In autumn 2019, Dr Alaric Aroojis asked me to interview Dr Shafique Pirani, a well-known teacher and advocate for the Ponseti method, to document his many clubfoot adventures. Dr Aroojis first met and was shown the method by Dr Pirani in 2002, and has since followed his contributions from showing correction of pathology in vivo by MRI to developing the Pirani Score to guide treatment, then teaching the method on every continent and developing public health programs for sustainable clubfoot care, and his current explorations in using technology to improve quality of care. I had the privilege of meeting him several times at his home in the fall of 2019. This is his story extracted from hours of footage. I am honored to tell it.

Supplementary Materials

Children with clubfoot often present after the walking age, especially in low- and middle-income countries where approximately 80% of children with clubfoot are born. With advancing age, there is increased stiffness of the soft tissue structures and decreased remodeling potential of the bones of the foot. Not all clubfeet in older children are rigid—some are flexible and amenable to stretching and conservative treatment. Hence, the initial evaluation of the deformity must include an assessment of correctability. The treatment of clubfoot in the older child is challenging and was traditionally performed using complex soft tissue and bony surgeries, often with poor outcomes in the long term. Recent literature has focused on the role of conservative treatment utilizing Ponseti principles of serial manipulation and casting, combined with limited surgery. The purpose of this review is to report the changing trends in the management of clubfoot in the walking child, to review the current literature regarding various treatment modalities, and to recommend a practical approach to treatment based upon age, inherent flexibility of the foot, available resources, and contextual factors.

The primary goal in managing non-idiopathic clubfeet is to attain a painless and plantigrade foot with as least number of procedures as possible. Preferably, it should be achieved before the walking age to prevent the adaptive changes in the bone. Serial casting by the Ponseti technique is gaining favor for primary management of these feet with encouraging initial correction results. However, recurrence of variable degree is expected. Certain modifications to the treatment are advisable in view of the non-pliability of these feet and high recurrence rates. Manipulation and plastering techniques similar to atypical feet maneuvers need to be practiced very often. Some rigid cases also need an early Achilles tenotomy or limited posterior soft tissue release (STR). The final goal is achieving brace-able plantigrade feet, but in view of the rigidity, an endpoint of abduction correction to 30–40° with 5–10° of dorsiflexion is acceptable. Ankle foot orthosis (AFO) in cases with concurrent hip and knee contractures is preferred over standard foot abduction braces (FAB). Recent literature showed that the number of non-idiopathic clubfeet undergoing extensive STR or radical bony procedures has drastically reduced over the years. The jury is still out about consensus on the ideal protocol.

Bracing is an integral and essential part of Ponseti's management of clubfoot. The standard foot abduction brace (FAB) maintains the affected foot in 60–70° abduction and 10–15° dorsiflexion while keeping the foot apart at a distance approximately equal to both shoulders’ width. Foot abduction brace is recommended to be worn full time for the initial 3–4 months and subsequently night/nap time till 4–5 years of age. Foot abduction brace prevents relapse by continuous stretching of posteromedial soft tissue of the foot and gradually ensuring their stress relaxation. Several designs of FAB are marketed like Denis Browne splint, Steenbeek brace, Mitchell-Ponseti brace, Dobbs brace, etc. The prolonged use of brace required for maintenance of deformity correction is however marred with issues of non-adherence and recurrence. Furthermore, several genetic, socioeconomic, parental, healthcare-related factors affect the overall functionality of the brace. Bracing in clubfoot is an evolving science. There are efforts to achieve better patient outcomes by eliminating these barriers, better brace designs, and following strategic guidelines.

Relapse is a recurrence of deformities in a previously corrected clubfoot. The incidence of relapse after the Ponseti method is reported between 26% and 48%. The etiology of relapse can be variable. Some of the predisposing factors that are predictive of relapse are drop toe signs, a lower ratio of correction improvement, and muscle imbalance. Relapse can be broadly categorized into decreased dorsiflexion, cavus, equines, adduction, heel varus, and dynamic supination deformity. The principles to be followed in the treatment of relapsed clubfoot are—restarting foot abduction brace protocol, extended Ponseti method and/or soft tissue surgery, bony procedures, and external fixation devices. The Ponseti method can be used even in older children with relapse or after soft tissue surgery. Split tibialis anterior transfer may be required in a child with dynamic supination deformity. It should be performed in children above 3 years. Many children may require >2 procedures. Soft tissue surgery carries the risk of over- and under-correction. The external fixator can be used in children with scarring due to multiple surgeries and severe rigid deformities. Salvage procedures may be required in older children or syndromic clubfeet. Conclusion: Children with clubfoot need to be followed up for a minimum of 5–6 years or maybe longer to diagnose and treat relapsed. Some feet are “deemed” to relapse. However, it is very difficult to identify these feet beforehand. An a la carte approach is required in the management of relapse and a surgeon treating these feet should be well versed with all the different procedures.

