Introduction: Idiopathic clubfoot (CF) involves structural abnormalities in the lower extremity. About half of the patients have unilateral CF, which could be due to different penetration between the two limbs during gene transcription. The contralateral unaffected foot may have a subclinical manifestation. The objectives were to compare ankle and foot kinematics and pedobarography in the unaffected foot of patients with unilateral CF and controls. Methods: Eleven children with unilateral CF (11 unaffected feet, 11.7±3.8 years) and 15 age-matched controls (30 control feet, 11.1±3.0 years) were enrolled. Five complete gait trials were performed. Data were obtained using 10 OptiTrack-Prime 17 W cameras and a 2-m-long Hi-end Footscan system and compared between groups using the Wilcoxon rank sum test. Results: All CFs underwent the selective soft tissue release procedure. Demographics were comparable between the groups. The unaffected feet had limited ranges in inversion-eversion and dorsiflexion-plantarflexion in kinematics. There was a delay in landing time in all regions of the foot during heel rise and propulsion. The peak time was significantly achieved later in the unaffected feet compared to the controls. Although plantar pressure parameters were comparable, unaffected feet had a larger contact area in the midfoot region. Conclusion: Data on the unaffected foot in patients with unilateral CF differed from controls, indicating that the unaffected foot had a suboptimal development despite an indistinguishable appearance from the normal foot or was affected by treatment. The contralateral unaffected foot and the CF need similar attention during follow-up, including muscle stretching and strengthening exercises.

Introduction. This paper aims to analyse the perception, the difficulties and the overcomes of the families both during the treatment with Ponseti method for clubfoot
Methods: We used a 41 questions questionnaire by Nogueira and Morquende. Questions were answered by the parents with children who already finished the treatment and who are still following it.
Results We interviewed 78 families. 40 with children of younger than 5 years, and 38 with children of 5 years of age or more. The worst handling phase for the parents appeared to be the cast phase in 64% of families due to hygiene difficulties and skin problems, while the brace phase seems more bearable. The tenotomy, even if classified as a minimal surgery, was perceived as an invasive procedure and therefore was overrated by 46 families.
Conclusions: Families perceived the Ponseti Method as a treatment of good quality. The anxiety about the diagnosis and the fear of the results of the treatment played a strong role. None of the difficulties encountered by the families decreased the treatment outcomes or affected families’ adherence to the protocol continued as well. The open-ended answers highlighted the positive and helpful relationship with the doctors, that plays a key role in the everyday compliance of families and the achievement of good results.

Background: Achilles tenotomy for idiopathic clubfoot was originally performed by Ponseti under LA in OPD. Currently, a few surgeons prefer to perform this procedure under GA in OR, citing safety and sterility as reasons. This RCT was done to compare the tenotomy done in OR and OPD setting in terms of clinical outcomes, parental anxiety, and surgeon’s preference. Methods: 20 cases each (28 feet) were allotted to OPD and OR group respectively through randomization. Tenotomy was performed as a day care procedure in both OPD and OR. Parental anxiety, surgeon satisfaction and ankle dorsiflexion were assessed. Results: The mean ankle dorsiflexion on 3-month follow-up in OPD group and OR group was 17.800 and 17.950 respectively. Intra-op bleeding was seen in 3 (15%) patients in OPD group and 1(5%) patient in OR group. The mean duration of the procedure was 19.80 min in OPD group and 53.50 min in the OR group (p value < 0.001). The mean infant mother separation time was 59.75 min in the OR group. Parental anxiety in the OPD group during the presentation, preoperative and postoperative times were comparable to the OR group. The mean total surgeon satisfaction scores favour OR (25.10) as their preferred place in comparison to OPD (23.05). Conclusion: Achilles tenotomy done in OPD under LA is safe, cost-effective with less infant mother separation time, with decreased overall procedural duration and having comparable clinical outcomes and parental anxiety during the pre-procedural and post-procedural period to that done under GA in OR.

