Use of the Ponseti method for recurrent clubfoot following posteromedial release

The Incidence of Clubfoot in the Czech Republic: A Nationwide Epidemiological Study from 2000 to 2014

Clubfoot is one of the most common musculoskeletal birth deformities worldwide. The prevalence varies among individual countries and populations. There is a lack of nationwide incidence studies in Central Europe. We analyzed the incidence of clubfoot in the Czech Republic over 14 years. Patients born with clubfoot in the Czech Republic were identified using The National Registry of Congenital Anomalies. Demographic data were included. Data from 2000 to 2014 were collected and analyzed regarding gender and regional distribution. The study's chosen time frame was grounded on the condition of the Czech industry. Following extensive transformations in 1989, the industry eliminated highly non-ecological operations with significant environmental impact and related health risks. The incidence of clubfoot during the study period was 1.9 (95% CI 1.8-2.0) per 1000 births; males comprised the majority (59%). The incidence significantly differed among individual regions of the Czech Republic (p < 0.001). The incidence in the Czech Republic was higher than in previous European studies. We found significant regional differences in incidence, which could indicate that there may be exogenous pathogenic factors. For this reason, we plan to follow up our work with an up-to-date study.

Narrative review of the management of a relapsed clubfoot

The management of idiopathic clubfoot has transformed over the past several decades as the Ponseti method for the correction of this deformity became the standard of care, and surgical release has almost all but been abandoned. The Ponseti method has shown very high initial success rate and excellent long-term functional results. Relapse of the deformity, however, continues to be a major problem, occurring in up to 40% of patient, and there is no consensus on the definition and management of the relapsed clubfoot. This review discusses the available management options for the treatment of a relapsed clubfoot deformity following initial treatment with the Ponseti method [including repeat casting, tendo-Achilles lengthening, plantar fascia release, and tibialis anterior tendon transfer (TATT)] as well as following initial surgical treatment with posteromedial release (including casting, hemiepiphysiodesis, revised posteromedial release, osteotomies, fusion, and the use of gradual distraction with external fixators). These are discussed from the least to the most invasive. Available evidence, and limitations of the literature, for the management of relapses following both the Ponseti method and initial surgical release is reviewed along with along with the reported outcomes. Future efforts should be geared towards standardizing the definition of a relapse with objective criteria for its management.

MRI recovery of the Achilles tendon after percutaneous tenotomy in older children

Background

An observational study was conducted to evaluate the recovery of older children with relapsed congenital clubfoot who underwent an Achilles tenotomy for the second time as part of the Ponseti treatment.

Methods

Thirteen patients (19 feet) with congenital clubfoot underwent Achilles tenotomy where magnetic resonance images of the severed tendons were taken after 1, 3, and 6 weeks post-procedure. The participants were categorized into older children who underwent tenotomy for the first time (group A: mean, 4.9±1.8, and range, 2.8–7 years old) and older children who underwent tenotomy for a second time (group B: mean, 4.9±1.5, and range, 3–6.8 years old). The area of high signal intensity between the severed tendons on MRI scans was computed using Python programming language and compared with clinical assessment.

Results

Three weeks after Achilles tenotomy, groups A and B had clinically intact tendons in 9 out of 11 and 2 out of 8 feet, respectively, according to both clinical and MRI assessment. From week 1 to week 3 post-tenotomy, computational analysis showed that the mean high signal intensity area of group A decreased by 88.5±15.2%, which was significantly different (P .048 < .05) than the percent reduction of high signal intensity area of group B (69.0±24.9%).

Conclusion

Children who underwent Achilles tenotomy for the second time showed slower tendon recovery on the third week post-procedure. A possible reason for slower healing times may be due to the location of tenotomy in being further away from the musculotendinous junction where extrinsic healing mechanisms take place.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02407-4.

