Pie bot: conceptos actuales / Clubfoot: current concepts

El pie bot es la deformidad congénita más frecuente de las extremidades inferiores del ser humano, afectando a 1 de cada 1000 recién nacidos vivos. Consiste en la presencia de cuatro deformidades estructurales en el pie y el tobillo: cavo del medio pie, aducto del antepié, varo del retropié y pie en equino.Su registro en la humanidad data del siglo XII A.C. en momias del antiguo Egipto.La fisiopatología de esta deformidad aún no está aclarada. El diagnóstico puede ser prenatal mediante visualización ecográfica, pero la forma más común de diagnóstico es postnatal. La evaluación de estos pacientes se basa en la exploración clínica. Entre las clasificaciones más utilizadas se encuentran: Diméglio, que enfatiza lo reductible ante maniobras manuales de la deformidad; Pirani, que evalúa la gravedad inicial y el progreso del tratamiento; y Ponseti International Association (PIA), que clasifica según etiología.Durante el siglo pasado se describieron numerosos procedimientos quirúrgicos, muchos de los cuales fueron quedando en desuso ante sus resultados insatisfactorios, pies rígidos y dolorosos, con función limitada. Actualmente el método Ponseti es el Gold estándar para su tratamiento, consistiendo en una manipulación y enyesado seriado buscando la corrección sistemática del pie, basado en los fundamentos de la cinemática y la fisiopatología de la deformidad.

Clubfoot is the most frequent congenital deformity of the lower extremities of humans, affecting 1 out of 1000 live newborns. It consists of the presence of four structural deformities in the foot and ankle: midfoot cavus, forefoot adductus, hindfoot varus, and equinus foot.Its records in humanity date from the 12th century B.C., in ancient Egyptian mummies.The pathophysiology of this deformity is still unclear. Prenatal diagnosis by ultrasound imaging is feasible, but most common diagnosis is postnatal. The evaluation of these patients is based on clinical examination. Among the most used classifications are: Diméglio, which emphasizes the reductibility with manual maneuvers; Pirani, who assesses initial severity and progress of treatment; and Ponseti International Association (PIA), which classifies according to etiology.During the last century, numerous surgical procedures were described, many of which were disused due to their unsatisfactory results, stiffness and painful feet, with limited functionality. Currently the Ponseti method is the gold standard for its treatment. It consists of serial manipulation and casting, looking for a systematic correction of the deformity, based on the fundamentals of kinematics and pathophysiology of the deformity.

Assessment of severity of clubfoot in walking children by combined multiple tools: A new classification system.

INTRODUCTION: Clubfoot is one of the most common congenital deformities that cause mobility impairment. In developing countries, however, due to lack of appropriate medical care, treatment is either not initiated or incompletely performed. Due to lack of consensus for evaluation of deformities in such patients, there is no standardized treatment protocol yet developed. So, a new evaluation system is devised to assess the deformity in untreated or previously managed conservatively clubfoot of walking children. METHODS: It was a prospective, observational study, conducted from December 2017 to July 2019. Patients from age 1-5 years, with unilateral deformity and previously managed conservatively were included. Patients having atypical clubfoot, syndromic clubfoot, or previously surgically intervened were excluded. Pre-treatment severity was graded with Diméglio score. Anthropometric, Foot Imprinting, Radiographic angles, and Ultrasonographic measurements were taken. Parameters taken were assessed and correlated with gradings of Diméglio score. RESULTS: 37 patients with mean age of 2.14 ± 0.87 years were included. Diméglio score was 11.57 ± 2.15 with 28 patients in 'severe' category. Talocalcaneal index and Tibiocalcaneal angle were correlating with the equinus whereas Bean shape ratio and Talocalcaneal index were correlating with varus deformity. Derotation of calcaneoforefoot block gradings correlating with Foot bimalleolar angle, Talo-first metatarsal angle, and MMN (medial malleolus to navicular distance) Ratio. FBM (Foot Bimalleolar) Angle, Talo-first metatarsal angle, MMN Ratio, and Medial soft tissue thickness were correlating with forefoot adduction. Following the correlation, a new classification system was devised to assess the severity of deformity at presentation. CONCLUSION: It is essential to develop an objective methodology to evaluate the severity of the clubfoot; whether the foot is responding to manipulation and casting; to detect the early signs of recurrences and predict the outcomes. The evaluation system should take into consideration the complex characteristics of the deformity and its three-dimensional aspects.

