Blog Elements - International Journal of Paediatric Orthopaedics

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

Atypical Clubfoot- A Systematic Review

Review Article | Volume 12 | Issue 1 | January-April 2026 | Page: 2-7 | Shabir A Dhar, Tahir Ahmed Dar, Reyaz Ahmed Dar, Abhishek Raina, Mohd Alam, Sabqat Farooq, Abdul Maajid DOI- https://doi.org/10.13107/ijpo.2026.v12.i01.254 Open Access License: CC BY-NC 4.0 Copyright Statement: Copyright © 2026; The Author(s). Submitted: 20/11/2025; Reviewed: 13/01/2026; Accepted: 02/02/2025; Published: 10/02/2026 […]

Bilateral Trevor’s Disease of Ankle: A Rare Presentation and Treatment Consideration

Case Report | Volume 11 | Issue 3 | September-December 2025 | Page: 24-27 | Gaurav Kumar, Amitosh Mishra, Abhishek Verma, Anuj Rastogi DOI- https://doi.org/10.13107/ijpo.2025.v11.i03.250 Open Access License: CC BY-NC 4.0 Copyright Statement: Copyright © 2025; The Author(s). Submitted: 29/09/2025; Reviewed: 18/10/2025; Accepted: 13/11/2025; Published: 10/12/2025 Authors: Gaurav Kumar MS Ortho [1], Amitosh Mishra D. […]

Atypical Clubfoot- A Systematic Review

Bilateral Trevor’s Disease of Ankle: A Rare Presentation and Treatment Consideration

Full Sized Blog Element (Big Preview Pic)

Atypical Clubfoot- A Systematic Review

DOI- https://doi.org/10.13107/ijpo.2026.v12.i01.254

Open Access License: CC BY-NC 4.0

Submitted: 20/11/2025; Reviewed: 13/01/2026; Accepted: 02/02/2025; Published: 10/02/2026

Authors: Shabir A Dhar MS Ortho [1], Tahir Ahmed Dar MS Ortho [1], Reyaz Ahmed Dar MS Ortho [1], Abhishek Raina MS Ortho [1], Mohd Alam MS Ortho [1], Sabqat Farooq MS Ortho [1], Abdul Maajid MS Ortho [1]

[1] Department of Orthopaedics, SKIMS Medical College, Bemina, Srinagar, Kashmir, India.

Address of Correspondence

Dr. Shabir A Dhar,
Department of Orthopaedics, SKIMS Medical College, Bemina, Srinagar, Kashmir, India.
E-mail: shabirdhar@yahoo.co.in

Abstract

Background: The management of congenital talipes equinovarus (clubfoot) has been transformed by the Ponseti technique. However, 5-7% of clubfeet present as atypical or complex variants that are resistant to standard treatment protocols. These challenging cases require early recognition and modified management strategies.
Purpose: To systematically review the literature on atypical/complex clubfoot, defining its clinical characteristics, pathogenesis, and evidence-based treatment modifications.
Methods: A systematic literature search was conducted across PubMed, Embase, Scopus, and Ovid databases through April 2025. Studies reporting on atypical or complex clubfoot characteristics, pathogenesis, management techniques, and outcomes were included. Quality assessment and data extraction followed PRISMA guidelines. A total of 32 studies met the inclusion criteria and were analyzed.
Results: Atypical clubfoot is characterized by a deep transverse plantar crease, hyperextension of the big toe, and a stubby foot appearance. Complex variants demonstrate excessive oedema and stiffness during casting. The challenges encountered during treatment are due to intrinsic anatomical factors and iatrogenic factors such as frequent cast slippage. Key management modifications include: prevention of cast slippage through metatarsophalangeal joint termination, application of the Ponseti 2 manoeuver for forefoot equinus correction, delayed tenotomy timing, and increased vigilance for recurrence. Recurrence rates range from 15-45%, higher than idiopathic clubfoot. Long-term outcomes demonstrate satisfactory correction with modified protocols, though complex clubfoot requires more casts and closer follow-up.
Conclusions: Early recognition of atypical/complex clubfoot enables timely implementation of treatment modifications. Prevention of iatrogenic cast slippage, appropriate application of the Ponseti 2 manoeuver, and extended follow-up are essential for optimal outcomes. Further research is needed to standardize terminology and establish evidence-based algorithms.
Keywords: Clubfoot, Atypical, Complex, Review

