Clubfoot recurrence: epidemiology, causes, and methods of correction

Background. Congenital clubfoot is one of the most common musculoskeletal deformities in children, occurring with a frequency of 0.6–1.5 cases per 1000 live births. Despite the high effectiveness of the Ponseti method, the recurrence rate reaches 40%, which represents a serious problem in pediatric orthopedics.

Objective — to summarize and systematize current data on the epidemiology, risk factors for the development of congenital clubfoot and methods of correcting its recurrence.

Materials and methods. A search and analysis of publications was conducted in the E-library and PubMed databases using the keywords "clubfoot recurrence", "clubfoot relapse" for the period 1964–2025. The descriptive review included 83 relevant clinical studies, reports and systematic reviews.

Results. It was found that the prevalence of clubfoot varies depending on geographic region (from 0.51 to 2.03 per 1000 live births) and ethnicity. The recurrence rate after Ponseti method treatment is 10–30%, after surgical treatment — 20–50%. The leading risk factors for recurrence are: non-compliance with brace wearing protocol (increases risk by 5.4 times), high initial Pirani score, age at treatment initiation over 3 months, bilateral clubfoot. An algorithm for selecting the recurrence correction method is presented depending on the patient's age and nature of deformity: from repeated Ponseti casting to complex reconstructive interventions (tendon transpositions, osteotomies, arthrodeses).

Conclusion. Clubfoot recurrences remain a relevant problem requiring a multidisciplinary approach. Key prevention factors are strict adherence to orthosis wearing protocol and regular follow-up. When recurrence develops, the choice of treatment method should be individualized considering the patient's age, severity of deformity and previous treatment. Further research is needed to standardize recurrence diagnostic criteria and develop innovative treatment methods.

1. Ansar A, Rahman AE, Romero L, Haider MR, Rahman MM, Moinuddin M et al. Systematic review and meta-analysis of global birth prevalence of clubfoot: a study protocol. BMJ Open. 2018;8(3):e019246 https://doi.org/10.1136/bmjopen-2017-019246

2. Wang H, Barisic I, Loane M, Addor MC, Bailey LM, Gatt M et al. Congenital clubfoot in Europe: A population-based study. Am J Med Genet A. 2019;179(4):595–601. https://doi.org/10.1002/ajmg.a.61067

3. Cady R, Hennessey TA, Schwend RM. Diagnosis and Treatment of Idiopathic Congenital Clubfoot. Pediatrics. 2022;149(2):e2021055555. https://doi.org/10.1542/peds.2021-055555

4. Panza R, Albano F, Casto A, Del Vecchio C, Laforgia N, Dibello D. Incidence and prevalence of congenital clubfoot in Apulia: a regional model for future prospective national studies. Ital J Pediatr. 2023; 49: 151 https://doi.org/1186/s13052-023-01559-9

5. Pavone V, Chisari E, Vescio A, Lucenti L, Sessa G, Testa G. The etiology of idiopathic congenital talipes equinovarus: a systematic review. J Orthop Surg Res. 2018; 13: 206 https://doi.org/10.1186/s1301

6. Rendy G, Dwi Winanto I, Ilham Abdullah Irsyam O. The effect of socioeconomic fac-tors on the first visit of a clubfoot to a health facility. IJRP. 2022; 101 https://doi.org/10.47119/IJRP1001011520223187

7. Fakeeha JH, Alessa AE, Alkhaldi MS, Alshathri MH, Althunayyan AN. Prevalence and epidemiological description of clubfoot at King Saud Medical City, Riyadh, Saudi Arabia. JMSR. 2021; 5: 246-249. https://doi.org/ 10.25259/JMSR_60_2021

8. Stoll C, Alembick Y, Dott B, Roth MP. Associated anomalies in cases with congenital clubfoot. Am J Med Genet A. 2020; 182: 2027-2036 https://doi.org/10.1002/ajmg.a.617218-018-0913-z

9. Divovich GV, Bronova AA, Romanyuk TI. Results of the treatment of congenital clubfoot and its relapses in children: outcomes of 8-year surgical practical work. Problems of Health and Ecology=Problemy Zdorov'ya i Ekologii. 2020;64(2):35-42. (In Russ.)

