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

Aims. This study aims to define a set of core outcomes (COS) to allow consistent reporting in order to compare results and assist in treatment decisions for idiopathic clubfoot. Methods. A list of outcomes will be obtained in a three-stage process from the literature and from key stakeholders (patients, parents, surgeons, and healthcare professionals). Important outcomes for patients and parents will be collected from a group of children with idiopathic clubfoot and their parents through questionnaires and interviews. The outcomes identified during this process will be combined with the list of outcomes previously obtained from a systematic review, with each outcome assigned to one of the five core areas defined by the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT). This stage will be followed by a two round Delphi survey aimed at key stakeholders in the management of idiopathic clubfoot. The final outcomes list obtained will then be discussed in a consensus meeting of representative key stakeholders. Conclusion. The inconsistency in outcomes reporting in studies investigating idiopathic clubfoot has made it difficult to define the success rate of treatments and to compare findings between studies. The development of a COS seeks to define a minimum standard set of outcomes to collect in all future clinical trials for this condition, to facilitate comparisons between studies and to aid decisions in treatment. Cite this article: Bone Jt Open 2021;2(4):255–260

Aims. The Ponseti method is an effective evidence-based treatment for clubfoot. It uses gentle manipulation to adjust the position of the foot in serial treatments towards a more physiological position. Casting is used to hold the newly achieved position. At first, the foot resists the new position imposed by the plaster cast, pressing against the cast, but over time the tissues are expected to adapt to the new position and the force decreases. The aim of this study was to test this hypothesis by measuring the forces between a clubfoot and the cast during treatment with the Ponseti method. Patients and Methods. Force measurements were made during the treatment of ten idiopathic clubfeet. The mean age of the patients was seven days (2 to 30); there were nine boys and one girl. Force data were collected for several weeks at the location of the first metatarsal and the talar neck to determine the adaptation rate of the clubfoot. Results. In all measurements, the force decreased over time. The median (interquartile range) half-life time was determined to be at 26 minutes (20 to 53) for the first metatarsal and 22 minutes (9 to 56) for the talar neck, suggesting that the tissues of the clubfoot adapt to the new position within several hours. Conclusion. This is the first study to provide objective force data that support the hypothesis of adaptation of the idiopathic clubfoot to the new position imposed by the cast. We showed that the expected decrease in corrective force over time does indeed exist and adaptation occurs after a relatively short period of time. The rapid reduction in the forces acting on the foot during treatment with the Ponseti method may allow significant reductions in the interval between treatments compared with the generally accepted period of one week

Aims. The gold standard for percutaneous Achilles tendon tenotomy during the Ponseti treatment for idiopathic clubfoot is a tenotomy with a No. 15 blade. This trial aims to establish the technique where the tenotomy is performed with a large-bore needle as noninferior to the gold standard. Methods. We randomized feet from children aged below 36 months with idiopathic clubfoot on a 1:1 basis in either the blade or needle group. Follow-up was conducted at three weeks and three months postoperatively, where dorsiflexion range, Pirani scores, and complications were recorded. The noninferiority margin was set at 4° difference in dorsiflexion range at three months postoperatively. Results. The blade group had more dorsiflexion at both follow-up consultations: 18.36° versus 18.03° (p = 0.115) at three weeks and 18.96° versus 18.26° (p = 0.001) at three months. The difference of the mean at three months 0.7° is well below the noninferiority margin of 4°. There was no significant difference in Pirani scores. The blade group had more extensive scar marks at three months than the needle group (8 vs 2). No major complications were recorded. Conclusion. The needle tenotomy is noninferior to the blade tenotomy for usage in Ponseti treatment for idiopathic clubfoot in children aged below 36 months. Cite this article: Bone Joint J 2024;106-B(8):871–878

Rocker bottom deformity may occur during the conservative treatment of idiopathic congenital clubfoot. Between 1975 and 1996, we treated 715 patients (1120 clubfeet) conservatively. A total of 23 patients (36 feet; 3.2%) developed a rocker bottom deformity. It is these patients that we have studied. The pathoanatomy of the rocker bottom deformity is characterised by a plantar convexity appearing between three and six months of age with the hindfoot equinus position remaining constant. The convexity initially involves the medial column, radiologically identified by the talo-first metatarsal angle and secondly by the lateral column, revealed radiologically as the calcaneo-fifth metatarsal angle. The apex of the deformity is usually at the midtrasal with a dorsal calcaneocuboid subluxation. Ideal management of clubfoot deformity should avoid this complication, with adequate manipulation and splinting and early Achilles’ percutaneous tenotomy if plantar convexity occurs. Adequate soft-tissue release provides satisfactory correction for rocker bottom deformity. However, this deformity requires more extensive and complex procedures than the standard surgical treatment of clubfoot. The need for lateral radiographs to ensure that the rocker bottom deformity is recognised early, is demonstrated

We reviewed the results of a selective à la carte soft-tissue release operation for recurrent or residual deformity after initial conservative treatment for idiopathic clubfoot by the Ponseti method. Recurrent or residual deformity occurred in 13 (19 feet) of 33 patients (48 feet; 40%). The mean age at surgery was 2.3 years (1.3 to 4) and the mean follow-up was 3.6 years (2 to 5.3). The mean Pirani score had improved from 2.8 to 1.1 points, and the clinical and radiological results were satisfactory in all patients. However, six of the 13 patients (9 of 19 feet) had required further surgery in the form of tibial derotation osteotomy, split anterior tibialis tendon transfer, split posterior tibialis transfer or a combination of these for recurrent deformity. We concluded that selective soft-tissue release can provide satisfactory early results after failure of initial treatment of clubfoot by the Ponseti method, but long-term follow-up to skeletal maturity will be necessary

The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia. This study supports selective ultrasound screening of hips in infants with CTEV

A total of 38 relapsed congenital clubfeet (16 stiff, 22 partially correctable) underwent revision of soft-tissue surgery, with or without a bony procedure, and transfer of the tendon of tibialis anterior at a mean age of 4.8 years (2.0 to 10.1). The tendon was transferred to the third cuneiform in five cases, to the base of the third metatarsal in ten and to the base of the fourth in 23. The patients were reviewed at a mean follow-up of 24.8 years (10.8 to 35.6). A total of 11 feet were regarded as failures (one a tendon failure, five with a subtalar fusion due to over-correction, and five with a triple arthrodesis due to under-correction or relapse). In the remaining feet the clinical outcome was excellent or good in 20 and fair or poor in seven. The mean Laaveg-Ponseti score was 81.6 of 100 points (52 to 92). Stiffness was mild in four feet and moderate or severe in 23. Comparison between the post-operative and follow-up radiographs showed statistically significant variations of the talo-first metatarsal angle towards abduction. Variations of the talocalcaneal angles and of the overlap ratio were not significant. Extensive surgery for relapsed clubfoot has a high rate of poor long-term results. The addition of transfer of the tendon of tibialis anterior can restore balance and may provide some improvement of forefoot adduction. However, it has a considerable complication rate, including failure of transfer, over-correction, and weakening of dorsiflexion. The procedure should be reserved for those limited cases in which muscle imbalance is a causative or contributing factor