References

1. Ponseti IV, Zhivkov M, Davis N, et al. Treatment of the complex idiopathic clubfoot. Clin Orthop Relat Res 2006;451:171-176.
2. Turco VJ. Recognition and management of the atypical idiopathic clubfoot. In: Simons GW, ed. The clubfoot: the present and a view of the future. New York, NY: SpringerVerlag, 1994:76-77.
3. Ponseti International Association. Clinical practice guidelines for the management of clubfoot deformity using the ponseti method; 2015. Available at: http://www.ponseti.info/. [Accessed 24 January 2018].
4. Masquijo J, Arana E. Complex clubfoot: my 5 tips for appropriate evaluation and treatment with the Ponseti method. Acta Ortop Mex. 2023; 37(4): 233-236.https://dx.doi.org/10.35366/113618
5. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop. 1995;4:129–136.
6. Goldner JL, Fitch RD. Classification and evaluation of congenital talipes equinovarus. In: Simons GW, ed. The Clubfoot: The Present and a View of the Future. New York, NY: Springer-Verlag; 1994:120-139.
7. Lehman WB, Mohaideen A, Madan S, Scher DM, Van Bosse HJ, Iannacone M, Bazzi JS, Feldman DS. A method for the early evaluation of the Ponseti (Iowa) technique for the treatment of idiopathic clubfoot. J Pediatr Orthop B. 2003;12:133–140.
8. Pandey S, Pandey AK. Clinical classification of congenital clubfeet. In: Simons GW, ed. The Clubfoot: The Present and a View of the Future. New York, NY: Springer-Verlag; 1994:91-92.
9. Smythe T, Kuper H, Macleod D, Foster A, Lavy C. Birth prevalence of congenital talipes equinovarus in low- and middle-income countries: a systematic review and meta-analysis. Trop Med Int Health. 2017; 22(3): 269-85. doi: 10.1111/tmi.12833.
10. Göksan SB, Bursali A, Bilgili F, Sivacioğlu S, Ayanoğlu S. Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complex deformities. Arch Orthop Trauma Surg 2006; 126:15–21.
11. Matar HE, Beirne P, Bruce CE, Garg NK. Treatment of complex idiopathic clubfoot using the modified Ponseti method: up to 11 years follow-up. J Pediatr Orthop B2017;26(2):137-42 doi:10.1097/BPB.0000000000000321[published Online First:Epub Date]|
12. Mandlecha P, Kanojia RK, Champawat VS, Kumar A. Evaluation of modified Ponseti technique in treatment of complex clubfeet. J Clin Orthop Trauma. 2019 May-Jun;10(3):599-608. doi: 10.1016/j.jcot.2018.05.017. Epub 2018 May 28. PMID: 31061597; PMCID: PMC6492221.
13. Mosca VS. Clubfoot pathoanatomy—biomechanics of deformity correction: a narrative review. Ann Transl Med 2021;9(13):1096 | https://dx.doi.org/10.21037/atm-20-7491.
14. Al-Mohrej OA, Alshaalan FN, Alhussainan TS. Is the modified Ponseti method effective in treating atypical and complex clubfoot? A systematic review. Int Orthop. 2021 Oct;45(10):2589-2597. doi: 10.1007/s00264-021-05092-4. Epub 2021 Jun 10. PMID: 34114108.
15. Sinha SK, Garg V, Singh V. The Tug Test and Modified Ponseti Casting: A Simple and Reliable Method to Improve the Efficacy of Casting in Complex Clubfoot. Indian J Orthop. 2023 May 30;57(7):1147-1152. doi: 10.1007/s43465-023-00910-w. PMID: 37384013; PMCID: PMC10293533.
16. Ibrahim S. Tincture of Benzoin to Prevent Cast Slippage in Clubfoot. Malays Orthop J. 2016 Nov;10(3):62-63. PMID: 28553455; PMCID: PMC5333691.
17. Rangasamy K, Baburaj V, Gopinathan NR, Behera P, Sudesh P, Ravi Subramanian S. Correction results of atypical clubfeet managed with modified Ponseti technique: A meta-analysis of 354 feet. J Clin Orthop Trauma. 2022 Jun 25;31:101939. doi: 10.1016/j.jcot.2022.101939. PMID: 35818375; PMCID: PMC9270237.
