The goal of treatment for pediatric idiopathic clubfoot is to enable the patient to comfortably walk on his or her soles without pain. However, currently accepted treatment protocols are not always successful. Based on the abnormal bone alignment reported in this disease, some studies have noted a correlation between radiographic characteristics and outcome, but this correlation remains debated.

To assess the correlation between immediately postoperative radiographic parameters and functional outcomes and to identify which best predicts functional outcome.

To predict the outcome and prevent early failure of the Ponseti's method, we used a simple radiographic method to predict outcome. Our study included newborns with idiopathic clubfoot treated with Ponseti's protocol from November 2018 to August 2022. After Achilles tenotomy and a long leg cast were applied, the surgeon obtained a single lateral radiograph. Radiographic parameters included the tibiocalcaneal angle (TiCal), talocalcaneal angle (TaCal), talofirst metatarsal angle (Ta1st) and tibiotalar angle (TiTa). During the follow-up period, the Dimeglio score and functional score were examined 1 year after surgery. Additionally, recurring events were reported. The correlation between functional score and radiographic characteristics was analyzed using sample and multiple logistic regression, and the optimal predictor was also identified.

In total, 54 feet received approximately 8 manipulations of casting and Achilles tenotomy at a mean age of 149 days. The average TiCal, TaCal, Ta1st, and TiTa angles were 75.24, 28.96, 7.61, and 107.31 degrees, respectively. After 12 mo of follow up, we found 66% excellent-to-good and 33.3% fair-to-poor functional outcomes. The Dimeglio score significantly worsened in the poor outcome group (P value < 0.001). Tical and TaCal showed significant differences between each functional outcome (P value < 0.05), and the TiCal strongly correlated with outcome, with a smaller angle indicating a better outcome, each 1 degree decrease improved the functional outcome by 10 percent. The diagnostic test revealed that a TiCal angle of 70 degrees predicts an inferior functional outcome.

The TiCal, derived from lateral radiographs immediately after Achilles tenotomy, can predict functional outcome at 1 year postoperatively, justifying its use for screening patients who need very close follow-up.

Clinical examination of the newborn's foot is a complex exercise that requires a lot of sensitivity, practice and deep understanding of normal and pathological anatomy, and the clinical assessment of a child with congenital talipes equinovarus, or congenital clubfoot, must be complete and it should not be limited to a simple orthopedic evaluation of the foot; the search for a cause is a pressing concern. This narrative review article aims to provide the key information about clinical examination of children with congenital clubfoot; classification systems are also described. Clinical examination of children with congenital clubfoot is essential. In particular, it is important to evaluate the mental age of the child (developmental milestones), to rule out the presence of a spinal dysraphism, to eliminate a mild form of neurological disease (congenital myopathy or arthrogryposis), as well as to carefully examine the face and hands of the patient. The examination of the foot and the classification of the clubfoot deformity complete the clinical evaluation. In the end, the pediatric orthopedic surgeon must not underestimate any clinical signs, and must act as a pediatrician. This narrative review summarizes the key points in taking a history and performing a comprehensive clinical examination for patients with congenital clubfoot; the review also briefly describes the normal foot anatomy and growth as to give the reader the opportunity to better understand the morphological and functional modifications secondary to congenital clubfoot.

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

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

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

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

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

Club foot (CF) is characterized by multiple deformities such as varus, adductus and internal rotation of the forefoot. It is well-known and a frequent congenital disorder. CF can concurrently be seen with several diseases but it can rarely manifest as a component of any other syndrome. Ritscher-Schinzel syndrome, or cranio-cerebello-cardiac syndrome, is rarely seen and has autosomal recessive inheritance. It is characterized by cranio-facial, cerebellar and cardiac abnormalities. We report a case diagnosed as Ritscher-Schinzel syndrome concurrent with persistent CF.

A two-year-old boy with persistent CF and concurrent congenital hip dysplasia. Despite successful serial casting and subsequent achilloplasty a clinical relapse was observed in our patient. After a detailed phenotypic evaluation, genetical tests and imaging technique the patient was diagnosed 3C Ritscher-Schinzel syndrome.

