Reproducibility of pop sensation, Thompson sign in achillotomy, and final Pirani score to predict clubfoot relapse: Achillotomy clinical signs and Pirani predictive ability.

Ultrasound (US) can guide and confirm percutaneous release of the achilles tendon in the clubfoot. However, this technique may not always be available; therefore, surgeons' reported feelings of tendon release ("click" or "pop") and the Thompson sign could demonstrate that they are sensitive and reliable for confirming complete tendon release. The purpose of this study was to compare the reproducibility of clinical maneuvers that aim to detect the reported "click" or "pop" sensation by the surgeon and the Thompson sign after surgical release in percutaneous achilles tenotomy compare with US in patients with clubfoot. A cross-sectional reproducibility study of consecutive patients with idiopathic clubfoot was conducted. All the patients were scheduled to undergo tenotomy in the operating room using the standard percutaneous achilles tenotomy technique under sedation. The surgeon's reported surgical sensation ("click" or "pop") and Thompson signs were compared to the US assessment of the cut. The final Pirani score was used to predict recurrence risk and was correlated with the number of plaster casts and age. Forty-five feet were affected in 30 patients. Eighteen (60%) men. Age range: 1 to 60 months. The sensation of "click" or "pop" was recorded in 38 patients, and complete release was confirmed by US in 37 patients, for a sensitivity (Se) of 0.95 and specificity (Sp) of 0.63. Thompson signs were positive in 33 and 36 patients at 2 evaluations, with Se values of 0.87 and 0.92 and Sp values of 0.88 and 0.75, respectively. The Pirani final score, a predictor of recurrence risk, had an area under the curve of 0.80 (95% CI = 0.63-0.97; P = .005), Se = 0.78, and Sp = 0.56, with a cutoff point of 2.75. The feeling of achilles tendon release and Thompson sign had high sensitivity, prevalence, accuracy, and posttest probability. The confirmation of tendon release based on clinical signs could prevent the use of US.

Anatomical study of the motor branches of the tibial nerve and incision design for hyperselective neurectomy.

PURPOSE: Selective tibial neurotomy (STN) is a surgical procedure for treating spastic equinovarus foot. Hyperselective neurectomy (HSN) of tibial nerve is a modified STN procedure, which was rarely discussed. This study aimed to describe the branching patterns of the tibial nerve and propose an optimal surgical incision of HSN for treatment of spastic equinovarus foot. METHODS: Sixteen lower limbs were dissected to determine the various branching patterns of the tibial nerve and categorized according to these branching patterns. The mean distances from the nerve entry points to the tip of femur's medial epicondyle were measured, as well as their percentage to the overall length of the leg. The surgical incision was designed according to the range of these nerve entry points. RESULTS: The tibial nerve sent out proximal and distal motor branches based on their position relative to the soleus muscle's tendinous arch. For proximal motor branches, the branches innervating the medial gastrocnemius, lateral gastrocnemius and proximal soleus were categorized into types I (9/16), II (5/16) and III (2/16). Measurements from the medial epicondyle to the nerve entry points into the medial gastrocnemius, lateral gastrocnemius and proximal soleus ranged from 14 to 33 mm (4-9% of leg length), 22-45 mm (6-12%) and 35-81 mm (10-22%), respectively. Distal motor branches including the distal soleus, posterior tibialis, flexor digitorum longus and flexor hallucis longus, were classified as types A (8/14), B (4/14) and C (2/14), with the distances from their respective terminal points to the medial epicondyle were 67-137 mm (19-39%), 74-125 mm (20-35%), 116-243 mm (33-69%) and 125-272 mm (35-77%). CONCLUSIONS: The motor branches of tibial nerve were classified into two groups and each subdivided into three types. Detailed location parameters may serve as an anatomical basis for designing incision of HSN.

Reliability of Percutaneous Achilles Tenotomy in the Treatment of Idiopathic Clubfoot.