10. Alomran AK, Alzahrani BA, Alanazi BS, Alharbi MA, Bojubara LM, Alyaseen EM. Prevalence and associated factors ofclubfoot in the eastern province of Saudi Arabia: A hospital-based study. World J Orthop. 2024; 15(7): 635-641 https://doi.org/10.5312/wjo.v15.i7.635

11. Kruse LM, Dobbs MB, Gurnett CA. Polygenic threshold model with sex dimorphism in clubfoot inheritance: the Carter effect. J Bone Joint Surg Am. 2008; 90: 2688-2694 https://doi.org/10.2106/JBJS.G.01346

12. Faldini C, Traina F, Nanni M, Sanzarello I, Borghi R, Perna F. Congenital idiopathic talipes equinovarus before and after walking age: observations and strategy of treatment from a series of 88 cases. J Orthop Traumatol. 2016;17(1):81-7. https://doi.org/10.1007/s10195-015-0377-4

13. Corbu A, Cosma DI, Vasilescu DE, Cristea S. Posteromedial release versus Ponseti treatment of congenital idiopathic clubfoot: a long-term retrospective follow-up study into adolescence. Ther Clin Risk Manag. 2020;16:813–819. https://doi.org/10.2147/TCRM.S262199

14. Gelfer Y, Wientroub S, Hughes K, Fontalis A, Eastwood DM. Congenital talipes equinovarus: a systematic review of relapse as a primary outcome of the Ponseti method. Bone Joint J. 2019;101-B:639–645. https://doi.org/10.1302/0301-620X.101B6.BJJ-2018-1421.R12

15. Masrouha K, Chu A, Lehman W. Narrative review of the management of a relapsed clubfoot. Ann Transl Med. 2021;9(13):1102. https://doi.org/10.21037/atm-20-7730

16. Smythe T, Kuper H, Macleod D, Foster A, Lavy C. Birth prevalence of congenital talipes equinovarus in low-and middle-income countries: a systematic review and meta-analysis. Trop Med Int Health. 2017;22:269–85. https://doi.org/10.1111/tmi.12833

17. Chen C, Kaushal N, Scher DM, Doyle SM, Blanco JS, Dodwell ER. Clubfoot Etiology: A Meta-Analysis and Systematic Review of Observational and Randomized Trials. J Pediatr Orthop. 2018;38(8):e462-e469. https://doi.org/10.1097/BPO.0000000000001191

18. Yolaçan H, Güler S, Özmanevra R. Clubfoot from past to the present: A bibliometric analysis with global productivity and research trends. Medicine (Baltimore). 2023; 102: e32803 https://doi.org/10.1097/MD.0000000000032803

19. Naveed A, Fatima SA, Riaz S, Awan SS, Waqas MS, Aslam S. Prevalence of leg pain and knee contractures in children having clubfoot. Rawal Med J. 2021; 46: 587-588.

20. Maghfuri HB, Alshareef AA. The Efficacy of the Ponseti Method in the Management of Clubfoot: A Systematic Review. Cureus. 2024; 16: e52482. https://doi.org/10.7759/cureus.52482

21. Dobbs MB, Nunley R, Schoenecker PL. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am. 2006;88:986–96. https://doi.org/10.2106/JBJS.E.00114

22. Anaraki N, Shirbache K, Presedo A, Nezameslami A, Nabian MH. Clubfoot: A Comprehensive Review of Anatomy, Etiology, Treatment, Follow-up and Relapse. Inn J Pediatr.2025;35(3):e151804.https://doi.org/10.5812/ijpediatr-151804

23. Esbjörnsson AC, Johansson A, Andriesse H, Wallander H. Epidemiology of clubfoot in Sweden from 2016 to 2019: A national register study. PLoS One. 2021;16(12):e0260336. https://doi.org/10.1371/journal.pone.0260336

24. Parker SE, Mai CT, Strickland MJ, Olney RS, Rickard R, Marengo L et al. Multistate study of the epidemiology of clubfoot. Birth Defects Res A Clin Mol Teratol. 2009;85:897–904. https://doi.org/10.1002/bdra.20625

25. Wynne-Davies R. Family studies and the cause of congenital club foot. Bone & Joint Journal. 1964;46:445–63.

26. Mathias RG, Lule JK, Waiswa G, Naddumba EK, Pirani S. Incidence of clubfoot in Uganda. Can J Public Health. 2010;101:341–4 https://doi.org/10.1007/BF03405299

27. Revkovich A.S., Ryzhikov D.V., Anastasieva E.A., Gubina E.V., Semenov A.L., Andreev A.V. Relapses like clubfoot; review of the literature and analysis of our own observations. Modern Problems of Science and Education 2016;6:131.

28. Yi L, Zhou GX, Dai L, Li KS, Zhu J, Wang Y. An descriptive epidemiological study on congenital clubfoot in China during 2001 to 2010. Sichuan Da Xue Xue Bao Yi Xue Ban 2013; 44: 606-609.

29. Kiani SN, Yang D, Zheng JL, Spiegel DA. Clubfoot and the Ponseti Method: A Bibliometric Analysis. JB JS Open Access. 2023;8(3):e23.00005. https://doi.org/10.2106/JBJS.OA.23.00005

30. Diméglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop B. 1995;4(2):129-36. https://doi.org/10.1097/01202412-199504020-00002

31. Zhao D, Li H, Zhao L, Kuo KN, Yang X, Wu Z et al. Prognosticating Factors of Relapse in Clubfoot Management by Ponseti Method. J Pediatr Orthop. 2018;38(10):514-520. https://doi.org/10.1097/BPO.0000000000000870 32

32. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics. 2004;113(2):376-80. https://doi.org/10.1542/peds.113.2.376

33. Lui TH. Case report: correction of neglected club foot deformity by arthroscopic assisted triple arthrodesis. Arch Orthop Trauma Surg. 2010;130(8):1007-11. https://doi.org/10.1007/s00402-010-1078-3

34. Lee BY, Mazelan A, Gunalan R, Albaker MZ, Saw A: Ponseti method of treating clubfoot-Is there difference if treatment is started before or after one month of age? Med J Malaysia. 2020, 75:511.

35. Mishra PK, Muthaiyan P. To evaluate the success rate of idiopathic clubfoot management by Ponseti technique under 2 years age group, and to determine the cause of relapse. Int J Life Sci Biotechnol Pharma Res. 2023, 12:4-5.

36. Zionts LE, Frost N, Kim R, Ebramzadeh E, Sangiorgio SN. Treatment of idiopathic clubfoot: experience with the Mitchell-Ponseti brace. J Pediatr Orthop. 2012, 32:706-13. https://doi.org/10.1097/BPO.0b013e3182694f4d

37. De Mulder T, Prinsen S, Van Campenhout A. Treatment of non-idiopathic clubfeet with the Ponseti method: a systematic review. J Child Orthop. 2018, 12:575-81. https://doi.org/10.1302/1863-2548.12.180066 38

38. Haque MS, Rahman MM, Perveen K, Sharmin M. Relapse of clubfoot after treatment with the Ponseti ethod. IOSR J Dent Med Sci. 2018; 17:56-62. https://doi.org/10.9790/0853-1706105662

39. Zhao D, Liu J, Zhao L, Wu Z. Relapse of clubfoot after treatment with the Ponseti method and the function of the foot abduction orthosis. Clin Orthop Surg. 2014;6:245-52. https://doi.org/10.4055/cios.2014.6.3.2451

40. Bensahel H, Csukonyi Z, Desgrippes Y, Chaumien JP. Surgery in residual clubfoot: one-stage medioposterior release "à la carte". J Pediatr Orthop. 1987;7(2):145-8. https://doi.org/10.1097/01241398-198703000-00005

41. Al Sh., Kozhevnikov V. V., Ryabchikov I. V., Basova O. A. Problems and achievements of correction of relapses of congenital clubfoot in children. Modern problems of science and education. 2025; 2:77 (In Russ) https://doi.org/10.17513/spno.34002.

42. Lykissas MG, Crawford AH, Eismann EA, Tamai J. Ponseti method compared with soft-tissue release for the management of clubfoot: A meta-analysis study. World J Orthop. 2013;4(3):144-53. https://doi.org/10.5312/wjo.v4.i3.144

43. Bocahut N, Simon AL, Mazda K, Ilharreborde B, Souchet P. Medial to posterior release procedure after failure of functional treatment in clubfoot: a prospective study. J Child Orthop. 2016;10(2):109-17. https://doi.org/10.1007/s11832-016-0728-6

44. Thomas HM, Sangiorgio SN, Ebramzadeh E, Zionts LE. Relapse Rates in Patients with Clubfoot Treated Using the Ponseti Method Increase with Time: A Systematic Review. JBJS Rev. 2019;7 (5):e6. https://doi.org/10.2106/JBJS.RVW.18.00124

45. Bent M, Hauschild M, Rethlefsen SA, Wren TAL, Liang A, Goldstein RY, et al. Gait Analysis Characteristics in Relapsed Clubfoot. J Pediatr Orthop. 2023; 43 (2):65–69. https://doi.org/10.1097/BPO.0000000000002314

46. Ganesan B, Luximon A, Al-Jumaily A, Balasankar SK, Naik GR. Ponseti method in the management of clubfoot under 2 years of age: a systematic review. PLoS One. 2017, 12:e0178299. https://doi.org/10.1371/journal.pone.0178299

47. Hu W, Ke B, Niansu X, Li S, Li C, Lai X, et al. Factors associated with the relapse in Ponseti treated congenital clubfoot. BMC Musculoskelet Disord. 2022;23(1):88. https://doi.org/10.1186/s12891-022-05039-9

48. Alves C, Escalda C, Fernandes P, Tavares D, Neves MC. Ponseti method: does age at the beginning of treatment make a difference? Clin Orthop Relat Res. 2009;467(5):1271-7. https://doi.org/10.1007/s11999-008-0698-1

49. Bhaskar A, Patni P. Classification of relapse pattern in clubfoot treated with Ponseti technique. Indian J Orthop. 2013;47:370-6. https://doi.org/10.4103/0019-5413.1149214

50. Chand S, Mehtani A, Sud A, Prakash J, Sinha A, Agnihotri A. Relapse following use of Ponseti method in idiopathic clubfoot. J Child Orthop 2018;12:566-74. https://doi.org/10.1302/1863-2548.12.1801175

51. Ippolito E, Farsetti P, Caterini R, Tudisco C. Long-term comparative results in patients with congenital clubfoot treated with two different protocols. J Bone Joint Surg Am 2003;85:1286-94. https://doi.org/10.2106/00004623-200307000-00015

52. Clarke NM, Uglow MG, Valentine KM. Comparison of Ponseti versus surgical treatment in congenital talipes equinovarus. J Foot Ankle Surg. 2011;50:529-34. https://doi.org/10.1053/j.jfas.2011.04.04014

53. Halanski MA, Davison JE, Huang JC, Walker CG, Walsh SJ, Crawford HA. Ponseti method compared with surgical treatment of clubfoot. a prospective comparison. J Bone Joint Surg Am. 2010;92:270-8. https://doi.org/10.2106/JBJS.H.0156015

54. Zapata KA, Karol LA, Jeans KA, Jo CH. Gross Motor Function at 10 Years of Age in Children With Clubfoot Following the French Physical Therapy Method and the Ponseti Technique. J Pediatr Orthop. 2018;38:e519-e523. https://doi.org/10.1097/BPO.000000000000121816

55. Nogueira MP, Ey Batlle AM, Alves CG. Is it possible to treat recurrent clubfoot with the Ponseti technique after posteromedial release?: a preliminary study. Clin Orthop Relat Res. 2009;467:1298-305. https://doi.org/10.1007/s11999-009-0718-919

56. Chu A, Lehman WB. Treatment of Idiopathic Clubfoot in the Ponseti Era and Beyond. Foot Ankle Clin. 2015;20:555-62. https://doi.org/10.1016/j.fcl.2015.08.00220

57. Garg S, Dobbs MB. Use of the Ponseti method for recurrent clubfoot following posteromedial release. Indian J Orthop. 2008;42:68-72. https://doi.org/10.4103/0019-5413.3858421

58. Ebert N, Ballhause TM, Babin K, Schelling K, Stiel N, Stuecker R et al. Correction of Recurrent Equinus Deformity in Surgically Treated Clubfeet by Anterior Distal Tibial Hemiepiphysiodesis. J Pediatr Orthop. 2020;40:520-5. https://doi.org/10.1097/BPO.000000000000160922

59. Al-Aubaidi Z, Lundgaard B, Pedersen NW. Anterior distal tibial epiphysiodesis for the treatment of recurrent equinus deformity after surgical treatment of clubfeet. J Pediatr Orthop. 2011;31:716-20. https://doi.org/10.1097/BPO.0b013e31822109b623

60. Seitz DG, Carpenter EB. Triple arthrodesis in children: a ten-year review. South Med J. 1974;67(12):1420-4. https://doi.org/10.1097/00007611- 197412000-00009

61. Galindo MJ Jr, Siff SJ, Butler JE, Cain TE. Triple arthrodesis in young children: a salvage procedure after failed releases in severely affected feet. Foot Ankle. 1987;7:319-25 https://doi.org/10.1177/10711007870070060143

62. Spires TD, Gross RH, Low W, Barringer W. Management of the resistant myelodysplastic or arthrogrypotic clubfoot with the Verebelyi-Ogston procedure. J Pediatr Orthop. 1984;4(6):705-10. https://doi.org/10.1097/01241398-198411000-0001045

63. Faldini C, Traina F, Di Martino A, Nanni M, Acri F. Can selective soft tissue release and cuboid osteotomy correct neglected clubfoot? Clin Orthop Relat Res. 2013;471(8):2658-65. https://doi.org/10.1007/s11999-013-2977-8

64. Najdi H, Mouarbes D, Makhour F, Dimassi A, Jawish R. Forefoot adduction in children. Management and Treatment. J Med Liban. 2016;64(3):134-41. https://doi.org/10.12816/0031521

65. Lehman WB, Atar D, Bash J, Grant A, Feldman D, Kissin Y et al. Results of complete soft tissue clubfoot release combined with calcaneocuboid fusion in the 4-year to 8-year age group following failed clubfoot release. J Pediatr Orthop B. 1999;8:181-6. https://doi.org/10.1097/01202412-199907000-0000824

66. Chu A, Chaudhry S, Sala DA, Atar D, Lehman WB. Calcaneocuboid arthrodesis for recurrent clubfeet: what is the outcome at 17-year follow-up? J Child Orthop. 2014;8:43-8. https://doi.org/10.1007/s11832-014-0557-425

67. Lascombes P, Popkov DA, Leonchuk SS. Reconstructive surgery in recurrent deformity (clubfoot relapse). Genij Ortopedii. 2021;27(4):435-440. https://doi.org/10.18019/1028-4427-2021-27-4-435-440

68. El-Sayed M. Ilizarov external fixation for management of severe relapsed clubfeet in older children. Foot Ankle Surg. 2013;19:177-81. https://doi.org/10.1016/j.fas.2013.04.002