Ponseti method in the treatment of post-operative relapsed idiopathic clubfoot after posteromedial release. A short term functional study

BACKGROUND

Relapsed clubfeet deformity after surgical treatment by posteromedial release are frequently encountered in pediatric orthopedic practice and further revision surgery may be needed. As surgery adds more fibrosis and scaring, complication may be devastating and treatment is challenging. Ponseti method, the gold standard technique for treatment of clubfoot may be of a value in the management of postoperative relapses.

AIM OF THE STUDY

Determine the effectiveness of Ponseti casting Method in treatment of relapsed idiopathic clubfoot in children after being treated with surgical posteromedial release.

MATERIALS AND METHODS

Prospective interventional study of 17 patients (25 feet) presented with a relapsed idiopathic clubfoot deformity after previous surgical posteromedial release. The patients were reviewed using Pirani and Dimeglio score. Ponseti method was done to obtain supple, flexible foot rather than a fully corrected foot, the residual deformity were treated by, heel cord lengthening or tenotomy, tibialis anterior transfer, follow up was for a minimum of 12 months.

RESULT

17 Patients (25 feet) their age ranging from 1 to 10 years were evaluated and treated. Casts were applied until the only deformities remaining were either hindfoot equinus and/or dynamic supination. 22 feet required a heel cord procedure for equinus and 13 required tibialis anterior transfer for dynamic supination. The follow up (average 56.1 months) was for a minimum of one year. 4 feet had persistent heel varus deformity which required Calcaneal osteotomy later. Three feet didn't need more casting and 2 feet were resistant cases that required further Ilizarov procedure, 4 needed lateral arch shortening and other 4 needed posterior capsulotomy. Improvement in the Pirani and Dimeglio scores was highly statistically significant.

CONCLUSION

Ponseti method for treatment of relapsed clubfeet after a previous posteromedial soft tissue surgical release is an effective, non invasive, with excellent results.

Ilizarov Frame Application Based on Ponseti Principles for Clubfoot Correction: A Case Report and Description of Surgical Technique

Ilizarov external fixator has proved to be a successful method in the management of neglected and relapsed clubfoot cases as it has lesser surgical morbidity, better functional outcome and does not cause shortening of foot as compared to other surgical methods. Though Ilizarov has been routinely used in the management of neglected/relapsed CTEV, residual varus and equinus deformities are still present/recur in some cases. Here we demonstrated a surgical technique in a case of 8-year-old child with residual club foot who achieved good functional outcome after being treated using Ilizarov frame application in lieu with Ponseti's principles.

Ponseti Method After Walking Age - A Multi-Centric Study of 429 Feet: Results, Possible Treatment Modifications and Outcomes According to Age Groups

OBJECTIVE

Ponseti method is suitable to treat neglected clubfoot after the walking age. However, limited evidence exists on its effectiveness, outcomes and rate of relapse. Methods: 429 clubfeet in 303 patients with no previous treatment and older than one-year were treated with the Ponseti method in 15 centers from seven countries. The median age at treatment onset was three years, and the median follow-up of 1.3 years. Standard Ponseti Method was applied. Bilateral abduction brace was recommended after casting. Patients were classified according to group ages (<2 years, 2-4 years, >4-8years, >8 years). Feet were evaluated by Pirani score and a clinical outcome classification. Relapses were described in a subset of 103 clubfeet with minimal follow-up of two years.

RESULTS

Ponseti method was able to correct the deformity in 87% (373 of 429) of neglected clubfeet, after a mean of 6.8 casts. Residual equinus was treated with percutaneous sectioning of the Achilles tendon in 356 (83%) of 429 clubfeet. A bilateral foot abduction brace was prescribed and used in 70% of children. Relapses occurred in 31% (32 of 103) of clubfeet and were associated with age less than 4 years at treatment onset, and bracing noncompliance.

CONCLUSION

The Ponseti method is effective to correct neglected clubfeet. Relapses occurred in one-third of clubfeet, mainly in children younger than four years and in noncompliance with the brace. Our study reinforces the recommendation for the Ponseti method with no major modification to treat neglected clubfoot in patients after walking age.Level of Evidence: IV.