A comprehensive literature review did not show any reports about concurrent hip dysplasia and clubfoot in Ritscher-Schinzel syndrome. We report that CF may be associated with rare genetical abnormalities.

With this report we would like to raise awareness about the possible association of persistent CF with this rare genetical disorder, Ritscher-Schinzel syndrome. It should be included in differential diagnosis of patients with persistent CF.

Percutaneous techniques for the correction of foot deformities are gaining popularity in the adult population, but remain poorly explored in children. Of the several surgical techniques described to treat persistent severe metatarsus adductus (MA) deformity in children, neither was percutaneous. The purpose of the study was to describe a percutaneous technique for MA correction in children, to report the outcomes, and to discuss the advantages it offers.

We designed a prospective study on 34 consecutive feet with MA deformity from 26 children undergoing percutaneous correction. All operated feet had severe, rigid MA deformities, most of which were components of residual/recurrent clubfoot deformities. The mean age at surgery was 5.7 years and the mean follow-up was 55.2 months. For clinical evaluation, we used the bisector method; the first cuneometatarsal angle and metatarsal-metaphyseal angle measured in weight-bearing radiographs and AOFASf score were determined preoperatively and postoperatively. In unilateral cases, we used the contralateral foot measurements as control. The operating time and the hospitalization time were also recorded. The surgical technique consisted of performing the Cahuzac procedure for MA correction with a percutaneous approach.

At the final follow-up all feet presented a normal heel bisector line. Radiologic parameters were normalized when compared with control feet. The mean surgical and hospitalization time was 14 minutes and 6 hours, respectively. Mean AOFAS score improved from 78 to 98.

A minimally invasive percutaneous technique allowed a successful correction of MA deformity in children and resulted in a substantive decrease in both surgical and hospitalization time and better cosmetic results.

Level II.

Treatment of the neglected and the relapsed clubfoot is one of the most controversial topics in pediatric foot care. This article reviews the breadth of treatment options for practicing podiatrists or orthopedists with a specialty in complex clubfoot treatment. Discussion includes the appropriate circumstances for the use of the different procedures presented and the author's preferred treatment algorithm, based on 15 years of treating neglected, relapsed, and nonidiopathic clubfeet.

Neglected or inadequately treated rigid congenitally deformed feet in older children are a nightmarish challenge for the child, the parents, and the orthopaedic surgeon. Because of the multiplicity of spatial deformities exhibited by these feet and legs, it was hypothesized that correction using the Taylor spatial frame (TSF) would decrease morbidity, facilitate correction, and minimize treatment time in children from remote regions with extremely rigid deformed feet.

Recent experience with the management of 11 such feet (Dimeglio type IV) in 9 children with an average age of 9.2 years using the TSF has been gratifying. Six children had associated leg length discrepancy, which was corrected by concomitant tibial lengthening. All feet underwent soft tissue releases, whereas forefoot and/or hindfoot osteotomies were performed in 7 feet.

All children attained plantigrade, functional feet, and were fully ambulatory and capable of wearing normal footwear. Complications were minor consisting of pin tract infections, residual metatarsus varus in 3, and wound dehiscence in 1. There were no neurovascular events. This was attributed to the slower 3 plane correction using the TSF technique as well as the elimination of the need for plaster immobilization thus allowing direct monitoring of the foot and limb.

The rigid foot deformity in the older child can be safely and effectively corrected with the aid of the TSF, which facilitates a 3 plane correction and concomitant limb lengthening.

To evaluate neonates and infants with clubfoot, clinical and imaging modalities are required. Conventional radiography is of limited value because the studied bones are not fully ossified.

We attempted to (1) evaluate clinically and sonographically the reliability of the Ponseti method in correcting clubfeet; and (2) determine whether various ultrasound (US) variables correlated with each other and with the Pirani score before and after treatment.

