and lateral views and the tibial-calcaneal angle (x-ray in maximum dorsal flexion ), were respectively, as an average of 20; 30,7; 21,9 degrees. At an average of 20 months follow up, 54 feet of 80 had a score of 0 or 1 of 20, and 14 had a score of 2; on radiological aspect the talo-calcaneal divergence in antero-posterior and lateral views and the tibial-calcaneal angle were respectively as an average of 29; 24,5; 14 degrees. At this evaluation the percentage of relapses of the deformity was 20% (17 cases). All the relapses have been treated again in plaster casts with 40% of success. So far, only four medial release operations have been necessary. Six feet benefited by the transfer of the tibialis anterior tendon to the third cuneiform and slight medial release. Discussion and Conclusion: The Ponseti’s method presents several advantages: high quality reduction of the clubfoot with the restoration of a “sub-normal” anatomy, low cost and small displeasing worry for the parents, with this method the functional re-education does not seem to improve the quality of results. The prevention of the relapse goes by good compliance to the splint

Aims

The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV.

Flat-top talus (FTT) is a complication well-known to those treating clubfoot. Despite varying anecdotal opinions, its association with different treatments, especially the Ponseti method, remains uncertain. This systematic review aimed to establish the aetiology and prevalence of FTT, as well as detailing management strategies and their efficacy. A systematic review was conducted according to PRISMA guidelines to search for articles using MEDLINE, EMBASE and Web of Science until November 2021. Studies with original data relevant to one of three questions were included: 1) Possible aetiology 2) Prevalence following different treatments 3) Management strategies and their outcomes. 32 original studies were included, with a total of 1473 clubfeet. FTT may be a pre-existing feature of the pathoanatomy of some clubfeet as well as a sequela of treatment. It can be a radiological artefact due to positioning or other residual deformity. The Ponseti method is associated with a higher percentage of radiologically normal tali (57%) than both surgical methods (52%) and non-Ponseti casting (29%). Only one study was identified that reported outcomes after surgical treatment for FTT (anterior distal tibial hemiepiphysiodesis). The cause of FTT remains unclear. It is seen after all treatment methods but the rate is lowest following Ponseti casting. Guided growth may be an effective treatment. Key words:. Clubfoot, Flat-top talus, Ponseti method, guided growth. Disclosures: The authors have no relevant disclosures

Aims. The Ponseti method is the benchmark treatment for the correction of clubfoot. The primary rate of correction is very high, but outcome further down the treatment pathway is less predictable. Several methods of assessing severity at presentation have been reported. Classification later in the course of treatment is more challenging. This systematic review considers the outcome of the Ponseti method in terms of relapse and determines how clubfoot is assessed at presentation, correction, and relapse. Patients and Methods. A prospectively registered systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that reported idiopathic clubfoot treated by the Ponseti method between 1 January 2012 and 31 May 2017 were included. The data extracted included demographics, Ponseti methodology, assessment methods, and rates of relapse and surgery. Results. A total of 84 studies were included (7335 patients, 10 535 clubfeet). The relapse rate varied between 1.9% and 45%. The rates of relapse and major surgery (1.4% to 53.3%) and minor surgery (0.6% to 48.8%) both increased with follow-up time. There was high variability in the assessment methods used across timepoints; only 57% of the studies defined relapse. Pirani scoring was the method most often used. Conclusion. Recurrence and further surgical intervention in idiopathic clubfoot increases with the duration of follow-up. The corrected and the relapsed foot are poorly defined, which contributes to variability in outcome. The results suggest that a consensus for a definition of relapse is needed. Cite this article: Bone Joint J 2019;101-B:639–645

In 2010, we published results of Ponseti versus primary posteromedial release (PMR) for congenital talipes equinovarus (CTEV) in 51 prospective patients. This study reports outcomes at a median of 15 years from original treatment. We followed 51 patients at a median of 15 years (range 13–17 years) following treatment of CTEV with either Ponseti method (25 patients; 38 feet) or PMR (26 patients; 42 feet). Thirty-eight patientsd were contacted and 33 participated in clinical review (65%), comprising patient reported outcomes, clinical examination, 3-D gait analysis and plantar pressures. Sixteen of 38 Ponseti treated feet (42%) and 20 of 42 PMR treated feet (48%) had undergone further surgery. The PMR treated feet were more likely to have osteotomies and intra- articular surgeries (16 vs 5 feet, p<0.05). Of the 33 patients reviewed with multimodal assessment, the Ponseti group demonstrated better scores on the Dimeglio (5.8 vs 7.0, p<0.05), the Disease Specific Instrument (80 vs 65.6, p<0.05), the Functional Disability Inventory (1.1 vs 5.0, p<0.05) and the AAOS Foot & Ankle Questionnaire (52.2 vs. 46.6, p < 0.05), as well as improved total sagittal ankle range of motion in gait, ankle plantarflexion range at toe off and calf power generation. The primary PMR group displayed higher lateral midfoot and forefoot pressures. Whilst numbers of repeat surgical interventions following Ponseti treatment and primary PMR were similar, the PMR treated feet had greater numbers of osteotomies and intra-articular surgeries. Outcomes were improved at a median of 15 years for functional data for the Ponseti method versus PMR, with advantages seen in the Ponseti group over several domains. This study provides the most comprehensive evaluation of outcomes close to skeletal maturity in prospective cohorts, reinforcing the Ponseti Method as the initial treatment of choice for idiopathic clubfeet

The April 2023 Children’s orthopaedics Roundup. 360. looks at: Can you treat type IIA supracondylar humerus fractures conservatively?; Bone bruising and anterior cruciate ligament injury in paediatrics; Participation and motor abilities after treatment with the Ponseti method; Does fellowship training help with paediatric supracondylar fractures?; Supracondylar elbow fracture management (Supra Man): a national trainee collaborative evaluation of practice; Magnetically controlled growing rods in early-onset scoliosis; Weightbearing restrictions and weight gain in children with Perthes’ disease?; Injuries and child abuse increase during the pandemic over 12,942 emergency admissions

Aims. To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population. Methods. In all, 73 children with idiopathic club foot were included: 31 children treated with the Ponseti method (mean age 8.3 years; 24 male; 20 bilaterally affected, 13 left and 18 right sides analyzed), and 42 treated with primary surgical correction (mean age 11.6 years; 28 male; 23 bilaterally affected, 18 left and 24 right sides analyzed). Foot function data was collected during walking gait and included Oxford Foot Model kinematics (Foot Profile Score and the range of movement and average position of each part of the foot) and plantar pressure (peak pressure in five areas of the foot). Oxford Ankle Foot Questionnaire, Disease Specific Index for club foot, Paediatric Quality of Life Inventory 4.0 were also collected. The gait data were compared between the two club foot groups and compared to control data. The gait data were also correlated with the data extracted from the questionnaires. Results. Our findings suggest that symptomatic children with club foot deformity present with similar degrees of gait deviations and perceived disability regardless of whether they had previously been treated with the Ponseti Method or surgery. The presence of sagittal and coronal plane hindfoot deformity and coronal plane forefoot deformity were associated with higher levels of perceived disability, regardless of their initial treatment. Conclusion. This is the first paper to compare outcomes between Ponseti and surgery in a symptomatic older club foot population seeking further treatment. It is also the first paper to correlate foot function during gait and perceived disability to establish a link between deformity and subjective outcomes. Cite this article: Bone Joint Open 2020;1-7:384–391

