Idiopathic Clubfoot Research Articles

The Influence of Achilles Tenotomy and Compliance with Foot Abduction Orthosis on the Relapse Rate of Ponseti Treatment for Idiopathic Clubfoot: A Regional Study

The Ponseti method for treating idiopathic clubfoot is based on gradual manipulations and corrective plaster castings followed by a years-long period of use of a foot orthosis. The role of surgery is limited. The factors that may affect outcome and their influence are subject of controversy. The aim of the study is to systematically and objectively evaluate the results of Ponseti treatment in our region of Southern Israel and focus on the role of the Achilles tenotomy and compliance to foot orthosis as factors that may influence outcome. The use of Ponseti method was retrospectively studied (level of evidence IV) by searching computerized medical files and clinical photos. The severity of deformity was evaluated by Dimeglio score (D-score) at baseline and at last examination. During 2006-2014, 57 children with idiopathic clubfoot (total 90 feet) were enrolled. An Achilles tenotomy was performed in 55/90 (61.1%) of the feet. If the D-score was 15 or higher there was a 20% increase in the incidence of Achilles tenotomy. The parental compliance had a weak protective effect against relapse. The treatment of idiopathic clubfoot by the Ponseti method was successful and reliable, proving efficiency and universality of the method. A dominant predictor for relapse was not seen. An incidental observation was that extended time in cast may buffer the adverse effects of low compliance rate. Although the initial severity, or compliance to braces are important, there may be other factors that affect the outcome such as, accuracy of the casting technique, time in the cast, access to a dedicated clubfoot clinic, cooperation with nurses and pediatricians, economic status that allows purchase of new generation of braces, cultural perception, and education level of the patient population are some examples.

A retrospective study of idiopathic clubfoot managed by Ponseti method using Pirani and Dimeglio scoring, in Indian population: a minimum 3-year follow-up.

Congenital talipo-equino-varus (CTEV) is one of the most common congenital deformities affecting children in India with an incidence of 1.19/1000 live births. Ponseti treatment regimen has been established as the gold standard of care for idiopathic clubfoot. We present quantitative and qualitative analysis of the results of Ponseti management in early presenting idiopathic clubfoot cases, with a minimum follow-up of three years after correction. We retrospectively analysed the data of 122 children (comprising a total of 191 feet) who were treated for clubfoot by the standard Ponseti method with a minimum 3-year follow-up post-correction at our clinic. All cases were treated under the supervision of a single senior Paediatric Orthopaedic Surgeon. The mean age at onset of treatment was 2.3 months. Mean follow-up period was 4.2 years. The mean number of casts applied was 6.7. The mean duration of treatment until the application of splint was 9.5 weeks. The mean Pirani score at the commencement of treatment was 4.5. At the completion of treatment (around 3.6 years of age), the Dimeglio score was 'Benign' (Good) in 106 cases, 'Moderate' (Fair) in 11 cases and 'Severe/Very Severe' (Poor) in 5 cases. The P-value was calculated to be 0.8 for the sex-wise comparison of the treatment outcome. Ponseti method of nonoperative treatment for idiopathic clubfeet remains a gold standard for all cases treated during infancy. Identifying atypical clubfeet is important as their prognosis ought to be guarded. Despite facing problems at various stages of management, adhering to the basic treatment principles laid down by Ponseti helps in achieving good outcomes in majority. Level of Evidence: IV.

A study on outcome of combined cuboid/cuneiform osteotomy for correction of residual forefoot adduction deformity in idiopathic clubfoot