We prospectively followed 17 infants (25 clubfeet) assessed using the Pirani score and US variables (medial malleolus navicular distance, navicular alignment in relation to the talar head, medial soft tissue thickness, talar length, and calcaneocuboid distance) and treated with the Ponseti method. The mean age of the patients at first casting was 30 days, and repeat assessment after treatment was performed at a mean age of 6.3 months. Patients were followed for a minimum of 0.75 months (mean, 14.1 months; range, 0.75-38 months).

The Ponseti method corrected all feet. We found three clinical/US correlations. Before treatment, we observed a negative correlation between the clinical midfoot score and the sonographic medial malleolus navicular distance. After treatment we observed two negative correlations: one between the midfoot score and the sonographic talar length and the other between the hindfoot score and medial malleolus navicular distance. Four feet had recurrence of varus, two of which had an increased calcaneocuboid distance despite full restoration of navicular alignment in one foot.

US can play a role in clubfoot assessment and may alert the surgeon to feet that may be prone to recurrence.

Level II, prospective study. See Guidelines for Authors for a complete description of levels of evidence.

Adduction of the forefoot is the most common residual deformity in idiopathic clubfoot. The 'bean-shaped foot', which is a term used to describe a clinical deformity of forefoot adduction and midfoot supination, is not uncommonly seen in resistant clubfoot.

Fifteen children (20 feet) with residual forefoot adduction in idiopathic clubfeet aged 3-7 years were analyzed clinically and radiographically. All of the cases were treated by double column osteotomy (closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy) with soft tissue releases (plantar fasciotomy and abductor hallucis release), to correct adduction, supination and cavus deformities. Pre-operative measurements of certain foot angles were compared with their corresponding postoperative values.

A grading system for evaluation of the results using a point scoring system was suggested to evaluate accurately both clinical and radiographic results after a follow-up period of an average of 2.3 years. Eight feet (40%) had excellent, eight (40%) good, three (15%) fair, and one (5%) poor outcome. There was no major complication. There was significant improvement in the result (P > 0.04).

Double column osteotomy can be considered superior to other types of bone surgeries in correction of residual adduction, cavus and rotational deformities in idiopathic clubfoot.

There are limited studies about the incidence, nature, and severity of symptoms in adults with treated clubfoot; the rate at which symptoms increase and function diminishes with advancing age; and the appropriate treatments. One of the principles of treatment of these patients includes recognition that no one description of deformities applies to all cases of painful deformity in adults after childhood treatment of congenital clubfoot. There is a spectrum of the types of deformity and a range of severity among these that must be taken into account in the decision making regarding treatment. Although the level of symptoms is very variable and ankle and hindfoot arthrodeses have the disadvantage of increasing mechanical stress and subsequent arthritis in the midfoot, arthrodesis and, to a lesser degree, osteotomy remain the mainstays of surgical reconstruction in the adult with painful deformity after treatment of congenital talipes equinovarus.

Neglected idiopathic clubfoot deformities, and severe recurrent deformity after previous surgery presents technical difficulties for correction and challenges for surgeons to achieve primary skin closure.

Between 2000 and 2006, 18 children (30 feet), had complete subtalar release (CSTR) for failed previous surgery in 28 feet and severe neglected congenital talipes equinovarus (CTEV) in 2 feet followed by cross leg fasciocutaneous flaps for reconstruction of residual defect at the ankle and foot after full correction of the deformity. Mean patients followed up were 4.5 years (average 2-8 years). 23 feet were classified as Dimeglio III and 7 feet as Dimeglio IV.

All cases achieved a plantigrade foot, better walking ability (p<0.03), and parental satisfaction with the result (p<0.001). Ankle joint doriflexion increased from mean (-21.33 degrees ) preoperatively to (12.5 degrees ) postoperatively. All cases showed postoperative improvement in their radiographic findings. The mean preoperative talocalcaneal angle increased from (15.7 degrees to 30.03 degrees ). The talo-first metararsal angle improved from a preoperative mean of -16 degrees mean of 5.53 degrees postoperatively. At the final follow-up cosmetically acceptable plantigrade foot was achieved in all feet. Four legs (14.28%) developed hypertrophic scars at the donar flap site. One patient developed 1.5cm marginal necrosis of the flap, which did heal after debridement by secondary intention. None of the feet had recurrence at the final follow up. Despite the enormous improvement clinically and radiologically, their was no statistical significant difference between preoperative and postoperative radiological angles (p<0.069). The number of previous surgical interventions had no influence on the outcome. All the previously treated feet had inadequate release of important tethered soft tissue.