Introduction: Ponseti treatment has become the gold standard for idiopathic clubfoot. High rates of non-adherence to treatment remain a challenge. This study aims to identify a seasonal pattern in drop-out during casting and identify patient-level socio-demographic predictors for increased risk of drop-out. Methods: A prospective cohort of 432 clubfoot patients was followed at the Pehla Qadam clubfoot clinic in Karachi, Pakistan. Data was collected on baseline demographics, living conditions of the child and family, and previous treatments received. Socio-economic status was assessed using the WAMI-index (Water, Assets, Maternal education and Income). A timeline analysis was done to assess for seasonality in drop-out rates. Results: Preliminary data of 333 children showed a drop-out rate of 5% during the casting phase. These drop-outs were older at time of enrollment (15 vs 8 months), had a lower socio-economic status (WAMI-index of 0.21 vs 0.30), had more often received prior treatment (50% vs 38%), and more often had a unilateral clubfoot (56% vs 51%). Drop-out was more frequent during summer heat, floods, winter cold spells, and COVID-19 waves registered in 2021. Casting for the 432nd child was started in December 2022. Data collection and analysis will be completed by August 2023. Conclusion: Drop-out from casting is not a random occurrence but is affected by predictable seasonal phenomena and unanticipated occurrences such as disease outbreaks. Prior treatment and late presentation are risk factors for drop-out at the individual level. These patterns may inform future casting regimens to increase adherence, especially in low socio-economic settings.

The aim of this study was to know when the foot turns neutral over the course of treatment and the quantitative effect of tenotomy on the individual deformities. Additionally, it aimed to graphically depict the progression of correction using the Dimeglio scoring system. The target population was infants with unilateral idiopathic clubfoot up to age six months. Each included foot was evaluated using the Dimeglio scoring by the same surgeon during each visit. The total score and individual components were recorded with every visit. There is simultaneous correction of all the deformities when treatment according to Ponseti protocol is initiated in idiopathic clubfoot. The first cast itself leads to significant correction of all the deformity parameters. Tenotomy has corrective effects on all aspects of the deformity correction including equinus. Studies with a larger sample size is the need of the hour to further standardize the graphs that this study has generated.

Introduction: 90% of children treated by the Ponseti method for clubfoot require an Achilles tendon tenotomy. The gold standard for performing a tenotomy is a 15 blade. The use of a large bore needle has been described sporadically in the literature with good results. This pilot study aims to compare the post-tenotomy degree of dorsiflexion and complication rate of a large-bore needle tenotomy compared to the gold standard. Methods: A sample size of 50 feet was determined to assess the safety features of the needle technique before implementing a randomized control trial. Patients with idiopathic clubfoot below the age of 3 years, who enrolled at our clubfoot program were randomized into the pilot study. Degree of dorsiflexion at 3 weeks and 3 months post-tenotomy was the primary outcome. Major and minor complications were the secondary outcome. Results: We enrolled 34 children with 50 clubfeet between May and November 2020. The average age was 10.2 months at the time of tenotomy with no differences in baseline characteristics between both groups. Mean dorsiflexion at 3 months in the blade group is 20.2° compared to 18.4° in the needle group (p>0.05). All patients achieved at least 15° dorsiflexion. No major complications have been recorded in either group. Discussion: Achilles tendon tenotomy with a large-bore 22 Gauge needle shows equal outcomes as the tenotomy performed with a blade. Needle tenotomy does not leave a scar mark on the heel and allows for engagement of non-orthopedic surgeons in performing Achilles tendon tenotomies in low-resource settings.