Introduction: Recurrence is by definition the development of one or more of the original deformities (equinus, varus, adductus and cavus) after the full correction of the clubfoot is obtained. Adduction of the forefoot is the most common residual deformity in clubfoot associated with supination of the foot [Tarraf and Carroll]. Under correction at the time of initial surgery, medial displacement of the anterior part of calcaneum and navicular bones around the talus were considered to be some of the causative factors. Aims & objectives: To analyse the effectiveness of the combined cuboid /cuneiform osteotomy for correction of residual forefoot adduction deformity in idiopathic clubfoot. To study the improvement in forefoot flexibility, gait and overall functional outcome. To study the advantage of this procedure over other techniques of osteotomy. Materials and methods: 16 cases (feet) in 11 children, who presented to our institution (Government Rajaji Hospital, Madurai) between November 2010 and November 2012 with residual forefoot adduction deformity. Children were followed up for a period 2 years. Ethical committee approval was obtained for the procedure. The mean age at the time of surgery was 6.5 years (range 3- 10 years). There were 7 boys (10 feet), 4 girls (6 feet). The right foot in 9 children and left foot in 7. Results: Results according to point scoring system: (modified Bensahel et al.) approved by the International clubfoot study group. Of the 16 feet treated, 8 feet (50%) had excellent results, 5 feet (32%) good, 2 feet (12%) fair and 1 foot (6%) poor results. Conclusion: The combination of a shortening osteotomy of the cuboid and elongation of the cuneiform was first described by Mc hale and Lenhart. The combined osteotomy is a safe procedure and allows satisfactory correction of the residual forefoot adduction deformity and achieving a straight plantigrade foot.

Quantification of differences in lower-limb appearance between idiopathic clubfeet treated by ponseti casting method versus normal feet in young children

Despite excellent functional correction of club foot, the appearance of the treated lower-limb differs morphologically from normal lower-limbs which has been described qualitatively in the past. The purpose of this study is to quantify the lower-limb appearance between idiopathic ponseti-treated clubfeet versus normal feet in terms of foot length, calf girth and internal tibial torsion in a group of young children. Materials and methods: 49 club foot patients (29 unilateral, and 20 bilateral) below the age of 12 months were treated using the Ponseti casting method. When patients reached walking age (average 14 months), the evaluation was done using the Pirani score. Upon a score of 0 (indicating full correction), the lower-limb appearance was defined by foot length, calf girth, and internal tibial torsion measurements. Results: Of the 29 patients with unilateral clubfoot (age: 14 ± 3 months), 86% had smaller foot length (11.9 ± 0.7 cm, p < 0.05), 69% had smaller calf girth (17.1 ± 1.7 cm, p < 0.05) and 79% had larger internal tibial torsion (16.1° ± 3.7°, p < 0.001) in comparison to normal lower-limbs (n=19). Of the 20 patients with bilateral clubfeet (age: 14 ± 3 months), 100% had smaller foot length (12.0 ± 0.7 cm, p < 0.05), 60% had smaller calf girth (17.1 ± 1.4 cm, p < 0.05) and 74% had larger internal tibial torsion (15.3° ± 3.9°, p < 0.001) in comparison to age-matched normal lower-limbs (n=19). However, when comparing all treated lower-limbs (n=49) to normal lower-limbs (n=20), 82% had significant difference in all these parameters. Conclusion: Children with Idiopathic Club Feet treated with Ponseti exhibit significant quantitative differences in terms of smaller foot length, smaller calf-girth and larger internal rotation as compared to normal individuals. Prior counselling of parents regarding these differences in unilateral cases is recommended.

The influence of laterality, sex and family history on clubfoot severity.

PurposeEpidemiological studies on idiopathic clubfeet have shown a typical distribution consistent across ethnic groups: bilaterality in about 50% of cases and a male to female ratio of 2:1. Whether this corresponds also to differences in severity according to laterality and sex has been poorly evaluated. As well, the correlation between family history and severity has not been previously investigated. The aim of this study was to investigate how laterality, sex and family history influence severity and treatment.MethodsIn all, 97 infants with idiopathic clubfoot (81 male, 16 female; 55 unilateral, 42 bilateral; 19 with a first or second-degree relative affected) consecutively treated with Ponseti method were prospectively enrolled. Initial severity (according to Dimeglio and Pirani scores) and treatment (number of casts and need for tenotomy) were analyzed in the different subgroups.ResultsInitial severity according to Pirani (p = 0.020) and Dimeglio score (p = 0.006), number of casts (p = 0.000) and tenotomy (p = 0.045) were significantly higher in bilateral than in unilateral cases. In bilateral cases, a significant correlation was found between the right and left foot of each patient in terms of initial severity, number of casts and tenotomy performed. No statistically significant difference was found according to sex and family history.ConclusionsThis study has confirmed the different behaviour of bilateral cases reported by previous studies; bilateral cases are more severe and show similar features in their right and left foot. This could be the result of different pathogenic mechanisms, likely on a genetic basis. Sex and family history did not seem to influence severity.Level of EvidenceLevel of evidence II