This is indicative of the enormous value of complete subtalar release combined with cross leg fasciocutaneous flap without the need for bony intervention in previously operated failed feet or neglected deformities.

A total of 38 relapsed congenital clubfeet (16 stiff, 22 partially correctable) underwent revision of soft-tissue surgery, with or without a bony procedure, and transfer of the tendon of tibialis anterior at a mean age of 4.8 years (2.0 to 10.1). The tendon was transferred to the third cuneiform in five cases, to the base of the third metatarsal in ten and to the base of the fourth in 23. The patients were reviewed at a mean follow-up of 24.8 years (10.8 to 35.6). A total of 11 feet were regarded as failures (one a tendon failure, five with a subtalar fusion due to over-correction, and five with a triple arthrodesis due to under-correction or relapse). In the remaining feet the clinical outcome was excellent or good in 20 and fair or poor in seven. The mean Laaveg-Ponseti score was 81.6 of 100 points (52 to 92). Stiffness was mild in four feet and moderate or severe in 23. Comparison between the post-operative and follow-up radiographs showed statistically significant variations of the talo-first metatarsal angle towards abduction. Variations of the talocalcaneal angles and of the overlap ratio were not significant. Extensive surgery for relapsed clubfoot has a high rate of poor long-term results. The addition of transfer of the tendon of tibialis anterior can restore balance and may provide some improvement of forefoot adduction. However, it has a considerable complication rate, including failure of transfer, over-correction, and weakening of dorsiflexion. The procedure should be reserved for those limited cases in which muscle imbalance is a causative or contributing factor.

There are many possible pitfalls of clubfoot releases and it is important to recognize the problems and provide proper timely treatment. Late residual deformity following clubfoot releases include: dynamic or stiff supination and forefoot adduction deformities, intoeing gait, overcorrection, rotatory dorsal subluxation of the navicular, vascular insult to the talus with collapse, and dorsal bunion. We reviewed 134 clubfeet in 95 children who had primary clubfoot releases between 1988 and 1991. In general, the patients who underwent surgery before 6 months of age had poorer results compared with older children. Twenty-one feet (15.7%) underwent additional procedures. The most common additional procedure was split anterior tibial tendon transfer. Not all patients with residual deformities underwent additional procedures. In treating recurrent and residual deformity following a clubfoot surgery, it is most important to keep function in mind. From this series of patients treated with comprehensive clubfoot release, we have identified the most common residual deformities encountered after the initial release and effective surgical treatment when necessary.

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

Recurrent dynamic and structural deformities following clubfoot surgery are commonly due to residual muscle imbalance from a strong tibialis anterior muscle and weak antagonists. We asked whether subcutaneous tibialis anterior tendon transfer effectively treated recurrent deformities following clubfoot surgery and whether the presence of structural deformities influenced the outcome. The patients were divided into two groups: Group I, dynamic supination deformity only (51 patients, 76 feet); and Group II, dynamic supination with other structural deformities (44 patients, 61 feet). The mean age at surgery was 4.3 years (range, 1.4-10.7 years); the minimum followup was 2 years (mean, 5.2 years; range, 2-12.5 years) for both groups. The results were graded according to our subjective rating system of restoration of muscle balance: good, restoration of muscle balance; fair, partial restoration of muscle balance; and poor, no improvement. The two groups had similar outcomes: in Group I, there were 65 good (87%), 11 fair (13%), and no poor results and in Group II, there were 54 good (88%), seven fair (12%), and no poor results. Our data suggest the tibialis anterior tendon transfer restores muscle balance in recurrent clubfeet; we observed no recurrences. This transfer improves function and may prevent secondary osseous changes. We believe the muscle imbalance supports, at least in part, the neuromuscular etiological aspects of congenital clubfeet.

