Original Article · Open access
Midterm outcomes of complex clubfoot treated with the modified Ponseti method: A comparative study of primary and referred cases
Abstract
Objectives: This study aims to evaluate the midterm clinical outcomes of patients with complex clubfoot treated using the Ponseti method and to assess the sustainability of deformity correction over time.
Patients and methods: Between January 2016 and January 2021, a total of 38 feet in 26 patients with complex clubfoot treated using the modified Ponseti method were retrospectively analyzed. The patients were divided into two groups: those treated entirely in our institution (study center group) and those referred from external centers after unsuccessful initial treatment (external center group). Clinical severity was assessed using the Pirani score, and ankle dorsiflexion (DF) was measured during follow-up. Functional outcomes were evaluated using the Pirani-Based Score (PBS) and the Oxford Ankle Foot Questionnaire (OxAFQ). Relapse rates, additional procedures, and treatment success were analyzed. Independent predictors of outcomes were identified.
Results: Of a total of 26 patients included in the study, 2 were male and 24 were female with a mean age of 6.78±1.29 (range, 5 to 8) years. Of these patients, 14 (53.8%) had unilateral involvement, while 12 (46.2%) had bilateral deformity. The external clinic group presented at a significantly later age than the study center group (p < 0.001), while baseline deformity severity was comparable. Pirani scores and DF measurements improved significantly in both groups, with no intergroup differences during follow-up (p > 0.05). Functional outcomes showed a significant difference in PBS scores, which were higher in the external clinic group (p = 0.045), indicating worse functional performance, while the OxAFQ scores were similar between groups (p = 0.911). Relapse rates were higher in the own clinic group but did not reach statistical significance (p = 0.254). Multivariate analysis revealed that age was the only independent predictor of treatment success (odds ratio [OR] = 2.067, p = 0.019), while referral status was not an independent determinant.
Conclusion: The modified Ponseti method provides effective midterm correction in complex clubfoot regardless of referral status. Although referred patients present later and may demonstrate worse functional outcomes, referral source does not independently influence treatment success. Early recognition and appropriate application of modified Ponseti principles remain critical for optimal outcomes.
Declarations
Author Contributions
M.A.D., A.Y.K., C.B.: Idea/concept; B.V.Ç.,, M.A.A.: Design control/supervision; M.I., T.B.: Data collection and/or processing; A.Y.K., M.I.: Analysis and/or interpretation literature; A.Y.K., C.B.: Review; M.A.D.,, A.Y.K.: Writing the article; M.A.A., C.B.: Critical review; M.I., T.B.: References and fundings; Materials; A.Y.K., M.I., M.A.D.
Conflict of Interest
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.
Financial Disclosure
The authors received no financial support for the research and/or authorship of this article
Data Sharing Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
AI Disclosure
The authors declare that artificial intelligence (AI) tools were not used, or were used solely for language editing, and had no role in data analysis, interpretation, or the formulation of conclusions. All scientific content, data interpretation, and conclusions are the sole responsibility of the authors. The authors further confirm that AI tools were not used to generate, fabricate, or ‘hallucinate’ references, and that all references have been carefully verified for accuracy.
References
- Ponseti IV. Congenital clubfoot: Fundamentals of treatment. Oxford: Oxford University Press; 1996.
- Dobbs MB, Gurnett CA. Update on clubfoot: Etiology and treatment. Clin Orthop Relat Res 2009;467:1146-53. DOI: 10.1007/s11999-009-0734-9.
- Schuster J, Zaldivar B, Ortiz D, Montoya D, Rodriguez AC, Caicedo-Gutierrz M. A modified ponseti method for skeletally mature patients with clubfoot and acquired complex foot deformities. Foot Ankle Orthop 2026;11:2473011426S00049. DOI: 10.1177/2473011426S00049.
- Ponseti IV, Zhivkov M, Davis N, Sinclair M, Dobbs MB, Morcuende JA. Treatment of the complex idiopathic clubfoot. Clin Orthop Relat Res 2006;451:171-6. DOI: 10.1097/01.blo.0000224062.39990.48.
- Bozkurt C, Sarıkaya B, Sipahioğlu S, Altay MA, Çetin BV. Using the modified Ponseti method to treat complex clubfoot: Early results. Jt Dis Relat Surg 2021;32:170-6. DOI: 10.5606/ehc.2021.77135.
- 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. DOI: 10.1007/s00402-005-0070-9.
- 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;27:428-34. DOI: 10.1097/BPB.0000000000000510.
- 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 B 2017;26:137-42. DOI: 10.1097/BPB.0000000000000321.
- Mandlecha P, Kanojia RK, Champawat VS, Kumar A. Evaluation of modified Ponseti technique in treatment of complex clubfeet. J Clin Orthop Trauma 2019;10:599-608. DOI: 10.1016/j.jcot.2018.05.017.
- Chu A, Lehman WB. Persistent clubfoot deformity following treatment by the Ponseti method. J Pediatr Orthop B 2012;21:40-6. DOI: 10.1097/BPB.0b013e32834ed9d4.
- 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;61:1081-5. DOI: 10.1053/j.jfas.2022.01.024.
- 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;44:1833-40. DOI: 10.1007/s00264-020-04529-6.
- 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;143:6097-104. DOI: 10.1007/s00402-023-04840-y.
- Böhm S, Sinclair MF. The PBS Score - a clinical assessment tool for the ambulatory and recurrent clubfoot. J Child Orthop 2019;13:282-92. DOI: 10.1302/1863-2548.13.190077.