We report the effect of introducing a dedicated Ponseti service on the five-year treatment outcomes of children with idiopathic clubfoot. Between 2002 and 2004, 100 feet (66 children; 50 boys and 16 girls) were treated in a general paediatric orthopaedic clinic. Of these, 96 feet (96%) responded to initial casting, 85 requiring a tenotomy of the tendo-Achillis. Recurrent deformity occurred in 38 feet and was successfully treated in 22 by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, The remaining 16 required an extensive surgical release. . Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls) were treated in a dedicated multidisciplinary Ponseti clinic. All responded to initial casting: 60 feet (83.3%) required a tenotomy of the tendo-Achillis. Recurrent deformity developed in 14, 11 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The other three required an extensive surgical release. . Statistical analysis showed that children treated in the dedicated Ponseti clinic had a lower rate of recurrence (p = 0.068) and a lower rate of surgical release (p = 0.01) than those treated in the general clinic. This study shows that a dedicated Ponseti clinic, run by a well-trained multidisciplinary team, can improve the outcome of idiopathic clubfoot deformity. Cite this article: Bone Joint J 2014;96-B:1424–6

Aims. The study was undertaken to compare the efficacy of Woodcast splints and plaster-of-Paris casts in maintaining correction following sequential manipulation of idiopathic clubfeet. Methods. In this randomized prospective trial, 23 idiopathic clubfeet were immobilized with plaster-of-Paris casts and 23 clubfeet were immobilized with a splint made of Woodcast that encircled only two-thirds the circumference of the limb. The number of casts or splints needed to obtain full correction, the frequency of cast or splint-related complications, and the time taken for application and removal of the casts and splints were compared. Results. The mean number of casts required to obtain full correction of the deformity (Pirani Score 0) was 4.35 (95% confidence interval (CI) 3.74 to 4.95) when plaster-of-Paris was used and 4.87 (95% CI 4.33 to 5.41) when the Woodcast splint was used (p = 0.190). The time required for application and removal of the Woodcast splint were significantly less than that required for application and removal of plaster-of-Paris casts (p < 0.001). Woodcast splint-related complications were not more frequent than plaster-of-Paris cast related complications. Conclusion. Though Woodcast splints covering two-thirds of the circumference of the lower limbs of infants were effective in maintaining the correction of clubfoot deformity during serial manipulation and casting treatment, the superiority of Woodcasts over plaster-of-Paris could not be established. Cite this article: Bone Joint J 2020;102-B(10):1399–1404

Previous studies have identified clinical and demographic risk factors for recurrence in the treatment of idiopathic clubfoot (congenital talipes equinovarus). Evertor muscle activity is not usually considered amongst them. This study aimed to evaluate whether recurrence could be predicted by demographic, clinical and gait parameters. From a series of 103 children with clubfeet, 67 had completed a follow-up of two years: 41 male and 26 female, 38 with idiopathic and 29 with non-idiopathic deformities. The mean age was 3.2 years (2.1 to 6.3). Primary correction was obtained in all 38 children (100%) with an idiopathic deformity, and in 26 of 29 patients (90%) with a non-idiopathic deformity. Overall, 60 children (90%) complied with the abduction brace regime. At a mean follow-up of 31.4 months (24 to 62), recurrence was noted in six children (15.8%) in the idiopathic and 14 children (48.3%) in the non-idiopathic group. Significant correlation was found between poor evertor activity and recurrence in both groups. No statistically significant relationship was found between the rate of recurrence and the severity of the initial deformity, the age at the time of treatment, the number of casts required or the compliance with the brace. After correction of idiopathic and non-idiopathic clubfoot using the Ponseti method, only poor evertor muscle activity was statistically associated with recurrence. The identification of risk factors for recurrent deformity allows clinicians to anticipate problems and advocate early additional treatment to improve muscle balance around the ankle. Cite this article: Bone Joint J 2014;96-B:1264–8

The outcome in 83 patients with congenital clubfoot was evaluated at a mean age of 64 years using three validated questionnaires assessing both quality of life (short-form (SF)-36 and EQ-5D) and foot and ankle function (American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle questionnaire). In SF-36, male patients scored significantly better than male norms in seven of the eight domains, whereas female patients scored significantly worse than female norms in two of the eight. Male patients scored better than male norms in both the EQ-5D index (p = 0.027) and visual analogue scale (VAS) (p = 0.013), whereas female patients scored worse than female norms in the VAS (p < 0.001). Both male and female patients had a significantly worse outcome on the AAOS Core Scale than did norms. There was a significant correlation for both genders between the SF-36 Physical Component Summary Score and the AAOS Core Scale. The influence on activities of daily life was limited to foot and ankle problems in all patients, and in females there was an adverse effect in physical aspects of quality of life

Aims

Our aim was to describe the mid-term appearances of the repair process of the Achilles tendon after tenotomy in children with a clubfoot treated using the Ponseti method.

We undertook a randomised clinical trial to compare treatment times and failure rates between above- and below-knee Ponseti casting groups. Eligible children with idiopathic clubfoot, treated using the Ponseti method, were randomised to either below- or above-knee plaster of Paris casting. Outcome measures were total treatment time and the occurrence of failure, defined as two slippages or a treatment time above eight weeks. A total of 26 children (33 feet) were entered into the trial. The above-knee group comprised 17 feet in 13 children (ten boys and three girls, median age 13 days (1 to 40)) and the below-knee group comprised 16 feet in 13 children (ten boys and three girls, median age 13 days (5 to 20)). Because of six failures (37.5%) in the below-knee group, the trial was stopped early for ethical reasons. The rate of failure was significantly higher in the below-knee group (p = 0.039). The median treatment times of six weeks in the below-knee and four weeks in the above-knee group differed significantly (p = 0.01). This study demonstrates that the use of a below-knee plaster of Paris cast in conjunction with the Ponseti technique leads to unacceptably high failure rates and significantly longer treatment times. Therefore, this technique is not recommended. Cite this article: Bone Joint J 2013;95-B:1570–4

