The present study was performed with the approval of our institution's
human subjects review board, and all participants signed an approved
informed-consent form.
A computer-generated search identified eighty-two patients who had been
treated for a clubfoot deformity at St. Louis Shriners Hospital for Children
between 1972 and 1979. Seventy-five patients had an extensive soft-tissue
release, with thirteen of them having an extensive posterior release and
sixty-two having an extensive combined posterior, medial, and lateral release.
The remaining seven patients had initially been treated elsewhere and were
managed at our institution with salvage procedures; they were not included in
this study. Of the seventy-five patients who had a complete soft-tissue
release at our institution, sixty-two met the inclusion criteria for this
study. The others were excluded because the clubfoot was associated with a
syndrome or a neuromuscular condition or because they were older than two
years of age at the time of the initial surgery. All patients underwent
surgical treatment only after the treating surgeon had determined that
application of serial casts had not adequately corrected the clubfoot
deformity.
The patients identified with the computer-generated search were located
with use of information in their medical records, with use of the state
Department of Motor Vehicles registry, and by means of a contract with a
private search service (ChoicePoint, McLean, Virginia). Of the sixty-two
patients who met the inclusion criteria, fifty-three were located. Of these
fifty-three patients, three refused to participate in the study and five were
willing to participate but were not evaluated because of time or financial
constraints. The remaining forty-five patients (with a total of seventy-three
clubfeet) made up the study group, a 73% rate of follow-up. Thirty-one
patients were male, and fourteen were female. The clubfoot was bilateral in
twenty-eight patients and unilateral in seventeen. The patients were divided
into two groups on the basis of the extent of the initial clubfoot release.
Eight patients had an extensive posterior release and plantar fasciotomy
(group 1), and thirty-seven patients had an extensive subtalar, posterior,
medial, and lateral release (group 2).
Information gathered from the medical records included demographic data
(including the sex of the patient), laterality of the clubfoot, age at
initiation of treatment, duration of cast treatment before the surgery, age at
the time of surgery, duration of cast treatment after the surgery, and details
of the initial and subsequent surgical procedures. In addition, we obtained
information from the charts of the seventeen patients who were lost to
follow-up or would or could not return for the final evaluation in this study
so that we could determine whether their postoperative course differed from
that of the patients who did participate in this study.
Treatment Method
The first group of eight patients (thirteen clubfeet), treated in the early
part of this series (between 1972 and 1974), underwent an extensive posterior
release and plantar fasciotomy after four to six months of cast treatment with
the Kite method35
had failed to achieve a complete correction. Postoperatively, these patients
were treated with three to four months of immobilization in a long leg plaster
cast followed by the use of a hinged ankle-foot orthosis with a plantar
flexion stop at neutral for several years. Recurrent deformities were treated
with repeat manipulations and application of long leg plaster casts followed
by a repeat posterior release when necessary to correct the equinus. Residual
deformities were managed with a variety of surgical procedures, including a
calcaneal slide osteotomy, distal tibial physeal stapling, tendon transfers,
and fusion procedures.
The second group of thirty-seven patients (sixty clubfeet) were treated
with an extensive combined subtalar, posterior, medial, and lateral
release5,36
after three to four months of manipulations and applications of casts as
described by Kite35
failed to achieve complete correction. The complete soft-tissue release, based
on the procedure described by
Turco36, involved
extensive dissection of the posterior, medial, and lateral portions of the
foot. The posterior release included (1) Achilles tendon lengthening; (2)
release of the posterior ankle and subtalar joints, including the posterior
talofibular ligament; (3) release of the thickened peroneal retinaculum and
tendon sheaths; and (4) lengthening of the tendons of the flexor digitorum
longus and flexor hallucis longus. The medial release included (1) lengthening
of the tibialis posterior tendon, (2) talonavicular joint capsulotomy, (3)
recession of the abductor hallucis tendon, (4) release of the medial and
plantar surfaces of the calcaneocuboid joint (in twenty-nine feet), (5)
release of the medial aspect of the subtalar joint, and (6) release of the
interosseous ligament. The lateral release involved the release of the lateral
aspect of the subtalar joint and the calcaneofibular ligament. A plantar
release, if performed, was done through a separate skin incision. In addition,
the talocalcaneal interosseous ligament was released completely in all but
four feet. A single smooth Kirschner wire was used to transfix the
talonavicular joint and was removed at an average of six weeks.
