Background
The effect of ethnicity on the incidence of congenital talipes equinovarus (CTEV) has been previously published. Genomic differences have also been reported but the authors are not aware of any published studies on the response to Ponseti treatment in different ethnic groups. Leicester is one of the most ethnically diverse cities in UK. Our aim was to investigate the effect of ethnicity on the treatment response in CTEV in White and Asian children treated by Ponseti method.

Methods
We included patients with idiopathic CTEV who presented between 2010 and 2020. The data was collected prospectively. Ethnic background, initial Pirani score, Pirani score after every cast, Achilles tenotomy and relapse were recorded. Data was collected prospectively as part of clinical care and analysed retrospectively. The study was registered with our audit department (Registration number 11191)

Results
132 patients with 176 feet were analysed. The overall incidence of CTEV in Leicester similar to other reports worldwide. In all 59% were Caucasian, 31% Asian and 9% with other ethnic background such as African and Caribbean, similar to our population. We found no significant statistical difference when comparing initial Pirani score (p = 0.36), forefoot Pirani score (p=0.19), individual forefoot scores, number of cast (p=0.25), tenotomy (p=0.29) or relapse rate(p=0.22).

Conclusion
We did not find any evidence that ethnicity influences response to Ponseti treatment. This may be due to the very high success rates achieved by Ponseti treatment, or due to the inability of our standardised ethnic groupings to reflect true genomic background.

Purpose: This study aims to evaluate changes in tarsal bones relationship after the use of one week accelerated Ponseti method in the treatment of severe idiopathic clubfoot using MRI. We hypothesize that one-week accelerated Ponseti is at least as effective as standard techniques Methods: This is a prospective study of 8 children with severe idiopathic clubfeet (Pirani 6) (4 unilateral and 4 bilateral) treated before the age of three months with one-week accelerated Ponseti technique, as described in a former study with minimum 2-year follow-up (38.3 months). The 8 corrected feet were compared with the 4 unilateral normal feet at clinical and radiological levels using a Pirani scoring system and an MRI, respectively. Results: Clinical results showed that Pirani score was 1.1 in the last follow up in comparison to Pirani 6 pretreatment (p < 0.05). MRI results indicated that the malleocalcaneal angle, axial malleocalcaneal index, coronal tibiocalcaneal angle, sagittal talocalcaneal angle, and talar head neck calcaneal rotation showed statistical difference between the two groups (p < 0.05). Sagittal malleocalcaneal index, sagittal tibiocalcaneal angle, talar head neck rotation related to talar body, and posterior calcaneal rotation, navicular subluxation showed no statistical difference between normal feet and clubfeet after correction (p value > 0.05). Conclusion: One-week accelerated Ponseti technique showed to be as effective and safe as other treatment methods through clinical and MRI follow up data. MRI role was to confirm the efficiency of this innovative accelerated technique, but not used as a routine follow up.

Purpose: To analyze the results of the Ponseti method in the treatment of non-idiopathic clubfeet and compare them with idiopathic clubfeet in a program-based setting using a standardized protocol. Methods: We reviewed two groups of 782 children treated prospectively in our Clubfoot Clinic: Group I comprising of 89 patients (146 feet) with non-idiopathic clubfoot and Group II comprising of 693 patients (1032 feet) with idiopathic clubfoot. Both groups were compared on basis of patient demographics, number of casts, tenotomy rate, success rate, rate of recurrences, and the need for additional secondary procedures. Results: Non-idiopathic clubfeet had a higher incidence of bilateral involvement (p=0.0093) and affected both males & females equally (p=0.002) as compared to idiopathic clubfeet. Non idiopathic clubfeet (Group I) required significantly more casts (6.75+4.2) compared to idiopathic clubfeet (4.23+4.14), had a higher rate of Achilles tenotomy (90.4% v/s 75%, p<0.0001), and a lower initial success rate compared to idiopathic clubfeet (92.5% v/s 100%, p<0.0001). There was a significant difference in the recurrence rates between the two groups as 42.5% of non-idiopathic feet (38 patients) relapsed as opposed to 10.2% (71 patients) in the idiopathic group (p<0.0001). Most recurrences in Group I were amenable to re-casting, with only nine patients (14 non-idiopathic clubfeet) requiring extensive soft-tissue releases. The final success rate in non-idiopathic group at a mean follow-up of 5.8 years (2 – 8 years) was 87.7%. Conclusions: We recommend the use of the Ponseti method as an effective treatment for non-idiopathic clubfeet associated with neuromuscular and syndromic conditions.

