Idiopathic Talipes Equinovarus Research Articles

Efficacy of the Ponseti method in the treatment of neglected idiopathic talipes equinovarus at a tertiary hospital in Nigeria

Objectives: Neglected clubfoot is common in our environment, for multifactorial reasons. It could cause pain and psychological distress to the patient and parents. We assessed the efficacy of the Ponseti method in the treatment of neglected clubfoot in a Nigerian Hospital. Material and Methods: This was a 15-month prospective and interventional study. Patients at least one-year-old with untreated idiopathic talipes equino varus (ITEV) or inadequately nonoperatively treated ITEV were the study population. The number of castings required for correction, tenotomy rate, dorsiflexion angle before and after tenotomy, and abduction angle after treatment were obtained. The chi-square test of independence was used to test the relationship between categorical variables. Logistic regression was used to assess if the Pirani score at the presentation predicted a successful correction at the end of the study. The level of significance was set at P < 0.05. Results: Forty-two children with 69 club feet were treated in this study. The mean age of presentation was 27.45 months (standard deviation [SD] = 19.22). The mean number of casting sessions required to achieve correction was 6.35 (SD = 1.95). The mean Pirani score at presentation was 4.27 (SD = 1.33) which reduced to 0.30 (SD = 0.35) after correction. The Pirani score at presentation had a positive correlation with the number of casts required for correction (r = 0.505, P < 0.001) but did not predict a successful correction after treatment. The success rate was 85.5%. Conclusion: The Ponseti method of treatment showed a high success rate in the treatment of neglected ITEV.

Experience with accelerated ponseti technique for treatment of idiopathic clubfoot in a regional orthopaedic hospital in Nigeria.

Idiopathic talipes equinovarus (ITEV) 'aka clubfoot' is the most common foot deformity in children. Ponseti technique had been accepted as a standard method for correction. The traditional Ponseti technique for correction is well known. Accelerated Ponseti technique is said to offer some advantages over the standard technique. The aim of this study was to determine and document the efficiency and success rate of accelerated Ponseti technique. This was a prospective interventional study which lasted 26 months from February 2017 to April 2019. Twenty-eight patients with 42 feets who met the inclusion criteria were recruited. They had serial manipulation and casting twice every week till percutaneous tenotomy was done as indicated. Final cast usually applied after tenotomy and left for 3weeks. Each patient was followed up for a year corresponding to 9 months after the commencement of night bracing. Data were analysed using SPSS version 20. The mean age was 8.1 months with a range of 1-36 months. The mean Pirani score recorded was 4.4, while the mean number of casting sessions was 3.6 and the mean duration of treatment was 12.4 days. The tenotomy rate recorded was 42.9%. Pre-bracing assessment of Pirani score, passive ankle dorsiflexion and foot abduction done and repeated after a year revealed optimal correction. The relapsed rate at 1 year was 4.8%. The only complication observed was pressure sore in a patient. The accelerated Ponseti technique is an efficient method of treatment of ITEV in a much shorter time with a higher success rate. It facilitates compliance with treatment.

Association of Socioeconomic Status With Relapse After Ponseti Method Treatment of Idiopathic Clubfeet.