Postoperatively, the limb was immobilized for four months in a long leg
plaster cast, which was changed every two to four weeks. The patient then wore
a hinged ankle-foot orthosis for two to four years. The ankle-foot orthosis
had a plantar flexion stop at neutral but allowed free ankle dorsiflexion.
Recurrent deformities were treated with a second medial or posteromedial
release as indicated. Again, residual deformities were treated with a variety
of surgical procedures, including a calcaneal slide osteotomy, distal tibial
physeal stapling, tendon transfers, and fusion procedures.
Three patients (four clubfeet) in group 1 and three patients (five
clubfeet) in group 2 had had only one surgical procedure on the feet at the
time of the latest follow-up. These patients were analyzed as a separate group
and then were compared with the rest of the patients in the series, who had
had more than one major surgical procedure on the feet.
Self-Reported Questionnaires
The results of treatment were evaluated with use of the 100-point system of
Laaveg and
Ponseti12. A score
of 90 to 100 points was rated as excellent; 80 to 89 points, as good; 70 to 79
points, as fair; and <70 points, as poor. All patients also completed the
Foot Function Index, which is a validated and reliable visual analog scale for
measuring limitation of activity, pain, and
disability37,38.
In addition, the Short Form-36 Medical Outcomes Study (SF-36 MOS, version
2.0)39 was
administered to all patients at the time of final follow-up. This
thirty-six-question generic health outcomes measure is useful for comparing
the relative burdens of disease in populations and the health benefits of
different treatments. The physical component summary score is based on
twenty-one questions, and the mental component summary score is based on
fifteen questions. In version 2.0 of the SF-36, the scoring system was
normalized to a mean of 50 points with a standard deviation of 10 points in
the general population of the United States. Norm-based scoring facilitates
comparisons between
populations40. The
reliability, internal consistency, responsiveness, construct validity,
discriminant validity, and convergent validity of this test have all been
supported41.
Clinical Evaluation
At the time of the latest follow-up (at a minimum of twenty-five years
after the index procedure), all subjects were interviewed about pain in, and
overall function of, the lower extremities and all had a physical examination
of both lower extremities. The clinical examination included assessment of the
patient's height and weight, limb lengths (measured from the anterior superior
iliac spine to the medial malleolus), circumference of the calves (in
centimeters), and length and width of the feet (in centimeters). The feet were
inspected for evidence of calluses and were palpated for areas of tenderness.
Gait was observed for limping. A handheld goniometer was used to measure
passive dorsiflexion and plantar flexion of the ankle with the knee straight
as well as supination and pronation of the forefoot and varus-valgus movement
of the heel. The motor strength of the anterior tibialis, posterior tibialis,
gastrocnemius-soleus, peroneals, extensor hallucis longus, extensor digitorum
communis, flexor hallucis longus, and flexor digitorum longus was evaluated
according to the Jones classification as reported by
Tachdjian42. The
patient stood on one foot and performed rapid toe-ups, stopping when he or she
had done forty of them or when there was moderate pain or fatigue in the
gastrocnemius-soleus. All patients were examined by one of us (M.B.D.).
Radiographic Examination
Radiographs made just prior to the complete soft-tissue release were
available for all but two patients. At the time of the latest follow-up (at a
minimum of twenty-five years after the index procedure), anteroposterior and
lateral radiographs of the affected foot, as well as the contralateral, normal
foot when applicable, were made with the patient standing. The anteroposterior
talocalcaneal angle, the navicular-first cuneiform angle, the angle between
the calcaneus and the fifth metatarsal, and the angle between the long axis of
the talus and the first metatarsal were measured on the anteroposterior
radiographs43. The
lateral talocalcaneal angle, the angle between the long axis of the talus and
the first metatarsal, the angle between the first and fifth metatarsals, and
the distance between the tip of the medial malleolus and the navicular were
measured on the lateral
radiographs43,44.
All radiographic angles were measured by one of us (M.B.D.). Osteoarthritic
changes of the tarsal joints were graded, according to the system of
Kellgren45,46,
by two musculoskeletal radiologists, who performed the measurements
simultaneously and reached a consensus regarding each one. All of the
radiographic measurements were compared between the seventy-three clubfeet and
the seventeen unaffected feet.
Statistical Methods
Continuous data are expressed as the mean and standard deviation.
Differences between the treatment groups with regard to the radiographic data
and the responses to the functional questionnaires were analyzed with use of a
paired t test. Unpaired t tests were used to compare the SF-36 scores in our
cohort with published normative values in the United
States47 and to
compare the functional scores in our cohort with those in two other groups of
patients with clubfoot reported on in the
literature12,14.
