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. Methods. A list of outcomes will be obtained in a three-stage process from the literature and from key stakeholders (patients, parents, surgeons, and healthcare professionals). Important outcomes for patients and parents will be collected from a group of children with idiopathic clubfoot and their parents through questionnaires and interviews. The outcomes identified during this process will be combined with the list of outcomes previously obtained from a systematic review, with each outcome assigned to one of the five core areas defined by the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT). This stage will be followed by a two round Delphi survey aimed at key stakeholders in the management of idiopathic clubfoot. The final outcomes list obtained will then be discussed in a consensus meeting of representative key stakeholders. Conclusion. The inconsistency in outcomes reporting in studies investigating idiopathic clubfoot has made it difficult to define the success rate of treatments and to compare findings between studies. The development of a COS seeks to define a minimum standard set of outcomes to collect in all future clinical trials for this condition, to facilitate comparisons between studies and to aid decisions in treatment. Cite this article: Bone Jt Open 2021;2(4):255–260

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

Purpose: Congenital idiopathic clubfoot is the most common musculoskeletal birth defect developing during the fetal period, but with no known etiology. MYH 2, 3, 7, and 8 are expressed embryonically or perinatally, the period during which congenital idiopathic clubfoot develops; are all components of Type II muscle, which is consistently decreased in clubfoot patients; and are associated with several muscle contracture syndromes that have associated clubfoot deformities. In this study, we hypothesized that mutations in embryonic and perinatal myosin genes could be associated with congenital idiopathic clubfoot. Methods: We screened the exons, splice sites, and predicted promoters of 24 bilateral congenital idiopathic clubfoot patients and 24 matched controls in MYH 1, 2, 3, and 8 via sequence-based analysis, and screened an additional 76 patients in each discovered SNP. Results: While many SNPs were found, none proved to be significantly associated with the phenotype of congenital idiopathic clubfoot. Also, no known mutations that cause distal arthrogryposis syndromes were found in the congenital idiopathic clubfoot patients. Conclusion: These findings demonstrate that congenital idiopathic clubfoot has a different pathophysiology than the clubfoot seen in distal arthrogryposis syndromes, and defects in myosin are most likely not directly responsible for the development of congenital clubfoot. Given the complexity of early myogenesis, many regulatory candidate genes remain that could cause defects in the hypaxial musculature that is invariably observed in congenital idiopathic clubfoot. Significance: This study further differentiates congenital idiopathic clubfoot as distinct from other complex genetic syndromes that can present with similar deformities, and thus facilitates further research to improve the clinical diagnosis and treatment of congenital idiopathic clubfoot

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

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

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). Method. 100 feet were treated in 66 patients. 61 of the 100 feet have been prospectively reviewed on an annual/ bi-annual basis since successful correction, with outcomes of the remaining feet obtained by retrospective analysis. Results. 96 feet responded to initial casting; of these, 31 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). 12 feet developed recurrence after 2 years (9 of whom were successfully treated with transfer of tibialis anterior tendon and 3 of whom required extensive soft tissue release) Mean dorsiflexion at average follow-up of 9 years is 15 degrees (95% CI 12.96 to 17.04) and mean abduction 41 degrees. (95%CI 37.65 to 45.07). Conclusion. The Ponseti regimen is a successful treatment option for the management of idiopathic clubfoot. The majority of recurrences occur in the first two years and so close follow-up should be undertaken during this period. The importance of strict compliance with boots and bars must be emphasised to parents at this treatment stage. These mid-term outcomes have highlighted that, although fewer recurrences occur after the first two years, it is difficult to predict which feet might recur; consequently, we recommend following children up in an annual/bi-annual fashion until their skeletal maturity

