The Ponseti method has been proven to be the gold standard of treatment for clubfoot. The question however remains about the treatment of atypical and complex feet with this method. The Ponseti technique has been used to treat all clubfeet at the our institution for the past 10 years. We interviewed 70 patients (114 affected feet) ages 5–9 regarding the current state of their clubfoot using the 10 item Disease Specific Instrument (DSI) developed by Roye et al. Of these, 16 patients had a complex foot defined by a transverse medial crease. The DSI scores from all patients were transformed onto a 100 point scale and compared based on overall score as well as functional outcome and satisfaction. There was no significant difference in the overall scores with a mean of 76.43 (sd= 21.1) in patients who did not have a complex deformity compared to a mean of 79.17 (sd= 19.4) in those who did have a complex foot (p=0.644). On the functional subscale the mean scores were 74.07 (sd=27.1) and 89.58 (sd=25.9) for patients who had non-complex and complex feet, respectively (p=0.474). Regarding satisfaction, the non-complex group had a mean score of 79.51 (sd=19.7) compared to the mean of 78.75 (sd=16.7) in the complex group (p=0.888). Primary treatment with the Ponseti method achieves very successful correction of the clubfoot deformity with good outcome scores. Furthermore, even in patients with a complex deformity, the Ponseti method still achieves equally successful outcomes

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

Clubfoot is one of the commonest congenital abnormalities and is 2–3 times commoner in African populations than Caucasian. From December 2000 in Lilongwe, Malawi, the Ponseti method was used for treatment of this condition combined with the Colombian Clubfoot Score. Over the study period 150 patients were treated, with an average age on presentation of 5.5 months. 43% of cases had completed the manipulation and casting part of treatment and 5.5 months. 43% of cases had completed the manipulation and casting part of treatment and had been braced, but 75% of these were no longer attending regular follow up. We believe that the method is useful for treating CTEV in Africa, but that the intensive nature of the therapeutic regime leads to compliance difficulties

Aims. To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population. Methods. In all, 73 children with idiopathic club foot were included: 31 children treated with the Ponseti method (mean age 8.3 years; 24 male; 20 bilaterally affected, 13 left and 18 right sides analyzed), and 42 treated with primary surgical correction (mean age 11.6 years; 28 male; 23 bilaterally affected, 18 left and 24 right sides analyzed). Foot function data was collected during walking gait and included Oxford Foot Model kinematics (Foot Profile Score and the range of movement and average position of each part of the foot) and plantar pressure (peak pressure in five areas of the foot). Oxford Ankle Foot Questionnaire, Disease Specific Index for club foot, Paediatric Quality of Life Inventory 4.0 were also collected. The gait data were compared between the two club foot groups and compared to control data. The gait data were also correlated with the data extracted from the questionnaires. Results. Our findings suggest that symptomatic children with club foot deformity present with similar degrees of gait deviations and perceived disability regardless of whether they had previously been treated with the Ponseti Method or surgery. The presence of sagittal and coronal plane hindfoot deformity and coronal plane forefoot deformity were associated with higher levels of perceived disability, regardless of their initial treatment. Conclusion. This is the first paper to compare outcomes between Ponseti and surgery in a symptomatic older club foot population seeking further treatment. It is also the first paper to correlate foot function during gait and perceived disability to establish a link between deformity and subjective outcomes. Cite this article: Bone Joint Open 2020;1-7:384–391

