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C OPYRIGHT 2014

BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

Walking Age of Infants with Idiopathic Clubfoot


Treated Using the Ponseti Method
Lewis E. Zionts, MD, Davida F. Packer, MD, Shannon Cooper, BS, Edward Ebramzadeh, PhD, and Sophia Sangiorgio, PhD
Investigation performed at the Orthopaedic Institute for Children, Los Angeles, California

Background: The Ponseti method is an established approach to treating idiopathic clubfoot in infants. The method
involves a period of cast immobilization and postcorrective bracing that potentially interferes with normal movements of
the lower extremities. In the present study, we investigated the age at which infants who had idiopathic clubfoot treated
using the Ponseti method achieved independent walking.
Methods: We prospectively evaluated patients of a single surgeon. Included in the study were all patients with idiopathic
clubfoot who were full term at birth, were no more than twelve weeks of age at the start of treatment, had received no prior
outside treatment, and were followed for a minimum of twenty-four months.
Results: Ninety-four patients were included. The mean age at which patients began walking independently was 14.5
2.6 months (range, ten to twenty-two months). By eighteen months, 90% of the patients were walking without assistance.
Patients with moderate or severe clubfoot deformity began walking earlier than did patients with very severe deformity (a
mean of 14.2 months compared with 15.8 months; p = 0.03). Patients who experienced a relapse before learning to walk
began walking later than those who did not relapse (a mean of 15.9 months compared with 14.2 months; p = 0.04). Other
patient and treatment-related variables had no significant influence on the onset of walking.
Conclusions: On the basis of our findings, parents of infants with idiopathic clubfoot treated using the Ponseti method
may expect their child to achieve independent walking approximately two months later than infants without clubfoot
deformity. A greater delay may be expected for those patients who have a very severe deformity or those who experience a
deformity relapse.
Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed
by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication.
Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

he Ponseti method is a well-established and widely accepted approach to treating idiopathic clubfoot in
infants1-5. The technique involves a series of specific
manipulations and cast applications to correct the forefoot,
midfoot, and subtalar components of the deformity. A percutaneous Achilles (heel-cord) tenotomy is usually required to
address any remaining equinus and provide final correction of
the foot. After the foot is corrected, a foot abduction orthosis is
used to prevent a relapse of the deformity. This device is worn
full time for three months and then at night and at naptime
until the child is at least four years old.

At the start of treatment, many parents express concern


over whether this treatment method will affect the motor development of their child, most notably the achievement of independent walking. Two recent studies have suggested that the
start of walking may be delayed in infants with idiopathic clubfoot managed using the Ponseti method6,7. Both of these investigations had limitations imposed by their small sample size.
Garcia et al.6 observed twenty-six infants with idiopathic clubfoot, only twelve of whom were treated using the Ponseti method.
Sala et al.7 noted a delay in the achievement of independent
walking in thirty-six patients whose clubfoot was managed using

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work,
with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has
had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this
work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2014;96:e164(1-6)

http://dx.doi.org/10.2106/JBJS.M.01525

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TABLE I Influence of Patient Factors on Achievement of Independent Walking


No. of Patients (%)

Age at Walking* (mo)

P Value

Total patient population

94 (100%)

14.5 2.6

N/A

Sex
Male
Female

68 (72%)
26 (28%)

14.3 2.7
15.1 2.5

0.17

Bilaterality
Yes
No

50 (53%)
44 (47%)

14.2 2.6
14.9 2.6

0.23

Deformity classification (Dimeglio)


Moderate or severe (5-14 points)
Very severe (15 points)

76 (81%)
18 (19%)

14.2 2.5
15.8 2.8

Family history of clubfoot


Yes
No

22 (23%)
72 (77%)

14.4 2.8
14.5 2.6

0.03
0.89

*Values are presented as the mean and standard deviation. N/A = not applicable.

