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BACKGROUND: The Ponseti method for treating clubfoot consists of initial treatment with serial casting accompanied by achillotenotomy if needed, followed by the maintenance phase including treatment with a foot abduction orthosis (FAO) for at least four years. This study aimed to examine the duration, course, and outcome of orthotic treatment in children with clubfoot. METHODS: 321 children with clubfoot, born between 2015 and 2017, registered in the Swedish Pediatric Orthopedic Quality Register (SPOQ), were included in this prospective cohort study. Data on deformity characteristics and orthotic treatment were extracted. For children with bilateral clubfoot, one foot was included in the analysis. RESULTS: Of the 288 children with isolated clubfoot, 274 children (95.5%) were prescribed an FAO, and 100 children (35%) changed orthosis type before 4 years of age. Of the 33 children with non-isolated clubfoot, 25 children (76%) were prescribed an FAO, and 21 children (64%) changed orthosis type before 4 years of age. 220 children with isolated clubfoot (76%), and 28 children with non-isolated clubfoot (84%) continued orthotic treatment until 4 years of age or longer. Among children with isolated clubfoot, children ending orthotic treatment before 4 years of age (n = 63) had lower Pirani scores at birth compared to children ending orthotic treatment at/after 4 years of age (n = 219) (p = 0.01). It was more common to change orthosis type among children ending orthotic treatment before 4 years of age (p = 0.031). CONCLUSIONS: The majority of children with clubfoot in Sweden are treated with an FAO during the maintenance phase. The proportion of children changing orthosis type was significantly greater and the Pirani score at diagnosis was lower significantly among children ending orthotic treatment before 4 years of age. Long-term follow-up studies are warranted to fully understand how to optimize, and individualize, orthotic treatment with respect to foot involvement and severity of deformity. LEVEL OF EVIDENCE: II.

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The Ponseti method of clubfoot treatment involves two phases: initial correction, usually including tenotomy; and bracing, to maintain correction and prevent relapse. Bracing should last up to four years, but in Uganda, approximately 21% of patients drop from clinical oversight within the first two years of using the brace. Our study compared 97 adherent and 66 non-adherent cases to assess the influential factors and effects on functional outcomes. We analyzed qualitative and quantitative data from clinical records, in-person caregiver interviews, and assessments of foot correction and functionality. Children who underwent tenotomy had 74% higher odds of adherence to bracing compared to those who did not undergo tenotomy. Conversely, children from rural households whose caregivers reported longer travel times to the clinic were more likely to be non-adherent to bracing (AOR 1.60 (95% CI: 1.11-2.30)) compared to those without these factors. Adhering to bracing for a minimum of two years was associated with improved outcomes, as non-adherent patients experienced 2.6 times the odds of deformity recurrence compared to adherent patients. Respondents reported transportation/cost issues, family disruptions, and lack of understanding about the treatment method or importance of bracing. These findings highlight the need to address barriers to adherence, including reducing travel/waiting time, providing ongoing education for caregivers on bracing protocol, and additional support targeting transportation barriers and household complexities.

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PURPOSE: There is however gross ambiguity regarding the use of term "foot abduction" in clubfoot treatment. We measured below defined angles at different stages of clubfoot treatment to decipher their precise interpretation. METHODS: In a prospective evaluation of 25 unilateral clubfeet in infants' age less than six months treated with Ponseti technique, clinical leg foot and thigh foot angle were measured at talar head reduction (LHT0), pre-tenotomy, and post-tenotomy stage. A "normal" reference was available in the form of measurements of contralateral limb. RESULTS: Talar head (LHT0) was reduced at mean leg foot angle of 26 degrees. The corresponding pre- and post-tenotomy angles were 42.6 and 50.0 degrees, respectively. The reference leg foot angles for contralateral limb were 49.8 degrees. The thigh foot angle for LHT0, pre-tenotomy, post-tenotomy, and contralateral side were, respectively, 39.2, 56, 68, and 65.6 degrees. There was an additional tibial external rotation component of mean 13.4 degrees (SD 4.5) in the thigh foot angle when compared to the leg foot angle at tenotomy. This increased to 18 degrees (SD 3.4) post-tenotomy. CONCLUSIONS: The study suggested that the foot abduction described in the "Ponseti Manual" probably intends thigh foot rather than leg foot angles. There was a significant difference in the angles when talar head reduced and tenotomy was decided. The foot abduction is an ambiguous term which should be replaced by the more specific leg or thigh foot abduction angle.

