What Is the Best Treatment for Idiopathic Clubfoot?

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Chapter 36 What Is the Best Treatment for Idiopathic Clubfoot?

The best treatment for idiopathic clubfoot is the simplest, safest, least expensive, and most rapid method to correct the clubfoot deformity, maintain correction, and allow lifelong normal foot function. Clearly, several potential questions need to be addressed. For example, the treatment that most rapidly corrects deformity may result in painful feet long term. The safest technique for initial correction may be less effective than other techniques. Clarifying the questions to be answered is critical to evaluating the quality of evidence available.

This chapter addresses the following questions: (1) What treatment best obtains initial correction in idiopathic clubfoot? (2) What treatment best maintains correction? (3) What treatment gives the best long-term foot function? Treatment techniques for severe recurrent deformities from failed treatment such a triple arthrodesis and Ilizarov approaches are not addressed.

Few investigations of “high-level” evidence address these questions. There are several reasons for this. First, true randomized studies of very different treatment methods have not been performed and will not be performed for ethical reasons. No orthopedic surgeons are agnostic with respect to the best treatment for clubfoot. Minor variations within a treatment approach are much more likely to be randomized. Second, the severity of clubfeet appears to vary in ways that are difficult to quantitate. This inability to classify feet results in stratification of individuals within a cohort of clubfoot patients who are treated in different ways based on nonquantifiable distinctions of their treating physicians, resulting in selection bias for a particular treatment. One practitioner’s “mild” deformity may be another practitioner’s “moderate” deformity. If these practitioners choose treatment with manipulation or posteromedial release (PMR) based on the “severity” of deformity, the results of their treatment regimens will not be comparable. Rating scales of severity at birth have not been shown to identify difficulty with initial correction, maintenance of correction, or long-term function for different treatment techniques. That a particular scale can predict success with a particular treatment technique has been shown, but this result cannot be generalized a priori to other techniques.¹ When a technique, such as the Ponseti method, results in near-universal early correction, there is no value of rating scales for predicting the likelihood of initial deformity correction. A useful rating scale would need to predict recurrence risk or long-term outcome. No such rating scale exists. Therefore, we do not have a common starting point for comparing treatment techniques that is validated, and there may never be one. This is particularly important because many case series are a mixture of techniques based on the treating physician’s view of the severity of the deformity. Thus, many case series describe a treatment given to a selected group of patients with clubfoot from a cohort that is not defined. Third, recurrence of deformity, as opposed to failure of complete correction, is ill-defined. Generally, recurrence is in the eye of the beholding physician. Proxy measures, such as repeat surgery or need for further casting, are crude measures of recurrence. Fourth, outcome studies of sufficient length and quality to answer the question “What treatment method gives the best lifelong foot function?” are rare. A true comparative study of different methods that met Level I or II standards would require funding and commitment at a level that such studies have not and may never be performed. One confounding factor that occurs commonly in all surgical fields is that the surgical procedure is constantly “tweaked” so that long-term studies are rarely strictly comparable with the present “best” surgical treatment.

Despite these problems, data do exist that suggest best treatments. Case series studies of similar patients treated by different treatments because of a change in practice of a single or group of practitioners can be compared. Outcome studies utilizing validated outcome instruments of case series are beginning to be performed, and such studies can be compared. Multiple case series of a specific technique can be compared with multiple case series using a different technique.

The data used to attempt to answer the questions come from an Embase and Medline search for Level I and II evidence studies written in the English language from 1950 to 2007. Almost no relevant studies were found. Using the same research strategy from 2000 to 2007, a few Level III evidence studies and several Level II studies, not initially identified, were found. Because of the paucity of information, the same databases were searched for Level IV evidence studies from 2000 to 2007, of which there were 77 identified. These case series studies were supplemented with earlier case series studies that the author believes were most informative. The analysis does not meet the standard of a systematic review. The quantity of case series studies before 2000 and in non–English language publications that would need to be surveyed for a systematic review was beyond the scope of this project but may be a worthwhile undertaking. I will attempt to give an accurate appraisal of the quality of evidence, but it should be noted that the quality of evidence is not what would be desired or expected for such a relatively common disorder.