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

The Ponseti method is the gold standard treatment for clubfoot. It begins in early infancy with weekly serial casting for up to 3 months. Globally, a commonly reported barrier to accessing clubfoot treatment is increased distance patients must travel for intervention. This study aims to evaluate the impact of the distance traveled by families to the hospital on the treatment course and outcomes for idiopathic clubfoot. No prior studies in Canada have examined this potential barrier. This is a retrospective cohort study of patients managed at a single urban tertiary care center for idiopathic clubfoot deformity. All patients were enrolled in the Pediatric Clubfoot Research Registry between 2003 and April 2021. Inclusion criteria consisted of patients presenting at after percutaneous Achilles tenotomy. Postal codes were used to determine distance from patients’ home address to the hospital. Patients were divided into three groups based on distance traveled to hospital: those living within the city, within the Greater Metro Area (GMA) and outside of the GMA (non-GMA). The primary outcome evaluated was occurrence of deformity relapse and secondary outcomes included need for surgery, treatment interruptions/missed appointments, and complications with bracing or casting. A total of 320 patients met inclusion criteria. Of these, 32.8% lived in the city, 41% in the GMA and 26% outside of the GMA. The average travel distance to the treatment centre in each group was 13.3km, 49.5km and 264km, respectively. Over 22% of patients travelled over 100km, with the furthest patient travelling 831km. The average age of presentation was 0.91 months for patients living in the city, 1.15 months for those within the GMA and 1.33 months for patients outside of the GMA. The mean number of total casts applied was similar with 7.1, 7.8 and 7.3 casts in the city, GMA and non-GMA groups, respectively. At least one two or more-week gap was identified between serial casting appointments in 49% of patients outside the GMA, compared to 27% (GMA) and 24% (city). Relapse occurred in at least one foot in 40% of non-GMA patients, versus 27% (GMA) and 24% (city), with a mean age at first relapse of 50.3 months in non-GMA patients, 42.4 months in GMA and 35.7 months in city-dwelling patients. 12% of the non-GMA group, 6.8% of the GMA group and 5.7% of the city group underwent surgery, with a mean age at time of initial surgery of 79 months, 67 months and 76 months, respectively. Complications, such as pressure sores, casts slips and soiled casts, occurred in 35% (non-GMA), 32% (GMA) and 24% (city) of patients. These findings suggest that greater travel distance for clubfoot management is associated with more missed appointments, increased risk of relapse and treatment complications. Distance to a treatment center is a modifiable barrier. Improving access to clubfoot care by establishing clinics in more remote communities may improve clinical outcomes and significantly decrease the burdens of travel on patients and families

Untreated clubfoot results in serious disability, but mild to moderate residual deformities can still cause functional limitations and pain. Measuring the impact of clubfoot deformities on children's wellbeing is challenging. There is little literature discussing the variability in outcomes and implications of clubfoot based on where geographically the child resides. Although the use of patient reported outcome measures (PROMs) is steadily growing in pediatric orthopaedics, few studies on clubfoot have incorporated them. The most widely used PROM for pediatric foot and ankle pathology is the Oxford Foot and Ankle Questionnaire for Children (OXFAQ-C) that include a physical, school and play, emotional and shoe wear domains. The aim of this study is to evaluate the validity and regional differences in scores of the OXFAQ-C questionnaire to identify functional disability in children with clubfoot in India and Canada. This is a retrospective cohort study of children in Indian and Canadian clubfoot registries aged 5-16 years who completed >1 parent or child OXFAQ-C. The OXFAQ-C was administered once in 01/2020 to all patients in the Indian registry, and prospectively between 06/2019 and 03/2021 at initial visit, 3, 6, 12 months post-intervention, then annually for the Canadian patients. Demographic, clubfoot, and treatment data were compared to OXFAQ-C domain scores. Descriptive statistics and regression analysis were performed. Parent-child concordance was evaluated with Pearson's Coefficient of Correlation (PCC). The cohort had 361 patients (253 from India, 108 from Canada). Non-idiopathic clubfoot occurred in 15% of children in India and 5% in Canada, and bilateral in 53% in India and 50% in Canada. Tenotomy rate was 75% in India and 62% in Canada. Median age at presentation was 3 months in India and 1 month in Canada. Mean Pirani score at presentation and number of Ponseti casts were 4.9 and 6.1 in India and 5.3 and 5.7 in Canada, respectively. Parents reported lower scores in all domains the older the child was at presentation (p Canadians scored significantly lower for all domains (p < 0 .001), with the difference being larger for child-reported scores. The greatest difference was for physical domain. Canadian parents on average scored their child 6.21 points lower than Indian parents, and Canadian children scored a mean of 7.57 lower than Indian children. OXFAQ-C scores differed significantly between Indian and Canadian children despite similar demographic and clubfoot characteristics. Younger age at presentation and tenotomy may improve OXFAQ-C scores in childhood. Parent-child concordance was strong in this population. The OXFAQ-C is an adequate tool to assess functional outcomes of children with clubfeet. Cultural validation of patient reported outcome tools is critical

