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Objectives We retrospectively investigated the clinical materials to seek the factors that lead to relapse after using the Ponseti method. Methods We retrospectively reviewed all children with congenital clubfoot treated with the Ponseti method in our hospital from June 2008 to June 2013. The data included the following factors: age, gender, initial Pinari score, number of casts, number of feet (unilateral or bilateral), age at the first casting, age of mother, tenotomy, walking age, and compliance with using bracing. All investigations were conducted in conformity with ethical standards. This study was approved by Guilin Peoples’ Hospital Ethics Committee. Results In this study, there were 148 cases (164 ft) in total that underwent the Ponseti method, with the follow–up period at least 5 years. Of them, 64 children presented with left side, 58 with right side, and 26 with bilateral cases. This study included 75 males and 73 females; sex did not affect the outcomes. The mean age of the first casting was 2.50 ± 2.15 months. The average initial Pirani score was 4.98 ± 1.33, and the average number of casts was 5.71 ± 2.28 times. The mean age of mothers at birth was 25.81 ± 2.38 years old. The walking age of children was at a mean of 14.83 ± 1.18 months. Forty-nine cases could not tolerate using braces, namely the rate of noncompliance in this study was 33.1%. Tenotomy was performed on 113 ft (76.4%). The average follow–up period was 7.27 ± 1.29 years (from 5 to 10 years). The rate of relapse was 21.6% (32 cases) at the end of the follow-up. The rate of relapse in the noncompliance with using bracing group was significantly higher compared to the compliance group . Conclusion The initial Pirani score, compliance with the foot abduction brace and the age at the first casting are three independent factors for relapse in clubfoot.

The adolescent neglected clubfoot is mostly treated in humanitarian programs by those with a great deal of surgical experience. This deformity needs a major correction, which can compromise the blood circulation and wound healing. A bony correction is preferable over an isolated soft tissue release. The extreme Lambrinudi arthrodesis with a double incision is therefore a preferred tool to correct a neglected clubfoot.

The Ponseti method for treatment of congenital clubfoot is well established and has been introduced in most pediatric orthopedic centers worldwide. However, reported rates of recurrence are largely variable and open joint surgery is still performed frequently, even in the age group younger than 6 years of age. Preventing recurrence and residual deformity can be achieved by strict adherence to the Ponseti method, ensuring and enforcing brace compliance, frequent follow-up, and early treatment of recurrence. This review discusses reasons for clubfoot recurrence, prevention of clubfoot recurrence, and the treatment of recurrent congenital clubfoot within the realm of the Ponseti method.

Congenital equinovarus clubfoot (EVC) is the second most common congenital anomaly of the musculoskeletal system in children and one of the most common causes of childhood disability in Ukraine. The frequency of EVC reaches 1–3 cases per 1 000newborns (35–40% of all foot deformities). Objective. To determine the features ofthe children ability with EVC recurrences, before and after surgical treatment by «traditional» methods and Ponseti method. Methods. Biomechanical examinations of 65 children with EVC recurrences were performed. They were divided into two groups: group I (33 patients) — treated by «traditional» methods, which provided initial surgery, in order to completely correct all components ofthedeformity; group II (32 patients) — treatment by Ponseti method. Weight-bearing function was studied for all patients, before treatment, after 6 and 12 months after surgery, with statography. Results. It was determined that thestanding parameters in thegroups were not statistically different. After 6 months after the treatment, according to the statograms, the weight-bearing displacement remained, under the conditions oftwo weight-bearing standing towards the contralateral limb, in both groups ofpatients. In group I, after treatment, this parameter did not change (p=0.924), and in group II it decreased by (2.7±4.7)% (p = 0.013). Weight-bearing on the operated limb in both groups, in 12 months from surgery increased by 45%. Conclusions. In patients, after treatment of EVC recurrences by Ponseti method, the weight-bearing function indicators, in the case of two weight-bearing standing, changed statistically significant. During the recovery process, when patients began to load the operated foot, a slight deterioration of standing parameters was observed in patients ofgroup I in 6months from surgery. In patients of groupII, acomplete restoration of statographic parameters occurred earlier, in 6 months, anormalization of weight-bearing and stability was observed. Thus, it can be argued that the use of Ponseti method in the complex treatment ofEVC allows to restore the ability ofweight bearing much earlier than with the «traditional» method. Key words. Congenital talipes equinovarus, children, Ponseti method, statography., Уроджена еквіноварусна клишоногість (УЕВК) є другою за частотою серед усіх уроджених аномалій кістково-м’язової системи в дітей і однією з найпоширеніших причин дитячої інвалідності в Україні. Частота УЕВК сягає 1–3випадки на 1000 новонароджених (35–40% усіх деформацій стоп). Мета. Визначити особливості опороспроможності дітей із рецидивами УЕВК до та після хірургічного лікування за «традиційними» методами та методикою Понсеті. Методи. Проведено біомеханічні обстеження 65 дітей із рецидивами УЕВК, яких розподілили на дві групи: І (33па­цієнти) — «традиційні» методи, які передбачали початкове хірургічне втручання для повного виправлення всіх компонентів деформації; ІІ (32) — методика Понсеті. Усім хворим до лікування, через 6 і 12 міс. після операції проводили дослідження опороспроможності методом статографії. Результати. Визначено, що параметри стояння в групах статистично не відрізнялися. Через 6 міс. після лікування за даними статограм відмічали збереження зміщення опори за умов двохопорного стояння у бік контралатеральної кінцівки в обох групах хворих. У І групі після лікування цей параметр практично не змінився (р=0,924), а у ІІ — зменшився на (2,7±4,7)% (р=0,013). Опора на оперовану кінцівку через 12 міс. після хірургічного лікування вобох групах збільшилася на 45%. Висновки. У хворих після лікування рецидивів УЕВК за методикою Понсеті показники опороспроможності в разі двохопорного стояння статистично значуще змінилися. У процесі відновлення, коли пацієнти починали навантажувати оперовану стопу, спостерігали незначне погіршення параметрів стояння впацієнтів Ігрупи через 6 міс. після операції. У хворих ІІгрупи повне відновлення статографічних параметрів відбувалося раніше, уже через 6 міс. спостерігали нормалізацію опор­ності та стійкості. Таким чином, можна стверджувати, що використання методики Понсеті вкомплексному лікуванні УЕВК дозволяє відновити опороспроможність нижніх кінцівок пацієнтів значно раніше, ніж застосування «традиційних» методів. Ключові слова. Уроджена клишоногість, діти, методика Понсеті, статографія

Background. In the case of relapses of congenital equinovarus clubfoot (CEVC) at the age of 3–10 years, the approaches to treatment differ significantly. Thus, the treatment of recurrent CEVC at the age of 3–10 years after primary conservative treatment by the Ponseti method is carried out with the transposition of the tendon of the tibialis anterior to the 3rd sphenoid bone. The treatment of recurrent CEVC in children of 3–10 years old after traditional methods of treatment is more complex and less effective. The purpose was to determine the features of the recovery of strength of the foot muscle groups in children with recurrent CEVC before and after surgical treatment by the Ponseti method and after traditional treatment methods. Materials and methods. Dynamometric studies were carried out in 65 children with recurrent CEVC. The patients were divided into 2 groups: group I (33 children) included traditional techniques, which included initial surgical intervention to completely correct all components of the deformity; group II (32 people) — Ponseti method. All patients underwent dynamometry of the muscle groups of the dorsal flexors and plantar extensors of the foot. The study was carried out before treatment, after 6 months, after surgery, and after 1 year. Results. The results of the study showed that in patients who were treated by the Ponseti method (group II), the strength of the dorsal flexor muscle groups of the foot increased statistically significantly (p = 0.002) to the 6th month after surgery. In patients who were treated by traditional methods, statistically significant changes in the strength of the dorsal flexors of the foot were observed only to the 12th month after surgery. In group I patients, a statistically significant increase (at the p < 0.05 level) in the strength of the muscle groups of the plantar extensors of the foot was observed at all stages of the study. In patients who were treated by the Ponseti method, a statistically significant (p = 0.028) increase in the strength of the plantar extensors of the foot was observed only at the first stage (up to 6 months). Subsequently, the increase in the strength of the muscles of the plantar extensors of the foot significantly slowed down and averaged 0.2 ± 2.3 kg, which is not statistically significant (p = 0.880). Conclusions. In children of group I, the increase in muscle strength occurs more slowly than in group II, and the percentage increase in muscle strength compared to the initial va-lues is much less. Twelve months after the operation, the ratio of the strength of the dorsal flexors to the plantar extensors is almost completely restored in children, which justifies the advisability of using the Ponseti method as the primary method of treating CEVC in children.

