Complex Clubfoot Research Articles

The Tug Test and Modified Ponseti Casting: A Simple and Reliable Method to Improve the Efficacy of Casting in Complex Clubfoot.

The clinical entity of complex clubfoot poses a significant challenge to correction by slippage of casts which further complicates the deformity and prolongs the treatment. A static and dynamic component associated with this deformity causing cast slippage was recognized. The purpose of this study was to evaluate the clinical outcomes at the end of the casting period while addressing these issues. A retrospective study of 17 patients with 25 complex clubfeet over a period of 2years was conducted. Tug test was used to ascertain the snugness of the cast. To address the dynamic component, distal extent of the cast was limited to metatarsal heads. The mean age of patients at diagnosis was 4.41months (2-7months). The mean pre-casting Pirani score was 4.8 (4-6) and post casting Pirani score was 0.4 (0-1). A total of 128 casts were applied to correct 25 complex clubfeet. The average number of casts required to achieve correction by the modified Ponseti technique was 5.12 (4-7). Overall, four incidences of cast slippage occurred. The modified Ponseti technique is effective in the correction of complex clubfoot. Tug test can detect casts which are prone to slippage. Limiting the distal extent of the cast to the metatarsal heads can reduce cast slippage by reducing the repeated downward pressure by the toes on the cast.Level of evidence Level 4. The online version contains supplementary material available at 10.1007/s43465-023-00910-w.

Complex, atypical clubfoot: follow-up after up to 16years reveals a high risk of relapse but good functional and radiological outcomes.

The treatment of complex atypical clubfoot poses many challenges. In this paper, we report on the course of complex clubfoot, primary correction using the modified Ponseti method and midterm outcomes. Special consideration is given to clinical and radiological changes in cases of relapse. Twenty-seven cases of complex, atypical, non-syndromic clubfoot were treated in 16 children between 2004 and 2012. Patient data, treatment data, functional outcomes and, in the relapse cohort, radiological findings were documented during the course of treatment. The radiological findings were correlated with the functional outcomes. All atypical complex clubfeet could be corrected using a modified form of the Ponseti method. Over an average study period of 11.6years, 66.6% (n = 18) of clubfeet relapsed. Correction after relapse showed an average dorsiflexion of 11.3° during a 5-years' follow-up period. Radiological results showed residual clubfoot pathologies such as a medialized navicular bone in four clubfeet. There were no instances of subluxation or dislocation of the talonavicular joint. Extensive release surgery was not necessary. Nevertheless, after 2.5 preoperative casts (1-5 casts), bone correction was performed in n = 3 feet in addition to Achilles tendon lengthening and tibialis anterior tendon transfer. Good primary correction of complex clubfoot using the modified Ponseti technique results in a high recurrence rate in the medium term. Relapse treatment without peritalar arthrolysis procedures produces good functional results even though minor residual radiological pathologies did persist in a minor number of cases.

Management of complex idiopathic clubfoot using modified Ponseti method

Clubfeet with rigid equinus, severe plantarflexion of all the metatarsals, a transverse crease in the sole of the foot, short and hyperextended great toe, forefoot adduction and supination and a deep posterior crease are categorized under the heading of complex clubfeet, which do not respond to the conventional Ponseti technique. Rather treatment of such feet with conventional Ponseti method results in the development of secondary deformities and thus failure of treatment. Hence modification of the technique is warranted for optimal correction of these feet as described by Ponseti. The aim of our study was to evaluate effectiveness of Modified Ponseti technique in the management of complex clubfoot. Thirty two complex clubfeet in 19 patients were managed by Modified Ponseti technique through the study period. Four patients with 7 complex clubfeet were lost to follow-up. At the end of study 15 patients with 25 complex clubfeet were available for final follow up assessment and evaluation. Pirani and Dimeglio score was allotted to each foot at every visit. There after each foot was manipulated and casted as per the Modified Ponseti technique at an interval of one week. Average number of casts required for deformity correction was 7.68. Tendo-achilles tenotomy was obligatory in 23 (93.33 %) feet. The mean follow-up duration was 12.35 months (Range 8-21 months). The mean pre-treatment Pirani score (initial PS) was 5.60±0.54 and mean post-treatment Pirani score (PS at SFAB) was 0.70±0.38. The change in mean score post intervention was found to be statistically significant. The mean pre-treatment Dimeglio score (initial DS) was 15.80±2.02 and mean post-treatment Dimeglio score (DS at SFAB) was 3.68±1.35. The change in mean score post intervention was found to be statistically significant. Relapse rate was 4% (n=1), which responded to re-casting with modified Ponseti technique and re-tenotomy of the tendo-achilles. Based on our study results and existing literature we recommend modified Ponseti technique as the first line initial treatment for these complex feet. However such feet require higher number of plaster casts with higher rate of tendo-achilles tenotomy, with high relapse rate than their classical idiopathic counterparts, nonetheless the eventual outcome is reasonable correction of deformity, negating the necessity of multifaceted operating procedures.