the Ponseti technique. The authors noted that they did not have a
sufficient number of patients to evaluate the effect of other variables, such as unilateral or bilateral involvement.
The purpose of the present study was to determine, with
use of a prospective, single-surgeon database, the age at which
infants with idiopathic clubfoot treated with the Ponseti method
begin to walk. We also evaluated the influence of other factors,
such as sex, bilaterality, severity of deformity, and early relapse, on
the achievement of independent walking.
Materials and Methods

his study was approved by the institutional review board of the University
of California, Los Angeles. We invited families of infants who had been
diagnosed with idiopathic clubfoot and were initially seen at our clinic between
July 2006 and August 2011 to participate in this prospective study. Exclusion
criteria included a gestational age of less than thirty-seven weeks, an age of more
than twelve weeks at the start of treatment, prior outside treatment, mild or
positional deformity, or orthopaedic problems other than clubfoot that might
affect motor development. We also excluded patients who were lost to followup prior to reaching twenty-four months of follow-up at our institution.
The severity of the foot deformity was graded at initial presentation by
8
the senior author (L.E.Z.) using the Dimeglio scale , a classification scheme
9
with very good interobserver relability . Feet were classified into one of four
categories: Grade I (0 to 4 points, mild), Grade II (5 to 9 points, moderate),
Grade III (10 to 14 points, severe), and Grade IV (15 to 20 points, very severe).
For infants with bilateral clubfoot, the greater of the two Dimeglio scores was
used for the analysis. Infants with a mild deformity (Grade I) were excluded
because the treatment of these feet was usually less extensive and often differed
from the standard Ponseti method.
The feet were manipulated at weekly intervals as prescribed by the Ponseti
2
method . The cavus, adductus, and varus components of the deformity were
corrected by positioning the foot in supination and then abducting the foot while
counter pressure was applied with the thumb over the head of the talus. We
applied casts using semi-rigid fiberglass material (3M Scotchcast Soft Cast Casting
Tape; 3M, St. Paul, Minnesota). When the foot achieved 70 of abduction relative
to the thigh, a heel-cord tenotomy was deemed indicated if there was less than 15
of dorsiflexion. Tenotomies were performed in the operating room with the
10
patient under sedation, after which a cast was worn for three weeks .

After the last cast was removed, the infants were fitted with a Mitchell11
Ponseti (MP) brace (MD Orthopaedics, Wayland, Iowa) . The parents were
instructed to apply the brace for twenty-three hours a day for three months,
followed by use at night and at naptime. In general, we instructed the parents to
perform heel-cord stretching exercises on the child before applying the brace.
None of the infants had any formal physical therapy prior to walking.
In general, once use of the brace began, the patients were followed at
three-month intervals. At each visit, the parents were interviewed to determine
whether, and when, the patient had begun to walk independently. The validity
of the parental report was supported by observation of the infant by the physician during the clinic visit. The parental report was deemed valid if the
physician observed the infant taking ten or more steps without assistance. The
age at which walking began was recorded to the nearest month.
Other data collected included patient age, sex, side of involvement, family
history of clubfoot, number of casts needed to obtain initial correction, need for
heel-cord tenotomy, noncompliance with bracing, and early relapse of deformity.
For the purposes of the present study, noncompliance with bracing was defined
as failure to use the brace as prescribed. Relapse was defined as the reappearance
of any of the components of the clubfoot deformity requiring further treatment.

Data Analysis
power analysis was conducted to determine the sample size
required to detect a difference of one month or greater
between patients with idiopathic clubfoot and otherwise healthy
infants in terms of a delay in walking age. A standard deviation
(SD) of 2.2 months, reported in a recent study7 that investigated
the age at which patients with idiopathic clubfoot achieve gross
motor milestones, was used for this analysis. Given a power of
80% and with a = 0.05, we estimated that seventy-seven patients
in each group would be sufficient to detect a difference of one
month or greater. As previous studies have examined the age at
walking for healthy patients with the use of much larger sample
sizes (816 to 3554 patients)12-14, a control group of children without
clubfoot was not included.
Independent sample t tests were performed to quantify
the certainty (p value) associated with each of the observed
differences in the mean age at walking as influenced by patient

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Fig. 1

Patient inclusion and exclusion criteria.