Purpose We aimed to compare our parent-based exercise programem's efficacy with the foot abduction brace (FAB) Ponseti manipulation as a retention programme. Methods We conducted this prospective multicentre cohort study between August 2009 and November 2019. The included children were allocated into one of two groups according to the retention protocol. The Pirani and Laaveg-Ponseti scores were used to assess the feet clinically and functionally. Radiological assessment was performed using standing anteroposterior and lateral radiographs of the feet. We assessed the parents’ satisfaction and adherence to the retention method. SPSS version 25 was used for the statistical analysis. Results A total of 1265 feet in 973 children were included. Group A included 637 feet managed with FAB, while group B included 628 feet managed with our retention programme. All patients were followed up to the age of four years. At the final follow-up, Pirani scores in group A participants were excellent, good and poor in 515, 90, and 32 feet, respectivel, while in group B the scores were excellent, good and poor in 471, 110 and 44 feet, respectively. The mean total score of Laaveg-Ponseti was 87.81 (sd 19.82) in group A and 90.55 (sd 20.71) in group B (p = 0.02). Group B participants showed higher satisfaction with the treatment method (p = 0.011) and more adherence to the treatment (p = 0.013). Conclusion The deformity's recurrence related to the brace's non-compliance in the Ponseti method might be reduced by substituting the brace with our home-based daily stretching exercises. Level of Evidence II

Objective.Based on an analytical assessment of the results of surgical treatment of children with equinovarus foot deformity of various origins (idiopathic clubfoot, syndromic clubfoot), to determine a way of rational selection of surgical techniquesin each specifc case.Materials and methods.The results of the treatment of 78 children with congenital idiopathic clubfoot over the period 2010–2018 were assessed in comparison with the results of the treatment of 41 children with recurrent congenital clubfoot, whose primary treatment had been carried out before 2010. We have gained the experience in treating 30 children with severe clubfoot syndrome (meningomyelocele, CNS lesions, chromosomal diseases and others).Results.In the treatment of congenital clubfoot with the Ponseti method, recurrences occur in 21.79 % of the cases, and in the traditional treatment — in 57.74 %. The Ponseti surgical treatment of recurrences consists in performing release operations on the tendon-ligament apparatus from mini-accesses. Cases of rigid, long-standing deformities require extensive releases on soft tissues, as well as resection and arthrodesis interventions on the joints of the foot. The treatment of clubfoot syndrome requires “surgically aggressive” methods of correction in early childhood.Conclusion.In the idiopathic variants of clubfoot and its relapses, it is possible to correct the vicious position of the feet by minimally invasive operations with minimal damage to the tissues of the circumflex joints and without damage to the flexor tendons and their sheaths in the medial ankle area. Long-standing recurrent rigid variants, as well as syndromic clubfoot, presuppose the performance of extensive releases, osteotomies and arthrodetic resections of the joints of the foot at an early age. A promising direction for clubfoot correction in the process of child development is a surgery with the use of the bone growth potential of the lower leg and foot.

BACKGROUND: In 2010, 2 authors of this current study reported the results of Ponseti treatment compared with primary posteromedial release (PMR) for congenital talipes equinovarus in a cohort of 51 prospective patients. This current study shows outcomes recorded at a median of 15 years after the original treatment. METHODS: Patient health records were available for all 51 patients at a median of 15 years (range, 13 to 17 years) following treatment of congenital talipes equinovarus with either the Ponseti method (25 patients [38 feet]) or PMR (26 patients [42 feet]). Thirty-eight of 51 patients could be contacted, and 33 patients (65%) participated in the clinical review, comprising patient-reported outcomes, clinical examination, 3-dimensional gait analysis, and plantar pressures. RESULTS: Sixteen (42%) of 38 Ponseti-treated feet and 20 (48%) of 42 PMR-treated feet had undergone a further surgical procedure. The PMR-treated feet were more likely to undergo osteotomies and intra-articular surgical procedures (15 feet) than the Ponseti-treated feet (5 feet) (p < 0.05). Of the 33 patients reviewed with multimodal assessment, the Ponseti group, compared with the PMR group, demonstrated better Dimeglio scores (5.8 compared with 7.0 points; p < 0.05), Disease Specific Instrument (80.7 compared with 65.6 points; p < 0.05), Functional Disability Inventory (1.1 compared with 5.1; p < 0.05), and American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Outcomes Questionnaire scores (52.2 compared with 46.6 points; p < 0.05), as well as improved total sagittal ankle range of motion in gait and ankle plantar flexion range at toe-off. The PMR group with clinical hindfoot varus displayed higher pressures in the lateral midfoot and the forefoot. CONCLUSIONS: Although the numbers of repeat surgical interventions following Ponseti treatment and primary PMR were similar, the PMR-treated feet had greater numbers of osteotomies and intra-articular surgical procedures. Functional outcomes were improved at a median of 15 years for feet treated with the Ponseti method compared with feet treated with PMR, with advantages seen in the Ponseti group over several domains. This study provides the most comprehensive evaluation of outcomes close to skeletal maturity in prospective cohorts, reinforcing the Ponseti method as the initial treatment of choice for idiopathic clubfeet. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

We questioned whether indications of Achilles tenotomy and standards of equinus correction as used for infants/young children hold true for use of the classical Ponseti technique in older children as well. Children aged 2-12 years with previously untreated unilateral/bilateral idiopathic clubfeet were included. For the purpose of this study, the subjects were treated by the classic Ponseti technique and underwent percutaneous tenotomy when talar head was reduced. A successful outcome and braceable feet were considered to be achieved when there was at least 10 degrees of ankle dorsiflexion post-tenotomy. The feet were classified into success and failure groups based on the above outcome and compared statistically. Furthermore, we documented the overall foot abduction and ankle dorsiflexion achieved post-tenotomy in older children. Final evaluations were done in 27 patients (39 feet; bilateral 12). Post-tenotomy, 16 feet (41%) constituted the success group. The average age (3.3 versus 5.8 years), foot abduction (39.4 versus 28.7 degrees) and ankle dorsiflexion (14.7 versus 4.1 degrees) for the success group were statistically different from the failure group. There were several residual foot deformities post-tenotomy, chiefly empty heel, varus, equinus and rotation. The reduction of lateral head of talus was not a reliable indicator for planning Achilles tenotomy in the older child. A 10-degree ankle dorsiflexion postclassical Ponseti method was achievable in only 41% feet for older children. Further, several residual deformities were present in treated feet post-tenotomy.

