Reoccurrence rate in Ponseti treated clubfeet: A meta-regression

Caregiver Impressions of Bracing and Its Association With Unsuccessful Outcomes Throughout the Ponseti Treatment

BACKGROUND

Clubfoot is a common congenital foot deformity, occurring in about 1 in 1000 live births. The Ponseti method consists of weeks of manipulation and serial casting, followed by years of orthotic wear. Recurrent or relapse deformity following the Ponseti method remains a challenging problem for many patients. Many studies have attributed relapse to noncompliance with the treatment plan, particularly during the maintenance phase. Many patient risk factors have been studied and attributed to recurrent deformity, but less emphasis has been placed on aspects of the treatment method from the caregiver's perspective.

METHODS

From 2010 to 2014, 127 patients between 1 and 354 days old who had been diagnosed with clubfoot were recruited for the parent study. At the initial visit, and each subsequent follow-up, the primary caregiver was given a questionnaire that included 21 binary belief questions exploring his or her experience with the Ponseti method. Univariate analyses were performed to find any relationship with caregiver responses and either clinical recurrence of the deformity or overall failure of treatment.

RESULTS

Of the recruited patients, 126 were enrolled in the parent study and 100 were able to complete the full 3-year follow-up. Patient demographics and characteristics (sex, race, family history of clubfoot, laterality, and severity of deformity) were similar. Statistical analysis of the questionnaire responses found that choosing "yes" for either "I don't feel the braces are necessary" or "I am not comfortable with applying and removing the braces" was associated with significantly increased risk of overall failure.

CONCLUSIONS

Gathering insight from the caregiver's perspective can help identify barriers to treatment not recognized by the provider. Lack of comfortability with the orthosis and lack of understanding are associated with increased risk of overall failure. A better understanding of the caregiver's perspective on barriers to treatment could help guide the Ponseti method provider's educational efforts.

LEVEL OF EVIDENCE

Level III.

Prospective, Randomized Ponseti Treatment for Clubfoot: Orthopaedic Surgeons Versus Physical Therapists

BACKGROUND

Clubfoot is a common congenital foot deformity in children. The Ponseti method of serial casting has become the standard of care in clubfoot treatment. Clubfoot casting is performed in many centers by both orthopaedic surgeons and physical therapists (PTs); however, direct comparison of outcomes and complications of this treatment between these providers is limited. This study prospectively compared the outcomes of patients with clubfoot treated by these 2 groups of specialists.

METHODS

Between January 2010 and December 2014, all patients under the age of 12 months with a diagnosis of clubfoot were included. Patients were randomized to an orthopaedic surgeon (MD) group or a PT group for weekly serial casting. Main outcome measures included the number of casts required to achieve correction, clinical recurrence of the deformity, and the need for additional surgical intervention.

RESULTS

One hundred twenty-six infants were included in the study. Patient demographics and characteristics (sex, race, family history of clubfoot, laterality, and severity of deformity) were similar between treatment groups, with the only significant difference being the mean age of entry into the study (5.2 weeks in the MD group and 9.2 weeks in the PT group, P=0.01). Mean length of follow-up was 2.6 years. The number of casts required trended to a lower number in the MD group. There was no significant difference in the rates of clinical recurrence or additional surgical intervention between groups.

CONCLUSIONS

Ponseti casting for treatment of clubfoot performed by orthopaedic surgeons and PTs results in equivalent outcomes without any difference in complications. Although the number of casts required trended to a lower number in the MD group, this likely did not result in any clinical significance, as the difference in cast number equaled <1 week's difference in the overall duration of serial casting.

LEVEL OF EVIDENCE

Level I-therapeutic.

Prognostic factors for recurrent idiopathic clubfoot deformity: a systematic literature review and meta-analysis

Background and purpose - After initial clubfoot correction through Ponseti treatment, recurrence rates range from 26% to 48%. Even though various factors have been associated with increased recurrence risk, systematic assessments of the prognostic capacity of recurrence risk factors and their clinical relevance are lacking. Therefore we assessed clinically relevant prognostic factors for recurrent idiopathic clubfoot deformity after initial correction through Ponseti treatment. Methods - PubMed, Embase, Cinahl, and Web of Science were systematically searched for studies investigating the association between clinically relevant factors and recurrence rates. Prognostic factors were qualitatively assessed and included in the meta-analysis if ≥ 2 studies investigated the same factor and methods were comparable. Results - 34 articles were included in the qualitative synthesis, of which 22 were also included in the meta-analysis. Meta-analysis revealed that poor evertor muscle activity (OR = 255, 95% CI 30-2,190), brace non-compliance (OR = 10, CI 5-21), no additional stretching (OR = 31, CI 10-101), more casts (OR = 3.5, CI 1.6-7.8), lower education level of parents (OR = 1.8, CI 1.2-2.6), non-marital status of parents (OR = 1.8, CI 1.1-3.0), and higher Dimeglio scores (OR = 1.9, CI 1.2-3.3) were associated with higher recurrence rates. Interpretation - Brace non-compliance and poor evertor muscle activity have been identified as main recurrence risk factors and are therefore important to be closely monitored during clinical follow-up of clubfoot patients. Adding additional stretching during the bracing protocol might be promising in the quest to prevent relapse, but scientific evidence for clear clinical treatment recommendations is still limited.