BACKGROUND: Talipesequinovarus is a congenital ankle/foot malformation that commonly affects newborns. In its treatment using the Ponseti method, an Achilles tenotomy is frequently needed to correct residual equinus deformity. Percutaneous (PC) tenotomy is the most commonly used technique and needs to be thoroughly evaluated. The question we needed to answer was: "Does PC Achilles tenotomy result in complete tendon sectioning"? METHODS: This clinical study included 56 idiopathic clubfeet in 36 patients who presented during the first 6 months of life and were treated with Ponseti manipulation and casting followed by PC Achilles tenotomy. PC tenotomy was done under general anesthesia, and Thompson's calf squeeze test was performed intraoperatively just after tenotomy. In case of a negative test (ie, ankle plantar flexion with calf squeeze), the percutaneous incision was extended to assess the cause of the negative test. RESULTS: Forty-nine feet (87.5%) had a complete tenotomy, as evidenced by a positive Thompson's calf squeeze test. While 7 feet (12.5%) showed a negative test, and therefore the percutaneous incision was extended and all were found to have an incompletely divided Achilles tendon. The tendons were then completely divided, after which Thompson's test became positive in all. CONCLUSION: Percutaneous Achilles tenotomy is a reliable procedure, but was found to result in incomplete tendon sectioning in 12.5% of cases, affecting the range of ankle dorsiflexion. Thompson's squeeze test is reliable in picking up cases of incomplete tenotomy after the PC technique, and in these cases the incision should be extended for complete sectioning. LEVEL OF EVIDENCE: Level I.

Correction of Equinus Deformity by Ilizarov Frame Using the Matsushita Method and Achilles Tendon Lengthening: A Case Report.

CASE: The patient was an 18-year-old man who had sustained diaphyseal fractures of the left femur and tibia in a traffic accident and underwent surgery at another hospital. A severe left foot equinovarus deformity developed in the early after surgery. The patient's left foot deformity was addressed using unconstrained gradual external fixator correction (the Matsushita method) in combination with soft-tissue contracture through Achilles tendon lengthening and was maintained after removing the external fixation. CONCLUSION: The Matsushita method can be effective in the correction of post-traumatic equinovarus foot deformities.

The infant with a clubfoot and amniotic bands: a comprehensive understanding and the role of the Ponseti method.

Amniotic band syndrome (ABS) and clubfoot are distinct congenital musculoskeletal conditions that can occasionally co-occur, creating unique challenges in their management. This paper summarizes the comprehensive discussion on the management of amniotic band syndrome (ABS) and clubfoot, emphasizing the critical role of the Ponseti method and the challenges faced in treatment, thereby providing a basis for further research and improved patient care.

El síndrome de banda amniótica (ABS) y el pie zambo son afecciones musculoesqueléticas congénitas distintas que ocasionalmente pueden coexistir, creando desafíos únicos en su manejo. Este artículo resume la discusión exhaustiva sobre el tratamiento del síndrome de bandas amnióticas (ABS) y el pie zambo, enfatizando el papel fundamental del método Ponseti y los desafíos que enfrenta el tratamiento, proporcionando así una base para futuras investigaciones y una mejor atención al paciente.

Investigations and management of complex congenital talipes equinovarus.

Congenital talipes equinovarus (CTEV) is a congenital deformity affecting the feet, commonly idiopathic in nature. We present a previously unreported cause of a non-idiopathic clubfoot and highlight the importance of poor response to initial treatment.A poor response to Ponseti serial casting for CTEV should alert a clinician to the fact that the foot may not be in the 'idiopathic' group and be of a more complex nature. Idiopathic clubfoot should correct with a maximum of eight serial manipulations, cast applications and Achilles tendon tenotomy. If this is not the case, a repeat careful history, full examination, further investigations and review of the treatment method are required.

Simple Talectomy is a Beneficial Surgical Procedure for Talipes Equinovarus and Other Severe Neuromuscular Foot Deformities.

Noninvasive techniques are gold standard to redress Severe Neuromuscular Foot Deformity (SNFD). However, simple talectomy may be considered to obtain a stable, plantigrade, pain-free foot. We present a 10-year follow-up accessing radiological correction rates, functional outcomes, complications, and patient satisfaction. This retrospective case series evaluated talectomies in 2012 to 2022. Simple talectomy was combined with Steinman pin fixation of calcaneus to tibia for approximately 6 weeks. Diagnoses primarily included arthrogryposis multiplex congenita and cerebral palsy. Indications were pain, wounds/pressure marks, severe rigidity, and residual/recurrent deformity. The primary outcome was radiological correction. Tibiotalar angle (TiTa) and tibiocalcaneal angle (TiCa) were measured on mediolateral projections. Secondary outcomes were functional scores of pain/deformity graded as good, fair or poor. Furthermore, validated patient-reported outcome measures, that is, EQ-5D-5L and the Scoliosis Research Society-30 Questionnaire (2 items) assessed health-related quality of life and patient satisfaction. Nineteen talectomies in 11 patients were analyzed. Mean follow-up was 62 months (range 9-112 months). Mean TiTa was 137° (95%CI 128;146). TiCa improved significantly: Mean difference -24° (95%CI -44;-5, p = .02). All feet became plantigrade and pain-free with no skin issues. Functional outcomes were graded as 9/19 good, 10/19 fair and 0/19 poor. Parents/primary caregivers were mainly satisfied. Perceived health was 54 (95%CI 34;75) out of 100 on a visual analogue scale, emphasizing complex medical conditions. In conclusion, simple talectomy is a suitable salvage procedure for SNFD.

Can the Achilles tendon regenerate completely following percutaneous tenotomy in older children with clubfoot?

PURPOSE: The aims of the study were to document the outcomes of percutaneous Achilles tenotomy (pAT) performed in older children with clubfoot, by assessing the clinical, functional and ultrasonographic evidence of Achilles tendon regeneration. METHODS: A retrospective case series of older children with clubfoot treated between August 2011 and July 2020 was studied. Clinical assessment of ankle range of motion and calf strength, functional assessment of triceps surae muscle endurance by single leg heel-rise test, and ultrasonographic assessment of Achilles tendon echotexture and dimensions to assess tendon regeneration were performed. RESULTS: Percutaneous Achilles tenotomy was performed on 31 children (48 clubfeet) at a mean age of 5.24 ± 2.14 years (1-10.2 years). At a mean follow-up of 4.86 ± 1.97 years, all children demonstrated normal calf strength with mean dorsiflexion range of 13.64° (0-25°) and mean plantarflexion range of 37.95° (10-40°). The heel-rise endurance test was completed by 27 children with mean 25.85 heel rises/minute (range 17-30) and mean height of heel rise of 6.29 cm (range 4-10 cm). Normal fibrillar tendinous echotexture with homogenous echogenicity was seen on ultrasonography in 41 feet (85.4%) with mean tendon width of 9.7 mm (3.3-16 mm) and thickness of 5.1 mm (1.8-15 mm), comparable with unaffected feet. CONCLUSIONS: Clinical, functional and ultrasonographic parameters unequivocally demonstrate complete regeneration of the Achilles tendon, when pAT is performed in older children with delayed-presenting idiopathic clubfoot treated using Ponseti principles.

Intraoperative tourniquet-induced hyperthermia in a pediatric patient: a forgotten association -a case report.

BACKGROUND: The intraoperative use of tourniquets is associated with several complications, including hyperthermia. We present the first documented case of tourniquet-induced hyperthermia in a pediatric patient at our institution. CASE: A 5-year-old female with no past medical history underwent tendon release surgery for congenital talipes equinovarus under general anesthesia. Following inflation of a pneumatic tourniquet to a pressure of 250 mmHg on her left thigh, the patient experienced a gradual increase in body temperature. Despite the implementation of cooling measures, the temperature continued to increase until it plateaued. The hyperthermia gradually resolved upon deflation of the tourniquet. CONCLUSIONS: Tourniquet-induced hyperthermia should be considered as a potential cause of intraoperative hyperthermia, particularly in the absence of typical signs of malignant hyperthermia. Early recognition and appropriate management, including deflation of the tourniquet and implementation of cooling measures, are crucial for preventing potential complications associated with hyperthermia.

Talar neck rotation angle in adults with clubfoot deformity: Observed values and intra- and inter-observer reliability using weightbearing CT.