18. Dragoni M, Gabrielli A, Farsetti P, Bellini D, Maglione P, Ippolito E. Complex iatrogenic clubfoot: is it a real entity? J Pediatr Orthop B. 2018 Sep;27(5):428-434. doi: 10.1097/BPB.0000000000000510. PMID: 29578933.
19. Williams ML, Dobbs MB. Clubfoot: Emphasis on the Complex and Atypical Subsets. Clin Podiatr Med Surg. 2024 Jan;41(1):17-25. doi: 10.1016/j.cpm.2023.06.009. Epub 2023 Jul 18. PMID: 37951674.
20. Yoshioka S, Huisman NJ, Morcuende JA. Peroneal nerve dysfunction in patients with complex clubfeet. Iowa Orthop J 2010; 30:24–28.
21. Edmonds EW, Frick SL. The drop toe sign: an indicator of neurologic impairment in congenital clubfoot. Clin Orthop Relat Res. 2009;467:1238e1242. https://doi.org/10.1007/s11999-008-0690-9.
22. Mandlecha P, Kanojia RK, Champawat VS, Kumar A. Evaluation of modified Ponseti technique in treatment of complex clubfeet. J Clin Orthop Trauma. 2019 May-Jun;10(3):599-608. doi: 10.1016/j.jcot.2018.05.017. Epub 2018 May 28. PMID: 31061597; PMCID: PMC6492221.
23. Chu A, Nechamie H, Lehman WB. Management of complex clubfoot. November 2019Journal of the Pediatric Orthopaedic Society of North America 1(1) DOI:10.55275/JPOSNA-2019-39]
24. Allende V, Paz M, Sanchez S, Lanfranchi L, Torres-Gomez A, Arana E, Nogueira MP, Masquijo JJ. Complex Clubfoot Treatment With Ponseti Method: A Latin American Multicentric Study. J Pediatr Orthop. 2020 May/Jun;40(5):241-245. doi: 10.1097/BPO.0000000000001469. PMID: 31688820.
25. Loose O, Fernandez Fernandez F, Langendoerfer M, Wirth T, Eberhardt O. Complex, atypical clubfoot: follow-up after up to 16 years reveals a high risk of relapse but good functional and radiological outcomes. Arch Orthop Trauma Surg. 2023 Oct;143(10):6097-6104. doi: 10.1007/s00402-023-04840-y. Epub 2023 May 17. PMID: 37195434.
26. Agarwal A, Gupta S, Rastogi P. Hallux length and deep medial crease in complex clubfeet: Do they recover? J Clin Orthop Trauma. 2020 May-Jun;11(3):453-456. doi: 10.1016/j.jcot.2020.03.004. Epub 2020 Mar 11. PMID: 32405208; PMCID: PMC7211816.
27. Gupta A, Hakak A, Singh R, et al. Atypical clubfoot: early identification and treatment by modification of standard Ponseti technique. Int J of Adv Res. 2015;3:1229–1234.
28. Bozkurt C, Sarıkaya B, Sipahioglu S, Altay MA, Çetin BV. Using the modified Ponseti method to treat complex clubfoot: early results. Jt Dis Relat Surg. 2021;32:170e176. https://doi.org/10.5606/ehc.2021.77135.
29. Duman S, Camurcu Y, Cobden A, Ucpunar H, Karahan N, Bursali A. Clinical outcomes of iatrogenic complex clubfoot treated with modified Ponseti method. Int Orthop. 2020;44:1833e1840. https://doi.org/10.1007/s00264-020-04529-6.
30. Elseddik HM, Helal MM, Kholeif MM, Sherif MM. Modified Ponseti manipulation and casting technique for treatment of atypical clubfoot. Egypt Orthop J. 2018; 55: 123-7.
31. Addosooki A, Tammam H, Morsy AF, Marzouq A, Ahmed EH, Ahmed AM, Said E. Correction to: Correlation of radiographic parameters with clinical correction in idiopathic congenital talipes equinovarus undergoing Ponseti treatment. Int Orthop. 2022 Aug;46(8):1911. doi: 10.1007/s00264-022-05453-7. Erratum for: Int Orthop. 2021 Dec;45(12):3139-3146. PMID: 35612667.
32. Patel A, Mongia AK, Sharma RK, Saini R, Chaudhary C, Singh S. Outcome of Atypical & Complex Clubfoot Managed by Modified Ponseti Method-A Prospective Study. J Foot Ankle Surg. 2022 Sep-Oct;61(5):1081-1085. doi: 10.1053/j.jfas.2022.01.024. Epub 2022 Jan 26. PMID: 35184957.

