ORIGINAL ARTICLE
A Single-center Prospective Evaluation of the
Ponseti Method in Nonidiopathic Congenital
Talipes Equinovarus
Paul J. Moroney, FRCSI (Tr. & Orth.), Jacques Noe¨l, FRCSI (Tr. & Orth.),
Esmond E. Fogarty, FRCSI, and Paula M. Kelly, FRCSI (Tr. & Orth.)
Background: The Ponseti method has revolutionized the man-
agement of idiopathic congenital talipes equinovarus (CTEV).
However, nonidiopathic CTEV is still often primarily treated by
extensive surgical soft tissue release. We believe that non-
operative treatment of these patients using the Ponseti method
may give very satisfactory results.
Methods: We examined the demographics of nonidiopathic
CTEV and the success of the Ponseti method in this population
over a 5-year period. We treated 29 patients with 43 nonidiopathic
and 97 patients with 138 idiopathic CTEV feet. Patients with
nonidiopathic CTEV made up 23% of all cases. The commonest
etiologies were arthrogryposis (5 cases), trisomy 21 (4 cases), and
spina bifida (3 cases). Average follow-up was 39 (nonidiopathic
group) and 35 months (idiopathic group).
Results: The Ponseti method was initially successful in 91% of
nonidiopathic and 98% of idiopathic feet. Recurrence of de-
formity occurred in 44% of nonidiopathic and 8% of idiopathic
feet. Thirty-seven percent of nonidiopathic feet required extensive
surgical release compared with 2% in the idiopathic group.
Conclusions: Although the success rate of the Ponseti method in
nonidiopathic CTEV is inferior to that in idiopathic CTEV,
63% of our nonidiopathic patients did not require extensive
surgery. We believe that the Ponseti method should be used in
all cases of nonidiopathic CTEV.
Level of Evidence: Level III—prospective cohort study.
Key Words: congenital talipes equinovarus, nonidiopathic,
Ponseti
(J Pediatr Orthop 2012;32:636–640)
C ongenital talipes equinovarus (CTEV) is the com-
monest congenital deformity of the foot, with an in-
cidence of 1 to 2 per 1000 live births.1,2 The majority of
cases are isolated deformities of unknown etiology. In a
minority of cases, however, an identifiable underlying
From the Our Lady’s Children’s Hospital, Dublin, Ireland.
None of the authors received financial support for this study.
The authors declare no conflict of interest.
Reprints: Paul J. Moroney, FRCSI (Tr. & Orth.), Suite 19, Sports
Surgery Clinic, Santry Demesne, Dublin 9, Ireland. E-mail: paul
moroney@rcsi.ie.
Copyright r 2012 by Lippincott Williams & Wilkins
636 | www.pedorthopaedics.com
pathologic condition exists. We have found there to be
2 broad groups of nonidiopathic CTEV—those charac-
terized by soft tissue laxity (eg, connective tissue disorders,
trisomy 21) and those in whom the soft tissues are ex-
ceptionally tight and resistant to corrective treatment.
Patients in this latter group often have a neurological
etiology such as arthrogryposis.
In the past, aggressive surgical correction was advo-
cated for all patients.3–6 Long-term results of such treat-
ment, however, have not been favorable. Dobbs et al7 have
radiologically documented unacceptable levels of ankle
and foot arthrosis with correspondingly poor levels of
patient satisfaction. The management of idiopathic CTEV
has been revolutionized by the work of Ignacio Ponseti.8,9
His method of gentle, systematic manipulation and casting,
followed by Achilles tenotomy and long-term bracing has
yielded outcomes that are superior to those after extensive
surgical releases.7,10 Many short-term and long-term studies
have demonstrated that the Ponseti method produces pain-
less, flexible feet.8,9,11 His method has been adopted world-
wide and now constitutes the gold standard treatment.