Idiopathic congenital talipes equinovarus is the most commonly encountered congenital deformity of the foot. Ponseti technique of manipulation is the treatment of choice. The Pirani classification is a reliable scoring system for clinical evaluation of clubfeet. The role of radiographic parameters in the evaluation and treatment of clubfeet is still controversial. The aim of this study was to evaluate the correlation of radiological parameters with clinical correction in patients with idiopathic clubfeet undergoing correction using Ponseti method. Between March 2018 and March 2019, 42 feet in 27 patients with idiopathic clubfeet were treated in our hospital. We used the Pirani scoring system for clinical evaluation. Anteroposterior and lateral views of the feet were taken before and after correction and at the last follow-up. The anteroposterior view was evaluated for the talocalcaneal angle and talo-first metatarsal angle, while the lateral view was only evaluated for the talocalcaneal angle. Twelve were boys (44.4%), and 15 were girls (55.6%). The deformity was bilateral in 15 patients (55.6%) and unilateral in 12 patients (44.4%). The average age was three months. According to the Pirani score, the mean Pirani Total score was 4.4 before correction and reduced to 0.4 after correction. The mean talocalcaneal angle in anteroposterior and lateral views was 15.1° and 7.8° before correction, increased to 32.7° and 31.8° after correction, respectively. The mean talocalcaneal index increased from 23.2 before correction to 64.5 after correction. The mean talo-first metatarsal angle in anteroposterior view improved from 25.7° before correction to − 1.6° after correction. The relation between the differences in Pirani scores before and after correction and the differences in measured radiographic parameters before and after correction revealed a statistically significant correlation. Radiographic parameters showed a statistically significant correlation with the clinical outcome. Thus, evaluation of clubfeet correction treated by Ponseti technique can rely mainly on clinical scores with limited utilization of radiological assessment.

BACKGROUND Pirani scoring system is one of the classification systems in management of club foot which is simple and easy to use. However, there is paucity of studies using Pirani system to determine the severity and monitor progress in the treatment of club foot. We therefore set out with the aim of assessing severity and monitoring the progress of treatment using the Pirani scoring system. The Pirani scoring system, together with the Ponseti method of club foot management, was assessed for its predictive value. METHODS It was a hospital-based prospective study of 57 club foot in 41 patients designed to evaluate the role of Pirani score in deformity assessment and management of club foot by Ponseti method. Consecutive patients presenting at the outpatient department at SVRRGGH, Tirupati with idiopathic club foot, and in-patients department with idiopathic club foot were recruited into the study. Informed consent was obtained from parents/guardians of the patients that were recruited in the study. This was a prerequisite for obtaining the ethical approval. Data collected from the study groups was entered into a worksheet, and analysis was performed using the statistical package for social sciences (SPSS) software for windows version 21. Significant statistical inferences were drawn at p & lt ; 0.05. RESULTS The correlation between the midfoot score, hindfoot score, Pirani score and the number of casts to achieve correction was significant (P = 0.001). Also, there was correlation between the Pirani score and the need for tenotomy (P = 0.001); between the number of casts to achieve correction and the need for tenotomy (P = 0.001). Moreover, the progress of treatment can be monitored with the Pirani score (P = 0.001). CONCLUSIONS Pirani scoring system is a simple, easy, quick and reliable system to determine severity and monitor progress in the treatment of club foot with excellent interobserver variability. KEYWORDS Pirani Score, Club Foot, Ponseti Method

Background Since Hippocrates, the treatment of idiopathic clubfoot has undergone many changes, with surgical techniques and conservative approaches evolving over the centuries. Today, a wide variety of practices exist in France and throughout the world; consequently, the treatment of idiopathic clubfoot remains controversial, but the Ponseti method and the functional method seem to stand out. Nevertheless, has one of them demonstrated superiority? Methods The purpose of this review is to compare these two methods. Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 recommendations, this research was conducted on Pubmed, Web of Science, and 1Findr. Only articles concerning patients with moderate or severe idiopathic clubfoot (10–17 on the Dimeglio scale) treated early using the Ponseti method or the functional method were eligible. Results After reviewing 49 studies, seven published between 2008 and 2018 were selected: five prospective cohort studies, one retrospective cohort study, and one meta-analysis. Each method, according to morphological and kinetic criteria, seems to have advantages that the other does not have. Conclusions Although the Ponseti method is becoming the gold standard and appears more appropriate in poor countries, it is impossible to affirm its superiority over the functional method. Therefore, the combination of their advantages deserves attention: a hybrid method could be an appealing prospect for the future.

Background The Ponseti method is the standard of care for managing idiopathic congenital talipes equinovarus (clubfoot) in the outpatient setting, but there are no clinical guidelines for inpatient treatment. Children in the neonatal intensive care unit (NICU) with clubfoot often delay treatment initiation due for medical reasons. Methods We systematically reviewed literature related to the treatment of clubfoot in the NICU, non-idiopathic clubfoot, and older infants, as well as barriers to care. Results In a mixed NICU population of syndromic and idiopathic clubfoot, the Ponseti method has good functional outcomes with minimal interference with medical management. The Ponseti method has good functional outcomes with reduced need for extensive surgical procedures in non-idiopathic clubfoot and idiopathic clubfoot with delayed presentation (under one year of age). Conclusions It is possible to begin Ponseti treatment in the NICU without compromising medical management. It is not clear if this confers an advantage over waiting for outpatient casting.

INTRODUCTION: The aim of this study is to assess the outcomes of ala carte posteromedial release in children over two years of age who were not responding to the Ponseti method of treatment of idiopathic clubfoot. MATERIALS AND METHODS: A retrospective observational study from September 2013 to August 2015 was conducted at a tertiary level medical teaching institution. The clubfeet were classified according to the Harold and Walker classification. Radiographic parameters assessed were the talocalcaneal angle (AP, lateral), talus-first metatarsal angle (AP, lateral) and calcaneal-fifth metatarsal angle. The scar and the functional score, according to Laaveg and Ponseti, were evaluated as outcome measures at the final follow-up. RESULTS: Twenty-four children with a mean age of 43.7 ± 24.7 months were enrolled in the study. There was a total of 36 clubfeet: 21 (65.6%) with a poor functional outcome; 12 (37.4%) with excellent to good scar in both horizontal and vertical components. There was a statistical significance between the pre-operative and post-operative radiological parameters (p

To compare the foot external rotation above-knee (FERAK) brace and the Denis Browne boot (DBB) brace in terms of relapse prevention and parents’ compliance after successful correction with Ponseti casting. A single-centre, randomized controlled study was conducted between 2016 and 2020. A total of 60 feet in 38 patients with idiopathic clubfoot initially corrected with the Ponseti method were included. They were randomized into two equal groups: the FERAK group and the DBB group. The primary outcome was the efficacy in maintaining correction measured by the Pirani score. The secondary outcomes were parents’ compliance and complications (e.g., relapses, skin complications). The follow-up period was 24 months for each patient. The mean final Pirani score was 0.42 ± 0.76 in the FERAK group and 0.57 ± 0.82 in the DBB group. This difference was statistically insignificant (p-value = 0.411). Regarding parents’ compliance in the FERAK group, 86.7% of parents had good and intermediate compliance while 13.3% had bad compliance. In the DBB group, 66.7% had good and intermediate compliance while 33.3% had bad compliance. This difference was also statistically insignificant (p-value = 0.118). Both braces achieved good comparable outcomes after Ponseti casting. However, the FERAK brace yielded slightly better parents’ compliance with a less recurrence rate.

In 2006, Ponseti modified the standard technique to treat cases of “atypical” and “complex” clubfoot. To determine the outcomes of Ponseti’s modified method to treat complex idiopathic clubfoot patients, we asked the following: (1) What is the deformity correction success rate? (2) What is the relapse rate after the correction? (3) What is the incidence of complications? We performed a systematic review by searching the EMBASE, MEDLINE, Cochrane Library, and Web of Science databases from inception to March 1, 2021. All studies on idiopathic, complex, and atypical clubfoot that assessed Ponseti’s modified technique were included. Of 699 identified articles, ten met the inclusion criteria. The mean index for non-randomized studies score for the included studies was 11.8 ± 1.7. Early detection of the deformity and modifying the standard protocol, as described by Ponseti, resulted in a high rate of success. Initial correction occurred in all children, with a mean ankle dorsiflexion of 15°. Relapse occurred often ranging between 10.5 and 55%. The incidence of complications associated with the modified Ponseti method ranged from 6 to 30%. Studies using the modified Ponseti technique have shown high initial correction rates and a smaller number of relapses. However, studies with prospective designs and long-term follow-up are required to conclude whether these observations are due to properly performing the modified method or if higher rates of relapse increase with further follow-up.