Background:The Ponseti method is today’s standard treatment of idiopathic talipes equinovarus (ITEV). Compliance with foot abduction bracing (FABO) and socioeconomic factors have been shown to impact treatment outcome. We wished to further study socioeconomic factors using the Area Deprivation Index (ADI), a more comprehensive way to evaluate socioeconomic status, which has not been done before.Methods:All TEV patients from 2010 through 2019 treated with the Ponseti method were reviewed. Standard demographic variables, as well as the number of casts to complete initial correction, FABO compliance, and occurrence of relapse were tabulated. Socioeconomic level was quantified with the 2018 ADI.Results:There were 168 children; 151 had typical and 17 complex TEV. Average follow-up was 4.3 ± 1.8 years; relapse occurred in 46%. There were no significant differences in the percentage of relapse by sex, race, or ADI. FABO noncompliance was present in 46%. Relapse increased with increasing time of follow-up and FABO noncompliance (76% vs 21%, P < 10−6). Multivariate logistic regression analysis revealed that only FABO compliance and length of follow-up were associated with relapse. The OR of relapse for FABO noncompliance was 17.9 (7.6, 42.4, P < 10–6) and for follow-up >4 years the OR was 4.97 (2.1, 11.70, P = .0003).Conclusion:The outcome of the Ponseti method for TEV treatment is dependent on local circumstances. In our state, socioeconomic status, as determined by the ADI, was not associated with the occurrence of relapse. Thus, each center needs to assess its results, and analyze its own reasons for relapse. There were no other demographic variables associated with relapse except FABO compliance and length of follow-up. Parents should be strongly advised that FABO compliance and follow-up appears paramount to achieving the best results, and that complex TEV are at greater risk for relapse.Level of Evidence:Level IV, case series

The demographics of talipes equinovarus in Indiana, with a particular emphasis on comparisons between clubfoot types.

Talipes equinovarus (TEV) can be an isolated idiopathic deformity or associated with various syndromes. The purpose of our study was to examine the demographics of TEV in Indiana. All TEV patients from 2010 to 2019 from our institution were reviewed, recording standard demographic variables. The socioeconomic level of the family was determined using the 2018 Area Deprivation Index (ADI). There were 568 patients; 456 had idiopathic TEV and 112 syndromic. Within the idiopathic group, 69.1% were male, 92.1% were typical and 7.9% were atypical. Medical issues during the pregnancy occurred in 19.5%, maternal smoking in 2.9%, hypertension in 3.9% and diabetes in 5.3%. The most common syndromic patients were myelomeningocele (29%) and arthrogryposis (17%). Patients with syndromic TEV had more bilateral involvement (68.2% vs. 45.2%) and other associated congenital deformities (67.0% vs. 11.4%). TEV was less common in Hispanics and Asians but more common in Whites and Blacks ( P = 0.003). Complex TEVs were less frequent in White (6.9%) and Black (5.0%) and more common in Hispanic (30%) children ( P = 0.0002). The ADI demonstrated no difference in prevalence across socioeconomic levels. There were no differences by state ADI levels for TEV type (syndromic/idiopathic), sex, maternal smoking or illicit drug use, or typical/complex TEV. This study is the first to describe the demographics of TEV in Indiana, demographic differences between typical and complex types of clubfeet, and TEV patients using the ADI. TEV did not show any difference in prevalence by socioeconomic level.

Incidence of Congenital Talipes Equinovarus among Children Reporting at Tertiary Care Hospital

Objective: To determine the incidence of congenital talipes equinovarus among children reporting at tertiary care hospital. Study setting &amp; Duration: The study was conducted at Watim Medical &amp; Dental College Rawat, Rawalpindi in the departments of Anatomy, Medical education &amp; Dentistry from January 2021 to December 2021. Materials and Methods: There were 988 participants in this study. An easy questionnaire was used to gather information on children with CTEV who presented themselves to the outdoor department. Both consanguineous and non-consanguineous relationships were considered. Results: A total of 96 (9.7%) children presented with congenital talipes equinovarus or club foot and out of these children 56 (5.7%) patients were males and 40 (4.04%) were female. Conclusion: Clubfoot or congenital talipes equinovarus is one of the most common abnormalities of the foot and idiopathic talipes equinovarus is most common in the studied population. It is more common in males and is mostly bilateral. It should be detected at birth and treated early to prevent permanent disability. Keywords: Children, CTEV, idiopathic, consanguinity

COMPARTIVE STUDY BETWEEN THE RESULTS OF ORIGINAL, ACCELERATED AND DECELERATED PONSETI TECHNIQUES IN TREATMENT OF CONGENITAL TALIPES EQUINOVARUS