The correction of a relapsed or neglected clubfoot by an external distractor is an alternative to a major operation which may involve triple arthrodesis and is often associated with skin problems. We report the use of the Ilizarov method to treat nine severely deformed feet, with satisfactory results in terms of function and appearance. The distractor enables treatment to be applied before maturity and avoids the shortening of the foot that results from wedge osteotomies. We discuss the indications, technique, complications and results of the method

We investigated 60 patients (89 feet) with a mean age of 64 years (61 to 67) treated for congenital clubfoot deformity, using standardised weight-bearing radiographs of both feet and ankles together with a functional evaluation. Talocalcaneal and talonavicular relationships were measured and the degree of osteo-arthritic change in the ankle and talonavicular joints was assessed. The functional results were evaluated using a modified Laaveg-Ponseti score. The talocalcaneal (TC) angles in the clubfeet were significantly lower in both anteroposterior (AP) and lateral projections than in the unaffected feet (p < 0.001 for both views). There was significant medial subluxation of the navicular in the clubfeet compared with the unaffected feet (p < 0.001). Severe osteoarthritis in the ankle joint was seen in seven feet (8%) and in the talonavicular joint in 11 feet (12%). The functional result was excellent or good (≥ 80 points) in 29 patients (48%), and fair or poor (< 80 points) in 31 patients (52%). Patients who had undergone few (0 to 1) surgical procedures had better functional outcomes than those who had undergone two or more procedures (p < 0.001). There was a significant correlation between the functional result and the degree of medial subluxation of the navicular (p < 0.001, r. 2 . = 0.164), the talocalcaneal angle on AP projection (p < 0.02, r2 = 0.025) and extent of osteoarthritis in the ankle joint (p < 0.001). We conclude that poor functional outcome in patients with congenital clubfoot occurs more frequently in those with medial displacement of the navicular, osteoarthritis of the talonavicular and ankle joints, and a low talocalcaneal angle on the AP projection, and in patients who have undergone two or more surgical procedures. However, the ankle joint in these patients appeared relatively resistant to the development of osteoarthritis

Aims. To analyze outcomes reported in studies of Ponseti correction of idiopathic clubfoot. Methods. A systematic review of the literature was performed to identify a list of outcomes and outcome tools reported in the literature. A total of 865 studies were screened following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 124 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Each outcome tool was assigned to one of the five core areas defined by the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT). Bias assessment was not deemed necessary for the purpose of this paper. Results. In total, 20 isolated outcomes and 16 outcome tools were identified representing five OMERACT domains. Most outcome tools were appropriately designed for children of walking age but have not been embraced in the literature. The most commonly reported isolated outcomes are subjective and qualitative. The quantitative outcomes most commonly used are ankle range of motion (ROM), foot position in standing, and muscle function. Conclusions. There is a diverse range of outcomes reported in studies of Ponseti correction of clubfoot. Until outcomes can be reported unequivocally and consistently, research in this area will be limited. Completing the process of establishing and validating COS is the much-needed next step. Cite this article: Bone Joint Open 2020;1-8:457–464

Club foot was diagnosed by ultrasonography in 91 feet (52 fetuses) at a mean gestational age of 22.1 weeks (14 to 35.6). Outcome was obtained by chart review in 26 women or telephone interview in 26. Feet were classified as normal, positional deformity, isolated club foot or complex club foot. At initial diagnosis, 69 feet (40 fetuses) were classified as isolated club foot and 22 feet (12 fetuses) as complex club foot. The diagnosis was changed after follow-up ultrasound scan in 13 fetuses (25%), and the final ultrasound diagnosis was normal in one fetus, isolated club foot in 31 fetuses, and complex club foot in 20 fetuses. At birth, club foot was found in 79 feet in 43 infants for a positive predictive value of 83%. Accuracy of the specific diagnosis of isolated club foot or complex club foot was lower; 63% at the initial ultrasound scan and 73% at the final scan. The difference in diagnostic accuracy between isolated and complex club foot was not statistically significant. In no case was postnatal complex club foot undiagnosed on fetal ultrasound and all inaccuracies were overdiagnoses. Karyotyping was performed in 25 cases. Abnormalities were noted in three fetuses, all with complex club foot and with additional findings on ultrasound

Our goal was to evaluate the use of Ponseti’s method, with minor adaptations, in the treatment of idiopathic clubfeet presenting in children between five and ten years of age. A retrospective review was performed in 36 children (55 feet) with a mean age of 7.4 years (5 to 10), supplemented by digital images and video recordings of gait. There were 19 males and 17 females. The mean follow-up was 31.5 months (24 to 40). The mean number of casts was 9.5 (6 to 11), and all children required surgery, including a percutaneous tenotomy or open tendo Achillis lengthening (49%), posterior release (34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue release combined with an osteotomy (2%). The mean dorsiflexion of the ankle was 9° (0° to 15°). Forefoot alignment was neutral in 28 feet (51%) or adducted (< 10°) in 20 feet (36%), > 10° in seven feet (13%). Hindfoot alignment was neutral or mild valgus in 26 feet (47%), mild varus (< 10°) in 19 feet (35%), and varus (> 10°) in ten feet (18%). Heel–toe gait was present in 38 feet (86%), and 12 (28%) exhibited weight-bearing on the lateral border (out of a total of 44 feet with gait videos available for analysis). Overt relapse was identified in nine feet (16%, six children). The parents of 27 children (75%) were completely satisfied.

A plantigrade foot was achieved in 46 feet (84%) without an extensive soft-tissue release or bony procedure, although under-correction was common, and longer-term follow-up will be required to assess the outcome.

Cite this article: Bone Joint J 2013;95-B:1721–5.