Spearman coefficients were used to determine significant relationships between
variables. For all statistical analyses, a p value of <0.05 was considered
to be significant.
The mean duration of follow-up was thirty-one years (range, thirty to
thirty-two years) in the first group of eight patients (thirteen feet) and
twenty-eight years (range, twenty-five to twenty-nine years) in the second
group of thirty-seven patients (sixty feet). The mean age at the time of the
initial surgical procedure was thirteen months (range, twelve to fifteen
months) in the first group and seven months (range, six to nine months) in the
second group. The mean duration of cast treatment before the surgery was four
months (range, one to six months) in both groups.
Of the forty-five patients, thirty-nine (five of the eight patients in
group 1 and thirty-four of the thirty-seven patients in group 2) had
additional surgical procedures on the clubfeet by the time of the latest
follow-up. Most of the additional surgical procedures were performed in
adolescence or early adulthood, which indicates that the initial correction of
the clubfoot deformities was satisfactory. The additional surgical procedures
in group 1 included a medial soft-tissue release (one foot) and a second
posterior release (five feet). In group 2, the additional surgical procedures
included a second extensive posterior, medial, and lateral soft-tissue release
(thirteen feet); a third extensive posterior, medial, and lateral soft-tissue
release (four feet); a second medial soft-tissue release (eight feet); a
second posterior release (four feet); distal tibial stapling and/or a
calcaneal slide osteotomy (seventeen feet); transfer of the tibialis anterior
tendon to the dorsum of the foot (three feet); and irrigation and
débridement because of wound infection (two feet). In addition, one
foot in group 1 and four feet in group 2 had fusion procedures because of
painful arthritis in the tarsal joints; these procedures included two
talonavicular fusions, two triple arthrodeses, and one subtalar arthrodesis
(Figs. 1-A and 1-B).
There was no significant difference between groups 1 and 2 with regard to
the results of the questionnaires (p > 0.68), ankle range of motion or heel
position (p > 0.73), or radiographic findings (p > 0.45). For that
reason, the treatment groups were combined for the statistical analyses of the
remainder of the reported results.
A review of the charts at the time of the last clinical evaluation of the
seventeen patients who met the inclusion criteria but did not participate in
the study revealed no difference, with the numbers available, between those
patients and the patients who were included in this study in terms of age at
the time of the initial surgery (p > 0.67), duration of cast treatment
before the surgery (p > 0.72), or number of subsequent operations (p >
0.94).
Questionnaires
According to the Laaveg-Ponseti scale, the mean functional score for the
seventy-three clubfeet in the series was 65.3 ± 10.6 points (range, 30
to 82 points). No foot had an excellent result, twenty-four feet had a good
result, fifteen had a fair result, and thirty-four had a poor result. Fifty
feet were occasionally painful during daily activities, sixty-two feet were
painful after strenuous activities, and thirty-six were painful during
walking. The patients in this study had significantly lower functional scores
than did similar cohorts of patients with clubfoot who had been treated with
the Ponseti method and followed for similar
durations12,14
(p < 0.001) (Tables I and
II). The six patients in our
study who had had only one surgical procedure by the time of the latest
follow-up had a mean functional score of 78.4 ± 3.5 points (range, 65
to 82 points). This score was significantly better (p < 0.005) than the
score (64.8 ± 2.4 points) for the patients who had had more than one
surgical procedure.
As measured with the Foot Function Index, overall activity limitation was
more severe on the clubfoot side than on the contralateral, normal side (mean,
21 compared with 8 points; p < 0.0001). There was also more overall foot
pain (mean, 30 compared with 12 points; p < 0.0001) and more overall foot
disability (mean, 34 compared with 13 points; p < 0.0001) on the clubfoot
side. The patients' responses to direct queries from the examiner about pain
in the ankle, subtalar, and midfoot regions revealed significantly more pain
on the clubfoot side than on the contralateral, normal side (p < 0.0001).
The mean scores for activity limitation, overall foot pain, and overall foot
disability did not differ significantly between the patients with bilateral
clubfoot and those with unilateral clubfoot.
The mean SF-36 scores for each of the eight domains tested as well as the
physical and mental component summary scores for the forty-five patients at
the time of the latest followup are shown in
Table III. The mean physical
component summary score was nearly two standard deviations below the average
normal population value, but the mean mental component summary score was
similar to the value for the normal population. The physical component summary
score for our cohort was similar to that reported for patients with several
other major medical
conditions47-56
(Table IV). The physical
component summary scores for the six patients in our study who had had only
one surgical procedure were consistently higher (p < 0.003) than the scores
for the patients who had had more than one surgical procedure, but they were
still lower than the age-based norms. The mental component summary scores did
not differ between the patients treated with one surgical procedure and those
treated with multiple procedures. The findings on the SF-36 were similar to
those on the Foot Function Index. As patients became more limited with regard
to their participation in vigorous activities, their scores for overall
activity limitation (r = 0.59, p = 0.002) and foot disability (r = 0.60, p =
0.005) increased. Similarly, as patients became more limited with regard to
their ability to walk >1 mi (1.6 km), their scores for overall activity
limitation (r = 0.58, p = 0.004) and foot disability (r = 0.56, p = 0.005)
increased.
Findings on Clinical Examination
On the average, there was no difference in the length of the lower
extremity with the clubfoot and the length of the normal, contralateral
extremity in the seventeen patients who had a unilateral clubfoot. The
circumference of the calf was on the average 3 cm smaller on the involved
side, and the clubfoot was on the average 1 cm shorter and 0.7 cm narrower
than the uninvolved foot.
Forty-nine clubfeet were associated with tenderness to palpation around the
ankle joint, in the sinus tarsi, or under the metatarsal heads. Nineteen (42%)
of the forty-five patients walked with a limp. Ankle dorsiflexion and plantar
flexion averaged 4.2° ± 5.0° and 15.9° ± 12.3°,
respectively, in association with the clubfeet treated with more than one
surgical procedure; 8.3° ± 5.4° and 20.4° ± 5.2°
in association with the clubfeet treated with one surgical procedure; and
16.2° ± 4.5° and 40.3° ± 6.1° in association
with the normal feet. The mean varus-valgus movement of the heel and
supination-pronation of the forefoot measured 8.1° ± 3.9° and
24.3° ± 7.7°, respectively, in the clubfeet treated with more
than one surgical procedure; 15.4° ± 4.9° and 41.4°
± 4.7° in the clubfeet treated with one surgical procedure; and
37.9° ± 8.1° and 65.3° ± 10.5° in the normal
feet. Each of the above angular measurements differed significantly between
the limbs with the clubfeet and the normal limbs (p < 0.0001 for all) as
well as between the clubfeet treated with one surgical procedure and those
treated with more than one surgical procedure (p < 0.004 for all). Nineteen
patients were unable to walk on their toes, and twenty-one were unable to walk
on their heels. The muscles were weaker than normal in sixty-two of the
seventy-three limbs. Most significant was gastrocnemius-soleus weakness, which
was noted in fifty-nine limbs. The patients treated with only one surgical
procedure had significantly less gastrocnemius-soleus weakness (mean grade of
5) than did those treated with more than one posterior release (mean grade of
3, p < 0.005). Thirty-one of the forty-five patients were unable to do
forty rapid toe-ups on the affected side. In contrast, all were able to do
forty toe-ups on the normal side.
Radiographic Results
The radiographs made at the time of the last follow-up showed several
differences between the clubfeet and the contralateral, normal feet
(Table V). The mean distance
between the tip of the medial malleolus and the navicular tuberosity was
smaller in the clubfeet than it was in the normal feet. Compared with the
normal feet, the clubfeet had decreased anteroposterior and lateral
talocalcaneal angles, indicating residual heel varus; an increased lateral
talus-first metatarsal angle and first-fifth metatarsal angle, indicating
residual cavus deformity (Figs. 2-A, 2-B,
and 2-C); and a decreased navicular-first cuneiform angle,
indicating that the cuneiforms were shifted more laterally. The
anteroposterior talus-first metatarsal angle and the calcaneus-fifth
metatarsal angle in the clubfeet reflected residual forefoot adduction. There
were no significant differences in any of the measured radiographic angles
between the clubfeet that had been treated with one surgical procedure and
those treated with more than one surgical procedure.
The radiographic grade of osteoarthritis, according to the system of
Kellgren46, was
consistently higher for each joint of the clubfoot in which it was measured
than it was for the same joint of the uninvolved foot
(Table VI). The joints that
were significantly more degenerated in the surgically treated clubfeet than in
the normal feet included, in rank order from the most involved to the least
involved, the talonavicular (p < 0.0001), calcaneocuboid (p < 0.0001),
subtalar (p < 0.0004), naviculocuneiform (p < 0.0003), and tibiotalar (p
< 0.0002) joints (Figs 3-A and
3-B). In the seventy-three clubfeet, forty-one talonavicular,
thirty-two calcaneocuboid, thirty subtalar, twenty-four naviculocuneiform, and
eighteen tibiotalar joints had moderate or severe osteoarthritis
(Table VI).