INTRODUCTION: Adults presenting with symptomatic clubfoot represent a challenging cohort of patients. An appreciation of the location and degree of deformities is essential for management. Talar anatomy is often abnormal with varus within the talar neck, however, there are few reproducible methods which quantify talar neck deformity in adults. We describe a technique of assessing talar neck deformity, and report on observed values and intra- / inter-observer reliability. METHODS: This was a single-centre, retrospective study including 96 feet from 56 adult patients with clubfeet (82 feet had clubfoot deformity, 14 were normal). Mean age was 34.3 ± 16.9 years and 31 (55.3%) were male. Weight-bearing CT scans captured as part of routine clinical care were analysed. Image reformats were oriented parallel to the long axis of the talus in the sagittal plane. In the corresponding axial plane two lines were drawn (on separate slices): 1) a line perpendicular to the intermalleolar axis, 2) a line connecting the midpoints of the talar head and narrowest part of the talar neck. The talar neck rotation angle (TNR angle) was the angle formed between these lines. Intraclass correlation coefficients (ICC) were performed for intra- and inter-observer reliability. RESULTS: Mean TNR angle in clubfeet was 27.6 ± 12.2 degrees (95%CI = 25.0 to 30.2 degrees). Mean TNR angle in normal feet was 18.7 ± 5.1 degrees (95%CI = 16.0 to 21.4 degrees) (p < 0.001). The ICC for clubfeet was 0.944 (95%CI = 0.913 to 0.964) for intra-observer agreement, and 0.896 (95%CI = 0.837 to 0.932) for inter-observer agreement. CONCLUSION: This measurement technique demonstrated excellent intra- and inter-observer agreement. It also demonstrated that compared to normal feet, clubfeet had about 9 degrees of increased varus angulation of the talar neck. This technique and data may be used for future research into clubfoot deformity and in planning treatment. LEVEL OF CLINICAL EVIDENCE: 3.

[Correlation analysis between Pirani score and talo-navicular angle,calcaneo-cuboid angle and tibio-calcaneall angle of infant clubfoot under ultrasound].

Objective: To explore the evaluation effect of ultrasonography and Pirani score on tarsal deformity, treatment effect and pseudo-correction of congenital clubfoot in infants and young children, and the correlation between the two methods. Methods: This is a retrospective case series study. The clinical data of 26 children (40 feet) with congenital clubfoot who were evaluated by ultrasonography in the Third Affiliated Hospital of Zhengzhou University from January 2020 to January 2023 were retrospectively collected. There were 16 males and 10 females. The age at the first ultrasound examination was (M(IQR)) 9.0 (18.0) days (range: 1 to 46 days). All patients were treated with Ponseti method by the same physician. The Pirani scores before and after treatment and at the last examination, and the talonavicular angle, calcaneocuboid angle and tibiocalcaneal angle measured by ultrasound were collected, and the treatment and follow-up were recorded. Paired sample t test, repeated measures analysis of variance or Kruskal-Wallis test were used for data comparison, and Spearman correlation analysis was used for correlation analysis. The receiver operating characteristic curve was used to calculate the efficacy of ultrasound in evaluating different Pirani scores. Results: The number of plaster fixation in 26 children was 4.0 (1.0) times (range: 2 to 8 times). The medial talonavicular angle and posterior tibiocalcaneal angle were significantly improved after treatment and at the last follow-up compared with those before treatment, and the differences were statistically significant (all P<0.01). There was no difference in lateral calcaneocuboid angle before and after treatment and at the last follow-up (F=1.971, P>0.05). Pseudo-correction occurred in 2 cases (2 feet) during the treatment, with an incidence of 5%. Correlation analysis showed that there was a moderate positive correlation between talonavicular angle and Pirani midfoot score (r=0.480, P<0.01). There was no correlation between calcaneocuboid angle and Pirani midfoot score (r=0.114, P=0.105). There was a moderate negative correlation between tibial heel angle and Pirani hindfoot score (r=-0.566, P<0.01). The cut-off point of Pirani midfoot score of 1.5 was 38.78°, the sensitivity was 0.90, the specificity was 0.56, and the area under the curve was 0.75. The cut-off value of angle was 27.51 °, the sensitivity was 0.16, the specificity was 0.92, and the area under the curve was 0.44.The cut-off points of Pirani midfoot score of 3.0 were 45.08°and 9.96°, the sensitivity was 0.94 and 0.91, the specificity was 0.37 and 0.42, and the area under the curve was 0.59 and 0.62, respectively. The cut-off values of Pirani hindfoot score of 2.0 and 3.0 were 167.46° and 160.15°, respectively. The sensitivity was 0.75 and 0.67, the specificity was 0.81 and 0.83, and the area under the curve was 0.78 and 0.71, respectively. Conclusion: Ultrasound can complement with Pirani score, visually and dynamically observe the morphology and position changes of talonavicular joint, calcaneocuboid joint and tibiotalocalcaneal joint, monitor the recovery and pseudo-correction of tarsal bones, and better evaluate the therapeutic effect.

The Importance of Having a Single, Dedicated Medical Team to Treat Congenital Talipes Equinovarus Using the Ponseti Method: A Retrospective Analysis of Treatment Outcomes After 3 Years of Follow-up.

BACKGROUND: Congenital talipes equinovarus (CTEV) is a relatively common pediatric orthopaedic disorder and a frequent cause of disability in adult populations. The Ponseti method has emerged as the generally preferred for treating children with CTEV. Strict adherence to this technique's basic principles is critical to achieving favorable outcomes. In 2013, our institution decided that every case of pediatric CTEV would be treated by a single dedicated medical team. The present study aimed to compare the treatment outcomes of children with CTEV treated using the Ponseti method in period I (multiple surgeons) versus those in period II (single dedicated team). PATIENTS AND METHODS: We included respectively the children with CTEV treated using the Ponseti method in Geneva University Hospitals' pediatric units from 2007 to 2018. Data on patient demographics, clinical characteristics, and the treatment outcomes were collected. The primary outcome was the number of relapsed feet (treatment failure) after 3 years of follow-up. The 2 periods' outcomes were compared using χ 2 and independent Student t -tests. Run charts were used to report yearly rates of complications, minor and major recurrences, treatment failure, brace noncompliance, and feet that underwent tenotomy. RESULTS: A total of 48 feet (32 patients) and 42 feet (29 patients) in periods I and II were included. The periods showed similar rates for participants' characteristics. The run charts illustrated the overall improvements in treatment outcomes in period II. A total of 8 relapsed feet (5 patients) were reported, all during period I. CONCLUSIONS: Since all the pediatric CTEV patients at our institution began to be treated by a single dedicated medical team, we have observed a decrease in all recurrences and complications and an absence of treatment failure. These results highlight the importance of the continuity of care and strict adherence to the Ponseti method. LEVEL OF EVIDENCE: Level-III Retrospective comparative study.

Determining the Optimal Treatment for Idiopathic Clubfoot: A Network Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Clubfoot, or congenital talipes equinovarus deformity, is a common anomaly affecting the foot in infants. However, clinical equipoise remains between different interventions, especially those based on the Ponseti method. The aim of this study was to examine the clinical outcomes of the various interventions for treating idiopathic clubfoot. METHODS: Searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Scopus, and CINAHL were conducted. Randomized controlled trials comparing different interventions, including the Ponseti method, accelerated Ponseti method, Ponseti method with botulinum toxin type A (Botox) injection, Ponseti method with early tibialis anterior tendon transfer (TATT), Kite method, and surgical treatment, were included. Network meta-analyses (NMAs) were conducted according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) reporting guidelines. The primary outcomes were the change in total Pirani score and maximal ankle dorsiflexion. Secondary outcomes were the number of casts, time in casts, and rates of tenotomy, total complications, relapse, adverse events, and additional required major surgery. RESULTS: Eleven randomized controlled trials involving 740 feet were included. According to the SUCRA (surface under the cumulative ranking curve)-based relative ranking, the Ponseti method was associated with the best outcomes in terms of Pirani score changes, maximal ankle dorsiflexion, number of casts, adverse events, and total complications, whereas the accelerated Ponseti method was associated with the best outcomes in terms of time in casts and tenotomy rate. Early TATT ranked best in terms of relapse rate. The Ponseti method with Botox injection was associated with the best outcomes in terms of the need for additional major surgery. CONCLUSIONS: The NMAs suggest that the Ponseti method is the optimal treatment overall, despite potential drawbacks such as longer time in casts and higher rates of tenotomy, relapse, and the need for additional surgery compared with other modified approaches. Therefore, clinicians should consider how treatments can be tailored individually. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

An Approach to Recurrent Clubfoot Deformity in Adolescents.

Even under ideal circumstances, recurrence of infantile clubfoot deformity following the Ponseti method of treatment is to be expected to occur in as many as 20% of patients. When encountered early in childhood, these recurrences are usually amenable to further casting and limited surgery. Creation of a plantigrade foot, however, becomes much more challenging when recurrences present during adolescence and early adulthood. Because of the stiffer nature of these deformities in older patients, the fact that they are often more severe because of varying lengths of neglect, and the often deleterious effects of prior intra-articular surgeries on joint health, a principled approach is recommended for both the assessment of these feet and development of an appropriate treatment plan. In doing so, the surgeon can select the combination of nonsurgical and surgical interventions that allows for as little surgery as possible to create a plantigrade foot while maintaining any motion that is present before treatment. Although no single algorithmic approach can be applied to the variety of deformities and potentially complicating factors that are encountered in treating such patients, an understanding of the utility of preoperative casting, gradual and acute corrective techniques, and the importance of identifying and mitigating deforming forces and tendon imbalance can greatly optimize outcomes.