WHAT TREATMENT BEST OBTAINS INITIAL CORRECTION IN IDIOPATHIC CLUBFOOT?

The question of what treatment best obtains initial correction in idiopathic clubfoot asks what nonoperative (or largely nonoperative technique if percutaneous tendo Achilles lengthening [TAL] is included) treatment is most effective is correcting clubfoot deformities. Neonatal surgical correction by major ligament release has not succeeded in giving lasting correction and has been abandoned. Many idiosyncratic techniques for manipulating and immobilizing clubfeet exist. In much of the literature, the question is not addressed because the studies are of surgical treatments. The authors simply state that feet uncorrected conservatively had their surgical treatment. When stated, the number of feet that were conservatively corrected varies from 5% to 60% in most studies, but specific treatment techniques are rarely specified. The most prominent published techniques are those of Kite and Denis Browne from the 1930s, Ponseti from the 1960s, and Dimeglio and Bensahel from the 1990s. The Kite method was by far the most common technique used in the United States until the recent popularity of the Ponseti method.

Sud and colleagues ² compared rates of initial correction and relapse comparing the Ponseti and Kite methods in a prospective, randomized study with outcome assessment by a surgeon who was blinded to the treatment. The clinic in which the children were treated had used the Kite method for 15 years and the Ponseti method for 1 year before beginning the study. Fifty-three patients with 81 feet were enrolled, and 8 were lost to follow-up and excluded from analysis. Thirty-six feet treated by the Ponseti method and 31 feet treated by the Kite method were followed for an average of 26 months. The Ponseti method had a 91.7% initial correction rate compared with 66.7% by the Kite technique. Ponseti method feet had a 21.1% relapse rate over the course of the study compared with a 38.1% relapse rate for the Kite method. The mean number of casts was statistically significantly less for the Ponseti method (6.2, Ponseti method; 10.7, Kite method), and the mean time to correction was significantly shorter for the Ponseti method (49.2 days, Ponseti method; 91.2 days, Kite method).

Three other studies address the question of early correction by comparing different methods. Herzenberg, Radler, and Bor ³ in Maryland and Israel compared their first 27 patients treated by the Ponseti method with 27 patients matched from their database who had been treated by a variety of manipulative techniques by the authors or referring physicians. Their major outcome variable was need for PMR in the first year of life because of failure to correct the deformity. Only 1 foot required PMR (97%) correction with the Ponseti technique compared with only 2 feet corrected without PMR in the historical control group, which had a 6% success rate. Segev and coworkers⁴ compared 61 clubfeet treated by a modification of the Kite and Lovell method and managed an average of 55 months with their initial 48 feet treated with the Ponseti method that were managed for an average of 29 months with a 16-month minimum. The feet treated by the Kite and Lovell method required surgical correction in 56% of the feet. Of the feet treated by the Ponseti method, 3 (6%) required surgical correction.

Aurell and researchers ⁵ in Sweden report a center randomized study of clubfeet treated by 2 different techniques. A consecutive series of children with clubfoot was treated by the Ponseti method at 1 hospital (9 feet) and by the Copenhagen method at another hospital (19 feet). The Copenhagen method involves manipulation by a physiotherapist 4 to 5 times per week with correction maintained by a plexidur splint for 1 month, followed by 1 or 2 times per week manipulation in the second week. At 2 months of age, a pediatric orthopedic surgeon decided whether further treatment was needed. All 9 feet treated by the Ponseti technique required only a percutaneous TAL. Of the 19 feet treated by the Copenhagen method, 12 required PMR (63%) and 1 required a posterior release (5%).