Introduction: Club foot management has been dramatically improved by Ponseti casting and subsequent splinting. Relapses requiring surgery do however, occur, as noted in the records of a Club Foot Clinic of 110 patients. Thirty Four needed surgery at an average age of 4.7 years. Most required a rebalancing anterior tibias tendon transfer. This indicates the presence of an ongoing neuromuscular imbalance. The typically thin calves in club foot suggest a muscle anomaly. Methods: Ninety muscle biopsies were obtained from the posterior and medial muscles during surgical correction of 13 club foot patients. All specimens were examined by electron microscope techniques. Enzyme specific stains were applied to 48 biopsies, which were then examined at the light microscopic level. Neuromuscular junctions were isolated and examined. Results: Consistent ultrastructural anomalies, Z-line streaming and complete disruption, occurred in all specimens. Histochemistry revealed a dominant Type 1 fiber population and grouping of Type 1 slow twich fibers. A correlated increase in Type 1 Neuromuscular junctions occurred in these areas. Fiber size alteration and inter-muscular fibrosis was present in some specimens. Conclusion: The function of a muscle, slow or fast twitch, is determined be the characteristic of the innervating nerve. The anomalies observed are well recognized as being neurologically determined. A neuromuscular abnormality is considered to be significant in the etiology and pathology of club foot. Long term follow-up and a more prolonged use of appropriate night splinting may limit relapse. A dorsiflexing night AFO, that avoids linking the feet, is effective in older children.

Severe rigid equinocavovarus deformity of the foot with associated ipsilateral hip and knee flexion contractures from an underlying Cerebral palsy, a neuromotor disease that causes pain, instability, and difficulty in walking, leads to major disability affecting daily function and quality of life. This case reports the utilization of Modified lambrinudi arthrodesis intended to create a plantigrade, pain-free and stable foot in a single event multilevel surgery, together with correction of hip and knee flexion contractures on a known-case of Cerebral palsy patient.

PURPOSE: To evaluate patients with arthrogryposis submitted to extensive surgical treatment with a minimum of 10 years of follow-up regarding the clinical and radiological aspects and the quality of life, using the 36-Item Short Form (SF-36) and the Disease-Specific Instrument (DSI). METHODS: A retrospective study was performed using the institution's surgical records, and 33 patients were selected, totalling 64 operated feet. RESULTS: The mean age of the patients was 17.9 years (12-39 years), and the mean follow-up time was 14.8 years (11-17). Amyoplasia represented 78.7% of syndromic diagnoses. Isolated posteromedial lateral release (PMLR) was performed in 21.8% of the feet, 27.2% of which required additional bone surgery, and about 50 feet (78.1%) were submitted to PMLR, lateral column shortening, and/or talectomy. In total, 46 talectomies were performed (71.8% of the feet), out of which 44 were the first procedure of choice. The responses to the SF-36 questionnaire were evaluated and showed that 93.9% of the patients did not have restrictive and disabling pain, and the same percentage considered themselves as healthy and had good expectations for the future. CONCLUSION: Arthrogrypotic feet are difficult to treat, require many recurrent surgical procedures, and relapses are the rule. Stiffness is a common feature of these feet, and residual deformities were frequent. Future studies will show whether there will be a difference in the outcome of the treatment of these feet by applying the current, more conservative initial approach.

Introduction: Clubfoot is a frequent deformity in patients with myelomeningocele, rigid and difficult to manage, with more frequent recurrences. Objective: To evaluate the mid-term results of patients with myelomeningocele with clubfoot who using the Ponseti method.
Method: Prospective descriptive cohort study of 37 patients (58 feet) with myelomeningocele treated with clubfoot using the Ponseti method, observing the variables: Pirani scale, number of casts, Achilles tenotomy, appropriate use of the orthosis, number of recurrences, follow-up time and complications.
Results: A total of 35 children with 58 clubfoot associated with myelomeningocele were included, with an average duration of follow-up of 3.5 years (range, 2 to 13 years). The average age at presentation was 1 year and 10 months, with an average score of 5.3 on the right and 5.6 on the left of Pirani. Initial correction was achieved in all children with an average of 3.88 casts (2-13). Recurrence occurred in twenty one of the 35 (60%) patients, most frequently in the period of 14 hours of orthosis (61.5%) and in 23 hours (38.4%). After Ponseti method, 72% of the feet showed good functional and painless results.
Conclusion: This method is effective for treating clubfoot associated with myelomeningocele to achieve painless functional feet. However, with higher risk of relapses and complications.

