Clubfoot Correction with Ponseti Technique: Three-Dimensional Alignment Analysis and Residual Adult Deformity Effects on Patient-Reported Outcomes

Abstract

Introduction/Purpose: Few studies have assessed the long-term outcomes of the Ponseti technique and none have utilized 3- dimensional weightbearing analysis. The goal of this study was to understand how potential residual 3D deformities and abnormalities influence patient reported outcomes (PROs). This was accomplished by assessing anatomical foot and ankle alignment in adult clubfoot patients treated with the Ponseti method using 3D weightbearing CT (WBCT) imaging and then correlating residual foot and ankle malalignment with PROs. Methods: There were 37 consecutive patients (57 feet) included and 14 volunteers healthy controls (28 feet) included in this study. Every participant was evaluated using a WBCT (HiRise©) in a bipedal standing position. From these scans Cavus, Adductus, and Varus components were evaluated using multiple 3D measurements calculated using the semi-automatic segmentation software Bonelogic®. Specific Cavus related measurements included sagittal talus-first metatarsal angle and the calcaneal inclination angle. Varus related measurements included talocalcaneal angle in both the sagittal and axial planes as well as the hindfoot moment arm and the hindfoot alignment angle. Adductus deformity was evaluated using talonavicular coverage angle. These measurements were then correlated with patient reported outcome surveys, which included Visual Acuity Scale for pain, PROMIS general health, PROMIS physical function, PROMIS pain interference, pain catastrophic scale, and European foot and ankle society score. Results: There was no significant overall residual 3D-deformity observed in clubfoot patients when compared to controls, with similar FAO measurements observed between the groups, clubfoot=2.63% (95%CI=1.41%-3.85%) and control=3.2% (CI=1.6%- 4.8%,P=0.58). The sagittal talus-first-metatarsal in the clubfoot-patients had a mean-value of -0.12° compared to the controls, −5.2°. Clubfoot patients also had a decreased calcaneal-inclination-angle relative to the controls, 13.01° and 21.5° respectively. Talocalcaneal-angle for clubfoot patients in both the sagittal-plane,44.28°, and axial-plane, 17.74°, were reduced compared to the controls, 57.51° and 25.78°. Talonavicular-coverage-angle in the clubfoot-group (18.63°) was less than the controls (29.19°). Talus- first-metatarsal-angle in the sagittal-plane was significantly correlated with VAS-scores (RSquare=0.19,P=0.0118) and the EFAS- Score (RSquare=0.27,P=0.0025). Talocalcaneal-angle in the sagittal plane was also significantly correlated with the PROMIS-Pain- Interference-score (P=0.038) and PROMIS-Physical-Function-score (RSquare=0.32,P=0.0007). Conclusion: The Ponseti technique is an effective nonsurgical treatment for the overall three-dimensional foot and ankle alignment of Clubfoot. While mild, but statistically significant residual Varus and Adductus deformities were observed in adult clubfoot patients, the overall 3D alignment (FAO) was found to be similar between clubfoot patients and controls. These findings highlight the efficacy of the Ponseti technique and potentially explain the overall good PROs. The results of this study could potentially provide insight into treatment targets that may be applied to help optimize patient outcomes when treating children with Clubfoot in the future. The Ponseti technique is an effective nonsurgical treatment for Clubfoot's overall three-dimensional foot and ankle alignment. While mild, but statistically significant residual Varus and Adductus deformities were observed in adult clubfoot patients, the overall 3D alignment (FAO) was found to be similar between clubfoot patients and controls. These findings highlight the efficacy of the Ponseti technique and potentially explain the overall good PROs. The results of this study could potentially provide insight into treatment targets that may be applied to help optimize patient outcomes when treating children with Clubfoot in the future.