The Ponseti method of clubfoot management requires a period of bracing in order to maintain correction. This study compared the effectiveness of ankle foot orthoses and Denis Browne boots and bar in the prevention of recurrence following successful initial management. Between 2001 and 2003, 45 children (69 feet) with idiopathic clubfeet achieved full correction following Ponseti casting with or without a tenotomy, of whom 17 (30 clubfeet) were braced with an ankle foot orthosis while 28 (39 clubfeet) were prescribed with Denis Browne boots and bar. The groups were similar in age, gender, number of casts and tenotomy rates. The mean follow-up was 60 months (50 to 72) in the ankle foot orthosis group and 47 months (36 to 60) in the group with boots and bars. Recurrence requiring additional treatment occurred in 25 of 30 (83%) of the ankle foot orthosis group and 12 of 39 (31%) of the group with boots and bars (p < 0.001). Additional procedures included repeat tenotomy (four in the ankle foot orthosis group and five in the group treated with boot and bars), limited posterior release with or without tendon transfers (seven in the ankle foot orthosis group and two in the group treated with boots and bars), posteromedial releases (nine in the orthosis group) and midfoot osteotomies (five in the orthosis group, p < 0.001). Following initial correction by the Ponseti method, children managed with boots and bars had far fewer recurrences than those managed with ankle foot orthoses. Foot abduction appears to be important to maintain correction of clubfeet treated by the Ponseti method, and this cannot be achieved with an ankle foot orthosis

The aetiology of congenital club foot is unclear. Although studies on populations, families and twins suggest a genetic component, the mode of inheritance does not comply with distinctive patterns. The Odense-based Danish Twin Registry contains data on all 73 000 twin pairs born in Denmark over the last 130 years. In 2002 all 46 418 twins born between 1931 and 1982 received a 17-page questionnaire, one question of which was ‘Were you born with club foot?’ A total of 94 twins answered ‘Yes’, giving an overall self-reported prevalence of congenital club foot of 0.0027 (95% confidence interval (CI) 0.0022 to 0.0034). We identified 55 complete twin pairs, representing 12 monozygotic, 22 dizygotic same sex (DZ. ss. ), 18 dizygotic other sex (DZ. os. ) and three unclassified. Two monozygotic and 2 DZ. ss. pairs were concordant. The pairwise concordance was 0.17 (95% CI 0.02 to 0.48) for monozygotic, 0.09 (95% CI 0.01 to 0.32) for DZ. ss. and 0.05 (95% CI 0.006 to 0.18) for all dizygotic (DZ. tot. ) twins. We have found evidence of a genetic component in congenital club foot, although non-genetic factors must play a predominant role

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

The Ponseti method of treating club foot has been shown to be effective in children up to two years of age. However, it is not known whether it is successful in older children. We retrospectively reviewed 17 children (24 feet) with congenital idiopathic club foot who presented after walking age and had undergone no previous treatment. All were treated by the method described by Ponseti, with minor modifications. The mean age at presentation was 3.9 years (1.2 to 9.0) and the mean follow-up was for 3.1 years (2.1 to 5.6). The mean time of immobilisation in a cast was 3.9 months (1.5 to 6.0). A painless plantigrade foot was obtained in 16 feet without the need for extensive soft-tissue release and/or bony procedures. Four patients (7 feet) had recurrent equinus which required a second tenotomy. Failure was observed in five patients (8 feet) who required a posterior release for full correction of the equinus deformity. We conclude that the Ponseti method is a safe, effective and low-cost treatment for neglected idiopathic club foot presenting after walking age

We have compared the density of nerve fibres in the synovium in club foot with that of specimens obtained from the synovium of the hip at operations for developmental dysplasia. The study focused on the sensory neuropeptides substance P; calcitonin gene-related peptide; protein gene product 9.5, a general marker for mature peripheral nerve fibres; and growth associated protein 43, a neuronal marker for new or regenerating nerve fibres. In order to establish whether there might be any inherent difference we analysed the density of calcitonin gene-related peptide-positive nerve fibres in the hip and ankle joints in young rats. Semi-quantitative analysis showed a significant reduction in the number of sensory and mature nerve fibres in the synovium in club foot compared with the control hips. Calcitonin gene-related peptide (CGRP) positive fibres were reduced by 28%, substance P-positive fibres by 36% and protein gene product 9.5-positive fibres by 52% in club foot. The growth associated protein 43-positive fibres also seemed to be less in six samples of club foot. No difference in the density of CGRP-positive nerve fibres was observed in the synovium between ankle and hip joints in rats. The lack of sensory input may be responsible for the fibrosis and soft-tissue contractures associated with idiopathic club foot

Continuous passive motion has been shown to be effective in the conservative treatment of idiopathic club foot. We wished to determine whether its use after operation could improve the results in resistant club feet which required an extensive soft-tissue release. There were 50 feet in the study. Posteromedial lateral release was performed in 39 feet but two were excluded due to early relapse. The mean age at surgery was eight months (5 to 12). Each foot was assigned a Dimeglio club foot score, which was used as a primary outcome measure, before operation and at 6, 12, 18 and 44 months after. Nineteen feet were randomly selected to receive continuous passive motion and 18 had standard immobilisation in a cast. After surgery and subsequent immobilisation in a cast the Dimeglio club foot score improved from 10.3 before to 4.17 by 12 months and to 3.89 at 48 months. After operation followed by continuous passive motion the score improved from 9.68 before to 3.11 after 12 months, but deteriorated to 4.47 at 48 months. Analysis of variance adjusted for baseline values indicated a significantly better score in those having continuous passive motion up to one year after surgery, but after 18 and 48 months the outcomes were the same in both groups

Most cases of club foot (congenital talipes equinovarus) respond to non-operative treatment but resistant cases may need surgery. It is broadly accepted that lengthening of tendo Achillis, the tendon of tibialis posterior and capsulotomy of the ankle and subtalar joints are necessary during surgical release, but there is no consensus as to whether lengthening of the tendons of flexor hallucis longus and flexor digitorum longus is required. We randomised 13 children with severe bilateral club foot deformities to undergo lengthening of the flexor hallucis longus and flexor digitorum longus tendons on one side and simple decompression on the other. We found no difference in the deformities of the toes between the lengthened and non-lengthened sides at a mean follow-up of four years (2 to 6). We conclude that routine lengthening of the tendons of flexor hallucis longus and flexor digitorum longus during soft-tissue surgery for resistant club foot is not necessary

We investigated the pathogenesis of soft-tissue contracture in club foot, using immunohistochemistry to study 41 biopsy specimens and 12 normal deltoid ligaments from cadavers. Five biopsy specimens were studied by electron microscopy (EM) to determine the presence of myofibroblasts. All 41 specimens of club foot stained positively for vimentin as against only one of the 12 control specimens. By contrast, there was no difference in staining for desmin or α-smooth muscle actin. EM showed some variability in the appearance of ligamentous cells. Most contained bundles of microfilaments in the cytoplasm and many had abundant pinocytotic vesicles, but no basal lamina or plasmalemmal attachment plaques. Cells of the medial ligamentous tissue in patients with club foot contain vimentin and others have myofibroblastic characteristics. Both features may contribute to recurrence after soft-tissue release

