Correlation between clinical outcome of surgically treated clubfeet and different radiological parameters

The goal of this study was to determine the relationship between the clinical outcome of surgically treated clubfeet and several radiological parameters. The talocalcaneal angle, talocalcaneal index, talo-first metatarsal angle and the calcaneo-first metatarsal angle were measured on anteroposterior and lateral radiographs of 54 children with 70 idiopathic clubfeet treated surgically between 2000 and 2004. Their age at surgery ranged from 4 to 23 months. These radiological parameters were compared with the clinical results. Follow-up was conducted after 24 to 69 months following surgery. Using the functional rating system of Laaveg and Ponseti, results were graded as excellent in 28.6% (20 feet), good in 40% (28 feet), fair in 17.1% (12 feet) and poor in 14.3% (10 feet). There was a statistically significant correlation between the clinical results and two angles: the talo-first metatarsal angle on the anteroposterior radiograph and the calcaneao-first metatarsal angle on the lateral radiograph. These two angles should be considered when designing an evaluation system of clubfeet.     

Predicting the need for tenotomy in the Ponseti method for correction of clubfeet

The purpose of this study was to determine how to predict the need for tenotomy at the initiation of the Ponseti treatment. Fifty clubfeet (35 patients) were prospectively rated according to Pirani and Dimeglio scoring systems. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required significantly more casts (P = 0.005). Of 27 feet with initial Pirani scores > or = 5.0, 85.2% required a tenotomy and 14.8% did not; 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and did not have a tenotomy. Children with clubfeet who have an initial score of > or = 5.0 by the Pirani system or are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy.     

Volume of tarsal bones in congenital clubfoot

To elucidate the growth of the tarsal bones in congenital clubfoot, relative to the growth of these bones in the unaffected feet and compared to growth in the feet of normal volunteers, we used a computed tomography (CT) scanner to measure the volume of all tarsal bones. The subjects of the study were 10 adults (7 men and 3 women) with unilateral congenital clubfoot (average age 20 years and 1 month). As controls, we examined 11 healthy volunteers. We calculated the ratio of the volume of each tarsal bone to the total bone volume and the ratio of the volume of each tarsal bone in clubfoot to the corresponding bone in the unaffected foot. The volume ratio of each tarsal bone was compared between clubfeet and unaffected feet because the differences of each tarsal bone ratio between the normal foot group and unaffected foot group were not significant. In the clubfeet (n=10), the talus and the medial cuneiform bones were smaller than those in the unaffected feet (n=10) but the cuboid bone was larger. The growth of the navicular did not differ from as that in unaffected feet. Our results suggested hypoplasia on the medial side of the foot in adult patients with congenital clubfoot. The 3 patients who had undergone medial release showed particularly marked hypoplasia of the medial side. In congenital clubfoot cases with severe deformities who had undergone wide soft-tissue release operations, there were clear growth suppressions in the talus and the medial cuneiform. We could not determine whether the cause of the growth suppression was the hypoplastic nature of tarsal bones themselves or the surgical obstacles to tarsal bone growth.     

Magnetic resonance imaging of severe idiopathic club foot treated with one-week accelerated Ponseti (OWAP) technique

PurposeThis study aims to evaluate changes in tarsal bones relationship after the use of one week accelerated Ponseti method in the treatment of severe idiopathic clubfoot using MRI. We hypothesize that one-week accelerated Ponseti is at least as effective as standard techniques in achieving the desirable MRI parameters.MethodsThis is a prospective study of 8 children with severe idiopathic clubfeet (Pirani 6) (4 unilateral and 4 bilateral) treated before the age of three months with one-week accelerated Ponseti technique, as described in a former study with minimum 2-year follow-up. The 8 corrected feet were compared with the 4 unilateral normal feet at clinical and radiological levels using a Pirani scoring system and an MRI, respectively.ResultsClinical results showed that Pirani score was 1.1 in the last follow up in comparison to Pirani 6 pretreatment (p < 0.05). MRI results indicated that the malleocalcaneal angle, axial malleocalcaneal index, coronal tibiocalcaneal angle, sagittal talocalcaneal angle, and talar head neck calcaneal rotation showed statistical difference between the two groups (p < 0.05). Sagittal malleocalcaneal index, sagittal tibiocalcaneal angle, talar head neck rotation related to talar body, and posterior calcaneal rotation showed no statistical difference between normal feet and clubfeet after correction (p value >0.05).ConclusionOne-week accelerated Ponseti technique showed to be as effective and safe as other treatment methods through clinical and MRI follow up data. MRI role was to confirm the efficiency of this innovative accelerated technique, but not used as a routine follow up.     