Despite the success of the Ponseti method in idio-
pathic CTEV, the published literature has been slow to
recommend it for the management of nonidiopathic
CTEV. The historical opinion was that nonidiopathic
CTEV feet were too rigid to respond favorably to manip-
ulation and casting; and several authors continued to ad-
vise destructive surgical procedures such as talectomy.12–15
In recent years, however, some groups have reported sat-
isfactory results in their cohorts of patients with non-
idiopathic CTEV treated by the Ponseti method.16–18
The purposes of this study were to document the
incidence of nonidiopathic CTEV in our patient pop-
ulation, to identify the underlying etiology, and to assess
the effectiveness of the Ponseti method in their treatment.
PATIENTS AND METHODS
This study was conducted in the largest pediatric
hospital in our country. We house the national centers for
cardiac surgery and for medical genetics, and we provide
a tertiary referral service for orthopaedics, rheumatology,
nephrology, and neurology. In April 2005, a Ponseti clinic
was established to provide formal multidisciplinary treat-
ment for children with CTEV. All patients with suspected
J Pediatr Orthop  Volume 32, Number 6, September 2012
J Pediatr Orthop  Volume 32, Number 6, September 2012
nonidiopathic CTEV are reviewed by a pediatric neurol-
ogist, a neonatologist, and a geneticist. Once referred, all
patients are seen at the next available Ponseti clinic
(usually within 1 to 2 wk of birth).
Patients are reviewed on a weekly basis. At each
appointment, the casts are removed, the children are
bathed, and their feet are scored according to the scoring
system of Pirani.19,20 Clinical photographs are taken. All
information is recorded prospectively on a computerized
database (MD Analyze; Medtech Global Ltd., Australia).
Manipulation is performed according to the technique
described by Ponseti8,21 and moulded, above-knee casts are
then applied. In our early experience, all patients received 6
casts before percutaneous Achilles tenotomy. Now the
number of casts applied pretenotomy is individualized for
each patient. Most patients with idiopathic CTEV now
only require 4 or 5 casts to achieve adequate correction.
Conversely, in some very stiff nonidiopathic feet, tenotomy
is performed early in their treatment. Achilles tenotomy is
performed in the clinic under local anesthesia whenever
<10 degrees of passive ankle dorsiflexion is present.
After Achilles tenotomy, an above-knee cast is ap-
plied for 3 weeks. Thereafter, a foot abduction orthosis,
comprising open-toed, high-top, straight-last shoes (Markell
Shoe Company, Yonkers, NY) attached to a Denis
Browne bar is applied. The feet are held in approximately
70-degree abduction. In cases of nonidiopathic CTEV, we
often use Mitchell shoes (MD Orthopaedics Inc., Iowa
City, IA) and hold the feet in 60-degree abduction. Pa-
rents are instructed to leave this orthosis in situ for 23 h/d
for the first 3 months and nighttime thereafter until the
age of 4 years. Advice is provided regarding home
stretching exercises.
We believe that it is essential to strive for a planti-
grade foot in all cases. Even when patients are non-
ambulators, a plantigrade foot facilitates seating, allows
the wearing of more comfortable footwear, and reduces
the risk of decubitus ulceration. Therefore, all patients
who fail conservative management with manipulation
and casting using the Ponseti method progress to surgical
correction. In general, such correction comprises poste-
rior and medial release or lengthening of the contracted
soft tissues—including the ankle, subtalar, and talona-
vicular joint capsules; the Achilles, tibialis posterior,
flexor digitorum longus, and flexor hallucis longus ten-
dons; the talofibular, tibiofibular, and calcaneofibular
ligaments; the plantar fascia and the abductor hallucis
muscle. The extent of surgical release is decided on an
individual basis—depending upon the difficulty encoun-
tered in achieving correction. Procedures such as tibialis
anterior transfer for correction of residual dynamic
forefoot supination are not uncommonly used to fine-
tune a CTEV foot when the child is older. Such proce-
dures are not considered in our study.