69. Silver L, Grant AD, Atar D, et al. Use of tissue expansion in clubfoot surgery. Foot Ankle. 1993;14:117-22. https://doi.org/10.1177/10711007930140030133

70. Lubicky JP, Altiok H. Regional fasciocutaneous flap closure for clubfoot surgery. J Pediatr Orthop. 2001;21:50-4. https://doi.org/ 10.1097/01241398-200101000-0001134

71. Hassan FO, Jabaiti S, El tamimi T. Complete subtalar release for older children who had recurrent clubfoot deformity. Foot Ankle Surg. 2010;16:38-44 https://doi.org/10.1016/j.fas.2009.05.00235

72. Mehrafshan M, Rampal V, Seringe R, Wicart P. Recurrent club-foot deformity following previous soft-tissue release: mid-term outcome after revision surgery. J Bone Joint Surg Br. 2009;91:949-54. https://doi.org/10.1302/0301-620X.91B7.2247436

73. Souchet P, Ilharreborde B, Fitoussi F, Morel E, Bensahel H, Penneçot GF et al. Calcaneal derotation osteotomy for clubfoot revision surgery. J Pediatr Orthop B. 2007;16:209-13. https://doi.org/10.1097/01.bpb.0000236227.99077.2837

74. Mubarak SJ, Dimeglio A. Navicular excision and cuboid closing wedge for severe cavovarus foot deformities: a salvage procedure. J Pediatr Orthop. 2011;31:551-6. https://doi.org/10.1097/BPO.0b013e31821f849a27

75. Lourenco AF, Dias LS, Zoellick DM, Sodre H. Treatment of residual adduction deformity in clubfoot: the double osteotomy. J Pediatr Orthop. 2001;21:713-8. https://doi.org/10.1097/01241398-200111000-0000328

76. Eidelman M, Keren Y, Katzman A. Correction of residual clubfoot deformities in older children using the Taylor spatial butt frame and midfoot Gigli saw osteotomy. J. Pediatr Orthop. 2012;32:527-33. https://doi.org/10.1097/BPO.0b013e318259ff2d29

77. Rathjen KE, Mubarak SJ. Calcaneal-cuboid-cuneiform osteotomy for the correction of valgus foot deformities in children. J Pediatr Orthop. 1998;18:775-82. https://doi.org/10.1097/01241398-199811000-0001530

78. Wicart P, Seringe R. Plantar opening-wedge osteotomy of cuneiform bones combined with selective plantar release and dwyer osteotomy for pes cavovarus in children. J Pediatr Orthop. 2006;26:100-8. https://doi.org/10.1097/01.bpo.0000189005.78045.1732

79. Du H, He XT, Yin XH, Gu JM, Zhou YX, Yang J et al. The Gradual Correction of Adult Severe Rigid Equinus Deformity Using Minimal Invasive UOsteotomy With Taylor Spatial Frame. Foot Ankle Int. 2023;44(1):62-70. https://doi.org/10.1177/10711007221138240

80. Grill F, Franke J. The Ilizarov distractor for the correction of relapsed or neglected clubfoot. J Bone Joint Surg Br. 1987;69:593-7 https://doi.org/10.1302/0301-620X.69B4.361116338

81. Gupta P, Bither N. Ilizarov in relapsed clubfoot: a necessary evil? J Pediatr Orthop B. 2013;22:589-94. https://doi.org/10.1097/BPB.0b013e32836486de39

82. Khanfour AA. Ilizarov techniques with limited adjunctive surgical procedures for the treatment of preadolescent recurrent or neglected clubfeet. J Pediatr Orthop B. 2013;22:240-8. https://doi.org/10.1097/BPB.0b013e32835f1f9942

83. Bashir J, Sherman A, Lee H, Kaplan L, Hare JM. Mesenchymal stem cell therapies in the treatment of musculoskeletal diseases. PM R. 2014;6(1):61-9. https://doi.org/10.1016/j.pmrj.2013.05.007