Dynamic foot-pressure measurement in the assessment of operatively treated clubfeet

BACKGROUND: Decreased motion of the subtalar joint is common after operative treatment of idiopathic clubfeet. The purposes of this study were to validate parameters of dynamic foot-pressure measurement that enable detection of physiological pronation of the subtalar joint and to analyze the consequences of absent or decreased pronation following clubfoot surgery on long-term functional results. METHODS: To validate parameters of dynamic foot-pressure measurement, we initially analyzed two control groups: one of forty asymptomatic normal feet and the other of five feet with a previous subtalar joint arthrodesis. The resulting parameters were then applied to a group of nineteen patients with twenty-four idiopathic clubfeet for whom initial conservative treatment had failed and in whom a posterior surgical release (lengthening of the Achilles tendon and release of the posterior ankle capsule) had been performed at a mean age of twenty months. The mean duration of follow-up was forty-one years. All feet were evaluated radiographically, and the clinical results were assessed with the American Orthopaedic Foot and Ankle Society score. RESULTS: An interruption in the rise of the pressure-time curve and a short medial deviation of the center of pressure path immediately after heel strike are reliable and objective characteristics of pronation movement of the subtalar joint. Nineteen clubfeet had a demonstrable pronation movement, and five clubfeet did not. The nineteen feet with pronation movement were either asymptomatic (twelve feet) or mildly painful on occasion (seven feet). The mean American Orthopaedic Foot and Ankle Society score for the nineteen feet was 87 points. The five feet without pronation movement were moderately painful during strenuous activities only (four feet) or were nearly always painful (one foot). The mean score for those feet was 57 points. There was a significant difference between these two groups with regard to the pain scores and the total scores (p < 0.001), but there was no appreciable difference regarding function and hindfoot motion. It was not possible to distinguish between these two groups on the basis of the findings of the physical or radiographic examinations. CONCLUSIONS: Idiopathic clubfeet with preserved hindfoot pronation have a better long-term prognosis. Preservation of functional mobility of the subtalar joint is a key factor in the treatment of clubfoot deformity.     

Development and validation of a delayed presenting clubfoot score to predict the response to Ponseti casting for children aged 2–10

The aim of the study was to develop a simple and reliable clinical scoring system for delayed presenting clubfeet and assess how this score predicts the response to Ponseti casting. We measured all elements of the Diméglio and the Pirani scoring systems. To determine which aspects were useful in assessing children with delayed presenting clubfeet, 4 assessors examined 42 feet (28 patients) between the ages of 2–10 years. Selected variables demonstrating good agreement were combined to make a novel score and were assessed prospectively on a separate consecutive cohort of children with clubfeet aged 2–10, comprising 100 clubfeet (64 patients). Inter-observer and intra-observer agreement was found to be greatest using the following clinically measured angles of the deformities. These were plantaris, adductus, varus, equinus of the ankle and rotation around the talar head in the frontal plane (PAVER). Measured angles of 1–20, 21–45 and?>?45 degrees scored 1, 2 and 3 points, respectively. The PAVER score was derived from both the sum of points derived from measured angles and a multiplier according to age. The sum of the points was multiplied with 1, 1.5 or 2 for ages 2–4, 5–7 and 8–10, respectively. This demonstrated a good association with the total number of casts to achieve a full correction (tau?=?0.71). A score greater than 18 out of 30 indicated a cast-resistant clubfoot. The score could be used clinically for prognosis and treatment, and for research purposes to compare the severity of clubfoot deformities.     