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PURPOSE: Quantifying the quality of life in clubfoot patients during bracing following the Ponseti method compared with healthy controls. METHODS: Data collected during the brace period of the Ponseti method and of a reference sample was retrospectively analyzed to investigate health-related quality of life scale (TAPQOL) in clubfoot patients compared with healthy controls. The TAPQOL instrument consists of 12 subscales comprising the 4 domains of health-related quality of life namely physical, social, emotional and cognitive functioning. RESULTS: Responses of 80 parents of clubfoot patients and 238 parents of healthy controls were analyzed. On average both study groups scored high on the 4 domains of the TAPQOL instrument. The clubfoot group scored significantly (p<0.0125) lower on the subscales motor functioning, sleep, lung and skin problems during bracing. No difference was observed between the study groups in the year the bracing had ended. CONCLUSION: Dutch clubfoot patients show an overall good health related quality of life. However, during the brace phase of the Ponseti treatment they score lower in subscales in the physical functioning domain. These results can be used in the counselling of parent and might alleviate some concerns that parents have about the bracing period. LEVEL OF EVIDENCE: Level III, Case control study.

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AIMS: The aim of this study was to gain an agreement on the management of idiopathic congenital talipes equinovarus (CTEV) up to walking age in order to provide a benchmark for practitioners and guide consistent, high-quality care for children with CTEV. METHODS: The consensus process followed an established Delphi approach with a predetermined degree of agreement. The process included the following steps: establishing a steering group; steering group meetings, generating statements, and checking them against the literature; a two-round Delphi survey; and final consensus meeting. The steering group members and Delphi survey participants were all British Society of Children's Orthopaedic Surgery (BSCOS) members. Descriptive statistics were used for analysis of the Delphi survey results. The Appraisal of Guidelines for Research & Evaluation checklist was followed for reporting of the results. RESULTS: The BSCOS-selected steering group, the steering group meetings, the Delphi survey, and the final consensus meeting all followed the pre-agreed protocol. A total of 153/243 members voted in round 1 Delphi (63%) and 132 voted in round 2 (86%). Out of 61 statements presented to round 1 Delphi, 43 reached 'consensus in', no statements reached 'consensus out', and 18 reached 'no consensus'. Four statements were deleted and one new statement added following suggestions from round 1. Out of 15 statements presented to round 2, 12 reached 'consensus in', no statements reached 'consensus out', and three reached 'no consensus' and were discussed and included following the final consensus meeting. Two statements were combined for simplicity. The final consensus document includes 57 statements allocated into six successive stages. CONCLUSION: We have produced a consensus document for the treatment of idiopathic CTEV up to walking age. This will provide a benchmark for standard of care in the UK and will help to reduce geographical variability in treatment and outcomes. Appropriate dissemination and implementation will be key to its success. Cite this article: Bone Joint J 2022;104-B(6):758-764.