Clubfoot from past to the present: A bibliometric analysis with global productivity and research trends.

Clubfoot, a common congenital abnormality, affects the lower extremities; however, the literature search revealed no bibliometric research on this subject. Thus, we aimed to holistically analyze scientific articles and reveal global productivity and trend issues. This study statistically analyzed 1417 published articles on clubfoot (1980-2021) from the Web of Science database. Bibliometric network visualization maps were created to reveal trend topics, citation analysis, and cross-country collaborations. The analysis was conducted using Spearman correlation analysis. An exponential smoothing estimator was used to predict article productivity. The United States of America (433, 30.5%), the United Kingdom (166, 11.7%), and India (107, 7.5%) are the top 3 countries contributing to the literature. The Journal of Pediatric Orthopedics (220 articles), the Journal of Pediatric Orthopedics-Part B (147 articles), and Clinical Orthopedics and Related Research (69 articles) are the top 3 most productive journals. Dobbs MB (34 articles) is the most active author, and Shriners Hospital Children (44 articles) is the most active institution. Bibliometric analysis revealed that recently studied trend topics included Pirani score, Dimeglio score, Ponseti method, Ponseti casting, tenotomy, recurrence, neglected, tendon transfer, bracing, gait, risk factors, pedobarography, complex clubfoot, and polymorphism. The most studied subjects included Ponseti technique, treatment/casting, recurrent/relapsed clubfoot, Pirani score, pediatrics/children, foot deformities, surgery, ultrasound, Achilles tendon/tenotomy, gait analysis, casting, outcomes, neglected clubfoot, and tenotomy. Research leadership was determined in the western and European countries and Canada in studies and scientific collaborations on clubfoot; its impact was remarkable in India, China, and Turkey.

The outcome of ponseti method for the treatment of clubfoot; a systematic review

Clubfoot is one of the most common congenital orthopedic disorders that is characterized by four structural deformities. The treatment of clubfoot could be conservative or surgical; however, conservative modalities should be the initial option for the management of clubfoot. Ponseti method is a conservative modality. Thus, this review was conducted to assess the outcomes of the ponseti method in the treatment of clubfoot by reviewing the previous studies conducted on this subject. Google Scholar and PubMed databases were explored for scientific articles using different keywords, including "clubfoot, treatment, management, outcomes and ponseti method." Original articles focused on the treatment of clubfoot by the ponseti method that were in English and available full-text articles were eligible for the analysis. After refining the findings, only nine articles were found eligible as per the inclusion criteria. The nine studies included a total number of 884 children. It was found that children were suffering from idiopathic clubfoot, neglected clubfoot, idiopathic and flexible clubfoot, complex clubfoot, or undefined clubfoot. Ponseti method is found effective and safe for the management of clubfoot, even for neglected clubfoot in older children with few complications and decreased rate of relapse.