先天性马蹄内翻足Ponseti治疗初跟腱手术的预测

目的探讨先天性马蹄内翻足（CCF）患儿治疗前预测患儿行跟腱手术的可行性。方法96例CCF（148足）患儿,均依据Ponseti方法治疗,平均（5.7±1.3）次石膏矫正后,背屈活动≤15°或Pirani评分HS（后足评分）≥1,MS（中足评分）〈1的患足需行跟腱切断手术。石膏去除后需佩戴外展支具。结果经过系列石膏矫正后,148足中125足（84.5%）行跟腱切断术,23足（15.5%）未行跟腱手术。在治疗初有102足（68.9%）Pirani评分≥5分,其中93足（91.2%）经系列石膏矫正后行跟腱手术。手术组跟腱愈合佳,跖屈有力。结论在治疗初Pirani评分≥5分时91.2%患儿需要跟腱手术,CCF患儿初次来诊时,对患足行Pirani评分,即可预测其是否需行跟腱手术。在治疗初预先判断患儿是否需行跟腱手术则既有利于医师了解治疗进展,又能更好地与家长沟通配合治疗进程。     

Initial severity rating of idiopathic clubfeet is an outcome predictor at age two years

This study was performed to determine if rating the severity of clubfeet before Ponseti treatment was predictive of the outcomes at age two years. Four hundred and seventy-nine idiopathic clubfeet (323 patients) were numerically rated for severity using Dimeglio classification. Eighty-six feet rated moderate, 305 feet rated severe, and 88 feet rated very severe. Outcomes were classified as Good (plantigrade foot with or without a tendoachilles lengthening), Fair (limited surgery), or Poor (posteromedial release). Significant correlation existed between initial severity of the foot and outcomes, with moderate better than severe and very severe, and severe better than very severe. Initial numerical severity rating strongly correlated with the probability of a good outcome (P<0.0001). Evaluating the severity of clubfeet before Ponseti treatment provides prognostic information for parents.     

A new scoring system for the evaluation of clubfoot: The IMAR-Clubfoot scale

BackgroundRecently much interest has been shown regarding the biomechanical techniques for the assessment of clubfoot but as yet their specific role in such an endeavour is unclear. Several scoring systems have been designed but none have been adopted as a standard. The ideal system should be simple, modular, reliable, repeatable and be able to assess functional deformity objectively.ObjectiveThis study was aimed to develop a comprehensive scoring system and to demonstrate the potential of such an assessment tool in evaluating clubfoot.MethodsA new innovative scoring system, the IMAR-Clubfoot scale, was designed, which incorporated clinical and biomechanical data. Clinical assessment was performed using a questionnaire and standard clinical criteria while the biomechanical evaluation was undertaken using the Podotrack^®, the optical dynamic pedobarograph and the GAITRite^® systems. Thirteen children (16 clubfeet) were recruited for assessment using the IMAR-Clubfoot scale.ResultsThe model can detect abnormalities related to talipes equinovarus and quantify them objectively. The results also emphasise the need for such a comprehensive system, which combines clinical and biomechanical data as there was no statistical correlation between these data.ConclusionThe scoring system would be helpful in assessing the deformity, deciding upon appropriate management and objectively defining the success/failure of treatment at patient follow-up.     

Modified Ponseti method of management of neonatal club feet

The aim of this study was to assess the outcome of a new protocol for the management of neonatal clubfeet that can be considered as a modification of the Ponseti method. The modifications consisted of performing the tenotomy of the Achilles tendon prior to the application of the first cast and using only one cast for a period of 3 weeks following tenotomy. We applied the modified method in 50 children (82 club feet) and assessed the degree of deformity using the Pirani and the Dimeglio scoring systems. The minimum follow-up period was 28 months (range: 24-32). The intermediate range follow-up results of this study showed that the modified Ponseti method was associated with a good outcome in 85% of cases of neonatal club feet with a Pirani score of 5 or less and a Dimeglio score of 15 or less. Persistently high Pirani or Dimeglio scores immediately after tenotomy and poor compliance with splintage were predictors of failure of the modified technique.     

Talectomy for the clubfeet treatment in children with myelomeningocoele]

