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Title: The effect of a six-week physiotherapeutic intervention in child patients with clubfoot evaluated with a change in ROM of ankle dorsiflexion and the quality of gait measured by 2D analysis. Objectives: The aim of this work was evaluation of six-week physiotherapeutic intervention focused on movement and stability improvement in child patients with clubfoot based on a change in ROM of ankle dorsiflexion and the quality of gait measured by 2D analysis. Methods: The work consists of a theoretical part, which summarizes the theoretical background to the chosen topic, and a practical part. For the purposes of the practical part, an intervention group of patients (aged from 3 to 6 years) who have already received medical treatment for clubfoot, was created. The physiotherapeutic intervention period was six weeks, during that period there were from 4 to 5 individual exercises supplemented with home exercises. At the beginning and at the end there were control measurements. The control measurements consisted of a clinical examination and a 2D analysis of gait, supplemented by a dynamometric examination of gait. Results: There were no verifiable improvements in measured parameters, especially in a combination of several factors related to both the intensity of the physiotherapeutic intervention and...

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, p0.001). 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.

To assess outcomes of the Ponseti method for treatment of talipes equinovarus in relation to patient age at its start.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.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. (p0.05). Of the three patients with an unfinished course of initial treatment, two underwent subtalar release later and one was lost to follow-up.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%).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.

To provide a detailed description of the Ponseti method and report the first results of its use, including factors that played a role.In the 2005-2007 period, 91 patients with idiopathic rigid clubfoot (133 feet) were treated by the Ponseti method. The group comprised 62 boys and 29 girls. In most patients the Ponseti method was used as primary treatment, or by 3 months of age when previous treatment failed. In five children this treatment was started between the 3rd and 8th months of age. The result were evaluated by the criteria described by Richards et al., who distinguished four groups. The result was regarded as good when a permanent plantigrade foot was achieved (group 1). Plantigrade feet likely to require posterior release later were considered indeterminate rusults (group 2). Feet that needed posterior release, anterior tibial muscle transfer or lateral column shortening fell in the fair result group (3). Feet requiring complete subtalar release were classified as poor results (group 4). The results achieved in each year were statistically evaluated using Fisher's test (p0.05).The overall evaluation for 3 years showed good results in 70%, indeterminate in 7.5%, fair in 6.76% and poor in 15.8% of the treated feet. A detailed analysis for each year revealed that, in 2005, good results (50%) were recorded in a significantly lower number of feet than in 2006 (72.2%; p=0.032) and 2007 (93%; p0.001). On comparison of the years 2006 and 2007, good results in 2007 were found in a significantly higher number of feet than in 2006 (p=0.019). The poor results were due to 1) very rigid feet (6%); 2) initial problems with availability of Denis-Brown splints (19 feet; 14.5%); 3) problems with shoes not made to custom and not fitting patient's little feet (20 feet; 15%) 4) faulty techniques of correcting the deformity (4 feet); 5) poor family cooperation in compliance with the bracing protocol (15 feet; 11.2%). Some of the factors were combined. A delayed beginning of the treatment had no significant effect on the results.Our 3-year results of clubfoot treatment, by which plantigrade foot position was acheved on average in 77.5% of the patients, are in agreement with those achieved outside Ponseti centres. However, there were clear differences, with the worst results in 2005. The results comparable with those of Ponseti and his co-workers were achieved by us only in 2007. In accordance with the findings of Richards et al. we suggest that the percentage of short-term good results can change insignificantly within 4 years because of increased recurrence of deformities.Although our initial results were worse than reported in the literature, it can be concluded that the Ponseti method of treating idiopathic clubfoot is more efficient that the methods used previously and can be recommended as an efficient, safe and economical technique. Good compliance with the protocol improves the therapeutic results.

The study present one of the possible surgical strategies of the therapy of the congenital varus club foot in the youngest patients, most frequently in infants and toddlers. This strategy is used in rigid varus club feet of Dimegli Group 1 and 2. It is possible also to use it in the rebelling varus club feet, however, the reconstruction is more difficult in these cases.In the period of 1983-2000 the method of posteroplantar release was used 93 times, of which 59 times as a primary surgery and 34 times during revision surgery. The youngest patients were 8 months old, the oldest children were during the revision surgery 8 years old.In case of the persisting adduction and varus deformity after conservative therapy of the congenital varus club foot first of all plantar release of the forefoot was performed and subsequently from a slightly oblique longitudinal approach a radical posterior capsulotomy with the lengthening of the Achilles tendon, by means of talocalcanear reduction with transfixation by K-wires. Plaster of Paris is applied during 3 months after the operation with the replacement of correction plaster casts after each 3-4 weeks. The shortest interval after the surgery was 9 months. The group comprised 47 patients (in total 62 feet).The followed-up group of patients was examined clinically with the simultaneous evaluation of radiographs. Excellent result--anatomical position of the foot was obtained in 68%, good result was recorded in 26%. Poor result was recorded in 2 patients in bilateral varus club foot with meningomyelocele. Radiographs showed during the evaluation of the mutual position of talus and calcaneus an increase of the angle in the lateral projection on average by 12 degrees, in anteroposterior projection by 10 degrees.The numbers of patients, indication and results of the followed-up group of patients are comporable with literary data. Excellent and good results of the posteroplantar release are even better than those of the complete release included in the literatury studies. The procedure starting by the release first the plantar structures is to a certain extent an original strategy. Usually after the operation on posterior structures the plantar release was used only subsequently in case of persisting adduction and varus deformity of the forefoot. Surgery even in case of a rebelling defect allows to use in future subsequent surgical procedures which is problematic after a complete release where there occurs in a certain percentage also necrosis of talus and calcaneus.Posteroplantar release is one of the possible surgical procedures in the solution of the rigid congenital varus club foot. Although the operation may be included in the so called procedure of small steps in most patients it solves finally the defect.