Congenital Idiopathic Talipes Equinovarus (CTEV), or clubfoot, is a complex deformity that involves pathological anatomical disorder in the foot with ankle equinus, hindfoot varus, midfoot cavus and forefoot adductus.Ponseti technique has become the gold standard of care for congenital club foot management. It is not only a thorough manipulation and casting process but also prevention and treatment of relapse. The procedure includes a series of plaster casts that have been modified weekly for a period of six weeks, accompanied by a percutaneous tenotomy of the Achilles tendon (PAT), and a further three-week healing castAIM OF THE WORKTo compare the results of original, modified accelerated and modified decelerated Ponseti techniques in treatment of congenital talipes equinovarus (club foot).Patients and MethodsPATIENTSSixty patients with congenital talipes equinovarus were recruited from the Orthopedic Department, Alexandria Main University Hospital (AMUH).The patients were divided randomly by sealed envelope method into three groups.Group I: Included 20 patients (31 feet) that were treated by traditional Ponseti technique using serial casts with one-week intervalGroup II: Included 20 patients (31 feet) that were treated by Modified decelerated Ponseti technique using serial casts with a two-week intervalGroup III: Included 20 patients (31 feet) that were treated by Modified accelerated Ponseti technique using serial casts with a three-day interval

Accelerated versus conventional Ponseti protocol for the treatment of idiopathic talipes equinovarus deformity: A short term follow up in Iraq

Background and objective: The accelerated protocol of Ponseti method was suggested to shorten the period of treatment of the conventional one for the cases of talipes equinovarus deformity. This study aimed to compare the accelerated protocol of Ponseti method in the treatment of clubfoot deformity with the conventional one. Methods: A prospective comparative study was conducted for infants less than six months with congenital talipes equinovarus deformity. The patients were randomized to either Group 1 (casts changed every week, conventional protocol of Ponseti method) or Group 2 (twice weekly, accelerated one). Pirani score was used to assess the severity of the deformity at presentation, at time of last cast removal, and at the last follow up visit (6th months). Results: The patients included were 48 cases with 79 feet. Group 1 (39 clubfeet) had a mean Pirani score of 5.6 (± 1.15) at presentation, which dropped to 0.47 (± 0.41) when the last cast was removed. In Group 2 (40 clubfeet), it dropped from 5.57 (± 0.83) to 0.77 (± 0.01). The result of each treatment protocol was significant, but the difference between them was not significant. Five cases (three patients aged more than three months) of Group 2 needed eight casts to reach an acceptable position of correction. The difference between the mean number of casts applied in Group 1 (5.09) and Group 2 (5.82) was statistically not significant. However, the difference between the mean number of days spent in the cast was significant. The complications occurred in 12 out of 79 feet, with no statistically significant difference between both groups. Conclusion: The accelerated protocol of Ponseti method for treating clubfoot deformity is as effective and as safe as the conventional one. It shortens the time required to complete the treatment program. Those who present lately (beyond the age of three months) may require an additional number of casts. Keywords: Clubfoot; Congenital talipes equinovarus; Ponseti; Accelerated; Cast.

A survey on idiopathic congenital talipes equinovarus (ICTEV) managed by the Ponseti technique at Mulago Hospital - Uganda.

IntroductionPonseti technique is the treatment of choice for idiopathic congential talipes equino varus (ICTEV) since 1950s with excellent treatment outcomes reported worldwide. However, despite the popularity of this technique, Uganda adapted it as a treatment modality for ICTEV in May 2005. Since then, the effectiveness of delivered Ponseti care to children with this very common orthopaedic deformity under the supervision of an orthopaedic surgeon was unknown. The implication of this undertaking was that, satisfactory outcomes would then support the Ministry of Health (MOH)-Uganda´s decision to embrace this mode of treatment and if the outcomes were unsatisfactory, MOH would then consider a policy revision in this regard. To assess the midterm treatment outcomes of children with ICTEV who had been enrolled for treatment at Mulago National Referral Hospital in the period of 2006-2009.Methodsin November/December 2013, a cross-sectional study was conducted to assess the treatment outcomes of 68 feet of 45 children using the designed questionnaire and the PBS score; a pilot study of 10 neonates was performed prior to research. A good treatment outcome meant having a foot or feet that did not require any major or minor surgery.Resultsforty-five (45) children with 68 ICTEV feet were evaluated; males 29 (64.4%) and 16 (35.6%) females with a mean age of 73.22 months (SD 11.364, range 48-96 months). Among the feet assessed, 46 (68%) had good to excellent outcomes while 22 (32%) had a relapse of moderate and severe deformity. Good functionality was seen in 61.8% out of which, 69% and 55.9% had no limitation in walking or running respectively.ConclusionPonseti treatment technique in children with ICTEV under the care of predominantly orthopaedic officers with some supervision from orthopaedic surgeons had fair to good midterm outcomes even in low resource settings like Uganda. Public health approach should be embraced in the management of clubfoot in Uganda by enhancing adequate comprehensive support supervision and establishment of reliable institutionalized systems for patient follow up which will lead to early detection and treatment of relapsed ICTEV cases or neglected clubfeet in the communities.

The Validity of Patient-reported Outcome Measurement Information System (PROMIS) Parent Proxy Instruments to Assess Function in Children With Talipes Equinovarus.

Idiopathic talipes equinovarus (ITEV) is a prevalent structural deformity of the foot and ankle in children. The disease-specific instrument (DSI) has commonly been used as an outcomes metric in these patients. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to examine the quality of life across various medical conditions. PROMIS has been validated for multiple conditions; however, no studies have evaluated the use of the PROMIS in children with ITEV. A prospective analysis was performed whereby the 2 questionnaires were mailed out to the parents of 91 patients, aged 5 to 17 years, with ITEV. Construct validity of the PROMIS Parent Proxy Profile short forms version was assessed by comparing its domains of Mobility, Fatigue, Pain Interference, and Pain Intensity to the DSI Function domain and PROMIS domains of Anxiety, Depressive Symptoms, Peer Relationships, and Pain Intensity to DSI Satisfaction domain. Thirty-one complete responses (34% response rate) were returned. The patients' current mean age was 8.8 years, 7 were female individuals, and 12 had unilateral ITEV. Bivariate correlation analysis, using Spearman correlation coefficients, demonstrated a moderate positive correlation between the DSI Function domain and the PROMIS Mobility domain (rs=0.52) and a moderate negative correlation between the DSI Function domain and the PROMIS Pain Interference domain (rs=-0.56), as well as the PROMIS Pain Intensity domain (rs=-0.75). A fair negative correlation (rs=-0.38) with PROMIS Fatigue domain was found. Correlations between the DSI Satisfaction domain and the PROMIS domains were fair or had little relationship. These results provide support for the validity of the PROMIS Mobility, Pain Interference, and Pain Intensity domains in this population, however there are no items in PROMIS that can assess overall satisfaction, as with the DSI. Level II-prospective comparative study.

Accelerated Ponseti method: First experiences in a more convenient technique for patients with severe idiopathic club feet

BackgroundCongenital Idiopathic Talipes Equinovarus (CTEV), or clubfoot, is a complex deformity that involves pathological anatomy in the foot with ankle equinus, hindfoot varus, midfoot cavus and forefoot adductus [1]. Universal agreement is established about Ponseti technique as the initial management for this deformity. This preliminary study aims to investigate the possibility of having a braceable foot through a proposed accelerated Ponseti method by which, manipulations, 5 castings and Achilles tendon tenotomy are implemented in a week. MethodsThis study included 11 patients with 16severe congenital idiopathic clubfeet treated by an accelerated Ponseti method. The method involves manipulation of the deformed foot, and 1st casting in one day, with the 2nd, 3rd, 4th, 5th castings in the 4th, 5th, 6th, 7th day post-manipulation. After the 4th cast removal, Achilles tenotomy was performed with subsequent three-week casting for all patients. Nonparametric tests were used for comparing the Pirani scores before starting the treatment and after removal of final cast. ResultsFive patients had bilateral club foot deformity. Average age at treatment was 54.8 days (range 8–150days). All patients, who had severe congenital idiopathic club feet with a Pirani score of 6, underwent the accelerated Ponseti technique. After removal of the three-week cast, the scores median was 0.59, (range 0–1.5), indicating a correction of the deformity and having braceable feet in all patients without experiencing any short-term complication. ConclusionsThe first step accelerated Pnoseti technique was found to be safe and effective for initial correction of severe idiopathic clubfoot deformity in children below three months of age , though it is an initial study that needs more studies with more follow up data.

