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Backgrounds: Clubfoot is a foot disorder frequently seen. Although, there are several studies about the efficiency of physiotherapy in the treatment of clubfoot, physiotherapy programs may be more efficient if the treatment apply step by step similar to the logic of the serial casting progression of the involved foot. Therefore, the aim of this study was to determine the effectiveness of three-phase physiotherapy program in children with clubfoot.Methods: Fifty-seven patients (37 males, 20 females; 7.26 ± 1.27 years) with clubfoot which had Ponseti treatment before were included. The ankle dorsiflexion (DF) and plantar flexion (PF) ranges of motion (ROM), one-leg standing time, sit-to-stand test, The Oxford Ankle Foot Questionnaire (OxAFQ) and treatment satisfaction were evaluated before and after treatment. A three-phase physiotherapy program was applied for 3 months.Results: DF, PF, one-leg standing time, sit-to-stand test, treatment satisfaction and all parameters of OxAFQ except 'Emotional' parameter of OxAFQ-Children significantly improved after treatment (p < 0.05).Conclusions: The three-phase physiotherapy program increased the ankle range of motion, improved functional status and treatment satisfaction in children with clubfoot. The three-phase physiotherapy might be a reasonable treatment for clubfoot. Although, there is a need for long-term studies to understand its effects on preventing relapse. [ABSTRACT FROM AUTHOR]

Objective: To assess the effects of written and visual briefing on parents' state and trait anxiety in newborns with newly diagnosed pes equinovarus (PEV) who were treated using the Ponseti method during the neonatal period. Materials and Methods: Eighty parents (mother and/or father) of neonatal PEV patients who were treated using Ponseti Method between September 2014 and July 2017were included in this study. Participants were assigned into two groups according to the written and visual briefing. Participants in both groups were asked to complete the State-Trait Anxiety Inventory (STAI) before the procedure. Then, written and visual briefing was given to the participants. All participants repeated the inventory after briefing to assess changes in state and trait anxiety. Results: After visual and written briefing, parents' response was evaluated. In both groups, a significant decline was observed in trait and state anxiety after both written and visual briefing (p

Introduction:Tibialis anterior tendon transfer (TATT) is a common treatment method used in the dynamic supination of the foot due to sequelae or relapse of pes equinovarus (PEV). In this method, the TAT is transferred from its insertion on the medial cuneiform to the lateral cuneiform. Therefore, TATT surgery may have a corrective effect on metatarsus adducus deformity by creating a force vector that pushes the middle of the foot from medial to lateral. However, there is limited literature on the effect of TATT on metatarsus adductus deformity, which is one of the components of clubfoot. The aim of our study was to investigate the effect of TATT on metatarsus adductus deformity.Methods:Sixteen feet of 11 patients who underwent TATT with the diagnosis of PEV between 2007-2015 were included in the study. Pre- and postoperative talus-1.metatarsal angle, talocalcaneal angle and 4. metatars-metaphyseal angle were measured on standing antero-posterior radiographs. The correction rate of metatarsus adductus deformity was statistically analyzed.Results:After a mean follow-up of 26±15 months, the mean talus – 1st metatarsal angle decreased from 18.8±1 degrees to 10.9±6 degrees, the mean talocalcaneal angle from 22.5 degrees ±8.6 to 24.4±9.3 degrees and the mean 4th metatarsalmetaphyseal angle from 38±14 degrees to 27±11 degrees after TATT. While there were statistically significant radiological corrections in talus – 1st metatarsal angle and 4th metatarsalmetaphyseal angle (p