Expanded Age Indication for Ponseti Method for Correction of Congenital Idiopathic Talipes Equinovarus: A Systematic Review

The deformity known as congenital idiopathic talipes equinovarus (CTEV) is probably the most common (1 to 2 in 1000 live births) congenital orthopedic condition requiring intensive treatment. With the perception that the treatment of idiopathic CTEV by extensive soft tissue release is often complicated by stiffness, recurrence, and the need for additional procedures, the minimally invasive Ponseti method has been accepted as the first line of treatment, which has achieved excellent results globally. The Ponseti method has achieved excellent results in children with idiopathic CTEV aged ≤2 years. However, the upper age limit for the Ponseti treatment has not yet been defined. We reviewed the published data to determine the efficacy of the Ponseti method in older children with neglected CTEV.

The 2017 ABJS Nicolas Andry Award: Advancing Personalized Medicine for Clubfoot Through Translational Research

BACKGROUND

Clubfoot is one of the most common pediatric orthopaedic disorders. While the Ponseti method has revolutionized clubfoot treatment, it is not effective for all patients. When the Ponseti method does not correct the foot, patients are at risk for lifelong disability and may require more-extensive surgery.

QUESTIONS/PURPOSES

(1) What genetic and morphologic abnormalities contribute to the development of clubfoot? (2) How can this information be used to devise personalized treatment paradigms for patients with clubfoot?

METHODS

Human gene sequencing, molecular genetic engineering of mouse models of clubfoot, MRI of clubfoot, and development of new treatment methods all have been used by our group to understand the biological basis and improve therapy for this group of disorders.

RESULTS

We gained new insight into clubfoot pathogenesis from our discovery that mutations in the PITX1-TBX4-HOXC transcriptional pathway cause familial clubfoot and vertical talus in a small number of families, with the unique lower limb expression of these genes providing an explanation for the lack of upper extremity involvement in these disorders. MRI studies revealed corresponding morphologic abnormalities, including hypomorphic muscle, bone, and vasculature, that are not only associated with these gene mutations, but also are biomarkers for treatment-resistant clubfoot.

CONCLUSIONS

Based on an understanding of the underlying biology, we improved treatment methods for neglected and syndromic clubfoot, developed new treatment for congenital vertical talus based on the principles of the Ponseti method, and designed a new dynamic clubfoot brace to improve strength and compliance.

Evertor muscle activity as a predictor for recurrence in idiopathic clubfoot

BACKGROUND

Clubfoot is a complex three-dimensional deformity. Although brace compliance after initial correction was previously found to be significantly associated with recurrence in clubfoot, few previous studies have specifically examined evertor muscle function as a factor that contributes to recurrence in children with idiopathic and non-idiopathic clubfoot. The aim of this study was to investigate the relationship among brace compliance, evertor muscle grading, and recurrence rate in pediatric clubfoot patients.

METHODS

Children with idiopathic clubfoot who were treated and followed for a minimum of 2 years were included. Patients who used their brace <20-23 h a day for the first 3 months and then <8-10 h per day during sleep and nap times thereafter were classified as group I. Patients who complied fully by using the brace 23 h a day for the first 3 months and then 8-10 h per day during sleep and nap times thereafter were classified as group II. Demographic and clinical data including age, gender, follow-up time, recurrence, evertor muscle grading, types of surgery, brace compliance, severity of initial deformity, age at onset, number of casts required for initial correction, and the need for Achilles tenotomy were collected and analyzed.

RESULTS

Seventy-nine children with clubfoot were included. There were 47 males and 32 females, mean age was 3.2 years (range 2.1-6.3), and the mean follow-up time was 31.4 months. All patients had follow-up of at least 2 years. Primary correction was obtained in all children. There was no significant difference in mean age, mean follow-up time, or recurrence rate between groups. There was, however, a statistically significant difference in mean brace time between groups (p = 0.002). The recurrence rate was 26.2% in group I and 22.2% in group II. The recurrence rate in group a (Pirani score 0) was 3.9%, group b (Pirani score 0.5) 43.8%, and group c (Pirani score 1) 75% (p < 0.001). No significant association was found between severity of the initial deformity, age at the onset of treatment, number of casts required for correction, or reported brace compliance and recurrence or rates of surgery. Only poor or absent evertor muscle activity was found to be statistically significantly associated with risk of recurrence.