Correction results of atypical clubfeet managed with modified Ponseti technique: A meta-analysis of 354 feet

Background/purposeAtypical clubfeet are distinct from idiopathic clubfeet. It is resistant to correction by conventional casting methods and often requires a modification of Ponseti's casting technique. Although the initial correction rates are reasonable, relapse and complications are frequent. There is limited literature on the results of modified Ponseti casting of these feet. We conducted this meta-analysis to study a few important aspects of atypical/complex clubfeet treatment by the modified Ponseti technique. Research questionWhat are the results of atypical or complex clubfeet after treatment by the modified Ponseti technique? MethodologyFive electronic databases (PubMed, Embase, Scopus, Ovid, and Cochrane Library) were searched for articles reporting on the results of atypical/complex clubfeet treated by the modified Ponseti technique. Details of the number of casts required for correction, rate of percutaneous Achilles tenotomy (PAT), other soft tissue procedures required, complications, and relapse rates were extracted into spreadsheets, and meta-analysis was carried out using OpenMeta Analyst software. ResultsTen studies were included for analysis with a total of 240 patients with 354 clubfeet. The initial correction was achieved in all feet. A pooled analysis of the data showed that a mean of six casts was required for the initial correction. The rate of PAT was 98.3%. The overall complication rate was 16.8%. 7.2% required an additional soft tissue procedure apart from the PAT, and relapse of the deformity was observed in a mean of 19.8% cases. ConclusionModified Ponseti technique is effective in the initial management of atypical/complex clubfeet. Although the PAT rate is slightly higher in the Modified Ponseti technique, the remaining result parameters are comparable with the results of idiopathic clubfoot managed with the Ponseti method of casting. However, these children should be kept under follow-up for a longer duration to find the exact relapse rates.

Outcome of Atypical & Complex Clubfoot Managed by Modified Ponseti Method—A Prospective Study

Atypical or complex clubfoot constitutes a small number of cases. Due to the difference in complexity of anatomy, standard deformity correction by Ponseti is not effective. Hence a modified Ponseti method was advised which focuses on deformity differences for treatment. We conducted a prospective study to analyze the outcome in atypical or complex clubfoot treated with the modified Ponseti method. All the children of age less than 1 year were included in the study with atypical or complex clubfoot. Every case was treated according to the modified Ponseti method and tenotomy. Pirani scores were measured at pretreatment, each visit, before application of a brace, and at the latest follow-up. Statistical analysis of all continuous and categorical variables was done. A total of 30 patients (47 feet) were included in the study. Mean Pirani score improved from 5.69 at presentation to 0.45 at time of brace application and latest follow-up 0.34 (p < .001). Six patients (9 feet) had a relapse which was managed with recasting. The mean Pirani score of relapse was 0.72, which after correction reduced to 0.11 (p = .008). Six patients had cast-related complications which were managed with conservative treatment. With an increase in popularity of the Ponseti method, a greater number of complex clubfoot cases are seen due to inadequate reduction or slippage of cast or improper cast application techniques. All these need to be identified at an early age. This helps in proper treatment and improves the quality of life as well as foot appearance.

Is the modified Ponseti method effective in treating atypical and complex clubfoot? A systematic review.

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

Effects of younger siblings on the brace compliance and recurrence in children with clubfoot during Ponseti treatment.

This study aimed to determine the effects of the number of total siblings, younger siblings, and complex clubfoot deformity on the brace compliance and recurrence in the management of children with clubfoot deformity using the Ponseti technique. The data from 91 children, including 22 girls and 69 boys (total 130 idiopathic clubfeet), seen from 2016 to 2019 were prospectively collected and retrospectively reviewed. The deformity was unilateral in 52 (57.1%) children (32 right, 20 left) and bilateral in 39 (42.9%). The mean age at presentation was 2 (range, 1-30) weeks, and the mean follow-up was 21.5 (range, 12-36) months. All the clubfeet were treated according to the Ponseti method. After removing the cast, a foot abduction brace (Dennis Brown splint) was worn. A complex clubfoot deformity was identified in 12% (n=11) children. At the follow-up, the Pirani score, recurrence status, and brace compliance were recorded. Recurrent deformity was defined as any deformity recurrence requiring manipulation, recasting, or surgical treatment. Brace compliance was assessed per the parents' report. The median number of children in a family was 3 (range, 1-12). A total of 53 (58.2%) parents had up to 3 children, and 38 (41.8%) parents had more than 3 children. Of the patients, 22 (24.2%) had younger siblings and 25 (26.4%) had a family history of clubfoot. A total of 58 feet (44.6%) in 40 children (43.9%) developed recurrence. Brace non-compliance was the main risk factor for recurrence, increasing the recurrence rate 32-fold compared with that of compliant parents (odds ratio [OR], 32.67, 95% confidence interval [CI], 10.02-106.49; p=0.001). The rate of non-compliance with brace use was 51.6% (n=47). Brace non-compliance was significantly associated with having a younger sibling (OR, 3.9; 95% CI, 1.36-11.2; p=0.011) and having a complex deformity (OR, 11.62; 95% CI, 1.42-95.1; p=0.022) but was not associated with the total number of children (OR, 1.61; 95% CI, 0.7-3.73; p=0.265). Our study shows that having new siblings in the first years of the Ponseti treatment may increase the brace non-compliance by minimizing the attention paid to the children with clubfeet by their parents. Nonetheless, complex clubfoot deformity may promote brace compliance by increasing the parents' interest during the treatment process. Level IV, Therapeutic Study.