Talectomy, despite its palliative character, seems to be a treatment of choice in many cases of severe neurogenic clubfeet. The aim of our study was to determine the value of talectomy in the treatment of equinovarus deformity in children with myelomeningocoele. MATERIAL AND METHOD: The material consists of 12 children with myelomeningocele (21 neurogenic clubfeet), treated by talectomy. The results of two post-operative follow-up examinations were included--first after 15 months (follow-up I, second after 30 months (follow-up II). The material was divided into two groups: I--consist of feet after talectomy combined with wedge resection of calcaneo-cuboid joint, and II--the feet which underwent "only" talectomy. The calcaneo-cuboid wedge osteotomy was performed to improve the forefoot position for the correction of the more severe deformity. The clinical and X-ray records concerning preoperative period were reviewed. At the follow-up the clinical, radiological and functional evaluation were performed with the special affiliation on modified Magone scale. RESULTS: Satisfactory clinical results were achieved in all feet except one which required reoperation. Walking ability in orthopaedic fit was present in 5 cases before surgery, and increased to 9 at follow-up. There were no radiological signs of the tibio-calcaneal fusion at the time of observation. During follow-up, on the basis of radiograms made in lateral position, gradual limitation of ROM in so called "tibio-calcaneal" joint was observed. At follow-up I according to modified Magone scale good clinical result was observed in 3 feet, satisfactory in 10, and unsatisfactory in the remaining 3 feet. At follow-up II 3 were defined as good, 4 were defined as satisfactory and the remaining 8 as pour results (only patients who underwent two postoperative examinations). The clinical deterioration does not correlate with the lost of feet shape correction--but mainly with the lost of the ROM in the new "tibio-calcaneal" joint. There were no statistically significant differences between the clinical outcome of feet from group I and II. The authors concluded that the additional wedge resection of calcaneo-cuboid joint improved the forefoot position and, by this way, makes the surgery correction easier.     

Patient-based outcomes after Ilizarov surgery in resistant clubfeet

We present the results of clinical evaluation and patient-based outcomes after Ilizarov surgery in resistant clubfeet (grade D clubfeet, Dimeglio-Bensahel system). This is a retrospective study of 26 resistant clubfeet in 23 children who were managed by the Ilizarov technique. The average age of the patients at the time of the operation was 9 years and the average follow-up period was 47 months. A calcaneal or mid-foot osteotomy followed by bony distraction was undertaken in nine feet and a soft-tissue distraction, with or without soft-tissue release, was undertaken in 17 feet. Clinical evaluation of the degree of correction of the deformity and functional evaluation, using patient-based questionnaires, were used in assessing the outcome in these patients. Patient-based outcomes give useful information about the functional status following surgery, complementing the objective assessment by the surgeon. Clinical evaluation revealed stiff, plantigrade feet in nine patients and a recurrent deformity after initial correction in the remaining 14 patients. The patient-based outcomes were good to excellent in 52% for satisfaction, 57% for cosmesis, 48% for walking and 73% for teasing (made fun of because of the shape of foot), showing that the functional results were better in these patients in spite of a poor surgical outcome.     

Comparative study of left colonic Peritonitis Severity Score and Mannheim Peritonitis Index

BACKGROUND: Prognostic evaluation of patients with left colonic perforation is useful in predicting mortality. The aims of this prospective study were to determine the prognostic value of the left colonic Peritonitis Severity Score (PSS) and to compare it with the Mannheim Peritonitis Index (MPI). METHODS: One-hundred and fifty-six patients underwent emergency operation for distal colonic peritonitis. The PSS and MPI were calculated for each patient. The Spearman rank correlation coefficient was used to measure the association between the two scores. The predictive power of the two scoring systems and their differences were studied using the area under the receiver-operator characteristic (ROC) curve. RESULTS: Forty-one patients died (26.3 per cent). The relationship between scores and mortality was statistically significant for each scoring system (P < 0.001). The Spearman rank correlation coefficient for the correlation between the MPI and PSS was 0.55 (P < 0.001). There was no difference between areas under the ROC curves for the two systems. CONCLUSION: The PSS and MPI are both well validated scoring systems for left colonic peritonitis. Their routine use might allow stratification of patients according to mortality risk.     