Purpose: To evaluate the predictive value of a prenatal ultrasound diagnosis of clubfoot, the ability to differentiate isolated clubfoot from complex clubfoot, and establish valid recommendations for follow-up and additional investigations. Materials and Methods: Clubfoot (CF) was diagnosed by prenatal ultrasound (US) in 85 feet in 48 fetuses at a mean gestational age of 21.6 weeks (14–35.6). All mothers were examined prenatally in a multidisciplinary clinic for fetal abnormalities. Postnatal outcome was obtained by chart review (24) or telephone interview (24) and feet were classified as Normal (N), Positional Deformity (PD), Isolated Clubfoot (ICF) and Complex Clubfoot (CCF). Results: At initial diagnosis, 65 feet in 38 fetuses were classified as ICF and 20 feet in 10 fetuses as CCF. Diagnosis was changed during follow-up US in 12 fetuses (25%) and final US diagnosis was N in one, ICF in 29 and CCF in 18 fetuses. Post natal clubfoot was found in 73 feet in 40 children giving a positive predictive value (PPV) of 85%. Accuracy of specific diagnosis was significantly lower – 65% initially and 75% at final US. No post natal CCF had been undiagnosed and inaccuracies were all overdiagnoses. 24 kariotypes were performed. Three were abnormal but had additional US findings and had been classified as CCF. No abnormal kariotypes were found in fetuses diagnosed as ICF. Conclusions:. The prenatal diagnosis of clubfoot carries a positive predictive value of 87% with lower values of ICF (76%) and CCF (69%). The diagnostic accuracy increases with follow up ultrasound examinations which should be performed periodically. The most problematic diagnosis to rule out is arthrogryposis and further diagnostic modalities should be researched. When Isolated Clubfoot is diagnosed, the indication for amniocentesis and kariotyping is questionable

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

Introduction: Congenital clubfeet have increasingly been detected in routine prenatal ultrasound. However, many clubfeet are still missed and surprise the mothers at birth. The complex deformity and different treatment options available seem to make prenatal counseling desirable. Despite published studies on prenatal clubfoot diagnosis by ultrasound, it is unknown if mothers would indeed prefer to know about their child’s clubfoot before birth or not. Methods: This survey included patients born between 2000 and 2007 who were treated for congenital clubfoot at one of the two participating institutions (center one: East coast USA; center two: Austria). Exclusion criteria were defined as underlying syndrome, genetic abnormality or pregnancy with multiple fetuses. A brief survey about the opinion of mothers towards ultrasound diagnosis of clubfoot consisting of three questions was sent out. A computer database was created for data collection and a statistic analysis was performed. Results: Surveys were sent out to 401 mothers of patients meeting inclusion criteria. A total of 220 surveys were received back with 105 surveys from center one and 115 surveys from center two. In 97 cases the clubfoot was unilateral and in 123 cases bilateral. Routine ultrasound showed a clubfoot in 91 cases (41%) and failed to show the deformity in 128 cases (59%). The detection rate in center one was 60% compared to 25% in center two. Bilateral clubfeet had a detection rate of 53% whereas unilateral clubfeet had a detection rate of 29%. Between 2000 and the end of 2003 the overall detection rate was 31% versus 50% between 2004 and the end of 2007. Overall 74% of mothers wanted to know about their baby’s clubfoot before birth and 24% after birth. Of the 91 mothers who had a positive ultrasound 96% wanted to know before birth. Of the 128 patients who had a negative ultrasound 59% would have wanted to know while 38% did not want to know about the clubfoot prenatally. In center one 89% of mothers wanted to know before birth versus only 60 % in center two. Comments on the survey form showed that mothers who had or wanted to have the prenatal diagnosis appreciated the time to prepare and to find out more about the condition and different treatment options. Many wished for more information at the time of prenatal diagnosis. Mothers that would prefer to find out about the clubfoot postnatally feared that the diagnosis would have affected the experience of the pregnancy. Discussion: Although the detection rate increased over time there are still cases of clubfeet missed in the routine ultrasound, especially in center two where the rate of detection was low. Mothers in the US are more reluctant to know before birth than mothers in Austria which is most likely related to the differences in the two health care systems. Detailed information about the nature and treatment of clubfeet should be given at prenatal diagnosis