Socio-demographic characteristics of clubfoot patients: An observational study

Introduction: Congenital idiopathic clubfoot is the most common birth defect of the musculoskeletal system affecting 1 in every 1000 live births each year. Despite numerous studies, the etiology and pathogenesis of clubfoot remains unknown. Till now, no epidemiological studies have been conducted in Jharkhand to assess the risk factors associated with clubfoot. Hence, this study was undertaken. Material and Methods: A descriptive case control study was conducted at Bokaro General Hospital, Bokaro, Jharkhand from April 2018 to April 2019 using structured questionnaires given to mothers of clubfoot patients (n=102) and mothers of children with no first or second degree family history of clubfoot as controls (n=102). Phenotypic characteristics was also noted. Results: Males were twice likely affected and half clubfoot cases had both feet affected. Right side was more affected in unilateral cases. Cause of clubfoot was idiopathic in 87% cases and non idiopathic in 13% cases. Positive family history was found in 12% cases. 51% clubfoot cases were first born children. Seasonal variation was not found to have association with clubfoot. None of the mothers, cases as well as controls were smoker. Maternal religion showed significant association: 20% cases were muslim compared to 5% muslim controls. Maternal age at birth of child and maternal diabetes did not show association with clubfoot. Conclusion: Males sex is twice likely affected by clubfoot and half of clubfoot cases are affected bilaterally. Right foot was more affected in unilateral cases. First born child was at risk of clubfoot. A family history of clubfoot was associated with risk of clubfoot. Maternal religion showed significant association with clubfoot. Maternal smoking, maternal diabetes and maternal age at birth of child were not found to be significantly associated with clubfoot in our study in contradiction to the numerous studies that have shown a strong association.

Circumventing tenotomy in idiopathic clubfoot

Background: Congenital talipes equinovarus (CTEV) is one of the most common congenital deformities faced by the orthopaedic fraternity. Although, the deformity is treated conservatively initially with Ponseti’s method, the procedure involves performing percutaneous Achilles tendon tenotomy, a procedure that has its own set of potential complications. We describe a novel manipulation technique to circumvent tenotomy in correcting the residual equinus deformity of idiopathic clubfoot. Materials and methods: A total of 30 (43 clubfeet) patients were included in the study and after the correction of cavus, adduction and varus deformity using Ponseti’s method, the residual equinus deformity was corrected using our technique. Results: All the cases with the residual equinus deformity could be corrected by our technique. Conclusion: Idiopathic CTEV presenting within a year can successfully be treated without performing percutaneous tendoachilles tenotomy irrespective of the initial Pirani score at presentation using the manipulation technique employed by us.

Suture Button Technique for Tibialis Anterior Tendon Transfer for the Treatment of Residual Clubfoot.

Background:The Ponseti method has revolutionized the treatment of idiopathic clubfoot, but recurrence remains problematic. Dynamic supination is a common cause of recurrence, and the standard treatment is tibialis anterior tendon transfer using an external button. Although safe and effective, the placement of the button on the sole creates a pressure point, which can lead to skin ulceration. In our institution, a suture button has been used for the tibialis anterior tendon transfer and we report our results here.Methods:Two senior authors’ case logs were retrospectively reviewed to identify 23 patients (34 feet) for tibialis anterior tendon transfer using a suture button. Complications and additional operative procedures were assessed by reviewing operative notes, follow-up visit clinic notes, and radiographs. The mean age of the patients was 6 years 2 months (SD 40 months) and the average follow-up duration was 67.1 weeks (SD 72 weeks).Results:There were 5 complications (14.7%). Recurrence occurred bilaterally in 1 patient (5.9%) but did not require reoperation. Other complications included a cast-related pressure sore (2.9%) and an infection (2.9%) requiring irrigation with debridement along with hardware removal.Conclusions:Tibialis anterior tendon transfer using a suture button was a safe procedure with theoretical advantage of providing stronger fixation and reducing the risk of skin pressure necrosis compared to the standard external button technique. We believe a suture button could allow earlier rehabilitation and may afford stronger ankle eversion. Prospective studies are required to compare the differences in functional outcomes between the procedures.Level of Evidence:Level IV, case series, therapeutic study.

