The effectiveness of the Ponseti method for treating clubfoot associated with arthrogryposis: up to 8 years follow-up

Outcomes of Ponseti Method for the Treatment of Clubfeet in Children With Arthrogryposis

INTRODUCTION

The Ponseti serial casting method is the method of choice in treating children with congenital clubfeet. The arthrogrypotic clubfoot has traditionally been considered challenging to treat, with higher rates of recurrence and the need for more corrective surgeries. However, initial reports have found promising results in using the Ponseti method to treat arthrogrypotic feet. This study aims to compare the outcomes of idiopathic versus arthrogrypotic clubfeet following initial treatment with the Ponseti serial casting method.

METHODS

A retrospective review of medical records from a single institution was conducted. Data was collected from children ages 0 to 18 with idiopathic or arthrogrypotic clubfoot treated from 2002 to 2022 with Ponseti-style serial casting with a minimum 2-year follow-up. Recurrence was defined as the need for additional casting or subsequent surgeries following initial correction. Data was collected on relevant patient demographics, previous treatment, casting records, Achilles tenotomies, and surgical treatments.

RESULTS

A total of 352 patients (546 feet) met inclusion criteria. In all, 334 idiopathic and 18 arthrogrypotic patients were analyzed with an average follow-up duration of 3.4 and 4.2 years, respectively. Twelve patients had distal arthrogryposis, and 6 had amyoplasia. In all, 93.4% of idiopathic and 72.2% of arthrogrypotic patients successfully achieved correction with Ponseti casting and Achilles tenotomy. Recurrence rates were significantly higher in the arthrogrypotic group at 83.3% compared with 44.6% in the idiopathic group (P=0.001). A posterior or posterior medial release was performed in 35.0% of idiopathic and 66.7% arthrogrypotic feet.

CONCLUSIONS

We report the largest series of arthrogrypotic clubfeet treated by Ponseti casting to the best of our knowledge. In contrast to earlier reports, our investigation underscores that while the Ponseti method may be able to secure initial correction in arthrogrypotic clubfeet, on average, at a 3-year follow-up, the prognosis is less favorable. These patients exhibit higher recurrence and often require operative treatment. Notably, a posterior medial release may eventually be needed in up to 6 of 10 patients.

LEVEL OF EVIDENCE

Level III-therapeutic studies-investigating the results of treatment.

[Nerve Transfers in Children with Non-traumatic Amyoplasia]

BACKGROUND

The treatment of obstetric brachial plexus palsy through primary reconstruction and nerve transfers has been established in the past decades. In the case of non-traumatic diseases that lead to flaccid paralysis and the inability to move the extremities, such as transverse myelitis (TM) or arthrogryposis multiplex congenita (AMC), which can have a wide variety of causes, the focus has been on rehabilitative therapy so far, while surgical interventions have been used to a lesser extent, e. g., in the form of osteotomies or muscle transfers. Our aim is to establish nerve transfers as a surgical option to improve mobility in non-traumatic amyoplasia.

PATIENTS

This work presents the needs-adapted treatment of a total of 23 patients (aged 4 months to 64 months, 18 with AMC and 5 with TM) using nerve transfers on the upper extremity.

RESULTS

We were able to show that early nerve transfers in the upper extremity enabled the reanimation of muscles in both AMC and TM.

CONCLUSION

This work shows that the treatment of non-traumatic amyoplasia in children with selective nerve grafts is a successful method. Nerve transfers allow patients to gain or regain important functions for managing independent everyday life. The surgical methods have been established in the treatment of traumatic nerve injuries. They are well-known and can be carried out safely. We believe that this is an important treatment option for paediatric patients with paralysis associated with TM or AMC, which should also be known to the treating physicians.

Multiple Serial Casting for Recurrent Clubfoot in Arthrogryposis Corrects Deformity With Diminishing Returns

PURPOSE

Arthrogryposis multiplex congenita (AMC) consists of more than 400 conditions involving severe joint contractures of at least two or more body regions. Management of clubfoot in patients with AMC is notoriously challenging, with a higher likelihood of recurrence than idiopathic clubfoot, which can be treated using the Ponseti technique to avoid or delay more invasive procedures. The purpose of this study is to determine the utility of multiple serial casting as a treatment of clubfoot in AMC using Pirani scores as an objective measure of deformity.

METHODS

Pirani scores were retrospectively collected from 17 AMC patients with a total of 30 clubfeet and two years follow-up from initiation of treatment. Patients with a minimum of three casting series were included. Pre-treatment and post-treatment deformity scores were examined across casting series using analysis of variance (ANOVA) statistical analysis.

RESULTS

The first series pre-treatment Pirani score improved from 4.80±1.54 to 1.68±1.48 (p<0.001). The second series improved from 4.23±1.03 to 2.72±0.916 (p<0.001). The third series had the smallest improvement from 3.87±1.07 to 2.82±1.02 (p<0.001). Change in Pirani scores showed a significant decrease from the first series to the second (p=0.001) and third (p<0.001). In addition, the number of casting days was found to significantly affect the change in scores during the third series (p=0.038).

CONCLUSIONS

The Ponseti technique can improve clubfoot in AMC as measured by the Pirani score. Data shows that early intervention yields better results, with a diminished yet effective ability to elicit change over time.

Effectiveness of the Ponseti method for congenital clubfoot in patients with arthrogryposis: A systematic review and meta-analysis of observational studies

Purpose

The aim of this systematic review was to address the Ponseti method in arthrogrypotic clubfoot treatment and evaluate the success, complication, and recurrence rates.

Method

A systematic review was performed in the PubMed, Scopus, Embase, and Web of Science databases on 9 January 2023, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Success, recurrence, and complication rates were evaluated and analyzed. Risks of bias and the quality of the studies were also evaluated.

Results

Five case series, including 53 patients (102 feet), were identified. According to this model, the initial success rate was 91% (95% confidence interval = 0.79-0.96) with I2 = 43%, and the final success was 68% (at 5.8 years of follow-up). Recurrence rate was 30% (95% confidence interval = 0.14-0.52).