Clubfoot for the primary care physician: frequently asked questions.

PURPOSE OF REVIEW: This review aims to provide primary care physicians with updates on recent literature regarding clubfoot and answer questions asked by parents and caregivers of children with clubfoot. The topics discussed include prenatal counseling, relapse after Ponseti treatment, long-term outcomes following successful treatment of clubfoot, and the effect of diagnosis and treatment on the parent or caregiver. RECENT FINDINGS: Clubfoot is one of the most commonly searched orthopaedic conditions on the internet by parents. There is a lack of evidence-based guidelines on clubfoot worldwide. Recent systematic reviews have identified emerging evidence of genetic and modifiable risk factors that lead to clubfoot. Patients treated by the Ponseti method show better ankle power and strength compared with those treated with surgery for residual deformity or recurrence. SUMMARY: The treatment of clubfoot is a long and involved process. Exposure to and familiarity with the Ponseti method will aid primary care physicians and parents in the optimization of children's clubfoot deformity correction using largely nonoperative management.

Congenital talipes equinovarus: a systematic review of relapse as a primary outcome of the Ponseti method.

AIMS: The Ponseti method is the benchmark treatment for the correction of clubfoot. The primary rate of correction is very high, but outcome further down the treatment pathway is less predictable. Several methods of assessing severity at presentation have been reported. Classification later in the course of treatment is more challenging. This systematic review considers the outcome of the Ponseti method in terms of relapse and determines how clubfoot is assessed at presentation, correction, and relapse. PATIENTS AND METHODS: A prospectively registered systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that reported idiopathic clubfoot treated by the Ponseti method between 1 January 2012 and 31 May 2017 were included. The data extracted included demographics, Ponseti methodology, assessment methods, and rates of relapse and surgery. RESULTS: A total of 84 studies were included (7335 patients, 10 535 clubfeet). The relapse rate varied between 1.9% and 45%. The rates of relapse and major surgery (1.4% to 53.3%) and minor surgery (0.6% to 48.8%) both increased with follow-up time. There was high variability in the assessment methods used across timepoints; only 57% of the studies defined relapse. Pirani scoring was the method most often used. CONCLUSION: Recurrence and further surgical intervention in idiopathic clubfoot increases with the duration of follow-up. The corrected and the relapsed foot are poorly defined, which contributes to variability in outcome. The results suggest that a consensus for a definition of relapse is needed. Cite this article: Bone Joint J 2019;101-B:639-645.

Prevalence and classification of equinus foot in bilateral spastic cerebral palsy.

BACKGROUND: Equinus is a common deformity in children with bilateral spastic cerebral palsy (BSCP). While dynamic equinus usually is treated by conservative therapy, fixed contractures need surgical correction. To choose the appropriate surgical method, it is important to discriminate between isolated gastrocnemius shortening and combined gastrosoleus complex contracture. METHODS: In a retrospective study 938 patients with BSCP were studied. Patients underwent gait analysis and clinical examination. 248 patients (496 limbs) met the inclusion criteria. Data from motion analysis and clinical examination were used to calculate the prevalence and to further classify fixed equinus foot. RESULTS: The prevalence of equinus was 83.3%. During clinical exam 246 (59.6%) limbs showed combined gastrosoleus complex contracture and 167 (40.4%) isolated gastrocnemius contracture. Max. DF at stance and mean DF at initial contact were significantly reduced in combined contracture, while max. ROM was increased (P < 0.05). CONCLUSIONS: Corroborating the results of previous studies, in this study there was a high prevalence of fixed equinus in patients with BSCP. The prevalence of equinus correlated with increasing age. As half of the patients with fixed equinus show a different involvement of gastrocnemius and soleus muscle, we recommend to apply Silfverskiöld's test to discriminate between those two types to choose the appropriate surgical therapy.

