Aims. To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity. Methods. Five databases (CENTRAL, CINAHL, PubMed, Embase, Web of Science) were systematically screened for studies investigating split tibialis anterior or split tibialis posterior tendon transfer for spastic equinovarus foot deformity, with gait-related outcomes (published pre-September 2022). Study quality and evidence were assessed using the Methodological Index for Non-Randomized Studies, the Risk of Bias In Non-Randomized Studies of Interventions, and the Grading of Recommendations Assessment, Development and Evaluation. Results. Overall, 17 studies (566 feet) were included: 13 studies used clinical grading criteria to report a postoperative ‘success’ of 87% (75% to 100%), 14 reported on orthotic use with 88% reduced postoperative use, and one study reported on ankle kinematics improvements. Ten studies reported post-surgical complications at a rate of 11/390 feet (2.8%), but 84 feet (14.8%) had recurrent varus (68 feet, 12%) or occurrence of valgus (16 feet, 2.8%). Only one study included a patient-reported outcome measure (pain). Conclusion. Split tendon transfers are an effective treatment for children and youth with CP and spastic equinovarus foot deformities. Clinical data presented can be used for future study designs; a more standardized functional and patient-focused approach to evaluating outcomes of surgical intervention of gait may be warranted. Cite this article: Bone Jt Open 2023;4(5):283–298

Aims. To assess if congenital foot deformity is a risk factor for developmental dysplasia of the hip (DDH). Methods. Between 1996 and 2012, 60,844 children were born in Sør-Trøndelag county in Norway. In this cohort study, children with risk factors for DDH were examined using ultrasound. The risk factors evaluated were clinical hip instability, breech delivery, a family history of DDH, a foot deformity, and some syndromes. As the aim of the study was to examine the risk for DDH and foot deformity in the general population, children with syndromes were excluded. The information has been prospectively registered and retrospectively analyzed. Results. Overall, 494 children (0.8%) had DDH, and 1,132 (1.9%) a foot deformity. Of the children with a foot deformity, 49 (4.3%) also demonstrated DDH. There was a statistically significant increased association between DDH and foot deformity (p < 0.001). The risk of DDH was highest for talipes calcaneovalgus (6.1%) and club foot (3.5%), whereas metatarsus adductus (1.5%) had a marginal increased risk of DDH. Conclusion. Compared with the general population, children with a congenital foot deformity had a significantly increased risk for DDH and therefore we regard foot deformity as a true risk factor for DDH. Cite this article: Bone Joint J 2020;102-B(11):1582–1586

Introduction. The arch of the foot has been described as a truss where the plantar fascia (PF) acts as the tensile element. Its role in maintaining the arch has likely been underestimated because it only rarely torn in patients with progressive collapsing foot deformity (PCFD). We hypothesized that elongation of the plantar fascia would be a necessary and sufficient precursor of arch collapse. Method. We used a validated finite element model of the foot reconstructed from CT scan of a female cadaver. Isolated and combined simulated ligament transection models were created for each combination of the ligaments. A collapsed foot model was created by simulated transection of all the arch supporting ligaments and unloading of the posterior tibial tendon. Foot alignment angles, changes in force and displacement within each of the ligaments were compared between the intact, isolated ligament transection, and complete collapse conditions. Result. Isolated release of the PF did not cause deformity, but lead to increased force in the long (142%) and short plantar (156%), deltoid (45%), and spring ligaments (60%). The PF was the structure most able to prevent arch collapse and played a secondary role in preventing hindfoot valgus and forefoot abduction deformities. Arch collapse was associated with substantial attenuation of the spring (strain= 41%) and interosseous talocalcaneal ligaments (strain= 27%), but only a small amount in the plantar fascia (strain= 10%). Conclusion. Isolated PF release did not cause arch collapse, but arch collapse could not occur without at least 10% elongation of the PF. Simulated transection of the PF led to substantial increase in the force in the other arch supporting ligaments, putting the foot at risk of arch collapse over time. Chronic degeneration of the PF leading to plantar fasciitis may be an early sign of impending PCFD

