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

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

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. Methods. The consensus process followed an established Delphi approach with a predetermined degree of agreement. The process included the following steps: establishing a steering group; steering group meetings, generating statements, and checking them against the literature; a two-round Delphi survey; and final consensus meeting. The steering group members and Delphi survey participants were all British Society of Children’s Orthopaedic Surgery (BSCOS) members. Descriptive statistics were used for analysis of the Delphi survey results. The Appraisal of Guidelines for Research & Evaluation checklist was followed for reporting of the results. Results. The BSCOS-selected steering group, the steering group meetings, the Delphi survey, and the final consensus meeting all followed the pre-agreed protocol. A total of 153/243 members voted in round 1 Delphi (63%) and 132 voted in round 2 (86%). Out of 61 statements presented to round 1 Delphi, 43 reached ‘consensus in’, no statements reached ‘consensus out’, and 18 reached ‘no consensus’. Four statements were deleted and one new statement added following suggestions from round 1. Out of 15 statements presented to round 2, 12 reached ‘consensus in’, no statements reached ‘consensus out’, and three reached ‘no consensus’ and were discussed and included following the final consensus meeting. Two statements were combined for simplicity. The final consensus document includes 57 statements allocated into six successive stages. Conclusion. We have produced a consensus document for the treatment of idiopathic CTEV up to walking age. This will provide a benchmark for standard of care in the UK and will help to reduce geographical variability in treatment and outcomes. Appropriate dissemination and implementation will be key to its success. Cite this article: Bone Joint J 2022;104-B(6):758–764

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.

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). Methods. A list of outcome measurement tools (OMTs) was obtained from the literature through a systematic review. Further outcomes were collected from patients and families through a questionnaire and interview process. The combined list, as well as the appropriate follow-up timepoint, was rated for importance in a two-round Delphi process that included an international group of orthopaedic surgeons, physiotherapists, nurse practitioners, patients, and families. Outcomes that reached no consensus during the Delphi process were further discussed and scored for inclusion/exclusion in a final consensus meeting involving international stakeholder representatives of practitioners, families, and patient charities. Results. In total, 39 OMTs were included from the systematic review. Two additional OMTs were identified from the interviews and questionnaires, and four were added after round one Delphi. Overall, 22 OMTs reached ‘consensus in’ during the Delphi and two reached ‘consensus out’; 21 OMTs reached ‘no consensus’ and were included in the final consensus meeting. In all, 21 participants attended the consensus meeting, including a wide diversity of clubfoot practitioners, parent/patient representative, and an independent chair. A total of 21 outcomes were discussed and voted upon; six were voted ‘in’ and 15 were voted ‘out’. The final COS document includes nine OMTs and two existing outcome scores with a total of 31 outcome parameters to be collected after a minimum follow-up of five years. It incorporates static and dynamic clinical findings, patient-reported outcome measures, and a definition of CTEV relapse. Conclusion. We have defined a minimum set of outcomes to draw comparisons between centres and studies in the treatment of CTEV. With the use of these outcomes, we hope to allow more meaningful research and a better clinical management of CTEV. Cite this article: Bone Jt Open 2022;3(1):98–106

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.

The Ponseti and French taping methods have reduced the incidence of major surgery in congenital idiopathic clubfoot but incur a significant burden of care, including heel-cord tenotomy. We developed a non-operative regime to reduce treatment intensity without affecting outcome. We treated 402 primary idiopathic clubfeet in patients aged < three months who presented between September 1991 and August 2008. Their Harrold and Walker grades were 6.0% mild, 25.6% moderate and 68.4% severe. All underwent a dynamic outpatient taping regime over five weeks based on Ponseti manipulation, modified Jones strapping and home exercises. Feet with residual equinus (six feet, 1.5%) or relapse within six months (83 feet, 20.9%) underwent one to three additional tapings. Correction was maintained with below-knee splints, exercises and shoes. The clinical outcome at three years of age (385 feet, 95.8% follow-up) showed that taping alone corrected 357 feet (92.7%, ‘good’). Late relapses or failure of taping required limited posterior release in 20 feet (5.2%, ‘fair’) or posteromedial release in eight feet (2.1%, ‘poor’). The long-term (> 10 years) outcomes in 44 feet (23.8% follow-up) were assessed by the Laaveg–Ponseti method as excellent (23 feet, 52.3%), good (17 feet, 38.6%), fair (three feet, 6.8%) or poor (one foot, 2.3%). These compare favourably with published long-term results of the Ponseti or French methods. This dynamic taping regime is a simple non-operative method that delivers improved medium-term and promising long-term results.

Cite this article: Bone Joint J 2013;95-B:271–8.