Conclusion

Ponseti method is indicated in the initial treatment of arthrogrypotic clubfeet, as it is a minimally invasive method with a high correction rate (91%). However, a high recurrence rate (30%) requires early detection and adequate treatment.

Level of evidence

Level III.

PROSPERO Protocol

CRD42020210373.

Partial tarsal arthrodesis with closing wedge ostectomy for treatment of bilateral twisted leg deformity in a cat

A 5-month-old male domestic shorthair cat was presented with severe bilateral hind-limb deformities that caused the cat to walk on the dorsal aspect of the metatarsals. Computed tomography (CT) images revealed that the calcaneus was externally rotated, and the distal end of the calcaneus was turned medially to the talus in both hind limbs. The cat was diagnosed with twisted leg deformity, a congenital tarsal hyperextension deformity (clubfoot). Based on CT images, closing wedge ostectomy was done at the level of the tarsometatarsal joint with the wider part facing laterally. Partial transection of the common calcaneal tendon was not performed. Nine weeks after surgery, the cat was able to walk and jump, with its paws correctly placed on the ground, despite the limited range of motion in the tarsal joints. Based on radiographs with maximum tarsal flexion, the angle of the partial tarsal arthrodesis limited the range of motion. This is apparently the first case report describing CT images and closing wedge ostectomy in a cat with twisted leg deformity. Key clinical message: This article reports the findings obtained from CT imaging of a cat with twisted leg deformity. The current case was successfully managed by closing wedge ostectomy without partial transection of the common calcaneal tendon.

A 5-years results of the Ponseti method in the treatment of congenital clubfoot: a retrospective study

BACKGROUND

Clubfoot is a common congenital deformity affecting mobility of children. It leads to pain and disability. The Ponseti treatment method is non-surgical method for the correction of clubfoot. There is variation from country to country in how the result of clubfoot management is measured and reported. This study aimed to assess the 5-years results of the Ponseti method in the treatment of congenital clubfoot which was performed for children aged under 2 years in western Amhara, Ethiopia.

OBJECTIVES

The objective of this study was to assess a 5-years results of the Ponseti method in the treatment of congenital clubfoot among under 2-years old children in Felege Hiwot Referral Hospital, Bahir-Dar, Ethiopia, from 2015 to 2019 G.C.

METHODS

A facility-based retrospective cross-sectional study was conducted. After receiving letter of ethical clearance from the University, IRB board, the data were collected from medical record/charts of patients' who received Ponseti treatment, and the collected data were entered and analyzed with Statistical Package for Social Sciences version 21. The results were presented with texts and tables.

RESULTS

A total of 200 children with 256 congenital clubfeet involved in the study. Among the total study subjects, 143 (71.5%) had unilateral clubfeet. The 5-years results of the Ponseti method in the treatment of congenital clubfoot conducted in 200 children with clubfeet were 187 (93.5%) with 95% (CI 90-99.5). Among the study participants, males were 66.5% (almost two times from females).

CONCLUSIONS AND RECOMMENDATIONS

According to the results from a 5-years data showed that the Ponseti method in the treatment of congenital clubfoot was successful with a success rate of 93.5%. We recommend that children with congenital clubfeet should be managed with Ponseti treatment method timely.

Effectiveness of Ponseti technique in management of arthrogrypotic clubfeet - a prospective study

BACKGROUND

Clubfoot constitutes roughly 70 percent of all foot deformities in arthrogryposis syndrome and 98% of those in classic arthrogryposis. Treatment of arthrogrypotic clubfoot is difficult and challenging due to a combination of factors like stiffness of ankle-foot complex, severe deformities and resistance to conventional treatment, frequent relapses and the challenge is further compounded by presence of associated hip and knee contractures.

METHOD

A prospective clinical study was conducted using a sample of nineteen clubfeet in twelve arthrogrypotic children. During weekly visits Pirani and Dimeglio scores were assigned to each foot followed by manipulation and serial cast application according to the classical Ponseti technique. Mean initial Pirani score and Dimeglio score were 5.23 ± 0.5 and 15.79 ± 2.4 respectively. Mean Pirani and Dimeglio score at last follow up were 2.37 ± 1.9 and 8.26 ± 4.93 respectively. An average of 11.3 casts was required to achieve correction. Tendoachilles tenotomy was required in all 19 AMC clubfeet.

RESULT

The primary outcome measure was to evaluate the role of Ponseti technique in management of arthrogrypotic clubfeet. The secondary outcome measure was to study the possible causes of relapses and complications with additional procedures required to manage clubfeet in AMC an initial correction was achieved in 13 out of 19 arthrogrypotic clubfeet (68.4%). Relapse occurred in 8 out of 19 clubfeet. Five of those relapsed feet were corrected by re-casting ± tenotomy. 52.6% of arthrogrypotic clubfeet were successfully treated by the Ponseti technique in our study. Three patients failed to respond to Ponseti technique required some form of soft tissue surgery.

CONCLUSION

Based on our results, we recommend the Ponseti technique as the first line initial treatment for arthrogrypotic clubfeet. Although such feet require a higher number of plaster casts with a higher rate of tendo-achilles tenotomy but the eventual outcome is satisfactory. Although, relapses are higher than classical idiopathic clubfeet, most of them respond to re-manipulation and serial casting ± re-tenotomy.

The Effectiveness of Serial Casting in the Treatment of Recurrent Equinovarus in Children With Arthrogryposis

BACKGROUND

Arthrogryposis multiplex congenita (AMC) is characterized by joint contractures in 2 or more body areas, often resulting in clubfoot deformities that are typically stiffer than those seen in idiopathic clubfoot deformities. While surgery is routinely used to treat clubfoot in AMC, it has a high rate of recurrence and complications. Current literature suggests serial casting (SC) could be useful in treating clubfoot in AMC, though evidence of its effectiveness is limited.