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

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

Little is known about the risk of later development of osteoarthritis after operative clubfoot correction. There are only a few long-term reports of 30 years and more after operative correction with a standard technique. Slight deformity after correction of an idiopathic clubfoot may be well tolerated by children and young adults. However, if these slight deformities become symptomatic with advancing age remains unsettled. To answer this question, a long-term follow-up of more than 30 years is needed. Functional and radiological correlation is poor in the adult foot with a slight under-corrected clubfoot deformity. A computer-assisted foot scan will provide the exact static and dynamic measurement of the pressure under each part of the foot at every moment of gait. This instrument allows better analysis of residual clubfoot. Between 1962 and 1966 we operated 15 children with the standard operative technique of Phelps-Codivilla. In all cases there was a persistent deformity after continuous casting since birth. In two cases a heal cord lengthening procedure had been previously performed. Mean age at operation of the four girls and 11 boys was four (1 to 8) years. Six had unilateral involvement, whereas the remaining nine patients required bilateral surgery. In four cases there was a second medial release for relapse. A Steindler procedure was used in two cases and in two cases correction of clawtoes was necessary. Operative technique: Two separate incisions were made. One was longitudinal posterior that enabled lengthening of the heel cord, the tendon of the tibialis posterior and long flexors, as well as release of the posterior capsule. A second incision was made on the medial aspect of the foot in order to release the talonavicular and navicularcuneiform joints. The reduced navicular was fixed with a K-wire. Twelve patients were examined clinically, radiologically and by functional testing after a mean follow-up of 33.5 (34 to 38) years. Eight patients had no pain and were not disturbed. There was a slight malreduction of the subtalar joint, but without any signs of joint degeneration. The foot pressure showed overpressure of the lateral forefoot. Four patients had pain and functional limitation. Their complaints had begun only two to four years earlier, and had been asymptomatic until then. All patients developed osteoarthritis of the subtalar joint, and their foot scans were abnormal. Definitive assessment of the successful treatment of idiopathic clubfoot deformity is only possible with a long-term follow-up study. A slight undercorrection can be functionally well tolerated for a long period of time. The first occurrence of pain is still possible at the age of 35 years and older. A computer-assisted assessment of foot pressure by using a foot scan is a sensitive diagnostic tool

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

We report the effect of introducing a dedicated Ponseti service on the five-year treatment outcomes of children with idiopathic clubfoot. Between 2002 and 2004, 100 feet (66 children; 50 boys and 16 girls) were treated in a general paediatric orthopaedic clinic. Of these, 96 feet (96%) responded to initial casting, 85 requiring a tenotomy of the tendo-Achillis. Recurrent deformity occurred in 38 feet and was successfully treated in 22 by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, The remaining 16 required an extensive surgical release. . Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls) were treated in a dedicated multidisciplinary Ponseti clinic. All responded to initial casting: 60 feet (83.3%) required a tenotomy of the tendo-Achillis. Recurrent deformity developed in 14, 11 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The other three required an extensive surgical release. . Statistical analysis showed that children treated in the dedicated Ponseti clinic had a lower rate of recurrence (p = 0.068) and a lower rate of surgical release (p = 0.01) than those treated in the general clinic. This study shows that a dedicated Ponseti clinic, run by a well-trained multidisciplinary team, can improve the outcome of idiopathic clubfoot deformity. Cite this article: Bone Joint J 2014;96-B:1424–6

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.

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

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

Aim: This study was designed to investigate the association between clinical assessment International Clubfoot Study Group (ICFSG) and quantitative gait data of the children. Methods: Nineteen patients with 30 surgically treated clubfoot were included in this study. Bilateral involvement was present in 11. Average age was 9 years (range 6–14 years) at the time of last follow-up. Patients were treated with different surgical techniques at early childhood period. At the final follow-up they were evaluated according to ICFSG clinical scale. This rating system is based on three main subgroups of evaluation as morphologic evaluation, functional evaluation and radiological evaluation. The maximum score is 12 in morphologic evaluation, 36 in functional evaluation and 12 in radiological evaluation. The total score is from 0 for a perfect result to 60 for the worst result. Further, a total score of 0–5 is rated as excellent, 6–15 as good, 16–30 as fair and over 30 as poor. Quantitative gait data was collected with the Vicon 370 (Oxford Metrics, Oxford, UK). Two force plates (Bertec, Colombus, Ohio, USA) were used for kinetic analysis. All time-distance (walking velocity, cadence, step time, step length, double support time), kinematic (joint rotation angles of pelvis, hip, knee and ankle in sagittal, coronal and transverse planes) and kinetic (ground reaction forces, moments and powers of hip, knee and ankle) data were processed using Vicon Clinical Manager software package. Spearman correlation analysis was used to evaluate if there is a correlation between total clinical score and gait parameters. Results: Average ICSG score was 8.63 (range 1–29). Outcome was excellent in 16, good in 8 and fair in 6 patients according to ICSG. There was a significant correlation between total ICSG score and walking velocity (rs=−0.195, p=0.004), step length (rs=−0.476, p=0.019), pelvic excursion in sagittal plane (rs=−0.429, p=0.026), hip excursion in sagittal plane (rs=−0.511, p=0.006), knee excursion in sagittal plane (rs=−0.486, p=0.019), Ankle excursion in sagital plane (rs=−0.413, p=0.040), peak ankle plantar flexion moment (rs=−0.600, p=0.039), peak ankle plantar flexion power (rs=−0.487, p=0.025). When we compare the gait parameters between groups only foot progression angle showed a significant difference (p=0.031). Conclusion: ICFSG score is a successful method to follow outcome in patients with surgically treated clubfoot. ICFSG score is correlated with many kinematic and kinetic gait data however foot progression angle is the only parameter predicting outcome in children with surgically treated idiopathic clubfoot. Quantitative gait analysis may help to define the liable factors of the functional deficits, and to prescribe novel rehabilitation techniques to enable better outcome for children with clubfeet

