Dorsiflexion has been studied in three normal feet and in three feet with talipes equinovarus to determine the anatomical features which might contribute to the failure of operative treatment to correct the deformity. In the normal feet the movement of dorsiflexion was found to be essentially rotatory in nature and not simply hinging; as dorsiflexion proceeds the fibula moves forwards relative to the os calcis and the calcaneal tendon. In the club feet a posterolateral tether was found; this prevented fibular movement and blocked dorsiflexion. As a result of this study a posterior and lateral release is advocated for the operative correction of the hindfoot in a child with a club foot deformity, particularly under the age of a year

We performed CT to investigate how treatment may modify the basic skeletal pathology of congenital club foot. Two homogenous groups of patients treated by one of the authors (EI) or under his supervision were studied. The first included 32 patients with 47 club feet reviewed at a mean age of 25 years and treated by manipulation, application of toe-to-groin plaster casts and an extensive posteromedial release. The second included 32 patients with 49 club feet reviewed at a mean age of 19 years and treated by the Ponseti manipulation technique, application of toe-to-groin plaster casts and a limited posterior release. At follow-up the shape of the subtalar, talonavicular and calcaneocuboid joints was found to be altered in many feet in both groups. This did not appear to be influenced significantly by the type of treatment performed. Correction of the heel varus and the increased declination angle of the neck of the talus was better in the club feet of the second group, whereas reduction of the medial subluxation of the navicular was better in the first. There was a marked increase in the external ankle torsion angle in the first group and a moderate increase of this angle in the second group, in which medial subluxation of the cuboid on the anterior apophysis of the calcaneum was always corrected. Equinus was corrected in both groups but three-dimensional CT reconstruction of the whole foot showed that cavus, supination and adduction deformities were corrected much better in the second group

1. The family history of, and associated congenital abnormalities in, patients with talipes equinovarus, talipes calcaneo-valgus and metatarsus varus living in Devonshire has been studied. 2. The chances of any individual having one of these deformities is approximately one per 1,000 in each case. 3. If one child in a family has the deformity, the chances of a second having it are one in thirty-five for talipes equinovarus and one in twenty for talipes calcaneo-valgus and metatarsus varus. 4. The male relatives of the female patients with talipes equinovarus are at particular risk. 5. It is suggested that the cause of club foot is partly genetic and partly environmental, from a factor acting on the foetus in the uterus. 6. The classification of associated congenital abnormalities leads to the suggestion that the genetic factor in talipes equinovarus and talipes calcaneo-valgus relates to defective formation of connective tissue

1. Lateral radiographs of fifty-seven club feet and seventeen normal feet were taken in forced flexion and forced extension. On these, the arcs traversed by the talus, the sole and the calcaneus were measured, as was the talo-calcaneal angle. 2. It was found that the ankle in club feet usually contributed more than half of the total sagittal movement of the foot. 3. Occasional cases were encountered in which the ankle was so damaged that it contributed only half or less than half of this movement. In such cases wedge excision of the ankle joint is theoretically justified in preference to wedge tarsectomy. 4. The talo-calcaneal angle is much reduced in club foot, and this element of deformity is extremely resistant to manipulative treatment. The reasons for this and a possible method of treatment are discussed

Aims. The Ponseti method is the benchmark treatment for the correction of clubfoot. The primary rate of correction is very high, but outcome further down the treatment pathway is less predictable. Several methods of assessing severity at presentation have been reported. Classification later in the course of treatment is more challenging. This systematic review considers the outcome of the Ponseti method in terms of relapse and determines how clubfoot is assessed at presentation, correction, and relapse. Patients and Methods. A prospectively registered systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that reported idiopathic clubfoot treated by the Ponseti method between 1 January 2012 and 31 May 2017 were included. The data extracted included demographics, Ponseti methodology, assessment methods, and rates of relapse and surgery. Results. A total of 84 studies were included (7335 patients, 10 535 clubfeet). The relapse rate varied between 1.9% and 45%. The rates of relapse and major surgery (1.4% to 53.3%) and minor surgery (0.6% to 48.8%) both increased with follow-up time. There was high variability in the assessment methods used across timepoints; only 57% of the studies defined relapse. Pirani scoring was the method most often used. Conclusion. Recurrence and further surgical intervention in idiopathic clubfoot increases with the duration of follow-up. The corrected and the relapsed foot are poorly defined, which contributes to variability in outcome. The results suggest that a consensus for a definition of relapse is needed. Cite this article: Bone Joint J 2019;101-B:639–645

There is some evidence that the anterior tibial vascular tree is poorly developed in children with club foot. We have found a significantly greater prevalence of absence of the dorsalis pedis pulse in the parents of such children. We also found significantly more tobacco smokers among the club-foot parents than in the control group

Somatosensory evoked potentials (SSEPs) measure the conduction pathways from the periphery to the brain and can demonstrate the site of neurological impairment in a variety of locomotor conditions. SSEPs were studied in 44 children (64 feet) with surgically corrected club feet. Four children had unreproducible responses, 18 showed abnormal recordings and 22 showed normal responses. In a further 31 feet (21 children) subjected to motor electrophysiological tests, 16 (52%) were abnormal. Overall, 44 of 95 feet (46%) showed abnormal SSEPs or motor electrophysiological tests. Neurological abnormality was related both to the severity of the deformity and the surgical outcome. It was seen in 38% of feet with grade-2 and in 53% of feet with grade-3 deformity. A fair surgical result was obtained in 36% of feet with a conduction deficit and in only 6% with no abnormality. These results suggest an association between neurological abnormality as demonstrated by SSEPs or motor electrophysiological studies and the severity of deformity in club foot and its response to surgical treatment