CONCLUSION

Good evertor muscle grading was found to be a significant protective factor against recurrence of idiopathic clubfoot. Thus, improvement in muscle balance around the ankle, especially the evertor muscle, should be emphasized to parents after the casting regimen is completed and correction is achieved.

The clubfoot over the centuries

The aim of this paper is to review all treatment methods of the clubfoot over the years through the documentation present in the literature and art with the aim of better understanding the pathoanatomy of the deformity, but to also clarify factors that allow a safe, logical approach to clubfoot management. The initial part of this paper traces the most representative iconographic representations of clubfoot in history to describe how his presence was witnessed since ancient times. Hippocrates, the father of medicine, was the first to present written references about treatment methods of clubfoot. After the dark period of the Middle Ages, during the Renaissance, there were more detailed studies on the disease, with the creation of the first orthopedic orthotics, designed to correct the deformity with the help of famous names in medicine's history. In the XVIII century, as we witness the birth of orthopedics as a distinct discipline in medicine, more and more brilliant minds developed complex orthoses and footwear with the aim of obtaining a proper correction of the deformity. In the last part of the paper, there is a description of the main surgical techniques developed over the years until the return to conservative treatment methods such as the Ponseti method, internationally recognized as the gold standard of treatment, despite the presence of some unresolved issues such as the possible recurrence of the disease.

Ponseti Treatment of Rigid Residual Deformity in Congenital Clubfoot After Walking Age

BACKGROUND

There is no established treatment for rigid residual deformity of congenital clubfoot (CCF) after walking age. Soft-tissue procedures, osseous procedures, and external fixation have been performed with unpredictable results. We applied the Ponseti method to patients with this condition in order to improve the outcomes of treatment.

METHODS

We retrospectively reviewed the cases of 44 patients (68 feet) with congenital clubfoot whose mean age (and standard deviation) at treatment was 4.8 ± 1.6 years. All patients had been previously treated in other institutions by various conservative and surgical protocols. Residual deformity was evaluated using the International Clubfoot Study Group Score (ICFSGS), and stiffness was rated by the number of casts needed for deformity correction. Ponseti manipulation and cast application was performed. Equinus was usually treated with percutaneous heel-cord surgery, while the cavus deformity was treated with percutaneous fasciotomy when needed. Tibialis anterior tendon transfer (TATT) was performed in patients over 3 years old. At the time of follow-up, the results were evaluated using the ICFSGS.

RESULTS

Before treatment, 12 feet were graded as fair and 56, as poor. Two to 4 casts were applied, with each cast worn for 4 weeks. Stiffness was moderate (2 casts) in 23 feet, severe (3 casts) in 30 feet, and very severe (4 casts) in 15 feet. Percutaneous heel-cord surgery was performed in 28 feet; open posterior release, in 5 feet; plantar fasciotomy, in 30 feet; and TATT, in 60 feet. The mean length of follow-up was 4.9 ± 1.8 years. Eight feet had an excellent result; 49 feet, a good result; and 11 feet, a fair result. No patient had pain. All of the feet showed significant improvement.

CONCLUSIONS

Ponseti treatment with TATT, which was performed in 88% of the feet, was effective, and satisfactory results were achieved in 84% of the feet. At the time of follow-up, no patient showed an abnormal gait, all feet were plantigrade and flexible, but 2 feet (2.9%) had relapsed.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical treatment of neglected congenital idiopathic talipes equinovarus after walking age in Eritrea: an Italo-Eritrean cooperation