Many case series studies address the effectiveness of the Ponseti method for early correction. Changulani and researchers ⁶ report their initial experience in the United Kingdom using the Ponseti method in 100 feet in 66 children. Ninety-six of 100 feet were fully corrected with 85 requiring percutaneous tenotomy. Colburn and Williams⁷ report complete initial correction of 54 of 57 feet (95%) of the first babies they treated by Ponseti method in San Francisco. Goksan and coauthors⁸ report on 134 feet with 97% follow-up to mean age of 46 months with a minimum of 2 years after initial casting in Turkey. Only 4 patients required PMR. Lehman and colleagues⁹ in New York reported successful correction in 92% of the first 45 feet treated by the Ponseti method. Tindall and coworkers¹⁰ report initial correction of 98 of 100 in Malawi by nonphysician orthopedic paraprofessionals. Shack and Eastwood¹¹ report initial correction of 39 of 40 children in a physiotherapist-delivered Ponseti program in the United Kingdom. Morcuende and colleagues¹² report initial correction in 98% of 256 feet treated by Dr. Ponseti and others at the University of Iowa.

A number of case series reports have been published of the French or Montpellier method of physiotherapy correction of clubfoot. Physiotherapy was developed and refined by Masse, Bensehal, Dimeglio, Metaizeau, and others. The technique has been published in English, but several case series in French are not included here. Dimeglio reported on three groups of feet during the evolution of the treatment in 1996. The best group consisted of 52 clubfeet. Forty percent were corrected without surgery; 35% required PMR or PMRL; and 25% required posterior release. Van Campenhout and investigators ¹³ evaluated their results of physiotherapy and continuous passive motion machine in 64 babies with 100 feet. The authors included only infants presenting at younger than 3 months whose family strictly adhered to the protocol. With a minimum follow-up of 18 months and a mean follow-up of 3.2 years, 75 (75%) of the feet required surgery. Richards and coauthors¹⁴ report on 142 feet in 98 babies treated by the French method.¹⁴ With an average follow-up of 35 months, 20% required PMR and 29% required posterior release. Souchet and colleagues¹⁵ report what appears to be a largely personal series of Bensahel of 350 clubfeet followed to skeletal maturity. Twenty-three percent required surgical treatment at a mean age of 1 year. Stromqvist and coworkers¹⁶ report on 75 feet treated by a strict physiotherapy and bracing regimen, and managed for an average of 8 years. Sixty-seven (89%) of the feet underwent posterior release (PR) (two thirds) or PMR (one third) between 2 and 5 months of age.¹⁶ Twenty-five feet (33%) required a second operation at a mean of 4 years, and 4 feet had a third operation.

Summary

Reasonably strong evidence exists that the Ponseti method is the best treatment to obtain initial correction in idiopathic clubfoot. Although high-level evidence studies are few, they are entirely consistent in supporting the Ponseti method as the most effective and rapid technique. Case series are persuasive because all show a more than 90% initial correction rate, which is greater than that reported in any report for other methods. Furthermore, most series report the authors’ early experience, and results would be expected to improve with experience. That the results have been replicated in many parts of the world by medical practitioners of varying levels of training, all support the conclusion that the Ponseti method is the “best” method for initial correction of idiopathic clubfoot.

WHAT TREATMENT BEST MAINTAINS CORRECTION?

Relapse of deformity that requires treatment in clubfoot is in the “eye of the beholder.” No technical cutoff exists to say when a correction is inadequate versus when a recurrence of deformity has developed. Therefore, relapse rates are likely to vary between different investigators. Nonoperatively treated clubfeet that lose correction will relapse into a clubfoot deformity with varying amounts of recurrent equinus, varus, adductus, and cavus. Operatively treated feet may relapse in a similar way but may also lose correction into foot positions such as severe planovalgus, severe cavus from dorsal dislocation of the navicular, dorsal bunion development, and any combination of relapse and overcorrection of the initial deformities. In general, recurrent deformity requiring further treatment is reported to compromise results. One long-term report of the Ponseti method suggests that relapse of a certain type, at a certain age, can be managed in a way (anterior tibial tendon transfer to the third cuneiform) that does not compromise long-term foot function.¹⁷ Nonetheless, most relapses in corrected clubfoot treated nonoperatively occur in the first 5 years of life. The surgical literature, which is largely short- to medium-term follow-up studies (2–8 years), also suggests that recurrent deformity or overcorrection tends to occur during the rapid growing period of the foot.

