Evaluation was performed for 42 feet in 28 infants (14 bilateral) with mean age of 42.5±39.2 days (range, 15 to 150 days). All the six components of PSS showed a significant change from the first cast till the pre tenotomy cast. Post tenotomy, there was a significant change in the scores of posterior crease (0.4±0.2 to 0.1±0.1, p < 0.001) and rigid equinus (0.8±0.3 to 0.1±0.2, p < 0.001). 66.7% (28/42) of the feet had an abnormal empty heel sign of either 0.5 [22/42 (52.3%)] or 1 [6/42 (14.4%)] at initiation of bracing. The non-zero empty heel component may require careful interpretation both post treatment and during follow ups.

Clubfoot is one of the most common congenital musculoskeletal deformities. Ponseti's method has significantly reduced the rate of surgical interventions for the treatment of this pathology. However, even after complete correction with this technique the recurrence rate is high. Anterior tibial tendon transfer (ATTT) is a technique included by Dr Ponseti for treatment of relapses after new serial casts. Multiple modalities of fixation of the anterior tibial tendon after its transfer have been described in the literature recently, including the use of anchors or interference screws. A review of the literature was conducted to investigate the complications associated with each of the techniques described. There were few publications where the type of fixation used in ATTT is clearly described or the complications related to it. In recent years, the use of suture anchors has grown exponentially, with cadaver studies recommending their use, as they are easier to use and less traumatic to the bone compared to techniques using bone tunnels. However, there are no publications that report complications associated with the use of suture anchors. We have failure reports from different colleagues, where anchors lost fixation, with the need for revision surgeries. The use of bioabsorbable screws has been associated with several complications, namely screw slippage, inflammatory reactions, and tendon laceration during insertion. Additionally, the use of this hardware is associated with higher costs. There were no reported failures in the revised anterior tibial transfer in 50 years of follow up in Iowa series.

Ponseti Method has a shot-term effectiveness rate of more than 90%,but there are studies that correlate treatment failure to socioeconomic levels. The aim of this study is to compare patients from a public and from a private Ponseti method reference clinic in Brazil, both conducted by the same orthopaedic team. 996 consecutive patients were assessed, from 2000 to 2023, with clubfoot, by retrospective analysis of medical records. We studied idiopathic and non-idiopathic patients, age at treatment, number of casts, tenotomies, complications, relapses, need of anterior tibial tendon transfer (ATT) and results. A total of 1604 feet was studied, 403 feet were of public clinic; from these, 55% were idiopathic, mean age of 1 year and 11 months at first visit , with 4,2 casts and 10,4% ATT, 11,9% of complication rate, and 22,5% relapses, 73% achieved good results. In the private clinic there were 1201 feet, 87,9% idiopathic, mean age of 1 year and 1 month at first visit, mean cast of 3,3; and 20% ATT with a 11,8% complication rate, 32,4% relapses, and 79% achieved good results. Public clinic presented more non idiopathic cases (45%vs12,1%), a higher mean age at first visit (1y11m vs 1y1m), and needed less ATT surgeries (10,4%vs20%). Both presented good results – no deformity with more than 10 degrees of dorsiflexion - (73%vs79%), and similar complication rates (11,7%vs11,8%) and relapses (22,5vs32.4%).

Purpose: To evaluate the outcomes of Ilizarov external fixator (IEF) and minimal invasive surgery (modified Ponseti technique) in correction of neglected club foot (NCF). Methods: Thirty-seven feet in 24 children, between five and 15 years old were diagnosed as NCF. All were treated with Achilles tendon lengthening (ATL) and IEF for gradual correction. ATL was performed via open approach through Z shaped technique then the frame had been applied, for gradual correction. After IEF removal, cast was applied for six weeks to maintain correction of the deformity. Results: There were 20 boys and four girls. Seven children had left (Lt), four children had right (Rt) while 13 children had bilateral foot deformity. The mean age at surgery was 10.3 years with an average follow-up of 32.5 months. All feet were graded as severe according to Pirani score. IEF was applied for an average six weeks. After two years follow-up, 23 feet (16 patients) showed good, five feet (3 patients) showed fair result and four feet (2 patients) had Rt side foot fair result while the Lt foot had good result in both patients. Five feet (3 patients) showed poor result. There were complications as pin site infection, skin infection, skin sloughing, and changes in color. Conclusion: We recommend lengthening of the Achilles tendon before applying of the IEF as this technique will help to get some acute correction of the hind foot varus and equinus and will shorten the Ilizarov time. Keywords: Neglected clubfoot, Ilizarov external fixator, Minimal invasive surgery.