Use of PROMIS in Assessment of Children With Ponseti-treated Idiopathic Clubfoot: Better Scores With Greater Than 3 Years of Brace Use.

Patient-Reported Outcomes Measurement Information System (PROMIS) is a well-validated tool used to measure health-related quality of life for children and adolescents with chronic medical conditions. The current study evaluates PROMIS scores in 3 domains for children with Ponseti-treated idiopathic clubfoot. This is a retrospective cohort study of 77 children, ages 5 to 16 years, treated by Ponseti protocol for idiopathic clubfoot. Three pediatric PROMIS domains (Mobility, Pain Interference, and Peer Relationships) were administered between April 2017 and June 2018. One-way analysis of variance with Bonferroni post hoc and independent sample t tests were performed to explore differences across PROMIS domain scores by sex, age, initial Dimeglio score, laterality, bracing duration, and whether the child underwent tibialis anterior transfer. In the self-reported group (ages 8 to 16), mean T-scores for all 3 domains in both unilaterally and bilaterally affected groups were within the normal range, with respect to the general reference pediatric population. However, children with unilateral clubfoot had a significantly higher mean Mobility T-score (54.77) than children with bilateral clubfoot (47.81, P=0.005). Children with unilateral clubfoot also had significantly lower mean pain scores (39.16) than their bilateral counterparts (46.56, P=0.005). Children who had braced >36 months had a significantly higher mean Mobility T-score (53.68) than children who braced ≤36 months (46.28, P=0.004).In the proxy group (ages 5 to 7), mean T-scores for all 3 domains in both laterality groups were within the normal range, with respect to the reference population. Children who had braced >36 months had a significantly higher mean Mobility T-score (52.75 vs. 49.15, P=0.014) and lower Pain Interference score (43.04 vs. 49.15, P=0.020) than children who braced ≤36 months. Children treated by Ponseti protocol for idiopathic clubfoot yielded PROMIS scores for Mobility, Pain Interference, and Peer Relationships domains similar to the reference population. Bracing duration >36 months and unilaterality were associated with less mobility impairment than their counterparts. These findings may help guide parent recommendations. Level III.

Comparison of the outcome of management of congenital idiopathic clubfoot treated by ponseti method with modified technique

Background: Ponseti's technique has become the standard and most effective treatment modality for correction of Congenital Talipes Equinovarus (CTEV) in newborn. With time, little modification has been done in the classic technique.&#x0D; Objective: Our objective in this study was to compare the outcome in the recent years (modified Ponseti technique) with the results of our previous study (classic Ponseti technique).&#x0D; Methods: A total number of 976 patients (1553 feet) of Congenital Talipes Equino Varus were treated from October 2009 to February 2019 in Khulna Medical College Hospital and in private hospitals. In this retrospective study (based on convenient sampling), there were two groups. In group A, a total 621 patients (with a total 1033 feet) were treated from October 2009 to August, 2015. In group B, 355 patients (520 feet) were treated from November 2015 to February 2019.&#x0D; Results: In this study, in group A, approximately 88.6% was in 0-6 months age group. 64.9% was male patients. 3.7% patients had positive family history. In group B, majority of the patients (301, 84.8%) was in 0-6 months age group. 211 patients (59.4%) was male child. In approximately 3.1% (11) patients family history was positive. Approximately in 95.9% (991 out of total 1033) and 96.5% (502 out of total 520) feet respectively in group A and B, tenotomy was required. Dropout rates were 7.6% and 4.1% in respective groups. Minor bleeding was observed in approximately 1.5% (15) and 1.4% (7) feet in respective groups, followed by plaster related complications in approximately 2.2% (23) and 1.0% (5) feet in group A and B. Patients' compliance was found significantly higher in group B in contrast to group A. In group B, it was over 90%, whereas in group A, it was approximately 64.1 %.&#x0D; Conclusion: The ultimate outcome of Ponseti repair is improving by less requirement of total number of plaster, resistant cases and reduction in overall dropout rate by the newer modification.&#x0D; Bang Med J (Khulna) 2019; 52 : 7-11

Is the Denis Browne Splint a Myth? A Long-Term Prospective Cohort Study in Clubfoot Management using Denis Browne Splint Versus Daily Exercise Protocol