The success of the Ponseti method in each patient was
recorded using the Pirani scoring system.19,20 We docu-
mented the rate of successful correction and that of re-
currence. The number of casts required to achieve correction
and the rate of surgical correction were also assessed.
r 2012 Lippincott Williams & Wilkins
Evaluation of the Ponseti Method in Non-idiopathic CTEV
Demographic characteristics and outcome measures
were compared with the entire cohort of idiopathic CTEV
patients who attended our clinic during the same time
interval.
Statistical analysis was performed using Instat
(Graphpad Software Inc., La Jolla, CA). Continuous
variables were assessed using unpaired t tests, whereas the
Fisher exact test was used to assess categorical variables.
All statistical tests were 2-tailed, with a level of sig-
nificance set at Pr0.05.
RESULTS
Demographics
All patients who attended our clinic with non-
idiopathic CTEV during the 5-year period from April
2005 to April 2010 and who had a minimum of 1-year
follow-up were included in the study. Twenty-nine such
patients were identified—17 males (59%) and 12 females.
During the same period, we treated 97 patients with idi-
opathic CTEV. Of this group, 80 were male (82%) and 17
were female. Patients with nonidiopathic CTEV com-
prised 23% of total new attendances.
Fifteen of our 29 nonidiopathic patients had bi-
lateral CTEV (52%), giving a total of 44 feet. Of the
remaining 14 feet, 8 were left and 6 were right. Bilaterality
was present in 41 (42%) idiopathic cases, giving a total of
138 feet. There was no significant difference in rates of
bilaterality between idiopathic and nonidiopathic groups
(P = 0.4). In 1 case of proximal femoral focal deficiency
(PFFD), it was decided not to correct the foot on the
affected limb, so as to preserve maximum length for later
fitting of a prosthesis. Therefore, 43 nonidiopathic feet
were treated according to the Ponseti method.
In our cohort, there was a large variety of diverse
diagnoses (Table 1). The commonest etiology was ar-
throgryposis (5 cases), followed by trisomy 21 (4 cases)
and neural tube defects (3 cases). In 4 clearly non-
idiopathic, neuromuscular cases, the underlying etiology
has not yet been established. One child has cerebral palsy
secondary to a postnatal intraventricular cerebral hem-
orrhage. He was born at 26 weeks’ gestation and had a
structural CTEV at birth. It is possible that his original
deformity was “idiopathic” CTEV; however, it is likely
that his postnatal foot deformity was driven by his ac-
quired neurological defect. Therefore, we believe that it is
appropriate to include him in this cohort. Arthrogryposis
was a clinical diagnosis, arrived at in conjunction with the
neonatology teams. Muscle biopsies were not performed.
Many children had very significant comorbidities includ-
ing 14 (48%) orthopaedic, 10 (34%) cardiorespiratory,
7 (24%) neurological, and 5 (17%) renal.