Arno Kerling,1 Gisela Stoltenburg-Didinger,2 Lena Grams,1 Uwe Tegtbur,1 Hauke Horstmann,1 Momme Kück,1 Holger Mellerowicz3 1Institute of Sports Medicine, Hannover Medical School, Hannover, Germany; 2Gisela Stoltenburg-Didinger, Institute of Cell and Neurobiology, Charité Universitätsmedizin Berlin CCO, Berlin, Germany; 3Holger Mellerowicz, Clinic for Pediatric Orthopedics and Traumatology, Helios Klinikum Emil von Behring, Berlin, Germany Purpose: Congenital clubfoot is one of the most common limb disorders in humans and its etiology is still unclear. In order to better understand the pathogenesis of patients with primary clubfoot, we examined whether there are quantitative changes in the extracellular matrix (ECM; based on common interstitial collagens [C] like CI and CIII, microfilamentous collagens like CVI, noncollagenous proteins like undulin, and enzymes like matrixmetalloproteinase [MMP]-2 and tissue inhibitor of matrixmetalloproteinase [TIMP]-2 that are known to play a role in fibrogenesis and fibrolysis) of muscles involved in the foot deformity of patients with primary clubfoot corresponding to fibrosis. Patients and methods: Thirty patients (age ranging from 4 months to 5 years and 7 months) with primary clubfoot were examined (23 male and 7 female patients), among whom 18 patients were affected on one side and 12 affected on both sides. Twenty-five biopsies were taken during the first operative foot correction (Crawford–McKay) and 5 in the context of relapses. Muscle biopsies were taken from the muscles involved in the defect (Musculus [M.] gastrocnemius and M. tibialis anterior) and from the M. vastus lateralis of the M. quadriceps femoris, which were treated as healthy comparison muscles. Quantitative analysis of the components of the ECM was performed using a computer-assisted fibrosis measurement of the immunohistochemically processed tissue samples. Results: We found higher values for M. gastrocnemius for CI, CIII, CVI and undulin in comparison with M. vastus lateralis. However, values for TIMP-2 were reduced. We found no significant differences for the components of M. tibialis anterior and M. vastus lateralis. There were no quantitative differences between male and female or between patients affected on one side and both sides. In patients who underwent relapse surgery, CI, CIII, CVI, and undulin of the gastrocnemius were significantly higher, while TIMP-2 was significantly lower. Conclusion: In the present study, we found manifest fibrosis in gastrocnemius due to quantitative changes in the ECM. In contrast to other studies, we found increasing fibrosis not just in contracted tissues but also in the muscle itself. Further studies are needed to clarify whether these changes are primarily responsible for the malfunction or whether they occur secondarily in the consequence of the dysfunction. Keywords: pes equinovarus, clubfoot, extracellular matrix, fibrosis, collagens, TIMP-2

Introduction: Tibialis anterior tendon transfer (TATT) is a common treatment method used in the dynamic supination of the foot due to sequelae or relapse of pes equinovarus (PEV). In this method, the TAT is transferred from its insertion on the medial cuneiform to the lateral cuneiform. Therefore, TATT surgery may have a corrective effect on metatarsus adducus deformity by creating a force vector that pushes the middle of the foot from medial to lateral. However, there is limited literature on the effect of TATT on metatarsus adductus deformity, which is one of the components of clubfoot. The aim of our study was to investigate the effect of TATT on metatarsus adductus deformity. Methods: Sixteen feet of 11 patients who underwent TATT with the diagnosis of PEV between 2007-2015 were included in the study. Pre- and postoperative talus-1.metatarsal angle, talocalcaneal angle and 4. metatars-metaphyseal angle were measured on standing antero-posterior radiographs. The correction rate of metatarsus adductus deformity was statistically analyzed. Results: After a mean follow-up of 26±15 months, the mean talus - 1st metatarsal angle decreased from 18.8±1 degrees to 10.9±6 degrees, the mean talocalcaneal angle from 22.5 degrees ±8.6 to 24.4±9.3 degrees and the mean 4th metatarsalmetaphyseal angle from 38±14 degrees to 27±11 degrees after TATT. While there were statistically significant radiological corrections in talus - 1st metatarsal angle and 4th metatarsalmetaphyseal angle (p<0.05), there was no statistically significant change in the talocalcaneal angle (p=0.51). Conclusion: TATT provides radiological improvement in the metatarsus adductus deformity in children with PEV. The reason for this is that the Tibialis in PEV works as an invertor rather than dorsiflexor/evertor of the ankle. In conclusion, the need for additional surgery for metatarsus adductus deformities in patients undergoing TATT should be reviewed. [ABSTRACT FROM AUTHOR]