variables and treatment variables. The patient variables included in the analysis were sex, bilaterality, family history of
clubfoot, and the severity of deformity. The treatment variables
included were the number of casts needed prior to tenotomy,
the need for tenotomy, noncompliance with brace use, and
relapse of deformity. In addition, the Spearman correlation
coefficient was used to determine the strength of correlation, if
any, between age at walking and weeks of casting.
In addition to the analysis above, the available data from
the twelve patients who did not complete twenty-four months
of clinical follow-up and therefore were excluded from the
analysis were compared with the data from the included patients,
to determine any differences in terms of Dime glio scores, demographic characteristics, and, if available, age at walking and
outcome variables, such as relapse.
Source of Funding
No external source of funding was obtained for this study.
Results
ne hundred and seventy consecutive infants with a diagnosis of idiopathic clubfoot were initially seen at the Orthopaedic Institute for Children Clubfoot Clinic between July
2006 and August 2011. Of the 154 patients for whom consent
was obtained, ninety-four met the inclusion criteria and were

followed for a minimum of two years. These patients formed the


study group (Fig. 1). The mean duration of follow-up (and SD)
was 43.8 14.6 months (range, 24 to 75.9 months).
Sixty-eight (72%) of the patients were male, and fifty
(53%) of the patients had bilateral involvement. Among those
with unilateral deformity, the left foot was affected in twentyfive (57%) of the cases. Twenty-two (23%) of the ninety-four
patients had a first-degree relative with clubfoot. Deformity
was classified as Dime glio Grade II (moderate) or Grade III
(severe) for seventy-six (81%) of the patients and Grade IV
(very severe) for eighteen (19%) of the patients.
The mean age at which treatment began was 4.1 2.4
weeks (range, 0.7 to 11.7 weeks). The mean number of casts
that were applied before the tenotomy was 5.5 (range, three to
twelve casts). Eighty-nine (95%) of the patients underwent a
heel-cord tenotomy. Initial correction of the deformity was
achieved in all patients. The families of twenty-one (22%) of
the patients were noncompliant with bracing prior to the onset
of walking. Fourteen (15%) of the patients had a deformity
relapse, which was managed with a series of one to three manipulations and casts, followed by the resumption of bracing.
The mean age at which patients began to walk independently was 14.5 2.6 months (range, ten to twenty-two months).
Table I shows the influence of the patient variables studied on the
mean age at walking. Table II shows the influence of treatment

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TABLE II Influence of Treatment Factors on Achievement of Independent Walking


No. of Patients (%)

Age at Walking* (mo)

P Value

Noncompliance with brace use prior to walking


Yes
No

21 (22%)
73 (78%)

14.9 2.7
14.4 2.6

0.41

Relapse prior to walking


Yes
No

14 (15%)
80 (85%)

15.9 2.6
14.2 2.6

0.04

Heel-cord tenotomy
Yes
No

89 (95%)
5 (5%)

14.5 2.6
14.0 2.6

0.69

Number of casts
4
5 or 6
7

22 (23%)
57 (61%)
15 (16%)

14.5 2.4
14.5 2.6
14.5 3.1

0.99

*Values are presented as the mean and standard deviation.