There was no significant difference with respect to the level of
osteoarthritis (mean Kellgren grade) in any of the joints measured between the
clubfeet treated with one surgical procedure and those treated with more than
one surgical procedure. However, patients treated with an extensive posterior
soft-tissue release alone had significantly less osteoarthritis in all of the
joints in which it was measured than did the patients treated with an
extensive subtalar, posterior, medial, and lateral soft-tissue release (p <
0.003 for all comparisons) with the exception of the ankle joint, in which the
grade of osteoarthritis was the same in the two groups.
Correlations Between Foot Function Index and Kellgren and Moore
Radiographic Scores
Separate subsections of the Foot Function Index were used to determine
whether each domain was associated with the radiographic findings. Activity
limitation correlated significantly with the Kellgren and Moore grades of
osteoarthritis of the talonavicular (r = 0.64, p = 0.0006), calcaneocuboid (r
= 0.54, p = 0.0001), and subtalar (r = 0.51, p = 0.0004) joints in the
clubfeet. Foot disability correlated significantly with the Kellgren and Moore
grade of osteoarthritis of the talonavicular joint (r = 0.53, p = 0.003) in
the clubfeet. Foot pain correlated significantly with the Kellgren and Moore
grades of osteoarthritis of the talonavicular (r = 0.62, p = 0.0002) and
subtalar (r = 0.57, p = 0.003) joints in the clubfeet.
Using three independent quality-of-life scales, we found significant
impairment of physical function at the time of long-term follow-up of patients
in whom clubfoot had been treated with an extensive soft-tissue release. In
fact, although the patients were evaluated at an average of thirty years after
the corrective surgery, the impact of these changes over a patient's lifetime
may be underestimated. This may be particularly the case for patients who have
radiographic evidence of arthritis in the foot and ankle but are not currently
symptomatic.
Many previous studies of clubfeet treated with an extensive soft-tissue
release showed good early results, but the followup in those studies was
limited and in no series were the patients followed into
adulthood4,5,7,8,13,19,31,32,57-60.
The few studies in which patients were followed to skeletal maturity showed
that the early results obtained with an extensive soft-tissue release
deteriorate with
time13,31,32,
indicating that longer follow-up is necessary to evaluate the lifelong
function of a surgically treated clubfoot. Ippolito et
al.13 found that
patients in whom clubfoot had been treated with a more extensive soft-tissue
release surgery functioned less well at skeletal maturity than did those
treated with the Ponseti method of manipulation and casts. Unsatisfactory
results were attributed to increased osteoarthritis in the foot and ankle,
increased ankle stiffness, and increased gastrocnemius weakness in the
patients treated with the more extensive surgery.
Direct comparisons of our surgically treated patients with patients treated
by Ponseti, as reported in previous
studies12,14,
demonstrated significantly fewer excellent or good outcomes in our surgically
treated group (Tables I and
II). In 1980, Laaveg and
Ponseti12 reviewed
the cases of patients who had been followed for an average of nineteen years
after treatment by Ponseti. In 1995, Cooper and
Dietz14 reported,
after an average duration of follow-up of thirty-four years, the results in
the same cohort of patients treated by Ponseti. Using a modification of the
functional scale described by Laaveg and Ponseti, they found that thirty-five
(78%) of forty-five patients had an excellent or good outcome. According to
the same functional scale, only twelve (27%) of our forty-five surgically
treated patients had an excellent or good outcome at an average of thirty
years postoperatively.
Radiographic evidence of degenerative changes in the foot and ankle have
been noted in patients with clubfoot who were followed to skeletal maturity
after having been treated with either primary cast immobilization or an
extensive soft-tissue
release13,14,61.
We found moderate-to-severe osteoarthritic changes in 56% of our surgically
treated patients, whereas Cooper and
Dietz14 noted only
mild degenerative changes in 35% of clubfeet treated with the Ponseti method
and followed for an average of thirty-four years. Ippolito et
al.13 noted
degenerative changes in 40% of patients treated with an extensive soft-tissue
release and followed for an average of twenty-five years, although the degree
of degenerative changes was not noted.
