PURPOSE OF THE STUDY To provide a detailed description of the Ponseti method and report the first results of its use, including factors that played a role. MATERIAL AND METHODS 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 (p<0.05). RESULTS 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 %; p<0.001). 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. DISCUSSION 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. CONCLUSIONS 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.

• MeSH
• kojenec MeSH
• lidé MeSH
• pes equinovarus terapie   MeSH
• protetické prostředky MeSH
• techniky fyzikální terapie MeSH
• Check Tag
• kojenec MeSH
• lidé MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH

Pes equinovarus congenitus (PEC) je složitá deformita nohy, složená z pěti hlavních komponent, které mohou v různé míře převažovat. Jsou to ekvinozita v hlezenním kloubu, inverze předonoží, varozita paty, exkavace (vyklenutí střední části nohy) a addukce předonoží. Pro léčbu PEC jsou používány v podstatě dvě metody: francouzská funkční metoda (fyzioterapie a postupné cvičení bez imobilizace) a Ponsetiho metoda (sádrování, tenotomie Achillovy šlachy, transpozice m. tibialis ant.). V literatuře se uvádí, že tato metoda má krátkodobý úspěch v impozantních 100 %, podobně vysoce úspěšné mají být i výsledky dlouhodobé. Sami se však domníváme, že údaje o úspěšnosti mohou být významně ovlivněny dobou, která uplyne od ukončení léčby. Zjistili jsme významný rozdíl mezi hodnocením krátkodobých a dlouhodobých výsledků: počet recidiv v průběhu prvních tří let léčby indikovaných pro chirurgický zásah byl významně nižší ve srovnání s pacienty, u nichž léčba začala před 5-9 roky. Primární korekce PEC je tedy možná u téměř 100 % pacientů, avšak pro korekci recidiv je třeba v některých případech použít jiné chirurgické řešení. Na základě vlastních zkušeností jsme dospěli k závěru, že kromě nedostatečné compliance ze strany rodičů je hlavním rizikovým faktorem čas: u dětí starších 3 let není možno recidivy léčit pouze Ponsetiho metodou, ale je nutno často přistoupit k operační léčbě.

Idiopathic pes equinovarus (also referred to as clubfoot) is a congenital deformity of the foot and lower leg; it has five components: equinus, varus, adductus, cavus and supination of the foot. At present two principle methods are mostly used for the treatment of clubfoot: physiotherapy and continuous motion without immobilization and the Ponseti method (serial manipulation, cast application, Achilles tenotomy and transposition of m. tibilalis ant.). This method has been reported to have short-term success rates approaching 100%, and the long-term results have been equally impressive. We believe, however, that the data on the success rate may be significantly influenced by the duration of the period after termination of the treatment. We have found difference between the evaluation of the short-term and long-term results: the number of relapses during the first three years of treatment, indicated for surgical intervention, is less as compared with patients where the treatment started five to nine years ago . Primary correction of pes equinovarus is possible in almost 100% of patients, but for the subsequent solution of relapses it is necessary to use surgical intervention.

• Klíčová slova
• konzervativní léčba,
• MeSH
• Achillova šlacha chirurgie   MeSH
• kojenec MeSH
• lidé MeSH
• manipulace ortopedická * MeSH
• pes equinovarus * diagnóza   klasifikace   terapie   MeSH
• předškolní dítě MeSH
• protetické prostředky MeSH
• recidiva MeSH
• rizikové faktory MeSH
• sádrové obvazy * MeSH
• tenotomie MeSH
• věkové faktory MeSH
• výztuhy MeSH
• Check Tag
• kojenec MeSH
• lidé MeSH
• předškolní dítě MeSH
• Publikační typ
• přehledy MeSH

Objective: The aim of this study was to verify whether the Pirani and Dimeglio clinical scoring systems could predict results of Ponseti therapy. Methods: Forty-seven patients with clubfoot deformities treated with the Ponseti method were enrolled in the study. Clinical evaluation with the Pirani and Dimeglio scoring systems was performed before the treatment and after the second cast fixation. The number of fixations, necessity for achillotomy, and recurrence of the deformity were determined as parameters of the therapy results. The patients were divided into three groups according to the severity of their deformities, and the groups were compared with one another. Results: Clubfoot correction required an average of 6.8 casts. Five patients developed a recurrence. Comparing the therapy outcomes among the groups, we found statistically significant differences in the Pirani classification after the second fixation (the number of casts [p =.003] and necessity to perform an achillotomy [p =.014]) and in the Dimeglio scores before therapy (number of casts [p =.034]) and after the second fixation (number of relapses [p =.032]). Conclusion: Although clinical scoring systems showed some dependence on the parameters of treatment outcomes, their predictive function can be used in only a limited way. Level of evidence II, Prospective comparative study.