Aims. After the initial correction of congenital talipes equinovarus (CTEV) using the Ponseti method, a subsequent dynamic deformity is often managed by transfer of the tendon of tibialis anterior (TATT) to the lateral cuneiform. Many surgeons believe the lateral cuneiform should be ossified before surgery is undertaken. This study quantifies the ossification process of the lateral cuneiform in children with CTEV between one and three years of age. . Patients and Methods. The length, width and height of the lateral cuneiform were measured in 43 consecutive patients with unilateral CTEV who had been treated using the Ponseti method. Measurements were taken by two independent observers on standardised anteroposterior and lateral radiographs of both feet taken at one, two and three years of age. Results. All dimensions of the lateral cuneiform on the affected side increased annually but remained smaller than the corresponding dimensions of the unaffected foot (p < 0.01). The lateral cuneiform resembled a 9 mm cube at two years and an 11 mm cube at three years. Conclusion. At one and two years, the ossification centre of the lateral cuneiform may not be large enough to accommodate a drill hole for tendon transfer. However, by three years, it has undergone sufficient ossification to do so. Cite this article: Bone Joint J 2017;99-B:1109–14

Statement of purpose:. A randomised clinical trial was undertaken to find out if treatment time and failure rate in children treated by the Ponseti method differed between below-knee vs above-knee cast groups. Methods and Results:. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below knee 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. Twenty-six children (33 feet) were entered into the trial, with a mean age of 17 days (range 1–40) in the above knee and 11 days (range 5–20) in the below knee group. Because of six failures in the below knee group (38%), the trial was stopped early for ethical reasons. Failure rate 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). Statement of conclusion:. Below knee plaster of Paris casts in conjunction with the Ponseti method showed significantly higher rates of failure than above knee plaster casts, requiring conversion to above knee casts, and a significantly longer treatment time. This higher rate of failure of below knee casts forced an early end of the trial. This study shows that a well moulded above knee plaster cast is safe and superior to a below knee plaster cast in conjunction with the Ponseti method. We do not believe that modifying the original Ponseti method in this manner is beneficial. Level of evidence: I

We reviewed the results of a selective à la carte soft-tissue release operation for recurrent or residual deformity after initial conservative treatment for idiopathic clubfoot by the Ponseti method. Recurrent or residual deformity occurred in 13 (19 feet) of 33 patients (48 feet; 40%). The mean age at surgery was 2.3 years (1.3 to 4) and the mean follow-up was 3.6 years (2 to 5.3). The mean Pirani score had improved from 2.8 to 1.1 points, and the clinical and radiological results were satisfactory in all patients. However, six of the 13 patients (9 of 19 feet) had required further surgery in the form of tibial derotation osteotomy, split anterior tibialis tendon transfer, split posterior tibialis transfer or a combination of these for recurrent deformity. We concluded that selective soft-tissue release can provide satisfactory early results after failure of initial treatment of clubfoot by the Ponseti method, but long-term follow-up to skeletal maturity will be necessary

The Ponseti method is the gold standard treatment for clubfoot. It begins in early infancy with weekly serial casting for up to 3 months. Globally, a commonly reported barrier to accessing clubfoot treatment is increased distance patients must travel for intervention. This study aims to evaluate the impact of the distance traveled by families to the hospital on the treatment course and outcomes for idiopathic clubfoot. No prior studies in Canada have examined this potential barrier. This is a retrospective cohort study of patients managed at a single urban tertiary care center for idiopathic clubfoot deformity. All patients were enrolled in the Pediatric Clubfoot Research Registry between 2003 and April 2021. Inclusion criteria consisted of patients presenting at after percutaneous Achilles tenotomy. Postal codes were used to determine distance from patients’ home address to the hospital. Patients were divided into three groups based on distance traveled to hospital: those living within the city, within the Greater Metro Area (GMA) and outside of the GMA (non-GMA). The primary outcome evaluated was occurrence of deformity relapse and secondary outcomes included need for surgery, treatment interruptions/missed appointments, and complications with bracing or casting. A total of 320 patients met inclusion criteria. Of these, 32.8% lived in the city, 41% in the GMA and 26% outside of the GMA. The average travel distance to the treatment centre in each group was 13.3km, 49.5km and 264km, respectively. Over 22% of patients travelled over 100km, with the furthest patient travelling 831km. The average age of presentation was 0.91 months for patients living in the city, 1.15 months for those within the GMA and 1.33 months for patients outside of the GMA. The mean number of total casts applied was similar with 7.1, 7.8 and 7.3 casts in the city, GMA and non-GMA groups, respectively. At least one two or more-week gap was identified between serial casting appointments in 49% of patients outside the GMA, compared to 27% (GMA) and 24% (city). Relapse occurred in at least one foot in 40% of non-GMA patients, versus 27% (GMA) and 24% (city), with a mean age at first relapse of 50.3 months in non-GMA patients, 42.4 months in GMA and 35.7 months in city-dwelling patients. 12% of the non-GMA group, 6.8% of the GMA group and 5.7% of the city group underwent surgery, with a mean age at time of initial surgery of 79 months, 67 months and 76 months, respectively. Complications, such as pressure sores, casts slips and soiled casts, occurred in 35% (non-GMA), 32% (GMA) and 24% (city) of patients. These findings suggest that greater travel distance for clubfoot management is associated with more missed appointments, increased risk of relapse and treatment complications. Distance to a treatment center is a modifiable barrier. Improving access to clubfoot care by establishing clinics in more remote communities may improve clinical outcomes and significantly decrease the burdens of travel on patients and families

Outcome studies of the Ponseti method from various centres have reported success rates ranging from 85–95%. The vast majority of patients can expect a supple, functional and pain free foot. The small percentage of feet that are resistant to Ponseti treatment often require open surgical correction, leading to scarring and stiffness. We present a method of correcting resistant equinus by a tenotomy and calcaneal pulldown technique. This method is complimentary to the Ponseti technique. Method. Prospective study of 40 feet in 28 patients who underwent an Achilles tenotomy and calcaneal pulldown technique. The indications for this method were resistant equinus and problems with casting. Feet scored with the Pirani method. Under a general anaesthetic, a standard Achilles tenotomy was performed. The equinus deformity corrected by traction of the calcaneum with a “catspaw” retractor and dorsiflexion of the forefoot. Further treatment was performed according to the Ponseti method. The Ponseti clubfoot brace was used to maintain correction. Results. 28 patients 40 feet. Mean preoperative Pirani score:3.0 (left 3.0, right 3.1 range 1.5–6). Mean preoperative Hindfoot Pirani score:2.5 (left 2.55, right 2.5 Range 1.5–3). Mean post operative Pirani score:2.0(left 2.0, right 2.0 Range 0.5–6). Mean postoperative Hindfoot pirani score:1.45. Three patients had severe arthrogryphosis, of whom 2 did not correct requiring open surgery. All idiopathic CTEV feet corrected with a range of 5–20 degrees of dorsiflexion at last follow up. The mean follow up was 43.64 months (range 7–96 months). Conclusions. The calcaneal pulldown technique is a useful complmentary adjunct to the Ponseti method. It enables the correction of equinus without the need for open surgery. Since the introduction of the technique to our unit it has negated the need for open surgery. The results are encouraging, it is a simple effective technique that can help in difficult CTEV cases

