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

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

The October 2023 Children’s orthopaedics Roundup. 360. looks at: Outcomes of open reduction in children with developmental hip dislocation: a multicentre experience over a decade; A torn discoid lateral meniscus impacts lower-limb alignment regardless of age; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Consensus guidelines on the management of musculoskeletal infection affecting children in the UK; Diagnosis of developmental dysplasia of the hip by ultrasound imaging using deep learning; Outcomes at a mean of 13 years after proximal humeral fracture during adolescence; Clubfeet treated according to Ponseti at four years; Controlled ankle movement boot provides improved outcomes with lower complications than short leg walking cast

Clubfoot is a complex three-dimensional deformity that is difficult to assess by clinical examination and conventional radiography. Pedobarography has been established as a useful technique for measuring pressure profiles of the foot, however its utility in the clubfoot population has not been established. The purpose of the present study is to describe the pedobarographic profiles of children with clubfeet and to establish the significant variables when compared with aged-matched controls. Pedobarographic profiles were obtained using the Tekscan HR Mat Pressure Measurement System and data was analyzed using a custom built LabView program. Clubfoot patients aged 18 months to four years (n = 190) were tested and compared to aged matched controls (n = 82). Each foot was divided into five segments (heel, medial and lateral midfoot, medial and lateral forefoot) and each segment was analyzed for timing of initiation of force, timing of termination of force, force distribution, and impulse. The mean and standard deviation were calculated for each variable. Clubfoot pedobarographic means were compared to the aged matched controls and significant variables were identified using Student’s paired t-test (p < .05). Nine of twenty-five variables were found to be significantly different in the clubfoot population. The heel showed a reduced force and impulse. The lateral mid-foot showed an increased force and impulse with an earlier initiation and later termination of forces. The medial forefoot showed a decrease force and impulse with a later initiation of force. Pedobarography has been found to be a useful tool in the evaluation of foot pathology, but its utility in the clubfoot population has yet to be established. In this study, we describe the pedobarographic profiles of children with clubfeet and have noted significant differences when compared to age-matched controls

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

Purpose: A retrospective study to determine the causes of failure of the Ponseti technique and treatment for those failed feet. Materials and Methods: Eighty-nine patients with 136 clubfeet were treated by the Ponseti technique and evaluated on the Dimeglio/Bensahel and Catterall/ Pirani scoring systems. Six patients with 9 clubfeet were not corrected and therefore did not enter the dynamic ankle-foot orthosis stage. These 6 patients started treatment after the age of 8 months, except for one patient who was 9 weeks old at the start of treatment. Of these 9 feet, 8 underwent open Achilles tendon releases combined with posterior releases. Three of these feet had percutaneous Achilles tenotomies prior to their failure and 1 foot underwent complete soft tissue clubfoot releases. Eighty-three patients (127 clubfeet) completed the Ponseti technique. Eighteen patients with 28 club-feet were lost to 2-year follow-up (Group A), and 65 patients with 99 clubfeet (78.3%) had a greater than 2-year follow-up (Group B). Results: Nine out of a total of 136 clubfeet failed the Ponseti technique. At 2-year follow-up, one-third (29/99) required additional procedure(s). At application of the dynamic ankle-foot orthosis in Group B, patients’ rating scores were similar. However, after 2-year follow-up, the noncompliant group’s scores (no orthosis) changed significantly for the worse when compared to the compliant group’s scores who used the orthosis for 2 years. After 2-year follow-up, Group B patients in the orthosis-compliant group had better scores than the 2-year failures (29 feet) who underwent further surgery and the initial 9 feet who failed the Pon-seti technique

Purpose of study: The aim of this study was twofold. Firstly, to compare a subjective clinical with an objective biomechanical assessment of operated clubfeet, using the optical Dynamic Pedobarograph foot pressure system. Secondly, to develop the latter into a classification system for future prospective studies and to complement clinical evaluation of patients, especially those with relapse. Methods and results: Sixteen patients (21 feet) were randomly selected from a pool of patients that had undergone clubfoot surgery. The operations were carried out by a single surgeon and consisted of a lateral-posteromedial peritalar release utilising the Cincinnati incision. Post-operatively, all feet were independently classified using a modified functional outcome scoring system. After completion of treatment, patients were referred to the Foot Pressure Analysis Clinic in Dundee where a novel method has been developed for the evaluation of clubfeet, using a static and dynamic foot pressure analysis system which provide both a graphical and analytical model for comparison. A three point grading scale was developed. The correlation between clinical and biomechanical outcomes in the 21 feet was calculated using Kendall’s tau rank test for non-parametric data. The t value was 0.3524, which was significant (p < 0.05). Conclusion: There is a significant correlation between the above mentioned subjective and objective outcome measurements. Biomechanical assessment can complement, support or change the line of management after clubfoot surgery. This technique has not only proven to be objective but also clinically valuable and cost effective. A prospective study to refine this biomechanical classification into a reliable predictor of relapse in surgically corrected clubfeet is currently being considered

The purpose of this study was to evaluate the longterm results of 736 cases of operatively treated clubfeet, and to examine if there is any difference in the results between our patients and referred patients. A follow-up examination was carried out in 736 cases of clubfeet operated on between 1966 and 1990. The average follow-up period was 14.7 years. Treatment was based on three pillars: well-organized care, conservative treatment and early operative treatment. In all of the reviewed cases, posteromedial soft tissue release was performed. Surgical intervention was indicated in cases of residual deformity after conservative treatment, cases of recurrent deformity, and cases of untreated clubfeet. Clinical evaluation contained the examination of residual deformities and the passive and active motions of the foot. In the radiological assessment, the anteroposterior talocalcaneal angle, the lateral talocalcaneal angle and the talometatarsal angle was measured. In the clinical evaluations equinus deformity was found in 3.35%, varus in 7.23%, valgus in 8.55%, adducted forefoot in 30.8%, inflexion of the forefoot in 7.14%, and overcorrection to the vertical talus in 3.35%. Range of motion was normal in only 36% of the cases. Average anteroposterior talocalcaneal angle was 13.05 preoperatively and 22.13 postoperatively. Average lateral talocalcaneal angle was 10.78 preoperatively and 27.66 postoperatively. Average talometatarsal angle changed from 26 to 5.5 after the operation. The overall success rate of the operated cases was 65%. After long-term follow-up, 65% of the cases were classified as successful. When comparing our patients with referred patients, there were considerable differences found in the rate of reoperation, age at the time of the first operation, and also in the results. These differences point out the importance of the early beginning of operative treatment, with regular follow-up and care

The purpose of this study was to evaluate the longterm results of 736 cases of operatively treated clubfeet, and to examine if there is any difference in the results between our patients and referred patients. A follow-up examination was carried out in 736 cases of clubfeet operated on between 1966 and 1990. The average follow-up period was 14.7 years. Treatment was based on three pillars: well-organized care, conservative treatment and early operative treatment. In all of the reviewed cases, posteromedial soft tissue release was performed. Surgical intervention was indicated in cases of residual deformity after conservative treatment, cases of recurrent deformity, and cases of untreated clubfeet. Clinical evaluation contained the examination of residual deformities and the passive and active motions of the foot. In the radiological assessment, the anteroposterior talocalcaneal angle, the lateral talocalcaneal angle and the talometatarsal angle was measured. In the clinical evaluations equinus deformity was found in 3.35%, varus in 7.23%, valgus in 8.55%, adducted forefoot in 30.8%, inflexion of the forefoot in 7.14%, and overcorrection to the vertical talus in 3.35%. Range of motion was normal in only 36% of the cases. Average anteroposterior talocalcaneal angle was 13.05 preoperatively and 22.13 postoperatively. Average lateral talocalcaneal angle was 10.78 preoperatively and 27.66 postoperatively. Average talometatarsal angle changed from 26 to 5.5 after the operation. The overall success rate of the operated cases was 65%. After long-term follow-up, 65% of the cases were classified as successful. When comparing our patients with referred patients, there were considerable differences found in the rate of reoperation, age at the time of the first operation, and also in the results. These differences point out the importance of the early beginning of operative treatment, with regular follow-up and care

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

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

Since 1987, we have treated 37 clubfeet with a continuous passive movement (CPM) machine rather than by surgical release. After 6 months of physiotherapy and splintage, all feet still exhibited equinus and varus deformities. CPM treatment improved equinus and varus in all cases and in 33 feet there was no need for surgery. However, there was progressive impairment: at 15-year follow-up, the results in six feet remained good, with some dorsiflexion possible, but recurrence of the equinus deformity in the other feet had necessitated surgical release, performed when patients were 2 to 10 years old. CPM treatment can eliminate the need for surgery in mild clubfeet, and delay surgery in more severe cases. Performing a surgical release after 3 years will perhaps reduce the rate of recurrence of the deformity

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

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

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

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

The aim of this study was to correlate two outcome measurements of clubfoot surgery. A modified, partially subjective, clinical scoring system was compared with an objective biomechanical assessment, using the optical Dynamic Pedobarograph foot pressure system. The outcomes of the latter method were developed into a classification system for future prospective studies and to complement clinical evaluation of patients, especially those with relapse. Many different functional outcome measures have been designed. Differing number of points are allocated to various subjective and objective items of relevance. The weighting given to each item in the overall score depends entirely on the importance the surgeon believes that particular item has on what he believes constitutes a good corrected clubfoot. This makes the scoring systems arbitrary and therefore results of clubfoot surgery between various centres impossible to compare. Sixteen patients [21 feet] were randomly selected from a poll of patients that had undergone clubfoot surgery. The operations were carried out by a single surgeon and consisted of a lateral-posteromedial peritalar release utilising the Cincinnati incision. Post-operatively, all feet were independently classified using a modified scoring system, based on the ones designed by Laaveg and Ponseti and the one by McKay, which scores both objective and subjective findings. This system has a good interobserver reproducibility. After finalisation of treatment, patients were referred to the Foot Pressure Analysis Clinic in Dundee where a novel method has been developed for the evaluation of clubfeet, using a static and dynamic foot pressure analysis system which provides both a graphical and analytical model for comparison. A pedobarographic classification system was developed. An excellent result entails that the patient does not require further treatment. A good result has been achieved if a near normal posture and pressure distribution is recorded. However, this means that there are still functional problems, which, as the foot matures, may lead to future relapse. These feet may therefore require long-term treatment with an orthotic support to let the foot develop its normal shape. A fair result requires major orthotic support of shoe adaptation, or further surgical releases. The correlation between clinical and biomechanical outcomes in the 21 feet was calculated using Kendall’s tau rank test for non-parametric data. The r value was 0.3524, which was significant [p< 0.05]. There is a significant correlation between the above mentioned outcome measurements. Biomechanical assessment cannot replace clinical evaluation, but can complement it and perhaps give a more subtle and earlier prediction of the need for further additional treatment. This technique has not only proven to be objective but also clinically valuable and cost effective. A prospective study to refine this biomechanical classification system into a reliable predictor of relapse in surgically corrected clubfeet is currently being considered

Background: In developing countries, many patients are seen with neglected, residual or recurrent CTEV. Treatment of resistant & neglected CTEV has been a subject of much controversy as the pathoanatomy becomes complex & the true cause of disability becomes difficult to ascertain at times. We treated such patients by controlled, differential, distraction using Joshi’s external stabilisation system (JESS). Aim of study: To explore the role & long term results (minimum follow up 3 years) of controlled, differential, distraction using JESS in relapsed & neglected clubfeet. Methods: 82 patients with 24 bilateral cases (106 feet) treated by JESS at the department of Orthopaedics, KGMU, India from 1992 onwards; followed up for a minimum of 3 years post surgery (average follow up 6.5 years). Patients with non-idiopathic club foot were not included in this study. Outcome evaluation was done by clinical, podographic(footprint), radiological & functional outcomes using Hospital for Joint diseases Orthopaedic Institute functional rating system for clubfoot surgery. Results: Excellent results were obtained in 63%, good in 30% & poor in 7% of the cases. 21% had a partial relapse with only 5% requiring further surgery for deformity correction. 11% of cases needed further surgery in the form of flexor tenotomies, subtalar & mid-foot fusion for persistent pain. Conclusion: Controlled, differential, fractional distraction with JESS is a safe & effective procedure for neglected, resistant & relapsed CTEV. It is effective even in patients after skeletal maturity in correcting the deformity. The procedure is less invasive and the results are good irrespective of the severity of the deformity or age of the patient

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

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