Purpose: Severe trauma in the mid-foot induces various foot deformities, causing pain. The mechanism and treatment of foot deformities following mid-foot trauma were evaluated. Materials: We evaluated feet showing dislocation and/or fracture of 2 or more joints or 2 or more tarsal bones encountered at our department between 1983 and 1996. The subjects were 24 males (26 feet) and 8 females (8 feet) aged 21–58 years (mean, 37 years). The injury that caused foot deformities was navicular bone fracture in 1 case, Chopart dislocation in 3, Lisfranc dislocation in 23, and fracture dislocation of the cuneiform in 5, The follow-up period was 2 years and 4 months _ 8 years (mean, 4 years and 9 months). Deformities occurred in these cases and associated factors were evaluated. Results: Flat foot deformity occurred in the 1 case of navicular bone dislocation and 2 of fracture dislocation of the cuneiform. Cavovarus deformity occurred in the 6 cases of Lisfranc fracture dislocation. Other deformities were observed in 3 feet. All patients complained of pain and fatigability during walking and were treated by corrective osteotomy and arthrodesis. Though the pain reduced, discomfort in the foot persisted, making heavy labor impossible in 3 cases. Discussion: In the mid-foot, there are many small tarsal bones, to which many tendons and ligaments are attached, forming the foot arch. Even though injury of one joint or one ligament (tendon), foot deformity can be induced. It is also possible that intraarticular injury was already severe at the time of injury, inducing secondary deformity. In trauma of the mid-foot involving multiple joints, the injured area should be adequately evaluated by preoperative stress X-P or MRI

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

Background. Weightbearing computed tomography scans allow for better understanding of foot alignment in patients with Progressive Collapsing Foot Deformity. However, soft tissue integrity cannot be assessed via WBCT. As performing both WBCT and magnetic resonance imaging is not cost effective, we aimed to assess whether there is an association between specific WBCT and MRI findings. Methods. A cohort of 24 patients of various stages of PCFD (mean age 51±18 years) underwent WBCT scans and MRI. In addition to signs of sinus tarsi impingement, four three-dimensional measurements (talo-calcaneal overlap, talo-navicular coverage, Meary's angle axial/lateral) were obtained using a post processing software (DISIOR 2.1, Finland) on the WBCT datasets. Sinus tarsi obliteration, spring ligament complex and tibiospring ligament integrity, as well as tibialis posterior tendon degeneration were evaluated with MRI. Statistical analysis was performed for significant (P<0.05) correlation between findings. Results. None of the assessed 3D measurements correlated with spring ligament complex or tibiospring ligament tears. Age, body mass index, and TCO were associated with tibialis posterior tendon tears. 75% of patients with sinus tarsi impingement on WBCT also showed signs of sinus tarsi obliteration on MRI. Of the assessed parameters, only age and BMI were associated with sinus tarsi obliteration diagnosed on MRI, while the assessed WBCT based 3D measurements were, with the exception of MA axial, associated with sinus tarsi impingement. Conclusion. While WBCT reflects foot alignment and indicates signs of osseous impingement in PCFD patients, the association between WBCT based 3D measurements and ligament or tendon tears in MRI is limited. Partial or complete tears of the tibialis posterior tendon were only detectable in comparably older and overweight PCFD patients with an increased TCO. WBCT does not replace MRI in diagnostic value. Both imaging options add important information and may impact decision-making in the treatment of PCFD patients

Aims. Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate a novel screening programme that included both the primary risk factors of breech presentation and family history, and the secondary risk factors of oligohydramnios and foot deformities. Methods. A five-year prospective registry study investigating every live birth in the study’s catchment area (n = 27,731), all of whom underwent screening for risk factors and examination at the newborn and six- to eight-week neonatal examination and review. DDH was diagnosed using ultrasonography and the Graf classification system, defined as grade IIb or above or rapidly regressing IIa disease (≥4. o. at four weeks follow-up). Multivariate odds ratios were calculated to establish significant association, and risk differences were calculated to provide quantifiable risk increase with DDH, positive predictive value was used as a measure of predictive efficacy. The cost-effectiveness of using these risk factors to predict DDH was evaluated using NHS tariffs (January 2021). Results. The prevalence of DDH that required treatment within our population was 5/1,000 live births. The rate of missed presentation of DDH was 0.43/1000 live births. Breech position, family history, oligohydramnios, and foot deformities demonstrated significant association with DDH (p < 0.0001). The presence of breech presentation increased the risk of DDH by 1.69% (95% confidence interval (CI) 0.93% to 2.45%), family history by 3.57% (95% CI 2.06% to 5.09%), foot deformities by 8.95% (95% CI 4.81% to 13.1%), and oligohydramnios nby 11.6% (95 % CI 3.0% to 19.0%). Primary risk factors family history and breech presentation demonstrated an estimated cost-per-case detection of £6,276 and £11,409, respectively. Oligohydramnios and foot deformities demonstrated a cost-per-case detected less than the cost of primary risk factors of £2,260 and £2,670, respectively. Conclusion. The inclusion of secondary risk factors within a national screening programme was clinically successful as they were more cost and resource-efficient predictors of DDH than primary risk factors, suggesting they should be considered in the national guidance. Cite this article: Bone Jt Open 2023;4(4):234–240