• Publikační typ
• časopisecké články MeSH

PURPOSE: Congenital club foot is one of the most common birth defects involving the musculoskeletal system. At present two methods are used for the treatment of this deformity: French and Ponseti method. The purpose of this study was to compare the short-term (up to three years) and long-term (three to seven years) results of treatment with the Ponseti method. METHODS: A total of 195 consecutive infants (143 boys and 52 girls) with idiopathic club foot treated with the Ponseti method in the period of 2005-2012 were included in this study; the total number of feet was 303. The severity of the foot deformity was classified according to Diméglio. When relapse occurred up until three years of age, we started with the casting again. If conservative treatment was unsuccessful we proceeded to surgical treatment. RESULTS: Primary correction was attained in all cases. Surgical correction of relapses was performed in 30 % of patients according to the Ponseti method (re-tenotomy of the Achilles tendon and transposition of the tibialis anterior) and in 70 % by alternative techniques. The number of relapses indicated for surgery increased with increasing period of follow-up: whereas in patients where the treatment started already in 2005 relapses occurred in 72 %, in patients included in 2011 the number of recurrences only reached 3 %. CONCLUSIONS: It follows from our results that it is impossible to cure all club feet with casting, tenotomy of the Achilles tendon and transposition of the tibialis anterior only.

• MeSH
• Achillova šlacha chirurgie   MeSH
• časové faktory MeSH
• kojenec MeSH
• lidé MeSH
• manipulace ortopedická MeSH
• novorozenec MeSH
• osteotomie MeSH
• pes equinovarus chirurgie   MeSH
• recidiva MeSH
• sádrové obvazy MeSH
• tenotomie MeSH
• výsledek terapie MeSH
• Check Tag
• kojenec MeSH
• lidé MeSH
• mužské pohlaví MeSH
• novorozenec MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• srovnávací studie MeSH

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.

• MeSH
• kojenec MeSH
• lidé MeSH
• novorozenec MeSH
• pes equinovarus klasifikace   diagnostické zobrazování   chirurgie   MeSH
• prediktivní hodnota testů MeSH
• recidiva MeSH
• reprodukovatelnost výsledků MeSH
• sádrové obvazy normy   MeSH
• stupeň závažnosti nemoci MeSH
• tenotomie metody   MeSH
• výsledek terapie MeSH
• výzkumný projekt normy   MeSH
• Check Tag
• kojenec MeSH
• lidé MeSH
• mužské pohlaví MeSH
• novorozenec MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

OBJECTIVE: The aim of this study was to assess the role of sonographic evaluation of Talar dysplasia in predicting the outcome of standard Ponseti method in the treatment of clubfoot deformity. METHODS: A total 23 children (15 boys and 8 girls; mean age: 18.2 ± 5.4 days (8-32)) who underwent Ponseti treatment were included in the study. Before the treatment, maximal talus length of affected and non-affected feet were measured by US and relative talar dysplasia ratio (RTDR) was calculated. The patients were categorized 2 groups according to RTDR: group A - mild and group B - severe deformity. Pirani score was used for clinical evaluation. The groups were compared in terms of number of the applied casts, need of percutaneous tenotomy of Achilles tendon (AchT) and frequency of deformity recurrence. RESULTS: Pirani score was 4.46 for population (4.33 for group A; 4.54 for group B). Number of casts significantly differed between groups (p < 0.001) and positive correlation was found (r = 0.851, p < 0.001). AchT was performed in 56% cases for group A and in 86% cases for group B; no statistically significant difference was obtained (p = 0.162). Recurrence occurred in 2 patients belonging to group B without significant difference compared to group A (p = 0.502). CONCLUSION: Talar dysplasia assessment appeared as a promising prognostic factor for predicting the outcome of the Ponseti technique in treatment of clubfoot deformity. LEVEL OF EVIDENCE: Level IV, diagnostic study.

• MeSH
• Achillova šlacha chirurgie   MeSH
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• pes equinovarus * diagnóza   patologie   patofyziologie   chirurgie   MeSH
• prediktivní hodnota testů MeSH
• prognóza MeSH
• recidiva MeSH
• sádrové obvazy MeSH
• talus * abnormality   diagnostické zobrazování   MeSH
• tenotomie * metody   statistika a číselné údaje   MeSH
• ultrasonografie metody   MeSH
• Check Tag
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• Geografické názvy
• Česká republika MeSH

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. DISCUSSSION 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.

• MeSH
• dítě MeSH
• dlahy využití   MeSH
• kojenec MeSH
• lidé MeSH
• manipulace ortopedická * metody   využití   MeSH
• neúspěšná terapie * MeSH
• pes equinovarus * epidemiologie   chirurgie   klasifikace   epidemiologie   chirurgie   klasifikace   MeSH
• sádrové obvazy využití   MeSH
• tenotomie MeSH
• vrozené deformity nohy (od hlezna dolů) * chirurgie   MeSH
• výsledek terapie * MeSH
• Check Tag
• dítě MeSH
• kojenec MeSH
• lidé MeSH

