In the current study, with a five-year follow-up of patients with clubfoot who were treated with Ponseti method, Pirani scores decreased, Dimeglio decreased, scores CAP scores decreased, ankle dorsiflexion improved, several radiological indicators improved, patients' foot condition was acceptable determined by the pedobarographic device, and patients' quality of life was favorable. The only adverse outcomes were lateral talocalcaneal angle and kite angle. This study showed that the results of the Ponseti treatment remained acceptable after five years. The results of this study are weaker than the short-term studies that have reported remarkable outcomes, and this difference may indicate a recurrence - albeit without functional problems - in patients [11, 13].
In this study, the mean Pirani score of patients remained significantly reduced and acceptable after five years of follow-up. In Azimi and Narouie's study of 32 clubfeet, the mean Pirani score dropped from 5.53 to 0.09 after 4 to 14 months of treatment, which was to be expected, given the scoring shortly after treatment . Kumar et al. have also reported a decrease in mean Pirani score from 5.3 to 0.8 following six to twenty months of Ponseti management .
Also, the patients' Demeglio score decreased significantly and remained acceptable after five years in this study, which indicates continuation of good function in the long run. Hallaj-Moghaddam et al. by designing a prospective study in patients with severe clubfoot reported a significant reduction in the mean Demeglio score from 16 to 1.6 . In another prospective study on 110 idiopathic clubfeet, Bouchoucha et al. reported a reduction in a mean of this score from 12.9 to 1.3 .
Improvement of ankle dorsiflexion following treatment and remaining this outcome for five years was one of the findings of this study. Spiegel et al. and Sanghvi and Mittal reported an average dorsiflexion angle of 12.5 and a maximum dorsiflexion angle of 12, respectively [25, 26].
In this study, children's quality of life was assessed five years after the start of treatment. The mean score of the standard questionnaire of PedsQL indicates the high quality of life in children - especially in female ones - following clubfoot treatment with the Ponseti method. A study by Smith et al. found that children who underwent surgery to treat clubfoot reported more pain than children who underwent Ponseti treatment; however, both groups were functional and had a high quality of life . Causes of decreased quality of life in these patients include prolonged use of braces and consequent inability to play and anxiety and discomfort caused by thinking of others about how they walk [5, 28].
Recurrence was observed in 12% of feet in this study. Porecha et al. observed recurrence of clubfoot in 19 feet (28.35%) of 14 patients subsequent to initial Ponseti treatment of 67 clubfeet of 49 patients . Hallaj-Moghaddam et al. also reported a recurrence rate of 27.1% after three years . The recurrence rate following Ponseti treatment varies considerably from study to study, with Gupta et al. reporting recurrence in 9 feet out of 154 clubfeet and Sud et al. reporting recurrence in 7 feet out of 33 clubfeet [30, 31]. Gelfer et al. by conducting a systematic review of 10535 clubfeet found that the relapse rate reported in various studies was between 1.9% and 45%, which increased over follow-up time . A study by Qudsi et al., which examined clinical outcomes and risk factors for the Ponseti method in 168 children with clubfoot, found that female gender and a higher Pirani score increased the risk of recurrence .
Although this study has significant advantages such as long-term follow-up, evaluation by various assessments, and prospective design, it also has disadvantages that should be noted. First, the number of patients in this study is small. Second, the assessments performed at follow-up visits did not include evaluations through the assessments mentioned in the materials and methods section, so they were not reported. Third, the ICSG assessment was not performed at the first visit.