The objective was a systematic evaluation of the existing publications to observe the effectiveness of the method in the treatment of clubfoot in children with myelomeningocele. Method: We performed a search in the EMBASE, Lillacs, Pubmed, Web of Science and Scopus databases using “myelomeningocele” AND clubfoot as keywords. Results: 763 articles were found. Of these, 294 duplicates were discarded and 463 were excluded because they did not meet the requirements. A total of 6 articles were obtained and included in the analysis. We were able to observe in the studies analyzed a success rate that varied between 66% and 93% in 5 studies, 1 of them with a lower success rate: 42.3%. Still in the analysis of the outcomes, we could observe that one of the studies does not report complications, in the other 4 reports a high rate of complications, reaching 50%, and one of the studies, with only 2.66%. Rrecurrence rate varied between 44 and 67%. Discussion: In these patients, the number of plasters required for correction is greater in these patients compared to idiopathic; however, the success of correction at the end of them is very similar, varying between 96 and 100% in 4 of the studies. We observed a higher rate of recurrence and complications, as well as a success rate lower than that observed in the literature. However, when compared to the success rate and relapses of patients with myelomeningocele surgically treated, these patients have a higher rate. similar for both outcomes.

Introduction: Clubfoot deformity is one of the most common birth defects. Despite the effectiveness of the therapy, relapses often occur. We have already described the increase in the level of vascularity and upregulation of almost 14 regulatory proteins in the contracted tissue of the relapsed clubfoot. This study primarily focuses on alterations in the composition of structural proteins in the affected tissue during such remodellation.
Methods: By means of the application of immunohistochemistry, light microscopy and an image analyzer, we were able to compare the concentration levels of Collagen type III, Collagen type VI, Collagen type XII and Collagen type XIV occurring in the tissue of the contracted, i.e. the medial side (M-side), and non-contracted, i.e. the lateral side (L-side) of the relapsed clubfoot. Samples from ten patients were analyzed (n=10 for M-side, n=10 for L-side).
Results: We have ascertained a significant increase in the level of extracellular Collagen type III, Collagen type VI, Collagen type XII and Collagen type XIV within the M-side of the relapsed clubfoot tissue.
Conclusions: Initially and for the first time, we have ascertained a significant increase in the level of above - mentioned structural proteins in the contracted tissue of the relapsed clubfoot. This excessive fibrosis is a commonplace pathological mechanism, which has already been uncovered among other fibroproliferative diseases, whereupon it thereby has become a possible therapeutical target. These revelations could possibly contribute to the clarification of the etiology of the disease and relapses thereof or not in clubfoot.

Abstract
Background: Complex clubfoot includes a variable range (neglected, resistant, relapsed, recurrent, residual, syndromic, neurogenic) that are refractory to conventional treatments or are treated inappropriately. We report a series of complex clubfoot deformities treated by limited surgery and Ilizarov distraction histogenesis. Purpose: To evaluate the corrective capability of the Ilizarov external fixator in the treatment of complex clubfoot. Methods: 26 patients (36 feet) with a mean age of 12 years with severely stiff foot deformities associated with complex clubfoot were reviewed, between September 2017 to August 2020. A limited soft-tissue dissection, Achilles tenotomy, and plantar fasciotomy were done. Progressive correction of the deformities was achieved through a simplified standard setting of the Ilizarov external fixator. The mean duration of fixator application was 4 months, after removal a short-leg walking cast was used for an additional 6 weeks, followed by an ankle-foot orthosis (AFO) for 6 months. The mean follow up period was 18 months. Results: At the time of removal of the fixator, a plantigrade foot was achieved in 32 of the 36feet. Out of 36 feet, 6 (16.66%) were rated as excellent, 19 (52.77%) as good, 7(19.44%) as fair, and 4(11.11%) as poor. residual varus deformity noted in four feet and recurrence of deformity in two feet. Conclusion: Our results indicate that the short term clinical and functional results of complex/resistant clubfoot deformities with Ilizarov's external fixator is promising and apparently a good option.