For the purposes of this section, I define “need for further surgery after initial correction” as a surrogate for relapse in reports of surgically treated feet. Investigations of feet treated surgically in infancy almost never report using manipulation and casting to treat recurrent deformity. Therefore, only further surgery indicates a change in foot morphology that the investigator thought required treatment. Adherents of the Ponseti method will treat relapse at an early stage with repeat casting, and at a later age with an anterior tibial transfer under most circumstances. This is not considered a failure based on current long-term follow-up data and, therefore, is discussed somewhat differently than a recurrence requiring further surgery. Note that some feet may require further treatment because of symptoms, without incurring new deformity. Therefore, need for further surgery is not a distinct end point but is the best available surrogate.

The literature I use to address this question is largely case series studies with follow-up periods shorter than skeletal maturity for most patients. Most of these studies purport to be “outcome” studies. Most of these studies use unvalidated, idiosyncratic rating scales that mix symptoms, physical finding, and radiographic findings in arbitrary ways to develop “excellent/good/fair/and poor” ratings. The only value of these studies is for assessing early complication rates such as relapse. These are not considered in the last section on long-term outcome. Bad results can be identified at any age, but I will not consider a study to address long-term foot function until the cohort studied is at least mostly skeletally mature. Another weakness of many of these studies is that comparisons of different treatment methods were done based on a change in practice so that the follow-up lengths are markedly different between the treatment groups. Finally, the reporting of basic data such as age at operation, length of follow-up, rate of follow-up, and rate of reoperation are often absent or unclear in the published manuscripts. Some interpretation is occasionally necessary, which certainly reduces accurate assessment of the data reported.

A number of Level III evidence studies comparing different surgical treatment techniques demonstrate the problem of markedly different follow-up periods between different techniques that were utilized at various times at single institutions.

Tschopp and colleagues reported on 18 feet treated by PMR managed for an average of 98 months and compared them with 17 feet undergoing complete subtalar release with an average follow-up of 39 months.¹⁸ Four feet needed further surgery in the PMR group, and one foot needed further surgery in the subtalar release group.

Centel and investigators ¹⁹ compared 17 feet treated by PMR and managed for 5 years with 46 feet treated by subtalar release and managed for 2 years. The PMR group had a 19% reoperation rate, and the subtalar release group had an 11% reoperation rate. Centel and investigators¹⁹ also reported on 20 patients who presented with only residual equinus who were treated by posterior release alone and who were managed for 4 years and had a 29% reoperation rate.

Nimityongskul and researchers ²⁰ compared 16 feet treated by Turco PMR and managed for an average of 8.5 years with 12 feet treated by McKay/Simons circumferential release managed for less than 4 years on average. Six of 16 PMR feet (37.5%) required further surgery, whereas no complete subtalar release feet needed further surgery during this short follow-up. The authors’ anticipated 55% of the PMR group and 17% of the complete subtalar release group would require further surgery.

Pavlovcic and Pecak ²¹ compared the results of posterior release in 96 feet (chosen for this treatment because of mild deformity) with PMR in 75 feet (chosen for this treatment because of severe deformity). Both groups were managed for slightly more than 12 years on average. Sixty-eight percent of the PR feet required further surgery, and 42% of the PMR feet underwent further surgery.

A single study compared 30 feet treated by PMR with 30 feet treated by PMR and an anterior tibial tendon lengthening.²² Follow-up was 11 and 9 years for the respective groups. Eight of 30 (27%) of the PMR-treated feet, and 2 of 30 (7%) of the feet with PMR plus anterior tibial tendon lengthening required further surgery. Seventeen percent of all feet required further surgery.

Simons ²³ report on 21 feet treated by PMR and lateral release with 25 feet treated with a complete subtalar release. A short follow-up of 3 years revealed that 4 feet (9% of the entire group) required further surgery. Two feet had PMR and 2 had complete subtalar release. Furthermore, Simons²³ describe, major complications that may require further surgery in an additional 24 patients (52%).

Otremski and coworkers ²⁴ compared 30 feet treated by PMR with an 8– to 14– year follow-up with 22 feet treated by a modified PMR with a 5-year average follow-up period. Five patients treated by PMR and 1 patient treated by modified PMR had further surgery at last follow-up examination (12% of the entire group).