The median age at application of first cast was 12
days (mean, 25 ± 37; range, 28 to 160) in the non-
idiopathic group. Seventy-three percent of patients were
seen within 2 weeks of birth. The average follow-up was
38.7 ± 15.5 months (range, 12 to 64 mo). In the idiopathic
group, the first cast was applied at a median age of 8 days
(mean, 20 ± 34; range, 0 to 180) (P = 0.55) and the mean
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Moroney et al J Pediatr Orthop  Volume 32, Number 6, September 2012

TABLE 1. Diagnosis and Comorbidities in Patients With TABLE 2. Results of Ponseti Treatment in Nonidiopathic and
Nonidiopathic Congenital Talipes Equinovarus Idiopathic Congenital Talipes Equinovarus Feet
Case Nonidiopathic Idiopathic
Number Bilateral Diagnosis Associated Features (N = 43) (N = 138) P
1 Yes CHILD Scoliosis, oligodactyly, absent Starting Pirani 5.1 ± 1 (1.5-6) 4.9 ± 1 (1.5-6) 0.311
syndrome kidney, meningocele score*
2 Yes Arthrogryposis DDH, camptodactyly, VSD, Final Pirani score 1.49 ± 1.46 (0-4) 0.12 ± 0.21 (0-0.5) < 0.0001
epilepsy, developmental delay No. casts 6.42 ± 2.25 (3-12) 5.14 ± 1.54 (3-11) < 0.0001
3 Yes Trisomy 21 ASD, PDA, hypothyroidism Initial correctionw 39 (91%) 135 (98%) 0.056
4 No Trisomy 21 Hearing impairment Recurrence 17/39 (44%) 11/135 (8%) < 0.0001
5 No Trisomy 21 PDA, UDT, thrombocytopenia, Ponseti success 27 (63%) 135 (98%) < 0.0001
hypoglycaemia Extensive soft tissue 16 (37%) 3 (2%) < 0.0001
6 No Trisomy 21 ASD release
7 Yes Arthrogryposis Microcephaly
8 Yes Arthrogryposis — *Continuous data are presented as the mean ± SD with the range in paren-
theses.
9 Yes Neuromuscular* Coxa valga wThe data for categorical variables are given as the number of patients with the
10 No Cerebral palsy Vocal cord palsy, tracheostomy frequency in parentheses.
11 Yes Nail patella Radial head dislocation
syndrome
12 Yes Larsen Scoliosis, windswept knees, cleft
syndrome palate, cardiac anomalies On average, 6.4 ± 2.2 pretenotomy casts were required to
13 No Arthrogryposis Contralateral calcaneovalgus achieve initial correction in the nonidiopathic group
foot, camptodactyly, clinodactyly (range, 3 to 12) compared with 5.1 ± 1.5 (range, 3 to 11)
14 Yes PFFD Short right femur in the idiopathic group (P < 0.0001). The Ponseti method
15 Yes Marden-Walker ASD, UDT,
syndrome tracheobronchomalacia, was initially successful in correcting 39 of 43 non-
cardiomegaly idiopathic feet (91%). In 17 feet (44%) (12 patients), re-
16 No Ito syndrome Syndactyly, UDT, hearing currence of deformity occurred. A further series of casting
impairment corrected 3 feet, and repeat Achilles tenotomy was nec-
17 Yes Spina bifida DDH essary in 1 bilateral case. Twelve relapses eventually re-
18 No Spina bifida Knee contractures
19 No Spina bifida — quired extensive surgical release. All recurrences were
20 Yes Moebius Cardiorespiratory, associated with problems in wearing of the abduction
syndrome developmental delay orthosis. In the idiopathic cohort, the Ponseti method was
21 No Caudal — initially effective in 135 of the 138 feet (98%) (P = 0.056).
regression
22 No Ehlers-Danlos — Recurrence occurred in 8.1% of cases (P < 0.0001).
syndrome After a course of weekly manipulations and casts,
23 No Tibial hemimelia — the final Pirani score in our cohort of nonidiopathic
24 No Tibial hemimelia — CTEV feet was 1.49 ± 1.46 (range, 0 to 4.5). For those
25 Yes DiGeorge Cystinosis, pulmonary atresia, who did not progress to extensive corrective surgery, the
syndrome ASD, VSD, PDA
26 No Neuromuscular* — average Pirani score was 0.35. The mean Pirani score in
27 Yes Neuromuscular* Blind, DDH those who did require extensive surgical releases was 3.7
28 No Arthrogryposis Torticollis, cleft palate at the time of surgery. The final Pirani score in the idio-
29 Yes Neuromuscular* ASD, scoliosis pathic group was 0.12 ± 0.21 (range, 0 to 0.5). A total of
*Neuromuscular conditions where an exact diagnosis has not yet been 16 out of 43 (37%) nonidiopathic CTEV feet underwent
identified. extensive surgical release. At the end of the study period,
ASD indicates atrial septal defect; CHILD, congenital hemidysplasia with
icthyosiform erythroderma and limb defects; DDH, developmental dysplasia of no other patients had been scheduled for future surgery.