Using the modified Ponseti method to treat complex clubfoot: Early results.

Objectives This study aims to present the results of complex clubfoot patients treated with modified Ponseti method and put forth the warning clinical signs of complex deformities.Patients and methods A total of 11 patients (10 males, 1 female; mean age 60.1±49.7; range, 2 to 180 days) with 16 complex clubfeet treated with modified Ponseti method were included in this study conducted between January 2016 and June 2019. All the data of the patients were collected prospectively and reviewed retrospectively. Demographic features, clubfoot severity, number of casts, position of each foot before cast removal, ankle dorsiflexion (DF), complications, and additional procedures were noted at all clinical visits.Results Eleven (11.2%) of 98 patients had complex clubfoot deformity. Six (7.7%) of 78 newly diagnosed patients and five (25%) of 20 referred patients had complex clubfeet. We treated 16 complex clubfeet of 11 patients. The mean follow-up period was 13.3 (range, 10 to 16) months. All deformities were initially corrected using a mean of seven (range, 5 to 8) casts and Achilles tenotomy. Relapses occurred in three (18.75%) patients, but all recovered after recasting. The creases above the heels disappeared in all of the patients, whereas plantar creases persisted on two (12.5%) feet. Pirani scores and DF improved statistically significantly after treatment, and DF improved significantly between tenotomy and the final visit.Conclusion The modified Ponseti method is an effective treatment for complex clubfoot. Classical clinical appearance, treatment-resistant deformities and referred patients should be warning signs for complex clubfoot.

Correlation of age and severity scores to the number of Ponseti casts in Indian infants with clubfeet

PurposeWorld over, age and various severity scores are among the foremost variables studied in relation to the number of casts in clubfoot. We studied the correlation between child’s age at presentation, initial Pirani, Dimeglio scores to the number of Ponseti casts in Indian clubfoot children. Further, we matched Pirani versus Dimeglio scores at different severities of deformity to derive a correlation between them. MethodsWe included 90 idiopathic clubfeet in 55 infants and scored them according to Pirani and Dimeglio grading systems. Syndromic, neurological, surgically intervened, atypical or complex clubfeet were excluded from the study. The number of casts before percutaneous tenotomy was counted. Correlations were calculated between corrective casts and age, Pirani, Dimeglio scores and their individual components. ResultsMean age of children was 63.7 days and average number of casts applied was 3.2. Age at presentation and number of casts had no correlation with r = 0.034 (p < 0.001). The correlation between initial Pirani score (average 5.39) and Dimeglio score (average 13.4) to number of casts was 0.35 (p < 0.001)and 0.56 (p < 0.0001) respectively. Among individual components of Pirani score, medial crease and rigid equinus had maximum correlation to the number of casts whereas empty heel sign had the lowest. For Dimeglio score, equinus and varus correlated the most and posterior crease the least. Pirani and Dimeglio scores were highly correlated (r = 0.87) to each other except for very supple or severe deformity. ConclusionsIn infancy, the age at presentation had no bearing on number of casts. Both scoring systems had positive correlation in terms of corrective casts for our population. The Dimeglio fared slightly better than Pirani scores.