Background. The gold standard of care of clubfoot is the Ponseti method of serial manipulation and casting, followed by percutaneous tendo-achilles tenotomy. In our setting, registrars work in district hospitals where they run Ponseti clubfoot clinics with little or no specialist supervision. They use the Pirani score to serially assess improvement of the deformity during casting and to determine whether the foot is ready for tenotomy. Purpose of Study. To test the inter-observer reliability of the Pirani score, and whether it can be used by non-specialist doctors running Ponseti clubfoot clinics. Methods. Ethics permission was obtained from our institution. This is a prospective study where patients under the age of one year with idiopathic clubfoot were recruited from clubfoot clinics at our institution, over a period of four months. Following a training session using the original description of the score, each foot was independently assessed using the Pirani score by two paediatric orthopaedic surgeons, two orthopaedic registrars and two medical officers. The inter-observer reliability was assessed using the Fixed-marginal Kappa statistic and Percentage agreement. The first 15 feet were used as a learning curve, and hence excluded from final analysis. Results. 73 feet in 37 patients with idiopathic clubfoot (25 boys, 12 girls) under the age of 1 year were included in the study. The Kappa statistic and percentage agreement for the six variables of the Pirani score were determined. Whilst the overall agreement was determined by the Kappa statistic to be slight to fair, the two consultants were found to have a higher inter-observer reliability than the registrars and medical officers. Conclusion. Our results conflict with previously published studies in that the inter-observer reliability of the Pirani score was poor. In addition, we feel that this score cannot be reliably used by non-specialist doctors running Ponseti clubfoot clinics. NO DISCLOSURES

Purpose. The rate of club foot recurrence following Ponseti treatment has been reported in the literature as between 14 and 58%. Recurrence is defined as any child who has been treated and is in need of recasting, surgery or bracing. True recurrence is defined as presentation 6 months after last treatment and incomplete treatment is defined as presentation within 6 months of last treatment. Currently no local data exists to determine the cause of recurrence in this unit. The aim of this study is to review all recurrences to improve the outcome of club foot management. Methods. A retrospective audit of all club foot recurrences was performed at an academic hospital. The review included the location of initial treatment, initial treatment method and abduction brace compliance as factors contributing to the recurrence rate. Results. Thirty seven (48%) patients attending the club foot clinic were recurrences – 68% were true recurrences and 32% were defined as incomplete treatments. The mean age at presentation of club foot recurrence was 25 months (Range 6–84 months). Seventy percent of recurrences were referred from outside healthcare facilities – all patients had serial manipulation and casting. The overall complete compliance for casting was 74%. Eighty percent of patients had a Tendo Achilles tenotomy at a mean age of 10.5 months (range 2–66 months) after initial plastering (mean 12.5 plasters). Post tenotomy, 65% had abduction bracing for a mean duration of 4.5 months and 35% had no bracing. No patient continued bracing until the recommended age of four years. Conclusion. Despite the challenges of compliance to casting the overwhelming identified problem is compliance with abduction bracing. The challenge is to improve bracing protocol and ensure compliance in this critical part in the treatment of club foot

Background. Neglected clubfoot in this series is defined as untreated equino-cavo-adducto-varus in older children, or adults. Relapsed clubfoot is the residual deformity that remains after single or multiple surgical interventions. Severe neglected clubfoot rarely exists today in developed countries, except in some emigrants from low- and middle-income countries. Acute surgical management with corrective mid-foot osteotomy and elongation of the Achilles tendon has excellent functional outcome. Objective. To assess the functional outcome of acute correction of neglected Talipes-quino-varus deformity in adults. Methods. This is cross sectional, hospital–based study that took place in Khartoum, Sudan. Forty patients were included in this study. Midfoot osteotomy and elongation of the Achilles tendon were performed to all patients. Data was collected using a questionnaire and the functional outcome has been assessed using the American Orthopaedic Foot and Ankle Society Score (AOFAS). This score was measured before surgery and one years after surgery. Results. The mean age was 19.9±4.7 years. Males were 25 (62.5%) and females were 15 (37.5%). The mean preoperative AOFAS score was 37.7±7.1 (poor). This score improved to 80.7±13.7 (good to excellent), two years after surgery. However, this indicates significant change in the functional outcome after the operation (P value < 0.05). Excellent post-operative functional outcome was found among patients aged 18 – 23 years 18 (50%) P. value: 0.021. The majority of patients 36(90%) were fully satisfied with the operation, 2(5%) partially satisfied and 2(5%) were unsatisfied. Conclusion. Acute correction of neglected and relapsed TEV with elongation of the Achilles tendon and single midfoot osteotomy has excellent functional outcome as assessed by AOFAS Score. The satisfaction with this procedure is impressive. The younger age population showed better outcomes with this procedure

