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Management of Clubfoot Relapses With the Ponseti Method

Results of a Survey of the POSNA Members

Hosseinzadeh, Pooya, MD*; Kiebzak, Gary M., PhD; Dolan, Lori, PhD; Zionts, Lewis E., MD§; Morcuende, Jose, MD, PhD

Journal of Pediatric Orthopaedics: January 2019 - Volume 39 - Issue 1 - p 38–41
doi: 10.1097/BPO.0000000000000953
Foot & Ankle

Background: Despite the high rate of initial success using the Ponseti method to manage idiopathic clubfoot deformity, relapse continues to be a problem. We surveyed the Pediatric Orthopedic Society of North America (POSNA) members about their experience with relapsed deformity following the initial correction of clubfeet.

Methods: We created a survey to focus on the management of clubfeet after initial correction of deformity. The survey included questions on postcorrective bracing, clinical findings used to identify relapse, the observed frequency of relapsed deformity, and how relapses are managed. The questionnaire was approved by the POSNA Evidence Based Committee and was sent electronically to all POSNA members.

Results: We received responses from 321 members (26%). Of those, 94% were fellowship trained in pediatric orthopaedics. The Ponseti method was used by 98% of respondents. The Mitchell-Ponseti orthosis was most commonly used (51%), followed by the Denis-Browne brace (25%). The duration of bracing used varied among members with 23% recommending only 2 years, 33% recommending 3 years, and 34% recommending 4 years. A tight heel cord was felt to be the first sign of relapse by 59% of respondents, and dynamic supination by 30%. The rate of relapse was observed to be <10% by 22% of the respondents, 10% to 20% by 52%, and 20% to 40% by 25%. Manipulation and cast treatment alone (55%) and cast treatment with tenotomy (23%) were reported as the 2 most common initial treatment approaches for a relapsed deformity. Cast treatment to correct relapsed deformity before tibialis anterior tendon transfer was reported by 62% of respondents. Heel cord tenotomy (75%) and posterior capsular release (43%) were the 2 most common procedures used in addition to tibialis anterior tendon transfer for the treatment of clubfoot relapse.

Conclusion: This study highlights the wide variation with which clubfoot relapses are evaluated and treated among the POSNA membership with differences in the recommended duration of bracing, identification of relapses, and their management. These wide differences highlight the need for future research and educational programs to inform and standardize the management of clubfoot using the Ponseti Method.

Level of Evidence: Not applicable.

*Miami Orthopedics and Sports Medicine Institute, Baptist Children’s Hospital

Pediatric Orthopedic Center, Baptist Children’s Hospital, Miami, FL

Department of Orthopedics, University of Iowa, Iowa City, IA

§Department of Orthopedics, David Geffen School of Medicine at UCLA, Los Angeles, CA

The study did not receive any funding.

The authors declare no conflicts of interest.

Reprints: Pooya Hosseinzadeh, MD, Miami Orthopedics and Sports Medicine Institute, Baptist Children’s Hospital, 8740N Kendall Dr, Suite 115, Miami, FL 33176. E-mail:

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