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

Percutaneous Achilles tenotomy is an integral part of the Ponseti technique. Though considered as a simple procedure, many authors have reported serious neurovascular complications that include iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation. The authors describe the results of their new tenotomy technique, the ‘Posterior to Anterior Controlled’ (PAC) technique in an attempt to eliminate such complications. This is a prospective study. Infants < 1 year of age with idiopathic clubfoot were taken up for the Ponseti technique of correction. Tenotomy was performed by the ‘PAC’ technique under local anaesthesia if passive dorsiflexion was found to be < 15 degrees. Outcome measures included completeness of the tenotomy (by ultrasonography), improvement in the equinus angle and occurrence of neurovascular complications. 40 clubfeet in 22 patients underwent ‘PAC’ tenotomy. The mean age was 3.5 months. The tenotomy was found to be complete in all cases. The equinus angle improved by an average of 78.5 degrees (range 70–95 degrees), which was statistically significant (p < 0.05, students t test). Mild soakage of the cast with blood was noted in 21 (52.5%) cases. No neurovascular complication was noted. The average follow-up was 12.2 months (range 9–18 months). The ‘PAC’ tenotomy virtually eliminates the possibility of neurovascular damage, maintains the percutaneous nature of the procedure, is easy to learn and can be performed even by relatively inexperienced surgeons safely and effectively as an office procedure under local anaesthesia

Aims. To analyze outcomes reported in studies of Ponseti correction of idiopathic clubfoot. Methods. A systematic review of the literature was performed to identify a list of outcomes and outcome tools reported in the literature. A total of 865 studies were screened following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 124 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Each outcome tool was assigned to one of the five core areas defined by the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT). Bias assessment was not deemed necessary for the purpose of this paper. Results. In total, 20 isolated outcomes and 16 outcome tools were identified representing five OMERACT domains. Most outcome tools were appropriately designed for children of walking age but have not been embraced in the literature. The most commonly reported isolated outcomes are subjective and qualitative. The quantitative outcomes most commonly used are ankle range of motion (ROM), foot position in standing, and muscle function. Conclusions. There is a diverse range of outcomes reported in studies of Ponseti correction of clubfoot. Until outcomes can be reported unequivocally and consistently, research in this area will be limited. Completing the process of establishing and validating COS is the much-needed next step. Cite this article: Bone Joint Open 2020;1-8:457–464

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

Introduction: Congenital clubfeet have increasingly been detected in routine prenatal ultrasound. However, many clubfeet are still missed and surprise the mothers at birth. The complex deformity and different treatment options available seem to make prenatal counseling desirable. Despite published studies on prenatal clubfoot diagnosis by ultrasound, it is unknown if mothers would indeed prefer to know about their child’s clubfoot before birth or not.

Methods: This survey included patients born between 2000 and 2007 who were treated for congenital clubfoot at one of the two participating institutions (center one: East coast USA; center two: Austria). Exclusion criteria were defined as underlying syndrome, genetic abnormality or pregnancy with multiple fetuses. A brief survey about the opinion of mothers towards ultrasound diagnosis of clubfoot consisting of three questions was sent out. A computer database was created for data collection and a statistic analysis was performed.