[Classification Systems to Evaluate the Clubfoot and Their Potential Use to Predict the Course and the Results of the Ponseti Method Treatment]. / Klasifikacní systémy hodnocení pes equinovarus congenitusa jejich mozné vyuzití v predikci prubehu a výsledku lécby Ponsetiho konceptem.

INTRODUCTION The clubfoot ranks among the most frequent paediatric structural deformities of the lower extremity. Currently, the Ponseti method is considered the gold standard for the treatment. To evaluate the degree and severity of the deformity, clinical classification systems have been developed, commonly used in clinical practice. This study aims to verify whether the Pirani and Dimeglio clinical scoring systems can be used to predict the results of treatment by the Ponseti method. MATERIAL AND METHODS The study included 31 patients. The patients had been referred from the neonatal departments to the Department of Paediatric Surgery, Orthopaedics and Traumatology in Brno with the diagnosed clubfoot deformity, where they were treated by an erudite orthopaedist experienced in this field according to the Ponseti treatment standards. The Pirani and Dimeglio clinical scoring of the deformity were performed always before the commencement of the therapy and after the second plaster cast fixation. The number of plaster cast fixations, the necessity to carry out achillotomy and the relapse rate were set as the parameters of treatment results. In the first stage of statistical analysis, the respective clinical systems were correlated with the treatment results, in the second part of the study the patients were based on the clinical evaluation divided into 3 groups depending on the severity of the deformity, and these groups were subsequently compared. RESULTS 22 patients from the group (71%) underwent percutaneous achillotomy and in 3 patients (9.7%) a relapse occurred. To correct deformities 7.1 corrective casts were used on average. The correlation between the number of plaster cast fixations and classification systems was significant in all the cases, with the strongest dependency shown by the correlation with the Pirani score after the second corrective cast (r = 0.594, p < 0.001). Positive correlation was found also between the necessity to perform achillotomy and both the classification systems. In this case the strongest correlation was established in the case of the Pirani clinical scoring after the second plaster cast fixation (r = 0.488, p = 0.003). Conversely, significant correlation was not established between the relapse rate and the used classification systems, not even in a single case (p ≥ 0.05). In the second stage of the statistical analysis, in the case of the Pirani scoring before the therapy no difference was found between the individual groups with diverse severity of clubfoot deformity during the evaluation of the aforementioned parameters of treatment results. In the Pirani classification after the second plaster cast fixation, a statistically significant difference was established in the number of plaster cast fixations (p = 0.003) and the necessity to perform achillotomy (p = 0.012). When the Dimeglio scoring was applied before the therapy, a statistically significant difference between the groups was found in the number of plaster cast fixations (p = 0.031) and after the second plaster cast fixation in the relapse rate (p = 0.035). DISCUSSION Although the clinical scoring systems belong to key indicators of severity of the deformity and are commonly used in clinical practice, the current literature provides only an inconsistent picture of their application in predicting the course and the results of treatment. Concurrently, the authors opinions on this issue differ. The scoring in later stages of treatment shows a better predictive value than the scoring at the beginning of the treatment, which was confirmed also by the results of our study. CONCLUSIONS Even though the clinical scoring systems show a certain dependency on the parameters of the treatment results, in practice their predictive function can be used to a limited degree only. The complexity of the evaluation of the deformity itself and subsequently of the results of treatment requires also the use of other parameters than the clinical classifications only so that the prediction of the course and results of the treatment of clubfoot according to Ponseti shows a higher degree of reliability. Key words:clubfoot, Ponseti, Pirani classification, Dimeglio classification.

Gross Motor Function at 10 Years of Age in Children With Clubfoot Following the French Physical Therapy Method and the Ponseti Technique.