Post-ponseti bracing compliance in Egyptian population during treatment of idiopathic talipes equinovarus

Background Several factors may play a role in influencing family acceptance of brace protocol after successful initial correction of talipes equinovarus by Ponseti method.Patients and methods A total of 40 children presented with relapsed sixty idiopathic talipes equinovarus were included. Their age ranged from 8 to 24 months, with a mean of 16 months. Twenty patients (40 clubfeet) (66.6%) were bilaterally affected, and 20 patients (20 club feet) (33.3%) were unilaterally affected. The patients comprised 25 (60%) boys and 15 (40%) girls. Pirani score was used to assess the relapse and severity. Several factors affecting bracing compliance in Egyptian population were studied and analyzed.Results The number of children per family, the ability of one parent alone to apply the brace, residence of parents, the baby’s compliance, bracing hour compliance, and parents get fed up early from using the brace had statistically significant relation with brace noncompliance.Conclusion Proper instructions, education, and encouragement to the parents in the proper use of the postcorrective brace are crucial factors for success of clubfoot treatment by Ponseti method.

OUTCOME OF PONSETI METHOD IN TREATING CONGENITAL IDIOPATHIC CLUBFOOT: FIVE YEARS’ EXPERIENCE AT A TERTIARY HOSPITAL

Objective: The earliest non-surgical treatment for the correction of congenital idiopathic talipes equinovarus (CTEV) deformity was described by Ignacio Ponseti. He suggested gentle manipulation and serial applications of casts followed by a period of bracing to maintain the correction. The main objective of this study was to evaluate the result of the Ponseti method with a subjective clinical scoring system using Pirani score, to compare the results with the published literature and to evaluate the effectiveness of foot abduction orthosis (FAO) or ankle-foot orthoses (AFO) in preventing relapse following correction.Methods: A cross-sectional study which was conducted at the Paediatric Orthopaedic Clinic, Universiti Kebangsaan Malaysia Medical Centre (UKMMC). A minimum of 12 months follow-up casting was observed before the patient was subjected to the subjective clinical scoring system. A total of 25 patients which included 5 right feet, 9 left feet, and 10 bilateral feet with idiopathic clubfeet were treated with Ponseti serial casting. Percutaneous Achilles tendon tenotomy was done for 28 feet (82.35%) to correct the equinus to achieve full correction.Results: Our results showed that the Ponseti method for treating CTEV was comparable to other published studies. Satisfactory and good results were observed in 97% of cases. A total of 41.18% underwent re-tenotomy of tendon Achilles due to recurrent and persistent equinus.Conclusion: The treatment of CTEV using Ponseti method will increase the successful correction. Meanwhile, the FAO gave better results for maintenance and prevention of recurrent deformity, compared to the AFO.

Idiopathic talipes equinovarus with preaxial polydactyly of the foot: a case report

The aim of this study is to report an unusual combination of congenital idiopathic talipes equinovarus with preaxial polydactyly of the foot. A newborn infant was brought to the polyclinic at the age of 1 week. In the right foot, preaxial polydactyly was seen in addition to the club foot deformity. The preaxial polydactyly of the patient was surgically excised. The sutures were then removed and a series of plaster casts were applied according to the Ponseti method Then a Dennis-Brown brace was applied with both feet. This case shows that combination of congenital idiopathic talipes equinovarus with preaxial polydactyly of the foot can be treated succesfully by apply the standard Ponseti method after the surgical excision of the polydactyly.

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

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

Treatment of the idiopathic and complex congenital talipes equinovarus with Ponseti method

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.