Club foot can be diagnosed by ultrasound of the fetus in more than 60% of cases. We have correlated the accuracy of the prenatal findings in 281 ultrasound surveys with the physical findings after birth and the subsequent treatment in 147 children who were born with club foot. The earliest week of gestation in which the condition was diagnosed with a high degree of confidence was the 12th and the latest was the 32nd. Not all patients were diagnosed at an early stage. In 29% of fetuses the first ultrasound examination failed to detect the deformity which subsequently became obvious at a later examination. Club foot was diagnosed between 12 and 23 weeks of gestation in 86% of children and between 24 and 32 weeks of gestation in the remaining 14%. Therefore it can be considered to be an early event in gestation (45% identified by the 17th week), a late event (45% detected between 18th and 24th weeks) or a very late event (10% recognised between 25th and 32nd weeks). We cannot exclude, however, the possibility that the late-onset groups may have been diagnosed late because earlier scans were false-negative results. The prenatal ultrasonographic findings were correlated with the physical findings after birth and showed that bilateral involvement was more common than unilateral. There was no significant relationship between the prenatal diagnosis and the postnatal therapeutic approach (i.e., conservative or surgical), or the degree of rigidity of the affected foot

We studied in vivo the talonavicular alignment of club foot in infants using MRI. We examined 26 patients (36 feet) with congenital club foot. The mean age at examination was 9.0 months (4 to 12). All analyses used MRI of the earliest cartilaginous development of the tarsal bones in the transverse plane, rather than the ossific nucleus. The difference in the mean talar neck angle (44.0 ± 8.1°) in club foot was statistically significant (p < 0.001) when compared with that of the normal foot (30.8 ± 5.5°). The difference between the mean angles in the group treated by operation (47.9 ± 6.7°) and those treated conservatively (40.1 ± 7.5°) was also statistically significant. The anatomical relationship between the head of the talus and the navicular was divided into two patterns, based on the position of the mid-point of the navicular related to the long axis of the head. In the operative group, 18 feet were classified as having a medial shift of the navicular and none had a lateral shift. In the conservative group, 12 showed a medial shift of the navicular and six a lateral shift. All nine unaffected normal feet in which satisfactory MRI measurements were made showed a lateral shift of the navicular. Club feet had a larger talar neck angle and a more medially deviated navicular when compared with normal feet. This was more marked in the surgical group than in the conservative group

We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot. Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30). The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients

We performed electrophysiological studies on both legs of 52 children, aged from 3 months to 15 years, with idiopathic club foot. In only nine (17%) was no abnormality found. Isolated peroneal nerve damage was seen in 14 (27%). Abnormality of both peroneal and posterior tibial nerves was found in five (10%). Four patients (8%) had evidence of isolated spinal-cord dysfunction, whereas combined spinal-cord and peripheral-nerve lesions were seen in 14 (27%). Six patients (11%) had variable neurogenic electrophysiological patterns. In 13 patients in whom the studies were repeated neither progression nor improvement of the electrophysiological parameters was observed. Pathological electrophysiological findings were found in 66% of conservatively-treated patients. In the 43 patients treated surgically, all 16 with fair and poor results had pathological electrophysiological findings and 12 required further operations. Multiplicity of the pathological findings was related to the severity of the deformity of the foot; normal studies represent a good prognostic sign. Electrophysiological studies are useful in idiopathic club foot with residual deformities after conservative or operative treatment. Our findings support the theory that muscle imbalance is an aetiological factor in idiopathic club foot

Treatment by continuous passive movement at home is an alternative to immobilisation in a cast after surgery for club foot. Compliance with the recommended treatment, of at least four hours daily, is unknown. The duration of treatment was measured in 24 of 27 consecutive children with a mean age of 24 months (5 to 75) following posteromedial release for idiopathic club foot. Only 21% (5) of the children used the continuous passive movement machine as recommended. The mean duration of treatment at home each day was 126 minutes (11 to 496). The mean range of movement for plantar flexion improved from 15.2° (10.0° to 20.6°) to 18.7° (10.0° to 33.0°) and for dorsiflexion from 12.3° (7.4° to 19.4°) to 18.9° (10.0° to 24.1°) (both, p = 0.0001) when the first third of therapy was compared with the last third. A low level of patient compliance must be considered when the outcome after treatment at home is interpreted

In 12 infants aged under 16 months with unilateral club foot we used MRI in association with multiplanar reconstruction to calculate the volume and principal axes of inertia of the bone and cartilaginous structures of the hindfoot. The volume of these structures in the club foot is about 20% smaller than that in the normal foot. The reduction in volume of the ossification centre of the talus (40%) is greater than that of the calcaneus (20%). The long axes of both the ossification centre and the cartilaginous anlage of the calcaneus are identical in normal and club feet. The long axis of the osseous nucleus of the talus of normal and club feet is medially rotated relative to the cartilaginous anlage, but the angle is greater in club feet (10° v 14°). The cartilaginous structure of the calcaneus is significantly medially rotated in club feet (15°) relative to the bimalleolar axis. The cartilaginous anlage of the talus is medially rotated in both normal and club feet, but with a smaller angle for club feet (28° v 38°). This objective technique of measurement of the deformity may be of value preoperatively

Primary skin closure after surgery for club foot in children can be difficult especially in revision operations. Between 1990 and 1996 a soft-tissue expander was implanted in 13 feet before such procedures. Two were primary operations and 11 were revisions. A standard technique was used for implantation of the expander. Skin augmentation was successful in 11 cases. There was failure of one expander and one case of wound infection. Sufficient stable skin could be gained at an average of five weeks. Primary skin closure after surgery was achieved in 12 cases. We conclude that soft-tissue expansion can be used successfully before extensive surgery for club foot. The method should be reserved for revision procedures and for older children. The technique is not very demanding, but requires experience to achieve successful results

The Pirani scoring system, together with the Ponseti method of club foot management, was assessed for its predictive value. The data on 70 idiopathic club feet successfully treated by the Ponseti method and scored by Pirani’s system between February 2002 and May 2004 were analysed. There was a significant positive correlation between the initial Pirani score and number of casts required to correct the deformity. A foot scoring 4 or more is likely to require at least four casts, and one scoring less than 4 will require three or fewer. A foot with a hindfoot score of 2.5 or 3 has a 72% chance of requiring a tenotomy. The Pirani scoring system is reliable, quick, and easy to use, and provides a good forecast about the likely treatment for an individual foot but a low score does not exclude the possibility that a tenotomy may be required

1. An operation which can correct congenital club foot deformity in older children is described. 2. The operation is based on the assumption that the essential element in a complex tarsal deformity is a displacement of the navicular bone on the talus and that all other elements of the deformity are secondary and adaptive. 3. The results of the operation are noted and the implications of some of its effects are discussed