the hip; PDA, patent ductus arteriosus; PFFD, proximal femoral focal deficiency; This number represents 10 patients—8 of whom had bi-
UDT, undescended testes; VSD, ventricular septal defect. lateral CTEV and 2 with unilateral pathology. Six of the 8
bilateral cases underwent surgery to both feet. The un-
follow-up was 34.9 ± 16.4 months (range, 12 to 60 mo) derlying diagnoses in the surgical cases were: CHILD
(P = 0.19). (congenital hemidysplasia with ichthyosiform erythroderma
and limb defects) syndrome, Ito syndrome, Larsen syn-
Treatment drome, Marden-Walker syndrome, Moebius syndrome,
For the purpose of this discussion, we considered caudal regression syndrome, PFFD, cerebral palsy, spina
individually the 43 feet managed with the Ponseti method. bifida, and tibial hemimelia.
Results are displayed in Table 2. In the idiopathic group, 3 feet (2%) (3 patients)
At presentation, the mean Pirani score in our non- required extensive surgical release (P < 0.0001).
idiopathic group was 5.1 ± 1.0 (1.5 to 6) compared with
4.9 ± 1.0 (1.5 to 6) in the idiopathic group. Only 3 feet DISCUSSION
had initial scores <4. One patient with trisomy 21 had a The modern management of idiopathic CTEV, us-
score of 3, whereas the patient with DiGeorge syndrome ing the Ponseti method, delivers excellent results. Long-
had scores of 1.5 and 2 after initial treatment elsewhere. term follow-up studies by Ponseti himself and others have

638 | www.pedorthopaedics.com r 2012 Lippincott Williams & Wilkins

J Pediatr Orthop  Volume 32, Number 6, September 2012
demonstrated excellent results in patients with idiopathic
CTEV treated according to his method.9,11 Nonetheless,
the principles of treatment of CTEV in nonidiopathic
cases have remained the same for decades.
Menelaus12 first advocated the use of talectomy in
cases of nonidiopathic CTEV in 1971. Drummond and
Cruess13 reviewed the treatment of arthrogrypotic foot
deformity in 1978. Manipulation and cast was of benefit
in only one of 32 patients. Talectomy was found to be the
most successful surgical technique in their series.
More recent studies have questioned the long-term
outcome after talectomy. Legaspi et al14 reported only
33% good results, with 42% fair and 25% poor at 20-year
follow-up. Similarly, radical soft tissue release has also
been proven to have significantly poorer long-term results
in idiopathic CTEV than the Ponseti method.7 Several
authors16–18 have since reported encouraging successes in
treating cases of nonidiopathic CTEV using the Ponseti
method.
In our series, 23% of all CTEV patients had non-
idiopathic CTEV. This figure is similar to those quoted in
studies by Janicki et al,18 Gurnett et al,22 Paton et al,23
and Madzivire et al24 (range, 13.5% to 30.5%). Given the
frequency of nonidiopathic CTEV, it is surprising that
how little individual attention has been given to the study
of its management. We believe that the spectrum of eti-
ologies documented in our series is an accurate reflection
of the relative importance of each condition. Our patient
population is not biased toward or against any 1 syn-
drome or disease.
Compliance with brace wearing has been identified
as the most critical factor in relapse of deformity in idi-
opathic CTEV.25 Despite an initial success rate of 91% in
correcting cases of nonidiopathic deformity, our overall
success rate (those who did not require extensive surgical
release) was only 63%. However, it should be recognized
that children and their parents face many challenges in
maintaining compliance with the abduction orthoses.
Slippage and potential blistering are ever-present con-
cerns. In our series, 1 case of recurrence occurred in a
patient with PFFD who was unable to wear an abduction
orthosis due to her significant leg length discrepancy.
