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.

The aim of our study was to assess the efficacy and complications of treatment of limb deformities using six axes deformity analysis and the Taylor TM Spatial Frame [TSF]

Between January 1997 and March 2000, we treated 75 lower limbs in 66 patients with deformities. Patients were divided into four groups. The groups were Blount’s disease, congenital deformities, traumatic deformities, and a miscellaneous group. The data was prospectively collected. This was a consecutive series of the first 66 patients treated at our institution with the TSF. Deformity correction using the TSF is done with the aid of computer software.

The mean age of the 66 patients was 18.7 years (range 0.5 to 72 years). The average frame time was 18.6 weeks (range 9 to 49 weeks). There was shortening present in 31 limbs with a mean of 18.6 mm (range 5 to 50 mm). Deformity correction with distraction osteogenesis was begun 7 days after the osteotomy. The mean length of time until correction was 6.7 weeks (range 3 to 13 weeks). There were a total of 10 complications (13.3%) in the series.

27 tibiae in 23 patients underwent correction with the TSF for Blount’s disease. There were 11 infantile and 16 adolescent forms. Correction of congenital deformity was performed in 20 tibiae and 8 femurs in 18 patients. There were 9 males and 9 females. There were 13 male and 8 female patients with traumatic lower limb injuries. There were 11 malunions and 10 nonunions (including 2 infected nonunions) that were corrected with the TSF.

The TaylorTM Spatial Frame is an effective technique in treating deformity. Angulation, translation, shortening and rotation can be corrected simultaneously.

Based on our results, we conclude that the TSF allows safe, gradual correction that is accurate and well tolerated.

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.

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.

To evaluate the effectiveness of a casting method for the early treatment of clubfoot deformity, a scoring system utilizing the French [DiMeglio], English [Pirani], and our functional rating system before and after each casting session was used to determine the final assessment and results of the Iowa [Ponseti] clubfoot technique.

Between Jan 2000 to June 2001, 49 clubfeet in 33 patients were assessed before and after the Ponseti casting at a minimum of 1 year follow up using the Dimeglio/ Bensahel, Hospital for Joint Diseases functional rating, and Catterall/Pirani scoring system. Mean age of presentation was 7 weeks [range 0.5 to 28 weeks]. Patients had casting +/− percutaneous TAL. At latest follow up patients who were compliant for Foot Abduction Orthosis [n=32 feet] had good results without any deterioration in their scores. Of the noncompliant patients 8 patients remained good. Of the nine feet that had poor results, 5 improved with recasting, 2 required percutaneous TAL and 2 required open TAL and posterior release.

Early treatment of the idiopathic clubfoot with serial [Ponseti] casting will be effective in over 90% of cases and patients will require no other treatment except for percutaneous tenotomy of the Achilles tendon.

Early use of the Iowa [Ponseti] technique [before the age of one year] will significantly reduce the current number of extensive surgical procedures performed for the treatment of clubfoot. Moreover, it will produce more flexible and supple feet and avoid the problem of stiff, recurrent post-surgical clubfoot.

To assess the efficacy of software assisted correction using six axes analyses for Blounts deformity.

Between 1998 and 2000, 22 tibiae in 19 patients underwent correction of Tibia Vara with the TSF. There were six females and thirteen males. There were 8 infantile and 14 adolescent forms. The mean patient age was 9.9 years (3–16 years). Shortening was present in 18 patients, averaging 11 mm (range: 3–30 mm). The mean follow up was 2.8 years (range: 2–4.1 years).

The mean preoperative varus deformity was 16.5 degrees (range, 8 to 50 degrees) which improved to 0 degree (−2 to 2 degrees), and mean procurvatum deformity was 12.2 degrees (2 to 21 degrees) which improved to 0.1 degree (−2 to 3 degrees). The plane of the deformity was an average of 31 degrees (0 to 62 degrees) from the coronal plane and the mean magnitude of the deformity was 20.5 degrees (11.3 to 3.8 degrees)

Taylor spatial frame uses the six axes software assisted analysis to correct complex deformities such as Blounts disease. It is very effective in correcting the Blounts deformity and has minimal complications.