• clubfoot
• congenital talipes equinovarus
• foot deformity
• pediatric orthopedics
• ponsti casting

• CTEV
• Clubfoot
• Developing countries
• Ponseti
• Resistant clubfoot

• Ponseti
• clubfoot
• delayed presentation
• immature
• neglected
• older child
• treatment
• walking age

• Humans
• Child
• Infant
• Adolescent
• Clubfoot/surgery
• Cross-Sectional Studies
• Casts, Surgical
• Foot/surgery
• Orthopedic Procedures
• Treatment Outcome

• Above-knee
• Below-knee
• Cast
• Clubfoot
• Cohort study
• Deformity
• Ponseti
• Walking

• Achilles Tendon/surgery
• Adolescent
• Casts, Surgical
• Child
• Child, Preschool
• Clubfoot/surgery
• Humans
• Infant
• Tenotomy
• Treatment Outcome

Introduction

Neglected clubfoot comprises clubfoot deformities with late presentation and weight-bearing on the affected foot. These deformities are stiff and need an aggressive approach for cast-based management. The modified versions of the Ponseti technique have been found effective in treating these deformities. However, these techniques’ long-term outcomes in neglected clubfoot and related correction maintenance with time progression have not been investigated. The current study aims to analyze the changes in deformity correction after a minimum of two years of follow-up in neglected clubfeet treated with a modified Ponseti method of corrective casting.

Methods

We retrospectively analyzed the clinical records of 25 patients with 38 neglected clubfeet with a mean follow-up of 37.9±4.1 months after the initial correction of the deformity. These patients were managed with a modified Ponseti technique. The modified technique incorporated simultaneous deformity manipulation before equinus correction and additional dorsiflexion manipulation after two weeks of tendo-achilles tenotomy. The Pirani and Dimeglio scores and individual deformity corrections at the final follow-up were compared with those at final cast removal.

Results

No significant differences were observed between the initial and the final follow-up Pirani and Dimeglio scores. Concerning the deformity correction parameters, there was a significant loss in heel varus and foot abduction correction. However, the change in these parameters was small (less than 3 degrees).

Conclusion

The neglected clubfoot deformity can be satisfactorily corrected with an aggressive Ponseti based corrective manipulation and casting at a low relapse rate. However, minor loss of deformity correction is noticed after two years of treatment which is not reflected in clinical scores. Therefore, a strict long-term follow-up and careful deformity assessment are required to predict the recurrence in these cases.

• clubfoot
• deformity
• delayed presentation
• neglected
• ponseti method

The Ponseti Method is recognized as the best treatment for congenital idiopathic clubfoot in newborns and its principles became also adopted for treating older children with neglected deformity. This review aims to evaluate the role and effectiveness of serial casting in the treatment of neglected clubfoot, worldwide. Clubfoot is a complex tridimensional congenital foot deformity that can be easily treated after birth by correct manipulation of the foot and serial casting, with a great majority of cases requiring a percutaneous Achilles tenotomy, which can be organized as an ambulatory day procedure, without need for general anesthesia. However, in many low-income countries, treatment is not readily available, and many children grow up with disabling foot deformities. When compared to a newborn’s clubfoot, a neglected clubfoot is different and more challenging to treat, as bones become ossified while malaligned and exposed to abnormal forces. Application of the Ponseti method in children with untreated idiopathic clubfoot older than walking age leads to satisfactory outcomes, has a low cost, and avoids surgical procedures likely to cause complications. The upper age limit for the use of Ponseti Method in clubfoot treatment is yet to be established. Success of clubfoot treatment is mostly defined as a pain-free, aesthetically acceptable plantigrade foot, with no need for extensive surgical tissue release after casting and tenotomy. The results of the Ponseti method for the treatment of clubfoot in children after the walking age are encouraging, with more than 80% of success in achieving initial correction and 18–62.5% of relapses. If Ponseti casting is not successful, any further interventions should be carefully selected and planned, in order to maintain the length of the foot and avoid intracapsular scarring or bony fusions.

• Neglected clubfoot
• Ponseti
• serial casting
• walking age

Idiopathic clubfoot affects approximately 1/1000 alive-born infants, of whom 80–91% are born in low- or middle-income countries (LMICs). This retrospective study aimed to evaluate the morphological, functional, and social outcomes in patients with neglected clubfoot in rural Bangladesh, after receiving surgical treatment.

Patients received a posteromedial release (PMR) with or without an additional soft tissue intervention (group 1), a PMR with an additional bony intervention (group 2), or a triple arthrodesis (group 3) according to our surgical algorithm. Patients were followed until two year post-intervention. Evaluation was done using a modified International Clubfoot Study Group Outcome evaluation score and the Laaveg-Ponseti score.

Twenty-two patients with 32 neglected clubfeet (ages 2–24 years) received surgical treatment. Nineteen patients with 29 clubfeet attended follow-up. At two year follow-up an excellent, good, or fair Laaveg-Ponseti score was obtained in 81% (group 1), 80% (group 2), and 0% (group 3) of the patients (p value 0.0038). Age at intervention is inversely correlated with the Laaveg-Ponseti score at two year follow-up (p < 0.0001). All patients attended school or work and were able to wear normal shoes.