Andrei Corbu,1 Dan Ionut Cosma,2 Dana Elena Vasilescu,3 Dan Vasilescu,4 Stefan Cristea1 1University of Medicine and Pharmacy Carol Davila Bucharest, Romania, Department of Orthopaedics and Traumatology, Bucharest, Romania; 2Clinical Rehabilitation Hospital Cluj-Napoca, Department of Orthopaedics and Traumatology, Cluj-Napoca, Cluj, Romania; 3University of Medicine and Pharmacy Iuliu Hatieganu, Cluj-Napoca, Romania; Department of Orthopaedics-Traumatology and Paediatric Orthopaedics, Cluj-Napoca, Cluj, Romania; 4Clinical Emergency Hospital Cluj-Napoca, Department of Radiology and Imaging, Cluj-Napoca, Cluj, RomaniaCorrespondence: Dan VasilescuClinical Emergency Hospital Cluj-Napoca, Department of Radiology and Imaging, Clinicilor 3-5, Cluj-Napoca, Cluj, RomaniaTel +40 264 592 771Email danvasi76@yahoo.comPurpose: One of the main features of congenital idiopathic clubfoot is the increased stiffness of soft tissues. With the growing popularity and availability of sonoelastography as a method to assess the stiffness of different tissues, we considered applying it to congenital clubfeet in order to to determine whether sonoelastography can be a useful imaging method for the evaluation of clubfeet, to assess whether there are any differences in stiffness of specific tendons between clubfeet and normal contralateral feet and to observe which treatment methods have an impact on the aspect of these structures on the elastograms.Patients and Methods: A case-control study was performed involving 10 adolescent patients with unilateral idiopathic congenital clubfeet who were treated either with the Ponseti method or surgically with posteromedial release (PMR) during early infancy. Using compression sonoelastography, we obtained semi-quantitative data expressed as fat to tendon ratios in treated clubfeet and normal contralateral feet. The tendons of the following muscles were examined: tibialis anterior, tibialis posterior, flexor hallucis longus, peroneus longus and Achilles tendon at three levels (calcaneal insertion, lengthened zone and musculotendinous junction).Results: The only statistically significant difference in the strain ratio (p = 0.023) between clubfeet and normal feet was at the level of the calcaneal insertion of the Achilles tendon, which was stiffer in clubfeet. Although other differences were not statistically significant, they may reflect some of the pathological modifications of clubfeet.Conclusion: Overall, sonoelastography may be a useful examination tool in the quantitative and qualitative assessment of soft tissue stiffness in clubfeet, but further research is necessary.Keywords: soft tissue elasticity, stiffness, tendons, clubfoot, ultrasound, elastography, Achilles tendon

The Ponseti method has revolutionized clubfoot treatment. Though completely neglected clubfeet are now rare, partially or incompletely and improperly treated feet are not uncommon. Relapses after successful correction may occur due to non-compliance with bracing. In scarred soft tissues due to previous surgery, soft tissue distraction using external fixation helps achieve correction. The Ilizarov fixator permits us to follow the Ponseti protocol, using correction methods that may either be constrained or unconstrained by hinges. Applying force vectors perpendicular to the moment arm allows us to correct the еquinus without damaging the ankle joint. All of the above is possible when the talus is round. Full correction of the deformity is possible. However, longterm follow-up of these patients has revealed stiffness of the ankle setting and frequently with tibio-talar osteophytes anteriorly. They are probably a reaction to excessive pressure developed in the joint due to the tight soft tissues. Hence the author has now added a mild shortening of the tibia and fibula to reduce soft tissue tension, rather than resorting to further soft tissue releases through scarred tissues. This allows faster correction with the Ponseti-Ilizarov protocol and allows good ankle range of motion to persist.

Background and objective: The accelerated protocol of Ponseti method was suggested to shorten the period of treatment of the conventional one for the cases of talipes equinovarus deformity. This study aimed to compare the accelerated protocol of Ponseti method in the treatment of clubfoot deformity with the conventional one. Methods: A prospective comparative study was conducted for infants less than six months with congenital talipes equinovarus deformity. The patients were randomized to either Group 1 (casts changed every week, conventional protocol of Ponseti method) or Group 2 (twice weekly, accelerated one). Pirani score was used to assess the severity of the deformity at presentation, at time of last cast removal, and at the last follow up visit (6th months). Results: The patients included were 48 cases with 79 feet. Group 1 (39 clubfeet) had a mean Pirani score of 5.6 (± 1.15) at presentation, which dropped to 0.47 (± 0.41) when the last cast was removed. In Group 2 (40 clubfeet), it dropped from 5.57 (± 0.83) to 0.77 (± 0.01). The result of each treatment protocol was significant, but the difference between them was not significant. Five cases (three patients aged more than three months) of Group 2 needed eight casts to reach an acceptable position of correction. The difference between the mean number of casts applied in Group 1 (5.09) and Group 2 (5.82) was statistically not significant. However, the difference between the mean number of days spent in the cast was significant. The complications occurred in 12 out of 79 feet, with no statistically significant difference between both groups. Conclusion: The accelerated protocol of Ponseti method for treating clubfoot deformity is as effective and as safe as the conventional one. It shortens the time required to complete the treatment program. Those who present lately (beyond the age of three months) may require an additional number of casts. Keywords: Clubfoot; Congenital talipes equinovarus; Ponseti; Accelerated; Cast.

BACKGROUND Though the Ponseti method has become the popular and standard of care for clubfoot correction, relapse of clubfoot deformity following correction is not uncommon. The relapsed feet can progress from flexible to rigid if left untreated and can become as severe as the initial deformity. The purpose of this study was to analyse the relapse pattern in clubfeet that have undergone treatment with the Ponseti method. METHODS Between 2015 and 2017, 78 children (134 feet), 58 boys and 20 girls were included in this study. It was a prospective observational study of relapse patterns in idiopathic clubfoot after one year of completion of the Ponseti method of treatment. Pirani scoring system was used to identify the relapse. RESULTS Dynamic, fixed, and complete relapse patterns were observed in this study. Patients were categorised into two groups - bilateral and unilateral. In the bilateral group, 18 children (36 feet i.e. 23 %) had decreased ankle dorsiflexion, 5 had (10 feet i.e. 6 %) rigid equinus, 22 had (44 feet i.e., 29 %) dynamic forefoot adduction or supination and 5 had (10 feet i.e. 6 %) fixed adduction in forefoot and midfoot. Six children from the bilateral group showed complete relapse. Among the unilateral group, 8 children (8 feet i.e. 36 %) presented with decreased ankle dorsiflexion, 4 had (4 feet i.e. 18 %) rigid equinus relapse, 6 had (6 feet i.e. 27 %) dynamic forefoot adduction or supination and 4 had (4 feet i.e. 18 %) showed fixed forefoot adduction. CONCLUSIONS Dynamic forefoot adduction or supination pattern is common to relapse pattern in the bilateral group and dynamic hind-foot relapse was common in the unilateral group. Age at initial presentation, initial Pirani score, and the number of casts required were not significantly related to the incidence of relapse. KEYWORDS Club Foot, CTEV, Ponseti Method, Relapse Pattern

Congenital clubfoot is a common congenital malformation, whose conservative treatment using the Ponseti method achieves excellent initial correction rates and good long-term results. On the other hand, neglected clubfeet, which are typically more frequent in underdeveloped and developing countries, pose treatment difficulties and render corrective surgery necessary. The main problems with correction are raised by the increasing stiffness present in the soft tissues and the dysplastic development of bones. Furthermore, the hyperlaxity of young children decreases with growth, contributing to the reduced overall elasticity of the affected soft tissues and clubfeet. Deciding upon which type of treatment would be appropriate is not always facile. In our clinic, we tend to start the treatment of neglected clubfeet with the modified Ponseti method, which can achieve partial correction or full correction in most cases, diminishing the need for extensive surgical procedures. The case report of a long time neglected bilateral clubfoot successfully corrected using the modified Ponseti method is presented below, followed by a relevant review of the literature.