Results: Surveys were sent out to 401 mothers of patients meeting inclusion criteria. A total of 220 surveys were received back with 105 surveys from center one and 115 surveys from center two. In 97 cases the clubfoot was unilateral and in 123 cases bilateral. Routine ultrasound showed a clubfoot in 91 cases (41%) and failed to show the deformity in 128 cases (59%). The detection rate in center one was 60% compared to 25% in center two. Bilateral clubfeet had a detection rate of 53% whereas unilateral clubfeet had a detection rate of 29%. Between 2000 and the end of 2003 the overall detection rate was 31% versus 50% between 2004 and the end of 2007.

Overall 74% of mothers wanted to know about their baby’s clubfoot before birth and 24% after birth. Of the 91 mothers who had a positive ultrasound 96% wanted to know before birth. Of the 128 patients who had a negative ultrasound 59% would have wanted to know while 38% did not want to know about the clubfoot prenatally. In center one 89% of mothers wanted to know before birth versus only 60 % in center two. Comments on the survey form showed that mothers who had or wanted to have the prenatal diagnosis appreciated the time to prepare and to find out more about the condition and different treatment options. Many wished for more information at the time of prenatal diagnosis. Mothers that would prefer to find out about the clubfoot postnatally feared that the diagnosis would have affected the experience of the pregnancy.

Discussion: Although the detection rate increased over time there are still cases of clubfeet missed in the routine ultrasound, especially in center two where the rate of detection was low. Mothers in the US are more reluctant to know before birth than mothers in Austria which is most likely related to the differences in the two health care systems. Detailed information about the nature and treatment of clubfeet should be given at prenatal diagnosis.

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.

We performed electrophysiological studies on both legs of 52 children, aged from 3 months to 15 years, with idiopathic club foot. In only nine (17%) was no abnormality found. Isolated peroneal nerve damage was seen in 14 (27%). Abnormality of both peroneal and posterior tibial nerves was found in five (10%). Four patients (8%) had evidence of isolated spinal-cord dysfunction, whereas combined spinal-cord and peripheral-nerve lesions were seen in 14 (27%). Six patients (11%) had variable neurogenic electrophysiological patterns. In 13 patients in whom the studies were repeated neither progression nor improvement of the electrophysiological parameters was observed. Pathological electrophysiological findings were found in 66% of conservatively-treated patients. In the 43 patients treated surgically, all 16 with fair and poor results had pathological electrophysiological findings and 12 required further operations. Multiplicity of the pathological findings was related to the severity of the deformity of the foot; normal studies represent a good prognostic sign. Electrophysiological studies are useful in idiopathic club foot with residual deformities after conservative or operative treatment. Our findings support the theory that muscle imbalance is an aetiological factor in idiopathic club foot

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.

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.

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.

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

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.

Continuous passive motion has been shown to be effective in the conservative treatment of idiopathic club foot. We wished to determine whether its use after operation could improve the results in resistant club feet which required an extensive soft-tissue release. There were 50 feet in the study. Posteromedial lateral release was performed in 39 feet but two were excluded due to early relapse. The mean age at surgery was eight months (5 to 12). Each foot was assigned a Dimeglio club foot score, which was used as a primary outcome measure, before operation and at 6, 12, 18 and 44 months after. Nineteen feet were randomly selected to receive continuous passive motion and 18 had standard immobilisation in a cast. After surgery and subsequent immobilisation in a cast the Dimeglio club foot score improved from 10.3 before to 4.17 by 12 months and to 3.89 at 48 months. After operation followed by continuous passive motion the score improved from 9.68 before to 3.11 after 12 months, but deteriorated to 4.47 at 48 months. Analysis of variance adjusted for baseline values indicated a significantly better score in those having continuous passive motion up to one year after surgery, but after 18 and 48 months the outcomes were the same in both groups

Treatment by continuous passive movement at home is an alternative to immobilisation in a cast after surgery for club foot. Compliance with the recommended treatment, of at least four hours daily, is unknown. The duration of treatment was measured in 24 of 27 consecutive children with a mean age of 24 months (5 to 75) following posteromedial release for idiopathic club foot. Only 21% (5) of the children used the continuous passive movement machine as recommended. The mean duration of treatment at home each day was 126 minutes (11 to 496). The mean range of movement for plantar flexion improved from 15.2° (10.0° to 20.6°) to 18.7° (10.0° to 33.0°) and for dorsiflexion from 12.3° (7.4° to 19.4°) to 18.9° (10.0° to 24.1°) (both, p = 0.0001) when the first third of therapy was compared with the last third. A low level of patient compliance must be considered when the outcome after treatment at home is interpreted

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.