METHODS

Passive range of motion (PROM), dynamic foot pressure, parent-reported Pediatric Outcomes Data Collection Instrument, brace tolerance, and the need for post-casting surgery were evaluated retrospectively in children with AMC treated with SC to address clubfoot deformities. Analysis of variance or paired t tests were used as appropriate on pre-casting, short-term (within 6 mo after SC) and/or longer-term (6 to 18 mo after SC) parameters to determine the effectiveness of SC. Brace tolerance before and after SC was analyzed using the Global Test for Symmetry, and medical records were reviewed to determine the need for surgery post-SC.

RESULTS

Forty-six children (6.1±3.1 y old) were cast an average of 2.5±1.9 times, resulting in 206 SC episodes. PROM showed improvement in ankle dorsiflexion and forefoot abduction in the short term (P<0.05), returning to baseline measurements in the long term (P=0.09). Brace tolerance improved after casting (P<0.05). Only 15% of feet required surgery at follow-up at 10.3±5.5 years. There were no significant changes in dynamic foot pressure or Pediatric Outcomes Data Collection Instrument results after SC, except for an increase in the pain subtest (P<0.05).

CONCLUSIONS

Serial casting in children with AMC can be effective in temporarily improving PROM and improving brace tolerance, but it does not impact dynamic barefoot position. Positive impact of conservative management in children with AMC can potentially delay or reduce the need for invasive surgical intervention by improving PROM and brace tolerance.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study.

Deformity-Correcting Ankle Fusions With Patient-Specific 3D Operative Planning and 3D-Printed Cut Guides: Report of 2 Cases

CASE

We report 2 cases of severe arthrogrypotic clubfeet presenting with multiplanar ankle deformities. Two patients (3 ankles) were treated with deformity-correcting ankle fusions using 3D preoperative planning and 3D-printed patient-specific cut guides. This technique enabled safe, accurate, and efficient surgical correction with good clinical outcomes. At 1 year, physical function and patient outcome measures improved.

CONCLUSION

In the setting of complex multiplanar deformities of the foot and ankle, the use of 3D preoperative planning and 3D-printed cut guides is a safe and accurate adjunct to ankle fusion.

What is New in Pediatric Orthopaedic Foot and Ankle

BACKGROUND

This paper aims to report on the last 5 years of relevant research on pediatric foot and ankle pathology with specific focus on clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans.

METHODS

The Browzine platform was used to review the table of contents for all papers published in the following target journals related to the treatment of pediatric foot and ankle conditions. Search results were further refined to include clinical trials and randomized controlled trials published from March 1, 2015 to November 15, 2021.

RESULTS

A total of 73 papers were selected for review based on new findings and significant contributions in treatment of clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans. Also included were several papers that did not fit into any of these categories but provided new insight into specific foot and ankle pathologies.

CONCLUSIONS

Treatment strategies for children with foot and ankle pathology are continually evolving. We review many of the most recent publications with the goal of improving understanding of these pathologies and highlighting current best practices.

LEVEL OF EVIDENCE

Level III.

Initiating Ponseti management in preterm infants with clubfoot at term age

PURPOSE

Currently, the optimal time to initiate treatment among preterm infants with clubfoot is unknown. The aim of this study was to describe treatment outcomes up to 1 year post-correction following Ponseti management in infants who were born preterm but treated at term age.

METHODS

A retrospective chart audit was conducted at a major pediatric hospital on preterm infants with clubfoot who commenced Ponseti management at term age (≥37 weeks of gestation). Data are expressed as mean values (±standard deviation) or 95% confidence intervals (95% CIs).

RESULTS

Twenty-six participants (40 feet) born at 32.6/40 (±3.1) weeks of gestation were identified. Thirteen (50%) were male, 14 (54%) presented bilaterally, and 7 (27%) presented with syndromic clubfoot. Ponseti management was initiated at 41.4/40 (±2.8) weeks gestation. Baseline Pirani scores were 5.2 (95%CI: 4.8-5.6) in the idiopathic group and 5.7 (95%CI: 5.0-6.4) in the syndromic group. The number of casts to correction was 5.9 (95% CI: 5.1-6.6) for those with idiopathic clubfoot and 6.1 (95%CI: 5.0-7.3) for those with syndromic clubfoot. Achilles tenotomies were required in 13 (21 feet) with idiopathic clubfoot and five (7 feet) with syndromic clubfoot. Recurrence occurred in four infants (5 feet): 4 feet required further casting and bracing, and 1 foot required additional surgery.

CONCLUSION

Ponseti management at term age in preterm-born infants yields comparable 1-year outcomes to term-born infants. Further research is required to determine whether outcomes beyond 1 year of age align with growth and development demonstrated by term-born infants who are managed with the Ponseti method.

LEVEL OF EVIDENCE

Level IV.

An analysis of treatment outcome following classical Ponseti technique in older children with clubfoot - A concept stretched too far?

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.

Clubfoot

Clubfoot or talipes equinovarus deformity is one of the most common anomalies affecting the lower extremities. This review provides an update on the outcomes of various treatment options used to correct clubfoot. The ultimate goal in the treatment of clubfoot is to obtain a fully functional and pain-free foot and maintain a long-term correction. The Ponseti method is now considered the gold standard of treatment for primary clubfoot. Relapse is common after primary treatment with the Ponseti method, and other interventions are discussed that are used to provide for long-term successful outcomes.

Comparative evaluation and analysis of outcomes in non-idiopathic and idiopathic clubfeet with Ponseti method at a tertiary care centre of a developing country

BACKGROUND

Idiopathic clubfoot (congenital talipes equinovarus, CTEV) is being managed worldwide by Ponseti method with high success rates, while for non-idiopathic clubfoot surgical interventions is being widely used with variable results. This study evaluated the effectiveness of Ponseti method in non-idiopathic clubfoot and compared the results with idiopathic clubfoot.

METHODS

The paper evaluated the epidemiological incidence and demographic profile of non-idiopathic clubfoot in a tertiary centre of developing country. A total of 108 subjects with 85 having idiopathic (group I;125 feet) and 23 having non-idiopathic variety (group II;34 feet) were managed with Ponseti method and were followed for a mean duration of 38.33 (12-62) and 36.27 months (12-58) in group I and II respectively. The most common associations were meningomyelocele (MMC/spina bifida,5), arthrogryposis multiplex congenita (AMC,4), developmental dysplasia of hip (DDH,3) and Down's syndrome and amniotic band syndrome (2 each).