Our treatment algorithm is in line with other surgical algorithms used in LMICs. Our data reconfirms that excellent results can be obtained with a PMR regardless of age. Our algorithm follows a pragmatic approach that takes into account the reality on the ground in many LMICs. Good functional outcomes can be achieved with PMR for neglected clubfoot. Further research is needed to investigate the possible role of triple arthrodesis.

The online version contains supplementary material available at 10.1007/s00264-021-05058-6.

• Clubfoot
• Developing country
• Surgery

The Ponseti method has been universally adopted for the treatment of children’s neglected clubfoot, but not for adult patients. In low- and middle-income countries, there are adult patients with neglected CTEV that remains untreated because the patients have limited access to specialized treatment.

The Ponseti method was applied in a 26-year-old adult female patient with neglected clubfoot with no previous treatment. The feet had functional mobility and no residual deformities at the end of follow-upperiod. An abduction foot orthosis was prescribed for 1 year after casting period. The patient returned to normal activities after an8-month follow-up period.

This unique therapeutic success in an adult patient with neglected idiopathic bilateral clubfoot showed that the Ponseti method was a good treatment option.

• Adult
• Neglected clubfoot
• Ponseti method
• Treatment outcome

Purpose

Deformation of talus in idiopathic clubfoot is a common problem both surgically and after treatment with the Ponseti technique, although the cause of deformation and its clinical impact on the function of the ankle is not yet known. The goal of this research was to evaluate factors leading to talar dome deformation (flat-top talus) after the Ponseti technique

Methods

This was a single-center, cross-sectional study. Fifty patients with virgin idiopathic clubfoot were enrolled from our consecutive series of data from August 2017 to January 2018 from our clubfoot patients who completed their casting and bracing protocol. Weight-bearing lateral X-rays of the ankle were examined in patients to determine the flattening of the talus dome and its correlation with age, sex, BMI, number of casts, and casting period. In these patients, the frequency of tenotomy and its relationship to the flat top talus was also examined.

Results

The study included a total of 50 children, of which 36 (72%) were boys and 14 (28%) were girls. The mean age, height, weight, and BMI of the children were 5.06 ± 0.79 years, 101.6 ± 6.34 cm, and 19.7 ± 1.57 kg, respectively. No significant difference between the normal and flat top talus category was found in age and BMI (p=0.611 and 0.997, respectively). Whereas, relative to normal children, the children who had flat-top talus were on casts for a longer period of time (median: 9 vs. 6 weeks, p=0.026). In addition, a higher proportion of children with more than six casts developed flat-top talus than those with fewer than six casts (69.2% vs. 30.8%, p=0.005). After treatment, a total of 13 (26%) patients developed flat top talus, of which 11 (84.6%) were boys and two (15.4%) were girls (p=0.303). No substantial association between tenotomy and flat top talus (p=0.340) could be identified.

Conclusion

Flat top talus is a complication of improper manipulation specifically correlated with the number of Ponseti casts applied. Maintenance of cast treatment for more than three months may result in flat-top talus with no significant association with tenotomy of the tendoachilles.

• clubfoot
• flat top talus
• ponseti
• ta tenotomy

• casts
• clubfoot
• neglected clubfeet
• ponseti method
• surgical

• Adolescent
• Adult
• Age Factors
• Braces
• Casts, Surgical
• Child
• Child, Preschool
• Clubfoot/therapy
• Combined Modality Therapy
• Female
• Humans
• Male
• Patient Compliance
• Recurrence
• Retrospective Studies
• Walking
• Young Adult

• Clubfeet
• Dimeglio score
• Older children
• Pirani score
• Ponseti method
• Walking child

• CTEV
• Clubfoot
• Outcomes
• Relapse
• Surgery

• Braces
• Casts, Surgical
• Clubfoot/classification
• Clubfoot/therapy
• Humans
• Infant
• Infant, Newborn
• Manipulation, Orthopedic
• Recurrence

The Ponseti Method has dramatically altered the management of clubfoot, with particular implications for limited-resource settings. We sought to describe outcomes of care and risk factors for sub-optimal results using the Ponseti Method in Haiti.

We conducted a records review of patients presenting from 2011–2015 to a CURE Clubfoot clinic in Port-au-Prince, Haiti. We report patient characteristics (demographics and clinical), treatment patterns (cast number/duration and tenotomy rates), and outcomes (relapse and complications). We compared treatment with benchmarks in high-income nations and used generalized linear models to identify risk factors for delayed presentation, increased number of casts, and relapse.