The authors provide an analysis of the results of surgery for clubfoot at the Vilnius University Children’s Hospital in Lithuania from 1979 to 1999. We operated 565 clubfeet in 464 patients. Average age of the patients was 4.1 years. From 1979 to 1993, 172 feet were operated. Most patients had the so-called Zacepin procedure for clubfoot release that contains a multi-stage release of different clubfoot components, but without attention to bony alignment restoration. At that time most patients were operated from 1.5 to 4 years of age. In that group 45% of the patients had a recurrence of the deformity and an additional operation was necessary. From 1993 to 1999, 393 clubfeet were operated. Mean age of the patients was 2.7 years (range 6 months to 7.4 years.). A more extensive release was introduced using the Cincinnati approach and restoration of normal talocalcaneal and talonavicular alignment following adequate soft tissue release. In this group 14% of the patients had a recurrence. The main goal of the clubfoot surgery was an exact reposition and fixation of the talocalcaneal and talonavicular alignment with adequate soft tissue release. The Cincinnati approach was the most effective and safe for correcting all of the components of the deformity. The best results were found in the patients who were operated at the age of six to eight months. In order to get a better functional outcome, at three to four years of age a number of our operated patients required an additional procedure such as a split tibialis anterior tendon transfer, a lateral column shortening, or a medial column lengthening. An excessive reposition of the talus produces a strange and severe foot deformity that is difficult to manage

Conventional surgical treatment of relapsed or neglected club foot deformities is not always successful or easy to apply. The presence of shortened neurovascular structures and unhealthy skin may preclude the surgical interference. Bone resection in severe deformities results in short foot which is not satisfactory functionally and cosmetically. Objectives. In this study we evaluate the use of the bloodless technique for management of relapsed or neglected club foot deformities. Methods. From Jan 2000–2006, 64 cases older than 2 years with relapsed or neglected club foot deformities were referred to our center. Four cases were excluded because of inadequate follow up data. This thesis based on 60 consecutive cases (67 feet). The patients average age was 8 years and 4 months (range, 2–16 years). Seven cases were bilateral, 20 Left sides, and 34 Right sides. There were 57 relapsed club foot (5 bilateral), and 3 cases were neglected (2 bilateral). Patients with relapsed club foot had average 3 previous operations (range, 1–8 operations). There was no preoperative assembling of the apparatus. The construct was designed according to the condition of deformity: equinus, varus forefoot etc. Additional procedures, elongation of tendoachilis was done concomitantly with the original procedure in 10 cases. The patients were discharged from the hospital the same day of the operation. Results. The range of operative time was 1–3 hours with an average of 1.5 hours. Average time in the fixator was 19.6 weeks (range, 10 weeks–38 weeks). After fixator removal cast was applied for 2 months, followed by night splint and special shoes for their daily activities. The average follow-up period was 30.6 months (range, 12–84 months) after fixator removal. The results were good in 55 feet, fair in 9, bad in 3. Complications. All cases suffered from some sort of pin tract inflammation. For 8 cases: one of the wires had to be removed without anaesthesia due to persistent infection. For 3 cases: replacement of wires under general anaesthesia was performed. Oedema developed in the leg and dorsum of the foot or the ankle in 34cases. Frame adjustment under general anaesthesia in 3 cases. There are others such as: migration of the calcanean wire, 2 cases; over correction with valgus heel, two cases; flatfoot, 4 cases; talar subluxationin, 2 cases; talonavicular subluxation, one case; first metatarsophalangeal subluxation, 2 cases; flat topped talus, one case; broken wire, 2 cases and recurrence in 2 cases. Discussion. It seems logic that osteotomy of the tarsus must be carried out whenever skeletal growth of the foot is at such an advanced stage that correction can not be established by means of articular repositioning and remodeling. However, equinovarus deformity of the foot in 65 adults (38 feet) was treated by external fixator without open procedure (Oganesyan et al, 1996). After an average follow-up 10 years, satisfactory results were obtained in all feet except four. Conclusion. Ilizarov Treatment is lengthy, difficult, fraught with complications, and a technically demanding procedure. However, the complications did not affect the final outcome too much. Ilizarov method also offers the advantage of performing many additional procedures for other associated lower limb deformity. We believe that the bloodless technique using Ilizarov external fixator is an effective method in treating relapsed or neglected club foot deformities

