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

Purpose: This study aims to identify factors associated with dropout from treatment during the Ponseti method of clubfoot management. Methods: A prospectively gathered database of all patients who received treatment at a high-volume urban clubfoot clinic over six years was queried for dropouts. A ‘dropout’ was identified as any child that had not had a visit within three weeks of casting, four weeks of tenotomy or six months of brace follow-up. The second part of the study was a telephonic interview with caregivers of the identified dropouts to ascertain their reasons for discontinuing treatment. Results: Of the 965 patients treated during the study period, there were 155 (16.06%) dropouts – 137 (88.38%) during bracing phase and 18 (11.62%) during casting phase. Age at presentation was significantly higher among the dropouts as compared to those who did not dropout (median 9.5 and 7 months for casting and bracing dropouts respectively vs 3.5 months for regular follow-ups, p<0.001). No significant correlation was found between patient dropout and sex (p=0.061), or laterality (p=0.071). Thirty-seven caregivers (23.8%) could be contacted telephonically; including six casting and 31 bracing dropouts. The most commonly cited reason for dropout from treatment was lack of family support (75.7%), followed by distance to the clinic (59.5%) and unavailability of transport (54.1%). Sixteen caregivers (43.2%) dropped out on account of migration to another town/state. Conclusion: Maintenance of a meticulous registry with regular update of caregivers’ contact details, and interventions to mitigate the identified hurdles can help in reducing treatment dropouts.

While dynamic supination commonly leads to clubfoot relapse, there is no consensus on how to diagnose it and some variance in treatments. This study uses the Delphi Panel approach to define dynamic supination and indications for treatment. An international panel of 15 pediatric orthopaedic surgeons with clinical and research expertise in childhood foot disorders participated in a modified Delphi Panel on dynamic supination in congenital clubfoot. Panelists voted on 51 statements about dynamic supination, clinical indications for treatment, operative techniques, and post-operative casting and bracing in two rounds, with an interim meeting for discussion. Responses were classified as unanimous consensus (100%), consensus (80% or above), near-consensus (70%-79%), and indeterminate (69% or less). Consensus was achieved for 34 out of 51 statements. Panelists agreed dynamic supination is present when the forefoot is supinated during swing phase of gait with initial contact on the lateral border of the foot, and is the result of muscle imbalance. There was no consensus on indications for posterior release of the ankle joint to improve dorsiflexion, or the incisional approach for tibialis anterior tendon transfer. Reference to planes of movement, the calcaneopedal unit concept, and phases of gait were deemed important factors when evaluating dynamic supination. Adapting standardized terminology will promote future collaborations about addressing dynamic supination and the treatment of clubfoot deformity relapse. Consensus statements from the expert panel can guide diagnosis and clinical decision-making related to preoperative casting, surgical intervention, and postoperative immobilization. Near-consensus and indeterminate statements can direct further areas of research.

Introduction: In Nepal, most clubfoot patients present from rural communities with limited access to health services. We assess whether clubfoot treatment can be effectively transferred to physiotherapists and paramedics to make local services more widely available. Methods: Hospital and Rehabilitation Centre for Disabled Children (HRDC), a pediatric orthopedic hospital, treats over 500 clubfeet annually, 60% of which are treated at four satellite clinics. A chart review was supplemented by a follow-up evaluation of physical findings and patient-reported outcomes. We compared treatment outcomes of 423 clubfoot cases (636 feet) recorded at HRDC hospital (central clinic) and Regional Rehabilitation Centers (RRCs). Successful initial treatment was defined as a plantigrade foot without the need for an extensive soft-tissue release and/or osseous procedure. Results: Average age at treatment was 4 years and average duration of follow-up was 7 years. Average presenting Pirani score at HRDC hospital and RRCs was 0.23 and 0.4, respectively. Patients received an average of 7 casts at all centers. Surgical treatment, most commonly a Heel Cord Release (HCR), was required in 97% of feet at RRCs and 95% at HRDC hospital. A plantigrade foot was achieved in 95% of the feet at HRDC hospital, and 93% at RRCs. Complete relapse was rare (1.3% at Central clinic and 2.3% at RRCs) and all patients had modified squat. Complete satisfaction was reported by 94% of RRC patients. Conclusions: Decentralized clubfoot services through trained physiotherapists and paramedical workforce can fill service gaps and reduce cost to patients without significant decrease in clinical outcomes.