RESULTS

Primary correction was achieved in both the groups in 98% and 87% in group I and II respectively, while recurrences of at least one deformity was observed in 11 (9%) and 12 (40%) feet in group I and II respectively. Favourable outcomes were noticed in 22 (65%) feet in non-idiopathic group and 12 feet (35%) underwent extensive soft tissue release as compared to 3 feet (2.4%) in idiopathic variety.

CONCLUSION

Deformities improved significantly in non-idiopathic clubfeet with Ponseti methods although complete correction was not possible. Extensive surgical interventions were reduced in up to 35% feet in non-idiopathic variety and hence, it is recommended as primary treatment for all variety of clubfeet, irrespective of their etiology.

Postnatal Diagnostic Workup in Children With Arthrogryposis: A Series of 82 Patients

OBJECTIVE

To describe a postnatal series of patients with arthrogryposis multiplex congenita by the causal mechanisms involved.

METHODS

In this single-center study, the local data warehouse was used to identify patients with arthrogryposis multiplex congenita. Patients were classified into different etiologic groups.

RESULTS

Of 82 patients included, the most frequent cause of arthrogryposis multiplex congenita was a neuromuscular disorder (39%), including skeletal muscle (n = 19), neuromuscular junction (n = 3), and peripheral nerve (n = 11) involvement. In other subgroups, 19 patients (23%) were classified by disorders in the central nervous system, 5 (6%) in connective tissue, 7 (8.5%) had mixed mechanisms, and 18 (22%) could not be classified. Contractures topography was not associated with a causal mechanism. Cerebral magnetic resonance imaging (MRI), electroneuromyography, and muscle biopsy were the most conclusive investigations. Metabolic investigations were normal in all the patients tested. Targeted or whole exome sequencing diagnostic rates were 51% and 71%, respectively. Thirty-three percent of patients died (early death occurred in patients with polyhydramnios, prematurity, and ventilatory dependency).

DISCUSSION

The benefits of a precise diagnosis in the neonatal period include more tailored management of arthrogryposis multiplex congenita and better genetic information.

Histological and radiographic evaluation of three common tendon transfer techniques in an un-ossified bone porcine model: implications for early anterior tibialis tendon transfers in children with clubfeet

PURPOSE

To compare the histological healing and radiographic effects of tendons transferred to ossified or unossified bone using different tendon fixation techniques.

METHODS

Nine new-born piglets underwent bilateral tendon transfers to either the ossified boney calcaneal body or unossified apophysis. The tendons were fixed using metallic suture anchors, sutures alone or a bone tunnel. At six weeks of age, calcanei were harvested, radiologically imaged and then prepared for histology. A semi-quantitative aggregated scoring system with values ranging from 0 (poor) to 15 (excellent), was used to grade healing at the surgical enthesis and the apophyseal ossification was graded by five independent reviewers in triplicate using a modified (1 to 4) validated scoring system.

RESULTS

Histologically, the cartilaginous transfers utilizing the tunnel and suture techniques also demonstrated the best average aggregated scores of entheses healing rivalling that measured in transfers using the classic bone tunnel technique (clinical benchmark), whereas suture anchor fixation demonstrated the worst healing in both the ossified and unossified samples. All three transfer techniques caused at least minor alterations in apophyseal ossification, with the most significant changes observed in the metallic suture anchor cohort. The tunnel and suture techniques demonstrated similar and more mild abnormalities in ossification.

CONCLUSION

Tendon transfers to unossified bone heal histologically as well as transfers classically performed through tunnels in bone. Suture fixation or tunnel techniques appear radiographically and histologically superior to suture anchors in our newborn porcine model.

LEVEL OF EVIDENCE

Ponseti Idiopathic and Nonidiopathic Clubfoot Correction With Secondary Surgeries

The Ponseti method has revolutionized clubfoot treatment for not only idiopathic clubfoot but also non-idiopathic clubfoot. This study aimed to validate the existing literature with respect to the Ponseti method serving as first line treatment for clubfoot. The purpose of this study was to compare clubfoot type and recurrence with secondary surgical procedures following Ponseti method. Kaiser Permanente Northern California database was queried to identify clubfoot children under 3 years old with a consecutive 3-year membership. Associated comorbidities and operative procedure codes were identified. Chart review was performed on all surgical clubfoot patients who completed Ponseti method. Patients' average age at time of surgery, frequency of surgeries, and types of procedures performed were recorded. A logistic regression analysis assessed the adjusted association between surgery status and clubfoot type. Clubfoot incidence was about 1 in 1000 live births. Of the 375 clubfoot children, 334 (89%) were idiopathic and 41 (11%) were non-idiopathic. In the total study population, 82% (n = 309) patients maintained Ponseti correction without a secondary surgery; 66 patients (18%) underwent subsequent secondary surgeries. The non-idiopathic clubfoot underwent surgery more frequently compared to idiopathic clubfoot patients (41.5% vs 14.7%, respectively, p = .0001). Non-idiopathic clubfoot children underwent surgery at a younger age. This study validates the Ponseti method is the first line treatment for clubfoot correction despite etiology. However, patients with recurrent clubfoot may require secondary surgery following Ponseti method. Clubfoot recurrence surveillance is key for identifying early symptomatic recurrence in order to minimize foot rigidity and the need for osseous procedures.

Management issues of congenital talipes equinovarus in the neonatal intensive care unit: A systematic review

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 to 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.

Talectomy for the Management of Resistant Talipes Equinovarus Deformity; Does Adding Ilizarov External Fixator Provide Extra Advantages?

BACKGROUND

The management of resistant talipes equinovarus (TEV) is challenging. Residual deformity and recurrence are among the most feared complications. This study was conducted to evaluate the effectiveness of talectomy in the management of arthrogrypotic TEV and to investigate the value of adding a simplified Ilizarov fixator (SIF).