The Ponseti technique is successful in idiopathic clubfoot management. However, the leading cause of relapse and recurrence is nonadherence to the Denis Brown bracing protocol. This necessitates more extensive soft tissue surgeries. Based on a detailed up-to-date search, we have found that no other studies provide such a modified Ponseti technique. This study is unique, as it depends on using specific stretching exercises instead of bracing during management. Between August 2009 and June 2019, a consecutive series of 194 isolated idiopathic clubfoot patients (251 feet) were included in this study. The mean follow-up was 93 months (range 72 to 146), mean 91.8 months. All patients underwent a clinical and functional assessment using the Laaveg-Ponseti score and radiological assessments. There were 132 boys (68.1%) and 62 girls (31.9%), a male-to-female ratio of 2:1. The mean age at initiation of treatment was 14.9 days. According to the Laaveg-Ponseti score, 51.7% yielded excellent results, 35.3% yielded good results, 11.55% yielded fair results, and 1.59% yielded poor results. Bracing noncompliance has been identified as a major cause for treatment failure. This presented exercise protocol not only eliminates the need for bracing and reduces the cost for the affected individuals but also provides excellent clinical and radiographic end results, comparable to the original treatment protocol using the Denis Brown brace.

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

The Ponseti method effectively treats idiopathic clubfoot, but its effectiveness in treating the stiffer clubfoot associated with arthrogryposis is less clear. The purpose of this study was to assess the comparative effectiveness of the Ponseti method in 5-year-old children with either idiopathic clubfoot or clubfoot due to arthrogryposis. The outcomes of the Ponseti method were retrospectively evaluated in children with idiopathic clubfoot and clubfoot associated with arthrogryposis. The children with clubfoot were seen at our hospital between 2012 and 2019 and were 4.0 to 6.9 years old at the time of their evaluation. Outcomes of the 2 groups of children with clubfoot were assessed using passive range of motion, foot pressure analysis, the Gross Motor Function Measure Dimension-D, and parent report using the Pediatric Outcomes Data Collection Instrument. These results were also compared with the same measures from a group of typically developing children. Surgical and bracing history was also recorded. A total of 117 children were included (89 idiopathic clubfoot and 28 associated with arthrogryposis) with an average age of 4.8±0.8 years. The historical gait analyses of 72 typically developing children were used as a control, with an average age of 5.2±0.8 years. Significant residual equinovarus was seen in both children with idiopathic clubfoot and associated with arthrogryposis according to passive range of motion and foot pressure analysis when compared with normative data. Children with arthrogryposis demonstrated limited transfer and basic mobility, sports functioning, and global functioning while children with idiopathic clubfoot were significantly different from their typically developing peers in only transfer and basic mobility. Although children with idiopathic clubfoot continue with some level of residual deformity, the Ponseti method is effective in creating a pain-free, highly functional foot. In children with clubfoot associated with arthrogryposis, the Ponseti method is successful in creating a braceable foot that can delay the need for invasive surgical intervention. Level III, Therapeutic Studies-Investigating the Results of Treatment.

Change in the severity of congenital clubfoot in the first week of life

Backgrоund. Congenital clubfoot or congenital equino-cava-varus deformity of the feet is one of the most common pathologies of the musculoskeletal system in children. Numerous articles in global literature have been published about changes in clubfoot severity during treatment; however, there are very few reports on how the severity of foot deformities with congenital clubfoot changes during the first week of life in the absence of deformity correction.&#x0D; Aim. To analyze changes in the severity of congenital clubfoot in the first week of life without any treatment.&#x0D; Materials and methods. The study group included 28 newborns with idiopathic congenital clubfoot (a total of 40 feet). The severity of clubfoot was evaluated on days one and seven after birth using the Dimeglio and Pirani scores.&#x0D; Results. During the initial examination of the newborns on the first day of life, the clubfoot severity recorded on the Pirani score was between 2 to 3 points and between 9 to 15 points on the Dimeglio score. Thus, in the first seven days of life in all patients who did not receive treatment, there was a significant increase in the severity of the equino-cava-varus deformity of the feet (p 0.05). The results of this study confirm that the severity of congenital clubfoot increases in the first week of life. This necessitates the beginning of the correction of severe idiopathic clubfoot in the first days after birth.&#x0D; Conclusions. The severity of congenital clubfoot during the first week of life significantly increased in all feet studied (p 0.05: 2 higher than in the table). If left untreated in the first week after birth, the equinus deformity progresses followed by varus deformity, anterior forefoot reduction, and, to a lesser extent, rotation.