Objective: To assess the effects of written and visual briefing on parents' state and trait anxiety in newborns with newly diagnosed pes equinovarus (PEV) who were treated using the Ponseti method during the neonatal period. Materials and Methods: Eighty parents (mother and/or father) of neonatal PEV patients who were treated using Ponseti Method between September 2014 and July 2017 were included in this study. Participants were assigned into two groups according to the written and visual briefing. Participants in both groups were asked to complete the State-Trait Anxiety Inventory (STAI) before the procedure. Then, written and visual briefing was given to the participants. All participants repeated the inventory after briefing to assess changes in state and trait anxiety. Results: After visual and written briefing, parents' response was evaluated. In both groups, a significant decline was observed in trait and state anxiety after both written and visual briefing (p<0.05). However, no significant difference was detected between groups regarding the effects of written and visual briefing on state anxiety. Conclusion: The provision of detailed written and visual information about the risk of complications of the illness and treatment method increased the parents' knowledge but did not increase their levels of anxiety. [ABSTRACT FROM AUTHOR]

The 22q11.2 Deletion Syndrome (22q11.2DS) occurs in ~1:3,000–6,000 individuals. Features less typically associated with 22q11.2DS, such as orthopedic manifestations, may be overlooked or may not lead to appropriate diagnostic testing. Club foot has a general population prevalence of ~1:1,000 and has been occasionally described in association with 22q11.2DS. Our hypothesis is that the prevalence of club foot is higher in patients with 22q11.2DS. We performed a retrospective review in two specialized 22q11.2DS centers to determine the prevalence of club foot. "True club foot" requires treatment (either conservative or surgical), therefore we only included those patients with proof of treatment. We investigated whether congenital heart disease (CHD) and/or cleft palate were associated with the presence of club foot within 22q11.2DS. The records of 1,466 patients were reviewed. Of these, 48 (3.3%) had confirmation of club foot (95% Confidence Interval: 2.4–4.3): 22 (46%) had a bilateral, 12 (25%) left, and 14 (29%) right club foot. Within our study, neither a CHD and/or a cleft palate were associated with a club foot. The prevalence of club foot in 22q11.2DS is 30 times higher than that observed in the general population. This suggests the diagnosis of club foot, especially in the face of other typically associated abnormalities of 22q11.2DS, should provoke consideration of 22q11.2DS as an underlying diagnosis, particularly in the neonatal setting. [ABSTRACT FROM AUTHOR]

Introduction: Tibialis anterior tendon transfer (TATT) is a common treatment method in relapsing clubfoot. Metatarsus adductus is one of the components of clubfoot and severe deformities are treated with osteotomies. TATT surgery improves the invertors-evertors imbalance so may have an indirect corrective effect on metatarsus adducus deformity. However, literature is limited on the impact of TATT on correcting effect of this deformity. The objective of the study is to describe the correcting effect of the TATT of metatarsus adductus deformity in children with clubfoot. Study design: Retrospective radiological analysis. Methods: The study is a retrospective analysis of 16 feet of 11 children of who underwent TATT procedure from 2006 to 2015. Mean age was 4.4 years. Preoperative and postoperative x-ray graphics were obtained from medical records. Pre and postoperative talus-1.metatarsal angle, talocalcaneal angle and 4. metatars-metaphyseal angle were measured on standing antero-posterior (AP) radiographs and compared. Results: The mean talus - 1st metatarsal angle was decreased from 18.8 ±1 to 10.9 ±6, with statistically significant difference (p <0.05). Also the mean 4th metatarsal -metaphyseal angle was decreased from 38 ±14 to 27 ±11 with statistically significant difference (p<0.05). Changes of talocalcaneal angle (22.5±8. to 24.4±9.3) were not statistically significant p>0.05). Conclusion: The study showed that tibialis anterior tendon transfer provides radiological improvement on the metatarsus adductus deformity in children with clubfoot.The reason is in recurrence of the PEV deformity, the tibialis anterior tendon works as an inventor rather than dorsiflexor/evertor of the ankle. In conclusion tibialis anterior tendon transfer has a corrective effect on the metatarsus adductus deformity. The need for additional surgery for metatarsus adductus deformities in patients undergoing tendon transfer should be reviewed. [ABSTRACT FROM AUTHOR]

Idiopathic pes equinovarus (clubfoot) is a congenital deformity of the foot and lower leg defined as a fixation of the foot in plantar flexion, adduction, supination and varus. The deformity does not affect only the foot position, which is usually investigated by radiography, CT, micro-CT, MRI or ultrasound but logically influence the whole gait biomechanics. It is supposed, that clubfoot belongs to a group of fibroproliferative disorders whose origin and multi-hierarchical effect remain unknown. It has been suggested that fibroblasts and growth factors may be involved. To gain a more global view, direct analysis of the protein composition of extracellular matrix, a proteomic approach was used. At present two principle methods are mostly used for the treatment of clubfoot: physiotherapy and the Ponseti method. The determination of the general biological and biomechanical parameters for various regions of the clubfoot can potentially help in the understanding of the mechanisms participating on this serious anomaly and thus contribute to the development of the more efficient therapeutic approach. This review summarizes the present knowledge on the possible pathogenetic mechanisms participating in the development of the clubfoot and their possible relation to the new therapeutic approaches. [ABSTRACT FROM AUTHOR]

Clubfoot is a common congenital deformity of the lower limbs. It should be treated as soon as possible so that its correction is more easily achieved. The objective of this systematic review was to assess the effectiveness of the Ponseti method in the treatment of clubfoot. A bibliographic search was carried out in different databases, including PubMed and SciELO. Filters such as full text and randomized controlled trial were selected to find those articles that best matched our search. Among the results, we selected the ones that interested us, and the rest were discarded, either because they did not meet the requirements for our work or because they were repeated. In total, we collected 19 articles, but after using the critical evaluation instrument CASPe, 7 of them were eliminated, leaving us with a total of 12 articles for our systematic review. After analyzing the results obtained in the selected articles, we concluded that the Ponseti method is effective in the treatment of clubfoot, presenting a high success rate.

Only few studies exist regarding the risk of a teratogenic effect of tramadol when used in early pregnancy. Using the Swedish Medical Birth Register, women (deliveries in 1997–2013) who had reported the use of tramadol in early pregnancy were identified. Maternal characteristics and concomitant drug use were analyzed. Among 1,682,846 women (1,797,678 infants), 1751 (1776 infants) had used tramadol, 96 of the infants had a congenital malformation and 70 of them were relatively severe. The adjusted odds ratio for a relatively severe malformation was 1.33 (95% CI 1.05–1.70). The odds ratios for cardiovascular defects (1.56, 95% CI 1.04–2.29) and for pes equinovarus (3.63, 95% CI 1.61–6.89) were significantly increased. The study suggests a teratogenic effect of tramadol but the risk increase is moderate. [ABSTRACT FROM AUTHOR]

Idiopathic pes equinovarus is a congenital deformity of the foot and lower leg defined as a fixation of the foot in adduction, supination, and varus. Although the pathogenesis of clubfoot remains unclear, it has been suggested that fibroblasts and growth factors are involved. To directly analyze the protein composition of the extracellular matrix in contracted tissue of patients with clubfoot. A total of 13 infants with idiopathic clubfoot treated with the Ponseti method were included in the present study. Tissue samples were obtained from patients undergoing surgery for relapsed clubfeet. Contracted tissues were obtained from the medial aspect of the talonavicular joint. Protein was extracted after digestion and delipidation using zip-tip C18. Individual collagenous fractions were detected using a chemiluminescent assay. Amino acid analysis of tissue samples revealed a predominance of collagens, namely collagen types I, III, and VI. The high content of glycine and h-proline suggests a predominance of collagens I and III. A total of 19 extracellular matrix proteins were identified. The major result of the present study was the observation that the extracellular matrix in clubfoot is composed of an additional 16 proteins, including collagens V, VI, and XII, as well as the previously described collagen types I and III and transforming growth factor β. The characterization of the general protein composition of the extracellular matrix in various regions of clubfoot may help in understanding the pathogenesis of this anomaly and, thus, contribute to the development of more efficacious therapeutic approaches. [ABSTRACT FROM AUTHOR]