Introduction. Recurrence in CTEV is not uncommon and as the child becomes older the foot in question is often stiffer and less amenable to the more traditional serial casting Ponseti method. Treatment of these recurrent CTEV feet with external fixators has been previously documented. We aim to present the Sheffield technique of an external circular frame with adjunctive hindfoot and midfoot osteotomies to correct relapsed CTEV and their associated Roye (outcome) scores. Materials and Methods. Retrospective analysis of patient records from 1999 to 2019 were performed for those undergoing frame correction of CTEV. Patients were included if there was adjunctive foot osteotomies in the setting of CTEV frame correction and willingness to partake in retrospective Roye outcome scoring. The Roye score was sent out in the mail to parents asking for scoring of the current level of symptoms. Results. 160 patients were contacted for Roye score evaluation. We successfully collected outcome data for 46 feet in 39 patients. 27 (69%) patients had idiopathic CTEV. Average age at fixator application 12.6 years (range 7–18). Mean length of follow up 10.6 years (1 – 20). 76% of patients were either very (22%) or somewhat (54%) satisfied with the status of their foot. The largest negative score was 61% of parents found difficulty in finding shoes to fit their child's feet after treatment. 39% of patients had significant persistent pain associated with their feet but 67% were not at all (26%) or only somewhat (41%) limited in their walking ability. Conclusions. We have demonstrated short to mid term follow up for relapsed CTEV treated via external fixation. The Roye score has demonstrated a large proportion of patients are overall satisfied with their outcome with the most common complaints being difficulties in finding shoes to fit and persistent pain on strenuous activity

The non-operative treatment of idiopathic clubfoot has become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular as a result of published short and long-term success rates in North America. Non-compliance with abduction bracing has been proven to be a major risk factor for recurrence of clubfoot. The purpose of this retrospective study was to identify those patients who were non-compliant with the abduction bracing post casting and to then assess the rate and severity of recurrence. One-hundred and fifty children (184 feet) with unilateral or bilateral clubfoot who were treated with the Ponseti method by the senior author from 1999 to 2008 were reviewed. We identified those patients who were non-compliant with the abduction bracing. Compliance was defined as three months full time wear followed by twelve months night-time/nap-time wear. Recurrence was classified as minor, defined as those requiring an extra-articular surgical procedure and major, requiring an intra-articular procedure. We identified fifty children with seventy clubfeet who were followed up for a minimum of 12 months. None of these patients were compliant with brace wearing. Of the 70 feet, 40 (57%) required surgical intervention. There were 30 (43%) feet with no clinical recurrence. In 5 of the bilateral cases only one of the feet had required corrective surgery. In the 29 patients who required surgical intervention we identified 52 procedures (37 extra-articular and 15 intra-articular). Compliance with the post correction abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformity treated with the Ponseti method. Despite non-compliance however there is a significant proportion of patients who do not require any surgical intervention. We recommend initiating the Ponseti technique on all patients with clubfeet rather than being selective due to anticipated compliance issues with the family

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

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

Introduction: Congenital clubfoot is a very common deformity in developing countries which leads to secondary socioeconomic problems. Clubfoot programs using the Ponseti method have been initiated in many third world countries in the last years. However, many treatment related, logistic, and structural problems are encountered during these efforts. We report our two-year experience with a clubfoot program in Mali. Methods: In April 2006 a clubfoot program was initiated in Bamako, Mali by Doctors for Disabled, an Austrian society for medical development cooperation. Teaching material and documentation forms were created and a first Ponseti course was held in Bamako in October 2006. Further visits for advanced teaching, documentation, follow-up and implementation of a clinical structure were scheduled approximately every three months. Parallel to the Ponseti program a program to operate neglected or resistant clubfeet was initiated. Regular meetings with the government at different levels were attained and efforts were made to include the clubfoot program into the national RBC program. Results: During workshops in October 2006 and January and March 2007 seven health care workers have been intensively trained in the Ponseti method. A review of our documentation showed that up to now 235 patients had been seen and treated. Out of 105 children with idiopatic clubfoot who presented younger than one year of age 52 were available for follow-up after the end of Ponseti treatment. The outcome was “good” or “medium” in 40 patients (77%) and “poor” in 12 children (23 %). The late age at presentation, the low compliance and the rare use of the abduction orthosis are ongoing problems which could not have been solved yet. Additionally, the structural improvements in our treatment center as well as the direct government support are still insufficient. Conclusion: Due to the low-tech and low-cost approach the Ponseti method is suitable for the developing world. Nevertheless, many obstacles have to be overcome to implement a sustainable project, most of which are not so much treatment associated but of structural, organizational and political nature

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

Previous studies have identified clinical and demographic risk factors for recurrence in the treatment of idiopathic clubfoot (congenital talipes equinovarus). Evertor muscle activity is not usually considered amongst them. This study aimed to evaluate whether recurrence could be predicted by demographic, clinical and gait parameters. From a series of 103 children with clubfeet, 67 had completed a follow-up of two years: 41 male and 26 female, 38 with idiopathic and 29 with non-idiopathic deformities. The mean age was 3.2 years (2.1 to 6.3). Primary correction was obtained in all 38 children (100%) with an idiopathic deformity, and in 26 of 29 patients (90%) with a non-idiopathic deformity. Overall, 60 children (90%) complied with the abduction brace regime. At a mean follow-up of 31.4 months (24 to 62), recurrence was noted in six children (15.8%) in the idiopathic and 14 children (48.3%) in the non-idiopathic group. Significant correlation was found between poor evertor activity and recurrence in both groups. No statistically significant relationship was found between the rate of recurrence and the severity of the initial deformity, the age at the time of treatment, the number of casts required or the compliance with the brace. After correction of idiopathic and non-idiopathic clubfoot using the Ponseti method, only poor evertor muscle activity was statistically associated with recurrence. The identification of risk factors for recurrent deformity allows clinicians to anticipate problems and advocate early additional treatment to improve muscle balance around the ankle. Cite this article: Bone Joint J 2014;96-B:1264–8

Introduction. The Ponseti method for the treatment of idiopathic club foot is the gold standard of treatment in South Africa. A study in New York reviewed attainment of gross motor milestones (GMM) in these children and found that independent ambulation was delayed on average by 2 months compared to unaffected children. Methods. A retrospective review of gross motor milestones was performed in patients treated at a South African clubfoot clinic. All patients were walking independently at review. Ages at attainment of motor milestones were recorded (sitting, crawling and walking independently). The World Health Organisation (WHO) published the normal range for achievement of these milestones in six regions across the world. We compared the results of our patients to the 50th percentile in that study. Results. Results show that patients in our study sat at a mean of 5.6 (standard deviation +− 1.4) months and crawled at a mean of 8.2 (sd +− 2.6) months both equal to the WHO 50th centiles for unaffected children. Independent walking however was achieved at a mean of 14.4 (sd +−3.7) months which is 2.4 months later than the 50th centile for unaffected children in the WHO study. In the current study, 87.5% of children achieved independent walking within the acceptable norms provided by the WHO. Conclusion. This information can be used to reassure parents that their children treated by the Ponseti method with idiopathic clubfeet will attain GMM with a delay of between two and three months before independent walking. The delay is not significant in terms of the functional outcome of these children. NO DISCLOSURES

