Patient-reported outcome using EFAS score in skeletally mature clubfoot patients treated at birth with Ponseti’s technique

Abstract

Introduction:

Idiopathic clubfoot is a frequent congenital deformity treated worldwide using the Ponseti method, which has become the gold standard due to its safety, reproducibility, and excellent short-term outcomes. However, long-term patient-reported outcomes in adolescents and young adults treated in infancy remain insufficiently documented. This study evaluates foot health perception in skeletally mature patients who underwent Ponseti treatment during early infancy, using the European Foot and Ankle Society (EFAS) score and the first two questions of the World Health Organization Quality of Life–Brief (WHOQOL-BREF) questionnaire.

Methods:

A retrospective study was conducted on patients older than 14 years who received complete Ponseti treatment for idiopathic clubfoot at a single pediatric university hospital. Clinical and demographic data were collected, and both EFAS and WHOQOL-BREF questionnaires were administered anonymously at follow-up.

Results:

A total of 28 patients completed the questionnaires. Most reported high satisfaction with overall foot health; 78.5% achieved excellent or good EFAS scores for daily activities, while 89.2% demonstrated excellent sports-related scores. Persistent pain or major functional limitations were uncommon, though a subset reported reduced endurance in common walking activity (21%) and altered gait perception (25%). The majority rated their overall quality of life as good or acceptable according to WHOQOL-BREF responses.

Conclusion:

Ponseti treatment, combined with long-term follow-up and occasional minor procedures, offers satisfactory long-term outcomes in young adults with idiopathic clubfoot. Although some report reduced walking endurance or gait differences, overall foot health and quality-of-life perception remain high. Further studies are needed to evaluate outcomes later in adulthood.

Introduction

Idiopathic clubfoot (CF) is a common congenital deformity of the foot, with an increasing pan-European trend. ¹ Muscular and ligamentous retraction contributes to the characteristic bony deformities, which include cavus of the midfoot, adductus of the forefoot, and varus and equinus of the hindfoot.

Treatment of clubfoot was revolutionized in the 1950s with the introduction of an innovative technique by Dr. Ignacio Ponseti. ² The Ponseti technique is based on regular manipulation and serial casting until the final correction of the foot is achieved. A percutaneous Achilles tenotomy is then performed to correct the equinus, followed by bracing to maintain the correction, completing the Ponseti method. The Ponseti technique began to gain popularity in the late 1990s and has since spread widely worldwide. Today, it is considered the gold standard for the treatment of newborn clubfoot due to its reproducibility, low cost, and high success rates in short-term follow-up. ³

As the Ponseti method is a relatively recent technique, long-term results in young adults remain limited in the literature, especially regarding patient-reported outcomes.^4,5 In this study, we assess adolescents’ and young adults’ perception of their own foot health after receiving Ponseti treatment for clubfoot in early infancy, using the European Foot and Ankle Society (EFAS) questionnaire. The first two questions of the World Health Organization Quality of Life–Brief (WHOQOL-BREF) questionnaire were also administered to assess the global perception of quality of life in this specific population.

Materials and methods

Following institutional review board approval (CER-VD 2022-01860), we performed a retrospective study on skeletally mature patients who underwent Ponseti treatment for idiopathic clubfoot in early infancy at our single university pediatric hospital. We enrolled all patients with idiopathic clubfoot aged more than 14 years during the study period who had received Ponseti treatment immediately after birth (0–20 weeks) and who had achieved complete correction of the deformity after the initial treatment. The age limit of 14 years was chosen because skeletal growth in the lower limb is almost complete at that stage.

Patients were excluded if they underwent surgery as the primary correction for clubfoot, if they started the Ponseti method after 6 months of age, or if they had a diagnosis other than idiopathic clubfoot (e.g., neuromuscular disease, arthrogryposis, and genetic disorders). Patients who declined consent, either personally or through their legal representatives, were also not enrolled.

A total of 65 patients fulfilled all inclusion and exclusion criteria and were contacted by regular mail to inform them about the study and to inquire whether they were interested in participating. Thirty-six patients returned signed informed consent forms and were therefore included in the study. In the following weeks, appointments were scheduled in our outpatient clinic. During these appointments, a clinical assessment of the lower limbs was performed, and demographic and anamnestic data were collected: age, gender, profession, height, unilateral or bilateral involvement, shoe size for each foot, type and duration of orthotic treatment, and type and timing of surgeries other than Achilles tendon tenotomy (if any). Information regarding orthotic use and additional surgeries was collected from parents when present. When data were missing, the patient’s medical file was reviewed.