Background: Investigations of pain and physiological responses response during Ponseti casting are in preliminary stage. This short-term study aims to quantify pain responses and to note the variations, if any, during subsequent casting sessions. Methods: In this prospective study, the pain parameters were evaluated in 34 clubfeet. Video recording of each casting session was done one minute prior, during casting and after one minute of casting. The videos were objectively scored using Neonatal Infant Pain Score (NIPS). Heart rate (HR) and oxygen saturation (SpO2) were recorded by using a pulse oximeter.
Results: There was progressive increase in pain response until at the last casting session, it was recorded as NIPS 4 (IQR 1) (p=0.02479). Pre, during and post cast HR rose significantly in succeeding sessions. The mean HR during first cast session was 175.5/ min (SD 27.2/ min) which increased to mean 197.3/ min (SD 18.9/ min) (p=0.000282). For third parameter of oxygen saturation, no differences were observed between the first and last cast.
Conclusion: There was moderate pain response during Ponseti casting sessions as demonstrated by NIPS. It rose significantly towards the last cast. The clubfoot child showed an exaggerated heart rate in succeeding cast sessions. No variations were noticed for oxygen saturation.

Introduction: Ponseti revolutionised the treatment of clubfoot. However, relapse occurrs in upto 40% of patient. Managing relapsed clubfoot can pose a challenge as there are various approaches and no consensus on the same. Objective: To assess the pattern of relapses, management and the outcomes of various treatment for relapsed clubfoot in our institute. Material and method: A Retrospective-prospective study involving all patients diagnosed with a relapsed idiopathic clubfoot who were managed at our institute between 2015 and 2020 were included. Retrospective review was done to identify the residual deformities, it’s causes and the intervention done. The relapsed clubfoot were classified using Bhaskar A et al classification of relapse pattern. Prospectively the children were followed up to assess for the outcomes using Assessing Clubfoot Treatment (ACT) score. RESULTS: Of the 1435 clubfoot treated at our clubfoot clinic we observed a relapse rate of 20.5% [294] . 27.9% had Grade IB, 22.1% had Grade IIA, 11.5% had Grade IIB and 38.4% had Grade III deformities. These children were treated with various procedures like repeat ponseti technique, ilizarov correction, soft tissue and other bony procedures. The mean follow-up duration was 1.4 years. ACT score on follow-up showed 70.9% good outcome and 5.5% had ocassional pain but not limiting activities. 8% had residual deformity [Grade I] and 4.4% had again presented with relapse of deformity. Conclusion: Ponseti method can help manage a majority of relapse cases but each type of relapse pattern requires different approach. Early identification and intervention will provide a satisfactory outcome.

Introduction: Dr Ignacio Ponseti revolutionised the treatment of clubfoot. In his description of the method, serial manipulative casting is initially and in a majority it is necessary to perform a percutaneous tenotomy of the Achilles tendon to complete the equinus correction. Despite OPD TA tenotomy being safe there have been debates on its safety and efficacy. Some argue Tenotomy done under GA gives a better correction. Our objective is to demonstrate the safety and efficacy of out patient percutaneous TA tenotomy in managing idiopathic clubfoot. Material and method: Study based at Indira Gandhi Institute of child health Bengaluru and data collected between 2010 -2020. All children with idiopathic clubfoot and treated by ponseti method with a minimum follow-up of 2 years were included. All children underwent Data was analyzed for correction achieved, any complication, rate of recurrence. Results : A total of 1500 feet were reviewed. The average pirani score of our study population was 5.5 and the average number of casts was 6 casts. Percutaneous tenotomy of tendoachilles was done in 94% of patients. 5.7% had inadequate equines correction. No adverse events were related to local anesthesia. 27 children were evaluated in the emergency room after the procedure because of parental concern and 5 children had excessive bleed. All other babies had an uneventful course. Retenotomy was performed in 85 feet. Conclusion: Outpatient percutaneous tendoachilles tenotomy is very safe and provides adequate equinus correction. It minimizes medical expenses and need for admissions in a busy clubfoot clinic.