Purpose of study. Serial manipulations and casting for the treatment of congenital clubfoot has long been the practice internationally. There are, however, a great variety of manipulative techniques being practiced with differing results. We aim to determine how the rate of major surgery, ie. a full posteromedial-release (PMR), as initial surgical intervention has changed since introducing the Ponseti method of plastering at our centre in 2002. We also aim to determine whether pre-operative radiographs have any bearing on the type of surgery performed. Methods. Clinical records and radiographs of all patients presenting to our clubfoot clinic in the years 1999–2000 and 2009–2010 respectively were reviewed. Patients were included if they had clinical clubfoot, and excluded if they presented after 3 months of age, had undergone prior treatment or suffered from associated congenital anomalies. We then determined which patients underwent PMR as primary surgical intervention following serial castings. We also measured the radiographic parameters on all available radiographs (tibiocalcaneal, talometatarsal-I, lateral and AP talocalcaneal angles) and performed a statistical analysis to determine their value in predicting the type of surgery required. Results. In the pre-Ponseti group we included 83 feet of which 34 had undergone PMR. In the Ponseti group there were 68 feet, of which none had undergone PMR. This was found to be statistically significant. Of the measured angles, the tibiocalcaneal and lateral talocalcaneal had the highest correlation with clinical severity (.67 and −.45 respectively). Conclusion. Employing the Ponseti method of plastering has significantly decreased the need for major surgery at our centre. This is in keeping with published results internationally. We found the tibiocalcaneal angle to be the most predictive of need for major surgery, and the talometatarsal-I to be the least predictive. The role of pre-operative X-rays, however, remains unclear as surgical decisions are made on clinical grounds. NO DISCLOSURES

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

Purpose: The main purpose of the study is to present our experience with the Ponseti casting followed by an Achilles tendon (AT) tenotomy in children with arthrogryposis multiplex congenita (AMC). Methods: 7 children with 14 severe clubfeet were treated by us with a Ponseti manipulations and casting followed by AT tenotomy. 5 children (10 feet) were followed at least 24 months after the AT tenotomy and were selected for the final evaluation. Their mean age at follow up was 38,4 months and average follow up period was 35,8 months. The treatment was begun within first month of life, the AT tenotomy to correct rigid equinus was performed at 14,4 weeks of life on average, after 7–10 cast changes (mean 8,4). Niki H. et al. clinical criteria and standard standing AP and lateral radiographs were analyzed for final evaluation. Results: There were 7 feet with clinically satisfactory results. Among 3 unsatisfactory feet there were two (1 child) with rocker-bottom pseudocorrections after repeated bilateral AT tenotomies and one recurrent clubfoot (1 child). Six feet required in soft tissue releases in 3, 12 and 21 months after the AT tenotomy due moderate equinus and adductus. 3 feet underwent repeated AT tenotomies in 6 and 15 months after the primary procedure. The mean interval between initial AT tenotomies and redo surgical procedures was 10,5 months (range 3–21 months). Two feet (20%) remain without significant deformity after AT tenotomies. Conclusion: Clubfeet in AMC respond initially to the Ponseti method of casting and the deformity may be corrected or diminished. In some children wide surgical treatment can be avoided, in other delayed. Despite necessity for additional surgical intervention, the Ponseti method of casting and Achilles tenotomy does seem to be an alternative for initial treatment in children with AMC

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

Introduction: In many developing countries clubfeet are not recognized at birth and usually remain untreated due to limited medical and financial recourses. With high births rates of up to 50 births per 1000 population in the poorest countries like Mali, Uganda or Niger the clubfoot deformity has become a socioeconomic problem. Methods: In April 2006 a clubfoot program was initiated in Bamako, Mali by Doctors for Disabled, an Austrian society for medical development cooperation. During the project design and planning members from an already established Ponseti program, the Uganda Sustainable Clubfoot Care Project, gave valuable advice and guidance for the planning of the Mali program. Teaching material and documentation forms were created and a first Ponseti course was held in Bamako in October 2006. Results: During workshops in October 06 and January and March 07 a total of 31 health care workers have been trained using the Ponseti method. Documentation as of March 07 shows that 124 clubfeet in 80 Patients have been treated. There were 54 male and 26 female patients which resembles the male to female ratio described in literature. The mean age at presentation was 12.1 months (range: 9 days to 37 months). The Pirani score was evaluated at presentation in 93 of 124 feet and was 4.23 at the average. In March 07 follow-up for patients in whom treatment was initiated from October to January was available for 25 patients with 38 clubfeet. A medium result (plantigrade foot, DF at least neutral) was seen in 11 feet, a good result (plantigrade foot, DF possible) in 23 feet, an early recurrence with need for re-casting in 4 feet. A release operation was performed in 2 feet (2 patients), and 11 feet (7 patients) are awaiting operation. These patients presented at a mean age of 22 months (12–36 months) and included 3 patients with secondary clubfeet. Conclusion: Due to the low-tech and low-cost approach the Ponseti method is suitable for the developing world and gives these infants in the poorest countries the rare opportunity to receive the same state-of-the-art treatment as infants in the richest countries around the world. Nevertheless, many obstacles have to be overcome to implement a sustainable project. The lack of doctors and especially orthopaedic surgeons can only partly be compensated by highly motivated health care workers. The lack of documentation and follow-up impedes quality control and evaluation needed for funding. Awareness programs to ensure treatment within the first months of live are most important to increase the success-rate but imply fully operable Ponseti clinics which are able to take care of the increasing patient flow