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

Rocker bottom deformity may occur during the conservative treatment of idiopathic congenital clubfoot. Between 1975 and 1996, we treated 715 patients (1120 clubfeet) conservatively. A total of 23 patients (36 feet; 3.2%) developed a rocker bottom deformity. It is these patients that we have studied. The pathoanatomy of the rocker bottom deformity is characterised by a plantar convexity appearing between three and six months of age with the hindfoot equinus position remaining constant. The convexity initially involves the medial column, radiologically identified by the talo-first metatarsal angle and secondly by the lateral column, revealed radiologically as the calcaneo-fifth metatarsal angle. The apex of the deformity is usually at the midtrasal with a dorsal calcaneocuboid subluxation. Ideal management of clubfoot deformity should avoid this complication, with adequate manipulation and splinting and early Achilles’ percutaneous tenotomy if plantar convexity occurs. Adequate soft-tissue release provides satisfactory correction for rocker bottom deformity. However, this deformity requires more extensive and complex procedures than the standard surgical treatment of clubfoot. The need for lateral radiographs to ensure that the rocker bottom deformity is recognised early, is demonstrated

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.

Achilles tenotomy is a recognised step in the Ponseti technique for the correction of idiopathic congenital talipes equinovarus in most percutaneous cases. Its use has been limited in part by concern that the subsequent natural history of the tendon is unknown. In a study of 11 tendons in eight infants, eight tendons were shown to be clinically intact and ten had ultrasonographic evidence of continuity three weeks after tenotomy. At six weeks after tenotomy all tendons had both clinical and ultrasonographic evidence of continuity.

Aims. The gold standard for percutaneous Achilles tendon tenotomy during the Ponseti treatment for idiopathic clubfoot is a tenotomy with a No. 15 blade. This trial aims to establish the technique where the tenotomy is performed with a large-bore needle as noninferior to the gold standard. Methods. We randomized feet from children aged below 36 months with idiopathic clubfoot on a 1:1 basis in either the blade or needle group. Follow-up was conducted at three weeks and three months postoperatively, where dorsiflexion range, Pirani scores, and complications were recorded. The noninferiority margin was set at 4° difference in dorsiflexion range at three months postoperatively. Results. The blade group had more dorsiflexion at both follow-up consultations: 18.36° versus 18.03° (p = 0.115) at three weeks and 18.96° versus 18.26° (p = 0.001) at three months. The difference of the mean at three months 0.7° is well below the noninferiority margin of 4°. There was no significant difference in Pirani scores. The blade group had more extensive scar marks at three months than the needle group (8 vs 2). No major complications were recorded. Conclusion. The needle tenotomy is noninferior to the blade tenotomy for usage in Ponseti treatment for idiopathic clubfoot in children aged below 36 months. Cite this article: Bone Joint J 2024;106-B(8):871–878

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

Background. The optimal management of idiopathic clubfoot has changed over three decades. Recently there has been an enthusiastic embracing of the Ponseti technique. The purpose of this 14-year comparative prospective longitudinal study was to directly assess the differences in results between these two treatment methods. Methods. Over the period of this study there were 52,514 births in the local population and all newborns with clubfoot were referred directly to the Pediatric Orthopedic Surgeon. Patient demographics, the Harrold & Walker Classification, and associated risk factors for clubfoot were collected prospectively and analyzed. If conservative treatment failed to correct the deformity adequately, a radical subtalar release (RSR) was undertaken (the primary outcome measure of the study). Results. There were 114 feet (80 patients): 64 feet treated ‘traditionally’ and 50 feet with the Ponseti technique. Idiopathic clubfoot was present in 76.25% of patients. Mean time to RSR was 33.3 and 44.1 weeks 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 25.5% (CI: 15.8 to 38.3%) in the Ponseti group. When idiopathic clubfoot alone was analysed, 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 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 clubfoot. Conclusions. Introduction of the Ponseti technique into our institution significantly reduced the need for RSR in fixed clubfoot

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

The December 2015 Children’s orthopaedics Roundup. 360 . looks at: Paediatric femoral fractures: a single incision nailing?; Lateral condylar fractures: open or percutaneous?; . Forearm refracture: the risks; Tibial spine fractures; The child’s knee in MRI; The mechanics of SUFE; Idiopathic clubfoot

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

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

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

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

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

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 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

