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

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. 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

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. Methods. A total of 11 international centres participated in this institutional review board-approved observational study. Data including demographics, information regarding presentation, treatment, and details of subsequent relapse and management were collected between 1 June 2022 and 30 June 2023 from consecutive clinic patients who had a minimum five-year follow-up. The clubfoot COS incorporating 31 parameters was used. A regression model assessed relationships between baseline variables and outcomes (clinical/QoL). Results. Overall, 293 patients (432 feet) with a median age of 89 months (interquartile range 72 to 113) were included. The relapse rate was 37%, with repeated relapse in 14%. Treatment considered a standard part of the Ponseti journey (recasting, repeat tenotomy, and tibialis anterior tendon transfer) was performed in 35% of cases, with soft-tissue release and osteotomies in 5% and 2% of cases, respectively. Predictors of relapse included duration of follow-up, higher initial Pirani score, and poor Evertor muscle activity. Relapse was associated with poorer outcomes. Conclusion. This is the first multicentre study using a standardized COS following clubfoot treatment. It distinguishes patients with and without relapse in terms of clinical outcomes and QoL, with poorer outcomes in the relapse group. This tool allows comparison of treatment methods and outcomes, facilitates information sharing, and sets family expectations. Predictors of relapse encourage us to create appropriate treatment pathways to reduce relapse and improve outcome. Cite this article: Bone Joint J 2024;106-B(7):735–743

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. Methods. In this randomized prospective trial, 23 idiopathic clubfeet were immobilized with plaster-of-Paris casts and 23 clubfeet were immobilized with a splint made of Woodcast that encircled only two-thirds the circumference of the limb. The number of casts or splints needed to obtain full correction, the frequency of cast or splint-related complications, and the time taken for application and removal of the casts and splints were compared. Results. The mean number of casts required to obtain full correction of the deformity (Pirani Score 0) was 4.35 (95% confidence interval (CI) 3.74 to 4.95) when plaster-of-Paris was used and 4.87 (95% CI 4.33 to 5.41) when the Woodcast splint was used (p = 0.190). The time required for application and removal of the Woodcast splint were significantly less than that required for application and removal of plaster-of-Paris casts (p < 0.001). Woodcast splint-related complications were not more frequent than plaster-of-Paris cast related complications. Conclusion. Though Woodcast splints covering two-thirds of the circumference of the lower limbs of infants were effective in maintaining the correction of clubfoot deformity during serial manipulation and casting treatment, the superiority of Woodcasts over plaster-of-Paris could not be established. Cite this article: Bone Joint J 2020;102-B(10):1399–1404

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

Introduction: 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

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

The 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

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

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

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

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

From a cohort of 110 idiopathic clubfeet, 26 feet in 18 children requiring surgery for severe relapse have been studied. Surgery was comprised of a lateral column shortening procedure (Lichtblau) plus or minus a plantarmedial release. Surgery was staged to avoid wound complications. Pre-operatively, feet were prospectively categorised into one of four grades according to a system reported by Dimeglio. Children were reviewed on two subsequent occasions. At review, feet were again graded. In addition, appearance and functional outcome was analysed and included an assessment of gait, activity and functional limitation. Three children were lost to follow-up, leaving 22 feet in seven male and eight female patients available for review. The mean age at surgery was 43 months (23–82). The mean time from surgery to first and second reviews was 35 and 56 months, respectively. There was a significant improvement in grading at first review compared to pre-operative grading (Wilcoxon signed ranks test). Although there remained a significant improvement in grading at second review compared to the preoperative grading, there was a significant reduction in the number of feet in which grading had improved when compared to first review. There was no significant change in function between the two post-operative reviews (Chi-square tests), with the majority of children experiencing little functional limitation. There were no wound complications. Relapse surgery, involving a lateral column shortening procedure for severe clubfoot, results in a significant initial improvement when assessed using a grading system. This improvement in grading subsequently decreases over time. However, the functional outcome in such cases remains favourable

The objective of our research is to elucidate the pathogenesis of soft-tissue contracture. Here we present a comparison of collagens isolated from deltoid ligament of 23 clubfeet classified according to the Dimeglio-classification and of 14 matched controls of normal feet. Collagens were isolated by acetic acid extraction and by limited pepsin-solubilisation and analysed by SDS-PAGE. Ligaments and solubilised collagens were analysed for their extent of hydroxylation of prolyl- and lysyl-residues, their content of galactosyl-hydroxylysine and glucosyl-galacto-syl-hydroxylysine and their content of lysyl-oxidase dependent cross-links histidinohydroxylysino-norleucine (HHL), hydroxylysylpyridinoline (HP) and lysylpyridinoline (LP). Analysis were carried out using an amino acid analyser (Bio-chrom 20, Amersham Pharmacia Biotech) and a reverse-phase HPLC system (Gynkothek). Percentage of collagen of total protein decreases in club-foot as compared to controls. SDS-PAGE of solubilised collagens shows a high content of type I, less of type III and small amounts of type V collagen in both groups. The extent of hydroxylation of proline appears to be very similar, whereas the degree of hydroxylation of lysine follows the Dimeglio-classification. In addition, glycosylation of hydroxylysine increases parallelly to the classification. However, the increase is found solely in the amount of disac-charides. Total content of HHL, the most important collagen cross-link in soft tissues, was increased significantly in club-feet as compared to controls. HP, the hard tissue specific collagen cross-link was increased slightly in clubfeet. Levels of LP were too low to detect differences precisely. The data presented show distinct differences in the post-translational modifications of collagen (hydroxylation of lysyl-residues, glycosylation and lysyl-oxidase dependent cross-links) isolated from congenital idiopathic clubfeet and from controls

Aim: Surgical treatment for idiopathic clubfeet aims to realign the foot and allow plantigrade weight bearing with adequate joint motion. In spite of satisfying clinical and radiological results for both the physician and the parents shortly after the operation, deterioration may occur years after the surgery. The aim of this study was to evaluate gait characteristics of children with surgically treated unilateral clubfoot and had good clinical outcome. Methods: Twelve children (mean age 5.9±2.3 years (4–9)) with surgically treated unilateral clubfoot before age one and twelve age matched healthy children were included in the study. Foot length, calf circumference, ankle range of motion and radiographic measurements were recorded. 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. Results: Foot length of the operated side was shorter than the unaffected side but the difference was not significant (p> 0.05). Calf circumference and ankle range of motion were significantly less than the unaffected side (p< 0.05). Quantitative gait data revealed that children with clubfoot had slower walking velocity (0.75±0.25 versus 1.02±0.18 m/sec, p=0.001), shorter stride length (0.72±0.23 versus 0.91±0.05 meters, p=0.001) and less ankle plantar flexor moment (0.73±0.22 versus 0.88±0.11 m/sec, p=0.007) than healthy children. Unaffected side showed increased pelvic excursions and medio-lateral ground reaction forces as well as decreased ankle and hip motion in sagittal plane. Conclusion: We detect various deviations in gait parameters even in so called well treated patients according to radiological and clinical criteria. Alterations in the unaffected foot may be the result of the subclinical involvement of the unaffected foot by disease as well as the compensatory mechanisms. These gait deviations may lead long-term morbidity later in adulthood

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

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

Aims

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.

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

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

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.

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.

Talipes equinovarus is one of the more common congenital abnormalities affecting the lower limb and can be challenging to manage. This review provides a comprehensive update on idiopathic congenital talipes equinovarus with emphasis on the initial treatment. Current management is moving away from operative towards a more conservative treatment using the Ponseti regime. The long-term results of surgical correction and the recent results of conservative treatment will be discussed.