Introduction: Idiopathic congenital talipes equinovarus (clubfoot) is a common complex deformity that occurs in approximately one or two per 1000 newborns. For many years, most surgeons considered it as a “surgical disease”. The long term results of the surgical release are disappointing, with increased foot pain, joints stiffness and muscle weakness. It would appear that the most successful conservative treatment for clubfoot is the method developed in the late 1940s by Ponseti. We recently reviewed the outcomes of treatment in Afula with the Ponseti method in our first 28 patients with minimum of five years follow-up. Materials and Methods: In our study are included 28 patients (38 feet). 22 males and six females, 18 unilateral and ten bilateral cases, with idiopathic clubfoot. The average follow-up duration is of 6.5 years (range 5–8.5). The cases were evaluated using the 6-point clssfication system described by Pirani. Each foot was assigned a total score of 6 points or less, with higher scores indicating more severe deformity, 0 points indicate a normal foot. Results: The average Pirani score at initial presentation was 5.5 (range 3–6). Only two feet out of 38 (7%), required complete surgical release, using the Turco method. The average number of casts applied was 7.5 (range, 5–13), and 35 of 38 (92%) feet required percutaneous Achilles tenotomy. We used the Garceau classification to assess residual deformity. The average scoring was 3.6 points (range 2–4). Twelve feet out of 36 (33%) (excluding the 2 feet who underwent PMR), ended up with some residual supination, according to the Garceau classification, 11 feet rated 3 points each, and only one foot 2 points. Only12 patients were defined as compliant with the use of the foot abduction brace. In seven out of 36 feet (18% of the feet, six patients) tibialis anterior transfer for residual supination was performed, only one of these patients was compliant with the use of the foot abduction brace. However, despite bad compliance with the use of the orthosis, eight out of 16 patients obtained good results. An average of 13 degrees (range. 0–25) of dorsiflexion and 50 degrees (40–70) of plantarflexion was noticed in all 36 feet (again excluded the 2 post PMR feet), and very supple subtalar joints. Conclusion: thirty-seven out of the 38 feet, at the latest follow-up, had an almost normal foot appearance. Discussion: During the last nine years, the Ponseti technique has become the gold standard of treatment for clubfoot, with countless surgeons abandoning the surgical technique in favor of the Ponseti method. Proper use of the foot abduction brace is essential. Those patients who underwent tibials anterior transfer, were non-compliant with the use of the brace. One of our patients whose parents refused to use the orthosis at all required complete open release with the Turco method. Few patients may end up with good result despite bad comliance with the use of the brace. Since this is unpredictable, parents should be recommended to be fully commited as to the use of the brace

Purpose. This study aimed to objectively define gait derangements and changes before and after Tibialis Anterior Tendon Transfer surgery in a group of patients treated using the Ponseti method. Methods. 21 feet in 13 patients with Ponseti treated clubfoot who showed supination in swing on clinical examination, underwent gait analysis before, and approximately 12 months after, Tibialis Anterior Tendon transfer. 3–4 weekly casts were applied prior to the surgery, which was performed by transfer of the complete TA tendon to the lateral cuneiform. A parental satisfaction questionnaire was also completed. Results. In all but one patient, increased supination in swing phase was confirmed on pre-operative gait analysis, with EMG evidence of poor Tibialis Anterior modulation through-out the gait cycle. Post-operatively all patients showed improved positioning at initial contact, with heel strike and an absence of supination, and a decrease in swing phase supination. In all patients, knees were overly flexed at initial contact, some continuing through stance phase; there was no change seen postoperatively. All parents reported marked improvements in gait and activity level post-operatively. Conclusion. Gait analysis can be useful to confirm the need for tibialis anterior tendon transfer. Improved post-operative gait patterns seen by parents and clinicians can be related to objective improvements seen during gait analysis, confirming the benefit of tibialis anterior tendon transfer in appropriate patients

Aims

There is a lack of high-quality research investigating outcomes of Ponseti-treated idiopathic clubfeet and correlation with relapse. This study assessed clinical and quality of life (QoL) outcomes using a standardized core outcome set (COS), comparing children with and without relapse.

Congenital talipes equinovarus (CTEV) is a complex three-dimensional deformity with an incidence of 1–3 per 1000 live births. The Ponseti method is widely accepted and practiced, giving reliably good long-term results. There are a number of studies showing the benefits of a physiotherapy led Ponseti service with outcomes similar to a consultant led service. We present the first prospective randomised series comparing a physiotherapy led Ponseti service with a standard orthopaedic surgeon led series. 16 infants with bilateral CTEV were randomised into two groups. Each infant had one foot treated by a physiotherapist and the other foot treated by an orthopaedic surgeon using the Ponseti technique. Both groups had a premanipulation Pirani score of 5.5. All patients were followed up for a minimum of 12 months and the results demonstrated no significant difference in the post-treatment Pirani scores (p=0.77) and no significant difference in the success rate the Ponseti technique (p=1.00). This study is the first of its kind and demonstrates the value of a physiotherapy led Ponseti service in the management of CTEV. Although overall supervision by a paediatric orthopaedic surgeon is still necessary, this service will allow the surgeon to spend more time dealing with more complex problems

Background: The aim of this study was to evaluate Ponseti’s method of clubfoot management objectively and quantitatively by using ultrasound. Methods: 22 newborns with 39 club feet were studied sonographically. Ultrasound examinations of all club feet were performed three times during the treatment according to Ponseti: at birth (1st measurement), one day before performing the percutaneous tenotomy of the Achilles tendon (2nd measurement) and 3 weeks after the operation (3rd measurement). In order to prove sonographic changes during the treatment precisely and quantitatively four angles (TnCe, TnMT1e, CaCue, TTd) were measured. Results: Statistical analyses by using student’s t-test were conducted. The results are expressed as the means SD. At the first measurement means for TnCe were 19,41 (SD 11,71), for TnMT1e 15,21 (SD 10,32), for CaCue -6,49 (SD 7,14) and for TTd 33,38 (SD 10,60). At the second measurement means for TnCe were -6,93 (SD 3,96), for TnMT1e -12,24 (SD 4,76), for CaCue -4,00 (SD 5,24) and for TTd 28,66 (SD 6,38). At the third measurement means for TnCe were -7,86 (SD 5,47), for TnMT1e -12,97 (SD 5,69), for CaCue -1,45 (SD 2,05) and for TTd 18,08 (SD 2,75). At the 3rd measurement all angles showed values within the 95% confidence intervals of normal feet. All differences approached high significance (p< 0,0001). Conclusion: During the treatment of idiopathic club-foot according to Ponseti the sonographically obtained measurements showed a significant improvement of all angles. Therefore this ultrasound technique can be used to evaluate the Ponseti method objectively and to compare one treatment to another

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: CT scan of the ipsilateral femoral neck in paediatric shaft fractures; Meniscal injuries in skeletally immature children with tibial eminence fractures: a systematic literature review; Post-maturity progression in adolescent idiopathic scoliosis curves of 40° to 50°; Prospective, randomized Ponseti treatment for clubfoot: orthopaedic surgeons versus physical therapists; FIFA 11+ Kids: challenges in implementing a prevention programme; The management of developmental dysplasia of the hip in children aged under three months: a consensus study from the British Society for Children's Orthopaedic Surgery; Early investigation and bracing in developmental dysplasia of the hip impacts maternal wellbeing and breastfeeding; Hip arthrodesis in children: a review of 26 cases with a mean of 20 years’ follow-up