1. An anatomical study of congenital club foot in various stages of foetal development is presented, and the literature is reviewed. 2. The most striking finding was deformity of the talus and in particular a change in its angle of declination. 3. That deformity was present in feet whose deformity could not be corrected by gentle manipulation; it was absent in feet whose deformity could be so corrected. 4. Abnormality of the tendon and insertion of the tibialis posterior muscle was found in most cases. 5. Speculations are advanced concerning the nature and cause of the talar deformity

Talectomy was performed on 10 patients (15 feet) for club foot deformity in arthrogryposis multiplex congenita. These were reviewed after an average follow-up of eight years. At follow-up nine feet were plantigrade, and six had less than 15 degrees residual equinus at the ankle. All the feet were asymptomatic but had mild residual adduction of the forefoot and marked stiffness of the hindfoot. Seven feet developed spontaneous bony ankylosis in the tibiotarsal joint. The common technical errors were incomplete removal of the talus and incorrect positioning of the calcaneus in the ankle mortise

1. The results of seventy-six transfers of the tibialis anterior tendon to the outer side of the foot to prevent relapse of congenital club foot are reviewed. 2. There were relapses in fifty-two of the seventy-six feet on which the operation had been performed. 3. The equinus component of the deformity is the dominant feature in all the relapses. 4. A test for occult equinus is described. 5. The factors contributing to the high relapse rate are discussed

A histochemical analysis was made of 103 muscle biopsies taken from 62 patients with idiopathic club feet. Any reduction in the diameter of the muscle fibres associated with wasting of the calf muscle was recorded. Histochemical abnormalities existing in these biopsies were revealed by comparison with normal biopsies obtained from the normal legs of 13 children with unilateral deformities. No significant difference was found between the diameter of the muscle fibres taken from normal and affected legs aged under six months. This indicates that wasting of the calf muscle is due to a reduction in the number of fibres rather than their size. The muscle structure was normal excluding denervation and reinnervation. The soleus muscle in patients aged under six months contained 61 per cent Type 1 fibres in the affected legs, compared to 44.3 per cent in normal legs. Similar values were found in the normal and abnormal tibialis posterior muscles, long flexors of the toe and peroneal muscles. The change in composition of the soleus muscle and the reduction in the number of fibres may be caused by a defective neural influence on the development of the limb in club foot

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.

We treated 37 infants with 53 idiopathic club feet by posterolateral release alone at a mean age of 2.4 months. They were reviewed after a mean follow-up of 10 years 7 months. Both function and appearance were studied. Seventeen feet had required further surgery, at an average of four years after posterolateral release. In all cases hindfoot equinus had been well corrected; the mean ankle dorsiflexion at review was 15 degrees. Most feet showed subtalar joint movement of between 50% and 75% of normal. Four feet showed poor results: one had a stiff subtalar joint, two feet in one child showed fixed forefoot varus, and one foot had required a Dillwyn-Evans operation at 5.5 years. The overall reoperation rate of 32% at ten years suggests that a radical release operation is not necessary in all patients. Of 59 patients who had only a simple posterolateral release 27 (46%) have satisfactory results.

One hundred and twenty-nine unselected club feet were classified at birth into three grades of severity; 123 were followed up. The results of primary treatment were analysed and it is shown that the bad feet did worst. Serial splinting in plasters achieved lasting correction in nine in ten mild club feet, in half of the moderately deformed, but in only one in ten of the severely affected. Surgical correction succeeded in two out of three of the resistant feet, but had to be repeated in the others.

We reviewed 24 feet in 15 patients who had undergone talectomy for recurrent equinovarus deformity; 21 were associated with arthrogryposis multiplex congenita, two with myelomeningocele and one with idiopathic congenital talipes equinovarus. The mean follow-up was 20 years. Good results were achieved in eight feet (33%) in which further surgery was not needed and walking was painless; a fair result was obtained in ten feet (42%) in which further surgery for recurrence of a hindfoot deformity had been necessary but walking was painless; the remaining six feet (25%) were poor, with pain on walking. All patients wore normal shoes and could walk independently, except one who was wheelchair-bound because of other joint problems. Recurrent deformity, the development of tibiocalcaneal arthritis and spontaneous fusion of the tibia to the calcaneum were all seen in these patients.

1. The tibialis posterior tendon was transferred in twenty-eight congenital club feet to maintain the correction obtained by serial wedge plasters.

2. There has been no relapse in twenty-seven of the twenty-eight feet in the period under review–namely, one to three years from operation.

3. The technique of the operation is described.

4. It appears that this operation should not be attempted when a soft-tissue correction has been done previously.

We describe three patients who developed gross calcaneus deformity following surgery for talipes equinovarus. One also had an associated valgus deformity and another had supination of the forefoot; all had intractable problems with footwear. Operation for transfer of the tibialis anterior to the heel, with correction of the associated deformities, was successful and improved both their gait and the shoe problems.

We describe a congenital deformity of the foot which is characterised by calcaneus at the ankle and valgus at the subtalar joint; spontaneous improvement does not occur and serial casting results in incomplete or impermanent correction of the deformities. Experience with five feet in four children indicates that release of the ligaments and tendons anterior and lateral to the ankle and lateral to the subtalar joint is the minimum surgery necessary; subtalar arthrodesis may be required in addition. The foot deformity described may occur as an isolated condition or in association with multiple congenital anomalies. The possibility of a neurological deficit should always be excluded.

A total of 67 patients with 94 resistant club feet were treated operatively as soon after birth as all other postnatal problems could be excluded, the mean age of the patients being 12 days. No treatment was attempted before operation. The results, after a follow-up period of a minimum of two years (mean 4.4 years) are comparable with the best published results. This method of treatment has many advantages but cannot be recommended for general use without reservations.

1. Seventy-three congenital club feet in fifty-one children have been reviewed between the ages of four and fourteen years to determine the incidence of residual adduction ofthe forefoot.

2. A radiological method of measuring metatarsus varus, based on the naviculo-metatarsal angle, is described.

3. On clinical examination 52 per cent of the feet had residual adduction of the forefoot, and metatarsus varus was present in 74 per cent of these.

4. There was no residual adduction in 48 per cent but only 45 per cent of these showed normal radiographic features. In the remainder various forms of spurious correction were seen.

5. For early treatment, detachment of the origin of the abductor hallucis muscle is recommended at the time of extended posterior release, with tenotomy of the tendon of insertion as an additional measure.