How to Cite this Article: Dhar SA, Dar TA, Dar RA, Raina A, Alam M, Farooq S, Maajid A. Atypical Clubfoot- A Systematic Review. International Journal of Paediatric Orthopaedics. January-April 2026; 12(1): 02-07.

(Article Text HTML) (Full Text PDF)

Bilateral Trevor’s Disease of Ankle: A Rare Presentation and Treatment Consideration

DOI- https://doi.org/10.13107/ijpo.2025.v11.i03.250

Open Access License: CC BY-NC 4.0

Submitted: 29/09/2025; Reviewed: 18/10/2025; Accepted: 13/11/2025; Published: 10/12/2025

Authors: Gaurav Kumar MS Ortho [1], Amitosh Mishra D. Ortho, DNB Ortho [2], Abhishek Verma DNB Ortho [1], Anuj Rastogi D. Ortho, DNB Ortho [2]

[1] Department of Orthopaedics, Hind Institute of Medical Sciences, Sitapur, UP, India.
[2] Department of Orthopaedics, Integral Institute of Medical Sciences & Research, Lucknow, UP, India.

Address of Correspondence
Dr. Amitosh Mishra,
Department of Orthopaedics, Integral Institute of Medical Sciences & Research, Lucknow, UP, India.
E-mail: dramitoshmishra@gmail.com

Abstract

Trevor’s Disease, also referred to as Dysplasia epiphysealis hemimelica (DEH), is an uncommon skeletal developmental disorder which is characterized by an asymmetrical growth of the epiphyseal cartilage. A 5-year-old boy presented with bilateral painless swelling on the medial aspect of both feet for 3 years which had progressively increased in size. X-ray and magnetic resonance imaging (MRI) showed swelling from the inferomedial aspect of the talus. It was managed surgically by excision of the swelling. Histopathology revealed an osteochondroma of the talus arising from the epiphysis. Early diagnosis and treatment are necessary to prevent articular dysfunction of the tibiotalar and subtalar joints.
Keywords: Epiphyseal tumors, Ankle osteochondroma, Ankle swelling, Dysplasia epiphysealis hemimelica, Trevor’s disease

