Beyond Initial Correction: Recurrence Patterns After Ponseti Treatment in 257 Children

Background: Recurrence remains a major challenge after Ponseti treatment for idiopathic clubfoot, and the long-term outcomes of treatment for recurrent deformity are incompletely characterized. This study evaluated recurrence, associated factors, and management outcomes, including the association between tibialis anterior tendon transfer (TATT) and repeat recurrence. Methods: We retrospectively reviewed 257 children treated with the Ponseti method for idiopathic clubfoot from 2007 to 2025, collecting demographic, perinatal, treatment, brace-adherence (full-time and part-time phases), and neighborhood socioeconomic data. Recurrence was defined as the reappearance of any component of the deformity after initial correction that prompted a change in management. Odds ratios (ORs) were estimated by univariable and multivariable logistic regression, and recurrence-free survival by the Kaplan-Meier analysis. Results: At least 1 recurrence occurred in 150 children (58.4%). Children with recurrence more frequently had prenatal or birth complications (OR=2.32; 95% CI: 1.34-4.01), less frequently underwent initial Achilles tenotomy (OR=0.50; 95% CI: 0.28-0.90), and had lower Child Opportunity Index percentiles ( P =0.032). Partial or absent adherence during full-time bracing was the strongest factor (adjusted OR=5.23; 95% CI: 2.53-10.84 for partial adherence), and among 171 children who reached part-time bracing, recurrence after the transition occurred in 70.3% with incomplete part-time adherence versus 29.0% with full adherence (OR=5.81; 95% CI: 2.94-11.46). Casting alone corrected 78% of first recurrences but was followed by further recurrence in 65%, compared with 25% after surgery alone. Younger age at first recurrence predicted repeat recurrence (OR=0.68 per year), and repeat recurrence was less frequent after surgery, including TATT (11.1% vs. 50.5%, P <0.0001). Conclusions: Recurrence after Ponseti treatment was common and was most strongly associated with incomplete brace adherence during both the full-time and part-time phases. Repeat casting frequently restored correction but was often followed by further recurrence, particularly after recurrence before 12 months of age, whereas TATT was associated with more durable correction. Adherence support should extend through the entire bracing period, with timely treatment of persistent muscle imbalance. Level of Evidence: Level III.