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A Long-term Follow-up of Young Adults With Idiopathic Clubfoot

Does Foot Morphology Relate to Pain?

Graf, Adam N. MS*; Kuo, Ken N. MD; Kurapati, Nikhil T. MD‡,§; Krzak, Joseph J. PT, PhD, PCS*,∥; Hassani, Sahar MS*; Caudill, Angela K. MPT*; Flanagan, Ann PT, PCS*; Harris, Gerald F. PhD, PE*,‡; Smith, Peter A. MD*

doi: 10.1097/BPO.0000000000001060
Club Foot

Background: Individuals with clubfoot, treated in infancy with either the Ponseti method or comprehensive clubfoot release, often encounter pain as adults. Multiple studies have characterized residual deformity after Ponseti or surgical correction using physical exam, radiographs and pedobarography; however, the relationship between residual foot deformity and pain is not well defined. The purpose of the current study was 2-fold: (1) to evaluate the relationship between foot morphology and pain for young adults treated as infants for idiopathic clubfoot and (2) to describe and compare pedobarographic measures and outcome measures of pain and morphology among surgically treated, Ponseti treated, and typically developing feet.

Methods: We performed a case-control study of individuals treated for clubfoot at 2 separate institutions with either the Ponseti method or comprehensive clubfoot release between 1983 and 1987. All subjects (24 treated with comprehensive clubfoot release, 18 with Ponseti method, and 48 controls) were evaluated using the International Clubfoot Study Group (ICFSG) morphology scoring, dynamic pedobarography, and foot function index surveys. During pedobarography, we collected the subarch angle and arch index as well as the center of pressure progression (COPP) on all subjects.

Results: Foot morphology (ICFSG) scores were highly correlated with foot function index pain scores (r=0.43; P<0.001), although the difference in pain scores between the surgical and Ponseti group did not reach significance. The surgical group exhibited greater subarch angle and arch indexes than the Ponseti group, demonstrating a significant difference in morphology, a flatter foot. Finally, we found more abnormalities in foot progression, decreased COPP in the forefoot and increased COPP in the midfoot and hindfoot, in the surgical group compared with controls.

Conclusions: Measures of foot morphology were correlated with pain among all treated for clubfoot. Compared with Ponseti method, comprehensive surgical release lead to greater long-term foot deformity, flatter feet and greater hindfoot loading time.

Level of Evidence: Level III—Therapeutic.

*Shriners Hospitals for Children, Chicago

Midwestern University, Downers Grove, IL

College of Medicine, Taipei Medical University, National Taiwan University Children Hospital, Taipei, Taiwan

Orthopaedic & Rehabilitation Engineering Center (OREC) Marquette University/Medical College of Wisconsin, Milwaukee, WI

§Medical College of Wisconsin, Milwaukee, WI

US Department of Health and Human Services—National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR): Advanced Rehabilitation Research Training in Pediatric Mobility for Physicians and Engineers. 90AR5022-01-00 (Formerly H133P140023-14).

NIDRR (National Institute on Disability and Rehabilitation Research): Conservative and Surgical Clubfoot Treatment, A Multi-Center Study. H133G060252, $450,000, G.F.H., Co-Principal Investigator. The remaining authors declare no conflicts of interest.

Reprints: Nikhil T. Kurapati, MD, Orthopaedic and Rehabilitation Engineering Center (OREC), Marquette University and the Medical College of Wisconsin, Olin Engineering Center, Room 323, P.O. Box 1881, Milwaukee, WI 53201-1881. E-mail:

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