Confirmation of Tenotomy Healing at 3 Weeks Using the Ponseti Protocol

Percutaneous Achilles tenotomy is an integral key element of the Ponseti method in clubfoot management. The duration of posttenotomy casting has been empirical. Evidence-based duration of healing in Achilles tendon is required to objectively determine the period of posttenotomy casting. This study aims to use clinical and ultrasonographic methods to evaluate the mean duration of Achilles tendon gap (ATG) closure and the weekly percentage of feet that achieved ATG closure after tenotomy. Prospectively, 37 feet of 25 patients <5 years old with idiopathic clubfoot were managed using Ponseti methods. The Achilles tendon was assessed clinically and ultrasonographically before and after tenotomy. The tendon stump gap was created at tenotomy, and posttenotomy assessments were done on a weekly basis until tendon stump gap closure was achieved, with a minimum follow-up of 2 years. The immediate posttenotomy ultrasonographic mean tendon gap area was 5 ± 2.8 mm. The mean duration of the tendon stump gap closure as determined clinically was 1.9 ± 0.8 weeks, whereas it was 2.6 ± 0.9 weeks as assessed ultrasonographically (p < .001). The significant difference between clinical and ultrasound methods of assessing the Achilles tendon gap closure appears to establish casting removal and ambulatory walking at 3 weeks after tenotomy for <5-year-old children with idiopathic clubfoot treated with the Ponseti method. We recommend that the duration of posttenotomy cast should be 3 weeks based on the ultrasonographic findings.

Is ponseti casting effective in neuromuscular clubfoot? A university hospital experience from eastern province in Saudi Arabia

Objectives: Clubfoot deformity occurs in approximately one in 1000 newborns. In patients with neuromuscular disease, the clubfoot deformity differs markedly from that in idiopathic clubfoot with respect to its severity and higher rate of complications. We aimed to compare the effectiveness of the Ponseti serial casting technique in treating idiopathic and neuromuscular clubfoot. Methods: We performed a retrospective study of patients with clubfoot identified from a pediatric orthopedic clinic database, who were treated at our hospital from 2004 to 2018. The follow-up period for patients in both groups ranged from 8 to 12 years. The information obtained included age at presentation and number of casts required for deformity correction. We measured the severity of the clubfoot using the modified Pirani score before and after Ponseti treatment. Results: The initial number of participants was 117; upon applying our inclusion and exclusion criteria, only 39 patients from the idiopathic group and 10 from the neuromuscular disease-associated clubfoot group were included. The average age in weeks of the participants in the idiopathic group and the neuromuscular disease-associated clubfoot group at diagnosis was 1.79 and 1.80, respectively. Both groups had a similar mean modified Pirani score before and after the Ponseti treatment. Conclusions: Ponseti casting is an effective primary modality of management for clubfoot associated with neuromuscular diseases, as it is in idiopathic clubfoot, to achieve functional pain-free feet and reduce the number of surgical interventions needed.

Evaluation and outcome of ponseti method in the form of treatment of congenital idiopathic clubfoot