References

1. P. A. A. Struijs, G. M. M. J. Kerkhoffs, and P: P. Besselaar, “Treatment of Dysplasia Epiphysealis Hemimelica: A Systematic Review of Published. Reports and a Report of Seven Patients,”Journal of Foot and Ankle Surgery, vol. 51, no. 5. 620:626.
2. V. Merzoug, P. Wicard, J. Dubousset, and G. Kalifa: Bilateral dysplasia epipysealis hemimelica: Report of two cases,. Pediatric Radiology, vol. 32, no. 6, pp. 431-434. 2002,
3. R. S. Kuo, M. C. Bellemore, F. P. Monsell, K. Frawley, and K.Kozlowski: Dysplasia epiphysealis hemimelica: Clinical features and management,. Journal of Pediatric Orthopaedics. 4:543-548.
4. D. Trevor: “Tarso-epiphysial aclasis; a congenital error of epiphysial development,” The Journal of Bone and Joint Surgery. British Volume, vol. 32:204-213.
5. A. F. Mavrogenis, P. J. Papagelopoulos, and P: N. Soucacos, “Skeletal osteochondromas revisited,” Orthopedics, vol. 31, no. 10. 1018:2008.
6. Fairbank TJ (1956: Dysplasia epiphysealis hemimelica (tarsoepiphyseal acalasis). J Bone Joint Surg Br. 38:237-257.
7. Carlson DH, Wilkinson RH: Variability of unilateral epiphyseal dysplasia (dysplasia epiphysealis hemimelica). Radiology. 1979, 133:369-73.
8. Connor JM, Horan FT, Beighton P: Dysplasia epiphysialis hemimelica. A clinical and genetic study . J Bone Joint Surg Br. 1983, 65:350-4.
9. Kettelkamp DB, Campbell CJ, Bonfiglio M: Dysplasia epiphysealis hemimelica. A report of fifteen cases and a review of the literature. J Bone Joint Surg Am. 1966, 48:746-65.
10. Bhosale SK, Dholakia DB, Sheth BA, Srivastava SK: Dysplasia epiphysealis hemimelica of the talus: Two case reports. J Orthop Surg. 2005, 13:79-82.
11. Hensinger RN, Cowell HR, Ramsey PL, Leopold RG: Familial dysplasia epiphysealis hemimelica, associated with chondromas and osteochondromas. Report of a kindred with variable presentations. J Bone Joint Surg Am. 1974, 56:1513-6.
12. R. Cruz-Conde, S. Amaya, and P: Valdivia, “Dysplasia epiphysealis hemimelica,”. Journal of Pediatric Orthopaedics, vol. 4. 5:625-629.
13. A. F. Mavrogenis, P. J. Papagelopoulos, and P: N. Soucacos, “Skeletal osteochondromas revisited,” Orthopedics, vol. 31, no. 10. 1018:2008.
14. W.-J. Bahk, H.-Y. Lee, Y.-K. Kang, J.-M. Park, K.-A. Chun, and Y.-G. Chung: Dysplasia epiphysealis hemimelica: radiographic and magnetic resonance imaging features and clinical outcome of complete and incomplete resection,. Skeletal Radiology, vol. 39, no. 1, pp. 85-90. 2010,
15. S. B. Rao and D. R. Roy: Dysplasia epiphysealis hemimelica: upper limb involvement with associated osteochondroma,. Clinical Orthopaedics and Related Research, no. 307. pp.:103-109.
16. Shinozaki T, Ohfuchi T, Watanabe H, Aoki J, Fukuda T, Takagishi K: Dysplasia epiphysealis hemimelica of the proximal tibia showing epiphyseal osteochondroma in an adult. Clin Imaging. 1999, 23:168-71.
17. DeVine JH, Rooney RC, Carpenter C, Pitcher JD: Dysplasia epiphysealis hemimelica in an elderly patient . Am J Orthop (Belle Mead NJ. 1997, 26:223-5.
18. Arkader A, Friedman JE, Moroz L, Dormans JP (2007: Acetabular dysplasia with hip subluxation in Trevor’s disease of the hip. Clin Orthop Relat Res. 457:247-252.
19. Segal LS, Vrahas MS, Schwentker EP (1996: Dysplasia epiphysealis hemimelica of the sacroiliac joint: a case report. Clin Orthop Relat Res. 333:202-207.
20. Azouz EM, Slomic AM, Marton D, Rigault P, Finidori G: The variable manifestations of dysplasia epiphysealis hemimelica. Pediatr Radiol. 1985, 15:44-9.

How to Cite this Article: Kumar G, Mishra A, Verma A, Rastogi A. Bilateral Trevor’s Disease of Ankle: A Rare Presentation and Treatment Consideration. International Journal of Paediatric Orthopaedics. September-December 2025; 11(3):24-27.

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

Full Sized Blog Element (Big Preview Pic)

Abstract

Abstract

License

Publisher