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

Relapse rates of surgically treated clubfeet are about 25%. We reviewed 43 patients (57 feet) treated for relapsed clubfoot deformity between 1992 and 2001 in our department. The average age of the patients at the time of revision surgery was 5.1 years, the mean follow-up was 6.6 years. Surgical therapy was performed using an algorithm according to age groups. The mean Atar score at follow-up was 77 points, representing a good outcome. Out of 57 feet, 20 (35%) were rated excellent, 24 (42%) good, 5 (9%) fair, and 8 (14%) poor. The number of previous surgical interventions had no influence on the outcome. Using an age related surgical algorithm, good postoperative results could be achieved in most of our patients, thus improving their functional situation. This emphasises the usefulness of the proposed algorithm in the difficult situation of recurrent clubfoot, while thorough analysis of the underlying deformity remains essential.

Clubfoot occurs in approximately 1 of every 1000 live births, with multiple theories proposed regarding the cause. The pathologic anatomy of the adult clubfoot consists of four components (cavus, adductus, varus, and equinus) and the specific soft tissue and bony procedures indicated for correction depend completely on the constellation of residual deformity that may exist. If the patient was successfully treated at a younger age and has only limited deformity, all that may be required is symptomatic treatment or bracing. Flexible deformities may be treated with a combination of soft tissue procedures and osteotomies or limited fusions, which will not compromise the essential joints of the ankle, subtalar, and talonavicular joints. More rigid deformities require fusions with their associated functional loss, in an attempt to obtain a plantigrade foot.

Extreme overcorrection and avascular necrosis are recognized complications in clubfoot surgery and are thought to be the result of division of the talocalcaneal interosseous ligament (TCIL). This is a preliminary report of a prospective study of the cases of 46 patients with 66 idiopathic clubfeet treated by means of soft tissue release using a posteromedial approach at a mean age of 9 months. The deformity was very severe in 51 feet and severe in 15. The feet were divided into 2 equal groups (33 feet each). In group A feet, the TCIL was released, whereas in group B, the ligament was left intact. At a mean follow-up period of 28 months, the result was satisfactory (excellent and good) in 96.9% of feet in group A and in 87.9% of feet in group B. When the mean overall clinical and radiological score was investigated, group A graded excellent whereas group B graded good. In feet with satisfactory outcome, group A showed statistically significant improvement of the anteroposterior and lateral talocalcaneal angles, talocalcaneal index, and lateral calcaneus-first metatarsal angles when compared with group B. This was reflected clinically on better hind foot correction with the release of the TCIL, with no evidence of significant overcorrection. Magnetic resonance imaging of the ankle and foot confirmed no evidence of talar avascular necrosis or extreme overcorrection in 40 feet (60.1%), 20 in each group. We conclude that it is advisable to release the TCIL in severe and very severe clubfeet.

We describe a 17-year follow-up of 44 surgically corrected clubfeet. They were classified preoperatively as mild, moderate or severe and grouped into those operated on before or after 3 months of age. Moderate and severe deformities underwent a posteromedial release after a trial of conservative management. The mean Ponseti score for both groups was 83.9 (good). Severely deformed feet achieved a more favourable result when operated upon before 3 months than those operated later. We conclude that early application of surgery yields better results with severely deformed feet and produces a good functional outcome in the majority of feet.

To describe a derotation calcaneal osteotomy technique and assess its efficacy in the correction of relapsed clubfoot. Twenty-one osteotomies were performed in 20 children with recurrent clubfoot. Nineteen children had been previously treated operatively. The derotation osteotomy was the first procedure performed in one case. The procedure combined medial and plantar releases, followed by a curvilinear osteotomy of the calcaneus. Patients were evaluated clinically and with standing dorsoplantar and lateral radiographs preoperatively, postoperatively and at follow-up. The talocalcaneal angle was considered as the most important criteria to evaluate the deformity correction. The clubfoot was idiopathic in 16 cases and neurological in five cases. Mean age at surgery was 7 years old (range 3.4-12 years). Total number of procedures per foot averaged 2.4 (range 4-1). The mean postoperative follow-up period was 2.8 years (range 2-6 years). The talocalcaneal angle increased significantly after the procedure (P<0.001), and no significant loss of correction was seen at latest follow-up (P=0.17). Two scarring complications occurred. Only one foot underwent further surgery after the calcaneal osteotomy for residual forefoot adduction, associated to a cavus and severe fibrosis. The calcaneal curvilinear osteotomy, in which the calcaneoforefoot unit derotation is performed around the talus but within the calcaneus, is a safe and efficient technique that can be proposed for clubfoot revision surgery.

