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

Untreated clubfoot results in serious disability, but mild to moderate residual deformities can still cause functional limitations and pain. Measuring the impact of clubfoot deformities on children's wellbeing is challenging. There is little literature discussing the variability in outcomes and implications of clubfoot based on where geographically the child resides. Although the use of patient reported outcome measures (PROMs) is steadily growing in pediatric orthopaedics, few studies on clubfoot have incorporated them. The most widely used PROM for pediatric foot and ankle pathology is the Oxford Foot and Ankle Questionnaire for Children (OXFAQ-C) that include a physical, school and play, emotional and shoe wear domains. The aim of this study is to evaluate the validity and regional differences in scores of the OXFAQ-C questionnaire to identify functional disability in children with clubfoot in India and Canada. This is a retrospective cohort study of children in Indian and Canadian clubfoot registries aged 5-16 years who completed >1 parent or child OXFAQ-C. The OXFAQ-C was administered once in 01/2020 to all patients in the Indian registry, and prospectively between 06/2019 and 03/2021 at initial visit, 3, 6, 12 months post-intervention, then annually for the Canadian patients. Demographic, clubfoot, and treatment data were compared to OXFAQ-C domain scores. Descriptive statistics and regression analysis were performed. Parent-child concordance was evaluated with Pearson's Coefficient of Correlation (PCC). The cohort had 361 patients (253 from India, 108 from Canada). Non-idiopathic clubfoot occurred in 15% of children in India and 5% in Canada, and bilateral in 53% in India and 50% in Canada. Tenotomy rate was 75% in India and 62% in Canada. Median age at presentation was 3 months in India and 1 month in Canada. Mean Pirani score at presentation and number of Ponseti casts were 4.9 and 6.1 in India and 5.3 and 5.7 in Canada, respectively. Parents reported lower scores in all domains the older the child was at presentation (p Canadians scored significantly lower for all domains (p < 0 .001), with the difference being larger for child-reported scores. The greatest difference was for physical domain. Canadian parents on average scored their child 6.21 points lower than Indian parents, and Canadian children scored a mean of 7.57 lower than Indian children. OXFAQ-C scores differed significantly between Indian and Canadian children despite similar demographic and clubfoot characteristics. Younger age at presentation and tenotomy may improve OXFAQ-C scores in childhood. Parent-child concordance was strong in this population. The OXFAQ-C is an adequate tool to assess functional outcomes of children with clubfeet. Cultural validation of patient reported outcome tools is critical

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

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

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

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

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

This study sought to determine if treatment of resistant clubfeet by the Ilizarov method influenced the pattern of recurrence. Forty-seven children were identified as having undergone treatment by the Ilizarov method. Inclusion criteria for treatment with the Ilizarov method were clubfeet belonging to diagnostic categories that had recognised tendencies for resistance to standard methods of clubfoot management or a previous history of soft tissue releases performed adequately but accompanied by rapid relapse. There were 60 feet with a mean follow-up of 133 months (46-224). Diagnoses included 34 idiopathic types, 7 arthrogryposis, 1 cerebral palsy, and 5 other. Summary statistics and survival analysis was used; failure was deemed as a recurrence of fixed deformity necessitating further correction. This definition parallels clinical practice where attainment of ‘normal’ feet in this group remains elusive, and mild to moderate relapses that remain passively correctable are kept under observation. Soft tissue releases were common primary or secondary procedures. The mean time to revision surgery, if a soft tissue release was undertaken as a primary procedure, was 36 months (SD 22), and 39 (SD 23) months if undertaken for the second time. This compares with 52 months (SD 32) if Ilizarov surgery was used. Using survival analysis, there is a 50% chance of a relapse sufficiently marked to need corrective surgery after 44 months following the first soft tissue release, 47 months if after the second soft tissue procedure and 120 months after the Ilizarov technique. We conclude that resistant club feet, defined as those belonging to diagnostic categories with known poor prognoses or those that succumb to an early relapse despite adequate soft tissue surgery, may have longer relapse-free intervals if treated by the Ilizarov method

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 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