1. Further consideration has been given to the lateral rotation which occurs at the ankle joint in uncorrected club feet. 2. Medial rotation osteotomy of the tibia may be used to restore more normal alignment to the hind foot at the expense of an increase in varus of the forefoot, which must be corrected at a second operation. 3. The early results in seven feet treated in this manner are reported. 4. We hope that this paper will be regarded more as a contribution to the understanding of the anatomy of uncorrected club foot than as advocacy of a new method of surgical treatment

We reviewed the long-term results of the Dillwyn Evans procedure for club foot in 60 feet of 45 patients with an average age of 29 years, using four different scoring systems. The results at 12 to 38 years were compared with those of an earlier study of the same group of patients. Function was satisfactory in 68% of feet; 90% of the patients were able to perform all desired activities. Mild residual deformity was compatible with satisfactory function, and poor function was related to ankle and subtalar stiffness. Our results suggest that this procedure has a low rate of deterioration and degenerative change with time

1. In a club foot the small inverted and elevated heel is considered to be the most important deforming influence in preventing complete correction and in promoting relapse. 2. Correction of the varus and an increase in the vertical height of the heel are achieved by opening up the medial aspect of the calcaneum and inserting a wedge of bone. This abolishes the inverting action of the calcaneal tendon and brings the heel down on to the ground directly under the line of the tibia so that it touches first in walking. The weight is then shifted on to the forefoot, as in the normal gait, thus producing gradual correction of supination and adduction. 3. The operation may have to be repeated, but with the varus fully corrected and a plantigrade heel there is no chance of relapse, and progressive improvement, not only in gait and shoe wear but also in the development of the foot and leg, can be expected. 4. Skin closure is a difficulty, and though the resulting scar is sometimes conspicuous, it is masked to some extent by being on the postero-medial aspect of the ankle. 5. The ideal age for the operation is about three to four years, but there is virtually no upper age limit. 6. In older patients presenting severe residual deformity it may be necessary to correct the heel and then the equinus of the forefoot by a tarso-metatarsal wedge, thus avoiding damage to the mid-tarsal and subtalar joints. 7. By adopting these principles, soft-tissue release operations, so often disappointing and sometimes damaging, can be avoided and in no patient should there ever be the need to resort to the mutilating "triple wedge" resection. 8. The most important feature of the operation is correction of the varus; it is better to over-correct than to under-correct (Figs. 20 and 21). It is a simple matter to deal with the valgus later if necessary

Between 1994 and 1997 we used the Ilizarov apparatus to treat 12 recurrent arthrogrypotic club feet in nine patients with a mean age of 5.3 years (3.2 to 7). After a mean of three weeks (two to seven) for correction of the deformity and 1.5 weeks (one to four) for stabilisation in the apparatus, immobilisation in a cast was carried out for a mean of 14 weeks (7 to 24). The mean follow-up period was 35 months (27 to 57). Before operation there were one grade-II (moderate), eight grade-III (severe) and three grade-IV (very severe) club feet, according to the rating system of Dimeglio et al. After operation, all the club feet except one were grade I (benign) with a painless, plantigrade platform. Radiological assessment and functional evaluation confirmed significant improvement. Two complications occurred in one patient, namely, epiphysiolysis of the distal tibia and recurrence of the foot deformity. These results suggest that our proposed modification of the Ilizarov technique is effective in the management of recurrent arthrogrypotic club foot in young children

We operated on 111 patients with 159 congenital club feet with the aim of correcting the deformity and achieving dynamic muscle balance. Clinical and biomechanical assessment was undertaken at least six years after operation when the patient was more than 13 years of age. The mean follow-up was for 11 years 10 months (6 to 36 years). Good and excellent results were obtained in 91.8%. Patients with normal function of the calf had a better outcome than those with weak calf muscles. The radiological changes were assessed in relation to the clinical outcome. The distribution of pressure under the foot was measured for biomechanical assessment. Our results support the view that muscle imbalance is an aetiological factor in club foot. Early surgery seems to be preferable. It is suggested that operation should be undertaken as soon as possible after the age of six months, although it may be carried out up to the age of five years. The establishment of dynamic muscle balance appears to be an effective method of maintaining correction. Satisfactory long-term results can be achieved with adequate appearance and function

Previous reports have suggested that the blood supply derived from the anterior tibial artery is absent or markedly diminished in 85% of severe, untreated club feet. To investigate these claims, we used a Doppler technique to study the arterial pulses in 40 children with 63 club feet. In feet with mild or moderate deformities the anterior tibial pulse was always present; in feet with severe deformities it was absent in two out of 30 feet in children under three years and in seven out of 18 feet in children over three years. These results confirm that the incidence of pulselessness increases with the severity and duration of deformity, but not to the extent previously suggested by angiographic studies. The significance of these findings is discussed.

1. The results of treatment of 186 club feet have been reviewed.

2. Early strong repeated manipulation and splintage produced correction in all, but only sixty-five out of 186 remained acceptable at three years. The other 121 relapsed.

3. Relapse occurred in the first year in eight, between twelve and eighteen months in twenty-five, between eighteen and twenty-four months in twenty-three, and between twenty-four and thirty-six months in sixty-five.

4. Relapse was slightly commoner when treatment began after the first month of life.

5. Relapse was treated either by manipulation and plaster or by soft-tissue correction, leaving fifty-two out of 121 acceptable at three years and sixty-nine which were not acceptable (this includes those in plaster after soft-tissue correction, necessitated by relapse around the ages of two and a half and three and is thus adversely loaded).

6. The three year results in 186 feet were studied: 63 per cent were acceptable and 37 per cent were not. Five year results in eighty-seven feet were studied: 87·4 per cent were acceptable and 12·6 per cent were not.

7. Soft-tissue correction is described. It produced 89 per cent acceptable feet but 11 per cent relapses in 280 operations.