Progressive collapsing foot deformity (PCFD) is a complex foot deformity with varying degrees of hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. In its management, muscle and tendon balancing are important to address the deformity. Peroneus brevis is the primary evertor of the foot, and the strongest antagonist to the tibialis posterior. Moreover, peroneus longus is an important stabilizer of the medial column. To our knowledge, the role of peroneus brevis to peroneus longus tendon transfer in cases of PCFD has not been reported. This study evaluates patient reported outcomes including pain scores and any associated surgical complications for patients with PCFD undergoing isolated peroneus brevis to longus tendon transfer and gastrocnemius recession. Patients with symptomatic PCFD who had failed non-operative treatment, and underwent isolated soft tissue correction with peroneus brevis to longus tendon transfer and gastrocnemius recession were included. Procedures were performed by a single surgeon at a large University affiliated teaching hospital between January 1 2016 to March 31 2021. Patients younger than 18 years old, or undergoing surgical correction for PCFD which included osseous correction were excluded. Patient demographics, medical comorbidities, procedures performed, and pre and post-operative patient related outcomes were collected via medical chart review and using the appropriate questionnaires. Outcomes assessed included Visual Analogue Scale (VAS) for foot and ankle pain as well as sinus tarsi pain (0-10), patient reported outcomes on EQ-5D, and documented complications. Statistical analysis was utilized to report change in VAS and EQ-5D outcomes using a paired t-test. Statistical significance was noted with p<0.05. We analysed 43 feet in 39 adults who fulfilled the inclusion criteria. Mean age was 55.4 ± 14.5 years old. The patient reported outcome mean results and statistical analysis are shown in Table one below. Mean pre and post-operative foot and ankle VAS pain was 6.73, and 3.13 respectively with a mean difference of 3.6 (p<0.001, 95% CI 2.6, 4.6). Mean pre and post-operative sinus tarsi VAS pain was 6.03 and 3.88, respectively with a mean difference of 2.1 (p<0.001, 95% CI 0.9, 3.4). Mean pre and post-operative EQ-5D Pain scores were 2.19 and 1.83 respectively with a mean difference of 0.4 (p=0.008, 95% CI 0.1, 0.6). Mean follow up time was 18.8 ± 18.4 months. Peroneus brevis to longus tendon transfer and gastrocnemius recession in the management of symptomatic progressive collapsing foot deformity significantly improved sinus tarsi and overall foot and ankle pain. Most EQ-5D scores improved, but did not reach statistically significant values with the exception of the pain score. This may have been limited by our cohort size. To our knowledge, this is the first report in the literature describing clinical results in the form of patient reported outcomes following treatment with this combination of isolated soft tissue procedures for the treatment of PCFD. For any figures or tables, please contact the authors directly

At our institution surgical correction of symptomatic flat foot deformities in children has been guided by a paradigm in which radiographs and pedobarography are used in the assessment of outcome following treatment. Retrospective review of children with symptomatic flat feet who had undergone surgical correction was performed to assess the outcome and establish the relationship between the static alignment and the dynamic loading of the foot. A total of 17 children (21 feet) were assessed before and after correction of soft-tissue contractures and lateral column lengthening, using standardised radiological and pedobarographic techniques for which normative data were available. We found significantly improved static segmental alignment of the foot, significantly improved mediolateral dimension foot loading, and worsened fore-aft foot loading, following surgical treatment. Only four significant associations were found between radiological measures of static segmental alignment and dynamic loading of the foot. Weakness of the plantar flexors of the ankle was a common post-operative finding. Surgeons should be judicious in the magnitude of lengthening of the plantar flexors that is undertaken and use techniques that minimise subsequent weakening of this muscle group. Cite this article: Bone Joint J 2013;95-B:706–13