Thompson and colleagues ^24a fashioned three groups from a population of 244 clubfeet of which 73% were managed for less than 10 years and 27% had longer than a 10-year follow-up period. The group treated with a limited or á la carte release (112 feet) required further surgery in 74% of feet and recasting in 8%. A second group was defined as having had a failed incomplete release and had undergone a complete PMR (39 feet). Ten percent of this group had subsequent surgery, and 28% were recasted. A group of 93 feet treated primarily by PMR had a 9% reoperation rate and an 11% recasting rate.

Case series studies with short-term results that shed light on recurrence rates are common but are subject to all the biases inherent in such studies. Fourteen representative studies are summarized with respect to recurrence of deformity requiring surgical treatment. Surgical treatment in these 14 reports were variously described as “Turco procedure,” “modified Turco,” “soft tissue release,” “selected soft tissue release,” “a la carte,” “complete subtalar release,” “Simon release,” “McKay release,” “early posterior release,” “Goldner release,” and “staged plantar medial followed by postero lateral release.” Follow-up ranged from 2 to 16 years with an average follow-up period of 8 years. Number of feet reported ranged from 16 to 271 with an average of 91 feet. Further surgery rates ranged from 0% to 68% with an average of 24%. These articles are by no means exhaustive of the case series published on short-term results of clubfoot, but they are representative of the English language articles including the work of Turco and McKay.²⁵^–³⁸

The method of physiotherapy is difficult to assess in this section because of the high rate of failed initial correction. However, the percentage of feet requiring extensive release surgery using this method is between 25% and 89% as reported earlier (see What Treatment Best Obtains Initial Correction in Idiopathic Clubfoot? section).

Relapse in the Ponseti method requires a somewhat different assessment. Few Ponseti method–treated feet undergo surgery at an early age (excluding percutaneous tenotomy), and relapses are treated by repeat manipulation and casting until the child is mature enough for an anterior tibial tendon transfer to the third cuneiform to be performed. Morcuende and colleagues ¹² reviewed 256 feet treated at the University of Iowa between 1991 and 2001 with an average follow-up of 26 months (6–96 months). Seventeen patients suffered a relapse (11% of feet). Four feet (2.5%) required PR or PMR, and four feet required anterior tibial transfer to the third cuneiform. The authors found that 2 of 140 patients (∼1%) whose parents reported compliance with the bracing regimen relapsed, whereas 15 of 17 patients whose parents were not compliant relapsed (89%).

Dobbs and researchers ³⁹ evaluated recurrence risk in 51 consecutive infants with 86 idiopathic clubfeet managed for an average of 27 months (24–35 months). They report complete initial correction. Twenty-seven feet relapsed, and all relapses were treated successfully by manipulation and recasting. All of the relapsed feet occurred in families who were noncompliant with brace wear. Compliance was related to relapse with an odds ratio of 183 (P < 0.00001).

Haft and coworkers ⁴⁰ report on 73 feet in 51 infants treated in New Zealand with a mean follow-up period of 35 months (24–65 months). They report a 41% relapse rate with only 51% brace compliance. Relapses were minor in 18% of patients and required only TAL or anterior tibial tendon transfer, or both. Relapses were major in 24% of patients and required PR or PMR. Noncompliance with brace treatment conferred a five times increased risk for relapse.

Summary

What can be concluded with regard to the question, What treatment best maintains clubfoot correction? Very little from an evidence basis. The studies are generally of poor design, and confounding factors are multiple and often invisible in the articles. Virtually all studies that compare a less with a more aggressive surgical procedure (PR vs. PMR; á la carte vs. PMR, PMR vs. complete subtalar release) found a lower reoperation rate with the more aggressive procedure. The more aggressive procedure was due to a change in practice and, therefore, had a shorter follow-up period. The wide range of recurrence requiring treatment in the early PR, PMR, and complete subtalar release series may depend on details of surgical technique, follow-up protocol, variability in defining a recurrence length of follow-up period, and a host of other factors. Relapse after Ponseti method correction appears to be dependent on compliance with the postcorrection brace protocol. Compliance with bracing could reasonably be expected to vary by population, physician, culture, among other factors. Comparison of relapse rate between Ponseti method and joint invasive surgical techniques is not possible given the available data.

