The Ponseti technique and improved ankle dorsiflexion in children with relapsed clubfoot: a retrospective data analysis Erika Marquez a , Verity Pacey a,b , Alison Chivers b , Paul Gibbons b and Kelly Gray a,b This study quantifies the change in passive ankle range of motion following modified Ponseti casting in children with relapsed idiopathic clubfoot. Fifty-three cases (feet) were retrospectively reviewed, with 6-month follow-up data available for 72% of participants. The median improvement in dorsiflexion was 15° (95% confidence interval: 12.5°–17.5°, P ≤ 0.05), with 85% achieving dorsiflexion ≥ 10°. At the 6-month follow-up, dorsiflexion remained significantly improved and 12 feet (32%) presented with subsequent relapse. Nine were referred for further casting and three were recommended for extra-articular surgery. Repeat modified Ponseti management clinically and statistically improves passive ankle dorsiflexion in relapsed idiopathic clubfoot. J Pediatr Orthop B 26:116–121 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Journal of Pediatric Orthopaedics B 2017, 26:116–121 Keywords: clubfoot, dorsiflexion, ponseti, relapse a Department of Health Professions, Macquarie University and b The Children’s Hospital at Westmead, Sydney, New South Wales, Australia Correspondence to Kelly Gray, PhD, Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, 75 Talavera Road, Macquarie University, Sydney, 2109 NSW, Australia Tel: + 61 2 9850 2795; fax: + 61 2 9850 6630; e-mail: kelly.gray@mq.edu.au Introduction Congenital talipes equinovarus (CTEV), commonly known as clubfoot, is characterized by equinus, forefoot adductus, hindfoot varus and cavus deformities. Occurring in approxi- mately one in every 1000 live births, clubfoot is one of the most prevalent congenital musculoskeletal conditions in chil- dren [1]. A greater understanding of the long-term implica- tions of previous treatments, for example, stretching [2] and surgery [1,3], led to the development of the Ponseti technique [4]. This method of casting involves gently manipulating the foot about the talus and serial casting for 6–8 weeks, with 80–90% of children then undergoing an Achilles tenotomy [5,6]. A boots and bar abduction brace is worn 23 h/day for the first 3 months after casting, and then during sleep until the child reaches 4 years of age. The Ponseti technique has cor- rected initial presentations of clubfoot, and has been shown to produce better long-term functional outcomes and a greater range of motion (ROM) compared with traditional interven- tions [3,6–10]. Despite this success, 37–56% of infants mana- ged with the Ponseti method present with relapse between 10 months and 5 years of age [11,12]. Traditionally, invasive procedures such as postermomedial soft tissue release (PMSTR) [13], osteotomies [13] and external fixator devices [14,15] have been used to correct relapses, but because of unsatisfactory outcomes, clinicians have begun to implement more conservative treatment options [4]. There is a lack of quality evidence supporting the use of repeat Ponseti serial casting in the management of chil- dren with clubfoot relapse [1]. Children who have undergone Ponseti management as infants have recorded a mean passive dorsiflexion of 16° and actively 15° during gait [16]. A minimum of 10° dorsiflexion is recommended to avoid repeat Achilles tenotomy [4]. ROM has impli- cations for function and the prevention of future surgery. No studies have quantified the dorsiflexion ROM that can be obtained through repeated Ponseti casting for relapsed clubfoot. Clinicians’ decision-making process would benefit from quantified ROM data in the literature. The primary aim of this study was to quantify the change in passive dorsiflexion ROM after repeat serial casting on the basis of the Ponseti method in children with idio- pathic clubfoot initially managed with the standard Ponseti method and presenting with their first relapse. The secondary aims were to quantify changes in ankle abduction ROM and the number of children continuing on to a subsequent relapse. We hypothesized that fol- lowing repeat Ponseti casting, there would be an improvement in dorsiflexion and abduction, and that bilateral cases would respond similarly to unilateral cases. Participants and methods A retrospective data analysis was carried out at The Children’s Hospital at Westmead, Sydney, Australia (CHW), with two authors (E.M. and A.C.) reviewing patient data. The Sydney Children’s Hospital Network and Macquarie University Human Research Ethics Committees provided ethical approval. For this study, relapse was defined as a loss of structural ROM, with or without a dynamic component. All children born with idiopathic clubfoot initially managed with the standard Ponseti method and attending the CHW clubfoot clinic exclusively for management of first relapse in 2005–2014 were eligible for inclusion. Children who had atypical or syndromal clubfoot and those children who had previously 116 Original article 1060-152X Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/BPB.0000000000000390 Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.