Background and purpose Spastic pes equinovarus is a frequent pathological posture of the lower extremity. Botulinum toxin ( Bo NT/ A) has been successfully applied to treat lower limb spasticity. However, the best time to initiate treatment remains unclear. A beneficial effect of an early treatment has been suggested in previous studies. Methods A single-centre double-blind randomized placebo-controlled trial was performed to investigate the efficacy of Bo NT/ A to reduce muscle hypertonicity at the ankle. Fifty-two patients with unilateral or bilateral spastic pes equinovarus with a modified Ashworth score (m AS) of at least 1+ after stroke, traumatic brain injury or hypoxic encephalopathy were allocated to receive either Bo NT/ A or placebo treatment. A second, open injection was optional at week 12. Patients received unilateral or bilateral injections with 230 or 460 U onabotulinumtoxinA, respectively. The course of the m AS was explored during the open study phase. Results Patients who had received Bo NT/ A treatment had lower m AS compared with placebo at week 12 ( P < 0.01). During the open label phase, patients from the placebo group showed further deterioration of muscle tone despite starting from a similar baseline and receiving Bo NT treatment. Spastic feet that had received Bo NT/ A in the first cycle had comparatively lower m AS scores over all follow-up data and at week 24 ( P < 0.01). Conclusions The study demonstrates a reduction of muscular hypertonicity in spastic pes equines with Bo NT/ A treatment given during the first 3 months after the lesion. Exploratory analyses of the course of muscular hypertonicity during the open phase favour earlier to later treatment. [ABSTRACT FROM AUTHOR]

Pes equinovarus is a congenital disease that can be successfully treated with serial casting and percutaneous achillotomy at the newborn stage in most of the cases. Complex surgical interventions are required for patients presenting at advanced age for correction of this deformity. The main problem encountered in the treatment for neglected pes equinovarus cases is repairing the posteromedial skin defect of the ankle due to surgical correction of this deformity. The sural flap is frequently used in the repair of a number of skin defects on the ankles, although reports on the use of this flap in pes equinovarus surgery are scarce. In this article, the technical details of sural flap application in cases with neglected pes equinovarus and the preliminary results of three extremities treated with this method have been presented. [ABSTRACT FROM AUTHOR]

The article evaluates the prenatal ultrasound detection of talipes equinovarus (TEV) in a large non-selected population. The study investigated all cases of pre- or postnatally diagnosed TEV between 1987 and 2004 within a non-selected population of 49, 314 deliveries. Thus, the total detection rate of TEV improved over the time by which prenatal detection was higher when TEV was bilateral and other anomalies are present.

Lymphangiomas are rare congenital malformations of the lymphatic system. Despite the benign histology, they are likely to grow rapidly and invade the surrounding tissues. In contrast to the cystic hygromas, lymphangiomas at the axillary region tend to have normal karyotype. However, associated hydrops makes the prognosis poor. Due to isolated few cases in the literature, the true incidence of foetal axillary lymphangiomas is not known. We present here a pre-natal ultrasonographic diagnosis of a 15-week foetus with rapidly growing axillary lymphangioma with ipsilateral foot abnormality which had normal karyotype. [ABSTRACT FROM PUBLISHER]