X-ray is important in the assessment of clubfoot. Stress radiographs give more information than routine radiographs. Because of the inaccuracy of the positioning and the disadvantages of radiation, paediatric orthopaedic surgeons do not like and do not use X-ray examination. In this study we report a technique we use to obtain stress radiographs in paediatric patients with clubfoot using a custom-made radiolucent modular splint. This technique provides better assessment of the initial status and the result of treatment. Although this method has limitations it can help to compare different feet and treatment results with regard to axis and angle. We validated this splint by means of a prospective study in 11 patients with 21 feet having type 2 clubfoot who underwent (PMSTR) in our centre. Two sets of radiographs were taken, one with manual positioning and one with our splint. We found significant differences in the values of midfoot and forefoot radiological parameters between the two sets. We found that the correlation between the clinical and radiological assessment of residual deformity improved significantly for these values when a splint was used to obtain stress views. Hence we recommend routine use of a radiolucent splint for taking stress views to assess residual deformity in clubfoot.

The Ponseti method has become the gold standard for the treatment of clubfoot. It is very safe, efficient, economical, and easy to teach, and it radically decreases the need for extensive corrective surgeries. Awareness of the excellent results provided by the Ponseti method is essential for counseling and providing treatment advice to the families of children born with this deformity.

The purpose of this study was to sonographically compare the early anatomical outcome of a group of clubfeet treated with the Ponseti method (group A, nine clubfeet) with a group treated with an adjustable plexidur splint, the Copenhagen method (group B, 19 feet). The clinical severity was assessed using the Diméglio-Bensahel classification. The need for complementary surgery was clinically assessed at the age of about 2 months. Ultrasound investigation was made in the neonatal period, after 2-3 months of non-surgical treatment and 1-2 months post-surgically. After 2 months of non-surgical treatment the correction obtained at the talo-navicular joint, expressed as the distance between the medial malleolus and the navicular (MM-N distance), was significantly greater in group A. After surgery, tenotomy of the Achilles tendon for all group A feet, and posterior or posteriomedial release for 13 feet in group B, the correction at the talo-navicular and calcaneo-cuboid joints was similar for the two groups. Anatomical correction of the displacement in these joints can be achieved without extensive interventional procedures. Ultrasound may be a valuable tool to assess the effects of different treatment protocols quantitatively.

The purpose of this study was to evaluate the efficacy of the Ponseti method in reducing extensive corrective surgery rates for congenital idiopathic clubfoot.

Consecutive case series were conducted from January 1991 through December 2001. A total of 157 patients (256 clubfeet) were evaluated. All patients were treated by serial manipulation and casting as described by Ponseti. Main outcome measures included initial correction of the deformity, extensive corrective surgery rate, and relapses.

Clubfoot correction was obtained in all but 3 patients (98%). Ninety percent of patients required </=5 casts for correction. Average time for full correction of the deformity was 20 days (range: 14-24 days). Only 4 (2.5%) patients required extensive corrective surgery. There were 17 (11%) relapses. Relapses were unrelated to age at presentation, previous unsuccessful treatment, or severity of the deformity (as measured by the number of Ponseti casts needed for correction). Relapses were related to noncompliance with the foot-abduction brace. Four patients (2.5%) underwent an anterior tibial tendon transfer to prevent further relapses.

The Ponseti method is a safe and effective treatment for congenital idiopathic clubfoot and radically decreases the need for extensive corrective surgery. This technique can be used in children up to 2 years of age even after previous unsuccessful nonsurgical treatment.

To assess the effect of internal foot progression angle (inturning) on knee dynamics in children with treated clubfeet.

