title: Ponseti Treatment of Rigid Residual Deformity in Congenital Clubfoot After Walking Age.
abstract: BACKGROUND
  There is no established treatment for rigid residual deformity of congenital clubfoot (CCF) after walking age. Soft-tissue procedures, osseous procedures, and external fixation have been performed with unpredictable results. We applied the Ponseti method to patients with this condition in order to improve the outcomes of treatment.
  
  
  METHODS
  We retrospectively reviewed the cases of 44 patients (68 feet) with congenital clubfoot whose mean age (and standard deviation) at treatment was 4.8 ± 1.6 years. All patients had been previously treated in other institutions by various conservative and surgical protocols. Residual deformity was evaluated using the International Clubfoot Study Group Score (ICFSGS), and stiffness was rated by the number of casts needed for deformity correction. Ponseti manipulation and cast application was performed. Equinus was usually treated with percutaneous heel-cord surgery, while the cavus deformity was treated with percutaneous fasciotomy when needed. Tibialis anterior tendon transfer (TATT) was performed in patients over 3 years old. At the time of follow-up, the results were evaluated using the ICFSGS.
  
  
  RESULTS
  Before treatment, 12 feet were graded as fair and 56, as poor. Two to 4 casts were applied, with each cast worn for 4 weeks. Stiffness was moderate (2 casts) in 23 feet, severe (3 casts) in 30 feet, and very severe (4 casts) in 15 feet. Percutaneous heel-cord surgery was performed in 28 feet; open posterior release, in 5 feet; plantar fasciotomy, in 30 feet; and TATT, in 60 feet. The mean length of follow-up was 4.9 ± 1.8 years. Eight feet had an excellent result; 49 feet, a good result; and 11 feet, a fair result. No patient had pain. All of the feet showed significant improvement.
  
  
  CONCLUSIONS
  Ponseti treatment with TATT, which was performed in 88% of the feet, was effective, and satisfactory results were achieved in 84% of the feet. At the time of follow-up, no patient showed an abnormal gait, all feet were plantigrade and flexible, but 2 feet (2.9%) had relapsed.
  
  
  METHODS
  Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Departments of Clinical Science and Translational Medicine (M.D. and G.V.) and Orthopaedics and Traumatology (P.F., D.B., and E.I.), University of Rome "Tor Vergata," Rome, Italy.
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Dragoni
authors.affiliation: Departments of Clinical Science and Translational Medicine (M.D. and G.V.) and Orthopaedics and Traumatology (P.F., D.B., and E.I.), University of Rome "Tor Vergata," Rome, Italy.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Farsetti
authors.affiliation: Departments of Clinical Science and Translational Medicine (M.D. and G.V.) and Orthopaedics and Traumatology (P.F., D.B., and E.I.), University of Rome "Tor Vergata," Rome, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Vena
authors.affiliation: Departments of Clinical Science and Translational Medicine (M.D. and G.V.) and Orthopaedics and Traumatology (P.F., D.B., and E.I.), University of Rome "Tor Vergata," Rome, Italy.
authors.forename: Diego
authors.initials: D
authors.lastname: Bellini
authors.affiliation: Orthopaedic Unit, Department of Surgery and Transplant Center, Bambino Gesù Children's Hospital, Fiumicino, Italy.
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Maglione
authors.affiliation: Departments of Clinical Science and Translational Medicine (M.D. and G.V.) and Orthopaedics and Traumatology (P.F., D.B., and E.I.), University of Rome "Tor Vergata," Rome, Italy ippolito@med.uniroma2.it.
authors.forename: Ernesto
authors.initials: E
authors.lastname: Ippolito
mesh_terms: D002370:Casts, Surgical; D002648:Child; D002675:Child, Preschool; D003025:Clubfoot / Q000601:surgery*; D000071938:Fasciotomy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D019637:Orthopedic Procedures / Q000379:methods*; D016896:Treatment Outcome