Background:Gentle passive manipulation and casting by the Ponseti method have become the preferred method of treatment of clubfoot presenting at an early age. However, very few studies are available in literature on the use of Ponseti method in older children. We conducted this study to find the efficacy of Ponseti method in treating neglected clubfoot, which is a major disabler of children in developing countries.Materials and Methods:41 clubfeet in 30 patients, presenting after the walking age were evaluated to determine whether the Ponseti method is effective in treating neglected clubfoot. This is a prospective study. Pirani and Dimeglio scoring were done for all the feet before each casting to monitor the correction of deformity. Quantitative variables were expressed as mean ± standard deviation and compared between preoperative and postoperative followup using the paired t-test. Also, the relation between the Pirani and Dimeglio score, and age at presentation with the number of casts required was evaluated using Pearson's correlation coefficient. No improvement in Dimeglio or Ponseti score after 3 successive cast was regarded as failure of conservative management in our study.Results:The mean age at presentation was 3.02 years (range 1.1 - 10.3 years). The mean followup was 2.6 years (range 2–3.9 years). The mean number of casts applied to achieve final correction were 12.8 casts (range 8 - 18 casts). The mean time of immobilization in cast was 3.6 months. The mean Dimeglio score before treatment was 15.9 and after treatment were 2.07. The mean Pirani score was 5.41 before treatment and 0.12 after treatment. All feet (100%) achieved painless plantigrade feet without any extensive soft tissue surgery. 7 feet (17%) recurred in our average followup of 2.6 years.Conclusions:Painless, supple, plantigrade, and cosmetically acceptable feet were achieved in neglected clubfeet without any extensive surgery. A fair trial of conservative Ponseti method should be tried before resorting to extensive soft tissue procedure.

Seven hundred and thirty-two cases of appendicectomy performed over a period of 5 years are reviewed to compare the incidence of complications and the length of the postoperative stay in hospital, depending on whether the appendix stump was simply ligated or was invaginated by purse string suture following ligation. No detrimental effects are noted following simple ligation, whereas patients who had stump invagination remained in hospital on average more than a day longer, mainly owing to a higher incidence of wound infection (16 per cent as against 6 per cent).

PurposeWe assessed the pattern of relapse as well as the correlation between the number of casts required for correction and Pirani and Dimeglio scores at presentation, and age at presentation. We hypothesized that the Ponseti method would be effective in treatment of relapsed clubfoot as well.MethodsWe evaluated 115 idiopathic clubfeet in 79 children presenting with relapse following treatment by the Ponseti method. The mean age was 33.8 months with mean follow-up of 24 months. All patients were assessed for various patterns of relapsed deformities. Quantification of deformities was done using the Pirani and Dimeglio scores. All relapsed feet were treated by a repeat Ponseti protocol.ResultsNon-compliance to a foot abduction brace was observed to be the main contributing factor in relapse, in 99 clubfeet (86%). Combination of three static deformities (equinus, varus and adduction) together was observed most commonly (38.3% feet). Overall, relapse of equinus deformity was noted most commonly followed by adduction. A painless plantigrade foot was obtained in all 115 feet with a mean of five casts. In all, 71 feet (61.7%) underwent percutaneous tenotomy. A total of 15 feet (13%) required tibialis anterior tendon transfer. Re-relapse rate in group 1 was 21% compared with 12.6% in group 2 and overall 16.5%.ConclusionWe conclude that the Ponseti method is effective and the preferred initial treatment modality for relapsed clubfeet. Surgical intervention should be reserved for residual deformity only after a fair trial of Ponseti cast treatment. Regular follow-up and strict adherence to brace protocol may reduce future relapse rates. Further research is required to identify high-risk feet and develop individualized bracing protocol.Level of evidence:IV

Achieving adequate dorsiflexion in neglected clubfoot cases remains challenging. On a close observation of the Ponseti method, we have now made certain modifications from the standard Ponseti protocol. This has helped us improve functional results, as well as reduce the number of casts in this walking-age group. From March 2011 onward, we managed 62 neglected clubfeet in 41 patients with the modified protocol. All these patients were treated with serial weekly above-knee casts. The feet were assessed by Dimeglio and Pirani scorings, which were done every week. These children were closely monitored and followed up at regular intervals for any signs of relapses. The mean age group was 3.1 years (1.1-12 years). The mean follow-up period for these feet was 3 years (1.2-4 years). Mean Dimeglio score before treatment was 15.9, and after treatment it was 0.52. Mean Pirani score before treatment was 4.21 and after treatment it was 0.03. The average number of casts before tenotomy with our modified method was 6.9. Percutaneous tenotomy was done in all the cases. The mean dorsiflexion achieved at the end of treatment was 21.3° (15°-40°). Our modified Ponseti technique is a very effective and reproducible method for correction of neglected clubfeet. We feel that an extensive soft tissue surgery may not be required for neglected clubfeet even up to the age of 10 years.

Background:Medial close wedge, lateral open wedge, dome and “V” osteotomies are the commonly to correct the genu valgum (GV) deformity. However, the ideal method for the correction of coronal plane deformity is controversial. This prospective study is to evaluate the functional and radiological result of supracodylar “V” osteotomy to correct GV deformity.Materials and Methods:“V” osteotomy was done in all patients with clinically significant GV deformity and was fixed with crossed K-wires. Weight-bearing mobilization was started after radiological union. Patients were evaluated for correction in different clinical and radiological parameters. The function of the knee was assessed by Bostman's score. The subjective score was used to assess the parent's satisfaction after the procedure.Results:187 limbs with genu valgum deformity (47 males and 71 females) were included in this study. We observed a significant improvement in the mean intermalleolar distance, clinical and radiological tibiofemoral angle and lateral distal femoral angle, from 17.3 to 3.9 cm, 23.8°to–4.5°, 25.6° to 6.1°, 76.6° to 88.4°, respectively. The mean Bostman score improved from 20.6 to 28.1. The parent's satisfaction assessed subjectively was 95.3 points.Conclusion:This osteotomy along with the fixation with K-wires is a safe, effective, reproducible technique with a short learning curve and a procedure requiring no repeat surgery for implant removal, with good functional results, and without major complications.