Summary: The Ponseti technique with an initial percutaneous Achilles tenotomy fully corrected 19 arthrogrypotic clubfeet. At 30 months follow-up, 74% were plantigrade, all were braceable, none had surgery.

Introduction: Surgical releases for arthrogrypotic clubfeet have high recurrence rates, requiring further surgery, resulting in short, stiff, painful feet. Hypothesis: a modified Ponseti technique could achieve plantigrade, braceable feet, without surgery during infancy or early childhood.

Methods: Ten patients with 19 arthrogrypotic clubfeet, mean age 16.2 months (range, 3–40), underwent an initial percutaneous Achilles tenotomy (PAT), followed by weekly Ponseti style castings. A second PAT was performed prior to the last 3 week cast, except if the ankle dorsiflexed at least 20°. Correction was maintained by continuous ankle-foot orthoses (AFOs) bracing.

Results: Mean follow-up was 30.6 months (range, 5–60), age 47 months (range, 11–86.5). Mean number of casts was 7.3 (range, 4–13), 10 feet required a second PAT. Initial Dimeglio/Bensahel (D/B) score was 16 (range, 12–18), and 5 (range, 2–9) at follow-up. Similarly, Catterall/Pirani (C/P) scores improved from 4.8 (range, 1.6–6.0) to 0.9 (range, 0–2.0). Mean ankle dorsiflexion improved from −45° (range, −30° to −75°) to 5° (range, −20° to 35°) at follow-up. Five feet (26%) developed an average equinus of 13° (range, 5° to 20°). All feet were braceable, none had surgery, and no patient’s ambulatory ability was compromised by foot shape. Five patients (10 feet) had more than 2 years follow-up (range, 39–59.5, average 49.7 months), with an average dorsiflexion of 6.5°, average D/B and C/P scores were 4.8 and 0.8, respectively.

Discussion and Conclusion: Arthrogrypotic clubfeet were corrected without extensive surgery during infancy or early childhood. The initial PAT was crucial for unlocking the calcaneus from the posterior tibia, allowing for correction with Ponseti casting. Correction was maintained with AFOs at the final follow-up of 30 months. Although limited surgery may be required as the children age, plantigrade, braceable feet were achieved effectively in these patients with arthrogryposis, creating a stable platform for weightbearing.

Purpose: The purpose of the study was to identify those characteristics of congenital tibial dysplasia (CTD) that portend the worst prognosis, including the probable failure of all surgical attempts to achieve union. Clear identification/ classification of this select population of cases could add earlier consideration of relevant treatment options.

Method: While several classification systems for CTD exist, the Crawford classification was used to review the literature and our hospital cases (6) to examine the relationship between case characteristics, treatment, and outcome.

Results: An atypical variation of Crawford’s type IIC was identified, herein referred to as type IID, that was characterized by early onset, frank pseudoarthrosis, and deformity of the distal-one third of the tibia and fibula. As well, these patients underwent failed multiple surgeries and numerous type treatments over time without good functional outcome and with prolonged physical difficulties.

Conclusion: The cases that fall into this newly defined category (IID) of the Crawford classification for CTD are best treated with early amputation rather than repeated attempts to gain union.

Significance: Amputation for patients with congenital tibial dysplasia (congenital pseudoarthrosis of the tibia) that are identified as type IID cases and carry the characteristics for a bad prognosis, provides better functional results than repeated surgeries, even when union is achieved. The family should be warned from the beginning that a stable union is unlikely in these cases. Amputation should be offered as a primary or an early option to the family with full disclosure of the long-term advantages and disadvantages of all therapeutic paths.

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.

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.

A retrospective review of records, radiographs, Computerized Tomography (CT) scans, and Magnetic Resonance Imaging (MRI) scans was done from January 1994 to January 2002. Of the 35 patients in this study, 15 were females and 20 males. The mean age of the patients was 12.8 years (range, 9 to 19 years). There were 14 feet with bilateral coalition, 8 were right and 13 were left. There were 28 talo-calcaneal (all middle facets) coalitions of which 9 were bilateral. There were 20 calcaneo-navicular coalitions of which 5 were bilateral. One patient had a naviculo-cuboid coalition. The mean followup was 6.4 months (range, 1.2 to 36 months). Twenty six patients were treated conservatively with satisfactory outcome. Of the 23 patients operated 16 patients had good outcome, 5 had fair outcome, and 2 had poor outcome. Totally there were 10 out of 329 patients that had multiple tarsal coalition when we reviewed our cases and the literature. This gave an incidence of 3 percent of all the symptomatic tarsal coalition i.e. in other words the true incidence of multiple coalition is around 0.03%. This is the only study that establishes the incidence of multiple coalition.