Introduction: Children with clubfoot treated by the Ponseti method of clubfoot management require anterior tibialis tendon transfer if there is persistent varus and supination deformity. However the size of bone is a determining factor in whether this transfer can be carried out. We have assesses the difference in the age at which the lateral cuneiform ossifies in normal feet compare with clubfeet. Methods: Foot x-rays of children less than 4 years old (AP view) carried out between 2003 and 2005 were obtained from the Radiology department Booth Hall Children’s Hospital. A total of 341 radiographs were analyzed. Exclusion criteria included: any condition affecting foot anatomy or weight bearing or any previous surgery (including surgery for clubfoot). The lateral cuneiform was measured with 1mm accuracy in the longest diameter. Results: We analysed the size of the lateral cuneiform in patients with and without clubfoot in relation to age. In children without clubfoot there was a R2 value of 0.517, showing a positive correlation between age and size of the bone. In children with clubfoot, R2 value was 0.207 showing no correlation between age and ossification rate of the lateral cuneiform. In addition, we compare the size of the lateral cuneiform between patients with and without clubfoot at different ages. There was a significance difference in the level of ossification of the lateral cuneiform in all age groups. In addition, a greater number of patients with no ossification of the lateral cuneiform were found amongst the clubfoot group in all age groups up to the age of 36 months. Conclusions: We have identified a delayed ossification in the lateral cuneiform in children with clubfoot when compared with normal feet. This delayed ossification should be taken into account when considering anterior tibialis tendon transfer for correction of clubfoot

Purpose: Congenital idiopathic clubfoot is the most common musculoskeletal birth defect developing during the fetal period, but with no known etiology. MYH 2, 3, 7, and 8 are expressed embryonically or perinatally, the period during which congenital idiopathic clubfoot develops; are all components of Type II muscle, which is consistently decreased in clubfoot patients; and are associated with several muscle contracture syndromes that have associated clubfoot deformities. In this study, we hypothesized that mutations in embryonic and perinatal myosin genes could be associated with congenital idiopathic clubfoot. Methods: We screened the exons, splice sites, and predicted promoters of 24 bilateral congenital idiopathic clubfoot patients and 24 matched controls in MYH 1, 2, 3, and 8 via sequence-based analysis, and screened an additional 76 patients in each discovered SNP. Results: While many SNPs were found, none proved to be significantly associated with the phenotype of congenital idiopathic clubfoot. Also, no known mutations that cause distal arthrogryposis syndromes were found in the congenital idiopathic clubfoot patients. Conclusion: These findings demonstrate that congenital idiopathic clubfoot has a different pathophysiology than the clubfoot seen in distal arthrogryposis syndromes, and defects in myosin are most likely not directly responsible for the development of congenital clubfoot. Given the complexity of early myogenesis, many regulatory candidate genes remain that could cause defects in the hypaxial musculature that is invariably observed in congenital idiopathic clubfoot. Significance: This study further differentiates congenital idiopathic clubfoot as distinct from other complex genetic syndromes that can present with similar deformities, and thus facilitates further research to improve the clinical diagnosis and treatment of congenital idiopathic clubfoot

Introduction. It has been postulated that a mild clubfoot does better than a severe clubfoot no matter what treatment course is taken. There have been previous efforts to classify clubfoot. For units worldwide that use the Ponseti Method of clubfoot management, the Pirani scoring system is widely used. This scoring system has previously been shown to predict the number of plasters required to gain correction. Our study aimed to investigate whether the Pirani score gave an indication of longer-term outcome using tibialis anterior tendon transfer as an endpoint. Methods. A prospectively collated database was used to identify all patients treated in the Ponseti clinic at the Royal Manchester Children's Hospital between 2002 and 2005 with idiopathic clubfoot who had not received any treatment prior to their referral. Rate of tibialis tendon transfer as well as the patient's presenting Pirani score were noted. Feet were grouped for analytical purposes into a mild clubfoot (Pirani score <4) and a severe clubfoot (Pirani score 4) category depending on initial examination. Clinic records were reviewed retrospectively to identify patients who were poorly compliant at wearing boots and bars and were categorised into having “good” or “bad” compliance with orthosis use. Results. 132 feet in 94 children were included in the study. 30 (23%) tibialis tendon transfers were performed at a mean of 4.2 years (range 2.3–5.5 years). Children with severe clubfoot had a significantly higher rate of tendon transfer compared with those with mild clubfoot (28% vs. 6%; p=0.0001). 81% of patients were classified as being “good” boot wearers. Tibialis tendon transfer rates in those who were poorly compliant with boot usage were significantly higher compared with those with good compliance (52% vs. 16%; p=0.0003). There was a significantly higher tendon transfer rate in those with severe disease and poor compliance compared with good compliance (69% vs. 20%; p=0.0002). There was no association between boot compliance and tendon transfer rates in those with mild disease. Conclusion. This study shows that late recurrences, requiring tibialis anterior tendon transfer, are associated with severity of disease at presentation and compliance with use of orthoses. Tendon transfer rates are higher for those with severe disease. We have confirmed previous reports that compliance with orthotic use is associated with recurrence. However, the novel findings regarding recurrence rates in mild clubfeet may have implications regarding usage of orthoses in the management of mild idiopathic clubfeet after initial manipulation using the Ponseti method