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The recommended treatment for idiopathic congenital clubfoot deformity involves a series of weekly castings, surgery, and a period of bracing using a foot abduction brace (FAB). Depending on the age of the child, the orthotic should be worn for periods that reduce in duration as the child develops. Compliance is vital to achieve optimal functional outcomes and reduce the likelihood of reoccurrence, deformity, or the need for future surgery. However, compliance is typically monitored by self-reporting, which is time-consuming to implement and lacks accuracy. This study presents a novel method for objectively monitoring FAB wear using a single 3-axis accelerometer. Eleven families mounted an accelerometer on their infant's FAB for up to seven days. Parents were also given a physical diary that was used to record the daily application and removal of the orthotic in line with their treatment. Both methods produced very similar measurements of wear that visually aligned with the movement measured by the accelerometer. Bland Altman plots showed a -0.55-h bias in the diary measurements and the limits of agreement ranging from -2.96 h to 1.96 h. Furthermore, the Cohens Kappa coefficient for the entire dataset was 0.88, showing a very high level of agreement. The method provides an advantage over existing objective monitoring solutions as it can be easily applied to existing FABs, preventing the need for bespoke monitoring devices. The novel method can facilitate increased research into FAB compliance and help enable FAB monitoring in clinical practice.

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Background: Congenital clubfoot (congenital talipes equinovarus) occurs in approximately one in 1000 live births and is one of the most common congenital birth defects. The Ponseti method is at present a well-established method of treatment for idiopathic clubfoot deformities. Aim: The aim of the present study was to evaluate the results of serial casting in clubfoot deformity with Ponseti method on the basis of Pirani's scoring and radiological findings before and after completion of treatment. Materials and Methods: A total of 30 patients were enrolled in the study and were treated with Ponseti's casting after grading the severity of deformity clinically by Pirani's scoring and radiological assessment by calculating the talo-first metatarsal angle in anteroposterior (AP) view and talocalcaneal angle in AP and lateral views. The same clinical and radiological assessment was done at the end of treatment before putting a patient on foot abduction orthosis (FAO). Results: The average number of casts applied before full correction was 5.56 (range: 5-8). The average duration of treatment was about 6.65 weeks before the patient was put on FAO. Pirani score significantly improved from an average of 5.50 (range: 4-6) on presentation to 0.24 (range: 0-2) after correction of deformity. Conclusion: The Ponseti method is an excellent method for the correction of all four deformities associated with congenital idiopathic clubfoot, and we found that the addition of radiographic to clinical evaluation helps in the better assessment of correction. It provides statistically significant results both clinically as measured by Pirani severity score and radiologically assessed by talocalcaneal and talo-first metatarsal angle.

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BACKGROUND: Our aims were (a) to determine whether subtalar arthroereisis (STA) as adjunct procedure improved radiographic correction of stage IIb adult-acquired flexible flatfoot deformity (AAFD); (b) to assess the STA-related complication rate. METHODS: A retrospective analysis of 22 feet (21 patients) diagnosed with stage IIb AAFD treated by medializing calcaneal osteotomy (MCO), flexor digitorum longus (FDL) transfer, spring ligament (SL) repair with or without Cotton osteotomy and with or without STA in a single institution was carried out. Seven measurements were recorded on pre- and postoperative (minimum 24 weeks) radiographs by 2 observers and repeated twice by 1 observer. Inter- and intraobserver reliabilities were assessed. The association of demographic (gender, side, age, body mass index) and surgical variables (Cotton, STA) with radiographic change was tested with univariate analysis followed by a multivariable regression model. RESULTS: Excellent inter- and intraobserver reliabilities were demonstrated for all measurements (intraclass correlation coefficient range, 0.75-0.99). Gender, side, Cotton osteotomy, and STA were included in the multivariable analysis. Regression showed that STA was the only predictor of change in talonavicular coverage angle (TNCA) (R2 = 0.31; P = .03) and in calcaneo-fifth metatarsal angle (CFMA) (R2 = 0.40; P = .02) on dorsoplantar view. STA was associated to a greater change in TNCA by 10.1° and in CFMA by 5°. Four patients out of 12 STA complained of sinus tarsi pain after STA, and removal of the implant resolved symptoms in 3 of them. CONCLUSION: In this series, STA as an adjunct procedure to MCO, FDL transfer, SL repair in the treatment of stage IIb AAFD led to improvement in correction of forefoot abduction. STA-related complication and removal rates were 33%. LEVELS OF EVIDENCE: Level IV: Retrospective cohort study.

