The risk of malpositioning of the syndesmotic screws is very high. A lack of standard radiological or physical references for accurate syndesmotic screw placement is a potential contributing factor in syndesmotic screw malpositioning. Malleolar tips are clinically as well as radiologically appreciable bony references. The purpose of this preliminary CT based study was to investigate the axial relations of the central syndesmotic axis with the malleolar tips. Methods: CT based studies of uninjured adult ankle joints with intact syndesmosis, conducted over a six months period were analysed. The axial differences between the coronal plane along the malleolar tips and that along the central syndesmotic axis in the axial plane were measured. Gender-based variations were also analyzed. Results: A total of 70 CT studies were analyzed, and the axial difference between the malleolar tips based coronal plane and that along the central syndesmotic axis was observed to be 3.70 ± 5.61 . The male and female measurements were comparable. Conclusion:Being in a static relation to the syndesmosis independent of the foot position and the limb rotation, the malleolar tips can be reliably used as references for directing syndesmotic screw in the axial plane. A knowledge of this axial difference between malleolar tips and central syndesmotic axis can help surgeons in an accurate syndesmotic screw placement.

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PurposeWe assessed the pattern of relapse as well as the correlation between the number of casts required for correction and Pirani and Dimeglio scores at presentation, and age at presentation. We hypothesized that the Ponseti method would be effective in treatment of relapsed clubfoot as well.MethodsWe evaluated 115 idiopathic clubfeet in 79 children presenting with relapse following treatment by the Ponseti method. The mean age was 33.8 months with mean follow-up of 24 months. All patients were assessed for various patterns of relapsed deformities. Quantification of deformities was done using the Pirani and Dimeglio scores. All relapsed feet were treated by a repeat Ponseti protocol.ResultsNon-compliance to a foot abduction brace was observed to be the main contributing factor in relapse, in 99 clubfeet (86%). Combination of three static deformities (equinus, varus and adduction) together was observed most commonly (38.3% feet). Overall, relapse of equinus deformity was noted most commonly followed by adduction. A painless plantigrade foot was obtained in all 115 feet with a mean of five casts. In all, 71 feet (61.7%) underwent percutaneous tenotomy. A total of 15 feet (13%) required tibialis anterior tendon transfer. Re-relapse rate in group 1 was 21% compared with 12.6% in group 2 and overall 16.5%.ConclusionWe conclude that the Ponseti method is effective and the preferred initial treatment modality for relapsed clubfeet. Surgical intervention should be reserved for residual deformity only after a fair trial of Ponseti cast treatment. Regular follow-up and strict adherence to brace protocol may reduce future relapse rates. Further research is required to identify high-risk feet and develop individualized bracing protocol.Level of evidence:IV

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IntroductionNeglected clubfoot comprises clubfoot deformities with late presentation and weight-bearing on the affected foot. These deformities are stiff and need an aggressive approach for cast-based management. The modified versions of the Ponseti technique have been found effective in treating these deformities. However, these techniques' long-term outcomes in neglected clubfoot and related correction maintenance with time progression have not been investigated. The current study aims to analyze the changes in deformity correction after a minimum of two years of follow-up in neglected clubfeet treated with a modified Ponseti method of corrective casting. MethodsWe retrospectively analyzed the clinical records of 25 patients with 38 neglected clubfeet with a mean follow-up of 37.9±4.1 months after the initial correction of the deformity. These patients were managed with a modified Ponseti technique. The modified technique incorporated simultaneous deformity manipulation before equinus correction and additional dorsiflexion manipulation after two weeks of tendo-achilles tenotomy. The Pirani and Dimeglio scores and individual deformity corrections at the final follow-up were compared with those at final cast removal. ResultsNo significant differences were observed between the initial and the final follow-up Pirani and Dimeglio scores. Concerning the deformity correction parameters, there was a significant loss in heel varus and foot abduction correction. However, the change in these parameters was small (less than 3 degrees). ConclusionThe neglected clubfoot deformity can be satisfactorily corrected with an aggressive Ponseti based corrective manipulation and casting at a low relapse rate. However, minor loss of deformity correction is noticed after two years of treatment which is not reflected in clinical scores. Therefore, a strict long-term follow-up and careful deformity assessment are required to predict the recurrence in these cases.