Moreover, increasing difficulty in tolerating an orthosis
may be secondary to (rather than the cause of) pro-
gression of the underlying condition.
Despite the altered sensation present in several of
our patients, we had no significant skin problems in our
series. We attribute this to a combination of factors. We
now use “soft cast” plasters that may be easily removed
by parents if they feel that their child is in pain due to a
slipped cast. When patients have progressed to boots, we
often opt to use Mitchell boots that are made of a softer
material than the Markell boots and may be padded over
bony prominences. Most importantly, we try to educate
parents on skin care and provide good support for any
concerns or queries that they may have, even outside
normal working hours.
At an average follow-up of 38.7 months, 37% of our
treated nonidiopathic CTEV feet had undergone extensive
r 2012 Lippincott Williams & Wilkins
Evaluation of the Ponseti Method in Non-idiopathic CTEV
surgical soft tissue release. There are still relatively few
reports of use of the Ponseti method in nonidiopathic
CTEV. Most of these studies concern arthrogryposis.
Various authors have published rates of surgery in ar-
throgrypotic feet managed by the Ponseti method that
range from 8% to 60%16,26 Gerlach et al17 reported a 14%
rate of extensive soft tissue release in 28 CTEV feet sec-
ondary to myelomeningocele. In a cohort of similar size
and diversity to ours, Janicki et al18 cited a rate of surgical
intervention of 28%.
Within our cohort of nonidiopathic CTEV, we
found great variations in response to manipulation and
casting. Typically, patients with conditions characterized
by ligamentous laxity corrected very easily. Our 4 patients
with trisomy 21 and 1 with the collagen disorder Ehlers-
Danlos syndrome were all successfully treated using the
Ponseti method. Deformity did not recur in any case.
Conversely, patients with conditions typified by extremely
tight soft tissues achieved only incomplete correction
through nonoperative means. Our patients with Larsen
syndrome, Marden-Walker syndrome, and Moebius
syndrome all had bilateral surgery. Clearly, these num-
bers are small due to the rarity of many of these
conditions. Although they reflect our experience, they do
not constitute proof that these trends will apply in all
cases.
It is worth noting, nonetheless, that the Ponseti
method has significant benefits even for those patients
who ultimately require extensive surgical release. In this
subgroup, the Pirani score fell from a mean score of 5.8
initially to 3.7 before surgery. In small deformed feet,
where access to the posteromedial aspect of the foot
is difficult, such an improvement is a huge advantage
intraoperatively.
In our idiopathic cohort, the initial correction rate
of 98%, relapse rate of 8%, and rate of extensive cor-
rective surgery (2%) are comparable with those in pa-
tients reported by Ponseti10 (98%, 11%, and 2.5%,
respectively).
This is a relatively large, prospective study. Ap-
proximately two thirds of patients with nonidiopathic
CTEV avoided extensive surgical soft tissue release due to
a successful period of Ponseti manipulation and casting.
At present, the results are only of a short-term nature.
Given the natural history of many of these conditions, it
is likely that there will be a number of late recurrences in
future years. A further study at some time in the future
may confirm or refute this. Equally, we are unable to
comment on the long-term outcomes of the patients who
underwent surgical correction.
Nonetheless, we believe that the Ponseti method
should now be widely adopted for the treatment of non-
idiopathic CTEV. The proven inferior results of tale-
ctomy and extensive soft tissue release7,14 need not
be inflicted on all patients with nonidiopathic CTEV.
With the support of an educated and well-motivated
multidisciplinary team, the Ponseti method may be most
successful in the care of these challenging, but very
rewarding, children.
www.pedorthopaedics.com | 639
Moroney et al
ACKNOWLEDGEMENTS
The management of these challenging children is very
much a multidisciplinary process. It would be impossible
without the skill and enthusiasm of our 2 clinical nurse
specialists—Catherine Howells and Olga Gallagher—and
the rest of our team.
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