Introduction: Clubfoot is among the most common pediatric deformity encountered in regular practice. Ponseti revolutionized the treatment of clubfoot, but the use of the same in managing non-idiopathic clubfoot has often been questioned. The study was conducted to analyze the outcomes of non-idiopathic clubfoot treated by Ponseti method. Method and materials: The study was conducted at a pediatric government tertiary hospital, all children (<2 years) diagnosed with non-idiopathic clubfoot were included in the study. After evaluation , Ponseti method of serial manipulation and casting was started . Post correction the children were followed up at regular intervals. The collected data was analyzed to assess the outcomes. Result: 196 patients with Non-idiopathic clubfoot were included in this study. 44.2% patients presented to us in first three months of life. 51% of them were associated with arthrogryposis, other include Larsen’s syndrome, adducted thumb and clubfoot syndrome, limb deficiency syndromes, constriction band syndrome, remaining had unnamed/miscellaneous syndromes. Neurogenic clubfoot was seen in 2.64% of patients which included spina bifida, sacral agenesis, spinal dysraphism myelomeningocele and myopathies. Percutaneous tenotomy of tendo-achilles was done in 94%. The initial correction was achieved in 132 patients. The average number of cast required to achieve correction was 13+/- 7 casts. The relapse rate in children treated by ponseti method at our centre was 38%. Conclusion: Ponseti method reduces the need for surgical intervention in non-idiopathic clubfoot. Though effective non-idiopathic clubfoot behaves differently, they often require greater number of cast and have higher need for surgical intervention and recurrence.

Ponseti method is well-established gold standard in managing clubfoot. Its effectiveness in walking children is often debated and questioned. The aim of this study is to evaluate the effectiveness of the Ponseti method in managing clubfoot after walking age. Material and method: This study was based at a tertiary paediatric government hospital in Bangalore between 2010 to 2022. After initial assessment and evaluation, all children underwent the standard manipulative casting technique described by Ponseti, including a percutaneous tenotomy of the Tendo Achilles. The collected data was analyzed for efficacy of casting in achieving correction, rate of tenotomy, relapses and need for surgical interventions. Results: A total of 187 (321 feet) children with a mean age of 2.5 years were included. The mean pirani score was 4.5 , there was significant change between the pre and post- casting Pirani scores. The average number of cast to correction was 9.46 and children aged more than 2 years needed more casts. 98% underwent tenotomy and 13% of feet had inadequate reduction and need soft tissue procedures. Relapse was seen in 32.4% of feet requiring recasting or surgical intervention. The main concern was non-compliance and breakage of casts. Conclusion : Ponseti method is effective in correcting deformities of clubfoot and minimizes the need for extensive surgeries, even after walking age. But its effectivity in correcting all deformity decreases with age.

Introduction: The Ponseti Method is the gold standard treatment for idiopathic clubfoot. It is also reproducible with good results in children after walking age. Objective: To evaluate the viability of the Ponseti Method in a complex case of a clubfoot child after walking age. Methods: J.G.S is a 6 -year-old girl from a metropolitan city in Brazil with relapsed, painful, bilateral clubfoot. Past history: hip dysplasia on her right hip, treated with Pavlik harness and recurrent patellar dislocation on her left knee, never treated. She started the Ponseti Method for clubfoot at 3 months of age, which was discontinued after 1 cast due to clinical conditions. Treatment was then resumed at 9 months of age. Several casts and bilateral posteromedial release were done without correction. Her family then sought a Ponseti Method reference clinic. She was treated with 7 casts weekly changed until 70 degrees of abduction and good improvement of the equine deformity were obtained. Bilateral Achilles tenotomy was performed under local anesthesia. Brace protocol started after removing the last cast. Results: The girl who had never worn regular shoes before was able to go to school with corrected, plantigrade, flexible and painless feet. Discussion: When it comes to a complex case very close attention should be payed to details. Good communication as well as good relationship with the family are crucial and the brace protocol can be followed. Conclusion: The Ponseti Method is viable with good results in a complex case of a clubfoot child after walking age

Congenital talipes equino varus treatment has been revolutionized by use of the ponsetti technique. However, the rates of recurrence have been significantly higher due to non-compliance to the follow up regimen prescribed by the surgeon. The study describes the follow up regimen used for both typical and atypical CTEV in 300 cases followed up to 5 years.(2015-2020) and enumerates various variations in gender, modification of braces and timely surgical intervention.The study shows that very low recurrence rate can be achieved if timely follow up and proper counselling is done of the parents.
The study also describes the use of various different braces and their use to prevent recurrence of the deformity on appearance of the early signs.