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

BackgroundWe reviewed a series of newborns, toddlers and ambulating children affected by idiopathic congenital talipes equinovarus (clubfoot). Taking into account the time of diagnosis, stiffness of the deformity and walking age, nonsurgical or surgical treatment was considered. This study reports clinical outcomes, early complications and relapse at mid-term follow-up.Materials and methodsFifty-two clubfeet were diagnosed at birth, 12 in non-ambulating children aged between 4 and 12 months and 24 in ambulating children. Feet were classified using the Pirani score. Newborns and toddlers were treated with serial casting (Ponseti); however, toddlers also underwent open Achilles tendon lengthening (2 feet) and posteromedial release (3 feet). In all ambulating children, surgical treatment was always performed: selective medial release combined with cuboid subtraction osteotomy (1 foot), posteromedial release (6 feet), and posteromedial release combined with cuboid subtraction osteotomy (17 feet).ResultsThe average follow-up was 5 years (1–6 years). In newborns treated with Ponseti, the results were excellent in 42 feet, good in 6, and poor in 4. In non-ambulating children, the results were excellent in 9 feet, and good in 3. In ambulating children, the results were excellent in 5 feet, good in 16, and poor in 3. No major complications were reported. No overcorrections were observed. The need for open surgery was higher in cases of delayed treatment. In cases of relapse, re-casting and/or more extensive surgery was considered.ConclusionsEarly treatment enables a high rate of good correction to be obtained with serial casting and limited surgery. Conversely, if the deformity is observed after walking age surgery should be considered. Serial casting in cases of late observation and relapse have demonstrated encouraging results.Level of evidenceIV.

Treatment of persistent forefoot adduction during ponseti method in treatment of idiopathic talipes equinovarus by minimal soft release

IntroductionAbductor hallucies tenotomy sometimes necessary in treatment of clubfoot. Material and methodsThirty children (45 feet) of one day old up to six months presented with idiopathic clubfoot. Patients were treated using the technique of Ponseti combined by abductor hallucies tenotomy after serial casting. ResultsAt a mean follow up period of 16.7 months, 43/45 feet were good (95%), 2/45 feet were bad (5%). The mean Pirani score at the final follow up was 1.05. ConclusionAbductor hallucies tenotomy shortens the duration of casts, decrease the cost and risk of leg atrophy.

Flexor digitorum accessorius longus muscle in resistant clubfoot patients: introduction of a new sign predicting its presence.

Clubfoot, talipes equino varus (TEV), is a common congenital foot anomaly. Some cases are resistant to conservative treatment. Many causes of resistance have been reported, among these, the presence of anomalous muscles; however, the effect of the presence of anomalous muscles on the outcome of conservative management is not well studied. These aberrant muscles are discovered during the extensive surgical release as an abnormal finding. The aim of this work is to study the demographic characteristics of patients with resistant TEV that necessitated extensive soft tissue release at Sudan Clubfoot Clinic and to document the prevalence of flexor digitorum accessorius longus (FDAL) muscle in a large series of clubfoot patients treated by extensive surgery: posteromedial release. Also, we introduce a new observation as an indication by which the surgeon can predict the presence of FDAL. On the basis of an observation that there is a special posture of the big toe in extension in relation to other flexed toes associated with the presence of FDAL, records of patients of clubfoot treated by extensive surgery between 2007 and 2012 at the Sudan Clubfoot Project were reviewed. Demographic characteristics were studied. Only patients with idiopathic TEV were included. Resistant clubfeet necessitated extensive release in 261 patients, 197 males and 64 females. Their ages ranged between 1 day and 15 years at presentation. FDAL muscle was found in 48 patients (54 feet) out of 261 patients (411 feet, 13.14%). In 46 of the 48 patients (95.8%), the presence of the FDAL could be predicted by a sign. FDAL is prevalent in 13% of resistant TEV cases requiring extensive soft tissue release, and the surgeon can expect resistant clubfoot and predict the presence of the FDAL in over 95% before he operates by observing the Samir-Adam sign.