The objective of the study was to evaluate minimally invasive methods in treatment of congenital clubfoot. Congenital talipes equinovarus (CTEV), or clubfoot, is the most common congenital foot deformity, occurring in 1 to 2 in 1000 live births. CTEV etiology is not yet completely clear. Essentially, the deformity is the result of an intrauterine dislocation of the joints between the talus, calcaneus, navicular and cuboid bone and it includes four components: cavus, adductus, varus and equinus (CAVE). The diagnosis is made by a clinical examination and foot radiography. The treatment is based on the repositioning of the dislocated joints. There are different treatment modalities available, from conservative to exclusively surgical CTEV treatment. The Ponseti method is a primarily conservative treatment method using corrective long-leg casts, sometimes associated with minimal surgi­cal intervention - Achilles tenotomy, followed by the use of an abduction brace. If needed, less invasive surgery (“a la carte”) might be used to correct uncorrected components of CTEV. Based on the reports published from 2010 to 2020, as retrieved from databases (PubMed, Medline, Scopus), pertaining mostly to conservative treatment methods and primarily to the Ponseti method and based on the comparison between the Ponseti method and surgical methods of treatment, as well as other conserva­tive methods of treatment, it can be concluded that the Ponseti method is the method of choice for the treatment of congenital CTEV in children today. Conclusion − The Ponseti treatment method, if used on time, fulfills all requirements that are expected from a contemporary medical procedure: simplicity in performance, minimally invasive, wide availability, cost effectiveness and successful treatment results.

BACKGROUND Amniotic band syndrome (ABS) is a congenital disorder resulting in fibrous bands that can cause limb anomalies, amputations, and deformities. Clubfoot has been reported in up to 50% of patients with ABS. The purpose of this study is to compare treatment characteristics and outcomes of clubfoot patients with ABS to those with idiopathic clubfoot treated with the Ponseti method. METHODS An Institution Review Board (IRB) approved retrospective review of prospectively gathered data was performed at a single pediatric hospital over a 20-year period. Patients with either idiopathic clubfeet or clubfeet associated with concomitant ABS who were

Objective: In our study, it is aimed to remove the cast more easily and safely without using the cutting tools by leaving the cast ends marked by folding in the idiopathic clubfoot patients treated with Ponseti method. Material and Methods: Forty feet of 29 patients treated for Pes Equinovarus were included in the study. Patients were followed up in two groups. The group treated with Ponseti method by cast marking were named as “modified group” and cast wrapped group without marking were named as “classical group”. Neurological, teratologic and syndromic clubfoot patients were not included in the study. During the six series of casting, cast removal times for each extremity are recorded in minutes and it is noted that whether any additional cutting tool is used during cast removal or not. A summary of the data was presented as mean, standard deviation and percentage. Comparisons of the categorical characteristics were analysed by using the Chi-square test and the Mann-Whitney test. IBM-SPSS 20 program was used for analysis. In all tests, the level of significance was adjusted to 0.05. Results: Thirteen (44.8%) of the 29 patients were male and 16 (55.2%) were female. While the mean time to start treatment for the 15 patients in the modified group was 3.46 (2-7) days, mean time for the 14 patients in the classical group was 3.78 (2-10) days. While the mean cast removal time of the 20 extremities of 15 patients in the modifying group was 10.9 minutes (8-14.3 min);it was 22.2 minutes (17.1-29.5 min) for the 20 extremities of 14 patients in the classical group. While no additional cutting tool was used during cast removal in the modified group, additional cutting tools were used during removal of cast in 75% (15/20) of the patients in the classical group and statistically significant difference was found between two groups in terms of the use of cutting tools (p

In the last decade, the Ponseti method has been recognized by most orthopedists around the world as the gold standard for clubfoot treatment. However, the efficiency of the Ponseti method in relapsing forms of congenital clubfoot in children has been under-examined. We analyzed 103 patients with relapsing clubfoot, aged 1 to 9 years, who were treated at the National Center of Rehabilitation and Prosthetics of the Disabled from 2017 to 2019. These patients had a relapse with typical clubfoot contractures without multiplanar deformity of the feet. The treatment process consisted in the application of the method of I. Ponseti for all patients; if indicated, transplantation of the tendon of the anterior tibial muscle was performed.

The Ponseti method of clubfoot treatment has revolutionized the clubfoot treatment. Participation of non-government organizations (NGOs) has helped expand the reach of clubfoot treatment and improve the outcomes. Establishing new clubfoot clinics may have their teething problems, which need to be anticipated and addressed for their efficient functioning. This retrospective observational study was performed using records of children enrolled in the initial 4 years of an NGO supported clubfoot clinic at a teaching public hospital. Patient details were analyzed to act as surrogate indicators of the challenges faced in the efficient delivery of care at this new clubfoot clinic. Furthermore, the authors’ suggestions would help other clinicians in starting a clubfoot clinic more effectively. Three hundred eighty-four children were enrolled in the initial 4 years. Two hundred ninety-seven children completed their cast treatment. Two hundred four (53.12%), which was more than half of all the enrolled children, had received some prior treatment. Only 86 (22.4%) children followed up for 4 years or more. A high dropout rate at different stages of treatment and follow-up was also noticed. The high dropout rate with the knowledge that most of the enrolled children had some prior treatment points to the clinicians’ and counselors’ failure to educate the parents. Electronic instead of manual data entry would play a role in tracing children in the setting of a new clubfoot clinic. A dedicated team of clinicians and counselors right from the beginning would help in gaining parental trust. Field visits by volunteers might be a useful additional strategy in improving the follow-up and the overall results.

Background. The standard Ponseti method is a mainstay of treatment for children with congenital talipes equinovarus (CTEV); involving weekly manipulation and long-leg casting, this approach has proven to produce good long-term outcomes. However, it takes approximately 45 weeks to correct all deformity components, making compliance a challenge for patients with limited economic resources and difficulty reaching healthcare centres. Aim. This study aims to compare treatment outcomes between standard Ponseti and an accelerated protocol applying the same casts but changing them more frequently, every 2-5 days for the CTEV pathology. Methods. A systematic search was conducted based on PRISMA guidelines to identify relevant studies through PubMed, Google Scholar, and Cochrane Database. A total of seven studies (324 patients, 408 feet) were included in the meta-analysis. Five outcomes were compared between the two procedures: post-procedure Pirani score, relapse rate, tenotomy rate, number of casts, and total duration of treatment. Results. For total duration of treatment, the accelerated Ponseti method was superior to standard Ponseti (24.25 vs. 41.54 days, p 0.00001). On the other hand, it achieved comparable efficacy as measured by post-procedure Pirani score (1.01 vs. 0.87, p = 0.19). Furthermore, the two procedures were also comparable in terms of the total number of casts needed (4.94 vs. 5.05, p = 0.76), tenotomy rate (73.29% vs. 65.27%, p = 0.07) , and relapse rate (27.72% vs 25.23%, p = 0.56). Conclusion. Accelerated Ponseti offers similar efficacy and shorter duration of treatment compared to the standard Ponseti technique.