Clinical outcomes of iatrogenic complex clubfoot treated with modified Ponseti method.

There are not enough studies demonstrating the results of the modified Ponseti method on iatrogenic complex clubfoot that occurs due to errors during the application of the method for treating idiopathic clubfoot. The present study aimed to present the treatment results of the modified method reported by Ponseti for treating feet that became complex solely due to errors during casting. Patients with the confirmed diagnosis of iatrogenic complex clubfoot were according to initial physicians' report and photographs were included in this retrospective case series study. Patients with congenital atypical feet, incomplete medical records, and accompanying pathologies were excluded from the study. Patients' clinical data and clinical scores were recorded at the initial visit and at the latest follow-up. There were 21 children (15 boys and 8 girls) with 32 complex clubfeet. Initial correction was achieved in all children, with an average of five serial casts (range 3 to 6 casts). At the last follow-up, ISGCF score of 25 feet (78.1%) was excellent and seven feet (21.9) was good. According to the results acquired from this study, an iatrogenic complex clubfoot can be successfully treated using the modified Ponseti method.

Hallux length and deep medial crease in complex clubfeet: Do they recover?

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

Complex Clubfoot Treatment With Ponseti Method: A Latin American Multicentric Study.

Complex clubfoot is a term used to describe those feet that present after treatment with a short first metatarsal, severe plantar flexion of all metatarsals, rigid equinus, and deep folds through the sole of the foot and above the heel. Ponseti has described a modification of his original technique for the treatment of the deformity. Few series have reported the treatment outcomes of this group of patients. The purpose of this study is to analyze mid-term results and complications of a large multicenter cohort. Patients with complex clubfoot treated at 6 tertiary-care institutions with a minimum of 1-year follow-up were retrospectively analyzed. Demographic data, previous treatment, number of casts, Achilles tenotomy, recurrences, complications, and additional procedures were documented. The patients were clinically evaluated at the time of presentation, after treatment, and at the last follow-up according to the Pirani score. All variables had a nonparametric distribution and are thus described as median (interquartile range (IQR), minimum-maximum). A comparison between the variables was performed using a Mann-Whitney U test, the change within each group was performed with a Wilcoxon-designated range test. A P-value <0.05 was used to indicate statistical significance. One hundred twenty-four feet (79 patients) were evaluated. The median age at initial treatment was 7 months (IQR, 15; min-max, 1 to 53 mo). The mean follow-up was 49 months (IQR, 42; min-max, 12 to 132 mo). A median of 5 casts (IQR, 5; min-max, 3 to 13) was required for correction. Percutaneous tenotomy of the Achilles tendon was performed in 96% of the feet. One hundred twenty-two feet (98%) were initially corrected; 2 feet could not be corrected and required a posteromedial release. The Pirani score improved significantly from a pretreatment mean of 6 points (IQR, 1; min-max, 4.5 to 6) to 0.5 (IQR, 0.5; min-max, 0 to 2.5) at the last follow-up (P <0.001). Seven feet (6%) presented minor complications related to casting. Relapses occurred in 29.8% (37/124). In this subgroup, the number of casts required at initial treatment was higher (6; IQR, 5; min-max, 1 to 12 vs. 4 IQR, 4; min-max, 1 to 13; P<0.001), and follow-up was significantly longer (62 mo; IQR, 58; min-max, 28 to 132 vs. 37 mo; IQR, 48, min-max, 7 to 115; P<0.001). Ponseti method is safe and effective for the correction of complex clubfeet. Early diagnosis and strict adherence to the Ponseti principles are key to achieve deformity correction. Patients with complex clubfoot require frequent follow-up because of a higher recurrence rate. Level III-therapeutic study.