The long-term physical impact of an extensive soft-tissue release in a
clubfoot was borne out by the results of the SF-36 questionnaire. To our
knowledge, we were the first to use a well-recognized health outcomes
measurement tool to evaluate the overall quality of life of patients who had
undergone an extensive soft-tissue release for the treatment of clubfoot. In
our cohort, the physical component summary score was, on the average, almost
two standard deviations below that of the normal population of the United
States. Perhaps even more surprising, the mean physical component summary
score for our patients in whom clubfoot was treated with extensive soft-tissue
release was equivalent to or worse than those of patients with end-stage
kidney disease49,
congestive heart
failure54, or
cervical spine pain and
radiculopathy56.
Changes in the mental component summary score were negligible in our study, as
they were for patients with the other conditions, suggesting that the main
effect of the clubfoot procedure is a profound impact on the patient's sense
of physical well-being.
We also found that patients who had been treated with only one major
surgical procedure on the clubfoot had, by the time of the latest follow-up, a
better range of motion of the ankle and subtalar joints, a better functional
result, less arthritis in the treated feet, and a better quality of life when
compared with the patients who had undergone multiple surgical procedures. The
amount and degree of foot and ankle osteoarthritis were more severe in the
patients who had had more extensive surgery. These findings suggest a
correlation between the extent of the soft-tissue release and the degree of
functional impairment, although the number of patients with only one surgical
procedure in our study was small.
One limitation of this study is that our surgical technique utilized in the
beginning of the study period (i.e., almost thirty-five years ago) differed
significantly from our current standard treatment. In our early surgical
experience, we typically released the entire subtalar joint in the manner
described by Turco in
197136. We also
routinely performed z-plasty lengthening of both the flexor digitorum communis
and the flexor hallucis longus tendons. In the patients treated with repeat
surgical releases, extensive scarring of those previously lengthened tendons
to each other and to the surrounding soft tissues was often noted. This
represents our initial experience with this operation for the correction of
clubfoot. A reported problem with this operation, which we also noted, was a
high rate of excessive internal rotation of the foot and valgus deformity of
the hindfoot5. In
1979, Turco recommended several modifications to his originally described
clubfoot release5.
Specifically, he recommended a less aggressive release of the talocalcaneal
interosseous ligament with transfixion of the subtalar joint to prevent
lateral translation of the calcaneus and resultant hindfoot valgus deformity.
Other investigators have also emphasized the importance of preserving the
talocalcaneal interosseous ligament in preventing hindfoot valgus
deformity9,21.
Using this modified approach, several investigators have reported good
short-term results with low early recurrence
rates58,62.
With experience and better understanding of the appropriate surgical
techniques, we also have observed similar good short-term results. These early
results may translate into improved long-term outcomes if the initial clubfoot
correction is maintained and the patients require fewer surgical procedures.
Recently, there has been a move by many authors toward an "a la
carte" approach to clubfoot surgery, rather than the all-or-nothing
approach8,63,64,
in the hopes of minimizing the extent of surgery necessary to achieve
correction.
Because the Ponseti technique has become the standard for the treatment of
clubfoot, it will be difficult to perform a randomized, controlled trial
comparing clubfeet treated with the Ponseti method with those treated with an
extensive soft-tissue release. Our patients were treated during a period (1972
to 1979) in which all patients with clubfoot underwent extensive soft-tissue
release and no patients were treated with casts alone. The Ponseti method of
manipulation and cast immobilization results in initial correction rates of
>90%, with very few patients (2.5%) needing an extensive soft-tissue
release15-17.
However, reports on the long-term success of the Ponseti method are limited
thus far to those from only a few treatment
centers12-14.
Although short-term success has now been reported at several
centers15,16,
longer follow-up will be required to assess whether the Ponseti method can
have equivalent results over the long term. Institutions currently vary
greatly in terms of the numbers of patients who eventually require soft-tissue
release to treat severe and resistant clubfoot deformity or for salvage
following recurrence related to poor compliance with
bracing16. It will
also be important to study the long-term results of clubfeet treated with
extensive soft-tissue release surgery with modern surgical techniques. To our
knowledge, systematic studies have not yet been performed to identify clubfoot
deformities that will ultimately require, and benefit from, extensive or
selective soft-tissue releases. Because there will probably always be patients
with clubfoot deformity who are treated surgically, our data suggest that an
operative plan that minimizes frequent or invasive surgical intervention may
result in greater long-term success. ?