PATIENTS AND METHODS

A total of 42 resistant TEV feet among 23 arthrogrypotic children were operated between January 2012 and 2016. The average age was 6.7 ± 1.67 years. The feet were divided into 2 groups; group A (Casting group) included 20 feet (11 children) that were managed by talectomy and casting, while group B (Fixator group) included 22 feet (12 children) that were treated using a SIF concomitant with talectomy. The results were evaluated morphologically by Dimeglio grading system and functionally by Legaspi system.

RESULTS

The average follow-up was 36.62 ± 3.88 months. With the numbers available in this study, there was significant improvement (p ≤ .05) in the Dimeglio scores in both groups, which was significantly more evident (p ≤ .05) among the fixator group. The majority of the good functional results were reported among the fixator group, while the poor feet were observed mainly in the casting group (p ≤ .05). The functional end results were significantly affected (p≤ .05) by the final Dimeglio scores. The age had also statistically significant effect (p≤ .05) on the functional end results in group A only.

CONCLUSION

Talectomy is an effective procedure for salvaging arthrogrypotic TEV. Supplementation of the procedure by SIF was associated with more satisfactory morphological and functional results particularly in older children.

Ponseti Casting vs. Soft Tissue Release for the Initial Treatment of Non-idiopathic Clubfoot

Purpose: Ponseti casting has universally been accepted as the gold standard for treatment of idiopathic clubfoot. Conversely, primary treatment for non-idiopathic clubfoot has not been established. The purpose of this study is to compare treatment outcomes following primary soft tissue release (STR) and Ponseti casting of non-idiopathic clubfoot.

Methods: An IRB-approved retrospective study of patients treated for non-idiopathic clubfoot between 2005 and 2020 was conducted. Patients were included if they began treatment before the age of 2 and had at least 1 year of follow up. Patients were placed into either the STR group or Ponseti group and variables of interest were documented including reoccurrence of deformity, number of surgeries performed, type of surgeries performed, anesthesia time, and surgery time. Data was analyzed using Mann-Whitney U test for continuous variables.

Results: A total of 33 children with 57 neuromuscular/syndromic clubfoot were identified of which 9 (15 feet) were treated with STR and 24 (42 feet) were treated with Ponseti casting. Average anesthesia and surgery time were found to be 291 and 179 min, respectively, for the STR group, and 113 and 67 min for the Ponseti group. The difference in operating time was determined to be significant (p = 0.02, p = 0.01). Patients treated with STR were found to have significantly more surgeries performed over the course of treatment than those treated with Ponseti casting (p = 0.001) with an average of 4.2 surgeries in the STR group and 1.5 surgeries in the Ponseti group. Extracapsular procedures were performed in 100% of the STR group and 97.6% of the Ponseti group (p = 0.55). Intracapsular procedures were performed in 100% of the STR group and 50% of the Ponseti group (p = 0.001).

Conclusion: The Ponseti method should serve as the primary approach in the initial treatment of non-idiopathic clubfoot as it can reduce the risk of future invasive intracapsular surgery and shorten anesthesia and surgery times when surgical treatment is necessary.

Level of Evidence: Level III retrospective case control study.

Syndromic clubfoot beyond arthrogryposis and myelomeningocele: orthopedic treatment with Ponseti method

INTRODUCTION

Talipes equinovarus or clubfoot is a congenital deformity of the foot with bone, muscle, and tendon involvement. It's one of the most frequent foot malformations in pediatric orthopedics. Although generally idiopathic, it may have a syndromic cause and be associated with musculoskeletal, neurological, or connective tissue conditions. The treatment of choice in idiopathic clubfoot is the Ponseti method based on manipulation and fixation with serial casts that seek progressive correction of the deformity. The Ponseti method effectiveness has been demonstrated in arthrogryposis and myelomeningocele clubfoot. There are few clinical studies demonstrating the efficacy of this therapeutic option in patients with syndromic clubfoot.

MATERIAL AND METHODS

Retrospective study with 6 patients (9 feet) with syndromic clubfoot treated in a tertiary center with the Ponseti method with a minimum follow up of two years (2-18). The results were evaluated with the Pirani classification, assessing clubfoot severity before and after treatment.

RESULTS

Of the six patients treated were used an average of 6.5 casts. The Pirani scale obtained a mean score of 5.2 before treatment, with a decrease to 1.27 after treatment, with a mean improvement of 3.93 points. In more than half of the cases it was necessary to lengthen the Achilles tendon to correct the equine deformity. In addition, an ankle-foot orthosis was used to reduce recurrences in patients with dysmetria or psychomotor retardation. The most frequently observed residual deformity was the adduct. A patient relapsed twice.

CONCLUSIONS

The Ponseti method obtains effective results in the correction of syndromic clubfoot, although it requires a greater number of corrective casts than other pediatric foot pathologies.

The 5-Year Outcome of the Ponseti Method in Children With Idiopathic Clubfoot and Arthrogryposis

BACKGROUND

The Ponseti method effectively treats idiopathic clubfoot, but its effectiveness in treating the stiffer clubfoot associated with arthrogryposis is less clear. The purpose of this study was to assess the comparative effectiveness of the Ponseti method in 5-year-old children with either idiopathic clubfoot or clubfoot due to arthrogryposis.

METHODS

The outcomes of the Ponseti method were retrospectively evaluated in children with idiopathic clubfoot and clubfoot associated with arthrogryposis. The children with clubfoot were seen at our hospital between 2012 and 2019 and were 4.0 to 6.9 years old at the time of their evaluation. Outcomes of the 2 groups of children with clubfoot were assessed using passive range of motion, foot pressure analysis, the Gross Motor Function Measure Dimension-D, and parent report using the Pediatric Outcomes Data Collection Instrument. These results were also compared with the same measures from a group of typically developing children. Surgical and bracing history was also recorded.

RESULTS

A total of 117 children were included (89 idiopathic clubfoot and 28 associated with arthrogryposis) with an average age of 4.8±0.8 years. The historical gait analyses of 72 typically developing children were used as a control, with an average age of 5.2±0.8 years. Significant residual equinovarus was seen in both children with idiopathic clubfoot and associated with arthrogryposis according to passive range of motion and foot pressure analysis when compared with normative data. Children with arthrogryposis demonstrated limited transfer and basic mobility, sports functioning, and global functioning while children with idiopathic clubfoot were significantly different from their typically developing peers in only transfer and basic mobility.

CONCLUSIONS

Although children with idiopathic clubfoot continue with some level of residual deformity, the Ponseti method is effective in creating a pain-free, highly functional foot. In children with clubfoot associated with arthrogryposis, the Ponseti method is successful in creating a braceable foot that can delay the need for invasive surgical intervention.

LEVEL OF EVIDENCE

Level III, Therapeutic Studies-Investigating the Results of Treatment.

The Ponseti method of treatment for neuromuscular and syndromic (non-idiopathic) clubfeet: evaluation of a programme-based approach at a mean follow-up of 5.8 years

PURPOSE

To analyse the results of the Ponseti method in the treatment of non-idiopathic clubfeet and compare them with idiopathic clubfeet in a programme-based setting using a standardized protocol METHODS: We reviewed two groups of 782 children treated prospectively in our programme-based Clubfoot Clinic: group I comprised of 89 patients (146 feet) with non-idiopathic clubfoot and group II comprised of 693 patients (1032 feet) with idiopathic clubfoot. Both groups were compared on the basis of patient demographics, number of casts, tenotomy rate, success rate, rate of recurrences, and the need for additional secondary procedures.

RESULTS

Non-idiopathic clubfeet had a higher incidence of bilateral involvement (p = 0.0093) and affected both males and females equally (p = 0.002) as compared with idiopathic clubfeet. Non-idiopathic clubfeet (group I) required significantly more casts (6.75 ± 4.2) compared with idiopathic clubfeet (4.23 ± 4.14), had a higher rate of Achilles tenotomy (90.4% vs 75%, p < 0.0001), and had a lower initial correction rate compared with idiopathic clubfeet (92.5% vs 100%, p < 0.0001). There was a significant difference in the recurrence rates between the two groups, as 42.5% of non-idiopathic feet (38 patients) relapsed compared with 10.2% (71 patients) in the idiopathic group (p < 0.0001). Most recurrences in group I were amenable to re-casting, with only nine patients (14 non-idiopathic clubfeet) requiring extensive soft tissue releases. The final success rate in the non-idiopathic group at a mean follow-up of 5.8 years (2-8 years) was 87.7%.

CONCLUSIONS

We recommend the use of the Ponseti method as an effective treatment for non-idiopathic clubfeet associated with neuromuscular and syndromic conditions.

Orthopaedic care of the child with arthrogryposis: a 2020 overview

PURPOSE OF REVIEW

The orthopaedic treatment of children with arthrogryposis multiplex congenita has evolved steadily over the past two decades. Interrelated factors have spurred this on, including better appreciation of the functional potential of persons with arthrogryposis, development of newer procedures specific for the arthrogrypotic deformities, and outcomes studies that provide understanding of the overall capabilities of adults with arthrogryposis and follow-up to determine which treatments were beneficial and which were not. This article briefly sketches out of some of these advances and indicates areas that need further development.

RECENT FINDINGS

Outcome studies show that the majority of adults with arthrogryposis are ambulatory but less than half are fully independent. Adults frequently experience ongoing pain, particularly foot and back pain, limiting ambulation and standing. Advancements in the upper extremity treatment include improving elbow function, wrist repositioning, and improving thumb positioning. In the lower extremities, correction of hip and knee contractures leads to improved ambulatory potential, and treating clubfeet with serial casting decreases poor outcomes.

SUMMARY

Clinical evaluation, both physical examination and assessment of the patient's needs, are important in directing treatment in arthrogryposis. Further outcomes studies are needed to continue to refine procedures and define the appropriate candidates.

Orthopedic guidelines for the care of people with spina bifida

Orthopedic or musculoskeletal problems are common in individuals with spina bifida. They can affect function and mobility and, in the case of spinal deformity, affect pulmonary function. We discuss the current treatment guidelines developed through collaboration with the Spina Bifida Association and the Orthopedics and Mobility working group using a specific methodology previously reported [1,2]. General considerations are discussed followed by evaluation and treatment guidelines for specific age ranges. References are provided where applicable, but where data is lacking treatment guidelines fall under the umbrella of clinical consensus. This leaves "research gaps" where areas of possible future study could be considered.

Results of Modified Ponseti Technique in Difficult Clubfoot and a review of literature

INTRODUCTION

Serial Ponseti casting achieves deformity correction in early presenting idiopathic clubfoot cases normally in around 7 casts. However, there are resistant patients where correction requires more casts than usual. In such patients a modification in standard technique might be required right from the beginning. Such patients were collectively called as difficult clubfoot. The aim of this study was to assess the outcome of our modification to Ponseti technique in difficult clubfoot.

METHODS

All idiopathic clubfoot cases who were 75th percentile or more in WHO age for weight chart (chubby infants) or untreated clubfoot patients presenting for first time to our clinic at more than 5 months age (late presenters and neglected cases) were included in the study. Patients who had been previously surgically intervened elsewhere, patients over 7 years of age, patients with syndromic clubfoot or clubfoot associated with neurological conditions were excluded from the study. The patients were treated by early tenotomy of tendoachillis and a plantar fascia release before starting serial casting by Ponseti technique. Post correction, strict bracing protocol was followed with regular follow up. Pirani scoring was done at each stage. Measurement of Talocalcaneal angle on AP radiograph, maximum degree of abduction and dorsiflexion was noted once every year.

RESULTS

There were total 28 patients in our study. In all, 47 feet were subjected to modified Ponseti protocol. There were 21 male patients. Median age at presentation was 4 months. Mean centile of weight for age as per WHO growth chart was 64. Mean Pirani score at presentation was 5.86 (S.D. ± 0.34). Mean number of casts required for correction was 3.75 ± 1.10. Maximum followup period was 25 months.

CONCLUSION

This modification of Ponseti casting for difficult clubfoot patients achieves correction in shorter duration with less number of casts.

Pain among children and adults living with arthrogryposis multiplex congenita: A scoping review

Clinical interventions and research have mostly focused on the orthopedic and genetic outcomes of individuals with arthrogryposis multiplex congenita (AMC), and although pain has gained recognition as an important issue experienced by individuals with AMC, it has received little attention within the AMC literature. The aims of this scoping review were to describe the pain experiences of children and adults with AMC, to identify pain assessment tools and management techniques, and document the impact of pain on participation in everyday activities among children and adults with AMC. A search of the literature was conducted in four search engines and identified a total of 89 articles. Once study eligibility was reviewed, 21 studies met the selection criteria and were included in this review. Pain appears to be more commonly experienced in adults with AMC compared with children with AMC, with individuals having undergone multiple corrective procedures self-reporting pain more often. In adult populations, musculoskeletal chronic pain is a significant problem, resulting in restrictions in activities of daily living, mobility, and participation. Researchers and clinicians must agree on the use of validated measures appropriate for evaluating pain in AMC and the use of appropriate pain management techniques to relieve pain. Pediatric studies should focus on determining how commonly pain is experienced in infants, children, and adolescents with AMC. Pain in adults with AMC should be acknowledged to offer proper client-centered interventions throughout the lifespan.

The relationship between joint surgery and quality of life in adults with arthrogryposis: An international study

Individuals with Arthrogryposis Multiplex Congenita (AMC) are born with multiple joint contractures in multiple body areas, typically manifested as clubfeet, extended or flexed knees and/or elbows, and internal shoulder rotation, and clasped hands. They require multiple surgeries as children, but there is little data that reports their aging and future quality of life (QOL). This study describes the relationship between AMC-related surgically-managed joints in childhood and adulthood, and QOL as adults. Participants (n = 83) from 14 countries completed an online questionnaire followed by a telephone/Skype interview as adults. Data points collected regarding total number of surgeries, affected joints, country of origin, sex, age, and SF-36's Physical Capacity Score (PCS) for QOL were analyzed using a beta regression model to explore which factors may potentially influence adult QOL. The average number of surgeries per participant was 9.8, with at least 50% performed during childhood. 78, 45, and 31% of participants had foot, knee, and hip surgeries, respectively. The model demonstrated that knee and/or shoulder surgeries were more likely to have a negative correlation with PCS; elbow surgery, however, showed a positive correlation, as elbow function may impact independent function. However, future expansion of this data set to a longitudinal registry would provide better ongoing surgery-specific data.

Challenging clubfeet: the arthrogrypotic clubfoot and the complex clubfoot

Within the realm of clubfoot deformities, teratologic and complex (or atypical) clubfeet stand out as the most difficult. Exemplarities of the teratologic types of clubfoot are those associated with arthrogryposis multiplex congenita. Treatment of arthrogrypotic clubfoot deformities has been controversial; many different procedures have been advocated, with variable success rates. These clubfeet have a high recurrence rate, regardless of treatment type. Often, the high recurrence rate has led to a high repeat surgery rate, and poor outcomes. Treatment strategies should highlight care that avoids the development of a stiffened foot and allows for a variety of options to regain correction when a relapse occurs. Modifications of the Ponseti method for idiopathic clubfeet have been successful in managing the deformity. The equinocavus variant of the arthrogrypotic clubfoot should be distinguished from the classic clubfoot, as it requires a different treatment method. The equinocavus clubfoot is very similar to the complex or atypical clubfoot. The complex, or atypical, clubfoot also requires a different treatment strategy compared with the typical idiopathic congenital clubfoot. The complex clubfoot appears to be idiopathic in some cases and iatrogenic (due to slipping stretching casts) in others. Dr. Ponseti's modification of his protocol has been effective in treating the deformity. The high recurrence rate suggests the difficulty in maintaining the deformity after correction. The author's preferred treatment for each deformity is included, with an emphasis on minimally invasive methods.

LEVEL OF EVIDENCE

Level V, expert opinion.

Evaluation of modified Ponseti technique in treatment of complex clubfeet

BACKGROUND

Complex clubfoot does not respond to ponseti method. In 2006 Ponseti et al published the results of treatment of such complex club foot by modified ponseti technique, since then it has become standard method of treatment for complex clubfoot. There has been only few published result of this method and hence, here we are evaluating our experience with 16 patients (27 clubfeet) with complex clubfeet treated at our center by modified ponseti method.

METHOD

Parents of patient fulfilling the criteria for complex clubfoot were consented and registered under the study. Pirani score at presentation, at prescription of foot abduction brace and at final follow up was noted. total number of casts required for desired correction, number of cast before and after tenotomy, need of tendoachilles tenotomy, relapse and complications were documented.

RESULT

Average follow up duration was 14.762 months (Range 6 month to 22 months). Of the total 16 patients 11 had bilateral complex clubfoot and 5 had unilateral complex clubfoot, the mean pirani score at the time of presentation was 5.5741 (range 4.5-6), Mean pirani score at latest follow up was 0.0556. Average no. of casts required for the complete correction with modified ponseti method was 7.44 (ranging from 6 to 10 casts). All 27 feet (100%) required tendo achillies tenotomy. Percutaneous tenotomy was done in 19 feet while 8 feet required Mini-Open tenotomy (due to thick pad of fat tendon was not palpable). Relapse rate was 11.11% (3 feet) [all had relapse of equinus, fore foot adduction treated by remanipulation by modified ponseti technique, retenotomy and casting]. An excellent result was achieved with at final follow-up in all 27 feet.

CONCLUSION

In our experience modified ponseti technique for treatment of complex clubfoot is a successful method of treatment if aided with tendoachilles tenotomy, also it has reduced the requirement of surgical intervention in such patients.Level of Evidence - Level IV.

Clinical outcomes and risk-factor analysis of the Ponseti Method in a low-resource setting: Clubfoot care in Haiti

Purpose

The Ponseti Method has dramatically altered the management of clubfoot, with particular implications for limited-resource settings. We sought to describe outcomes of care and risk factors for sub-optimal results using the Ponseti Method in Haiti.

Methods

We conducted a records review of patients presenting from 2011–2015 to a CURE Clubfoot clinic in Port-au-Prince, Haiti. We report patient characteristics (demographics and clinical), treatment patterns (cast number/duration and tenotomy rates), and outcomes (relapse and complications). We compared treatment with benchmarks in high-income nations and used generalized linear models to identify risk factors for delayed presentation, increased number of casts, and relapse.

Results

Amongst 168 children, age at presentation ranged from 0 days (birth) to 4.4 years, 62% were male, 35% were born at home, 63% had bilateral disease, and 46% had idiopathic clubfeet. Prior treatment (RR 6.33, 95% CI 3.18–12.62) was associated with a higher risk of delayed presentation. Risk factors for requiring ≥ 10 casts included having a non-idiopathic diagnosis (RR 2.28, 95% CI 1.08–4.83) and higher Pirani score (RR 2.78 per 0.5 increase, 95% CI 1.17–6.64). Female sex (RR 1.54, 95% CI 1.01–2.34) and higher Pirani score (RR 1.09 per 0.5 increase, 95% CI 1.00–1.17) were risk factors for relapse. Compared to North American benchmarks, children presented later (median 4.1 wks [IQR 1.6–18.1] vs. 1 wk), with longer casting (12.5 wks [SD 9.8] vs. 7.1 wks), and higher relapse (43% vs. 22%).

Conclusions

Higher Pirani score, prior treatment, non-idiopathic diagnosis, and female sex were associated with a higher risk of sub-optimal outcomes in this low-resource setting. Compared to high-income nations, serial casting began later, with longer duration and higher relapse. Identifying patients at risk for poor outcomes in a low-resource setting can guide counseling, program development, and resource allocation.

Treatment of non-idiopathic clubfeet with the Ponseti method: a systematic review

PURPOSE

Although non-idiopathic clubfeet were long thought to be resistant to non-surgical treatment methods, more studies documenting results on treatment of these feet with the Ponseti method are being published. The goal of this systematic review is to summarize current evidence on treatment of non-idiopathic clubfeet using the Ponseti method.

METHODS

PubMed and Limo were searched, reference lists of eligible studies were screened and studies that met the inclusion criteria were included. Data on average number of casts, Achilles tendon tenotomy (ATT), initial correction, recurrence, successful treatment at final follow-up and complications were pooled. The Methodological Index for Non-Randomized Studies was used to assess the methodological quality of the selected studies.

RESULTS

In all, 11 studies were included, yielding a total of 374 non-idiopathic and 801 idiopathic clubfeet. Non-idiopathic clubfeet required more casts (7.2 versus 5.4) and had a higher rate of ATT (89.4% versus 75.7%). Furthermore, these feet had a higher recurrence rate (43.3% versus 11.5%) and a lower rate of successful treatment at final follow-up (69.3% versus 95.0%). Complications were found in 20.3% of the non--idiopathic cohort. When comparing results between clubfeet associated with myelomeningocele and arthrogryposis, the first group presented with a lower number of casts (5.4 -versus 7.2) and a higher rate of successful treatment at final follow-up (81.8% versus 58.2%).

CONCLUSION

The Ponseti method is a valuable and non-invasive option in the primary treatment of non-idiopathic clubfeet in young children. Studies with longer follow-up are necessary to evaluate its long-term effect.

LEVEL OF EVIDENCE

Level III - systematic review of Level-III studies.This work meets the requirements of the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and -Meta-Analyses).

Treatment of syndrome-associated congenital talipes equinovarus using the Ponseti method: 4-12 years of follow-up

to evaluate the effectiveness of the Ponseti method in treating syndrome-associated (nonidiopathic) congenital talipes equinovarus. This was a retrospective consecutive review over a 12-year period in a tertiary centre of all patients with syndrome-associated talipes equinovarus treated with the Ponseti method. The primary outcome measure at the final follow-up was the functional correction of the deformity. There were 16 (28 feet) children, with an average follow-up of 7 years (range: 4-12). The average age at presentation was 6.1 (range: 2-17) weeks. Deformities were severe, with an average Pirani score of 5.0 (range: 3.0-6.0). Initial correction was achieved in all children, with an average of 6 (range: 4-9) Ponseti casts and a tendo-Achilles tenotomy performed in 21/28 (75%) feet. Satisfactory outcome at the final follow-up was achieved in 23/28 (82%) feet. The Ponseti method is an effective first-line treatment for syndrome-associated talipes equinovarus to achieve functional painless feet; children will often require more casts and have a higher risk of relapse.

Inferior results with unilateral compared with bilateral brace in Ponseti-treated clubfeet

PURPOSE

The Ponseti method for treating clubfoot was introduced in Norway in 2003, and a cohort of children has been followed for 8 to 11 years. In a previous study, we found good results after follow-up of two to five years, with 3% rate of extensive surgery (posterior release or posteromedial release). During 8 to 11 years of follow-up, the rate of extensive surgery increased to 11%. The children had been treated with a bilateral brace or a unilateral brace. In this multicentre study we aimed to compare these two post-corrective treatment methods.

METHODS

In all, 94 children (133 feet) were initially treated according to the Ponseti method, and had post-corrective treatment with either a bilateral foot abduction brace or a unilateral above-the-knee brace. The children were examined at a mean age of 9.3 years (8 to 11) regarding flexibility and deformity of the foot and ankle. Information including type of brace, brace compliance and surgical procedures was -obtained from the patient records. The parents answered questionnaires and radiographs were taken of the feet.

RESULTS

Feet treated with a bilateral brace had better dorsal flexion (p = 0.008), plantar flexion (p = 0.02), external rotation (p = 0.001) and less forefoot adduction (p = 0.04) than feet treated with a unilateral brace. Children using a bilateral brace had a better Functional Rating System score (p = 0.005) and Disease Specific Instrument score (p = 0.02).

CONCLUSION

Children treated with a bilateral brace had better parent-reported outcomes and more flexible feet than children treated with a unilateral brace. Our results do not support the use of a unilateral foot abduction brace in clubfoot treatment.