Since 2016 the combined alliance of PIA ( Ponseti International Association ) Brazil and Rotary International trained orthopaedic surgeons aiming to increase the public treatment network in Brazil for children with clubfoot. The training took place in 5 stages, one in each region of Brazil. All trainers had online theoretical classes before arriving at the practical training site. The practical mentorship consisted of workshop on plastic models, live interaction with patients in a model called megaclinics and case discussions. 73% of the trained orthopaedic surgeons established Ponseti reference clinics in the public system. The network is decentralized, standardized, connected, with nationwide coverage. It is supported by the parent’s association, local Rotary clubs and communities. The next step will be to access treatment costs and disease burden (cost-effectiveness) in Brazil and raise awareness of the Ministery of Health for a unified public policy for clubfoot treatment.

Ponseti method has currently become consolidated worldwide as the first line in the treatment of clubfoot, but there are still differences in the literature regarding the management of relapses. This study aims to demonstrate the results of management of relapses among patients diagnosed with clubfoot, idiopathic and non-idiopathic, in a specialized Brazilian clinic. Patient records from 2000 to 2023 were analyzed, including children diagnosed with idiopathic and non-idiopathic congenital clubfoot treated with the Ponseti method. The study population was 996 patients (1604 feet). Among these 1277 (79.6%) were idiopathic and 327 (20.4%) were non-idiopathic. The mean age of treatment onset was 1 year and 3 months. Relapses were found in 327 feet (20.4%) slightly more frequently in non-idiopathic than in idiopathic cases (respectively 24.8% vs 18.8%). The combination of new serial casts, Achilles tenotomy, and tibialis anterior transfer was necessary in 152 patients (46.5%). Satisfactory results were found in 52 (16%) of the patients without tenotomy or anterior tibial transfer- only using a cast and orthosis. In the last treatment evaluation, foot was corrected and had more than 10 degrees of dorsiflexion in more than 90% of the recurrences, regardless of the type of foot. In cases of loss of dorsiflexion after 4 years of age, the reintroduction of the abduction orthosis was indicated to increase flexibility before relapses.

Introduction: The question we needed to answer was "does Percutaneous (PC) Achilles tenotomy result in complete sectioning of the tendon"? Patients Methods & Results: 36 patients under the age of 6 months, with 56 clubfeet, were treated using the Ponseti method. 20 patients had bilateral affection and the mean age of all patients at start of treatment was 29.4 days, with a baseline mean Pirani score of 4.4. PC tenotomy was performed, by a middle grade or senior surgeon, under general anaesthesia when the midfoot score was 0.5 or 0, at a mean age of 4.6 months. Patients were placed in the supine position, with knee flexion, hip external rotation, and the foot was maximally dorsiflexed. An 11 guage surgical blade was introduced medially through a puncture anterior to the tendon, 1 cm proximal to its calcaneal insertion. The tendon was then sectioned from anterior to posterior. This resulted in sudden increase in dosiflexion in all feet. The completeness of tenotomy was then assessed based on performing the Thompson calf squeeze test. In 49 feet (87.5%) the test was positive which meant that the tendon was completely severed. In 7 feet (12.5%) the test was negative (with residual foot plantar flexion on calf squeeze), indicating that the tenotomy was incomplete. In those with a negative test, the puncture was then extended longitudinally, and in all the Achilles tendon was found to be incompletely severed. Intact fibres were then divided resulting in a positive test. There were no false negative results.