The October 2024 Children’s orthopaedics Roundup. 360. looks at: Cost-effectiveness analysis of soft bandage and immediate discharge versus rigid immobilization in children with distal radius torus fractures: the FORCE trial; Percutaneous Achilles tendon tenotomy in clubfoot with a blade or a needle: a single-centre randomized controlled noninferiority trial; Treatment of hip displacement in children with cerebral palsy: a five-year comparison of proximal femoral osteotomy and combined femoral-pelvic osteotomy in 163 children; The Core outcome Clubfoot (CoCo) study: relapse, with poorer clinical and quality of life outcomes, affects 37% of idiopathic clubfoot patients; Retention versus removal of epiphyseal screws in paediatric distal tibial fractures: no significant impact on outcomes; Predicting the resolution of residual acetabular dysplasia after brace treatment in infant DDH; Low prevalence of acetabular dysplasia following treatment for neonatal hip instability: a long-term study; How best to distract the patient?

We studied 16 club feet and 27 normal feet from spontaneously aborted human fetuses in the second trimester of gestation and measured the length of the spring ligament, and the declination angle and size of the talus. We also studied the cellular characteristics of the spring ligament and the immunohistochemical features of the medial ankle ligaments using monoclonal antibodies against type-III collagen, desmin, vimentin, and smooth muscle actin. Histomorphometric results indicated that the talar deformity was not the primary lesion. Histological and immunohistochemical findings showed that the cells and collagen fibres of the medial ankle ligaments of club feet appeared to be the site of the earliest changes, in that they had lost their spatial orientation and had contracted. In severe club feet before the third trimester of gestation, myofibroblast-like cells seemed to create a disorder of the ligaments resembling fibromatosis. This led to contraction and resulted in typical club-foot deformity.

We treated 91 congenital club feet in 59 children using a modified Denis Browne splint, and followed them for an average of 6 years and 3 months. The modified splint has an aluminium crossbar holding a pair of plastic shoe inserts moulded into corrected positions, and its use was started in children whose ages ranged from four weeks to nine months. Operation was later required in only 31 feet in 20 children. We have reviewed the other 60 feet in 39 children treated by splintage alone. All 60 feet had excellent or good function and from radiographic assessment, equinus, adduction, varus and cavus deformities had all been well corrected. Our results show that the modified splint can give good results.

Forty-four feet in 28 children previously treated by a one-stage posteromedial release operation (the Turco procedure) were reviewed clinically and radiologically to determine the cause of residual adduction of the forefoot. In 21 clinically adducted feet (48%) the main cause of residual deformity was metatarsus varus alone or metatarsus varus in spite of talonavicular overcorrection; in five feet the cause was talonavicular subluxation. There was no residual adduction in 23 feet (52%) but only 12 had normal radiographic measurements. In the remaining feet, various forms of spurious correction of metatarsus varus and talonavicular subluxation or both were seen, resulting in normal-looking feet. Recession of the origin of abductor hallucis and release of the short plantar muscles and fascia at the time of posteromedial release is recommended. The forefoot adduction was satisfactorily corrected in 91% of the feet subsequently operated on using this modified procedure.

Achilles tenotomy is a recognised step in the Ponseti technique for the correction of idiopathic congenital talipes equinovarus in most percutaneous cases. Its use has been limited in part by concern that the subsequent natural history of the tendon is unknown. In a study of 11 tendons in eight infants, eight tendons were shown to be clinically intact and ten had ultrasonographic evidence of continuity three weeks after tenotomy. At six weeks after tenotomy all tendons had both clinical and ultrasonographic evidence of continuity.

We reviewed 19 children with 24 congenital club feet at a mean of 11 years after one-stage posteromedial release at the age of five years or older (mean 6.8 years). Thirteen feet had undergone previous surgery. Nineteen feet were functionally excellent or good, three were fair and two had required subtalar arthrodesis. Radiographs showed good alignment of the tarsal bones, although mild adduction or varus deformity remained in several feet. Deformities of the bones were more common in feet which had had previous surgery.

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

The June 2012 Children’s orthopaedics Roundup. 360. looks at; open reduction for DDH; growing rod instrumentation for scoliosis; acute patellar dislocation; management of the relapsed clubfoot; clubfoot in Iran; laughing gas and fracture manipulation; vascularised periosteal fibular grafting for nonunion; slipped upper femoral epiphysis; intramedullary leg lengthening and orthopaedic imaging and defensive medicine

The April 2023 Children’s orthopaedics Roundup. 360. looks at: CT scan of the ipsilateral femoral neck in paediatric shaft fractures; Meniscal injuries in skeletally immature children with tibial eminence fractures: a systematic literature review; Post-maturity progression in adolescent idiopathic scoliosis curves of 40° to 50°; Prospective, randomized Ponseti treatment for clubfoot: orthopaedic surgeons versus physical therapists; FIFA 11+ Kids: challenges in implementing a prevention programme; The management of developmental dysplasia of the hip in children aged under three months: a consensus study from the British Society for Children's Orthopaedic Surgery; Early investigation and bracing in developmental dysplasia of the hip impacts maternal wellbeing and breastfeeding; Hip arthrodesis in children: a review of 26 cases with a mean of 20 years’ follow-up

Aims. To identify the minimum set of outcomes that should be collected in clinical practice and reported in research related to the care of children with idiopathic congenital talipes equinovarus (CTEV). Methods. A list of outcome measurement tools (OMTs) was obtained from the literature through a systematic review. Further outcomes were collected from patients and families through a questionnaire and interview process. The combined list, as well as the appropriate follow-up timepoint, was rated for importance in a two-round Delphi process that included an international group of orthopaedic surgeons, physiotherapists, nurse practitioners, patients, and families. Outcomes that reached no consensus during the Delphi process were further discussed and scored for inclusion/exclusion in a final consensus meeting involving international stakeholder representatives of practitioners, families, and patient charities. Results. In total, 39 OMTs were included from the systematic review. Two additional OMTs were identified from the interviews and questionnaires, and four were added after round one Delphi. Overall, 22 OMTs reached ‘consensus in’ during the Delphi and two reached ‘consensus out’; 21 OMTs reached ‘no consensus’ and were included in the final consensus meeting. In all, 21 participants attended the consensus meeting, including a wide diversity of clubfoot practitioners, parent/patient representative, and an independent chair. A total of 21 outcomes were discussed and voted upon; six were voted ‘in’ and 15 were voted ‘out’. The final COS document includes nine OMTs and two existing outcome scores with a total of 31 outcome parameters to be collected after a minimum follow-up of five years. It incorporates static and dynamic clinical findings, patient-reported outcome measures, and a definition of CTEV relapse. Conclusion. We have defined a minimum set of outcomes to draw comparisons between centres and studies in the treatment of CTEV. With the use of these outcomes, we hope to allow more meaningful research and a better clinical management of CTEV. Cite this article: Bone Jt Open 2022;3(1):98–106

The August 2012 Children’s orthopaedics Roundup. 360. looks at: whether 3D-CT gives a better idea of coverage than plain radiographs; forearm fractures after trampolining accidents; forearm fractures and the Rush pin; the fractured distal radius; elastic stable intramedullary nailing for long-bone fractures; aponeurotic recession for the equinus foot; the torn medial patellofemoral ligament and the adductor tubercle; slipped capital femoral epiphysis; paediatric wrist arthroscopy; and Pirani scores and clubfoot

Aims

The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV.