Talipes equinovarus or clubfoot, in the definition is a congenital deformity concludes of cavus, forefoot adduction, heel varus, ankle equinus and internal tibial torsion. The overall demographic prevalence of clubfoot was 1.30 per 1000 live births; 1.37 among non-Hispanic whites, 1.30 among Hispanics, and 1.14 among non-Hispanic blacks or African Americans. Unilateral clubfoot is somewhat more common than bilateral clubfoot and may occur as an isolated defect or in association with other disorders (eg, chromosomal aberrations, cerebral palsy, spina bifida, arthrogryposis). Our study aim was to evaluate Ponseti Method in the form of treatment of congenital idiopathic clubfoot. This was a quasi-experimental study was conducted in the department of Orthopaedic Surgery in Rajshahi Medical College Hospital, Rajshahi, Bangladesh during the period from January 2018 to December 2019. Data were collected prospectively in randomized pattern from patients with idiopathic clubfoot, presenting in this hospital. Both, unilateral, bilateral were included in the study. In this study, we have treated 47 children with idiopathic clubfoot by Ponseti Method of correction of serial manipulation and casting. Among the 47 children, 24 had unilateral and 23 bilateral involvement. Male were 27 and remaining 20 were female. Most children had grade III and grade IV (Dimeglio et al grading) deformity. The mean number of casts required was 5.67 (4 to 10). Tenotomy was required for 18 patients (38.29%). The scores for the entire group ranged from 4.0 to 7.0 (of 19) and 4 to 19 (of 28) in the Dimeglio classification. Pirani scores for the age group 0- 6 months were 4.45, 6 months to 1 year were 5.29 and 1-2 years were 5.65 respectively. The results were excellent in 37 (79 %), good in 7 (14 %) and inefficient in 3 (6 %). Initial and final scores were statistically evaluated with paired „ T‟ test with a „ T‟ value of 37.13 with a „ P‟ value of less than 0.001. Thus there was a significant reduction in the score from the pre level because of intervention. Results: Similar good results and low requirement for surgical interventions other than Achilles tenotomy, which forms part of the Ponseti regimen, were found. In terms of number of patients, the success rate is 93.6% and in terms of the number of feet the success rate is 93.6%. This study demonstrates that treatment of congenital talipes equine varus by conservative management of Ponseti Method can considered as one of the most common and effective treatment method.

Rare presentation: concomitant incidence of congenital idiopathic clubfoot and simple metatarsus adductus

Background Congenital idiopathic clubfoot and simple metatarsus adductus deformities have often been presented individually. In this series, we attempted to report a rare concomitant incidence of both deformities and explain the way they have been treated simultaneously. Patients and methods Four patients presented with idiopathic clubfoot on one side and simple metatarsus adductus deformity on the other side between January 2012 and October 2014. These patients were treated using Ponseti and Kite’s techniques for clubfoot and metatarsus adductus, respectively. Results Mean follow-up period was 39 months (range, 22–56). Patients’ mean precorrection Dimeglio score was 9.75 (range, 8–12), whereas the mean postcorrection score was 2.75 (range, 2–4). No relapses have been reported for both deformities. The clubfeet had a mean ankle dorsiflexion of 20°, and the contralateral feet showed normal heel bisector. Conclusion Concomitant incidence of clubfoot and metatarsus adductus deformities even if rare should be considered while evaluating newborns with bilateral foot deformities.

Study of result of postero medial soft tissue release (PMSTR) in congenital talipes equinus varus (CTEV) children with Pirani score

Specific Objectives: Congenital talipes Equinovarus (clubfoot) is most common congenital deformity of foot. It can be treated by PONSETI technique with high rate of success but surgery is indicated for rigid deformities that cannot be corrected by serial casting. In our study, our aim is to assess the outcome of Posteromedial Soft Tissue Release (PMSTR) in child with rigid CTEV by PIRANI score. Material and Methods: Between November 2018 to November 2019, we treated twenty (20) feet with idiopathic CTEV with PMSTR. All children with idiopathic clubfoot will be screened. First trial of CTEV cast will be given upto 3 casts. Child with clubfoot deformity which was not corrected with CTEV cast will be selected. Deformity will be assessed with pre-operative PIRANI score. Blood investigations and clinical examination will be done. Surgically fit child will be posted for POSTEROMEDIAL SOFT TISSUE RELEASE. After operative procedure, correction achieved is measured with immediate post-operative PIRANI score. Then above knee slab is given to patient up to stitch removal (12 days). Then after stitch is removed and above knee POP is applied to maintain correction. Patient is called at hospital at every 15 days. Old cast is removed and correction is assessed with PIRANI score. Below knee POP is applied at every 15 days and PIRANI score is assessed at every 15 days. Parents are encouraged to walk their child with cast. This procedure is followed until satisfactory correction is achieved (Usually 6-8 casts). Results: All 20 feets were treated between 7 months to 48 months age-group children with mean age of 19 months. Postoperatively the patients were followed up for every 15 days upto 6 month and everytime correction is noted with PIRANI score. According to these 20 feet evaluated. Among this, 12 children (60%) having excellent result with final PIRANI score

