title: Long-term results of comprehensive clubfoot release versus the Ponseti method: which is better?
abstract: BACKGROUND
  Clubfoot can be treated nonoperatively, most commonly using a Ponseti approach, or surgically, most often with a comprehensive clubfoot release. Little is known about how these approaches compare with one another at longer term, or how patients treated with these approaches differ in terms of foot function, foot biomechanics, or quality-of-life from individuals who did not have clubfoot as a child.
  
  
  OBJECTIVE
  We compared (1) focused physical and radiographic examinations, (2) gait analysis, and (3) quality-of-life measures at long-term followup between groups of adult patients with clubfoot treated either with the Ponseti method of nonsurgical management or a comprehensive surgical release through a Cincinnati incision, and compared these two groups with a control group without clubfoot.
  
  
  METHODS
  This was a case control study of individuals treated for clubfoot at two separate institutions with different methods of treatment between 1983 to 1987. One hospital used only the Ponseti method and the other mainly used a comprehensive clubfoot release. There were 42 adults (24 treated surgically, 18 treated with Ponseti method) with isolated clubfoot along with 48 healthy control subjects who agreed to participate in a detailed analysis of physical function, foot biomechanics, and quality-of-life metrics.
  
  
  RESULTS
  Both treatment groups had diminished strength and motion compared with the control subjects on physical examination measures; however, the Ponseti group had significantly greater ankle plantar flexion ROM (p < 0.001), greater ankle plantar flexor (p = 0.031) and evertor (p = 0.012) strength, and a decreased incidence of osteoarthritis in the ankle and foot compared with the surgical group. During gait the surgical group had reduced peak ankle plantar flexion (p = 0.002), and reduced sagittal plane hindfoot (p = 0.009) and forefoot (p = 0.008) ROM during the preswing phase compared with the Ponseti group. The surgical group had the lowest overall ankle power generation during push off compared with the control subjects (p = 0.002). Outcome tools revealed elevated pain levels in the surgical group compared with the Ponseti group (p = 0.008) and lower scores for physical function and quality-of-life for both clubfoot groups compared with age-range matched control subjects (p = 0.01).
  
  
  CONCLUSIONS
  Although individuals in each treatment group experienced pain, weakness, and reduced ROM, they were highly functional into early adulthood. As adults the Ponseti group fared better than the surgically treated group because of advantages including increased ROM observed at the physical examination and during gait, greater strength, and less arthritis. This study supports efforts to correct clubfoot with Ponseti casting and minimizing surgery to the joints, and highlights the need to improve methods that promote ROM and strength which are important for adult function.
  
  
  METHODS
  Level III, prognostic study.
authors.affiliation: Shriners Hospitals for Children, 2211 North Oak Park Avenue, Chicago, IL, 60707, USA.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Smith
authors.forename: Ken N
authors.initials: KN
authors.lastname: Kuo
authors.forename: Adam N
authors.initials: AN
authors.lastname: Graf
authors.forename: Joseph
authors.initials: J
authors.lastname: Krzak
authors.forename: Ann
authors.initials: A
authors.lastname: Flanagan
authors.forename: Sahar
authors.initials: S
authors.lastname: Hassani
authors.forename: Angela K
authors.initials: AK
authors.lastname: Caudill
authors.forename: Fredrick R
authors.initials: FR
authors.lastname: Dietz
authors.forename: Jose
authors.initials: J
authors.lastname: Morcuende
authors.forename: Gerald F
authors.initials: GF
authors.lastname: Harris
mesh_terms: D000328:Adult; D001696:Biomechanical Phenomena; D016022:Case-Control Studies; D002370:Casts, Surgical; D003025:Clubfoot / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000523:psychology / Q000601:surgery / Q000628:therapy*; D005260:Female; D005528:Foot / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D005684:Gait; D006801:Humans; D008297:Male; D053580:Muscle Strength; D019637:Orthopedic Procedures / Q000379:methods*; D011788:Quality of Life; D011859:Radiography; D016059:Range of Motion, Articular; D020127:Recovery of Function; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult