Journal of Pediatric Orthopaedics - 2026-06-22 - Journal Article
Factors Associated With Flat-Top Talus in Radiographically Evaluated Ponseti-Treated Clubfeet.
Galán-Olleros M, Samara E, Ahmed AM, Delayun C, Adebayo T, Younoszai M, Tremonti C, Tretiakov M, Bouchard M
Topics
Key Takeaway
Flat-top talus occurred in 68% of Ponseti-treated clubfeet undergoing radiographic evaluation, with prior surgery carrying a 4.29-fold increased odds of its presence.
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Summary
This dual-center retrospective cohort study identified clinical and treatment-related factors associated with flat-top talus (FTT) in Ponseti-treated idiopathic and non-idiopathic clubfeet using blinded qualitative talar morphology classification on lateral radiographs. FTT was present in 104/152 feet (68%); higher Pirani score at diagnosis (OR 1.58), ≥13 corrective casts (OR 2.72), each additional cast (OR 1.13 per cast), and prior surgery (OR 4.29) were all independently associated with FTT. Relapse rates did not differ between FTT and non-FTT feet, suggesting FTT reflects intrinsic deformity severity and treatment burden rather than driving recurrence.
Key Limitation
Radiographs were obtained at variable, non-standardized timepoints across an 18-year span, making it impossible to determine whether FTT is a static deformity present early or a progressive change related to ongoing growth and loading.
Original Abstract
INTRODUCTION
Flat-top talus (FTT) is a recognized sequela of clubfoot associated with stiffness and early ankle degeneration. However, its frequency after Ponseti treatment and associated clinical and treatment-related factors remain poorly defined. This study aimed to identify clinical and treatment-related factors associated with FTT in Ponseti-treated clubfeet.
METHODS
We performed a retrospective dual-center cohort study (2005 to 2023) of children with idiopathic and non-idiopathic clubfoot treated using the Ponseti method who had at least one adequate lateral radiograph for evaluation. Talar morphology was classified qualitatively (flat vs. round) by independent blinded raters. Clinical variables and treatment exposures were analyzed at the foot level, and univariate logistic regression identified factors associated with FTT.
RESULTS
Ninety-eight patients (152 feet) met inclusion criteria. FTT was identified in 104 of 152 radiographically evaluated feet (68%). Higher Pirani score at diagnosis was associated with increased odds of FTT (OR: 1.58, 95% CI: 1.09-2.48; P=0.027). Feet with FTT demonstrated more limited pre-tenotomy dorsiflexion (P=0.034 in idiopathic feet). Greater cumulative casting exposure was associated with FTT, including ≥13 corrective casts before imaging (OR: 2.72, 95% CI: 1.06-7.15; P=0.038). In site-specific analysis, each additional cast increased the odds of FTT by 13% (OR: 1.13, 95% CI: 1.03-1.27; P=0.020), and surgery before imaging was associated with increased odds of FTT (OR: 4.29, 95% CI: 1.40-14.50; P=0.013). Relapse rates after radiographic detection did not differ significantly between groups.
CONCLUSIONS
FTT in Ponseti-treated clubfeet undergoing radiographic evaluation is associated with greater baseline deformity severity, cumulative casting exposure, and prior surgery. FTT seems to represent a marker of intrinsic rigidity and treatment burden rather than an independent driver of recurrence. Recognition of these associated factors may assist clinicians in monitoring talar morphology and counseling families regarding possible long-term limitations in ankle dorsiflexion.
LEVEL OF EVIDENCE
Level III-Retrospective cohort study.