PURPOSE: To evaluate gross motor skills [Bruininks-Oseretsky Test of Motor Proficiency, 2nd ed (BOT-2)] of patients with idiopathic clubfoot initially treated nonoperatively with either the French functional physical therapy (PT) method or the Ponseti technique, at age 10 years. METHODS: The BOT-2 was administered by trained physical therapists on patients with idiopathic clubfoot at age 10 years. The cohort was divided by initial treatment method (PT or Ponseti), and compared. Subsequent analyses included comparisons of: initial clubfoot severity (Dimeglio scores: ≤13 vs. >13), laterality (unilateral vs. bilateral), and surgical versus nonoperative outcome. RESULTS: Of the 183 patients tested, 172 were included. The Ponseti and PT groups did not significantly differ according to age, height, weight, body mass index, ankle dorsiflexion, sex, average initial Dimeglio score, laterality, or surgical versus nonsurgical outcome. Overall, patients with treated clubfoot had average gross motor BOT-2 scores compared with age-matched peers. Patients in the PT group scored higher on Running Speed/Agility (P=0.019), Body Coordination percentile rank (P=0.038), and Strength and Agility percentile rank (P=0.007) than patients treated by the Ponseti technique. Patients with bilateral clubfoot scored significantly lower on the Balance subtest (P<0.01), and Body Coordination percentile rank (P<0.01), than those with unilateral clubfoot. Patients who required surgery scored significantly lower on the Balance subtest (P=0.04) than those who did not require surgery. CONCLUSIONS: Clubfoot may impair balance in 10 year olds with bilateral involvement and those requiring surgery. Future research should evaluate whether components of the PT method may improve gross motor outcomes as a supplement to the Ponseti technique. LEVELS OF EVIDENCE: Level II.

Correlations between physical and ultrasound findings in congenital clubfoot at birth.

BACKGROUND: At birth, clinical classifications are the only available tools for evaluating the severity of congenital clubfoot. Ultrasound provides an assessment of the anatomical abnormalities. The objective of this study was to assess correlations between physical and ultrasound findings at birth. HYPOTHESIS: Physical and ultrasonography provide different findings in congenital clubfoot and should therefore be used in conjunction. MATERIAL AND METHOD: One hundred and forty-five clubfeet in 108 patients born between 2006 and 2010 were included in a retrospective study. Clubfoot severity was classified using two methods, the modified Dimeglio classification based on physical findings and an ultrasound score based on the talo-navicular angle (TNA) and metaphyso-talo-calcaneal angle (MTCA). Each of these two methods distinguished three severity grades. Agreement between the two methods was assessed by computing the coefficient. RESULTS: The results confirmed the hypothesis by showing low agreement between the clinical and ultrasound classifications. The severity grades were identical with the two methods for only 83/145 (57%) feet. The coefficient was 0.086. DISCUSSION: The two ultrasound views used to measure the TNA and MTCA, respectively, added an assessment of the three main deformities that characterise congenital clubfoot (equinus, adduction of the forefoot, and adduction of the calcaneo-pedal unit). Ultrasonography complements the physical examination at birth. In the future, using both physical examination and ultrasound scanning to monitor babies with clubfoot may allow early treatment adjustments aimed at optimising the outcome. LEVEL OF EVIDENCE: IV, retrospective observational study.

The Influence of Sex and Laterality on Clubfoot Severity.

BACKGROUND: Idiopathic clubfoot is bilateral in approximately 50% of cases and has been widely reported to affect males more frequently than females. Despite these observations, the correlation between sex and severity of the deformity has not been established. As well, the difference in severity between unilateral and bilateral clubfeet has not been extensively investigated. Therefore, the goals of the present study were to: (1) examine the relationship between sex and severity of deformity and (2) determine the relationship between laterality and severity of deformity. METHODS: The families of infants with idiopathic clubfoot deformity treated at our institution were prospectively invited to participate in this institutional review board-approved study. Severity of the deformity was assessed by a single surgeon for each patient using the Dimeglio criteria at the first clinic visit. After evaluating the distributions, the correlations were quantified by nonparametric analyses. RESULTS: Over 8 years, 240 infants met the inclusion criteria. There was no significant difference in the severity of deformity due to sex (P=0.61): the median Dimeglio score for males was 13 (variance 4.8) and for females, the median was 13.0 (variance of 5.1). In contrast, severity was distributed differently among unilateral versus bilateral patients. Although both unilateral and bilateral patients had a median Dimeglio score of 13, the ratio of bilateral patients was higher among those with moderate or very severe deformities compared with those with severe deformities (P<0.01). CONCLUSIONS: Although idiopathic clubfoot is commonly considered to affect male patients disproportionately, this is the first study to document no difference in severity due to sex. Further, this study demonstrated that on average, bilateral patients did not have increased severity, but presented with a larger range of severity than those patients with unilateral deformity. LEVEL OF EVIDENCE: Level III-prognostic.