Collaboration between Paediatrician and Orthopaedician in Management of Congenitial Talipes Equino Varus by Ponseti Method

Introduction: Congenital Talipes Equino Varus (CTEV) or Clubfoot is one of the commonest orthopaedic problems observed in infants. Deformity involving in utero malalignment of calcaneo-talar-navicular complex of the foot is known as CTEV. Due to lack of treatment capacity and less knowledge about “Appearance, Pulse, Grimace, Activity, and Respiration.” (APGAR) Score in low income countries, CTEV end up with neglected clubfoot deformity (untreated children &gt;2 years). About 1-2/1000 live births is the estimated incidence of idiopathic clubfoot. Aim: To assess the clinical profile and efficacy of Ponseti technique in the management and treatment of CTEV by Paediatrician and Orthopaedician collaboration. Materials and Methods: The observational study was conducted at AdiChunchanagiri Institute of Medical Sciences (AIMS). The data was recorded in a standard predesigned proforma which contained all details of patients like name, age, sex, parent details, address, family history, pregnancy and delivery details of mother, any prior treatment taken for clubfoot and examination details of spine, hips, upper and lower limbs with both feet and also other systems for associated clinical problems. The parents of the patients visiting Paediatric Out Patient’s Department (OPD) with CTEV were informed regarding the deformity and were sent to Orthopaedic Department. In Orthopaedic Department, after counselling of the parents regarding the ponseti method, all patients were treated and managed. All patients were followed over a two year period and assessed for any deformities which were subsequently managed surgically. All the data was documented, statistically analysed using suitable statistical methods. Results: Total 53 patients had 81 idiopathic CTEV or Clubfoot between the period of three years from 2015 to 2018. The age of patients varied upto one year after birth. Among 53 patients, 38 (72%) were males and 15 (28%) were females. Out of 53 infants, 35 had one clubfoot and 23 had bilateral clubfoot (total 81 clubfoot in 53 infants). The mean age of initial presentation to treatment was 3.5 weeks, 11 out of 53 infants came in 1st week of life. Out of 53 infants, 21,14,6,5,4,2 were followed-up for 7-12 months, 13-18 months, 0-6 months, 25-30 months, 19-24 months and 31-36 months, respectively. Out of 81 clubfoot; 76 (93.83%) had achieved near normal correction, five clubfoot (6.17%) required posteromedial soft tissue release, 67 foot (82.71%) had undergone percuteneoustenotomy and nine foot (11.11%) got corrected without tenotomy. Conclusion: CTEV or clubfoot is treated very safely and effectively by using ponseti method. It is rapidly decreasing the necessity of extensive surgery. This method should be encouraged to be set as the gold standard treatment of congenital clubfoot or CTEV by national efforts.

RESULTS OF TREATMENT OF IDIOPATHIC CONGENITAL CLUBFOOT IN CHILDREN: A 3-YEAR FOLLOW UP STUDY

The aim: Was to analyze the outcome, recurrence rate and complications between Ponseti method and soft-tissue release 3 yearsafter the initial treatment. Materials and methods: This prospective cohort study was conducted in congenital idiopathic clubfoot patients who underwent primary treatment by either Ponseti serial casting or soft tissue release between 2006 to 2016 at department of traumatology and orthopedics National Children's Specialized Hospital "Okhmatdet". Total of 113 feet in 95 patients (61 males and 34 females), sixty-two feet (62 patients) were in the Ponseti group and thirty-three feet (33 patients) were in the surgical treatment group. For both groups, descriptive statistics were calculated Pirani score (2004) result before and 3 years after treatment, recurrence rate and complications. The comparison of the Pirani score result and complications between the two groups was analyzed by nonparametric tests (Mann-Whitney U-tests). Statistical data processing was performed in SPSS 17.0 program. Results: The results of Pirani score reveal satisfactory outcomes for both groups. But Ponseti method has the more conservative approach and lower complication rate (11,29±5,27% and 24,24±11,74%, p=0,52). Conclusions: Ponseti method is a safe, effective method for treatment of congenital idiopathic clubfoot in children from first days after birth. Open surgery should be reserved for deformity that cannot be completely corrected or for treatment of recurrences.