An Italian team of orthopaedic surgeons joined Eritrean colleagues to perform a clinical study in ambulating children affected by neglected idiopathic congenital talipes equinovarus (clubfoot). This study reports the surgical strategy as well as clinical outcomes, early complications and relapse at a mid-term follow-up. Four expeditions of 7 days were organized between 2012 and 2015 from Italy to the Halibet Hospital of Asmara in Eritrea. In each expedition were included two experienced surgeons, two assistants and one anaesthesiologist. During these expeditions, a total of 468 patients were evaluated together with Eritrean colleagues and 45 cases of neglected talipes equinovarus in ambulating children were diagnosed and selected for surgery. Follow-up range was 1-3 years. During the four expeditions, the Eritrean team of orthopaedic surgeons learned to manage most cases of neglected talipes equinovarus. No major complications were reported. Sixteen feet were considered excellent, 25 good and four poor. No overcorrections were observed. Neglected congenital talipes equinovarus is the result of delayed treatment of congenital deformity in developing countries, and its treatment often requires extensive surgery. Collaboration with foreign expert surgeons may help local doctors to learn how to treat this disease. The current study demonstrates that surgical expeditions in developing countries, when organized in collaboration with local doctors, help to manage on site this severe deformity.

Congenital idiopathic talipes equinovarus before and after walking age: observations and strategy of treatment from a series of 88 cases

BACKGROUND

We reviewed a series of newborns, toddlers and ambulating children affected by idiopathic congenital talipes equinovarus (clubfoot). Taking into account the time of diagnosis, stiffness of the deformity and walking age, nonsurgical or surgical treatment was considered. This study reports clinical outcomes, early complications and relapse at mid-term follow-up.

MATERIALS AND METHODS

Fifty-two clubfeet were diagnosed at birth, 12 in non-ambulating children aged between 4 and 12 months and 24 in ambulating children. Feet were classified using the Pirani score. Newborns and toddlers were treated with serial casting (Ponseti); however, toddlers also underwent open Achilles tendon lengthening (2 feet) and posteromedial release (3 feet). In all ambulating children, surgical treatment was always performed: selective medial release combined with cuboid subtraction osteotomy (1 foot), posteromedial release (6 feet), and posteromedial release combined with cuboid subtraction osteotomy (17 feet).

RESULTS

The average follow-up was 5 years (1-6 years). In newborns treated with Ponseti, the results were excellent in 42 feet, good in 6, and poor in 4. In non-ambulating children, the results were excellent in 9 feet, and good in 3. In ambulating children, the results were excellent in 5 feet, good in 16, and poor in 3. No major complications were reported. No overcorrections were observed. The need for open surgery was higher in cases of delayed treatment. In cases of relapse, re-casting and/or more extensive surgery was considered.

CONCLUSIONS

Early treatment enables a high rate of good correction to be obtained with serial casting and limited surgery. Conversely, if the deformity is observed after walking age surgery should be considered. Serial casting in cases of late observation and relapse have demonstrated encouraging results.

LEVEL OF EVIDENCE

IV.

Treatment of Severe Recurrent Clubfoot

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.

Does the Ponseti technique affect the vascular development in patients with congenital talipes equinovarus?

In this study, we have evaluated the changes observed in the main arteries of the foot before and after the Ponseti technique. Arterial structures of seven patients were examined using Doppler ultrasound and the parameters studied included the course of the arteries, lumen filling, flow direction, pattern, and velocity. Before the treatment, the side with congenital talipes equinovarus deformity showed decreased blood flow in all arteries, except for the posterior tibial artery. At the second examination, the increase in the flow velocity of both arteries except tibialis anterior arteries was statistically significant. The Ponseti method results in normalization of the arterial structures in extremities with congenital talipes equinovarus.