Current conservative management and classification of club foot: A review.

Clubfoot, known as congenital talipes equinovarus, is one of the complex paediatric foot deformity with the incidence of 1 in every 1000 live births. It consists of four complex foot abnormalities such as forefoot adductus, midfoot cavus, and hindfoot varus and ankle equinus. There are a number of surgical techniques (soft tissue releases, arthrodesis) used to correct clubfoot. However currently the conservative management (manipulation, serial casting, and braces) of clubfoot is considered as the best choice and it is widely accepted among orthopaedists. Clubfoot treated with surgical techniques might suffer various complications such as soft tissues contractures, neurovascular complications, infections, and shortening of the limbs. Although conservative method is generally considered as an effective method, it is still challenging to cure clubfoot in advance stages. Also, the classification of the initial severity of clubfoot is essential to evaluate the outcome of the treatment. In this review, the aim is to review the different types of conservative method and the assessment of clubfoot severity.

What's New in Idiopathic Clubfoot?

This update summarizes selected research highlights pertaining to idiopathic clubfoot deformity that were published in peer-reviewed journals between January 2010 and December 2013.

A Clinical Evaluation of the Pirani and Dimeglio Idiopathic Clubfoot Classifications.

The clubfoot classifications described by Pirani and by Dimeglio are in widespread use today in foot and ankle surgical practice and are used to differentiate between lesions and compare treatment results. The aim of the present study was to determine whether in an independent center, one or both classification systems can be implemented practically and in a reproducible manner. From January 2004 to January 2014, we conducted a prospective study concerning the classification systems for clubfoot. The study group included 280 children (411 feet). The mean Dimeglio score noted by the 2 examiners was 10.3 ± 0.69 and 10.6 ± 0.81 points for the 411 feet, respectively. The mean difference in the Dimeglio scoring system was 1.11 ± 0.43 points (95% confidence interval 1.5 points). The Pearson correlation coefficient was 0.85. The corresponding mean Pirani scores were 5.1 ± 0.23 and 5.3 ± 0.17 points for the 411 feet. The mean difference in the Pirani score was 0.65 points (95% confidence interval 0.45 points). The Pearson correlation coefficient was 0.89. The good correlation coefficient for the Dimeglio and Pirani systems recommends their simultaneous use in clubfoot examinations, because the aspects under investigation (reducibility and foot aspect) are both different and complementary.

Correlation of Pirani and Dimeglio scores with number of Ponseti casts required for clubfoot correction.

BACKGROUND: A number of grading systems for severity of clubfoot have been reported in the literature, but none are universally accepted. The aim of this study was to find the correlation between 2 of the most widely utilized classification systems (the Pirani score and the Dimeglio score) with number of Ponseti casts required to achieve initial clubfeet correction. METHODS: A retrospective study of prospectively collected data was performed. All clubfeet assessed at our dedicated clubfoot clinic from January 2007 to December 2011 were included. Clubfoot severity was assessed using both the Pirani score and the Dimeglio score. The total number of casts was calculated from the first cast to the time of initiation of the foot abduction orthosis. RESULTS: The mean number of Ponseti casts required to achieve initial correction was 5.8 (range, 2 to 10 casts). A low correlation (rs 0.21) was identified when the total Dimeglio score was compared with the number of casts. No correlation (rs 0.12) was identified between the Pirani score and the number of casts. CONCLUSIONS: The Dimeglio and Pirani scores remain the most widely accepted clubfoot severity grading systems. However, their prognostic value remains questionable, at least in the early treatment stages. LEVEL OF EVIDENCE: Prognostic study level II.