Background: The Ponseti method of treatment for clubfoot which utilizes serial manipulations and casting is considered the gold standard for clubfoot treatment. Exposure of new technology in the scientific literature is associated with the diffusion and adoption of that technology in clinical practice. The aim of this study sought to identify tendencies in the thematic changes in medical literature regarding the treatment of congenital clubfoot over a period of twenty three years, from 1997 to 2021.
Methods: The Medline databases were searched for articles containing the keyword “clubfoot”. Articles from 1997 to 2021 were identified and analyzed by institutions which published the articles, and whether treatment was with the Ponseti method or surgical interventions. We also observed in order the geographic diffusion of the Ponseti method.
Results: 2067 articles were found in Pubmed referencing clubfoot, and in these publications 577 addressed the Ponseti method and 273 articles discussed surgical treatment. From 1997 – 2000, the only articles discussing the Ponseti Method were from Iowa,in the United States. The increasing number of publications about the Ponseti method and the decrease in publications about surgical treatment for clubfoot occurred after 2003. In 1997, only one country had a publication regarding the Ponseti method; by 2018,24 countries published articles on the method.
Conclusions: These results suggest a trend of dissemination of knowledge to additional countries, reflecting the more widespread usage of the method throughout the world, and global outreach as a result of the work of Ponseti International Association.

Introduction: One of the most common sequelae of successful non operative treatment with the Ponseti technique of congenital talipes equinovarus deformities (clubfoot) is dynamic supination from a strong tibialis anterior muscle and weak antagonists, particularly the peroneal and tibialis posterior muscles. The objective of this study is to evaluate the evaluate functional and radiological results of tibialis anterior tendon transfer for residual supination deformity after Ponseti. Materials and Methods: This retrospective study included the cases of 20 children who residual dynamic supination caused by strong tibialis anterior in the period from March 2014 and March 2019. All patients have unilateral or bilateral idiopathic club foot, Ponseti method used for initial treatment, age more than 2 years, deformity is dynamic and corrected with no structural deformity existing, all were treated by total transfer of tibialis anterior tendon from its insertion to the lateral cuneiform. Follow up ranged from one to three years Results: the functional results were graded as excellent in fifteen patients (75%), good in five patients (25%), with no fair or poor results. there was significant improvement of, anterior talo-first metatarsal angle and anterior talocalcaneal angle. Complications found in the study were irritation of the sole of the foot occurred in three patients 15%, Tendon bull out occurred in one case 5%, Conclusion: Total tibialis anterior tendon transfer to the lateral cuneiform is safe and effective procedure in treatment of residual dynamic supination of corrected club foot.

Introduction: Globally, many international non-government organisations organise special training programmes in the Ponseti method of clubfoot treatment. The purpose of this retrospective evaluation was to evaluate the effectiveness of a one-day training programme for clubfoot correction among resident doctors.
Methods: This was a retrospective cohort study. Out of 134 patients registered in the clubfoot clinic of the institute from November 2012 to June 2015, 64 patients (93 feet) treated by resident orthopaedic surgeons were included in the study. All the resident doctors have received classical training in the Ponseti technique. The comparative evaluation was done between the results of 41 patients (60 feet) treated by five resident orthopaedic surgeons who were additionally trained in a one-day Ponseti training course with that of 23 patients (33 feet) treated by resident doctors who did not receive any additional training.
Results: The results revealed that Percutaneous Tendo-Achilles (PTA) tenotomy was performed in 73% (44/60) feet when treated by additionally-trained group compared to 51.5% (17/33) in the classically-trained group and the difference was statistically significant (P=0.03). The rate of successfully treated patients was 35% (21/60) and 39% (13/33) in the additionally-trained and the classically-trained group respectively (P=0.26). The mean duration of cast phase in the additionally-trained group was 10.5 weeks and that in the classically-trained group was 9.4 weeks (P=0.27).
Conclusion: The rate of PTA tenotomy was significantly higher in the additionally-trained group compared to the classically-trained group, however, both the groups were similar in terms of successful treatment and duration of cast phase.