Purpose. The rate of club foot recurrence following Ponseti treatment has been reported in the literature as between 14 and 58%. Recurrence is defined as any child who has been treated and is in need of recasting, surgery or bracing. True recurrence is defined as presentation 6 months after last treatment and incomplete treatment is defined as presentation within 6 months of last treatment. Currently no local data exists to determine the cause of recurrence in this unit. The aim of this study is to review all recurrences to improve the outcome of club foot management. Methods. A retrospective audit of all club foot recurrences was performed at an academic hospital. The review included the location of initial treatment, initial treatment method and abduction brace compliance as factors contributing to the recurrence rate. Results. Thirty seven (48%) patients attending the club foot clinic were recurrences – 68% were true recurrences and 32% were defined as incomplete treatments. The mean age at presentation of club foot recurrence was 25 months (Range 6–84 months). Seventy percent of recurrences were referred from outside healthcare facilities – all patients had serial manipulation and casting. The overall complete compliance for casting was 74%. Eighty percent of patients had a Tendo Achilles tenotomy at a mean age of 10.5 months (range 2–66 months) after initial plastering (mean 12.5 plasters). Post tenotomy, 65% had abduction bracing for a mean duration of 4.5 months and 35% had no bracing. No patient continued bracing until the recommended age of four years. Conclusion. Despite the challenges of compliance to casting the overwhelming identified problem is compliance with abduction bracing. The challenge is to improve bracing protocol and ensure compliance in this critical part in the treatment of club foot

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

Specific brace-fitting complications in idiopathic congenital talipes equinovarus (CTEV) have been rarely described in published series, and usually focus on non-compliance. Our primary aim was to compare the rate of persistent pressure sores in patients fitted with Markell boots and Mitchell boots. Our additional aims were to describe the frequency of other brace fitting complications and identify age trends in these complications. A retrospective analysis of medical files of 247 idiopathic CTEV patients born between 01/01/2010 - 01/01/2021 was performed. Data was collected using a REDCap database. Pressure sores of sufficient severity for clinician to recommend time out of brace occurred in 22.9% of Mitchell boot and 12.6% of Markell boot patients (X. 2. =6.9, p=0.009). The overall rate of bracing complications was 51.4%. 33.2% of parents admitted to bracing non-compliance and 31.2% of patients required re-casting during the bracing period for relapse. For patients with a minimum follow-up of age 6 years, 44.2% required tibialis anterior tendon transfer. Parents admitting to non-compliance were significantly more likely to have a child who required tibialis anterior tendon transfer (X. 2. =5.71, p=0.017). Overall rate of capsular release (posteromedial release or posterior release) was 2.0%. Neither medium nor longterm results of Ponseti treatment in the Australian and New Zealand clubfoot have been published. Globally, few publications describe specific bracing complications in clubfoot, despite this being a notable challenge for clinicians and families. Recurrent pressure sores is a persistent complication with the Mitchell boots for patients in our center. In our population of Australian clubfoot patients, tibialis anterior tendon transfer for relapse is common, consistent with the upper limit of tibialis anterior tendon transfer rates reported globally

Purpose of study. The primary treatment of congenital talipes equinus varus with the Ponsetti method remains the gold standard of treatment. Relapsed, neglected and/or teratogenic clubfeet pose a significant treatment challenge as the long term outcome of posteromedial release surgery is poor. Advances in circular fixation offer predictable deformity correction without the need for extensive soft tissue release. The Taylor Spatial Frame utilizes the correction principles of the “Ponsetti Method”, but little literature exists describing the correction of relapsed clubfeet with these fixators. This study assesses the outcome of relapsed clubfeet treated with the Taylor Spatial Frame Circular fixator. Methods. Ethics approval was obtained for a prospective descriptive study (N10-10-338). Patients with clubfeet who met inclusion criteria were treated with a Taylor Spatial Frame. The International Clubfoot Study Group Score was used to assess the feet preoperatively and six months postoperative. This scoring system scores the morphology, functionality and radiographic parameters of the clubfoot. Quality of life was assessed by means of the Child Health Questionnaire. Results. Ten feet (6 bilateral, 4 unilateral) were included in the study. Seven male and three female patients with average age of 6 years (range 3 – 13 years, sd ±4) qualified for the study. Feet were scored using the International Clubfoot Study Group Score. All feet scored poor preoperatively (average score 37±6). Postoperatively two feet scored excellent, seven good and one fair (Average score 9±4). This was statistically significant, p=0.00000. Two patients required additional surgical procedures for residual deformity. Five patients had superficial pin tract infection and one tibia fracture occurred. Conclusion. Treatment of relapsed clubfeet with the Taylor Spatial Frame gives a predictable correction of deformities without the need for extensive soft tissue and bony procedures. TSF assisted clubfoot correction constitute a useful salvage treatment modality. NO DISCLOSURES