In the same setting, both the complete EFAS questionnaire (part 1-regular and part 2-sport form) and the first two questions of the WHOQOL-BREF questionnaire were administered. Both questionnaires were offered in the country’s official language (French) and are available in Supplemental Annexes 1 and 2. The first six questions of the EFAS score (EFAS part 1) evaluate subjective global foot health. Each question of the score is rated from 0 to 4: score <2 is considered as low, score equal to 2 as moderate, score equal to 3 as good, and score equal to 4 as excellent. A total of 24 points can be reached. Scores >20 points were considered excellent, 16–19 good, 12–15 moderate, and <11 low. The last four questions of the EFAS score (EFAS part 2) assess subjective foot health related to sports activities. A maximum of 16 points can be achieved. Scores >12 were considered excellent, 8–11 good, 4–7 moderate, and <3 low. The first two questions of WHOQOL-BREF can be used as an independent indicator of global health without the completion of the entire WHOQOL-BREF questionnaire. Categories for this part of the survey were set as follows: score 4 indicates excellent perception of global health, 3 a good perception of global health, 2 a moderate perception of global health, and <1 a low perception of global health.

The questionnaires, which remained completely anonymous, were returned immediately after completion.

Results

Thirty-six questionnaires were collected during the study period. Five questionnaires were incomplete and therefore excluded from the study. Three patients completed the questionnaire but didn’t sign the informed consent; their data were excluded from the cohort and not used for the present study. A total of 28 questionnaires were retained for the statistical analysis. The mean age at the time of the survey was 16.2 years (14–22 years). Demographic and anamnestic data are summarized in Table 1. Additional surgery after the first Achille’s tendon tenotomy (TAL) in the neonatal period consisted of further TAL procedures (8 patients, 28.6%, mean age 7.2 years) and tibialis anterior transfers (5 patients, 17.8%, mean age 6.6 years). Major surgeries, such as postero-medial release (1 patient, age 9 years) or calcaneal osteotomy (1 patient, age 15 years), were uncommon.

Table 1.

Demographic and anamnestic data.

Category	Subcategory	Number (n)	% of total (n = 28)	Mean LLD (cm)	Mean Δ shoe size (cm)
Sex	Male	22	78.6	—	—
	Female	6	21.4	—	—
Profession	Student	21	75	—	—
	Professional	7	25	—	—
Laterality	Bilateral (B)	7	25	0.00	0.14
	Unilateral—Left (L)	9	32.1	—	—
	Unilateral—Right (R)	12	42.9	—	—
Unilateral (L + R)	Combined	21	75	0.36	0.57
Height (cm)	Mean	168.2
	Range	152–180.3
Age at physical examination (years)	Mean	16.1
	Range	14–22

LLD : long lenght discrepancy ; Δ : difference.

Regarding the type of brace, very few parents were able to recall the exact type and duration of treatment. Therefore, digital patient files were reviewed. The duration of brace use was usually documented, with a mean of 3.1 years. Data regarding the specific type of brace were more difficult to obtain, as older medical records often mentioned only the term “brace” without further details. We therefore decided to note cases where no brace at all had been used. In our cohort, all patients underwent a bracing period following the initial casting and tenotomy.

Considering the first part of the EFAS questionnaire, 64.3% (n = 18) and 14.3% (n = 4) of patients reported being very satisfied (score >20 points) or satisfied (score 16–19 points) with the global health of their feet and. However, 21.5% (n = 6) reported reduced endurance and experienced some degree of pain after walking a moderate distance (EFAS part 1 Q2). Twenty-five percent (n = 7) also reported a change in gait appearance (EFAS part 1 Q3). Constant pain during ordinary walk (10.7% n = 3; EFAS part 1 Q5) and difficulty to walk on uneven surface (14.4% n = 4; EFAS part 1 Q4) were uncommon (Figure 1).

Figure 1.

Unsatisfactory results for individual question of EFAS score part 1.

In the second part of the EFAS questionnaire, 85.7% (n = 24) of patients were very satisfied with their foot health during sports activities (score >12), while only 7.1% (n = 2) had a score <7 points, considered an unsatisfactory outcome.

Analysis of the WHOQOL-BREF questionnaire showed that almost all patients (78.6%, n = 22; WHOQOL-BREF Q1) rated their quality of life as “excellent” or “good” (14.3%, n = 4; WHOQOL-BREF Q1) and stated that they were overall satisfied (92.8%, n = 26) with their health (score >3 “good” WHOQOL-BREF Q2). Figure 2 summarizes the EFAS and WHOQOL-BREF results.

Figure 2.

Comparison between EFAS score parts 1 and 2 and the first two questions of the WHOQOL-BREF.