Introduction: Congenital talipes equinovarus (CTEV) or clubfoot, is one of the most common congenital anomalies involving the musculoskeletal system. This continues to challenge the skills of surgeons, as it has a strong tendency to relapse, regardless of the mode of treatment. Aim of the work: Our aim was to deliver a comprehensive Algorithm to help in the management of different types of clubfoot. Patients and Methods: We reviewed the published algorithms and we found none of them was comprehensive or included all stages of clubfoot. Our aim was to deliver a comprehensive Algorithm to help in the management of different types of clubfoot. We added the age and flexibility of the deformity as determinant factors. We have chosen the age of 4 years as determinant factor as clubfoot has a strong tendency to relapse before four years of age because of the original pathology regardless the mode of treatment. We used it for assessment and decision making of all grades and types of clubfoot. Results: We used this algorithm for management of clubfoot cases since 2011 and till now. It is under observation and evaluation. Pilot study is being conducted nowadays and this is our proposal algorithm for discussion. Conclusion: Our Algorithm is comprehensive and considered the age of the child, flexibility of the deformity, time of intervention, conservative methods e.g. Ponseti technique, other surgical modalities and recurrence or relapse of the deformity. Key words: Clubfoot, Algorithm, Children.

To date, Ponseti method is the gold standard for treatment of idiopathic clubfeet. For non-idiopathic, neglected and relapsed clubfeet after posteromedial release,the result of this method is controversial. Aim of study: Determine the effectiveness of Ponseti casting method in treatment of this kind of clubfeet. Materials and methods:prospective study of 39 patients (60 feet) presented with non-idiopathic(n:26;38 feet), idiopathic neglected(n:6;8 feet) and relapsed (n:7,14 feet) treated by Ponseti method. The patient was assessed in each casting using Pirani score. Number of casts, success rate, rate of recurrences and the need for additional procedures was noted. Minimum follow up was 6 months. The mean follow up was 10 months(6- 26 months).Results: the mean age was 20 months (14 days – 9 years). The average number of cast was 7(4-14):7(5-11) in neglected,6(4-8) in relapsed and 7(4-14) in non-idiopathic clubfeet. Achilles tenotomy (or lengthening for relapsed feet) for hindfoot equinus was performed for all patients. Tibialis anterior transfer was performed when residual dynamic supination was observed (4 cases).In 8 cases,Achilles tenotomy before correction of the other deformities was performed when a stagnation of Pirani score was observed. 4 feet had recurrent clubfoot, 2 was operated on(postero medial release) and 2 managed by Re-Ponseti with good results. 2 feet had recurrent heel equinus managed by re-tenotomy. 2 cases needed lateral arch shortening for residual adductus. Conclusion:Ponseti method for treatment of non-idiopathic, neglected and relapsed clubfeet after posteromedial release needs more cast and additional procedures but it is an effective, non-invasive method with good results.

Introduction: Congenital clubfoot is a common pediatric malformation that affects approximately 0.1% of all births. 80% of the cases appear isolated, while 20% can be secondary or associated with complex syndromes. To date, two genes that appear to play an important role are PTIX1 and TBX4, but their actual impact is still unclear. Our study aimed to evaluate the prevalence of pathogenic variants in PITX1 and TBX4 in Italian patients with idiopathic clubfoot.
Methods and Results: PITX1 and TBX4 genes were analyzed by sequence and SNP array in 162 patients. We detected only four nucleotide variants in TBX4, predicted to be benign or likely benign. CNV analysis did not reveal duplications or deletions involving both genes and intragenic structural variants.
Conclusion: Our data proved that the idiopathic form of congenital clubfoot was rarely associated with mutations and CNVs on PITX1 and TBX4. Although in some patients, the disease was caused by mutations in both genes; they were responsible for only a tiny minority of cases, at least in the Italian population. It was not excluded that other genes belonging to the same TBX4-PITX1 axis were involved, even if genetic complexity at the origin of clubfoot required the involvement of other factors.

Introduction: Joshi's External Stabilization System (JESS) is an external fixator based system to correct different deformities of club foot using differential distraction.Material and methods: 10 difficult clubfeet feet in 15 patients who were untreated, neurogenic or relapsed were treated using JESS between July 2018 to April, 2023. All patients achieved correction of all components of the clubfoot.Results: However, one patient required tibialis anterior transfer for dynamic forefoot adduction at the end of treatment. The mean total duration in JESS fixation was 64 days/foot and the mean time to achieve correction within JESS averaged 46 days. The deformities improved as per Dimeglio score. The objective radiological assessment of the deformities revealed improvements in the talocalcaneal angle on AP view and on lateral view.Conclusion: JESS is an effective method for managing difficult cases of clubfeet.Many surgeons favour differential distraction as it had shown a distinct and rare advantage that in addition to deformity correction; it also produces a cosmetic foot with near normal foot size. With the same concept, we too managed these feet by differential distraction by JESS. As it does not require any open or percutaneous surgical procedure for the deformity correction, it has been labeled as “extended conservative management”.