The Ponseti method for the treatment of clubfoot is in widespread use around the globe, and while a variety of measures or tools have been used to evaluate outcomes, few have been validated in different contexts, and none have been standardized or universally accepted. Our goal is to review how outcomes are currently reported in the clubfoot literature, and we have chosen to frame the discussion based on a conceptual model, namely the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF). We have chosen to group outcome measures based on whether they are “impairment-based” or “function-based”, the latter being subcategorized as healthcare provider-reported, patient/proxy-reported, or hybrid. Finally, we discuss the limitations of how clubfoot outcomes are currently reported, the challenges in accepting a universal outcome measure, and encourage the clubfoot researchers and clinicians to develop an outcome measure that can be used across cultures and throughout the developed and developing world, to homogenize clubfoot outcome measures and improve the standard-of-care.

Introduction: Foot length (FL) and width (FW) were measured in unilateral idiopathic congenital talipes equinovarus (CTEV) treated via the Ponseti method and difference was compared in foot sizes, if any. Material and methods: Total 30 patients were enrolled in study, comparing FL and FW in affected vs unaffected in unilateral clubfeet and analyzed statistically. Results: The mean FL for affected foot was 11.2433 cm and 11.8380 cm for unaffected foot. The mean FW for affected foot was 5.5433 cm and 5.5867 cm for unaffected foot. The difference between the FL and FW was assessed by the paired t test. The mean FL difference between the affected and unaffected foot was found to be 0.05600 and a p value of 0.716 was found to be statistically insignificant. Likewise, the mean FW difference was found to be 0.0233 and a p value of 0.742 was also statistically insignificant. Both the size difference was statistically insignificant and was comparable to each other. Conclusion: Foot length and FW between the affected and the unaffected foot are comparable to each other and the mean difference between these two is statistically insignificant.

Aim and objective: Ponseti method is a well-established treatment method for clubfeet. It has been suggested that pooling of data for unilateral and bilateral idiopathic congenital talipes equinovarus (ICTEV) is not appropriate. Therefore, this study aimed to evaluate the clinical and radiological outcome and their correlation in bilateral clubfeet. Materials and methods: Thirty infants (19M:11F) with bilateral ICTEV underwent the Ponseti method of treatment. Pirani scores and X-rays were recorded at the first visit (pre-treatment) and at the end of 12 months (post-treatment). Radiological angles were measured on anteroposterior (AP) and lateral (Lat) views of the foot and ankle. Results: The mean age was 6.7 ± 3.4 weeks (range 1–11 weeks). The mean initial Pirani score was 4.28 ± 1.1 (left) and 4.23 ± 1.09 (right). Successful outcomes were observed in 27/30 (90%) and 28/30 (93%) of the left and right foot, respectively. The mean number of casts required for left and right were (5.3 ± 1.1) and (4.9 ± 1.0), respectively. Achilles tendon (TA) tenotomy was performed in 76% (left) and 73% (right) feet. The postprocedure Pirani scores significantly correlated with talocalcaneal angle on AP (TCAP) and lateral views (TCL) on left (r_AP = 0.63, r_Lat = 0.76) and right feet (r_AP = 0.65, r_Lat = 0.73) (p < 0.01). Talocalcaneal index (TCI) has been significantly correlated with postprocedure Pirani score in left (r = 0.77) and right (r = 0.64) feet (p < 0.01). Tibiocalcaneal lateral angle (TiCL) has been significantly correlated with postprocedure Pirani score in the left feet (p < 0.01). Conclusion: Bilateral ICTEV can be treated successfully by the Ponseti method in infants. There was a good correlation between clinical scores and radiological parameters.

Aim and objective: This study aims to describe the rare case of neglected congenital clubfoot. Background: Congenital clubfoot is the most present type of foot deformity. The treatment of this severe congenital deformity begins immediately after birth and it can be very complex. There are different bone and soft tissue surgery procedures using in the treatment of these deformities. Severe cases of neglected congenital clubfoot are treated by triple arthrodesis. Cases of neglected congenital clubfoot are rarely noticed in actual literature. Case description: There is a case of a 56-year-old female patient with neglected congenital clubfoot deformity. She was born with this deformity and she had never had a medical treatment before. Clinical examination revealed the unsatisfactory cosmetic and functional status of the right foot. Triple arthrodesis of the foot after corrective closed wedge osteotomies in the midfoot and subtalar complex with posterior capsulotomy and Achilles tendon lengthening had been performed. Final cosmetic and functional results are good and the final psychological effect on the patient is excellent. Conclusion: Corrective osteotomies of the foot with triple arthrodesis and Achilles tendon lengthening is the method giving good and acceptable results. Clinical significance: Surgical correction of the deformity is very important because the effects of surgical correction positively reflect on the function of limbs, esthetic appearance, and a positive psychological effect on the patient.