The equinovarus hind foot deformity is one of the most common deformities in children with spastic paralysis and is usually secondary to cerebral palsy. Split posterior tibialis tendon transfer is performed to balance the flexible spastic varus foot and is preferable to posterior tibialis lengthening, as the muscle does not loose its power and therefore the possibility of a valgus or calcaneovalgus deformity is diminished. The cohort of the study consisted of 50 children with cerebral palsy who underwent split posterior tibial lengthening to manage spastic equinovarus hind foot deformity. Our inclusion criteria were: ambulatory patients with cerebral palsy, age less than 6 years at the time of the operation, varus deformity of the hind foot during gait, flexible varus hind foot deformity, and the follow-up at least 4 years. We retrospectively evaluated 33 ambulant patients with flexible spastic varus hind foot deformity. Twenty-eight patients presented unilateral and 5 bilateral involvement. The mean age at the time of the operation was 10,8 years (6–17) and the mean follow-up was 10 years (4–14). Eighteen feet presented also equinus hind foot deformity, requiring concomitant Achilles cord lengthening. Clinical evaluation was based on the inspection of the patients while standing and walking, the range of motion of the foot and ankle, callus formation and the foot appearance using the clinical criteria of Kling et al. Anteroposterior and lateral weight-bearing radiographs of the talo-first metatarsal angle were measured. The position of the hind foot was evaluated according to the criteria of Chang et al for the surgical outcome. 20 feet were graded excellent, 14 were graded good and 4 were graded poor. Feet with recurrent equinovarus deformity or overcorrection into valgus or calcaneovalgus deformity were considered as poor results. There were 23 feet presenting concomitant cavus foot component that underwent supplementary operations performed at the same time with the index operation. None of the feet presented mild or severe valgus postoperatively, while 4 feet presented severe varus deformity and underwent calcaneocuboid fusion sixteen and eighteen months after the index operation. On the anteroposterior and lateral weight-bearing radiographs the feet with severe varus had a negative talo-first metatarsal angle (mean −26,8 ± 18,4), those with mild varus had a mean of −14,5 ± 12,2. In feet with the hind foot in neutral position the mean value was 5.0 ± 7.4. The results of the feet in patients with hemiplegic pattern were better and significantly different than the diplegic and quadriplegic ones (p = 0.005). The results in our cases were in general satisfactory as 34 out of 38 feet were graded excellent and good. The feet with poor results presented a residual varus deformity due to intraoperative technical errors

The exceptionally high prevalence of diastrophic dysplasia in Finland has enabled us to analyse the foot deformities of 102 patients at their first orthopaedic evaluation and classify 204 feet into five categories. The most common finding (43%) was a foot with tarsal valgus deformity and metatarsus adductus; 37% showed either equinovarus adductus (29%) or equinus (8%) deformities. At the first examination 13% showed metatarsus adductus deformity alone, and 7% were clinically normal. The expression 'club foot', generally used for the foot deformity in diastrophic dysplasia is a misnomer. There is a wide spectrum of deformities, some of them specific for the condition

Introduction. Congenital deficiency of the fibula frequently presents as spectrum of musculoskeletal anomalies involving the ipsilateral hip, femur, knee, tibia/fibula, ankle and foot. Until recently the treatment of choice for sever type-II fibular hemimelia has been Syme’s or Boyd’s amputation. The present technique of limb lengthening with distraction osteogenesis have proved to be a valid alternative. The study shows that simultaneous treatment of tibial and foot deformities allows the patient to obtain a plantigrade foot and to avoid the prosthetic choice of treatment. Materials and methods. 12 patients with 15 involved extremities underwent tibial lengthening and correction of the foot deformities for congenital tipe II fibular hemimelia with Ilizarov apparatus. There were 10 boys and 2 girls, range 7 years 3 month to 16 years 2 month (mean 10 years 7 month). The mean follow up time was 28 months ( range 15–63 month). Most of the patients had hypoplasia of the lateral femoral condyle and femoral shortening and simultaneous lengthening of femur in 9 cases was performed. Valgus-procurvatum deformity of tibia was present in all cases, absent lateral rays were present in 8 feet, foot coalition in 5 feet. Results. Lengthening of the tibia was performed at one level in 4 cases In the other 11 it was performed simultaneously with a proximal osteotomy of tibia to correct thevalgus and with a supramalleolar osteotomy to obtain axial realignment of ankle. Correction of the foot deformities was performed by closed method in 5 cases with overcorrecton in varus-adduction and plaster cast. Subtalar osteotomy in the presence of coalition was performed in 5 cases, osteotomy of calcaneus for equinus in3, and in 2 cases osteotomy through rigid subtalar joint. Osteotomy of midfoot for abducted and equines forefoot was performed in 3 cases. In two difficult rigid cases ankle arthrodesis was needed to stabilise the foot. Prophylactic anlage excision with soft tissue release and Achilles-tendon lengthening in 13 cases. Good results were achieved in 12 cases. 2 were successful and one poor because the patient refused continuing treatment with external fixator. There were 5 major and 16 minor complications. Complications involving delayed consolidation, bending or deformation of regenerated bone, early consolidation were observed in 4 cases. Complications involving soft tissue were observed in 9 cases, There were no permanent neurological and vascular injures. Conclusions. The Ilizarov technique provides a means of achieving simultaneous lengthening of the femur and tibia, angular and rotational deformities correction in children with congenital type II fibular hemimelia. This method should be combined with simultaneous ankle and foot reconstruction for correction of eqininovalgus deformity associated instability and subluxation of ankle. This method should be combined with simultaneous ankle and foot reconstruction for correction of eqininovalgus deformity associated instability and subluxation of ankle. Various types of osteotomy of the hind and mid food give the possibility to achieve the stable result of correction

In a consecutive series of 124 children with spina bifida we found that 220 (89%) of the 248 feet were deformed: 70 had a calcaneus deformity; 126 were in equinus; 16 were in valgus; 3 were in varus; and 5 had convex pes valgus. Operations were performed on 171 (78%) of the deformed feet. Spasticity of the muscles controlling the foot was detected in 36 (51%) of the 70 calcaneus feet and in 22 (17%) of the 126 equinus feet. The deformities were symmetrical in 94 children. There is a high incidence of foot deformity in patients with spina bifida who have no voluntary activity in the motors of the feet

Introduction Twenty-one feet in fifteen patients underwent osteotomies of the calcaneus and one or more metatarsals for symptomatic cavo-varus foot deformity. Methods Seven (nine feet) were male, and eight (12 feet) were female. The etiology included hereditary motor sensory neuropathy (HMSN) (15 feet), post-polio syndrome (two feet) sacral cord lipomeningicoccle (two feet), parietal lobe porencephalic cyst (one foot) and idiopathic peripheral neuropaty (one foot). Presenting complaints were metatarsalgia (15 feet), ankle instability (five feet and ulceration beneath the second metatarsal head (one foot). Eleven feet were assessed using the Maryland Foot Rating Score (MFRS). Results MFRS improved from 72.1 (average) pre-operatively to 89.9 (average) post-operatively (follow-up 70.9 months average). Eight feet were assessed using the AOFAS ankle-hindfoot and midfoot scores. The AOFAS ankle-hindfoot score improved from 46.3 (average) pre-operatively to 89.1 (average) post-operatively and the AOFAS midfoot score improved from 40.9 (average) pre-operatively to 88.8 (average) post-operatively (follow-up 20.8 months average). Two patients were lost to follow-up and were not included in the study. Ankle, hindfoot and midfoot motion was maintained or improved in 16 feet. Complications included delyed union in two and non-union in three of 66 metatarsal osteotomies. While three patients required an AFO (ankle-foot orthosis) for ambulation pre-operatively, all patientrs were brace free post-operatively and expressed willingness to undergo the same procedure again if it were necessary. Weight bearing radiographs were available for 17 feet. Radiographic analysis revealed a decrease in forefoot adduction (9.6° average) and a reduction in both hindfoot (9.1° average) and forefoot cavus (10.6°) leading to an overall 13% reduction in the height of the longitudinal arch. Conclusions Lateral sliding elevating calcaneal ostetomy combined with doso-lateral closing wedge osteotomies of one or more metatarsal bases in the severe symptomatic cavovarus foot can provide a pain free, plantigrade foot with a lowered longitudinal arch and a stable ankle without sacrificing motion. In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits

Introduction. Corrective fusion for the unstable deformed hind foot in Charcot Neuroarthropathy (CN) is quite challenging and is best done in tertiary centres under the supervision of multidisciplinary teams. Patients and methods. We present our results with a series of 42 hind foot deformity corrections in 40 patients from a tertiary level teaching hospital in the United Kingdom. The mean patient age was 59 (33–82). 16 patients had type1 diabetes mellitus, 20 had type 2 diabetes and 4 were non-diabetic. 18 patients had chronic ulceration. 17 patients were ASA 2 and 23 were ASA grade 3. All patients had acute single stage correction and Trigen hind foot nail fusion performed through a standard technique by the senior author and managed peri-operatively by the multidisciplinary team. Our outcome measures were limb salvage, deformity correction, ulcer healing, weight bearing in surgical shoes and return to activities of daily living (ADL). Results. At a mean follow up of 37 months (7–79) we achieved 100% limb salvage initially and 97% healing of arthrodesis. One patient with persisting non-union has been offered amputation. Deformity correction was achieved in 100% and ulcer healing in 89%. 72.5% patients are able to mobilize and manage independent ADL. There were 11 patients with one or more complications including metal failure, infection and ulcer reactivation. We performed nine repeat procedures including one revision fusion and one vascular procedure. Conclusion. Single stage corrective fusion for hind foot deformity in CN is an effective procedure when delivered by a skilled multidisciplinary team

Between January 1996 and December 2006, 130 patients were operated on for acquired varus equinus foot deformity. The most frequent aetiologies were stroke or brain damage due to head trauma. The primary indications for surgery included pain, caused by pressure of the foot or toes on the floor or in shoes, ankle instability due to varus deformity, or difficulty wearing orthopaedic shoes or braces. Split anterior tibial transfer was generally done after lengthening of Achillis tendon and tenotomy of long and short toe flexors during the same session. The author did compare preoperative and postoperative autonomy, and shoe or orthosis requirements. The results of this study include significant improvement in patient autonomy demonstrated by an improved ability to ambulate independently and a decreased need to wear orthopedic shoes and orthoses, as well as an increased ability to wear normal shoes, or the ability to ambulate bare foot. Adequate knee flexion during swing phase of the stride was the best indicator for better result. This procedure is safe and yields good results with minimal complications. The indications are very common, inasmuch as the number of young hemiplegic patients surviving after a stroke or head injury is increasing. This procedure can result in definite improvement for these disabled patients and can increase their autonomy

We reviewed the outcome of 30 patients treated with an Ilizarov frame for resistant clubfoot deformity. Each patient was assessed using objective and subjective outcome measures. We used clinical examination, X-ray analysis, pedobarography and gait analysis and the Activities Scale for Kids questionnaire, developed and validated by The Hospital for Sick Children, Toronto, Canada. The average questionnaire score was 83. This suggested a good subjective outcome when compared to the average score of 38 achieved by children with untreated clubfoot. Patients were into 2 groups using this score. Patients scoring over 75 were considered to have a good outcome and those scoring less than 75 were considered to have a bad outcome. The objective results were then compared. We found no difference between the 2 groups using clinical examination and X-ray. Pedobarography showed lower pressures in the bad subjective group, in particular virtually no pressure was generated under the heel when walking. The pressure distribution also showed the bad group to have the pressure balance towards the front of the foot over the 5. th. metatarsal head. Gait analysis showed differences. The bad group had increased pelvic obliquity and increased pelvic movement suggesting an inefficient gait, increased hip abduction in swing, hyperextension of the knee on loading and decreased dorsiflexion of the ankle in swing when compared to the good group. Our conclusions were that subjectively this group of patients did well after surgical treatment using an Ilizarov frame. Clinical examination can show significant intra- and inter-observer error and X-ray is unreliable in children whose feet are congenitally deformed. Pedobarography and gait analysis seem to correlate better with subjective outcome. We know that a good foot is a functional foot and it may be that functional assessment is a more appropriate means of assessing results of treatment in these patients

This paper outlines a valid and reliable, clinical method of assessing the amount of deformity in the congenital clubfoot. Clinical & MRI clubfoot scoring systems were developed to score the amount of deformity clinically & to image & score osteochondral pathology of the club-foot -MRI Total Score (MTS), MRI Hindfoot Contracture Score (MHCS), & MRI Midfoot Contracture Score (MMCS), Clinical Total Score (CTS), Clinical Hindfoot Contracture Score (CHCS), Clinical Midfoot Contracture Score (CMCS). Three independent observers tested the Clinical scoring systems Inter-observer reliability (Kappa Statistic) over one hundred consecutive clubfeet. Kappa values were CTS-0.92, CMCS-0.91, and CHCS-0.86- (almost perfect inter-observer reliability). Nineteen clubfeet were scored clinically and by thirty-eight MRI evaluations during treatment. Validity was evaluated by correlating the MRI and clinical scores (Pearson Correlation). The Pearson Correlations between clinical & MRI scores were CTS: MTS = 0.786 (P< 0.01), CHCS: MHCS = 0.712 (P< 0.01) & CMCS: MMCS = 0.651 (P< 0.01). All correlations were highly significant confirming validity. There is neither reliability nor validity in current methods of clubfoot assessment. This paper outlines a method of assessing the amount of deformity in the congenital clubfoot deformity using six well-described simple clinical signs that has been tested & found to be both valid and reliable. A clinical clubfoot scoring system was created- Clinical Total Score (CTS)- comprised of a Clinical Hind-foot Contracture Score (CHCS) & a Clinical Midfoot Contracture Score (CMCS). One hundred consecutive congenital clubfeet were scored for clinical deformity each week during cast treatment by three independent observers. Inter-observer reliability (Kappa Statistic) of this clinical scoring system was evaluated. A clubfoot MRI protocol & scoring system were developed to visualise & score osteochondral pathology of the clubfoot -MRI Total Score (MTS)- comprised of a MRI Hindfoot Contracture Score (MHCS) and a MRI Midfoot Contracture Score (MMCS). Nineteen clubfeet were scored clinically and by thirty-eight MRI evaluations during treatment. All MRI films were scored for amount of osteochondral pathology. Validity of this clinical scoring system was evaluated by correlating the MRI and clinical scores (Pearson Correlation). The Kappa values for inter-observer reliability were CTS-0.92, CMCS-0.91, and CHCS-0.86. All scores showed almost perfect inter-observer reliability. The Pearson Correlations between clinical & MRI scores were CTS: MTS = 0.786 (P< 0.01), CHCS: MHCS = 0.712 (P< 0.01) & CMCS: MMCS = 0.651 (P< 0.01). All correlations were highly significant confirming validity of the clinical scores. We have developed a clinical scoring system for club-feet that is reliable and valid

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.

Introduction and Aims: The role of tendon transfer in progressive hereditary motor sensory neuropathy (CMT) is controversial. This paper examines a large single surgeon cohort and reviews the surgical outcome of tendon transfers against a large group of CMT patients represented by the Australian CMT Health Survey 2001. Method: A retrospective review was carried out in 19 patients (36 feet) with CMT, managed surgically by a single author (GW). Functional outcomes were measured using standard tools such as SF36, American Orthopaedic Foot and Ankle Score (AOFAS) rating scale, and a clinical review including a specially designed questionnaire. Quality of life and functional outcome has been compared with the Australian CMT Health Survey 2001 in 324 patients. Results: Nineteen patients were managed with tendon transfers, typically by flexor to extensor transfer of toes, combined with peroneus longus release and transfer, and tibialis posterior transfer. The Levitt classification of the objective results of surgery rates 79% of patients as having good-excellent outcomes. Eighty-nine percent of patients report an improvement overall with surgery, specifically 53% report improvement in pain, 79% feel their gait has benefited, and 58% report an improvement in the appearance of their foot deformity, as a direct result of their surgery. All patients reviewed would recommend similar surgery to others, and 95% of those surveyed wished they had their surgery much earlier (months to years). The AOFAS clinical rating system for ankle-hindfoot showed an average improvement of 39.7 points out of 100. In general patients treated by this method were improved when considered against a larger cohort both in quality of life measures and functional outcome. This combination was not always successful and a small number of disappointed patients were identified. Conclusion: Tendon transfer in the younger patient has a role in treating flexible deformity in CMT and improving quality of life. Traditionally surgery has been advised by means of arthrodesis in patients with more advanced fixed deformity and pain due to secondary osteoarthritis. This paper study shows that patients may benefit at an earlier stage in the progression of their disease by tendon transfer