Management of Idiopathic Clubfoot by Ponseti Technique in Children Presenting After One Year of Age

We conducted a study to determine the effectiveness of the Ponseti technique in the management of idiopathic congenital clubfoot in patients older than 1 year of age. A total of 19 patients with 28 clubfeet (16 males [84.2%], 3 females [15.8%]) were included in the present study. The mean age at presentation was 2.7 (range 1 to 3.5) years. The results of treatment using the Ponseti technique were evaluated using the Pirani and Dimeglio scoring systems. The mean precorrection total Pirani score was 4.84 (range 3.5 to 5.5) and the mean precorrection Dimeglio score was 12.96 (range 10 to 14). The mean postcorrection total Pirani score was 0.55 (range 0 to 1), and the mean postcorrection Dimeglio score was 2.32 (range 2 to 3). These differences were statistically significant (p < .001 and p < .001, respectively). In 92.8% of the feet, satisfactory correction of the deformity was achieved. The mean number of casts applied was 8 (range 5 to 12). All but 1 (3.6%) of the clubfeet required tenotomy to achieve correction. The mean follow-up duration was 2.7 (range 1.5 to 3.5) years. We have concluded that the Ponseti technique is an effective method for the management of idiopathic congenital clubfoot, even in toddlers.

Results of clubfoot management using the Ponseti method: do the details matter? A systematic review

BACKGROUND

Although the Ponseti method is accepted as the best choice for treatment of clubfoot, the treatment protocol is labor intensive and requires strict attention to details. Deviations in strict use of this method are likely responsible for the variations among centers in reported success rates.

QUESTIONS/PURPOSES

We wished to determine (1) to what degree the Ponseti method was followed in terms of manipulation, casting, and percutaneous Achilles tenotomy, (2) whether there was variation in the bracing type and protocol used for relapse prevention, and (3) if the same criteria were used to diagnose and manage clubfoot relapse.

METHODS

We conducted a systematic review of MEDLINE, EMBASE(TM), and the Cochrane Library. Studies were summarized according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement. Five hundred ninety-one records were identified with 409 remaining after deduplication, in which 278 irrelevant studies and 22 review articles were excluded. Of the remaining 109 papers, 19 met our inclusion criteria. All 19 articles were therapeutic studies of the Ponseti method.

RESULTS

The details of manipulation, casting, or percutaneous Achilles tenotomy of the Ponseti method were poorly described in 11 studies, whereas the main principles were not followed in three studies. In three studies, the brace type deviated significantly from that recommended, whereas in another three studies the bracing protocol in terms of hours of recommended use was not followed. Furthermore no unified criteria were used for judgment of compliance with brace use. The indication for recognition and management of relapse varied among studies and was different from the original description of the Ponseti method.

CONCLUSIONS

We found that the observed clinically important variation may have been the result of deviations from the details regarding manipulation, casting, percutaneous Achilles tenotomy, use of the bar-connected brace, and indication for relapse recognition and management recommended for the classic Ponseti approach to clubfoot management. We strongly recommend that clinicians follow the Ponseti method as it initially was described without deviation to optimize treatment outcomes.

Ilizarov in relapsed clubfoot: a necessary evil?

This study aims to retrospectively evaluate the results of soft tissue distraction using Ilizarov in relapsed clubfeet following a previous posteromedial soft tissue release. This study, as compared with previous studies, has a cohort of patients with relapsed clubfeet only following posteromedial soft tissue release. Fifteen patients (16 feet) were assessed using the International Clubfoot Study Group score and plantigrade foot was achieved in all except one patient who had equinus deformity. Fourteen feet were graded as showing excellent or good result on the basis of the International Clubfoot Study Group (ICFSG) score. Although no patient had an ICFSG score of 0, parental satisfaction was good. This report supports the use of Ilizarov as the benefits offered outweigh the risk of associated complications, making this potentially cumbersome apparatus a useful tool in the armamentarium to treat relapsed clubfeet following soft tissue release.

Anterior distal tibial epiphysiodesis for the treatment of recurrent equinus deformity after surgical treatment of clubfeet

The treatment of clubfeet has changed constantly. Before the acceptance of the Ponseti serial casting, extensive surgical release was widely used. The treatment of relapse in these surgically treated clubfeet can be very challenging. Many methods have been used ranging from osteotomies to new posteromedial release, or correction using the Ilizarov fixator. Supramalleolar osteotomy was practiced for the treatment of residual equinus. The aim of this study is to evaluate the effect of anterior epiphysiodesis of the distal tibia on recurrent equinus deformity in patients with clubfeet treated surgically.