factors (noncompliance with brace use prior to the onset of walking,


relapse prior to walking, the need for heel-cord tenotomy, and the
number of casts) on the mean age at walking.
Overall, the patient factor that had the greatest influence
on the mean age at walking was the severity of deformity (Fig.
2, Table I). For the purposes of analyzing the data and comparing for significance, due to the limited number of patients
(eight) with Grade-II (moderate) deformity, the Grade-II and
Grade-III patients were combined, as was done in a previous
study11. We found that patients with an initial diagnosis of a
moderate or severe clubfoot deformity began walking more
than one month sooner than the patients whose deformity was
classified as very severe (14.2 months compared with 15.8 months;
p = 0.03). The male patients tended to walk slightly earlier (0.8
months earlier) than the female patients, but this trend was not
significant (p = 0.17). A family history of clubfoot appeared to
have the least influence on the age at which patients began to
walk (p = 0.89) (Table I).
Of the treatment factors, the occurrence of a relapse prior
to walking was the most influential factor. Patients who experienced a relapse before learning to walk began walking nearly
two months later than those who did not relapse (15.9 months
compared with 14.2 months; p = 0.04) (Table II). The number
of casts used prior to tenotomy, the need for heel-cord tenotomy, and noncompliance with brace use did not significantly
influence the age at which patients began to walk.
In the present study, slightly more than 50% of the
patients (forty-nine) had achieved walking by fourteen
months of age, regardless of severity of deformity, relapse, sex,
or any other patient or treatment-related factor. By 16.5 months,
seventy-one (75%) of the patients were walking, and by eighteen months, eighty-five (90%) of the patients were walking
(Table III).
The characteristics of the twelve patients who met the
inclusion criteria but who did not complete twenty-four months

of follow-up were similar to those of the patients who were


included in the study. The mean duration of follow-up was
15.8 5.5 months; three patients were known to have moved.
Ten of the patients were classified as having severe deformity
and two, very severe, on the basis of the Dime glio scale. All
patients underwent heel-cord tenotomy, and the mean number
of casts prior to tenotomy was 5.6 1.7. During the known
follow-up period, eight patients had been noted to have brace
noncompliance and, of those eight, four relapsed prior to being

Fig. 2

Boxplots represent the age at which patients began to walk as a function of


deformity severity. The median is represented by the thick band within each
box, and the top and bottom of the box represent the 25th and 75th
percentiles. The whiskers represent the high and low values, excluding
outliers between 1.5 and 3.0-box lengths from the median. The circle at the
top of the figure represents an outlier.

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TABLE III Comparison with Previous Reports of Infants without Deformity on Achievement of Walking*
Present Study

13

Denver II (Frankenberg et al.)

12

WHO Multicenter

14

Neligan and Prudham

Total no. of patients

94

2096

816

3554

Age at walking (mo)


Mean SD
50% of patients
75% of patients
90% of patients

14.5 2.6
14.0
16.5
18.0

NR
12.3
13.6
14.9

12.1 1.8
12.0
13.1
14.4

NR
12.8
14.2
15.8

*NR = not reported.

lost. Walking age was reported for five of the patients, a mean of
13.8 1.3 months.
Discussion
arents often perceive normalcy during their infants first
year of life based on when independent walking is achieved15. The reported mean age at which otherwise healthy
infants begin to walk has ranged from 11.7 to 12.8 months12-16.
The present study found that, among infants with idiopathic
clubfoot managed using the Ponseti method, the mean age at
which unassisted walking began was 14.5 months (range, ten
to twenty-two months).
We found that 50% of patients were walking by 14.0
months of age and 90% were walking by 18.0 months. In
contrast, in a study of 816 healthy patients, the World Health
Organization (WHO)12 reported a mean walking age of 12.1
1.8 months, with 50% of the patients walking at 12.0 months
(Table III). The difference in mean age between that of our
study and the WHO study (2.4 months) was significant (p <
0.0001). The authors of two other studies have reported the
distribution in walking age for healthy subjects13,14. Although
these studies did not present the mean and standard deviation,
on the basis of our power analysis and estimations, the patients
with clubfoot in our study walked, on average, 1.2 to two
months later than the healthy subjects of those studies (p <
0.0001).
This finding agrees with that of two other studies that
found that infants with idiopathic clubfoot, treated using the
Ponseti method, may begin to walk approximately two months
later than the walking age reported for healthy infants6,7. Garcia
et al.6 used the Alberta Infant Motor Scale (AIMS) when comparing the gross motor performance of a group of twenty-six
infants treated for idiopathic clubfoot using the Ponseti technique (twelve infants), French physical therapy method (nine
infants), or both (five infants), with that of a group of twenty-six
normally developing infants. While they found no difference in
gross motor development between the groups at three and six
months, the AIMS scores for the infants with clubfoot were
lower at nine and twelve months than the scores of the infants in
the other group. Also, the percentage of infants who were not yet
walking at twelve months was greater in the clubfoot group
(81%) than in the normal group (48%). The authors reported