Background: Congenital idiopathic clubfoot is a complex deformity which occurs in an otherwise normal child. The Ponseti method of clubfoot management has been shown to be effective, producing better results and fewer complications than traditional surgical methods. Weekly manipulation and plaster casting reduce the deformity. Most feet also require a percutaneous Achilles tenotomy. The correction is maintained by a foot abduction brace (Dennis Browne splint). Recent studies suggest that the Ponseti method can be successful in up to 98% of feet. Objective: The purpose of this study was to assess the results of correction of idiopathic clubfoot by Ponseti method and its complications in children below 2 years of age. Methodology: It is a prospective study in 37 children below 2years of age with idiopathic clubfoot treated by Ponseti method. The study was conducted from august 2016 to august 2018 in Yashoda Superspeciality Hospital, Hyderabad. Observation and Analysis: The mean age of the patient’s was 35 weeks (0-120). Of 37 patients, 25 children presented between 0-6 months, 6 between 6 to 12 months and 6 between 1- 2 years. Among 37 children, 29 were male and 8 were female. Most children had grade III and grade IV (Dimeglio et al. grading) deformity. The average number of casts was 5.1, 5.5 and 7.4 for the age groups 0-6 months, 6 months to 1 year and 1-2 years respectively. The mean number of casts required was 5.76 (4 to 10). Tenotomy was required in 51 feet (100%). The scores for the entire group ranged from 4.0 to 7.0 (of 10) and 4 to 19 (of 20) in the Dimeglio classification. Pirani scores for the age group 0- 6 months were 4.46, 6 months to 1 year were 5.36 and 1-2 years were 5.75 respectively. The results were excellent in 88.3% and good in 11.7%.The mean of initial and final Pirani score is 3.52083 with a ‘ p’ value is 0.000 which is less than 0.01 hence they are statistically significant. Conclusion: Congenital talipes equinovarus (C.T.E.V) is the commonest of all the foot deformities being commoner in male children and bilateral in 66% of cases, idiopathic type being the commonest form. We conclude that the Ponseti method is safe and effective treatment for congenital idiopathic clubfoot in children up to 6 years of age.

Background: Many authors have highlighted the role of muscle strength imbalance around the ankle in the development of recurrent clubfoot following Ponseti treatment. However, this possible underlying mechanism behind recurrence has not been investigated sufficiently to date. This study aimed to explore whether there is a relationship between Achilles tendon elongation and recurrent metatarsus adductus deformity in children with unilateral clubfeet treated by the Ponseti method. Methods: A retrospective chart review was performed on 20 children (14 boys and six girls; mean age, 7 years; age range, 5–9 years) with a recurrent metatarsus adductus deformity treated by the Ponseti method for unilateral idiopathic clubfoot. At the final follow-up, isometric muscle strength was measured using a portable, hand-held dynamometer in reciprocal muscle groups of the ankle. The length of the tendons around the ankle was measured ultrasonographically. Results: The plantarflexion-to-dorsiflexion ratio was lower on the involved side (P = .001). No significant differences in the strength ratio of inversion to eversion were found (P = .4). No difference was observed in lengths of tibialis anterior and posterior tendons (P = .1), but the Achilles tendon was longer on the involved side (P = .001; P < .01). A significant negative correlation was discovered between involved-to-uninvolved Achilles tendon length ratios and involved-to-uninvolved plantarflexion strength ratios (r = –0.524; P = .02) Conclusions: Achilles tendon elongation may be a contributor to the muscle imbalance in clubfeet with relapsed forefoot adduction treated by the Ponseti technique.

Introduction: Ponseti method has become the mainstay of congenital clubfoot treatment in children presenting at early age. The initial efficacy rate of Ponseti method reaches almost 100%. The Ponseti method is also effective in older children with varied degree of success and preventing open joint surgery in almost every case. The Pirani method of evaluating the deformity and treatment outcome is easy and fairly reproducible and corresponds to the functional outcome of the treated feet. Aim: The present study aims at elucidating the efficacy of Ponseti method of clubfoot correction in an inexperienced hand and evaluating the feasibility and worth of Pirani severity scoring system in deformity and treatment evaluation. Materials and Methods: This is a prospective study carried out ii our institution Shri Guru Ram Rain Medical College Dehradun, India over a period of 2 ½ years from June 2015 to December 2017 and includes 44 idiopathic Clubfeet corrective cast application at weekly interval as per Ponseti protocol and were assessed with Pirani scoring system. The cases were followed up regularly at least for 6 months. Results: Following Ponseti protocol, we were able to achieve success rate of 95.45%. We experienced only a few minor complications such as plaster sores and overcrowding of toes that too in initial phase of study. Conclusion: Ponseti method is truly the gold standard of clubfoot management. Using Ponseti method, one can expect to achieve almost 100% success rate. It is also fairly effective in older children though with varied outcome or can at least prevent open joint surgery in them. The Pirani scoring system is clinical based, easy to apply and is in sync with Ponseti method. Keywords: Clubfoot, Ponseti method, Pirani score.

Objective: To analyze the profiles of the individuals who access the website regarding congenital clubfoot (CC) information and the first ten years of Ponseti method implementation in Brazil. Methods: This is a retrospective documentary study, with quantitative database analysis, from 2002 to 2012. Parents or caregivers completed a semi-structured questionnaire regarding the main difficulties encountered, the search for different professionals in the area, and what were the main questions the reader might have when searching on a technical website. Results: In total, 94% of participants had a family member or acquaintance with CC, most participants were women (74%), higher education level (40%), married (75%), income above one minimum wage (80%), working in administrative positions (21%,) and living in the urban area (99%). Of the participants, 44% sought three or more physicians at the beginning of treatment, and an average of 77% of the participants used health insurance or a private physician. Conclusion: The participants’ profile regarding CC is composed of women, married, living in urban areas, predominantly from Southeastern Brazil, higher education level, with income above 1.5 minimum wages, and who were treating their children with a private physician. Level of Evidence II, Retrospective study. RESUMO Objetivo: Analisar o perfil de indivíduos que acessam o site de informações sobre o pé torto congênito (PTC) e o tratamento do Método Ponseti nos primeiros dez anos da implantação do método no Brasil. Métodos: Trata-se de um estudo retrospectivo com análise de bases de dados, de caráter quantitativo, de 2002 a 2012. Aplicou-se um questionário semiestruturado que abordou as dificuldades encontradas, busca por diferentes profissionais e quais eram as principais dúvidas. Resultados: dos respondentes, 94% tinham algum familiar com PTC, os respondentes foram 74% do sexo feminino, 40% com ensino superior, 75% casados(as), 80% com renda acima de um salário mínimo, 21% de cargos administrativos e 99% residentes em área urbana. Dos respondentes, 44% procuraram três ou mais médicos no início do tratamento, e, em média, 77% fizeram o tratamento usando convênio médico ou usando médico particular. Conclusão: O perfil de indivíduos que acessam o site de informações sobre PTC e o tratamento do Método Ponseti é composto de respondentes do sexo feminino, casadas, residentes em área urbana, predominantemente do sudeste do Brasil, com ensino superior, com renda acima de 1,5 salários mínimos, e que estavam tratando seus filhos pela rede de saúde particular. Nível de Evidencia II, Estudo retrospectivo.