Treatment of congenital idiopathic talipes equinovarus with the Ponseti method

Introduction Congenital idiopathic talipes equinovarus (clubfoot) is a complex deformity that can always be treated conservatively if the right technique is followed. The aim of treatment is to correct its five components so that the patient has a functional, pain-free, plantigrade foot, with good mobility and without calluses, and does not need to wear modified shoes. Aim of the work The aim of this study is to present the authors’ experience with the Ponseti technique in correcting clubfoot and to stress the importance of percutaneous tenotomy in management. Patients and methods We treated 21 feet in 15 patients with clubfoot deformity using the Ponseti technique in Aljedaani Hospital, Ibn Sina College for Medical Science, KSA, and El Hussein University Hospital, Alazhar University, Cairo, Egypt, between August 2006 and August 2009. The severity of the initial clubfoot deformity was classified according to the system of Dimeglio and colleagues. Age at the initiation of the treatment, severity of the initial deformity, total duration of the treatment, the details of tenotomy, Denis-Browne splint, and modified shoes were all studied in relation to the recurrence of the deformity. Results The mean number of casts that were applied to achieve correction was six (range 4–9 casts). Tenotomy was performed in 17 feet. In 19 feet, good results were achieved. Two patients developed recurrence of the deformity because of noncompliance of the parents on the use of orthoses. Conclusion The Ponseti method is a safe and effective treatment for congenital idiopathic clubfoot and markedly decreases the need for extensive corrective surgery. The percutaneous tenotomy of tendo-Achilles is an important step in the management. Noncompliance with orthotics has widely been reported to be the main factor leading to failure of the technique. The outcome has no relation with the severity of the deformity, but the younger the age, the less the number of casts needed. The total duration of the treatment is about 2 months and we found almost normal range of motion at the average 2-year follow-up. Parents of 13 patients (87%) found the final appearance of the foot acceptable.

Orthosis Noncompliance After the Ponseti Method for the Treatment of Idiopathic Clubfeet

Idiopathic talipes equinovarus is the most common congenital defect characterized by the presence of a congenital dysplasia of all musculoskeletal tissues distal to the knee. For many years, the treatment has been based on extensive surgery after manipulation and cast trial. Owing to poor surgical results, Ponseti developed a new treatment protocol consisting of manipulation with cast and an Achilles tenotomy. The new technique requires 4 years of orthotic management to guarantee good results. The most recent studies have emphasized how difficult it is to comply with the orthotic posttreatment protocol. Poor compliance has been attributed to parent's low educational and low income level. The purpose of the study is to evaluate if poor compliance is due to the complexity of the orthotic use or if it is related to family education, cultural, or income factors. Fifty-three patients with 73 idiopathic talipes equinovarus feet were treated with the Ponseti technique and followed for 48 months after completing the cast treatment. There was a male predominance (72%). The mean age at presentation was 1 month (range: 1 wk to 7 mo). Twenty patients (38%) had bilateral involvement, 17 patients (32%) had right side affected, and 16 patients (30%) had the left side involved. The mean time of manipulation and casting treatment was 6 weeks (range: 4 to 10 wk). Thirty-eight patients (72%) required Achilles tenotomy as stipulated by the protocol. Recurrence was considered if there was a deterioration of the Dimeglio severity score requiring remanipulation and casting. Twenty-four out of 73 feet treated by our service showed the evidence of recurrence (33%). Sex, age at presentation, cast treatment duration, unilateral or bilateral, severity score, the necessity of Achilles tenotomy, family educational, or income level did not reveal any significant correlation with the recurrence risk. Noncompliance with the orthotic use showed a significant correlation with the recurrence rate. The noncompliance rate did not show any correlation with the patient demographic data or parent's education level, insurance, or cultural factors as proposed previously. The use of the brace is extremely relevant with the Ponseti technique outcome (recurrence) in the treatment of idiopathic talipes equinovarus. Noncompliance is not related to family education, cultural, or income level. The Ponseti postcasting orthotic protocol needs to be reevaluated to a less demanding option to improve outcome and brace compliance.