Background. The gold standard of care of clubfoot is the Ponseti method of serial manipulation and casting, followed by percutaneous tendo-achilles tenotomy. In our setting, registrars work in district hospitals where they run Ponseti clubfoot clinics with little or no specialist supervision. They use the Pirani score to serially assess improvement of the deformity during casting and to determine whether the foot is ready for tenotomy. Purpose of Study. To test the inter-observer reliability of the Pirani score, and whether it can be used by non-specialist doctors running Ponseti clubfoot clinics. Methods. Ethics permission was obtained from our institution. This is a prospective study where patients under the age of one year with idiopathic clubfoot were recruited from clubfoot clinics at our institution, over a period of four months. Following a training session using the original description of the score, each foot was independently assessed using the Pirani score by two paediatric orthopaedic surgeons, two orthopaedic registrars and two medical officers. The inter-observer reliability was assessed using the Fixed-marginal Kappa statistic and Percentage agreement. The first 15 feet were used as a learning curve, and hence excluded from final analysis. Results. 73 feet in 37 patients with idiopathic clubfoot (25 boys, 12 girls) under the age of 1 year were included in the study. The Kappa statistic and percentage agreement for the six variables of the Pirani score were determined. Whilst the overall agreement was determined by the Kappa statistic to be slight to fair, the two consultants were found to have a higher inter-observer reliability than the registrars and medical officers. Conclusion. Our results conflict with previously published studies in that the inter-observer reliability of the Pirani score was poor. In addition, we feel that this score cannot be reliably used by non-specialist doctors running Ponseti clubfoot clinics. NO DISCLOSURES

The October 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Outcomes of open reduction in children with developmental hip dislocation: a multicentre experience over a decade; A torn discoid lateral meniscus impacts lower-limb alignment regardless of age; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Consensus guidelines on the management of musculoskeletal infection affecting children in the UK; Diagnosis of developmental dysplasia of the hip by ultrasound imaging using deep learning; Outcomes at a mean of 13 years after proximal humeral fracture during adolescence; Clubfeet treated according to Ponseti at four years; Controlled ankle movement boot provides improved outcomes with lower complications than short leg walking cast.

Aim. Following successful adoption of the Ponseti method for clubfoot treatment, a team of physiotherapists and orthotists and one surgeon in Jalalabad, Afghanistan have begun to treat Congenital Vertical Talus (CVT) by the technique described by Dodds et al, adapted to locally available resources. We have reviewed the outcome. Method. Since 2010, 38 feet in 31 patients have been treated. Diagnosis of CVT is confirmed with a stress radiograph. The underlying conditions are diverse. The technique involves serial passive stretches and plaster of Paris casts. Once the talo-navicular joint is judged to be reduced, the joint if fixed with a percutaneous pin under local anaesthetic and an Achilles tenotomy performed. Post-operative treatment is as per the Iowa technique with night-time bracing and an AFO for ambulant patients. Results. There have been no major complications and no complete relapses. The result was compromised in 6 patients at the beginning of the series by omission of talo-navicular fixation or tenotomy, since which time the protocol has been followed more closely with improved results. All patients are reported to be wearing normal footwear with no complaints of pain. Conclusion. Specialist surgical treatment for children is not readily available in Afghanistan and the risk of postoperative infection is very high. Effective physiotherapy and orthotic services are available however, typically supported by foreign NGOs, and the Ponseti technique for clubfoot treatment is now successfully applied across the country. This case series from Jalalabad shows that the outcome of treatment of CVT in an out-patient setting can be very good and a significant improvement on the alternatives available. It also demonstrates that this treatment method can be adapted for use in the developing world

Introduction. In cases of unilateral clubfoot, the leg and foot is visually smaller than the opposite, uninvolved side. Parents want to know how much smaller the leg and foot will be. The purpose of this study was to answer this question and compare the results of children treated with a posterior medial release (PMR) with those treated with the Ponseti method (PM). Methods. This is a prospective, longitudinal study of calf circumference and foot length. We measured the calf circumference with a tape measure at the visually maximum girth of the uninvolved side and at the symmetrical position of the involved side. We measured each foot length from the tip of the hallux to the end of the heel. We recorded the measurements at each follow-up visit in a database and analysed the data using linear regression analysis. Results. We followed 93 children (65 PMR, 28 PM) for a mean of 68 months (SD 55, range 6-252) The ratio men/women was 53/40. Mean percent calf size difference was 9.83% (95%CL 8.74-10.92%). Mean percent foot size difference was 8.70% (95%CL 7.54-9.87%). From the numbers available, no differences between the two procedures are evident. Conclusion. Children with a unilateral clubfoot have c10% smaller calf circumference and foot length as compared to the uninvolved side. We found no differences between children treated with PMR or PM, implying the smaller size is intrinsic to the condition and not due to type of treatment

Aims

To identify the minimum set of outcomes that should be collected in clinical practice and reported in research related to the care of children with idiopathic congenital talipes equinovarus (CTEV).

Purpose of Study. The management of idiopathic clubfoot has changed substantially over the past fifty years with the Ponseti method of treatment gaining increasing popularity in recent years. The advantages of this method are its simplicity and minimal resource requirements with high published success rates. One of the disadvantages is that unless treatment protocols are meticulously adhered to, especially in the bracing stage, recurrence will occur. This study explores the demographics and highlights existing barriers to successful clubfoot treatment outcomes at two academic hospitals. Description of Methods. A cross sectional study was conducted of all children undergoing clubfeet treatment between June and December 2011. A stratified questionnaire was used at two academic hospitals. Summary of Results. A total of 135 children were included, 49 (36.3%) female and 86 (63.7%) male. Over 98% of the children were born in hospital. Fifty five children, (40.8%, almost half), travelled over 30 km to attend the clinic every week. One hundred and thirteen children (83.7%) made use of public transport. Most parents (83 children, 63.7%)had secondary school education. The majority of families, 111 children (82.2%), had a combined household income of less than R2000 per month. Sixty four children (47.4%) received a child dependency grant. Conclusion. The majority of children attending these two clubfoot clinics came from households earning less than R2000 a month and almost half of them travelled more than 30 km a week to attend the clubfoot clinic. Outreach programmes and satellite clinics with properly trained staff for the management of clubfoot are desperately needed in Gauteng Province to ease the burden on the families of children with clubfeet and facilitate compliance with treatment. NO DISCLOSURES

Early results of Ponseti treatment in 14 children (17 feet) aged between 2 and 10 years at the start of treatment are assessed. Method and Results 14 children aged between 2 and 10 years (mean 5.4) presented with relapsed or under- corrected club feet. All had previous treatment with strapping and bebax or pedro boots. 8 had subsequently undergone posterior release of the Achilles tendon, ankle and subtalar joint through a longitudinal posterior incision. All patients presented with absent heel strike, walking on the lateral border of the foot. 14 feet had a varus heel and 15 had an internal foot progression angle. Mean Pirani score was 2.14. Photographs and videos were taken. Ponseti casting was implemented. 15 feet required an Achilles tenotomy, and 15 feet had a tibialis anterior transfer to help maintain the correction. Pirani scores improved from a mean of 2.64 to 0.21 in the group that had had previous surgery, and 1.64 to 0.07 in those that had had previous conservative treatment. All patients achieved a heel strike and ceased to walk on the lateral border of the foot. Heel varus corrected in 11/14 and partially corrected in 3. Internal foot progression resolved in 12/15 and improved in 3. At latest follow up (16 months- 20 months), all transfers were working and all patients walked with heel strike and a plantargrade foot. 2 patients required further casting for relapse in forefoot adductus, and one for recurrent posterior tightness. Conclusions The Ponseti method has been successful in the under corrected or relapsed club foot in children aged between 2 and 10 years in this series, including those with previous surgical intervention