Authors present transposition and hemitransposition of anterior tibial muscle as one of the supporting surgeries in the treatment of neurogenous but also congenital club foot.In the period of 30 years they indicated and performed transposition of anterior tibial muscle 79 times in 75 patients and hemitransposition of anterior tibial muscle in 27 patients. Most frequently they used this method in patients with childrens' cerebral palsy, least frequently in patients with congenital club foot.The authors prefer hemitransposition of anterior tibial muscle (Biesalski-Mayer) at the younger age and transposition of the whole anterior tibial muscle in children above the age of 9 years and in cases where the foot is more rigid or where bone changes already have developed. From the medial approach they expose the distal origin of the tendon of anterior tibial muscle, separate one or both origins of the tendon in compliance with the nature of the transposition, transpose over a supporting section above the ankle and fix the tendon to base V or IV of the metatarsal. The evaluated group included patients who at the given period attended the control check, i.e. 14 patients after hemitransposition and 45 patients after complete transposition. The shortest interval after the surgery was 9 months.In the evaluated group the authors performed clinical examination and radiograph. They report excellent results in hemitransposition in 57.1% with achieved plantigrade position of the foot and the function of transposed muscle 4 according to the muscle test. In 42.9% of cases the result was good. Similar results they recorded in complete transposition, excellent result in 23 cases (48.9%), good result in 8 patients (38.2%), in 2 patients there occured valgus overcorrection (4.3%), in 8.5% of patients with progressive disease the position subsequently worsened. Radiograph examination showed in the younger age group until the age of 8 years an increased value of the talocalcanear angle.By the number of patients, indication and results the evaluated group is comparable with literary data. The authors present reasons for the localization of transposition to Vth or IVth metatarsal in contradiction to biomechanical studies. This operation is not usually indicated as a separate surgery, most often it is performed simultaneously with the operation on m. triceps surrae and operation after Steindler.The method of transposition of anterior tibial muscle is recommended by authors mainly in neurogenous club foot where a combined operation on muscles may result in the final remedy of the defect. The method of complete transposition of anterior tibial muscle may be used also in progressive neurogenous diseases with the purpose of postponing resection sub talo.

The authors evaluated a group of 256 children operated in 1983-1992 at the Orthopaedic Clinic of the Faculty Hospital on account of congenital pes equinovarus. These children account for 25% of the total number of children treated because of this inborn defect by conservative treatment. The authors draw attention to the lack of uniformity of contemporary treatment of congenital pes equinovarus, and based on their own experience, they recommend an exact therapeutic plan. They emphasize the importance of early treatment by means of corrective plaster bandages, they describe the tactics of treatment by this method, as any deviation from this therapeutic pattern leads to incomplete elimination of the defect and to relapses. The authors present also a general review of possible surgical treatment and emphasize the tactics of postoperative treatment, incl. intensive rehabilitation and correction by footwear. They emphasize in particular the necessity of systematic and uninterrupted conservative treatment which is essential as preoperative preparation, as only by intensive care before and after surgery, incl. a correctly indicated and implemented operation, the desired goal, i.e. an anatomical position of the foot can be achieved.

The results of the surgical treatment by the method of extensive subtalar release after McKay is observed on the group of 35 feet operated on in 23 patients. In 17 feet it was the case of the recurrence after the operation, 18 feet were operated on primarily either after the conservative therapy or after no preceding therapy. Surgical technique is described in which major stress is put on the considerate approach and perfect correction of all abnormalities within one operation. A three-grade evaluation was used for the assessment of the results: good, fair, poor. Good results were achieved in 60 per cent of operated feet, 23 percent were evaluated as fair and 17 per cent as poor results. In the group of patients operated on beforehand the number of poor results is higher than in the group of patients operated on for the first time. As a supplementary procedure enucleation of os cuboideum is applied either during the basic operation or in the following period, in the second phase metatarsal osteotomy and transposition of the tendon of m. tibialis ant. into the base of Vth metatarsal are performed. This method of surgical treatment provides very satisfactory results. With the adequate performance of surgical treatment the number of complications is minimal. This type of operation is indicated for children between 1 and 4 years of age, exceptionally it can be performed also in older patients (the oldest boy in the group was 6 years old).