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 EvidenceLevel V, expert opinion

Outcome in prenatal diagnosis of isolated or complex clubfoot – systematic review and case series

Clubfoot represents a congenital limb deformity, with a frequency of 1/1000 pregnancies, and it is one of the most common musculoskeletal deformities presenting at birth. Although it is diagnosed at birth, many cases are detected from the antenatal period, following an ultrasound examination. In about half of the cases, both feet are affected, boys being twice more likely than girls to have the deformity. Objective. This study aims to review the literature regarding the outcome of isolated clubfoot and the risk that stems from its association with other anomalies. Materials and method. The online database was used to detect studies that have evaluated the outcome of isolated clubfoot or associated with other abnormalities. The information from literature was compared with our experience at the Antenatal Diagnostic Unit from the Emergency County Clinical Hospital of Craiova, based on the ultrasound assessments performed during 2018. Results. If the malformation is isolated, it will have a good prognosis. It may be postural, especially in pelvic presentations associated with a reduced amniotic fluid. In complex clubfoot cases, associated with other structural abnormalities, a chromosomal abnormality may be diagnosed, or the cause may be neurological or muscular, and it is part of a syndrome. Conclusions. Because of the significant different prognosis, it is important to carry out an antenatal ultrasound diagnosis, as complex as possible, to discriminate between the presence of an isolated clubfoot from the cases where this abnormality is associated with other malformations.

Complex iatrogenic clubfoot: is it a real entity?

In our study, we aimed to demonstrate whether a complex iatrogenic clubfoot really exists; identify the causative mechanisms; and determine the outcome if properly treated. We observed 54 clubfeet previously treated unsuccessfully by manipulation and casting elsewhere. All the feet had been classified at diagnosis as typical clubfeet. In 26 cases, the cast had slipped down, entrapping the foot in a plantar-flexed position. Nine clubfeet out of those 26 cases presented the clinical features of a complex iatrogenic deformity. These were treated with the modified Ponseti protocol and evaluated at follow-up according to the International Clubfoot Study Group Score. The length of follow-up averaged 7.2 years. Two feet showed an excellent result, five feet showed a good result, and two feet showed a fair result. The relapse rate was 55% in complex clubfeet. Relapsed clubfeet were treated by Achilles tenotomy or lengthening and anterior tibial tendon transfer. We believe that faulty manipulation and a poor casting technique may convert a typical clubfoot into a complex iatrogenic deformity. Risk factors include severe clubfoot, short and stubby foot, and unmolded casts slipping down.

Evaluation of modified Ponseti technique in treatment of complex clubfeet

BackgroundComplex 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. MethodParents 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. ResultAverage 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. ConclusionIn 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.

Fetal Neurosonogaphy: Ultrasound and Magnetic Resonance Imaging in Competition.

Fetal Neurosonogaphy: Ultrasound and Magnetic Resonance Imaging in Competition.

Zdravljenje idiopatskega in kompleksnega prirojenega talipes ekvinovarusa z metodo po Ponsetiju

Abstract:Congenital idiopathic clubfoot is a deformity typically occurring in an otherwise healthy child which occurs in 11,4 in 10.000 live births. Approximately one-half of cases present with bilateral deformity and affects boys and girls equally. Clubfoot is characterized by adduction, supination and cavus deformity of the forefoot and midfoot, varus of the heel, and a fixed plantar flexion (equinus) of the ankle. Treatment od idiopathic type of clubfoot consists of corrective manipulation and casting by the Ponseti method, where usually four to six casts are needed. Equinus is corrected with tendo Achillis tenotomy followed by foot abduction brace application.Complex type of clubfoot, which has more severe rigid deformation, is present in 6,5% of all clubfeet and is refractory to the usual corrective manipulation and casting by the Ponsetti method. Clinically, complex clubfoot is characterized as short, stubby foot, having rigid equinus, severe adduction and plantar flexion of all metatarsals, a deep crease above the heel and a transverse crease in the sole of the foot. Modified Ponsetti method for treatment of complex clubfoot consists of simultaneus correction of adduction and heel varus and subsequent cavus and rigid equinus correction. After the Achillis tendon tenotomy, modified foot abduction brace is applied, where foot is in 40° outer rotation in contrast to 70° abduction used in less rigid congenital idiopathic clubfoot. Relapse occurs in 14% and is ussually related to problems with shoe fit and patient coplience.