Purpose of study. The results clinically & statistically of a 14 year longitudinal study comparing the traditional ‘stretch & strap’ method (1994-2002) with the Ponseti technique (2002-2008). Methods & Results. A 14 year prospective longitudinal comparative study was undertaken into management and outcome of CTEV. There were 114 feet (80 patients), 64 feet (45 patients) treated traditionally and 50 feet (35 Patients) with the Ponseti technique. Patient demographics, the Harold & Walker Classification, and associated risk factors for CTEV were analysed. If conservative treatment failed a radical sub-talar release operation (RSR) was undertaken. The incidence of fixed CTEV was 1.6 per 1000 live births with a male to female ratio of 2.8 to 1. Idiopathic CTEV was present in 77.5% of patients, (22.5% with a primary aetiology). Mean time to RSR was comparable: 37.43 weeks (CI: 33.65 to 41.21) and 46 weeks (CI: 39.18 to 52.82) for the traditional and Ponseti groups respectively. In the traditional group 65.6% (CI: 53.4 to 76.1%) of feet underwent RSR surgery compared to just 25.5% (CI: 15.8 to 38.3%) in the Ponseti group, When idiopathic CTEV was analysed separately these rates reduce to 56.5% (CI: 42.3 to 69.8%) and 15.8% (CI: 7.4 to 30.4%) respectively. The Relative Risk of requiring RSR surgery in traditional compared to Ponseti groups was 2.58 (CI: 1.59 to 4.19) for all patients and 3.58 (CI: 1.65 to 7.78) for idiopathic CTEV (statistically significant). The results of the Ponseti method improved with time suggesting a learning curve. Conclusion. In this study, the Ponseti technique has significantly reduced the need for RSR surgery in fixed CTEV

Purpose: The Ponseti method of clubfoot treatment has revolutionised the management of this condition. Prior to the introduction of the Ponseti regime to the UK in the late 1990’s children were frequently treated by open surgical releases. The aim of our study is to compare the patient’s perspective of outcome following Ilizarov treatment against the long-term outcome generated by the formal scoring systems. Method: We identified nine patients and 14 feet from the theatre logbooks, treated by the senior author (CB), with recurrent deformity of idiopathic clubfeet, using an ilizarov external fixator between 1994 and 1996. A variety of objective and subjective scoring systems were used to compare the results following Ilizarov treatment. Results: International Clubfoot Study Group (ICFSG) scores on six patients gave two excellent feet, one good foot, four fair feet and one poor foot. Giving an excellent/ good rate of only 37.5% with a mean follow up of 13.5 years. The Reinker & Carpenter scoring system resulted in five feet graded as excellent, one as good and two were rated poor. Giving an excellent/good rate of 75%. Functional questioning was also undertaken, six of seven (85%) patients deemed their treatment a success and were glad to have undergone treatment with an ilizarov frame. All but one patient is in higher education pursuing a vocational career or are in full time employment. Conclusion: Our results show that 85% of our patients who were treated with an Ilizarov frame for correction of a relapsed clubfoot were happy with their long term outcome. Thus the patient’s perspective of the long term results of Ilizarov treatment for relapsed club foot are very encouraging. These results do not appear to correlate well with the International Clubfoot Study Group scores

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

Introduction: Children with clubfoot treated by the Ponseti method of clubfoot management require anterior tibialis tendon transfer if there is persistent varus and supination deformity. However the size of bone is a determining factor in whether this transfer can be carried out. We have assesses the difference in the age at which the lateral cuneiform ossifies in normal feet compare with clubfeet. Methods: Foot x-rays of children less than 4 years old (AP view) carried out between 2003 and 2005 were obtained from the Radiology department Booth Hall Children’s Hospital. A total of 341 radiographs were analyzed. Exclusion criteria included: any condition affecting foot anatomy or weight bearing or any previous surgery (including surgery for clubfoot). The lateral cuneiform was measured with 1mm accuracy in the longest diameter. Results: We analysed the size of the lateral cuneiform in patients with and without clubfoot in relation to age. In children without clubfoot there was a R2 value of 0.517, showing a positive correlation between age and size of the bone. In children with clubfoot, R2 value was 0.207 showing no correlation between age and ossification rate of the lateral cuneiform. In addition, we compare the size of the lateral cuneiform between patients with and without clubfoot at different ages. There was a significance difference in the level of ossification of the lateral cuneiform in all age groups. In addition, a greater number of patients with no ossification of the lateral cuneiform were found amongst the clubfoot group in all age groups up to the age of 36 months. Conclusions: We have identified a delayed ossification in the lateral cuneiform in children with clubfoot when compared with normal feet. This delayed ossification should be taken into account when considering anterior tibialis tendon transfer for correction of clubfoot

Aims

This study aims to define a set of core outcomes (COS) to allow consistent reporting in order to compare results and assist in treatment decisions for idiopathic clubfoot.

Introduction: Tibialis anterior tendon transfer (TATT) is a common procedure for recurrence in clubfeet treated with the Ponseti method. Fixation usually includes passing the tendon through a drill hole in the lateral cuneiform using sutures brought out through the plantar aspect of the foot. Drilling of the tunnel and passing the sutures holds potential for neurovascular damage. We performed a cadaver study to evaluate plantar nerve structures at risk during TATT. Method: TATT was performed to the lateral cuneiform in fresh frozen adult cadaver limbs. In 3 feet, the drill hole was made perpendicular to the surface of the lateral cuneiform (group A), in 3 feet, the drill hole was perpendicular to the weight bearing surface of the foot (group B), in 3 feet, the drill was directed at 15 degrees in the frontal and sagital planes (group C) and in another 3 feet the drill was aimed at the middle of the foot (group D). The tendon sutures were pulled through the plantar aspect using two Keith needles aimed in the same direction as the drill hole. A layered dissection was performed. The distance from the drill hole to the nearest nerve or nerve branch was measured. Keith needles were passed 20 times per foot. With each pass, damage to nerve structures was noted. Results: In group A, the drill was in proximity to the medial plantar nerve at a mean distance of 1.7mm (1–3mm). The bifurcation of the nerve trunk was found more proximally at a mean distance of 5mm (2–9mm). In group B, the drill was found to be close to the lateral plantar nerve branches at a mean distance of 0.3mm (0–1mm) with a mean distance to the bifurcation of 25.3mm (16–37mm). The drill hole in group C was at a mean distance of 1.7mm (0–3mm) to the lateral plantar nerve bifurcation and at a distance of 1mm to the lateral nerve branch in one case. In group D, the drill exited in the middle of the plantar aspect at a mean distance of 7.7mm (5–11mm) from the medial nerve branch and 13mm (10–18mm) from the bifurcation of the medial nerve and at a mean distance of 4.3mm (3–6mm) from the lateral nerve branch and 14.7mm (11–19mm) from the lateral nerve bifurcation. Passing the Keith needles resulted in hitting a nerve structure 12 times in group A, 20 times in group B, 6 times in group C and once in group D. Conclusion: In TATT, the drill hole should be aimed at the middle of the foot in the transverse and longitudinal planes. This results in a maximum distance to both the lateral and medial nerve. A blunt Keith needle might allow a safer passing of the sutures to avoid damage to nerves and vessels

Aims

To analyze outcomes reported in studies of Ponseti correction of idiopathic clubfoot.