Management of idiopathic clubfoot in toddlers by Ponseti's method

The Ponseti method has been reported to have successful results in clubfoot patients less than 6 months of age but the literature on its efficacy in older clubfoot patients still remains sparse. In our study, we prospectively evaluated 55 clubfeet (37 patients) to determine clinically whether the Ponseti method is effective in the management of clubfoot in older children between the age of 12 and 36 months (mean: 24.8 months). All the patients belonged to moderate or severe grades of deformity as per the Pirani scoring. Painless, supple, plantigrade and cosmetically acceptable feet were achieved in 49 clubfeet. Seven patients (seven feet) developed recurrence of adduction, varus and equinus deformity whereas three patients (five feet) developed isolated recurrence of equinus deformity. These seven patients responded to repeat treatment and obtained satisfactory outcome. Four of these seven patients underwent tibialis anterior transfer to third cuneiform for dynamic supination. Three patients, those developed isolated recurrence of equinus deformity, underwent repeat tenotomy. One foot achieved satisfactory amount of dorsiflexion, three feet underwent tendoachilles lengthening whereas another foot underwent posterior release to obtain satisfactory dorsiflexion. Six to 12 numbers of casts (mean: 10) were required to obtain correction of clubfoot deformities. Mean period of immobilization in a cast was 13.9 weeks (10-15 weeks). We found that the Ponseti method is effective in children between the age of 12 and 36 months.     

Clinico-Radiological and Functional Outcome of Difficult Talipes Equinovarus Deformity Corrected With an Ilizarov Fixator

Relapsed, resistant, and untreated congenital talipes equinovarus poses significant challenges in view of functional outcome following conventional serial casting and soft tissue release procedures. The Ilizarov ring fixator here offers significant possibilities as an extended conservative treatment modality. The aim of the present study was to critically evaluate effectiveness of the Ilizarov ring fixator with regard to radiological, clinical, and functional outcomes, in the difficult clubfeet. The study was carried out on patients presenting with relapsed, resistant, or untreated congenital talipes equinovarus deformity, who underwent deformity correction using the Ilizarov ring fixator application. All patients were reviewed at 6 monthly intervals for over 3 years following fixator removal with an objective clinical, radiological, and functional assessment. Twenty-three patients with 30 clubfeet were enrolled in our study. The mean age was 8.3 ± 3.6 (range 4-17) years. The postoperative clinical, radiological, and functional scores showed statistically significant improvement among all patients when compared with the preoperative data. All 30 feet developed varying complications during treatment with pin track infections being the most common. However, they were managed while continuing the distraction correction process. The Ilizarov ring fixator is an effective and reliable solution for difficult and challenging clubfeet. However, one must be aware of a strict adherence to a bracing protocol to avoid recurrence of deformities. A regular periodical functional and clinical follow up must be ensured among these children for a favorable outcome.     

Preoperative equinus angle and prognosis in congenital talipes equinovarus: a preliminary report

This study examines the hypothesis that the preoperative, clinically determined, equinus angle of congenital talipes equinovarus correlates with the surgical outcome. Data were obtained on 30 feet from 20 patients. All the patients had failed to respond to conservative measures of serial strapping and/or casting, and underwent radical primary subtalar release. Postoperatively, the Magone, Turco and McKay score systems were used for evaluation with 2 years minimum follow-up (range, 24-60 months; average, 42 months). There was a negative mathematical correlation between the equinus angle and the three system scores (Magone, Turco and McKay). In the three systems, the Pearson correlation with the equinus angle was negative and statistically highly significant: Magone, r = -0.629, P < 0.001; Turco, r = -0.651, P < 0.001; McKay, r = -0.717, P < 0.001. The correlation coefficients between the scoring systems were highly significant demonstrating a very close relationship between the systems. Excellent category outcomes were associated with smaller equinus angles.     

The history of treatment of congenital clubfoot at the Royal Liverpool Children's Hospital: improvement of results by early extensive posteromedial release

The results of treatment in 77 clubfeet were assessed after an average follow-up of 8 years. In those patients with surgical treatment it was found that the Turco posteromedial release within the first 3 months of life resulted in 13 of 16 satisfactory feet. In comparison, only five of 21 feet had satisfactory results when the average age of operation was delayed to 3.7 years and a less extensive release performed. At follow-up, abnormal radiological findings were not found in the early operated cases. The average talocalcaneal index was 47 degrees. The late operated feet showed major abnormal X-ray film findings, and their average index was 38 degrees. Good functional results, however, often coexisted with abnormal radiological findings in the midfoot. Abnormal findings of the hindfoot were always associated with unsatisfactory results. We conclude that the use of early (3 months) Turco posteromedial release can offer excellent results in treating severe resistant clubfeet.     