Purpose: Recurrences following clubfoot correction by the Ponseti method can be prevented by regular use of a foot abduction brace (FAB) till the child is 4 – 5 years old. However, there is lack of an objective method to measure actual hours of brace usage. The aim was to develop a functional prototype of a SMART (Sensor-integrated for Monitoring And Remote Tracking) clubfoot brace using sensors to record accurate brace usage and transmit the data remotely to healthcare providers treating clubfoot. Methods: A collaborative team of engineers and doctors was formed to investigate various types of sensors and wireless technologies to develop a functional prototype of a SMART brace. Results: Several types of sensors were investigated before finalizing infrared sensors to detect if the feet were placed inside the shoes and magnetic Hall effect sensors to detect that the shoes were latched on to the bar of the FAB. Brace usage data were captured by the sensors every 15 minutes and stored locally on a data card. A Bluetooth Low Energy (BLE) based wireless transmission system was used to send the data daily from the brace to the remote cloud server via a smartphone application. Accurate brace usage data could be recorded by the sensors and visualized in real-time on a web-based application. Conclusion: Our low-cost SMART brace prototype can accurately measure and remotely transmit brace usage data and has the potential to transform caregivers’ behaviour towards brace adherence, which could result in a tangible reduction in recurrence rates.

This systematic review examines long term patient outcomes of different treatment modalities of clubfoot.

A comprehensive search was conducted of PubMed, CINAHL, Web of Science, and Cochrane from inception to December 2020. Using PRISMA guidelines, the search terms clubfoot OR clubfeet OR clubbed foot OR clubbed feet OR talipes equinovarus were used. Articles available in the English language containing more than three human subjects were included. The results were screened for longitudinal studies of pediatric idiopathic clubfoot management with extensive surgery or the Ponseti method.

The initial search yielded 2907 articles, of which 29 articles reporting 2597 pediatric idiopathic clubfeet were included in this review, managed with either the Ponseti method, (group P = 1545 feet), or other surgical techniques, (group S = 1052 feet). Meta-analysis of the proportions of good and fair results from a subgroup of 684 feet from group P with a mean follow-up of (21±13) years, and 1028 feet from group S with a mean follow-up of (16±5) years was performed. The results of the Ponseti method were significantly superior to those of other surgical techniques (p = 0.0002). The odds ratio of Ponseti vs non-Ponseti was 1.478. Multivariate meta-analysis was performed on a subset of 2104 feet with reported age at presentation from 1 to 24 months (7.448±6.09). No significant difference in outcome was detected for presentation within 24 months after birth (p = 0.128).

The Ponseti method has high efficacy in long term treatment of congenital clubfeet when performed within twenty-four months after birth.

Background: Clubfoot is one of the most common musculoskeletal birth deformities worldwide, with variable prevalence among individual countries and populations. Thus, we analyzed the situation in the Czech Republic, looking for potential etiological factors. As additional research, the ankle stiffness measurement was performed in clubfoot patients and developmental kinesiology examination to obtain an objective basis for our future work. Materials and Method: The incidence study used data from the National Registry of Congenital Anomalies from 2000 to 2014 and analyzed gender and regional distribution. The pilot testing was performed in 15 infants (<14 months) with unilateral isolated clubfoot without major surgery. Six postural responses acc. to Vojta were evaluated. The ankle stiffness was calculated from hand-held dynamometry data in the passive dorsiflexion test. The information was supplied by surface EMG of the ankle muscles. Results: The incidence in the studied period is 1.9 (per 1000 births). The incidence significantly differs among individual Czech regions. Postural responses correspond with age-appropriate psychomotor development. Dynamometry data cannot confirm any correlation between ankle stiffnesses and deformity. The surface EMG is not usable due to unspecific signals and artifacts. Conclusion: Based on the current findings, we want to continue our studies to identify the main reasons for regional incidence differences and understand the affected tissues’ processes. We found no significant difference between affected and healthy leg in terms of ankle stiffness. Full correction, achieved by initial treatment, is essential for the functional foot. That suggests exploring further postoperative physiotherapy to restore the soft tissue´s function.

Introduction: Triple-Arthrodesis and Dorsolateral-Mid-Foot-Arthrodesis were performed in patients with idiopathic or neuropathic clubfoot-deformity. A post-operative follow-up of 10-19 years in 15 patients (mean age 46 years at follow-up) existed at time of gait analysis using in-shoe pressure-distribution on a walkway. Only a few studies deal with pressure distribution in these kind of arthrodesis; non with the medio-lateral loading factor (MFL) indicating medio-lateral load-differences of the foot.
Methods: The foot-function was evaluated using the McKay-Score as well as the patient-satisfaction incl. pain and the radiological outcome using the Simons-Score. The MFL (norm 1,6) was calculated out of 8 foot-regions.
Results:12 Patients were satisfied or very satisfied with the results. 3 patients with still remaining problems had neuropathic diseases. Pain-free walking distance increased from preoperative 840m to 7500m. The MLF values showed in all but two feet a value <1 indicating a higher pressure in the lateral edge of the foot. Force peaks were seen in the medial foot regions. The McKay Score results 75 % in a good, only 7% in a moderate condition. The radiological score revealed in only 4 patients a moderate, all others ended in a good to very good result. The VAS was reduced by 2.2 points for stress-induced pain and 0.2 points for pain at rest in the long-term interval of 10 to 19 years after surgery.
Conclusion: The Triple-Arthrodesis and Dorsolateral-Mid-Foot-Arthrodesis result in the long-term in satisfying radiological as well as functional results. Gait analysis using pressure distribution can help in optimizing orthopedic insoles.

