congenital talipes equinovarus is recognized as the  down and in  foot , often resembling a club - like appearance . it is the most important cause of physical disability among all congenital musculoskeletal defects occurring in an otherwise normal child.1 for many years , the kite 's method was used for the correction of clubfoot , but it took enormous amount of time for correction and produced excellent results only in the hands of kite.2 in recent years , the ponseti method has become the gold standard for correction of clubfoot.12 however , most of the studies on ponseti method are done in younger children , before the walking age . neglected clubfoot is the primary problem in developing nations , where social stigma , lack of education , poverty and lack of proper health services hinder the early presentation and treatment of a child with clubfoot . the deformity becomes worse by walking as the weight bearing takes place on the side or dorsum of the foot , causing further contracture of the medial soft tissues and plastic deformation of bones.3 most of the literature on treatment of neglected clubfoot focuses on soft tissue release surgery , osteotomy or fixators . the problem in developing country is the large number of patients and scarcity of skilled surgeons and ot time . further , the good short term results have shown to deteriorate over longer followup resulting in rigid painful feet.45 the scars are cosmetically unacceptable . this calls for a simpler method that can be easily applied to larger population with better results . inspired by the success of ponseti method in idiopathic clubfeet , the method was tried in neglected feet as well in past , but in small series.6789 we here present one of the largest prospective studies published till date . we wanted to evaluate the effect of ponseti method of casting on neglected feet , to assess its failure and recurrence rate . we also wanted to evaluate if there is any improvement in radiological parameters following serial casting by ponseti method . further , we wanted to find if any correlation exists between total number of casts and initial pirani and dimeglio scores , and age of initial presentation of the patients . 41 feet of 30 patients with mean age of 3.02 years ( range 1 - 10.3 years ) were included in this prospective study children with virgin idiopathic clubfoot , with no previous treatment , in the age group of more than 1 year at the time of presentation were included in the study . consent was taken prior to enrolment in the study after explaining the mode of treatment . quantification of various components of clubfoot deformity was done using the dimeglio score10 and pirani score11 prior to application of every cast and at each followup . anteroposterior ( ap ) and lateral standing radiographs of the feet were taken prior to treatment , immediately after correction and at the time of the latest followup . child was placed on a specially designed step stool to take standing lateral x rays , with the lateral border of foot touching the cassette and rays perpendicular to the foot [ figure 1 ] . on the ap view , the talo - calcaneal and the talar - first metatarsal angles were recorded . on the lateral view the beatson - pearson index12 ( sum of the talo - calcaneal angle in the ap and lateral views ) was used for overall radiological assessment . the casts followed standard ponseti protocol.13 initially , cast was applied in full supination for the correction of cavus . percutaneous tenotomy of the tendo - achilles was done once the forefoot deformity was corrected with a fully reducible talar head which was assessed using pirani scoring ( lateral head talar sign in pirani scoring was 0).11 tenotomy was performed either under general or local anesthesia . the technique was always percutaneous and in no case we had to resort to open lengthening [ figure 2a and b ] . tenotomy of the tendo - achilles was done in all patients , even up to the age of 10.3 years . a repeat tenotomy of tendo - achilles was done in children where adequate dorsiflexion , i.e. , at least ten degree of dorsiflexion was not achieved by the first tenotomy . posttenotomy cast was removed at 3 weeks in patients aged <3 years and 4 weeks in patients aged more than 3 years . despite our initial apprehensions regarding tenotomy in older children plantar flexion was checked at 3 months and 6 months using clinical and radiological studies . clinically the strength was considered adequate when child could stand on toes unassisted and radiologically we used ultrasound to assess adequacy of the tendon . in no case was tendo - achilles found inadequate with most children found to stand on toes in 34 months unassisted . no strict protocol is present in the available literature regarding the splinting in children of older age group . it was applied for 23 h a day for the first 3 months in all the patients and advised for sleep time use up to the age of 4 years or 1 year in children older than 4 years . clinical photographs showing ( a and b ) anteroposterior and lateral technique of taking x - rays clinical photographs showing ( a ) pretenotomy foot with equinus and ( b ) posttenotomy foot with correction of equinus during our study , we assessed the age at the time of presentation , severity of deformity by the pirani and dimeglio score at each visit , the number of casts required for the correction , amount of ankle dorsiflexion after tenotomy , need for any other surgery , change in the pirani and dimeglio score , and residual deformities . the quantitative variables were expressed as mean  standard deviation and compared between preoperative and postoperative followup using the paired t - test . also , the relation between the pirani and dimenglio score and age at presentation with the number of casts required was evaluated using pearson 's correlation coefficient . statistical analysis was performed using spss version 15.0 software(ibm software , united states ) and a p < 0.05 was considered statistically significant . the mean number of casts applied , to achieve final correction , were 12.8 casts ( range 8 - 18 casts ) . the average dorsiflexion achieved was 12.26 ( range 320 ) at the end of treatment . the average dorsiflexion achieved in age group 13 years was 15.48 , between 3 and 5 years was 8.54 and > 5 years was 7 [ figure 3 ] . the older children had lesser dorsiflexion , yet the children and parents were satisfied with the final results as they were able to wear normal footwear and carry on most of the functions . in seven cases , where the dorsiflexion was less than ten degree after the tenotomy of tendo - achilles , we did a repeat tenotomy , after 1 month , to further improve the dorsiflexion . scatter diagram showing that final dorsiflexion achieved depends on the age at which treatment is started . less dorsiflexion with increasing age clinical photograph of 5-year - old child showing ( a ) neglected bilateral clubfeet at presentation ( b ) neglected bilateral clubfeet after 8 casts in tenotomy clinical photograph of 4-year - old child showing ( a ) neglected unilateral clubfoot before treatment ( b ) neglected unilateral clubfoot after 7 casts and tenotomy cavus was seen as one of the most severe deformities and in 5 children cavus remained even after complete correction of other deformities . a percutaneous plantar fasciotomy was needed in these 5 feet for the correction of residual cavus . three patients developed casting related complications of erythema and superficial sore , which were managed by generous padding in the subsequent casts . one patient with bilateral clubfeet developed flat top talus probably as a result of more number of casts ( n = 18 ) and the dorsiflexion achieved was less , ( 3 ) even after tenotomy . we calculated the correlation between the number of casts required for correction versus the initial age , pirani scores , and dimeglio scores . there was a significant positive correlation between age and number of casts required ( r = 0.528 , p < 0.001 ) . this has also been shown in the scatter diagram where an increasing trend is seen in the number of casts required for maximal correction with increasing age [ figure 6 ] . also , age was negatively correlated with initial pirani score ( r = 0.510 , p = 0.001 ) and positively correlated with initial dimeglio score ( r = 0.439 , p = 0.004 ) . figure 7 shows a scatter diagram showing a relationship between pirani score and age of patient . on the other hand , number of casts required had no significant correlation with initial pirani score ( r = 0.234 , p = 0.141 ) while it was positively correlated with initial dimeglio score ( r = 0.413 , p = 0.007 ) . scatter diagram where an increasing trend is seen in the number of casts required for maximal correction with increasing age scatter diagram , where the initial pirani scores show a decreasing trend with increasing age , despite the stubborn foot deformity the range of ap talo - calcaneal angle , precorrection , was from 0 to 14 , with a mean of 5.04. the postcorrection ap talo - calcaneal angles ranged from 15 to 35 , with a mean of 26.14. the range of lateral talo - calcaneal angle , pre correction , was from 0 to 16 , with a mean of 5.29. the range of postcorrection lateral talo - calcaneal angle was 1540 with a mean of 25.24. [ figures 8 and 9 ] show ap and lateral x - rays of our clinical case at pre- and post - treatment time . the mean beatson - pearson index before treatment was 10.34. after correction our mean beatson - pearson index was 51.39.8 anteroposterior x - ray of foot before treatment showing ( a ) parallel talo - calcaneal relation ( b ) radiological improvement with talo - calcaneal angle nearing 30 in both planes lateral x - ray of foot before treatment showing ( a ) parallel talo - calcaneal relation ( b ) radiological improvement with talo - calcaneal angle nearing 30 in both planes 7 patients developed recurrence of the deformity . the time to wear brace in these cases was less than 8 hours a day . it was mainly a recurrence of equinus in 3 feet whereas adduction cavus and equinus in four . these were treated by repeat ponseti casting and tenotomy in 4 feet and 3 patients required a tibialis anterior tendon transfer . the children with neglected clubfoot deformity are unable to mix with their peers because of stigmatization , and as a result very few go to school . most of the literature on treatment of neglected clubfoot has focused on extensive soft tissue release surgery , osteotomies , and various types of fixators or arthrodesis.451314 long term studies of surgical procedures have shown poor results with complications like painful feet , arthritis , stiffness of ankle and subtalar joint , and residual deformity.4514 the few studies , evaluating the use of ponseti method in children with neglected clubfeet have shown promising results.6789 loureno and morcuende treated 17 patients ( 24 feet ) with neglected clubfeet , with mean age of 3.9 years and found good results in 16 feet ( 66.6% ) without further surgery.6 verma et al . evaluated ponseti method in toddlers and found it to be very useful.7 khan and kumar treated neglected clubfoot in 21 children ( 25 feet ) over 7 years and found good results in 18 feet ( 85.7%).8 the comparison of these studies is described in table 1 . comparison of various published studies the mean number of casts in our study before tenotomy was 12.8 weekly casts with an average of 3 months of immobilization . loureno and morcuende6 treated with 9 biweekly casts which meant an immobilization of about 4.5 months that was slightly more than we observed . however , khan and kumar8 and mehtani7 had treated patients in 12.1 and 10 casts , respectively , which was comparable to our study . also , the amount of final dorsiflexion achieved in our study was slightly more than other published series [ table 1 ] . spiegel et al.9 in their study of 260 feet in the age group of 16 years observed mean dorsiflexion of 12.5 up to 2 years and 910 in 35 years of age , which is comparable to our result . in our study , all the 41 feet treated by the ponseti method of cast application achieved painless , supple , plantigrade , and cosmetically acceptable feet within a mean period of 3.6 months . the recurrence rate of 17.07% in our series is also is comparable to that of most of the studies done in infants . however , there were certain striking differences between the results of ponseti method in infants and older children . the average dorsiflexion achieved in our study was 12.26 , which is more than that achieved by loureno and morcuende6 ( 5 ) but less than that achieved in younger children . the feet could not be abducted to 70 as advised in younger children and passive abduction was possible up to 40 with a mean of 20.87. even loureno and morcuende in their study mentioned that abduction was attempted to approximately 3040 instead of 70 as recommended in infants . despite these limitations , we also compared the initial pirani and dimeglio scores for correlation with the number of casts required for correction and found that while dimeglio score had a moderate positive correlation ( 0.439 ) with the number of casts required , the pirani score had a low negative correlation ( 0.278 ) . hence , pirani scoring is not a sensitive enough tool for assessing the deformity in children of older age group and gives fallacious low values , due to low scores for empty heel and posterior crease and medial crease , despite resistant , rigid deformities . this is also shown by the scatter diagram , where the initial pirani scores show a decreasing trend with increasing age , despite the stubborn foot deformity [ figure 9 ] . the number of casts required for correction also showed an increasing trend with the age . despite the encouraging results seen in our study second , we found that older children had difficulty accepting the foot abduction brace and no definite protocol is available regarding bracing in older children . we advocated at least 1 year of night time bracing even in older children but 5 patients who did nt tolerate the foot abduction brace had to be given a custom made ankle foot orthosis ( afo ) . recurrence was seen in seven cases , but feet were still supple and responded to repeat ponseti casting unlike surgical recurrence . an early tibialis anterior transfer to the third cuneiform , which would act as internal bracing might be helpful in preventing the relapses . the larger patient samples and followup period would be required to establish fully the efficacy of ponseti method for treating neglected clubfoot but our results our encouraging . also , the bracing protocol is difficult particularly in older children . we feel that ponseti method either fully takes care of this stubborn deformity or reduces the extent of residual surgical release and it should be a good alternative for treatment of neglected clubfoot .