Idiopathic pes equinovarus (clubfoot) is a congenital deformity of the foot and lower leg defined as a fixation of the foot in plantar flexion, adduction, supination and varus. The deformity does not affect only the foot position, which is usually investigated by radiography, CT, micro-CT, MRI or ultrasound but logically influence the whole gait biomechanics. It is supposed, that clubfoot belongs to a group of fibroproliferative disorders whose origin and multi-hierarchical effect remain unknown. It has been suggested that fibroblasts and growth factors may be involved. To gain a more global view, direct analysis of the protein composition of extracellular matrix, a proteomic approach was used. At present two principle methods are mostly used for the treatment of clubfoot: physiotherapy and the Ponseti method. The determination of the general biological and biomechanical parameters for various regions of the clubfoot can potentially help in the understanding of the mechanisms participating on this serious anomaly and thus contribute to the development of the more efficient therapeutic approach. This review summarizes the present knowledge on the possible pathogenetic mechanisms participating in the development of the clubfoot and their possible relation to the new therapeutic approaches.

• MeSH
• chůze (způsob) fyziologie   MeSH
• fibroblasty patologie   MeSH
• kolagen genetika   MeSH
• lidé MeSH
• ortézy nohy (od hlezna dolů) využití   MeSH
• pes equinovarus genetika   patologie   terapie   MeSH
• terapie cvičením metody   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

Idiopathic pes equinovarus is a congenital deformity of the foot and lower leg defined as a fixation of the foot in adduction, supination, and varus. Although the pathogenesis of clubfoot remains unclear, it has been suggested that fibroblasts and growth factors are involved. To directly analyze the protein composition of the extracellular matrix in contracted tissue of patients with clubfoot. A total of 13 infants with idiopathic clubfoot treated with the Ponseti method were included in the present study. Tissue samples were obtained from patients undergoing surgery for relapsed clubfeet. Contracted tissues were obtained from the medial aspect of the talonavicular joint. Protein was extracted after digestion and delipidation using zip-tip C18. Individual collagenous fractions were detected using a chemiluminescent assay. Amino acid analysis of tissue samples revealed a predominance of collagens, namely collagen types I, III, and VI. The high content of glycine and h-proline suggests a predominance of collagens I and III. A total of 19 extracellular matrix proteins were identified. The major result of the present study was the observation that the extracellular matrix in clubfoot is composed of an additional 16 proteins, including collagens V, VI, and XII, as well as the previously described collagen types I and III and transforming growth factor β. The characterization of the general protein composition of the extracellular matrix in various regions of clubfoot may help in understanding the pathogenesis of this anomaly and, thus, contribute to the development of more efficacious therapeutic approaches.

• MeSH
• aminokyseliny analýza   MeSH
• extracelulární matrix - proteiny metabolismus   MeSH
• kojenec MeSH
• kolagen metabolismus   MeSH
• lidé MeSH
• pes equinovarus metabolismus   patologie   terapie   MeSH
• proteomika metody   MeSH
• transformující růstový faktor beta metabolismus   MeSH
• Check Tag
• kojenec MeSH
• lidé MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

BACKGROUND: Clubfoot deformity (pes equinovarus) is one of the most common birth defects, and its etiology is still unknown. Initial clubfoot treatment is based on the Ponseti method throughout most of the world. Despite the effectiveness of this therapy, clubfoot may relapse. Recent studies confirm the theory of active fibrotic remodeling processes in the extracellular matrix of the affected tissue. The aim of this study was to clarify whether relapses in clubfoot therapy are associated with altered angiogenesis and to suggest possible regulatory pathways of this pathologic process. METHODS: We compared microvessel density, arteriole density, and concentration of angioproliferative-related proteins found between tissues in the contracted, that is, the medial side (M-side), and noncontracted, that is, the lateral side (L-side) of the relapsed clubfeet. Tissue samples from 10 patients were analyzed. Histopathologic analysis consisted of immunohistochemistry and image analysis. Real-time polymerase chain reaction was used to study mRNA expression. RESULTS: An increase in microvessel and arteriole density was noted in contracted, relapsed clubfoot tissue. This was accompanied by a significant increase in the levels of the vascular endothelial growth factor, vascular endothelial growth factor receptor 2, β catenin and active β catenin. Vascular endothelial growth factor, vascular endothelial growth factor receptor 2, and CD31 overexpression was also seen with mRNA analysis. CONCLUSIONS: Increased microvessel and arteriole density in the contracted side of the relapsed clubfoot was noted. These processes are mediated by specific proangiogenic proteins that are overexpressed in the contracted tissue. These findings contribute to the etiology and the development of relapses in the treatment of clubfoot. LEVEL OF EVIDENCE: Level II-analytical and prospective.

• MeSH
• arterioly * MeSH
• beta-katenin metabolismus   MeSH
• lidé MeSH
• patologická angiogeneze * MeSH
• pes equinovarus etiologie   metabolismus   terapie   MeSH
• předškolní dítě MeSH
• prospektivní studie MeSH
• receptor 2 pro vaskulární endoteliální růstový faktor metabolismus   MeSH
• recidiva MeSH
• sádrové obvazy MeSH
• vaskulární endoteliální růstový faktor A metabolismus   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• mužské pohlaví MeSH
• předškolní dítě MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH