SLR - January 2021 - Tyler D. Sten

Successful Ponseti-treated Clubfeet at Age 2 Years: What Is the Rate of Surgical Intervention After This?

Reference: Siebert M, Karacz C, Richards B. Successful Ponseti-treated Clubfeet at Age 2 Years: What Is the Rate of Surgical Intervention After This?, Journal of Pediatric Orthopaedics: November/December 2020 - Volume 40 - Issue 10 - p 597-603.

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Tyler D. Sten, DPM
Residency Program: Ascension St. Vincent Hospital – Indianapolis, IN

Podiatric Relevance: Clubfoot is one of the most common congenital orthopaedic deformities with a global prevalence between 0.51 and 2.01 per 1000 live births. Over time, clubfoot treatment evolved from a primarily surgical intervention to the widespread gold standard of the Ponseti method. Multiple studies have determined the long-term functional outcomes of feet treated nonoperatively to be superior to surgical treatment. However, studies have reported 11 percent to 48 percent relapse of the deformity. The purpose of this study was to better quantify the frequency and timing of surgical intervention, and surgical procedures performed in patients with idiopathic clubfeet who had reached the age of two years that had successful outcomes from the Ponseti method.

Methods: This was a retrospective review of prospective registry of clubfoot patients between 2001 and 2019. Inclusion criteria were patients under the age of three months with idiopathic clubfeet, had the Ponseti method of nonoperative treatment (with the exception of Achilles tenotomy), reached the age of two years with plantigrade feet without requiring surgical intervention, and had a minimum five-year follow-up. Exclusion criteria were patients with nonidiopathic clubfeet associated with another musculoskeletal, neurological, neuromuscular, chromosomal abnormality, or as a part of a syndrome. 

Results: The study included 336 patients for a total of 504 feet. Average follow-up was 8.8 years. One hundred twenty-six total patients (36.3 percent) underwent surgical intervention. Seventy-nine patients (23.5 percent) between the ages of two and five years underwent surgery. Fifty-three patients (20.1 percent) over the age of five years underwent surgery. Ten of the 53 patients had previously undergone surgery between two and five years of age. The most common procedures performed between the two cohorts were limited to: TA tendon transfer, posterior release, plantar fascia release and tendo Achilles lengthening. There was no significant difference in procedure selection between the two groups. Percutaneous TAL was performed in 71.8 percent of patients as part of their initial Ponseti casting. There was no significant difference in the rate of later surgical intervention in those that had a TAL versus those that did not.

Conclusions: Patients with idiopathic clubfoot who reached the age of two years with successful outcomes from Ponseti casting eventually underwent surgical intervention in 36.3 percent of cases. The most commonly performed procedures included TA tendon transfer, posterior capsular release, plantar fascia release and TAL. It can be concluded that over one-third of children that have been successfully treated by Ponseti method will require surgical intervention after two years of age. This information will further help clinicians to evaluate clubfoot patients, and to educate parents on the long-term outcomes of clubfoot treatment.

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