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

There is controversy whether congenital foot abnormalities are true risk factors for pathological dysplasia of the hip. Previous United Kingdom screening guidelines considered congenital talipes equinovarus (CTEV) to be a risk factor for hip dysplasia, but present guidelines do not. We assessed the potential relationship between pathological dysplasia of the hip and fixed idiopathic CTEV. We present a single-centre 21-year prospective longitudinal observational study. All fixed idiopathic CTEV cases were classified (Harrold and Walker Types 1 to 3) and the hips clinically and sonographically assessed. Sonographic Graf Type III, IV and radiological irreducible hip dislocation were considered to be pathological hip dysplasia. Over 21 years there were 139 children with 199 cases of fixed idiopathic CTEV feet. Sonographically, there were 259 normal hips, 18 Graf Type II hips, 1 Graf Type III hip and 0 Graf Type IV hip. There were no cases of radiological or sonographic irreducible hip dislocation. Fixed idiopathic CTEV should not be considered as a significant risk factor for pathological hip dysplasia. This conclusion is in keeping with the current newborn and infant physical examination guidelines in which the only risk factors routinely screened are family history and breech presentation. Our findings suggest CTEV should not be considered a significant risk factor in pathological dysplasia of the hip. Cite this article: Bone Joint J 2014;96-B:1553–5

The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia. This study supports selective ultrasound screening of hips in infants with CTEV

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

In a prospective study over 11 years we assessed the relationship between neonatal deformities of the foot and the presence of ultrasonographic developmental dysplasia of the hip (DDH). Between 1 January 1996 and 31 December 2006, 614 infants with deformities of the foot were referred for clinical and ultrasonographic evaluation. There were 436 cases of postural talipes equinovarus deformity (TEV), 60 of fixed congenital talipes equinovarus (CTEV), 93 of congenital talipes calcaneovalgus (CTCV) and 25 of metatarsus adductus. The overall risk of ultrasonographic dysplasia or instability was 1:27 in postural TEV, 1:8.6 in CTEV, 1:5.2 in CTCV and 1:25 in metatarsus adductus. The risk of type-IV instability of the hip or irreducible dislocation was 1:436 (0.2%) in postural TEV, 1:15.4 (6.5%) in CTCV and 1:25 (4%) in metatarsus adductus. There were no cases of hip instability (type IV) or of irreducible dislocation in the CTEV group. Routine screening for DDH in cases of postural TEV and CTEV is no longer advocated. The former is poorly defined, leading to the over-diagnosis of a possibly spurious condition. Ultrasonographic imaging and surveillance of hips in infants with CTCV and possibly those with metatarsus adductus should continue

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

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

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

The aim of this study was to define objectively gait function in children with treated congenital talipes equinovarus (CTEV) and a good clinical result. The study also attempted an analysis of movement within the foot during gait. We compared 20 children with treated CTEV with 15 control subjects. Clinical assessment demonstrated good results from treatment. Three-dimensional gait analysis provided kinematic and kinetic data describing movement and moments at the joints of the lower limb during gait. A new method was used to study movement within the foot during gait. The data on gait showed significantly increased internal rotation of the foot during walking which was partially compensated for by external rotation at the hip. A mild foot drop and reduced plantar flexor power were also observed. Dorsiflexion at the midfoot was significantly increased, which probably compensated for reduced mobility at the hindfoot. Patients treated for CTEV with a good clinical result should be expected to have nearly normal gait and dynamic foot movement, but there may be residual intoeing, mild foot drop, loss of plantar flexor power with compensatory increased midfoot dorsiflexion and external hip rotation

Purpose of study. Results clinically & statistically of a 10 year prospective observational longitudinal study of the effects of sonographic screening for ‘risk’ factors in DDH. Methods & Results. From 1997 to 2006 the project analysed the results of a sonographic screening programme for clinical instability & ‘risk factors’ in Blackburn (modified Graf system). ‘Risk factors’ included: breech presentation, strong family history, foot deformities & oligohydramnios. Statistically 95% confidence intervals, relative risk, sensitivity, specificity PPV & NPV were calculated. The outcome measure was irreducible dislocation of the hip joint. There was a birth population of 37,510, of which 2693 were ‘at risk’ & 132 clinically unstable. Three subsections:. 1. Clinically unstable hips (birth). 2 irreducible dislocations. 2. ‘At risk’. 6 irreducible dislocations. 3. Secondary referral (GP screening). 11 irreducible dislocations. The overall irreducible dislocation rate was 0.51 per 1000 live births. ‘Risk factors’: mGraf Type III/IV/ Irreducible:. CTCV:. 1: 13.8. RR = 26.5. Family history:. 1:18.5. RR = 23.3. Breech:. 1:35. RR = 14.8. Oligohydramnios. 1:99.5. TEV (postural). 1:202. CTEV (fixed). 0.0. Narrow 95% CI for Breech, CTCV & CTEV. Wide 95% CI for Family history, oligohydramnios & TEV (postural). 95% CI (RR) for Oligohydramnios & TEV not significant. RR for clinical hip instability was 983.6. Percentage female. 18/19 irreducible hips. 94.74%. 64/92 Type IV hips. 69.56%. 26/30 Type III hips. 86.66%. 34.15% of clinically unstable hip joints had a ‘risk factor’. Conclusion. Only 13 from 2693 ‘at risk’, had Type IV or Irreducible hips. Only 7 were treatable by splintage. Clinically & statistically screening for at ‘risk hips’ alone has a poor return. Female gender & clinical instability appear more important

Aims

A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children’s Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening.

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.

Aims

The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children.