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PURPOSE: Recurrences following clubfoot correction by the Ponseti method can be prevented by regular use of a foot abduction brace (FAB) until the child is four to five years old. However, there is a 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 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: Infrared sensors were used 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 existing 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 in a pre-clinical setting, demonstrating feasibility in clinical practice. CONCLUSION: The low-cost SMART brace prototype that we have developed 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.

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PURPOSE: We measured the foot size and shoulder width in North Indian children with idiopathic clubfoot and calculated the corresponding metal rod length for abduction brace. The differences in the foot length in unaffected, unilateral and bilateral clubfeet were also measured. PATIENT AND METHODS: Two sets of measurements were taken on each child: feet size and shoulder width. Using statistical analysis, the following were compared: Differences in the manual prescribed and our calculated SFAB bar length, foot size in unilateral clubfoot and unaffected foot and both feet in bilateral clubfoot. RESULTS: There were 156 patients with 76 unilateral (37 left + 39 right) and 80 bilateral feet. The mean prescribed bar length for foot sizes 8-14 in the Steenbeek manual is 30.18 cm. The mean predicted bar length worked out to be 22.33 cm in our series (p < 0.001). In unilateral clubfoot, the mean foot length (11.9 cm) when matched with unaffected foot (12.6 cm) was comparable (p = 0.08). Bilateral clubfeet lengths (12.29 cm versus 12.3 cm) were also comparable (p = 0.978). CONCLUSIONS: There was significant difference between the prescribed and the predicted bar length in foot sizes 8-14 with a smaller bar length measurement of Indian children. The Ponseti treated unilateral club foot length matched the unaffected foot. The foot lengths in bilateral feet disease were also similar.

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PURPOSE: We prospectively investigated the foot abduction characteristics following Steenbeek foot abduction brace (SFAB) use in corrected clubfeet. The foot abduction achievable in SFAB with knee flexion and extension was calculated to find the effectiveness and stretch exerted by it. METHODS: Only children with corrected idiopathic clubfeet using SFAB for greater than 3 months were enrolled. The foot abduction with and without brace in knee extended and flexed positions was measured. Hip range of motion (ROM) with and without brace was also recorded. RESULTS: The average age of 42 children ( 62 feet) was 24.25 months (range: 5-48 months). There was difference in foot abduction of 22.2° in knee extension and flexion with SFAB on. A significant change in foot stretch of 25.5° observed when the knee was moved from extended to flexed position indicated SFAB dynamicity. The SFAB was found to be an effective orthosis as it brought the corrected clubfoot into maximum abduction permissible in the foot during the phase of knee flexion. The tibial rotation accounted for a major component (61%) of apparent foot abduction with the brace on. A hip ROM of 52.2° was required for SFAB function. CONCLUSION: SFAB is a dynamic brace that functions better in flexed knee position. It is able to induce a near equivalent actual abduction available in the foot in flexed position of knee. There is a significant component of tibial external rotation in SFAB-induced foot abduction. SFAB function is also dependent on hip mechanics.