Introduction and aim of the work: Conventional surgical treatment of relapsed clubfoot deformities is not always successful or easy to apply. In this study we evaluate the use of the distraction histogenesis technique for management of post-surgical failure in clubfoot deformities. Methods: fifty three cases 2- 6 years old with relapsed clubfoot deformities with history of average 3 previous operations (range, 1-8 operations).This thesis based on 50 consecutive cases (61 feet), of average age 4 years and 3 months (range, 2- 6 years). We used preoperative assembly of the leg construct of the apparatus but ankle and foot construct was designed according to the condition of deformity. Twenty patients were discharged from the hospital the same day of the operation. Results: The range of operative time was 1 – 2.5 hours (average of 1.5 hours). Average time in the fixator was 18weeks (range, 10 weeks - 30 weeks). After fixator removal cast was applied for one month, followed by night splint and special shoes for their daily activities. The average follow-up period was 42 months (range,36 - 84 months) after fixator removal. The results were: good in 50 feet, fair in 7, bad in 4. Conclusion: Ilizarov Treatment is lengthy, fraught with complications, and a technically demanding procedure. However, we believe that Minimal invasive use of distraction histogenesis in relapsed clubfoot using Ilizarov external fixator in a closed management method in treating relapsed club foot deformities in the gray old age zone is an effective.

The purpose of this study was to determine the recurrence rate of idiopathic clubfoot in patients treated with the Ponseti method in an inner-city population, and to identify patient-specific modifiable risk factors. We retrospectively reviewed the charts of all patients with idiopathic clubfoot treated with the Ponseti method at our institution, from July 2010 to July 2020. Demographic data such as gender and race of the infant, marital status, educational level and income of the parents, and type of insurance were obtained. The number of casts required to obtain correction, types of procedures performed, age and time of recurrence, and severity of the deformity were also recorded. Foot abduction orthotic (FAO) tolerance was assessed via patient-reported surveys. After exclusion criteria, 88 clubfeet in 56 patients were analyzed, with an average follow-up of 3.7 years. The average number of casts required to achieve correction was 7.2. Rate of recurrence was found to be 43.2% (33/88). Of the 38 recurrent cases, 22 (58%) required surgical intervention. There was a higher rate of recurrence observed in patients who were not compliant with the foot abduction orthosis (p=0.034), had multiple providers (p=0.0076), atypical clubfeet (p=0.029) and those who were of African-American descent (p=0.036). Among patients with idiopathic clubfoot deformity in an inner-city population, lack of tolerance with FAO, multiple providers, atypical clubfoot, and African descent were associated with higher rates of recurrence. Recognition of modifiable risk factors may result in better patient selection and interventions to improve outcomes in this underserved population.

Cerebral palsy (CP) can lead to various foot deformities, including equinocavovarus, or clubfoot, position. Patients with CP present a greater challenge when treating clubfoot, as there is aberrant muscle tone and motor dysfunction.

A comprehensive search was conducted of PubMed, CINAHL, Web of Science, and Cochrane publications from inception to December 2020 to identify all available literature on clubfoot. Using PRISMA guidelines, search terms clubfoot OR clubfeet OR clubbed foot OR clubbed feet OR talipes equinovarus, only articles containing more than three human subjects, cerebral palsy, and available in English, were included. Full-text papers were screened so that two authors independently verified that each paper met the predetermined criteria for inclusion.

An initial search yielded 9,080 articles, after review, 46 remained. Of these, 41.3% (n=19) articles documented surgical tibial transfer (TT): anterior TT (n=9) (mean-age 17.65 ±16.33yrs), posterior TT (n=8) (mean-age 11.46 ±2.72yrs), and both anterior and posterior TT (n=2). There were 8.67% (n=4) articles referencing tendon lengthening (Achilles and posterior tibial) (mean-age 11.4 ± 3.2yrs), 6.52% (n=3) botox injections (mean-age 6.41 ±0.80yrs), 6.52% (n=3) casting, 4.35% (n=2) (mean-age 4.96 ±0.67yrs), Ilizarov technique (mean-age 12.15 ±7.55yrs), and 4.35% (n=2) orthotics (mean-age 7.3±1.4yrs). There was a difference in age for patients receiving tendon transfer versus those receiving casting (14.2±6.3 years old vs 4.96 ±0.67 years, p<.001).

These results indicate the preferred modality of talipes equinovarus correction in CP patients is surgical tibial transfer. The average of patients receiving surgical treatments was higher than those with costing, Botox, or orthotics.