Ponseti method has become the most common and validated initial non-operative and/or minimally invasive treatment modality of idiopathic clubfoot regardless of the severity of the deformity worldwide. Despite hundreds of publications in the literature favoring Ponseti method, the data about secondary procedures performed in the follow-up period of clubfoot and their incidence remains sparse and given as small details in the articles. The objective of this study was to analyse our incidence of secondary procedures performed in the midterm followup period of idiopathic clubfoot patients treated with Ponseti method and review of the relevant literature. For this purpose 86 feet of 60 patients with idiopathic clubfoot who were treated with original Ponseti method were enrolled in this retrospective case control study. Unilateral ankle foot orthosis (AFO) was used rather than standart bar-connected foot abduction orthosis varying from 12 months to 25 months in the follow-up period and 74 of 86 (86%) feet required percutaneous achilles tenotomy. The average age of initial cast treatment was 12.64 days (range 1 to 102 days). The mean follow-up time was 71 months (range 19 to 153 months). Thirty seven feet of 24 patients recieved secondary procedures (43%) consisting of; supramalleolary derotational osteotomy (SMDO) (1 patient/2 feet), complete subtalar release (3 patients/5 feet), medial opening lateral closing osteotomy (double osteotomy) (2 patients/3 feet), double osteotomy with transfer of tibialis anterior tendon (TTAT) (2 patients/3 feet), partial subtalar release (PSTR) (3 patients/5 feet), PSTR with SDO (1 patient/1 foot), posterior release (PR) with repeated achillotomy (1 patient/2 feet), TTAT (6 patients/10 feet), TTAT with PR (2 patients/2 feet), TTAT with Vulpius procedure (1 patient/1 foot) and TTAT with SMDO (2 patients/3 feet) respectively. The amount of percutaneous achilles tenotomy (86%) in our study correlated with the literature which ranged from 80 to 90 %. The transfer of tibialis anterior tendon continued to be the most performed secondary procedure both in our study (51%) and in the literature, but the amount of total secondary procedures in our study (43%) was determined to be higher than the literature data varying from 7 to 27 percent which may be due to unilateral AFO application after Ponseti method for idiopathic clubfoot deformity in our study

Objective: Starting from results of studies made in the last ten years about the presence of myofibroblasts as the main cells involved into fibro-contractile disease, we investigated if this cells were also involved into pathogenesis of club foot deformities. Methods: Specimens removed surgically from five patients affected by congenital club foot were investigated. Each specimen was cut in three parts: the first, was fixed for optical microscopy in formalin; the second was fixed for trasmission electron microscopy (TEM) in glutaraldehyde and postfixed in osmium tetroxide; the third was immediately placed in cold (4°C) tissue culture medium. We have stained the first part of each specimen with: haematoxylineosin, Pasini, Masson, Congo red, Van Gieson, Martius scarlet blue and immunostaining for a-smooth muscle actin (a-SM actin). The third part of each specimen, dissected into 2mm. cubes, was place in standard medium and cultured at 37°C. On the cultured cells, we have valued metalloproteinases and a-SM actin expressions. Moreover, a part of culture cells, when reached confluence, were detached with trypsin-EDTA and centrifuged for 10 min. at 2000 rpm. to obtain a pellet, subsequently fixed for TEM. Results: Optical and electron microscopy have showed, only in one of our cases, the presence of myofibroblast’s clusters in the Henry’s nodule and in the medial and lateral fibrous nodules, that are characteristic nodule of congenital club foot. Conclusions: Starting from the results of our studies, we would like to study in detail the role of myofibroblast in the pathogenesis of club foot