The December 2015 Children’s orthopaedics Roundup. 360 . looks at: Paediatric femoral fractures: a single incision nailing?; Lateral condylar fractures: open or percutaneous?; . Forearm refracture: the risks; Tibial spine fractures; The child’s knee in MRI; The mechanics of SUFE; Idiopathic clubfoot

Aims

After the initial correction of congenital talipes equinovarus (CTEV) using the Ponseti method, a subsequent dynamic deformity is often managed by transfer of the tendon of tibialis anterior (TATT) to the lateral cuneiform. Many surgeons believe the lateral cuneiform should be ossified before surgery is undertaken. This study quantifies the ossification process of the lateral cuneiform in children with CTEV between one and three years of age.

The Ponseti and French taping methods have reduced the incidence of major surgery in congenital idiopathic clubfoot but incur a significant burden of care, including heel-cord tenotomy. We developed a non-operative regime to reduce treatment intensity without affecting outcome. We treated 402 primary idiopathic clubfeet in patients aged < three months who presented between September 1991 and August 2008. Their Harrold and Walker grades were 6.0% mild, 25.6% moderate and 68.4% severe. All underwent a dynamic outpatient taping regime over five weeks based on Ponseti manipulation, modified Jones strapping and home exercises. Feet with residual equinus (six feet, 1.5%) or relapse within six months (83 feet, 20.9%) underwent one to three additional tapings. Correction was maintained with below-knee splints, exercises and shoes. The clinical outcome at three years of age (385 feet, 95.8% follow-up) showed that taping alone corrected 357 feet (92.7%, ‘good’). Late relapses or failure of taping required limited posterior release in 20 feet (5.2%, ‘fair’) or posteromedial release in eight feet (2.1%, ‘poor’). The long-term (> 10 years) outcomes in 44 feet (23.8% follow-up) were assessed by the Laaveg–Ponseti method as excellent (23 feet, 52.3%), good (17 feet, 38.6%), fair (three feet, 6.8%) or poor (one foot, 2.3%). These compare favourably with published long-term results of the Ponseti or French methods. This dynamic taping regime is a simple non-operative method that delivers improved medium-term and promising long-term results.

Cite this article: Bone Joint J 2013;95-B:271–8.

The December 2012 Foot & ankle Roundup. 360. looks at: correcting the overcorrected club foot; syndesmotic surgery; autograft for osteochondral defects; sesamoidectomy after fracture in athletes; complications in ankle replacement; the arthroscope as a treatment for ankle osteoarthritis; whether da Vinci was a modern foot surgeon; and a popliteal block in ankle fixation

The February 2014 Children’s orthopaedics Roundup. 360 . looks at: flexible plasters; dual 8-plate or ablation for knee epiphysiodesis; ultrasounds for pulled elbow; leg length without the radiation; Boyd amputation in limb deficiencies; gold standard club foot treatment; quadrupled semitendinosis graft effective in paediatric ACL reconstruction; and predicting complications following cerebral palsy hip reconstruction

Aims

The Ponseti method is the gold standard treatment for congenital talipes equinovarus (CTEV), with the British Consensus Statement providing a benchmark for standard of care. Meeting these standards and providing expert care while maintaining geographical accessibility can pose a service delivery challenge. A novel ‘Hub and Spoke’ Shared Care model was initiated to deliver Ponseti treatment for CTEV, while addressing standard of care and resource allocation. The aim of this study was to assess feasibility and outcomes of the corrective phase of Ponseti service delivery using this model.

1. Talipes equinovarus is a specific type of club foot which has a genetic basis. Its occurrence along with certain neurological disorders has been noted. 2. An investigation of its incidence in 1,447 mental defectives, excluding those with cerebral palsy, revealed an incidence of 228 per 1,000, which is about ten times that for the general population. 3. There may be an upset early in embryonic development to account for the co-existence of both mental deficiency and talipes equinovarus

In the 1950s Frederick Dwyer evolved the concept of treating resistant and relapsed clubfoot by osteotomy of the calcaneum. He published the results of his medial opening wedge procedure in 1963 with a mean follow-up of five years. We present the structured, radiographic and functional results at a mean elapsed time of 27 years of 36 feet (26 patients) all operated on by Dwyer. Their mean Laaveg and Ponseti (1980) grading was 83.7%. In 94% the heel was in neutral or valgus and 86% of the feet were plantigrade. A good range of movement was present in the ankle and subtalar joints in 83%

Talipes equinovarus is one of the more common congenital abnormalities affecting the lower limb and can be challenging to manage. This review provides a comprehensive update on idiopathic congenital talipes equinovarus with emphasis on the initial treatment. Current management is moving away from operative towards a more conservative treatment using the Ponseti regime. The long-term results of surgical correction and the recent results of conservative treatment will be discussed

Aims

Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

A modified Lambrinudi arthrodesis is described which has given excellent results in forty-two out of the forty-four operations for the severest types of club foot

The October 2023 Children’s orthopaedics Roundup³⁶⁰ 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.

1. Two cases of congenital diastasis of the inferior tibio-fibular mortise are described. 2. No previous description of this condition has been found in the literature. 3. it is suggested that the cause is osteochondrosis of the distal tibial epiphysis associated with a club foot

1. An unusual muscle anomaly found during an operation for a severe club foot is recorded. 2. This muscle fitted the description of the flexor accessoreus longus and may add support to the phylogenetic theories of development of the long flexor muscles suggested by Wood Jones

1. The movements of the talus are described with particular reference to the anatomy of congenital talipes equinovarus. 2. It is suggested that the fundamental deformity in severe club foot is the fixed plantar-flexion of the talus. 3. Early operation is advised whenever serial stretching fails to bring the heel quickly into its normal position

1. The clinical and radiological features of thirty-two feet with congenital vertical talus are described and subdivided into groups determined by the presence or absence of associated abnormalities. 2. The differential diagnosis of congenital vertical talus from flat foot, talipes calcaneus and uncorrected club foot is discussed. 3. No benefit came from either non-operative treatment or tenotomy of the tibialis anterior