Prospective study dividing a population of clubfeet according to the factor inturning.

Excessive internal or external foot progression angle increases knee flexion by a backward shift of the ground reaction force to the knee joint in children with cerebral palsy. Similarly, inturning in clubfeet was hypothesized to shift the ground reaction force backwards with reference to the knee joint, increasing the external knee flexion moment and the maximal knee flexion at stance.

Three-dimensional gait analysis was performed on 20 children with surgically treated clubfeet (n=28) to assess alterations of knee dynamics related to inturning (>7 degrees ) and on 13 normal children.

Inturning occurred in 46% of the clubfeet and was associated during stance, at maximal knee flexion, to an increase in maximal knee flexion (+7 degrees ), external knee flexion moment (+60%) and related lever arm to the knee (+100%) and at minimal knee flexion, to a reduction in external knee extension moment (-62%) and related lever arm (-58%). Inturning was associated with a more frequent prolongation of internal knee extension moment and of rectus femoris activity exceeding 50% of stance.

Inturning in clubfeet is associated with knee dynamics alteration, which might contribute to the long-term development of knee osteoarthritis.

The therapeutic correction of inturning in clubfeet would be of importance if the consecutive knee dynamics alteration is shown by further studies to contribute to long-term degenerative knee pathology.

The etiology of idiopathic congenital talipes equinovarus is unknown, and there is no consensus as to the best treatment. Increasingly, ultrasound is being used to diagnose the condition prenatally, but the diagnosis remains clinical postnatally. Radiographs can help confirm the diagnosis and ascertain the severity of the condition. There are many classification schemes, but none offers adequate prognostic value. The mainstay of treatment is manipulation and casting, usually followed by soft-tissue release. However, some patients have been successfully treated with intensive physiotherapy instead of surgery.

Gait analysis and pedobarography were done on 58 surgically corrected clubfeet in 40 children. The average age of patients at the time of surgery was 6.7 months. The average age of the children at the time of the gait analysis was 6.1 years. Twenty-two children (32 feet) were 5 years old and younger. Eighteen children (26 feet) were older than 5 years old. Cadence, velocity, duration of single-limb stance, step length, and ground reaction force measurements were not significantly different from normal children. Differences noted in clubfeet were: 1) duration of single-limb stance among bilateral clubfeet did not increase with age; 2) increased ankle plantarflexion between opposite foot-strike and toe-off was not present; 3) the feet were internally rotated throughout (toe-in gait); 4) anterior and lateral ground reaction force measurements revealed differing trends with age; and 5) mid- and forefoot pressures increased in the surgically treated group. Gait analysis and pedobarography could detect more subtle abnormalities in corrected clubfeet and provide more objective assessments of persistent deformities.

Surgical treatment for clubfoot has been largely directed at finding the best one-stage operation for the resistant clubfoot. Eighteen patients with 27 clubfeet (average follow-up 11 years since first surgery; range, 3.5-24 years) were reviewed. More than one clubfoot operation was required in 56% of cases. Forty-six percent were corrected after one surgery; 33% required a second surgery and 14% required a third operation. One patient with particularly severe feet required a fourth operation on each foot. The mean age at the time of surgery was 1.26 years, 5.12 years, and 8 years for the first, second, and third operations, respectively. The first operation consisted of a soft-tissue release. The second and third operations consisted of more extensive soft-tissue release and various rearfoot and forefoot procedures. Radiographic values revealed an AP talocalcaneal angle of 18 degrees, AP talo-first metatarsal angle of 6 degrees, lateral talocalcaneal angle of 29.6 degrees, lateral talo-first metatarsal angle of 15 degrees, and calcaneo-first metatarsal angle of 143 degrees. At follow-up all patients had adequate function as determined by personal interview and clinical examination. We conclude that correction of resistant congenital clubfoot often requires more than one surgery, not because of a "failed first operation," but due to dynamic muscle imbalances that may not be fully recognized in infancy and early childhood. Thus, the need for a second operation should not be perceived as a failure of the first, but as part of the natural history of congenital clubfoot.