Ponseti clubfoot treatment has become more popular during the last decade. We reviewed the medical records of 74 consecutive infants (117 club feet) who underwent Ponseti treatment. Minimum followup was 5 years (mean, 6.3 years; range, 5–9 years). We studied age at presentation, previous treatment, the initial severity score of the Pirani scoring system, number of casts, need for Achilles tenotomy or other surgical procedures, and brace use. We measured final ankle motion and parents’ perception of outcome. Late presentation and previous non-Ponseti treatment were associated with lower initial severity score, fewer casts, and less need for tenotomy. Forty-four percent of patients had poor brace use. We observed better brace use (75%) in babies who presented late for treatment. Good brace use predicted less need for extensive surgical procedures. Twenty-four (32%) babies underwent additional surgical procedures other than tenotomy, including 21% who underwent tibialis anterior tendon transfer. At followup, 89% of feet had adequate dorsiflexion (5° or greater). Parents indicated high satisfaction with the treatment results. Ankle motion was not associated with parents’ satisfaction. The Ponseti method is effective, even if treatment starts late or begins after failure at other centers. Brace use influenced the success of treatment. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Purpose: Traditionally, angular deformities are treated by means of osteotomy. In patients who are skeletally immature, this major intervention can be avoided by influencing or guiding the growth of the affected physis. Recently, a new device was presented as an alternative to the widely used Blount staple. Stevens developed a technique using a two-hole, non-locking plate with two screws to perform temporary hemiepiphysiodesis in children. We studied the effectiveness of this new device in correcting angular deformities in children even younger than 5 years of age. Methods: We evaluated our first series of 11 patients (17 eight-Plates) who underwent treatment for angular deformities of various origins and were followed to completion of correction. The average age at hemiepiphysiodesis was 10 years and 2 months (age range 4 years and 11 months–13 years and 8 months). The device was inserted in the lateral distal femur (two cases), the medial distal femur (eight cases), the lateral proximal tibia (two cases), the medial proximal tibia (four cases), and the medial distal tibia (one case). Results: The eight-Plate was inserted for an average of 9.5 months (range 5–13 months). The joint orientation angles and the mechanical axis improved in all patients, with the exception of one 13-year and 8-month-old boy with a resected osteosarcoma and a compromised growth plate. In valgus cases (12 limbs, 13 eight-Plates), the mechanical axis deviation improved by an average of 30.7 mm (range 13–55 mm). In varus cases (four limbs, four eight-Plates), the mechanical axis deviation improved by an average of 38.8 mm (range 0–74 mm). No hardware failures, extrusion, growth arrest, or other complications were observed. None of our patients required an osteotomy or repeat eight-Plate insertion. Conclusions: We consider the eight-Plate to be an ideal tool for treatment of angular deformities in growing children. It allows for precise insertion and is reliable. It is also less likely to extrude like the Blount staple.

Patients with congenital limb shortening can present with joint instability, soft tissue contractures, and significant leg length discrepancy. Classically, lengthening is done with external fixation, which can result in scarring, pin site infection, loss of motion, and pain. We therefore developed an alternative to this approach, a new, controllable, internal lengthening device for patients with congenital limb shortening. We evaluated this device in terms of (1) healing index, (2) complications, (3) accuracy of the device’s external controller, and (4) adjacent-joint ROM. Between January 2012 and May 2013, we treated 66 patients for congenital limb shortening, of whom 21 were treated using this device. During this period, general indications for using the device were patients with leg length discrepancies of 2 cm or more, with intramedullary canals able to withstand rods of at least 12.5-mm diameter and 230-mm length, without active infection in the affected bone, able to comply with the need for frequent lengthening, and without metal allergies or an implanted pacemaker. We included only those patients who had completed their course of treatment and were currently fully weightbearing, leaving 18 patients (21 bone segments) available for followup at a minimum of 6 months after limb lengthening (mean, 14 months; range, 6–22 months). Mean age was 19 years (range, 9–49 years). Sixteen femurs and five tibias were lengthened a mean of 4.4 cm (range, 2.1–6.5 cm). Mean distraction index was 1.0 mm/day (range, 0.5–1.8 mm/day). Healing index, complications, device accuracy, and ROM were recorded. To date, 10 of the 21 devices have been removed. This was typically done 12–24 months after insertion when the bone was solidly healed on all four cortices. Mean healing index was 0.91 months/cm (range, 0.2–2.0 months/cm). There were seven complications requiring an additional unplanned surgery, including one hip flexion contracture, three femurs with delayed healing, one tibia with delayed healing, one hip subluxation/dislocation, and one knee subluxation. The external controller was accurate as programmed and actual lengthening amounts were consistent. ROMs of the hip, knee, and ankle were essentially maintained. This device is completely internal, allowing for satisfactory joint motion during treatment in most patients. Lengthening was achieved in an accurate, controlled manner, and all patients reached their goal length. Complications remain a concern, as is the case with all approaches to this complex patient population. Both future comparative studies and longer-term followup are needed. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background: The Baumann procedure consists of intramuscular lengthening (recession) of the gastrocnemius muscle in the deep interval between the soleus and gastrocnemius muscles. The goal of the procedure is to increase ankle dorsiflexion when ankle movement is restricted by a contracted gastrocnemius muscle. Unlike the Vulpius procedure, the Baumann procedure truly isolates the lengthening site to the gastrocnemius muscle and does not lengthen the soleus muscle. The Baumann procedure has not previously been studied in cadaver specimens. Methods: The gastrocnemius and soleus muscles of 15 normal cadaver specimens had four sequential releases: a single gastrocnemius recession, a second gastrocnemius recession, a single soleus recession, and an Achilles tenotomy. Ankle dorsiflexion was measured with a goniometer initially, after each muscle recession, and after the tenotomy. Results: After the second gastrocnemius recession, the average increase in ankle dorsiflexion measured 14 degrees with the knee extended and 8 degrees with the knee flexed. Conclusions: The Baumann procedure treats equinus contracture of the gastrocnemius muscle by improving ankle joint dorsiflexion. The procedure is indicated when the results of the Silfverskiöld test are positive.

Treatment of clubfoot with the Ponseti method is successful when performed immediately after birth. We treated 23 infants (36 feet) who presented to us after casting, applied at other institutions, failed or after 3 months of age. Twenty-two infants had serial casting started during the first 2 months, and one infant who was 6 months old at presentation had not received previous treatment. The original orthopaedists of 18 patients advised posteromedial release. The parameter studied was the need for posteromedial release (ie, failure of Ponseti casting and percutaneous Achilles tenotomy to obtain satisfactory clinical appearance). Only one (2.8%) of 36 feet required open surgical release (posterior only). Thirty-five feet required percutaneous Achilles tenotomy. A mean of six Ponseti casts were applied before tenotomy. Two feet (two infants) required anterior tibialis transfer for mild relapse; three other feet (two infants) required repeat casting for mild relapse. Most pediatric orthopaedists think that successful clubfoot casting depends on treatment started immediately after birth. Our data suggest that older infants with clubfoot can be treated successfully without extensive surgery. Our results in older infants are similar to the results of a previous study we conducted with younger infants. In that study, one (2.9%) of 34 feet required posteromedial release surgery. Level of Evidence: Therapeutic study, Level IV (Case series). See the Guidelines for Authors for a complete description of levels of evidence.

Worldwide spread of the Ponseti method for clubfoot