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

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

To evaluate the effectiveness of a casting method for the early treatment of clubfoot deformity, a scoring system utilizing the French [DiMeglio], English [Pirani], and our functional rating system before and after each casting session was used to determine the final assessment and results of the Iowa [Ponseti] clubfoot technique. Between Jan 2000 to June 2001, 49 clubfeet in 33 patients were assessed before and after the Ponseti casting at a minimum of 1 year follow up using the Dimeglio/ Bensahel, Hospital for Joint Diseases functional rating, and Catterall/Pirani scoring system. Mean age of presentation was 7 weeks [range 0.5 to 28 weeks]. Patients had casting +/− percutaneous TAL. At latest follow up patients who were compliant for Foot Abduction Orthosis [n=32 feet] had good results without any deterioration in their scores. Of the noncompliant patients 8 patients remained good. Of the nine feet that had poor results, 5 improved with recasting, 2 required percutaneous TAL and 2 required open TAL and posterior release. Early treatment of the idiopathic clubfoot with serial [Ponseti] casting will be effective in over 90% of cases and patients will require no other treatment except for percutaneous tenotomy of the Achilles tendon. Early use of the Iowa [Ponseti] technique [before the age of one year] will significantly reduce the current number of extensive surgical procedures performed for the treatment of clubfoot. Moreover, it will produce more flexible and supple feet and avoid the problem of stiff, recurrent post-surgical clubfoot

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

Purpose: Currently, clubfoot is initially treated with non-operative methods including Ponseti casting and the French physical therapy program (PT). Our purpose was to evaluate the function of children treated with these techniques. Methods: Seventy-six idiopathic clubfoot patients were enrolled. Successful non-operative outcomes were achieved in 32 patients (44 feet) treated with casting and 44 patients (66 feet) treated by PT. Initial Dimeglio scores were 10–17. At average age 2.3 years (1.9–3.3yr), subjects’ gait was evaluated with a VICON 512 motion analysis system. Cadence and kinematic data was classified as abnormal if it fell outside of one standard deviation from normal. Results: No statistical differences for cadence parameters were found between the two groups. Two kinematic patterns were identified: Children treated with PT walked with knee hyperextension (41% of feet)*, equinus (17%)*, and foot-drop (28%)*; whereas zero casted patients walked in equinus and only one demonstrated foot-drop. In contrast, the casted group demonstrated increased stance dorsiflexion (47%)* and calcaneus (18%). More PT feet had increased internal foot progression angle (34% vs. 13%)* and increased shank-based foot rotation (56% vs. 33%)*. Both groups had equal rates of normal sagittal-plane ankle motion (59% PT vs. 55%). [*p< 0.05]. Conclusions: Half of the two year-old patients treated non-operatively for clubfoot had normal sagittal-plane ankle motion. Less than 20% in each group experienced calcaneus and equinus gaits, respectively. These differences may be the result of performing percutaneous tendo Achilles lengthening as part of the Ponseti casting technique, but not as part of the PT program

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

The purpose of this paper is to report on the use of a tendon transfer (anterior tibial to midfoot) to correct dynamic foot and ankle varus deformity. Anterior tibial tendon transfer to mid-foot is useful to consider in planning treatment where there is a need to rebalance a foot in which the unopposed or weakly opposed anterior tibial causes the abnormal varus position of the foot and ankle. 12 patients, 22 feet had anterior tibial tendon transfers performed. 10 were bilateral. 10 patients had neuromuscular disease as the underlying cause for the foot imbalance, 1 patient had idiopathic clubfoot with residual, recalcitrant varus after earlier posteromedial release and 1 patient was hemiplegic secondary to stroke caused by encephalopathy. Age of the patients at the time of their initial procedure(s) ranged from 2 to 34. There was at least 1 year follow-up after each procedure for the patient to be entered into this study. A 1-grade functional loss was encountered following tendon transfer of anterior tibial muscles grading between 4–5. (4=good, 5=being normal). The transferred muscles allowed the dynamic varus deformity to be removed and the foot to become plantigrade. In its transferred position, it functioned to actively contract and contributed to give support of the ankle. After an initial period of cast use post-operatively and bracing for 6 months to support the transfer, continued use of AFO was no longer necessary. Anterior tibial tendon transfer to mid-foot, originally described by Garceau continues to be an useful method for rebalancing a foot in which the abnormal pull of the normal or almost normal functioning anterior tibial muscle. This muscle is unopposed or weakly opposed because of the underlying neuromuscular disorder or previous surgery. Thus, it causes the foot and ankle to turn into varus. The technique used is straightforward and simple. It is a useful procedure to consider when rebalancing a foot may be needed