Comparing patient-reported outcomes of the Oxford Ankle and Foot Questionnaire in children with clubfoot from two different geographic and cultural environments: a cohort study in India and Canada.

PURPOSE: The purpose of this study is to compare the results of the Oxford Ankle and Foot Questionnaire (OxAFQ) in children with clubfoot in Canada and India to assess its ability to predict outcomes and capture patient experiences in different cultural contexts. METHODS: This is a retrospective study of children with clubfoot in India and Canada who completed the OxAFQ. Statistical analyses were implemented on registry-collected data to test for independent predictors of poor outcomes and compare scores between countries, among children and their parents, and in Canada where relapse data was collected and the effect of a relapse on scores. RESULTS: A total of 361 children were included. The mean Indian OxAFQ scores were higher (p < 0.001) in all domains. Pirani score, tenotomy, laterality, and age at presentation were found to be predictive of outcomes between the sites (p < 0.05). OxAFQ scores decreased after relapse for children in Canada (p < 0.05). Canadian children were found to generally have lower OxAFQ scores in all domains compared to their parents (n = 95; Z = -3.178, -3.493, -3.353, and -3.635 for physical, school and play, emotion, and footwear, respectively; p < 0.001). Indian parents and children showed no significant differences in their scores. CONCLUSIONS: A difference was observed in scores between both sites, suggesting there may be differences in how these populations assess personal health outcomes. These findings support the need for cultural validity of patient-reported outcome measures.

Clinical application of 3D printing-assisted patient-specific instrument osteotomy guide in stiff clubfoot: preliminary findings.

BACKGROUND: The orthopedic treatment of the stiff clubfoot is challenging for clinicians, and the purpose of this study was to explore the preliminary findings of 3D printing-assisted patient-specific instrument (PSI) osteotomy guide for use in the orthopedic treatment of the stiff clubfoot. MATERIAL AND METHODS: There were 20 patients (25 feet) with stiff clubfoot admitted from December 2018 to June 2022, including 13 males (16 feet) and 7 females (9 feet), aged 24-52 years, mean 40.15 years; 8 left feet, 7 right feet, 5 bipedal. All patients underwent triple arthrodesis and were divided into 10 cases (12 feet) in the PSI group (n = 12) and 10 cases (13 feet) in the conventional surgery group (n = 13) according to the surgical approach. The duration of surgery and the number of radiation exposures were recorded in all cases, and the American Orthopedic Foot and Ankle Society (AOFAS), and International Congenital Clubfoot Study Group (ICFSG) scoring systems were applied postoperatively to assess the effect of corrective treatment. All measurement data were expressed as mean ± standard deviation, and differences between groups were determined by Student's t test. All count data between the two groups were compared using the chi-square test or Fisher's exact test analysis. RESULTS: All 20 patients (25 feet) were followed up for 1 year. No major complications related to osteotomy, such as overcorrection, incomplete correction, or bone nonunion, were observed in the PSI and conventional surgery groups at the final follow-up, and the PSI group had the advantage of shorter operative time (P < 0.01), less radiation exposure (P < 0.01), and higher excellent rate compared with the conventional surgery group. The AOFAS score (P > 0.05) and ICFSG score (P > 0.05) at the last follow-up were not statistically significant in both groups, but the excellent rate at the last follow-up was 91.7% in the PSI group which was significantly higher than that of the conventional surgery group at 76.9%. CONCLUSIONS: The utilization of 3D printing-assisted PSI osteotomy guide in orthopedic surgery for stiff clubfoot offers a safe and effective surgical tool for triple joint fusion treatment. This technology simplifies surgical procedures, minimizes intraoperative radiation exposures, reduces surgical time, and enables precise and personalized treatment.

A single-center, single-blinded, randomized, parallel-group, non-inferiority trial to compare the efficacy of a 22-gauge needle versus a 15 blade to perform an Achilles tendon tenotomy in 244 clubfeet-study protocol.