Objectives A prospective study to find a correlation between the severity of clubfoot and the number of casts required for the correction was conducted. The relationship of early relapse with the severity of the deformity was also studied. Materials and methods A total of 42 infants (61 feet) with primary and idiopathic clubfeet were included in the study. Previously treated and clubfeet due to secondary causes were excluded. All clubfeet were treated by the Ponseti method, and the Pirani score, Dimeglio score and Foot Bimalleolar (FBM) angle were taken at presentation and before every casting and at 6 months of follow-up. Results The average age of the child at presentation was 24 days, the average initial Pirani score was 4.172, the average initial Dimeglio score was 14.36 and the average FBM angle was 63.87 degrees. The average number of corrective casts given was 5.08 (range 2-8). The regression analysis showed a low correlation between Pirani and Dimeglio scores with the number of casts. There was no correlation between FBM angle and casting. Eleven of the 61 feet had a relapse (18%). Ten of 11 relapsed feet had a midfoot Pirani score of equal to or more than 2. Conclusion The regression analysis shows a low correlation between Pirani and Dimeglio scores with the number of casts. There was no correlation between FBM angle and casting. Midfoot score equal to or more than 2 is a significant risk factor for relapse.

Background: Clubfoot occurs in approximately 1 in 1000 live births and is one of the most congenital birth defects. The Non operative technique for the treatment of idiopathic club foot is described by Ponesti as a popular method. Tenotomy is on integral step of this method. The purpose of this study was to evaluation of predictive factors for tonotomy at the initiation of the Ponesti treatment. Methods: In this descriptive cross-sectional study, all patients with idiopathic clubfoot under the age of 6 months who had referred to the orthopedic clinic of Imam Khomeini Hospital in Urmia from April 1 to March 2017, and were treated by pontic method, were included in the study. Parametric statistical tests such as chi-square and t-test were used. The significance level for all tests was below 0.05. All analyzes were performed using SPSS software version 21. Results: Tenotomies were performed in 39 feet of 52 feet (75%). Of 22 feet with initial Pirani scores ≥ 5.0, 95.5% required a tonotomy. Of 11 feet with an initial scores≤2.5, only 18.2% required a tenotomy. There was a significant difference between the need for tenotomy and severity of the deformity at onset of treatment (P

Background. Compliance with the foot abduction brace (FAB) is essential for idiopathic clubfoot (ICF) managed by the Ponseti method. The deep squatting posture (DSP) was correlated with favorable outcomes in ICF. Aim. The aims of the study were to identify the noncompliance rate with the FAB, and assess how the routine practice of ankle stretching and Asian-style DSP affected the ICF correction during the Ponseti method. Materials and methods. Of 42 children with ICF, 63 ICF underwent the Ponseti method at an average age of 8.7 12.6 weeks using an average of 5.4 1.7 casts followed by FAB wear. The children practiced the DSP exercise as an adjunct to the FAB protocol. Children noncompliant with the FAB protocol but compliant with the DSP exercise (group A) were compared with children noncompliant with both FAB protocol and DSP exercise (group B). Results. At an average follow-up of 3.5 1.4 years, 8 of 42 children compliant with the FAB protocol. The FAB protocol deviation was documented at an average of 10.3 4.8 months. Children who did not adhere to the practice of the DSP exercise had a higher recurrent rate of any ICF deformity (OR 7.82, 95% CI 1.3553.79, p = 0.003). Of the 34 children (48 feet) noncompliant with FAB, the children in group A (39 feet) had lower recurrence rate (p = 0.02), a better Dimeglio grade (p = 0.005), and a better Pirani score (p 0.001) at the most recent evaluation than children in group B (nine feet). However, recurrent metatarsus adductus was more prevalent in group A. Conclusion. The DSP exercise should be advocated as a supplemental modality but cannot substitute the regular use of FAB.

Objective: To assess the effectiveness of Pirani scoring system in predicting the need of percutaneous Achilles tenotomy in cases of idiopathic club foot. Study Design: Case control study. Place and Duration of Study: Orthopaedic department of CMH Kohat, from Mar 2017 to Aug 2018. Methodology: This study included newborn babies to the age of 3 months with idiopathic club foot. The patients were treated by Ponseti method. The Pirani Score was calculated at initial presentation before starting treatment with casting according to Ponseti method. After three months percutaneous tenotomy was performed based on progression. The data was analyzed by applying unpaired t-test to determine the statistical significance keeping p-value

Purpose Although many short-term studies have shown the superiority of Ponseti treatment to surgical treatment, studies with long-term follow-up of patients into adolescence are lacking. The aim of this study was to compare the morphological, functional and radiological results of the two methods into and during adolescent age, when both soft tissue and bony procedures can be performed to correct residual deformities. Patients and Methods We retrospectively evaluated two groups of patients diagnosed with congenital idiopathic clubfoot and treated with either the Ponseti method (34 clubfeet) and surgery in the form of posteromedial release (31 clubfeet). All included clubfeet were clinically fully corrected after initial treatment and final plaster removal. Evaluation was performed with the International Clubfoot Study Group (ICFSG) score. Results The age at follow-up was 12.8±1.6 years in the Ponseti group and 13.5±1.7 years in the surgical group. Excellent or good results were obtained in 26 feet (76%) of the Ponseti group and in 14 feet (45%) in the surgical group. The Ponseti treatment was significantly superior to posteromedial release in terms of the final score (10.58±6.49 versus 17.26±8.83, p

The aim of this study is to evaluate children in middle childhood with clubfoot treated with Ponseti method vs posterior-only release and to compare their results to a control group with 4 modules (physical examination, gait study, radiographic measurements, and questionnaires). From 01/01/2004 until 01/01/2009, 31 children (45 feet) were treated with the posterior-only release protocol and 22 patients (34 feet) were treated with the Ponseti method. In 2016, patients were evaluated and compared with 25 children without neuromuscular disorders. Parents completed 3 outcome questionnaires. Radiographs evaluated residual deformity and osteoarthritis. A physical examination and a 3-dimensional gait analysis were performed to evaluate range of motion, kinematic, and kinetic data. Recurrence rate was similar between treatment groups; however, type of surgery to treat residual deformity was more aggressive in the posterior-only release (91% required major surgery), p?=?.024. Radiographic examination showed similar residual deformity with greater hindfoot varus in posterior-only release (68%), p?=?.02. Reduced cadence, increased stance dorsiflexion, calcaneus gait and forced eversion prior to swing were the main characteristics of gait in posterior-only release. Four (11%) feet treated with posterior-only release vs 11 (33%) feet treated with Ponseti method had a normal gait, p?=?.016. Our study showed that biomechanical function and long-term outcomes of children in middle childhood treated with the Ponseti method more closely compare with healthy individuals than those treated using posterior-only surgical technique. Copyright © 2020 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

BACKGROUND: A prospective study of motor milestones achieved in severe clubfeet treated by Ponseti method and comparison between unilateral and bilateral clubfoot will help us gain further insight of motor milestones in these children. METHODS: Prospective study of 150 consecutive children with idiopathic clubfoot who were treated by Ponseti method and in whom percutaneous tendoachilles tenotomy was performed. The gross motor milestones recorded were: rolls from back to stomach, sitting without support, standing with assistance, walks with assistance, standing alone, walking alone. This was compared with published regional and World Health Organization (WHO) normal data. RESULT: 15 patients were excluded due to non-compliance and recurrence. Children with unilateral clubfoot (80 children) and bilateral clubfoot (55 children) showed a delay of 0.2–2.1 months in various milestones, and this was statistically significant when compared with both normal data. 95% children with unilateral clubfoot had independent ambulation by 17 months and in bilateral ambulation by 17.8 months. There was also a statistically significant difference in unilateral and bilateral clubfeet in all variables except sitting without support and walking with support. CONCLUSION: There is a delay in achievement in all children with clubfoot, with more delay in bilateral clubfoot as compared to unilateral clubfoot. The probable reasons could be plaster treatment, possible weakness due to tendoachilles tenotomy, use of orthosis or the inherent pathology associated with clubfeet. Parents hence need to be explained about this delay.

Background: CTEV (Clubfoot) is the most common congenital orthopaedic condition of lower limb and being treated worldwide by the Ponseti method. The treatment is started as soon as possible after birth. Despite treatment with ponseti method many patients develop relapse during follow up. A study was conducted with the aim to find out pattern of relapse and its subsequent management. Methods: It is a Oupatient department based retrospective (Medical Record) along with prospective (Follow-up) study design,during period of June 2017 to November 2018 with medical record data since year 2012 of all enroled CTEV relapse cases. The method used for the management was serial manipulation and long leg plaster of Paris casting after getting the Pirani score at every visit. Results: A total of 30 children (with age 0-5 year) with relapsing CTEV were selected and treated with Ponseti method. Patients showed a significant decrease in the mean Pirani score post treatment. Conclusion: Ponseti method in management of relapsing CTEV showed excellent results (82%) followed by good (17%) and fair (1%).

Background In recent decades, nonoperative Ponseti casting has become the standard of care in the treatment of idiopathic clubfoot. However, the rate of recurrence, even after successful Ponseti treatment is not insignificant. The purpose of this study was to determine the future rate, timing, and type of surgery needed in patients whose idiopathic clubfeet treated by Ponseti casting were considered successful at the age of 2 years. Methods Inclusion criteria for this retrospective study were patients under 3 months with idiopathic clubfoot treated exclusively by Ponseti casting, who had successful outcomes at 2 years of age without surgery, and who had at least 5 years of follow-up. The total number of surgical interventions in the age range 2 to 5 and above 5 years, the number and type of procedures performed, and the timing of surgery were reviewed. Results Three hundred thirty-six patients with a total of 504 clubfeet fulfilled the inclusion criteria. One hundred twenty-two of these 336 patients (36.3%) eventually underwent surgical intervention. Between 2 and 5 years of age, 79 patients (23.5%) with 104 feet (20.6%) underwent surgery. The most common procedures performed between 2 and 5 years were limited (a la carte) in scope: tibialis anterior tendon transfer, posterior release, plantar fascia release, and repeat tendo-Achilles lengthening. At age above 5 years, 53 patients (20.1%) with 65 feet (16.9%) underwent surgery. Ten of these 53 patients had already undergone surgery between 2 and 5 years of age. The procedures most commonly performed were similar. Conclusions In patients with idiopathic clubfoot who reached 2 years of age with successful outcomes from Ponseti cast treatment, ∼35% eventually underwent surgical intervention, mostly limited (a la carte), to regain or maintain a plantigrade foot. The most commonly performed procedures include tibialis anterior tendon transfer, posterior capsular release, plantar fascia release and repeat tendo-Achilles lengthening, either in isolation or in combination. However, before considering surgery, the need for these procedures can, and should, be minimized by recasting recurrent deformities using Ponseti method. Level of evidence Level III.

Clubfoot is a complex 4-dimensional deformity involving the hindfoot, midfoot, and forefoot. The fourth dimension is time. Treatment aims at achieving a pain-free, plantigrade, and mobile foot but, over time, flexible deformities become fixed and more difficult to manage. The Ponseti method of serial manipulation and casting can be used successfully in older children and may reduce the need for extensive open surgery. Alternatively, gradual correction of by an external device enables simultaneous correction of all components of the deformity without shortening the foot. Combining gradual soft tissue distraction with open releases and/or bony procedures may achieve a pain-free and plantigrade foot.

Background The procedure of percutaneous Achilles tenotomy (PAT) is an important component of the Ponseti method. However, few studies reported the influence of Achilles tendon on kinematic coupling relationship between tarsal bones. The purpose of present study was to demonstrate the effect of Achilles tendon on the kinematic coupling relationship between tarsal bones, and to illustrate how kinematic coupling relationship between tarsal bones works in term of finite element analysis. Methods A three-dimensional finite element model of foot and ankle was constructed based on the Chinese digital human girl No.1 (CDH-G1) image database using the software of mimics, Geomagic studio, HyperMesh, and Abaqus. The last manipulation of the Ponseti method before the procedure of PAT was simulated. The talus head and the proximal tibia and fibula bone were fixed in all six degrees of freedom, and the outward pressure was added on the first metatarsal head to investigate the kinematic coupling relationship between tarsal bones. Results The least relationship of kinematic coupling between tarsal bones was found in calcaneus. Stress concentration was mainly observed at the navicular, talus and the medial malleolus. The difference in displacement of the navicular was only found with the Achilles tendon stiffness of 0 N/mm and others. No difference in the navicular displacement was found in the stiffness of Achilles tendon between 40, 80, 200, 400, and 1000 N/mm. The maximum displacement of navicular was observed at the ankle position of PF-20° (plantar flexion-20°). The difference in displacement of the navicular was greater at the ankle position of PF-20° with the Achilles tendon stiffness of 0 N/mm than that at the ankle position of PF-40° with the Achilles tendon stiffness of 40 N/mm. Conclusions Based on the findings from this study, it was demonstrated that the Achilles tendon existence or not and ankle position had great influence, while increased stiffness of Achilles tendon had no influence on kinematic coupling relationship between tarsal bones. For the cases with severe equinus, earlier implementation of PAT procedure (with the purpose of release the Achilles tendon and reduce the degree of ankle plantar flexion) may be beneficial to the deformity correction.

Background Clubfoot deformity (pes equinovarus) is one of the most common birth defects, and its etiology is still unknown. Initial clubfoot treatment is based on the Ponseti method throughout most of the world. Despite the effectiveness of this therapy, clubfoot may relapse. Recent studies confirm the theory of active fibrotic remodeling processes in the extracellular matrix of the affected tissue. The aim of this study was to clarify whether relapses in clubfoot therapy are associated with altered angiogenesis and to suggest possible regulatory pathways of this pathologic process. Methods We compared microvessel density, arteriole density, and concentration of angioproliferative-related proteins found between tissues in the contracted, that is, the medial side (M-side), and noncontracted, that is, the lateral side (L-side) of the relapsed clubfeet. Tissue samples from 10 patients were analyzed. Histopathologic analysis consisted of immunohistochemistry and image analysis. Real-time polymerase chain reaction was used to study mRNA expression. Results An increase in microvessel and arteriole density was noted in contracted, relapsed clubfoot tissue. This was accompanied by a significant increase in the levels of the vascular endothelial growth factor, vascular endothelial growth factor receptor 2, β catenin and active β catenin. Vascular endothelial growth factor, vascular endothelial growth factor receptor 2, and CD31 overexpression was also seen with mRNA analysis. Conclusions Increased microvessel and arteriole density in the contracted side of the relapsed clubfoot was noted. These processes are mediated by specific proangiogenic proteins that are overexpressed in the contracted tissue. These findings contribute to the etiology and the development of relapses in the treatment of clubfoot. Level of evidence Level II-analytical and prospective.

Objective The shortened hallux and deep medial crease are a significant cosmetic deformity in complex clubfeet. We quantitatively determined the correction of hallux length and deep medial crease following treatment of complex clubfeet. Methods A chart review of 11 patients (17 feet) with complex clubfeet treated with modified Ponseti method was undertaken. Pretreatment clinical photographs and Pirani scores were compared with those obtained at a recent follow-up to analyze outcomes. Hallux length was matched with 2nd toe and graded similar to Pirani score. Results Mean patient age at enrollment was 26.8 weeks. Average follow up was 22.6 months. Pre treatment and follow up Pirani score averaged 5.8 and 0.2 respectively. The average number of cast utilized was 7. Incomplete/non correction of hallux was observed in 6 feet (35%), of which 4 suffered an equinus relapse. Deep medial crease corrected in all. Conclusions The study describes a clinical method of hallux length quantification in complex clubfeet. Medial crease recovered in all feet. The recovery of hallux length was delayed in some patients and might indicate persistent posteromedial soft tissue contracture/fibrosis in these feet.