Functional and Radiological Outcomes After Tarsal Coalition Resections: A Minimum 5-Year Follow-Up

Few studies have evaluated the long-term functional and radiological outcomes of tarsal coalition resections. This study aimed to report and compare the functional and radiological outcomes after talocalcaneal (TC) and calcaneonavicular (CN) coalition resections. Thirty-three patients between 12 and 35 years old with symptomatic tarsal coalitions participated, each undergoing tarsal coalition resections (24 TC and 9 CN). The range of motion, visual analog scale score, American Orthopedic Foot and Ankle Society hindfoot scale, Maryland foot score, tripod index, and modified Kellgren-Lawrence scale for subtalar osteoarthritis were used to evaluate the functional and radiological outcomes. The mean age at the time of surgery and mean follow-up in the TC group were 17.8 ± 5.6 years (range 13 to 35) and 6.2 ± 1.7 years (range 5 to 12), respectively, and 16.0 ± 4.4 years (range 12 to 23) and 7.7 ± 3.0 years (range, 5 to 12) in the CN group. There was no difference in the range of motion, outcome scores, tripod index score, and modified Kellgren-Lawrence scale score between patients in the 2 groups. A positive correlation was noted between the size of the TC coalition, coalition/joint surface ratio, and hindfoot valgus angle regarding outcome scores. However, there was no association between the modified Kellgren-Lawrence scale score and outcome scores. At the minimum 5-year follow-up, the functional and radiological outcomes were similar between TC and CN resections. Subtalar joint osteoarthritis developed in all patients with TC resections and most patients with CN resections, but patients did not have functional impairment.     

Use of the foot abduction orthosis following Ponseti casts: is it essential?

The purpose of this study was to evaluate the need for the use of a foot abduction orthosis (FAO) in the treatment of idiopathic clubfeet using the Ponseti technique. Forty-four idiopathic clubfeet were treated with casting using the Ponseti method followed by FAO application. Compliance was defined as full-time FAO use for 3 months and part-time use subsequently. Noncompliance was failure to fulfill the criteria during the first 9 months after casting. Feet were rated according to the Dimeglio and Pirani scoring systems at initial presentation, at the time of FAO application, and at 6 to 9 months of follow-up. At the time of application, no significant differences in scores were found between the groups. At follow-up, the compliant group's scores were significantly (P < 0.01) better than those of the noncompliant group. From the time of application to follow-up, for the compliant group, the Dimeglio scores improved significantly (P = 0.005). For the noncompliant group, the Dimeglio scores deteriorated significantly (P = 0.001). The feet of patients compliant with FAO use remained better corrected than the feet of those patients who were not compliant. Proper use of FAO is essential for successful application of the Ponseti technique.     

Treatment of clubfoot with the Ponseti method: a comparison of casting materials

BACKGROUND: Popular initial treatment for congenital clubfoot includes the use of serial manipulations and casting as described by Ponseti et al. Plaster of Paris and semirigid fiberglass are 2 materials commonly used for casting. To our knowledge, no study to date has compared the clinical results of these 2 materials. The objective of this randomized prospective study was to compare the effectiveness of these materials in the initial management of clubfoot. METHODS: All clubfeet presenting to the 2 senior authors' outpatient clinics over a 15-month period were offered enrollment. Patients were randomly assigned for treatment with either plaster or semirigid fiberglass casts. The severity of the clubfoot deformity was documented using the scoring system devised by Diméglio et al. Serial casts were applied according to the technique described by Ponseti et al. At the completion of nonsurgical treatment, the final clubfoot severity was documented. RESULTS: A total of 42 clubfeet in 34 patients were enrolled in the study. After exclusion of 3 patients, 13 patients (16 feet) received fiberglass, and 18 patients (23 feet) received plaster casts. The mean baseline severity scores of the 2 groups were not significantly different. The mean final severity score was significantly higher in the feet treated with fiberglass than those treated with plaster (6.4 vs 4.1; P = 0.037). There was a trend toward higher scores for cast tolerance, durability, and parent satisfaction in the fiberglass group, but this did not reach significance. CONCLUSIONS: This study supports the use of plaster casting with the Ponseti technique. The use of plaster casts resulted in a statistically lower Diméglio-Bensahel score at the completion of serial casting. There was a trend toward higher patient satisfaction in the fiberglass-treated group. Whether this difference has an effect on long-term outcomes and recurrence remains to be studied. LEVEL OF EVIDENCE: Level II. Nonblinded randomized controlled prospective study.