BACKGROUND: Achilles tendon tenotomy is an integral part of the Ponseti method, aimed at correcting residual equinus and lack of dorsiflexion after correction of the adductus deformity in clubfoot. Percutaneous tenotomy using a number 15 scalpel blade is considered the gold standard, resulting in excellent results with minimal complications. The use of a large-bore needle to perform Achilles tendon tenotomies has been described in literature, but a large-scale randomized controlled trial is currently lacking. In this trial, we aim to show the non-inferiority of the needle tenotomy technique compared to the gold standard blade tenotomy technique. METHODS: We will randomize 244 feet into group A: needle tenotomy or group B: blade tenotomy. Randomization will be done using a block randomization with random block sizes and applying a 1:1 allocation to achieve an intervention and control group of the exact same size. Children will be evaluated at 3 weeks and 3 months post-tenotomy for primary and secondary clinical outcomes. The primary clinical outcome will be the range of dorsiflexion obtained the secondary clinical outcomes will be frequency of minor and major complications and Pirani score. The non-inferiority margin was set at 4°, and thus, the null hypothesis of inferiority of the needle technique will be rejected if the mean difference between both techniques is less than 4°. The statistical analysis will use a multi-level mixed effects linear regression model for the primary outcomes and a multi-level mixed effects logistic regression model for the secondary clinical outcomes. The physician performing the evaluations post-tenotomy will be the only one blinded to group allocation. TRIAL REGISTRATION: This trial was registered prospectively with ClinicalTrials.gov registration number: NCT04897100 on 21 May 2021.

Selective Tibial Neurotomy for Spastic Equinovarus Foot: Operative Technique.

BACKGROUND AND OBJECTIVES: Spastic equinovarus foot (SEF) is a common complication of stroke and other upper motor neuron injuries. It is characterized by a plantigrade and inverted foot, often with toe curling, causing significant disability from pain, gait, and balance difficulties. Management includes physical therapy, antispasticity drugs, orthoses, chemical neurolysis, or botulinum toxin, all of which may be insufficient, sedating, or transient. Selective tibial neurotomy (STN) provides a surgical option that is effective and long-lasting. Our goal is to provide a concise description of our technique for performing the STN for treatment of SEF. We discuss the standard posterior approach with surgical variations used by other groups and a medial approach, should the posterior approach be insufficient. METHODS: A posterior leg approach allows access to the tibial nerve and its branches to the bilateral gastrocnemius muscles, soleus, posterior tibialis, and extrinsic toe flexors. A medial approach is used if the toe flexors cannot be accessed sufficiently from the posterior approach. Nerve branch targets identified by preoperative functional assessment are carefully exposed and fully neurolysed distally to identify all terminal branches to each muscle of interest before neurotomy. RESULTS: The STN is a powerful tool for treating SEF, with an immediate and lasting effect. Approximately 80% of the target muscle should be denervated to ensure long-term efficacy while maintaining adequate function of the muscle through collateral innervation. CONCLUSION: The STN is a safe and effective outpatient procedure that can be performed by an experienced nerve surgeon to improve balance and ambulation and reduce pain for patients with SEF. Large clinical trials are necessary to further establish this underutilized procedure in the United States.

Treating Older Children with Clubfoot: Results of a Cross-Sectional Survey of Expert Practitioners.

Treating clubfoot in walking-age children is debated, despite studies showing that using the Ponseti casting principles can correct the midfoot effectively. We aimed to explore techniques and approaches for the management of older children with clubfoot and identify consensus areas. A mixed-methods cross-sectional electronic survey on delayed-presenting clubfoot (DPC) was sent to 88 clubfoot practitioners (response rate 56.8%). We collected data on decision-making, casting, imaging, orthotics, surgery, recurrence, rehabilitation, multidisciplinary care, and contextual factors. The quantitative data were analysed using descriptive statistics. The qualitative data were analysed using conventional content analysis. Many respondents reported using the Pirani score and some used the PAVER score to aid deformity severity assessment and correctability. Respondents consistently applied the Ponseti casting principles with a stepwise approach. Respondents reported economic, social, and other contextual factors that influenced the timing of the treatment, the decision to treat a bilateral deformity simultaneously, and casting intervals. Differences were seen around orthotic usage and surgical approaches, such as the use of tibialis anterior tendon transfer following full correction. In summary, the survey identified consensus areas in the overall principles of management for older children with clubfoot and the implementation of the Ponseti principles. The results indicate these principles are well recognised as a multidisciplinary approach for older children with clubfoot and can be adapted well for different geographical and healthcare contexts.