Objective. In many institutions, serial casting and splinting requires many weeks of treatment and frequently results in surgery. This study evaluated the results of neonatal clubfoot correction with the Furlong method. This method was created by Furlong M.B. and Lawn G.W. in New York and was published in Archives of Pediatrics in 1960. Materials and Methods. This study reviews 95 neonates with 128 severe clubfeet (initial Pirani score 4,0 or more). Patients with arthrogrypotic clubfeet and other syndromes were not included. Age at presentation ranged from 4 hours to 18 days. All patients had no previous treatment. The cast application with extra space above the foot was performed as follows: a special elastic pad was placed on the dorsal aspect of the foot and fixed with a cotton bandage. Then plaster cast was applied with knee flexion 110–120 degrees. After the cast was set, the elastic pad was removed, leaving a reserve space on the dorsal aspect of the foot. The cast was changed every 3–7 days. Typical corrective maneures were performed. Foot displacement into dorsiflexion occured spontaneously as an active motion and also with manipulations. Abduction braces or knee-flexed splints were applied after the complete foot correction. Pirani score and foot dorsiflexion angle were documented during each step of correction. Results. A detailed rating system (with radiologic criteria) was used for result evaluatiion. Correction was successful in all but 5 patients. 90 % required less than 6 casts. There were 12 recurrences and they were related with compliance with the abduction brace, but not with age or number of casts required for correction. Only 13 patients required surgery (6 posterior releases, 6 posteromedial releases and 1 complete subtalar release). Mean follow-up was 12 years. 23% of feet were evaluated as excellent, 71 %- as good and 6%- as poor results. Conclusion. The Furlong method is succesful in obtaining initial correction in the idiopathic clubfoot patient. This method corrects the neonatal congenital clubfoot in 85% without any surgery

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

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

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: Correction of residual clubfoot deformities remains a great surgical challenge, and treatment failure is not uncommon. Open surgical reconstruction often leads to more scarring, risk of neurovascular injury, and a stiff foot. The Ilizarov external fixator allows for osseous realignment without open incisions. The Taylor spatial frame (TSF) is a relatively new external fixator that is capable of simultaneous six-axis deformity correction. Our method applies the Ponseti principles of clubfoot correction to a two-stage TSF correction (i.e., varus and internal rotation correction and then equinus correction). The Ponseti type 1 frame is programmed to correct varus and internal rotation first and then equinus. The Ponseti type 2 frame follows the same sequence as the type 1 frame but includes a final phase in which the foot ring is cut on two sides to allow separate correction of forefoot cavus and adductus. We present our initial multicenter experience with this Ponseti-inspired method. Methods: During a five-year period, seventeen patients (22 feet) were treated for residual clubfoot deformities with the TSF. Nine patients had idiopathic clubfoot, five had arthrogryposis, one had myelomeningocele, one had developmental clubfoot, and one had clubfoot associated with fibular hemimelia. Eight boys and nine girls were treated. The average age was 6.5 years (age range, 1.75–15 years). Equinus, internal rotation, and varus were addressed in nine patients (Ponseti type 1 frame), equinus, internal rotation, and forefoot deformity (adduction and/or cavus) in six patients (Ponseti type 2 frame), and equinus only in two patients. All patients underwent correction with standard two-ring frames using a long bone program. Results: All frames were removed after an average of 3.6 months (range, 3–8 months). One patient had under correction of residual equinus, but all others achieved full correction of deformities. Complications included superficial pin site infection in nine patients, talar subluxation in one patient, and subluxation of the first metatarsophalangeal joint in two patients. Infections were successfully treated with oral antibiotics. The one case of talar subluxation was reduced by the residual TSF program. The subluxated great toe was pinned in a separate surgery in two cases. Conclusions: We believe that the Ponseti sequence of correction can be applied to older children with residual club-foot deformities even if they have previously undergone surgery. Our method with the TSF is a safe, accurate (computer-based), and effective treatment. It does not require open surgery, so the potential for scarring is minimized. It also allows for any subsequent treatments as needed. Significance: The Ponseti-inspired method of residual club-foot deformity correction with the TSF is accurate and is a viable alternative to repeat open surgical procedures