METHODS

We evaluated 25 children (31 feet) with recurrent equinus deformity after surgical treatment of clubfoot treated in our institution from 2003 through 2009. There were 16 boys and 9 girls, of whom 11 had recurrent equinus deformity on the left side, 8 on the right side, and 6 on the bilateral side. Three patients were treated with Richard staples and 22 were treated with 8-plates. Patients were examined clinically and radiologically, preoperatively. The mean dorsiflexion of the ankle was 2.5 degrees (-5 to 10 degrees) and the anterior distal tibial angle (ADTA) was 85 degrees. The patients were followed postoperatively and evaluated clinically and radiographically. The plates or staples were removed if the desired effect of around 15 degrees of dorsiflexion was achieved, or the ADTA shifted >15 degrees.

RESULTS

Mean follow-up was 22 months. Mean improval of dorsiflexion was 2 degrees, with a mean of dorsiflexion of 4.5 degrees, and mean radiological changes of ADTA were 13 degrees. We found no correlation between the radiographic changes and the clinically measured dorsiflexion.

CONCLUSIONS

The use of anterior distal tibial epiphysiodesis does not seem to give a clinically significant improvement in dorsiflexion of the ankle despite a marked shift in the ADTA.

Differential distraction for relapsed clubfoot deformity in children

PURPOSE

To evaluate the long-term outcome of clubfoot correction following differential distraction using the Joshi external stabilisation system (JESS).

METHODS

13 male and 9 female patients aged 1.5 to 5 years with 28 idiopathic clubfeet underwent differential distraction using JESS for relapsed deformity after posteromedial soft-tissue release. They were available for review after a mean of 12 years. Deformities of the feet were rigid and graded as Dimeglio type III or more. Pain, function, and satisfaction were evaluated using a questionnaire. Alignments of the forefoot and hindfoot, subtalar motion, ankle range of movement, muscle power, foot size, calf circumference, and limb length discrepancy were also evaluated. Each foot was rated using the Ponseti scale.

RESULTS

In 16 patients with unilateral clubfoot, the abnormal side differed significantly from the normal side in terms of foot size, calf circumference, ankle motion, and Ponseti score. Most affected feet were smaller. The mean Ponseti score for the 28 clubfeet was 80. 20 of the feet had good-to-excellent and 5 had fair scores, whereas 3 had poor scores (because of recurrence of deformity). Most patients were able to perform activities of daily living without any problem. The function of the ankle and subtalar joints was limited. Only 3 feet achieved ankle dorsiflexion of <10 degrees, 15 were beyond neutral to 10 degrees, 7 were neutral, and 3 were less than neutral. Most patients developed pin site infection, but none necessitated premature removal of the assembly or any surgical intervention.

CONCLUSION

Differential distraction using JESS enabled long-term maintenance of correction and good function, despite hindfoot stiffness.

Evaluation of neglected idiopathic ctev managed by ligamentotaxis using jess: a long-term followup

Background. This study was conducted with the aim of evaluating the role of Ligamentotaxis in the management of neglected clubfeet managed by ligamentotaxis using Joshi's External Stabilisation System (JESS). Method & Material. Total 20 subjects (28 feet) were studied, which were corrected by differential ligamentotaxis using JESS. All were evaluated clinically, radiologically, podogrammically, and by Catterall Pirani Scoring System, both before and after the correction. Results. Severity of the deformities and clinical correction was assessed by Pirani score. All patients achieved good clinical results as per Pirani score, which was statistically significant. Radiological evaluation showed that all subjects achieved the normal range of values. The pre- and postcorrection difference in FBA was statistically significant. Conclusion. Differential distraction by fixator for the correction of neglected idiopathic CTEV is an effective and patient-friendly method of management.

Treatment of clubfoot with the Ponseti method: should we begin casting in the newborn period or later?