Introduction and Aims: The Ponseti technique of clubfoot treatment consists of serial manipulation and casting. Most cases require a percutaneous Achilles tenotomy. Very few cases, if any, require surgical correction. This paper reports the short- to medium-term results of the Ponseti technique at one centre. Method: All idiopathic clubfeet presenting at the clinic over a two-year period from October 2001 to September 2003 were included in the study. The feet were graded weekly using the Pirani score. The first cast attempts to correct the cavus by lifting the first metatarsal. Subsequently, the foot is manipulated and caste weekly, to obtain maximum forefoot abduction, against a fulcrum at the lateral aspect of the talar head. The heel (calcaneum) is free to rotate under the talus at the subtalar joint. No attempt is made to correct the equinus till Achilles tenotomy. Results: Fifty-four idiopathic clubfeet in 38 consecutive babies were treated using the Ponseti technique. All cases scored five or 6/6 on the Pirani score on presentation. Ten babies had been manipulated elsewhere and offered surgery due to ‘failure to respond’ to the manipulation. Four feet presented late at between six and 12 months of age. An average of six casts were applied prior to the Achilles tenotomy. Six feet (four babies) corrected without a tenotomy. Forty-eight feet required the tenotomy, with a score of 1.5/6 prior to the tenotomy. Four of these six feet required a delayed tenotomy. Correction without surgery was obtained in all cases. All feet were maintained in straight lace shoes with abduction bar, with the feet externally rotated to 45 degrees. Abduction bar compliance issues were seen in three babies. At walking age the babies wore straight last high-top lace-up shoes. Residual dynamic forefoot adductus was seen in 11 feet and may require a tibialis anterior tendon transfer at age three years. Inadequate heel descent was seen in four cases. Residual internal tibial torsion was seen in one case. Conclusions: The Ponseti method offers a reliable alternative to ‘traditional’ casting and surgery. Babies presenting early had an excellent chance of achieving full correction without surgery. We included children older than six months in the Ponseti program; the treatment is considered to work best with children under three months at presentation

Aims

The study was undertaken to compare the efficacy of Woodcast splints and plaster-of-Paris casts in maintaining correction following sequential manipulation of idiopathic clubfeet.

Aim. To compare outcomes for children treated for idiopathic clubfeet with the Ponseti regimen before (2002–2004) and after (2005–2006) implementation of a dedicated Ponseti service. Method. A retrospective analysis of outcomes for all patients with idiopathic clubfeet treated in the 2 years before and after implementation of a dedicated Ponseti service was undertaken. Results were statistically analysed using Fisher's exact t-test. Results. In the original cohort treated between 2002–2004, with an ad-hoc service where children were treated in general paediatric orthopaedic clinics by a number of different consultants, 100 feet in 66 children were treated. 96 feet (96%) responded to initial casting. 85 feet (85%) required tendo-achilles tenotomy. 31 feet had a recurrence within the first 2 years (16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, the remaining 15 requiring extensive soft tissue release). Between 2005–2006, with a dedicated Ponseti service, 72 feet in 53 children were treated. 72 (100%) responded to initial casting. 60 feet (83.3%) required tendo-achilles tenotomy. Relapse of the initial deformity occurred within 2 years in 11 feet – 4 children required repeat serial casting, 3 feet required tendon of tibialis anterior transfer, 3 required repeat tenotomy of tendo-achilles and one foot required extensive soft tissue release. Conclusion. Our results have shown that a dedicated Ponseti service leads to improved outcomes in the treatment of idiopathic clubfeet. We have shown a statistically significant reduction of recurrence (p=0.02) and extensive soft tissue release (0.002) in those children treated in a specialist service compared to an earlier ad hoc treatment programme

Introduction: The management of idiopathic talipes equino varus remains controversial. Excellent long term results have been reported with non operative management using the Ponseti technique. Aim: To assess prospectively the early radiologic and clinical results in idiopathic club feet treated in New Zealand by the Ponseti technique. Method: We have reviewed prospectively 29 feet in 19 consecutive patients presenting with idiopathic club feet. The initial assessment consisted of a clinical examination, assessment of the Pirani score and clinical photographs. At follow-up the Pirani score, ankle range of motion, foot length and calf circumference were measured and radiographs were taken. Follow-up was at an average age of 7.3 months. Results: The Pirani score improved from an average of 4.9 to 0.5. The range of motion averaged 32 degrees dorsiflexion and 42 degrees plantar flexion. Radiographs showed good correction of the hindfoot with a mean talocalcaneal index of 55 degrees, and a dorsiflexion tibiocalcaneal angle of 62 degrees. A normal mean AP talo-first metatarsal, AP calcaneo-fifth metatarsal angle, and lateral talo-first metatarsal angle showed good correction of midfoot adductus and cavus. Forced dorsiflexion radiographs showed that ⅗ ths of dorsiflexion motion occurred in the hindfoot and ⅖ ths in the midfoot. Complications were all minor. One non-compliant patient required bilateral posteromedial releases. Conclusions: This is the largest reported series outside of Iowa City using this technique and the first to show the early radiographic findings. Excellent early clinical and radiographic results have been shown

Introduction and Aims: Pivotal to most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of Botulinum A toxin (BTX-A) in defunctioning the triceps surae muscle complex as an alternative to tenotomy was investigated. Method: Newborns, infants and children referred for suspected clubfoot deformity to the authors’ institution from September 1, 2000 to September 17, 2003 were reviewed consecutively for inclusion in this prospective study. Patients underwent manipulation and castings (above knee casts) emulating Ponseti’s principles until hindfoot stall was encountered. In order to defunction the triceps surae muscle complex, BTX-A at 10 IU per kilogram was injected into this muscle complex. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: Group I (< 30 days old) and Group II (> 30 days and < 8 month old). Results: Fifty-one patients with 73 feet met the criteria for inclusion in the study with 29 patients in Group I and 22 in Group II. Mean age of Group I was 16 months (2.5–33 months) and average follow-up was nine months post-BTX-A injection (1 week-27 months post-injection). Mean age of Group II was 23.5 months (3.8–44.6 months) and average follow-up was 15 months post BTX-A injection (1 week–27 months post-injection). Ankle dorsiflexion in knee flexion and extension remained above 20/15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. All but one patient (one foot) who reached the point of hindfoot stall during the protocol of manipulations and castings had successful defunctioning of the triceps surae complex using a single BTX-A injection. This one patient out of 51 (1.9% of patients and 1.3% of feet) did not respond to the protocol. Of the 50 patients who responded to the protocol, nine patients lost some degree of dorsiflexion due to non-compliance with boots and bars, with fitting problems accounting for two cases. All these patients have corrected with either a return to manipulations and casting alone (one patient), or a combination of repeated BTX-A injection and further manipulations and castings (eight patients). Conclusion: These results are comparable to those reported in the literature using Ponseti’s method or the physical therapy method and were achieved without the need of tenotomy or more frequent manipulations. The use of BTX-A as an adjunctive therapy in the non-invasive approach of manipulation and casting in idiopathic clubfoot is an effective and safe alternative and one that may be preferable to parents