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

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

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

We have compared the density of nerve fibres in the synovium in club foot with that of specimens obtained from the synovium of the hip at operations for developmental dysplasia. The study focused on the sensory neuropeptides substance P; calcitonin gene-related peptide; protein gene product 9.5, a general marker for mature peripheral nerve fibres; and growth associated protein 43, a neuronal marker for new or regenerating nerve fibres. In order to establish whether there might be any inherent difference we analysed the density of calcitonin gene-related peptide-positive nerve fibres in the hip and ankle joints in young rats. Semi-quantitative analysis showed a significant reduction in the number of sensory and mature nerve fibres in the synovium in club foot compared with the control hips. Calcitonin gene-related peptide (CGRP) positive fibres were reduced by 28%, substance P-positive fibres by 36% and protein gene product 9.5-positive fibres by 52% in club foot. The growth associated protein 43-positive fibres also seemed to be less in six samples of club foot. No difference in the density of CGRP-positive nerve fibres was observed in the synovium between ankle and hip joints in rats. The lack of sensory input may be responsible for the fibrosis and soft-tissue contractures associated with idiopathic club foot

In order to determine the incidence of avascular necrosis after osteotomy of the talar neck, we re-evaluated 11 patients (16 feet) with idiopathic club foot who had undergone this procedure at a mean age of eight years (5 to 13) to correct a residual adduction deformity. All had been initially treated conservatively and operatively. The mean follow-up was 39 years (36 to 41). Surgery consisted of a closing-wedge osteotomy of the talar neck combined, in 14 feet, with lengthening of the first cuneiform and a Steindler procedure. At follow-up eight feet were free from pain, three had occasional mild pain and five were regularly painful after routine activities. Two patients were unlimited in their activity, six occasionally limited after strenuous and three regularly limited after strenuous activity. Using the Ponseti score, the feet were rated as good in four, fair in three and poor in nine. In seven feet avascular necrosis with collapse and flattening of the talar dome had occurred. In all of these feet the children were younger than ten years of age at the time of surgery. In three feet, avascular necrosis of the talar head was also observed. We conclude that osteotomy of the talar neck in children under the age of ten years can cause avascular necrosis and should be abandoned

The April 2023 Children’s orthopaedics Roundup³⁶⁰ 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

Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

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

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.

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).

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.

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.

The outcome in 83 patients with congenital clubfoot was evaluated at a mean age of 64 years using three validated questionnaires assessing both quality of life (short-form (SF)-36 and EQ-5D) and foot and ankle function (American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle questionnaire). In SF-36, male patients scored significantly better than male norms in seven of the eight domains, whereas female patients scored significantly worse than female norms in two of the eight. Male patients scored better than male norms in both the EQ-5D index (p = 0.027) and visual analogue scale (VAS) (p = 0.013), whereas female patients scored worse than female norms in the VAS (p < 0.001). Both male and female patients had a significantly worse outcome on the AAOS Core Scale than did norms. There was a significant correlation for both genders between the SF-36 Physical Component Summary Score and the AAOS Core Scale.

The influence on activities of daily life was limited to foot and ankle problems in all patients, and in females there was an adverse effect in physical aspects of quality of life.

Club foot was diagnosed by ultrasonography in 91 feet (52 fetuses) at a mean gestational age of 22.1 weeks (14 to 35.6). Outcome was obtained by chart review in 26 women or telephone interview in 26. Feet were classified as normal, positional deformity, isolated club foot or complex club foot.

At initial diagnosis, 69 feet (40 fetuses) were classified as isolated club foot and 22 feet (12 fetuses) as complex club foot. The diagnosis was changed after follow-up ultrasound scan in 13 fetuses (25%), and the final ultrasound diagnosis was normal in one fetus, isolated club foot in 31 fetuses, and complex club foot in 20 fetuses.

At birth, club foot was found in 79 feet in 43 infants for a positive predictive value of 83%. Accuracy of the specific diagnosis of isolated club foot or complex club foot was lower; 63% at the initial ultrasound scan and 73% at the final scan. The difference in diagnostic accuracy between isolated and complex club foot was not statistically significant. In no case was postnatal complex club foot undiagnosed on fetal ultrasound and all inaccuracies were overdiagnoses. Karyotyping was performed in 25 cases. Abnormalities were noted in three fetuses, all with complex club foot and with additional findings on ultrasound.