WHAT TREATMENT GIVES BEST LONG-TERM FOOT FUNCTION?

Multiple reports of “long-term” follow-up of clubfoot exist. Few of these studies report on a cohort whose members are all skeletally mature much less middle aged or elderly and, therefore, can scarcely be called long term. The mean life span in most of the developed world is the late 70s. These studies are only long term from the perspective of an orthopedic surgeon’s career, which is not an appropriate determinant of length of follow-up. Data from long-term follow-up studies of Legg–Calve–Perthes disease should be cautionary. Most patients responded well until the middle of the sixth decade of life, at which time disabling arthritis requiring THR became common. “Good” functional results in the teens, 20s, 30s, and so on cannot be extrapolated without data. For example, Krauspe and colleagues ⁴¹ used the McKay rating system (a nonvalidated, multidomain, idiosyncratic measuring scheme) to assess the outcomes of 104 feet in 64 patients treated by the Scheel technique (a PR with PMR as needed with a traction suture on the calcaneus). The results deteriorated markedly from less than 10 to 10 to 20 years to greater than 20 years (Table 36-1).

TABLE 36-1 Deterioration of Surgical Clubfoot Results with Advancing Age

Long-term results of clubfoot treatment are generally a confused mix of ages, procedures, and evaluations. A classic and typical report is the 1964 report by Wynne-Davies.⁴² She reports on 84 patients with 121 feet (88% follow up) who had completed treatment. Completion of treatment was arbitrarily defined as older than 10 years. Ninety-three feet belonged to patients 10 to 21 years of age, and 28 feet belonged to patients 22 to 35 years of age. Twenty-eight feet had closed treatment only; 51 feet had PMR, anterior tendon transfer laterally, or both; and 24 feet had arthrodesis, of which 10 had had a prior soft-tissue procedure. Patient-centered outcomes consisted of the following copied directly from the article:

Occupation—Few of the patients limited their activities on account of deformed feet [Table 36-2].⁴²

TABLE 36-2 Activities (N = 84)

Symptoms—These were few. The commonest complaint, only elicited by direct questioning, was of callosities on the lateral border of the foot (in one-quarter of the patients). Occasional pain and “tiring easily” was noted in only fifteen out of eighty-four patients. Although there were many stiff feet, only seven patients had noticed any difficulty in walking on rough ground.

Unfortunately, much of the literature of the ensuing 40 years is no more informative than this early attempt at an outcome study.

Only one investigation has been published that reports outcomes in skeletally mature clubfoot patients evaluated by a validated outcomes instrument. Dobbs and coworkers ⁴³ report on 73 feet in 45 patients treated by posterior and plantar release in 13 feet (average follow-up, 31 years; range, 30–32 years) and Turco-type PMR in 60 feet (average follow-up, 28 years; range, 25–29 years). They were able to find 73% of eligible patients. Using the health survey Short Form-36 (SF-36) for evaluation of health-related quality of life, this cohort scored nearly 2 standard deviations less than the average on the physical functioning scale and average on the mental functioning scale. No study has been reported with which to compare this validated outcome result, but the physical functioning level was similar to cohorts of patients with chronic heart failure, awaiting coronary bypass surgery, and suffering cervical radiculopathy. The authors of this study used other outcome measures as well that, although not validated, have been used in other long-term follow-up studies of patients with clubfoot.

Cooper and Dietz ¹⁷ reviewed 45 patients with 71 clubfeet who were treated under the supervision of Dr. Ponseti at an average age of 34 years (range, 25–42 years). Only 36% of the eligible cohort was evaluated. The authors of this study administered a questionnaire to a control group of 97 patients of similar age (21–50 years old) and sex to the clubfoot cohort who were screened only for the absence of a congenital foot abnormality. The questionnaire began as follows:

1. My foot (feet)

a. is never painful

b. occasionally causes mild pain

c. is painful after strenuous activities only

d. is painful in routine day to day activities

e. is painful in routine walking

f. is painful at rest or at night

2. In my daily living, my foot (feet)

a. does not limit my activities

b. occasionally limits my activities

c. limits me in strenuous activities

d. limits me in routine day to day activities

e. limits me in routine walking

After reviewing the responses of the first 34 control participants’ responses to these questions, the authors defined the following groups:

Excellent = a foot that does not limit activities of daily living and is never painful or occasionally causes mild pain

Good = a foot that occasionally limits activities of daily living or strenuous activities or is painful after strenuous activities.