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PURPOSE: Steenbeek foot abduction brace (SFAB) has been widely used in various national clubfoot programs. The aim of the study was to define effectiveness and dynamicity of SFAB in terms of dorsiflexion and pronation for the corrected clubfoot. METHODS: Differences in foot dorsiflexion and pronation measurement with brace in knee flexed and extended position were recorded as dynamicity1 and dynamicity2, respectively. The residual soft tissue stretch lag despite brace use was calculated by determining the difference between maximum foot dorsiflexion (stretchlag1) and pronation (stretchlag2) achievable without and with brace in knee flexed. Statistical difference between measurements were calculated using paired t tests. RESULTS: There were a total of 63 feet in 40 patients. The mean foot dorsiflexion with brace on in knee extension was 7.57° and in flexion was 15.20°. The foot pronation with brace on in knee extension was 9.46° and in flexion was 16.77°. Thus, SFAB exerted statistically significant differences in foot dorsiflexion and pronation between the knee extended and flexed positions. Dynamicity1 and dynamicity2 were 7.63° and 7.31°, respectively. Stretchlag1 was 18.47° and stretchlag2 was 17.63°. CONCLUSIONS: SFAB demonstrates effective dynamicity in maintaining corrected foot dorsiflexion and pronation. There is a residual soft tissue stretch lag both in dorsiflexion and pronation in corrected clubfoot despite use of SFAB. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

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UNLABELLED: Introduction The purpose of this study was to determine whether foot abduction and heel angles have any influence on resultant equinus correction and whether hindfoot dorsiflexion can be predicted based on these parameters.Material and Methods Twenty-four children with 39 unintervened idiopathic clubfeet who completed Ponseti's casting and percutaneous Achilles tenotomy with satisfactory equinus correction (≥15°) were included. Measurements included foot abduction and heel angle at the beginning of cast treatment, pre-tenotomy, and post-tenotomy along with post-tenotomy hindfoot dorsiflexion. Statistical relationships were calculated using Pearson's coefficients.Results The changes in heel angle correlated better with post-tenotomy dorsiflexion achieved than changes in foot abduction. Pre-tenotomy foot abduction or heel angle did not have any statistically significant correlation with post-tenotomy dorsiflexion. Furthermore, there was a significant relationship between post-tenotomy foot abduction and post-tenotomy dorsiflexion.Conclusions Changes in foot abduction and heel angle (from initial casting to pre-tenotomy measurement) statistically correlated to post-tenotomy hindfoot dorsiflexion achieved. Absolute degree measurements of pre-tenotomy abduction or heel valgus did not correlate with the post-tenotomy hindfoot dorsiflexion achieved. There was also significant correlation between post-tenotomy abduction and post-tenotomy hindfoot dorsiflexion. Correlation between post-tenotomy heel valgus and post-tenotomy hindfoot dorsiflexion was weak. LEVELS OF EVIDENCE: Prognostic, Level II: Prospective study.

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Ponseti clubfoot treatment has become more popular during the last decade because of its high initial correction rate. But the most common problem affecting the long-term successful outcome is relapse of the deformity. Non-compliance with Ponseti brace protocol is a major problem associated with relapse. Although more comfortable braces have been reported to improve the compliance, they all have the same design and no significant changes have been made to the protocols. After refinement in the Ponseti method and emphasizing the importance of brace to parents, the relapse rate has been markedly decreased. Nevertheless, there are patients who do not have any recurrence although they are not completely compliant with the brace treatment, whereas other patients have a recurrence even though they are strictly compliant with the brace treatment. The aim of this article is to review the relapse of clubfoot and the function of the brace and to develop an individualized brace protocol for each patient by analyzing the mechanism of the brace and the biomechanical properties of muscles, tendons, and ligaments.

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Ponseti clubfoot treatment has become more popular during the last decade because of its high initial correction rate. But the most common problem affecting the long-term successful outcome is relapse of the deformity. Non-compliance with Ponseti brace protocol is a major problem associated with relapse. Although more comfortable braces have been reported to improve the compliance, they all have the same design and no significant changes have been made to the protocols. After refinement in the Ponseti method and emphasizing the importance of brace to parents, the relapse rate has been markedly decreased. Nevertheless, there are patients who do not have any recurrence although they are not completely compliant with the brace treatment, whereas other patients have a recurrence even though they are strictly compliant with the brace treatment. The aim of this article is to review the relapse of clubfoot and the function of the brace and to develop an individualized brace protocol for each patient by analyzing the mechanism of the brace and the biomechanical properties of muscles, tendons, and ligaments.

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