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

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

Aim. The treatment of relapsed clubfeet presents a significant challenge. The Ilizarov method of gradual correction has been shown to provide satisfactory outcome. Since 2001 we have employed a newer differential soft tissue distraction using an Ilizarov frame in relapsed feet based on the Ponseti principles. The aim of our study was to analyse the outcome of this treatment. Material and Methods. All feet treated with soft tissue distraction only were studied. The feet were assessed using international clubfoot study group evaluation, pedobarography, and gait analysis, X-rays and ASK (activity scale for kids) questionnaire. Results. Out of 35 feet, 16 children with 27 feet attended for follow-up. The indications for surgery were failed multiple surgeries in 19 feet and failed Ponseti in 8 feet. The average age at operation was 5 years and the median follow-up was 5 years. The average duration of the frame was 5 months. Using international club foot scoring evaluation 25 feet scored ‘good’ and 2 scored ‘fair’. The pedobarography and gait analysis showed improvement when compared to the pre-operative assessment. The ASK functional questionnaire showed all 16 children were able to be independent most of the time. Grade 1 infection was noted in all cases. There were no physeal disruptions, growth arrest or joint subluxations. Five feet needed tibialis anterior transfer, 2 underwent supramalleolar osteotomy, 1 needed percutaneous tendo achilles lengthening and 1 needed scar revision as further surgical procedures. The deformity has recurred in 1 foot and is waiting for bony correction. Conclusion. We conclude that the Ponseti principles of soft tissue differential distraction with Ilizarov frame give reasonable results

We present our experience of using tension band plates to achieve guided growth in children for correction of calcaneus deformity of the ankle. 11 consecutive patients (13 ankles) fulfilled the inclusion criteria over a 4-year period. All underwent surgical treatment using a flexible two hole plate and screws on the posterior aspect of distal tibial physis. Measurements were done on preoperative, intraoperative screening and 1-year post operative plain AP and lateral ankle radiographs. The anterior distal tibia angle (ADTA), lateral distal tibial angle (LDTA) and screw divergence angle (angle subtended by lines passing through the long axis of the screws) were used to assess the deformity correction. A 2 tailed student t-test was carried out on the initial and 1-year post-op measurements to determine statistical significance with a p value <0.05 considered as significant. There were 10 residual clubfoot deformities, 2 post-traumatic deformities and 1 spinal tumor causing deformity. The average age of the patients was 10 years 5 months (range 4 to 13 years). There were 9 males and 2 females. The ADTA showed a statistically significant change with a p value of 0.0008 with a mean correction of 8.6 degrees (range of 2.3 to 15.6 degrees). The SDA demonstrated a mean correction of 15.4 degrees (range 0.3 to 41.8 degrees), p=0.002. The LDTA did not change significantly (p= 0.08), thus confirming no coincidental coronal plane deformity had occurred. 5 ankles required revision of fixation due to metalwork reaching its maximum limit of divergence at an average of 1 year. 2 ankles had screw pulled out due to osteolysis around the screw. There were no cases of infection. We report satisfactory short-term results of correction of calcaneus deformity using a flexible tension band plate and screws system

Congenital talipes equinovarus occurs in 1.2 per 1000 live births in Europe and is twice as common in boys. Over the last decade, non-surgical management has re-established itself as the first line treatment; after long-term follow-up of surgically treated patients, revealed high rates of over correction, stiffness and pain. The commonly practiced non-surgical approaches are the Ponseti technique of serial manipulation and casting, and French taping. Ram's technique of taping is a truly conservative approach with a higher success rate to address this problem. Unlike French taping, it involves taping alternate days during the first week followed by twice in the second week, then once the following week, which is left in situ for a further two weeks. After the initial five weeks of taping, patients are provided with talipes splint for all time use, up till a year. This is followed by talipes shoes for walking and splint for nighttime use for another year. At the end of two years patients can wear normal shoes. The study includes 225 patients with 385 clubfeet, who were treated with Ram's taping technique from September 1991 to August 2008. Inclusion criteria were age up to three months and previously untreated clubfeet. Average follow up was of 5.6 years. Outcome ratings at a minimum of two years were performed. Initial correction rate at the end of five weeks was 99%. A relapse of 21% was noted, two-third of which was salvaged via further taping and exercise, while remaining one third needed some form of surgical intervention. The comparative outcome for Ram's taping is better to Ponseti or French taping with good outcome in 93%, in comparison to 72% and 67% respectively. To conclude Ram's taping is a fast, more effective, less cumbersome and fully conservative approach of correcting the clubfoot deformity

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