Discussion

The Ponseti manipulative technique is considered the gold standard approach for the treatment of clubfoot, and its clinical outcomes have been extensively explored in the literature over the past 50 years.^{2,6 –8} Whereas earlier studies focused mainly on radiological and structural outcomes, more recent literature concentrates on functional and subjective results, increasingly using three-dimensional gait analysis, pedobarography, functional tests, and the administration of Patient-Reported Outcome Measures (PROMs).^{4 –7}

Several questionnaires have been used to assess patient-reported outcomes in the clubfoot population, targeting mainly parents or young children. Some of these instruments were designed to evaluate the general state of health in clubfoot patients, such as PROMIS, PedsQL, and the Pediatric Outcomes Data Collection Instrument.^{8 –10}

Other surveys were specifically designed for clubfoot patients, including the Roye Disease-Specific Instrument (Roye score/DSI), the Bangla Clubfoot Tool, and the Assessing Clubfoot Treatment (ACT) score.^{11 –14} These are mainly conceived to survey parents’ satisfaction regarding foot function and aesthetics of their child with clubfoot, and they are not validated for children as primary respondents.

The Laaveg–Ponseti score is a disease-specific tool conceived for adolescents and adults. Unlike the Roye DSI or Bangla/ACT tools, it is hybrid and cannot yet be considered a pure PROM. Despite including a clinician-assessed section, it also has a large self-reported component addressing pain, satisfaction, activity, and footwear use. The Laaveg–Ponseti score was the first disease-specific questionnaire for clubfoot and has been used in adult clubfoot populations, mainly to assess long-term outcomes after posteromedial release. ¹⁴

Introduced in 2008, the Oxford Ankle Foot Questionnaire for Children is a valuable tool for assessing the impact of ankle and foot conditions in children from both child and parent perspectives. However, despite its proven validity and reliability, it is better suited to children and pre-adolescents, as several items are specific to school-related contexts and therefore less appropriate for late adolescents and young adults who have already entered professional practice. Very few papers have reported subjective outcomes after Ponseti treatment in young adult patients, but the existing literature, such as the study by Cadena-Pérez et al., ¹⁵ shows globally satisfactory results.

In our study, we surveyed foot health perception in skeletally mature clubfoot patients who received Ponseti treatment during the neonatal period. Global foot health emerged as good, both during daily activities and sports. Additional surgery did not appear to negatively affect overall patient satisfaction. However, some fair to poor results were observed in walking endurance, and a different perception of gait was also reported by a subset of patients. Patients seem to have better functional results in shorter but more intense physical activities, such as running or jumping, than in ordinary walking, possibly due to different compensatory mechanisms during sports (shorter stance phase, less excursion in Achilles’ tendon, less subtalar compensation). Constant pain during walk and difficulty to walk on uneven surface were uncommon in our cohort.

These results are encouraging, as Ponseti treatment, in combination with extended surveillance and minor additional procedures, seems to guarantee good patient satisfaction at the end of skeletal growth. This study also opens perspectives for prenatal counseling. Parents who receive clubfoot counseling before birth often inquire about long-term outcomes for Ponseti’s technique, and our findings provide more concrete elements to reassure them regarding the favorable evolution of clubfoot.

These findings can also add information for professional counseling: although overall outcomes are good, reduced endurance and some mild pain may be expected in this population during daily activities. These limitations, although generally minor, could influence the choice of physically demanding occupations. Early counseling during the adolescent period may help patients set realistic expectations and choose suitable career paths.

This study has some limitations. The cohort size was relatively small, reflecting the difficulty of maintaining contact with late adolescents and young adults. During childhood, routine pediatric orthopedic follow-up ensures continuous monitoring, but in adulthood, patients with good outcomes do not require regular consultations, and those needing additional care may transition to adult orthopedic services or private practice, complicating long-term tracking. ¹⁰

Finally, although our cohort included skeletally mature patients, many were still students. Professional environments may place different mechanical demands on the feet, such as prolonged standing or mandatory protective footwear, which could influence satisfaction outcomes in the future. Further research should therefore explore how satisfaction evolves once patients enter the workforce, providing an even more representative picture of adult clubfoot outcomes.

Conclusion

Ponseti treatment, in addition to long follow-up and minor surgery, seems to guarantee a satisfactory result in skeletally mature clubfoot patients. Some changes seem to be perceived in endurance and gait appearance. Further studies need to be conducted to determine if subjective benefits persist in the older population.

Supplemental Material

sj-pdf-1-cho-10.1177_18632521261427193 – Supplemental material for Patient-reported outcome using EFAS score in skeletally mature clubfoot patients treated at birth with Ponseti’s technique

Supplemental material, sj-pdf-1-cho-10.1177_18632521261427193 for Patient-reported outcome using EFAS score in skeletally mature clubfoot patients treated at birth with Ponseti’s technique by Ambra Donzelli, Jeanne Voute, Aline Bregou, Franziska Kocher and Pierre-Yves Zambelli in Journal of Children’s Orthopaedics