• The number of lower-limb clinical patterns treated with incobotulinumtoxinA increased with dose at each cycle. • IncobotulinumtoxinA lower-limb treatment improved muscle tone after 4 weeks. • IncobotulinumtoxinA treatment for pes equinovarus improved ankle joint muscle tone. • Lower-limb treatment reduced lower-limb score on the resistance to passive movement scale. • At the end of 3 injection cycles, 42% of patients could walk independently. Lower-limb spasticity can impair ambulation and gait, impacting quality of life. This ancillary analysis of the TOWER study (NCT01603459) assessed the efficacy of incobotulinumtoxinA for lower-limb post-stroke spasticity including pes equinovarus. Participants received escalating incobotulinumtoxinA doses (400–800 U) across 3 injection cycles. Changes were compared for those treated in the lower limb (with/without upper-limb treatment) or the upper limb only or for participants treated or untreated for pes equinovarus. Outcome measures were those used in the seminal study: resistance to passive movement scale (REPAS), Ashworth Scale (AS), functional ambulation and lower-limb goal attainment. Among 132/155 (85%) participants with post-stroke spasticity, in cycles 1, 2 and 3, 99, 119 and 121 participants received lower-limb treatment with mean (SD) total limb incobotulinumtoxinA doses of 189.2 (99.2), 257.1 (115.0) and 321.3 (129.2) U, respectively. Of these, 80, 105 and 107, respectively, were treated for pes equinovarus. The mean (SD) improvement in REPAS lower-limb score was greater with treatment in the lower limb versus the upper limb only: –1.6 (2.1) versus–0.4 (1.4); –1.9 (1.9) versus –0.6 (1.6); –2.2 (2.2) versus –1.0 (0.0) (P = 0.0005, P = 0.0133 and P = 0.3581; analysis of covariance [ANCOVA], between-group differences) in cycles 1, 2 and 3, respectively. For all cycles, the mean improvement in ankle joint AS score from injection to 4 weeks post-treatment was greater for participants treated versus not treated for pes equinovarus, with a significant between-group difference in cycle 1 (P = 0.0099; ANCOVA). At the end of cycle 3, 42% of participants walked independently and 63% achieved 2 of 2 lower-limb treatment goals (baseline 23% and 34%, respectively). This study supports the efficacy of incobotulinumtoxinA for treatment of pes equinovarus and other patterns of lower-limb post-stroke spasticity. [ABSTRACT FROM AUTHOR]

Amniotic band syndrome (ABS) is a condition which occurs due to the constrictive bands formed by the early rupture of amnion membrane, and may cause different disorders depending on the organ involved. It is especially characterized with the deformation, malformation, amputation and craniofacial anomalies in the extremities. Its incidence rate varies between 1/1234 and 1/15,000 live births in different series. Although the etiopathogenesis of ABS is not known well, there have been many theories. In the etiology, infection, ischemia, trauma, amniocentesis, vasoconstrictive substance use decreasing uterine blood flow, antimitotic drug use during the first trimester and connective tissue tissues are suspected. Twenty-year-old patient with her first pregnancy had first degree kin marriage. The patient had no disease or surgery in her medical history, and she was not using alcohol or smoking. She had no characteristics in her family history. It was found in the fetal obstetric US of the patient referred to our clinic with external hydrocephaly pre-diagnosis that she was on 24 weeks of gestation. AFI was normal, placenta was on anterior, amnion membrane was ruptured and in direct contact with fetal tissues freely. In the fetal head examination, hydrocephaly, frontal encephalocele, and cleft palate and lip were observed. There was pes equinovarus deformity in both feet. After required information was provided to the patient, she decided to maintain the pregnancy and was transferred to a tertiary center. In the external follow-up of the patient, it was learnt that she had c-section delivery close to the term, and the baby was ex on postpartum 15th minute. Consequently, ABS should be remembered in cases with extremity anomaly and craniofacial defects. [ABSTRACT FROM AUTHOR]

Understanding the pathoanatomy of severe recurrent clubfoot and its implication on treatment options is important for the successful treatment. A comprehensive clinical evaluation of the different components helps in selecting procedures. Individual needs and social and psychological factors influencing treatment and the impact of treatment on the child have to be considered. With increasing dissemination and improved understanding of the Ponseti method, a further decrease in the frequency of severe recurrent clubfoot can be hoped for and expected., (Copyright © 2015 Elsevier Inc. All rights reserved.)