Photographic recording of the features of the Pirani classification for club feet--a case study.

Club foot is a common congenital abnormality, and a complex deformity. In the past twenty years, the deformity has been better classified by considering the different components of deformity. The Pirani scoring system is widely used--and analogous standardised photographic views can be used to document this condition and its progress. Here I describe four views that aid in deformity assessment, correlating to component deformities assessed in the Pirani score.

Prospective evaluation of a prenatal sonographic clubfoot classification system.

BACKGROUND: The purpose of this study was to prospectively evaluate our recently described fetal sonographic classification system for prenatal diagnosis of clubfoot. METHODS: Over 18 months, we prospectively enrolled consecutive pregnant patients evaluated for a prenatally diagnosed clubfoot. Prenatal sonographic scores assigned by a radiologist were compared to final clinical diagnosis and severity given by a pediatric orthopedic surgeon. Pearson's χ(2) test and logistic regression were used in statistical analyses on the subject level. Generalized estimating equations were used in analyses on the foot level to account for intrasubject correlation. RESULTS: There were 50 subjects, with 26 unilateral and 24 bilateral clubfeet, according to the prenatal ultrasound (US). A total of 51 (69%) of 74 feet and 36 (72%) of 50 subjects had a postnatal diagnosis of clubfoot. The accuracy of diagnosis in cases of a severe, moderate, and mild US score was 94, 70, and 25%, respectively (p = 0.003 comparing moderate-severe vs. mild). US severity correlated with the Dimeglio classification scoring system (Spearman's correlation 0.30). CONCLUSION: The fetal sonographic scoring system is predictive of clinical severity after birth, and improves the ability to counsel families with a prenatal diagnosis of clubfoot.

3D MRI analysis of the lower legs of treated idiopathic congenital talipes equinovarus (clubfoot).

BACKGROUND: Idiopathic congenital talipes equinovarus (CTEV) is the commonest form of clubfoot. Its exact cause is unknown, although it is related to limb development. The aim of this study was to quantify the anatomy of the muscle, subcutaneous fat, tibia, fibula and arteries in the lower legs of teenagers and young adults with CTEV using 3D magnetic resonance imaging (MRI), and thus to investigate the anatomical differences between CTEV participants and controls. METHODOLOGY/PRINCIPAL FINDINGS: The lower legs of six CTEV (2 bilateral, 4 unilateral) and five control young adults (age 12-28) were imaged using a 3T MRI Philips scanner. 5 of the CTEV participants had undergone soft-tissue and capsular release surgery. 3D T1-weighted and 3D magnetic resonance angiography (MRA) images were acquired. Segmentation software was used for volumetric, anatomical and image analysis. Kolmogorov-Smirnov tests were performed. The volumes of the lower affected leg, muscle, tibia and fibula in unilateral CTEV participants were consistently smaller compared to their contralateral unaffected leg, this was most pronounced in muscle. The proportion of muscle in affected CTEV legs was significantly reduced compared with control and unaffected CTEV legs, whilst proportion of muscular fat increased. No spatial abnormalities in the location or branching of arteries were detected, but hypoplastic anomalies were observed. CONCLUSIONS/SIGNIFICANCE: Combining 3D MRI and MRA is effective for quantitatively characterizing CTEV anatomy. Reduction in leg muscle volume appears to be a sensitive marker. Since 5/6 CTEV cases had soft-tissue surgery, further work is required to confirm that the treatment did not affect the MRI features observed. We propose that the proportion of muscle and intra-muscular fat within the lower leg could provide a valuable addition to current clinical CTEV classification. These measures could be useful for clinical care and guiding treatment pathways, as well as treatment research and clinical audit.

Farriery for the hoof with a high heel or club foot.

A club foot or flexural deformity may affect a horse at any stage of life from neonate through adulthood. The emphasis of this article is on defining and recommending the appropriate farriery for flexural deformities involving the deep digital flexor tendon and the distal interphalangeal joint. Clinical management of the flexural deformity is influenced by the severity, duration, and etiology of the club foot as well as the degree and source of lameness. Also discussed is the management of mismatched hoof angles, which remains a controversial subject for both farrier and veterinarian.