Amongst 168 children, age at presentation ranged from 0 days (birth) to 4.4 years, 62% were male, 35% were born at home, 63% had bilateral disease, and 46% had idiopathic clubfeet. Prior treatment (RR 6.33, 95% CI 3.18–12.62) was associated with a higher risk of delayed presentation. Risk factors for requiring ≥ 10 casts included having a non-idiopathic diagnosis (RR 2.28, 95% CI 1.08–4.83) and higher Pirani score (RR 2.78 per 0.5 increase, 95% CI 1.17–6.64). Female sex (RR 1.54, 95% CI 1.01–2.34) and higher Pirani score (RR 1.09 per 0.5 increase, 95% CI 1.00–1.17) were risk factors for relapse. Compared to North American benchmarks, children presented later (median 4.1 wks [IQR 1.6–18.1] vs. 1 wk), with longer casting (12.5 wks [SD 9.8] vs. 7.1 wks), and higher relapse (43% vs. 22%).

Higher Pirani score, prior treatment, non-idiopathic diagnosis, and female sex were associated with a higher risk of sub-optimal outcomes in this low-resource setting. Compared to high-income nations, serial casting began later, with longer duration and higher relapse. Identifying patients at risk for poor outcomes in a low-resource setting can guide counseling, program development, and resource allocation.

• Braces
• Casts, Surgical
• Child, Preschool
• Clubfoot/therapy
• Female
• Haiti
• Humans
• Infant
• Infant, Newborn
• Linear Models
• Male
• Recurrence
• Retrospective Studies
• Risk Factors
• Tenotomy
• Treatment Outcome

• K24 AR057827 NIAMS NIH HHS
• T32 AR055885 NIAMS NIH HHS
• National Institutes of Health
• National Institute of Arthritis and Musculoskeletal and Skin Diseases

The prevalence of untreated congenital clubfoot among children older than walking age is higher in developing countries due to limited resources for early care after birth. The Ponseti method represents an intervention option for older, untreated children.

A metanalysis was conducted of observational studies selected through a systematic review of articles included in electronic databases (Medline, Scopus, Embase, Lilacs, and the Cochrane Library) until June 2017. A pooling analysis of proportions with 95% confidence intervals (CIs) and a publication bias assessment were performed as routine. Estimates of success, recurrence, and complication rates were weighted and pooled using the random effects model.

Twelve studies, including 654 feet diagnosed with congenital clubfoot in children older than walking age (older than 1 year old), were included for analysis. The rate of satisfactory outcomes found via a cluster metanalysis of proportions using the random effects model was 89% (95% CI = 0.82–0.94, p < 0.01), relative to the total analysed. The recurrence rate was 18% (95% CI = 0.14–0.24, p = 0.015), and the rate of casting complications was 7% (95% CI = 0.03–0.15, p = 0.19).

Application of the Ponseti method in children with untreated idiopathic clubfoot older than walking age leads to satisfactory outcomes, has a low cost, and avoids surgical procedures likely to cause complications. The results obtained exhibited considerable heterogeneity.

• Casts, Surgical/adverse effects
• Child
• Child, Preschool
• Clubfoot/physiopathology
• Clubfoot/surgery
• Clubfoot/therapy
• Female
• Humans
• Infant
• Male
• Manipulation, Orthopedic/adverse effects
• Manipulation, Orthopedic/methods
• Walking

• Ponseti method
• adolescent
• clubfoot
• neglected CTEV

Recent trends have led to an interest in Ponseti treatment for correcting neglected congenital clubfoot. Although good clinical and functional outcomes have been reported, the plantar pressure distribution after the treatment of neglected clubfoot has not been explored yet. The present study aimed to investigate whether plantar pressures normalized following Ponseti treatment in patients with neglected congenital clubfoot. Pedobarographic, clinical, and functional examinations were performed in 22 children (aged, 91.0 ± 40.3 months) with unilateral neglected congenital clubfeet, treated using Ponseti method at 27.8 ± 12.1 months of age. Plantar pressure parameters were recorded using a Footscan pressure plate. The contact time, contact area, peak pressure, and pressure-time integral were determined. The data of the affected feet were compared with those of the unaffected feet and healthy controls. Although clinical and functional examinations showed satisfactory results according to the Dimeglio and Pirani scores, considerable differences in plantar pressure parameters were identified among the affected feet, unaffected feet, and healthy controls. Internal foot progression angle and a load transfer from the medial forefoot and hindfoot to the lateral forefoot and midfoot were observed in the affected feet. Future studies should attempt to investigate the factors accounting for plantar pressure deviations and the possible effect of these deviations on the lower limb musculoskeletal development of children.

To evaluate the effectiveness of the Ponseti method for initial correction of neglected clubfoot cases in multiple centers throughout Nigeria.

Patient charts were reviewed through the International Clubfoot Registry for 12 different Ponseti clubfoot treatment centers and 328 clubfeet (225 patients) met inclusion criteria. All patients were treated by the method described by Ponseti including manipulation and casting with percutaneous Achilles tenotomy as needed.

A painless plantigrade foot was obtained in 255 feet (78%) without the need for extensive soft tissue release and/or bony procedures.

We conclude that the Ponseti method is a safe, effective and low-cost treatment for initial correction of neglected idiopathic clubfoot presenting after walking age. Long-term follow-up will be required to assess outcomes.

• Ponseti method
• Neglected clubfoot
• Nigeria
• Walking age