الفهرس 
Introduction and aim of the workOnly 14 pages are availabe for public view
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Abstract
Congenital talipes equinovarus (clubfoot) is a complex, congenital, contractural malalignment of the bones and joints of the foot and ankle that is difficult to correct, The individual deformity has four components: Equinus of the hindfoot, Varus (or inversion) at the midtarsal joint complex, Cavus (plantar flexion of the forefoot on the hindfoot), and Adductus of the forefoot on the midfoot. (2)
Congenital talipes equinovarus (CTEV) is one of the most common congenital anomalies encountered in pediatric orthopedics .Its incidence is approximately one in every 1000 live births. It and may be unilateral or bilateral. Bilateral deformities occur in 50% of patients. Boys are affected twice as often as girls. (3)
The true etiology of idiopathic congenital talipes equinovarus is still unknown. Several theories have been proposed regarding the cause; one of the most accepted theories is that a primary germ plasm defect in the talus causes continued plantar flexion and inversion of this bone, with subsequent soft-tissue changes in the joints and musculotendinous complexes. (214)
The talipes equinovarus deformity is classified into congenital and acquired. The congenital is further classified into idiopathic and non-idiopathic types. The idiopathic type is typically an isolated skeletal anomaly, usually bilateral, has a higher response rate to conservative treatment and a tendency towards a late recurrence. The causes of the non-idiopathic type include deformity occurring in genetic syndromes, teratologic anomalies, neurological disorders of known (e.g., spina bifida), arthrogryposis, absent bone; fibula or tibia and unknown etiology and myopathies. The non-idiopathic type is characterized by presence of other anomalies and a poor response to conservative or operative treatment. Acquired equinovarus has neurogenic causes (e.g., poliomyelitis, meningitis, sciatic nerve damage) and vascular causes. (150)
The initial treatment of recurrent clubfoot, regardless of its severity or rigidity, is nonoperative by serial manipulation and casting that should begin as early as possible. Historically, the treatment consists of Forcible Serial Manipulation by correcting all the deformity simultaneously with fulcrum at the calcaneo-cuboid joint as describe by Kite. The efficacy of manipulation and casting is attributable to the viscoelastic, or rate-dependent, behavior of the ligaments and tendons. (215)
In our study , Of the 16 patients (25 feet); 11 patients (68.75%) were males, 5 (31.25%) patients were females. 9 patients (56.25%) had bilateral involvement, 7 patients (43.75%) had unilateral involvement. The age of patients at the time of presentation varied from 3 months after birth up to 2 years. The total duration of the treatment from application of the cast to Denis-Browne Splint varied from 3-9 weeks. The mean number of the casts required was about 5 casts. Tenotomies were performed on 21 feet of 25 (84%) requires tenotomy while 4 feet (16%) not require the tenotomy that means achieved correction of the rigid equinus up to 15 degree when abduction is up to 70 degree and no residual varus deformity is there.
According to Pirani score the results of our study were excellent in 23 feet (92 %) and good in 2 feet (8 %). The total duration of the treatment from application of the cast to Denis-Browne Splint varied from 3-9 weeks. Tenotomies were performed on 21 feet of 25 (84%) .
Over the past decade Ponseti management has become accepted throughout the world as the most effective and least expensive treatment of recent & recurrent clubfoot. The Ponseti technique corrects the deformity by gradually rotating the foot around the head of the talus over approximately period of 6 weeks by weekly manipulations followed by plaster cast applications. At the time of the final cast, most infants require percutaneous achilles tenotomy to gain adequate lengthening of the achilles tendon. When the final cast is removed, the infant is placed in a brace that maintains the foot in its corrected position (foot abduction orthosis). (8)
Conclusions
A lot has been said and done for evaluation of correction of recurrent clubfoot with Ponseti method; from our prospective study we conclude the followings:-
1- Our study is one of the 1st studies to describe Ponseti technique for treating recurrent cases of congenital talipes equinovarus specially with early detection of recurrence & younger patient age.
2- Our results in treating recurrent cases are very similar to results of treating primary cases.
3- The early onset of treatment will lead to improved outcome.
4- The Ponseti method is strongly recommended and becomes the gold standard to treat recurrent clubfoot deformity in our university hospital.
5- Ponseti serial corrective cast management is an Easy, Effective and Economical method of CTEV correction when it is applied in idiopathic clubfoot.
6- Results of our study were excellent specially when it was applied within a Golden period of CTEV that means early detection of recurrence & immediate management. This early management results in marked decrease in number of casts needed.
7- The use of surgical treatment in recurrent clubfoot decreased too much specially with early detection and younger patients.
8- The parents must be instructed to apply a Dennis Brown Splint for the patients as it is essential to prevent another relapse.