The Ponseti method has become accepted worldwide as the treatment of choice for nonoperative management of clubfoot. However, there has been no research on whether casting should begin in the newborn period (< or = 30 days old) or later (> 30 days but < 1 year old) or on whether the length of the foot at the beginning of casting is predictive of the outcome of therapy. Therefore, we conducted an investigation to compare outcomes in patients started on casting therapy in the newborn period or later. Outcomes were based on Pirani and Diméglio scores. The study population was comprised of 40 clubfeet in 29 consecutive infants with no associated neuromuscular disease, who underwent Ponseti treatment. The median follow-up was 34 months (range, 20-47 months). Casting began in the newborn period on 26 feet of 18 patients (newborn group), and after 1 month of age on 14 feet of 11 patients (older infant group). Final Diméglio scores were significantly worse for the patients whose casts were applied in the newborn period, compared with those who had the first cast applied at a time >30 days postpartum (P = .04). Infants with feet > or =8 cm in length at the start of cast treatment had better final Diméglio scores than those with feet <8 cm. Our findings suggest that casting according to the Ponseti method should begin in infants older than 1 month of age, or with an involved foot > or =8 cm in length.

Ponseti method for untreated idiopathic clubfeet in Nepalese patients from 1 to 6 years of age

Although the Ponseti method has been effective in patients up to 2 years old, limited information is available on the use of this method in older patients. We retrospectively reviewed the records of 171 patients (260 feet) to determine whether initial correction of the deformity (a plantigrade foot) could be achieved using the Ponseti method in untreated idiopathic clubfeet in patients presenting between the ages of 1 and 6 years. A mean of seven casts was required, and there were no differences in the number of casts between the different age groups. Two hundred fifty (95%) of the 260 feet were treated surgically for residual equinus after a plateau in casting, and procedures included percutaneous tendo-Achilles release (n = 205 [79%]), open tendo-Achilles lengthening (n = 8 [3%]), posterior release (n = 21 [8%]), and extensive soft tissue release (posteromedial release, n = 16 [6%]). The mean dorsiflexion after removal of the last cast was 12.5 degrees for the entire group and was greater in 1 year olds compared with 3 year olds. Although all patients achieved a plantigrade foot, the importance of the mild loss of passive dorsiflexion remains to be determined. An extensive soft tissue release was avoided in 94% of patients using the Ponseti method. We intend a followup study to ascertain whether the correction is maintained.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Is it possible to treat recurrent clubfoot with the Ponseti technique after posteromedial release?: a preliminary study

The Ponseti technique for treating clubfoot has been popularized for idiopathic clubfoot and more recently several syndromic causes of clubfoot. We asked whether it could be used to treat recurrent clubfoot following failed posteromedial release. We retrospectively reviewed 58 children (83 clubfeet) treated by the Ponseti technique for recurrent deformity after posteromedial release in three centers. The minimum followup was 24 months (average, 45 months; range, 24-80 months). We determined initial and final Pirani scores and range of motion of the ankle and subtalar joint. Plantigrade and fully corrected feet were obtained in 71 feet (86%); 11 feet obtained partial correction; one patient failed treatment and underwent another posteromedial release. Recurrences occurred in nine patients (12 feet or 14%). Initial Pirani scores improved in all but one patient; severity of deformity was also inferred by number of casts used for treatment. The age at treatment and numbers of casts did not influence the scores of Pirani et al. The scores were similar among the three orthopaedic surgeons.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Update on clubfoot: etiology and treatment

Although clubfoot is one of the most common congenital abnormalities affecting the lower limb, it remains a challenge not only to understand its genetic origins but also to provide effective long-term treatment. This review provides an update on the etiology of clubfoot as well as current treatment strategies. Understanding the exact genetic etiology of clubfoot may eventually be helpful in determining both prognosis and the selection of appropriate treatment methods in individual patients. The primary treatment goal is to provide long-term correction with a foot that is fully functional and pain-free. To achieve this, a combination of approaches that applies the strengths of several methods (Ponseti method and French method) may be needed. Avoidance of extensive soft-tissue release operations in the primary treatment should be a priority, and the use of surgery for clubfoot correction should be limited to an "a la carte" mode and only after failed conservative methods.

LEVEL OF EVIDENCE

Level V, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.