that the mean age at walking was 13.9 months for the clubfoot
group. The authors acknowledged that the significance of their
findings was limited by the small sample size.
In a more recent study, Sala et al.7 evaluated the acquisition of gross motor milestones in thirty-six infants with
idiopathic clubfoot treated using the Ponseti method. They
reported that the mean age of independent walking was 13.9
months, which was approximately two months later than that
reported in two studies of normally developing infants. These
authors noted that they did not have a sufficient number of
patients to evaluate the effect of other variables, such as unilateral or bilateral involvement.
The mean age at walking in the present study was higher
than that reported by Sala et al.7 (14.5 months compared with
13.9 months). This difference may be due to our inclusion of
patients who experienced an early relapse. In the present study,
patients who did not experience an early relapse walked at a
mean of 14.2 months.
We evaluated several patient variables that might affect
the age at which our patients began to walk (Table I). We found
no significant influence of sex, bilaterality, or a family history
of clubfoot. Similarly, Garcia et al.6 found no significant difference between infants with bilateral clubfoot and unilateral
clubfoot in terms of AIMS scores at any of the assessment
intervals in their study.
Our patients who were initially classified as having a very
severe deformity, based on the Dime glio classification, achieved
independent walking more than one month later than those
patients who had a moderate or severe deformity. This finding
contrasts with that of Garcia et al.6, who concluded that the
severity of the deformity at initial presentation, also assessed
with use of the Dime glio score, did not influence the attainment of motor skills.
Among the treatment variables we evaluated (Table II),
the number of casts applied prior to tenotomy, the need for a
heel-cord tenotomy, and noncompliance with the brace protocol
had no significant influence on the age at which the patients
began walking. However, infants who experienced an early relapse of the deformity began walking at an average of 1.7 months
later than those patients who did not experience a relapse. This
finding may be attributable to the need for additional cast applications and increased time in the postcorrective brace that was

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required to regain and maintain correction of the feet in these


patients. Perhaps most importantly, this finding underscores the
importance of achieving and maintaining a complete correction
to the attainment of independent walking as early as possible.
The reason why infants with idiopathic clubfoot walk
later than other children is subject to speculation. Garcia et al.6
suggested that early constraints on movement of the lower
extremities imposed by the use of casts and splints may lead
to alterations in balance or the strength of certain muscle
groups. They also hypothesized that the presence of clubfoot
may be a marker for an underlying mild dysfunction in motor
development.
The validity of the results of this study is limited by the
accuracy of the parents report as to when their infant began to
walk. Majnemer and Rosenblatt17 examined the consistency of
a parents memory of developmental milestones. They found
that the mean discrepancy in parental recall of their infants
first steps was less than 0.4 months at three and five years after
the occurrence. We expect that the parental reporting of infant
age at walking in the present study was accurate, because the
frequent follow-up intervals allowed for nearly concurrent
observation by the physician.
In conclusion, and on the basis of our findings, the
parents of infants who have idiopathic clubfoot deformity

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treated with use of the Ponseti method should generally expect


their child to achieve independent walking approximately two
months later than infants without clubfoot deformity. This
finding does not appear to be affected by sex, bilaterality, a
family history of clubfoot, the number of casts required, or the
need for tenotomy. However, a greater delay may be expected
for patients with a very severe deformity or for those who
experience a relapse of the deformity. n
NOTE: The authors thank Jennifer Hall, BS, who assisted in the collection of data for this study.

Lewis E. Zionts, MD
Shannon Cooper, BS
Edward Ebramzadeh, PhD
Sophia Sangiorgio, PhD
Orthopaedic Institute for Children,
403 West Adams Boulevard,
Los Angeles, CA 90007.
E-mail address: LZionts@mednet.ucla.edu
Davida F. Packer, MD
Department of Orthopaedics,
Miami Childrens Hospital,
3100 S.W. 62nd Avenue, Miami FL 33155

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