Poor = a foot that limits daily activities or routine walking, or is painful in daily activities, walking, or at night

The outcome as defined earlier was not different between the control and Ponseti-treated patients with clubfoot. Dobbs and coworkers ⁴³ administered these questions and compared them with quite different results (Box 36-1).

BOX 36-1

Several studies have used the Laaveg and Ponseti functional rating system for clubfoot as their only or 1 of several outcome measures. This rating scheme is not validated but combines reasonable elements of outcomes that are arbitrarily weighted and scored. Excellent was defined as 90 to 100 points, good as 80 to 89, fair as 70 to 79, and poor as less than 70. The rating scheme is presented in Table 36-3. Tables 36-4 and 36-5 summarize long-term follow-up articles.

TABLE 36-3 Functional Rating System for Club Foot ⁴⁴

CATEGORY	POINTS
Satisfaction (20 points)
I am
a. very satisfied with the end result	20
b. satisfied with the end result	16
c. neither satisfied nor unsatisfied with the end result	12
d. unsatisfied with the end result	8
e. very unsatisfied with the end result	4
Function (20 points)
In my daily living, my clubfoot
a. does not limit my activities	20
b. occasionally limits my strenuous activities	16
c. usually limits me in strenuous activities	12
d. limits me occasionally in routine activities	8
e. limits me in walking	4
Pain (30 points)
My clubfoot
a. is never painful	30
b. occasionally causes mild pain during strenuous activities	24
c. usually is painful after strenuous activities only	18
d. is occasionally painful during routine activities	12
e. is painful during walking	6
Position of heel when standing (10 points)
Heel varus, 0 degrees or some heel valgus	10
Heel varus, 1–5 degrees	5
Heel varus, 6–10 degrees	3
Heel varus, greater than 10 degrees	0
Passive motion (10 points)
Dorsiflexion	1 point per 5 degrees (up to 5 points)
Total varus-valgus motion of heel	1 point per 10 degrees (up to 3 points)
Total anterior inversion-eversion of foot	1 point per 25 degrees (up to 2 points)
Gait (10 points)
Normal	6
Can toe-walk	2
Can heel-walk	2
Limp	−2
No heel-strike	−2
Abnormal toe-off	−2

TABLE 36-4 Characteristics of Long Term Follow-up Studies Using Laaveg-Ponseti Rating Scale

TABLE 36-5 Laaveg-Ponseti Rating Scale Outcomes for Long term Follow-up Studies

What can be concluded from the available data? The single study using validated outcome measures and follow-up past skeletal maturity showed poor results for PMR. The single study using a control group of nonclubfoot subjects for comparison sho-wed equal quality of foot function between Ponseti method–treated patients and control subjects who were without congenital foot deformity. Comparison of these 2 studies, each with 30-year average follow-up, shows superior results for the Ponseti method over the PMR method that Dobbs described. The long-term Ponseti method studies are flawed by a relatively small percentage of eligible patients being evaluated.

Ippolito and researchers’⁴⁵ PMR cohort scored statistically significantly more poorly on the Laaveg and Ponseti scale than did their Ponseti with PR cohort. A detail that may be important is that Ippolito’s PR was an ankle capsulotomy alone. Most of the other descriptions of PR that are reported here (Hutchins et al³⁸ and Haasbeek and Wright⁴⁶) include a posterior subtalar joint and ligament release as well. The devil may be in the details—the more joints opened, the worse the results. In contrast, there was no significant difference between Haasbeek and Wright’s PMR and PR group. Haasbeek and Wright’s PMR group had significant numbers of skeletally immature subjects, as did Hutchins’s group and Laaveg and Ponseti’s group.