Correlation of foot bimalleolar angle with Pirani score to assess the severity of congenital talipes equinovarus deformity.

Various reported scores for congenital talipes equinovarus are presented with observer variations and lack in objective evidence of severity of deformity. Anteromedial foot bimalleolar angle (FBM), an objective assessment of deformity and correction, was correlated and compared with Pirani scores 0.5-2, 2.5-4, 4.5-6 as grouped I to III for mean and SD in 244 club feet in 137 children. The mean FBM angles of groups I to III were 79.72°, 68.4°, and 53.27°, respectively. The FBM angle gives an objective assessment of the severity of deformity and can be used as objective evidence of improvement/deterioration of deformity.

Initial severity rating of idiopathic clubfeet is an outcome predictor at age two years.

This study was performed to determine if rating the severity of clubfeet before Ponseti treatment was predictive of the outcomes at age two years. Four hundred and seventy-nine idiopathic clubfeet (323 patients) were numerically rated for severity using Dimeglio classification. Eighty-six feet rated moderate, 305 feet rated severe, and 88 feet rated very severe. Outcomes were classified as Good (plantigrade foot with or without a tendoachilles lengthening), Fair (limited surgery), or Poor (posteromedial release). Significant correlation existed between initial severity of the foot and outcomes, with moderate better than severe and very severe, and severe better than very severe. Initial numerical severity rating strongly correlated with the probability of a good outcome (P<0.0001). Evaluating the severity of clubfeet before Ponseti treatment provides prognostic information for parents.

[Results of the Ponseti treatment evaluated at four to six years after it started]. / Výsledky Ponsetiho metody v odstupu 4 az 6 let od zacátku terapie.

PURPOSE OF THE STUDY: To assess outcomes of the Ponseti method for treatment of talipes equinovarus in relation to patient age at its start. MATERIAL AND METHODS: In the 2006-2010 period, 115 children (163 feet) with talipes equinovarus were treated using the principles of Ponseti. The right foot was affected in 44, the left foot in 23, and the bilateral form was treated in 48 patients. In order to obtain results for at least 3 years of follow-up, we included the patients treated by the Ponseti method between 2006 and 2008, in whom 83 affected feet were analysed (23 isolated right feet, 14 left feet, 23 bilateral forms). According to the Dimeglio scoring system used to assess the severity of clubfoot deformity, there were four feet in group II, 37 feet in group III and 42 feet in group IV. RESULTS: Subtalar release was performed in 29 feet (34.9%), in two feet being only posterior. Moreover, foot deviations, e.g. adduction of the forefoot less than 10° (5 feet, 6%), varus deformity of the heel less than 5° (6 feet, 7.2%), and failure to complete the Ponseti treatment (3 feet, 3.6%) were recorded. For assessment of the effect of age at start of casting on the outcome, two patient subgroup were distinguished: group 1, the treatment stared and continued in the first 8 postnatal weeks; group 2, the treatment was initiated and carried out between 9 and 20 weeks postnatally. Subsequently, subtalar release was performed in 18 of 61 feet (29.5%) in group 1, and in 11 of 21 feet (52.4 %) in group 2. Using Fischer's exact test, the difference was found statistically significant. (p<0.05). Of the three patients with an unfinished course of initial treatment, two underwent subtalar release later and one was lost to follow-up. DISCUSSION: Contrary to many recent reports, the frequency of Ponseti treatment failure in this study is substantially higher. Nevertheless, we adhered strictly to the Ponseti protocol of treatment, tenotomy was performed under general anaesthesia and Ponseti splinting was maintained properly in all but seven patients (8.4%). CONCLUSIONS: Irrespective of rather frequent failure of the initial Ponseti treatment, its contribution for the patient is beneficial as it can reduce the extent of subtalar release required. However, a modern family will hardly accept several years of applying splints every night, irrespective of maximally sophisticated bracing. This becomes critical usually at the age when the child starts walking. Nowadays, families cooperate quite well due to the fact that a new method with high mass-media coverage has been offered to them.