Long-term outcomes of the Ponseti method for treatment of clubfoot: a systematic review

PURPOSE

The Ponseti method has revolutionized the clubfoot treatment and has been adopted globally in the past couple of decades. However, most reported results of the Ponseti method are either short or midterm. Studies reporting long-term outcomes of the Ponseti method are limited. The following systematic review aimed to provide a comprehensive overview of the published articles on long-term outcomes of the Ponseti method.

MATERIAL AND METHODS

A literature search was performed for articles published in electronic database PubMed (includes Medline) and Cochrane for broad keywords: "Clubfoot"; "Ponseti method/technique"; "long term outcomes/results." Studies selected included full-text articles in English language on children less than one year with primary idiopathic clubfoot treated by the Ponseti method with mean ten year follow-up. Non-idiopathic causes or syndromic clubfoot and case reports/review articles/meta-analyses were excluded. The following parameters were included for analysis: number of patients/clubfeet, male/female, mean age at treatment, mean/range of follow-up, relapses, additional surgery, range of motion, various outcome scores, and radiological variables.

RESULTS

Fourteen studies with 774 patients/1122 feet were included. The male:female ratio was 2.4:1. Mean follow-up recorded in studies was 14.5 years. Relapses occurred in 47% patients with additional surgery being required in 79% patients with relapses. Of these, 86% of surgery were extra-articular while 14% were intra-articular. Plantigrade foot was achieved in majority patients with mean ankle dorsiflexion of 11 degrees. The outcome scores were in general good in contrast to radiological angles which were mostly outside normal range with talar flattening/navicular wedging/degenerative osteoarthritis changes occurring in 60%, 76%, and 30%, respectively.

CONCLUSIONS

Long-term follow-up of infants with primary idiopathic clubfeet treated by the Ponseti method revealed relatively high relapse and additional surgery rates. Radiologically, the various angles were inconsistent compared to normal ranges and anatomical deformations/degenerative changes were present in treated feet. Moreover, the relapse rates and requirement of additional surgery increased on long-term follow-up. Despite this, majority feet were plantigrade and demonstrated good clinical results as measured by various outcome tools. There should be emphasis on long-term follow-up of children with clubfeet in view of late relapses and secondary late changes.

Relapses in clubfoot treated with Ponseti technique and standard bracing protocol- a systematic analysis

PURPOSE

The analysis determined the relapses in clubfoot children treated with Ponseti technique and standard bracing protocol and their correlation with overall follow up duration using pooled data from various series. It also tested the prescribed timelines of 5 and 7 years for slow-down/cessation of relapses in clubfoot children.

METHODS

A systematic literature search was performed for articles published in "Pubmed (includes Medline indexed journals)" electronic databases using key words: "Clubfoot or CTEV or congenital talipes equinovarus", "Ponseti" for years 1st January 2001 to 15th November 2020. Included were studies that addressed treatment of idiopathic clubfoot using the standard Ponseti technique, followed a well defined brace protocol (maintenance of corrected deformity using a central bar based brace and prescribed duration mentioned), reported a minimum mean follow up of 4 years and having relapse as one of their outcome measure. Studies reporting Ponseti technique for non-idiopathic clubfoot, child's age older than 1 year at the time of primary treatment, clubfoot with previous interventions before Ponseti treatment, where relapse and residual deformities were not identified distinctly in follow up, abstract only publications, letter to the editors, case reports, technique papers and review articles were excluded. The following characteristics of clubfoot patients in the selected articles were included for analysis: Patient numbers/feet treated with Ponseti technique; follow up years (<5; 5-7 and >7 years; overall) and corresponding relapse percentages for patients.

RESULTS

There were total 2206 patients in the included 24 studies. Average follow up was 6 years. The average relapse rates for clubfoot patients in the pooled data stood at 30%. The overall relapse rates increased with a longer follow up and the curve befitted a linear regression equation with weak positive correlation (Pearson correlation coefficient = 0.08). The relapse rates in follow up categories of <5 years (26.6 ± 15.6%), 5-7 years (30.8 ± 16.3%) and >7 years (28.4 ± 6.2%) were similar statistically (Analysis of variance, ANOVA).

CONCLUSIONS

Approximately 1 in 3 clubfoot patients suffer relapse post Ponseti technique and standard bracing protocol. A weak positive correlation was observed for relapses when correlated with increasing follow up years. The relapses however tend to slow down after initial growth years. There is a need to educate the care receivers regarding the possibility of late relapses despite proper Ponseti treatment and accordingly to keep them under supervised follow up for longer periods.

Is the Denis Browne Splint a Myth? A Long-Term Prospective Cohort Study in Clubfoot Management using Denis Browne Splint Versus Daily Exercise Protocol

The Ponseti technique is successful in idiopathic clubfoot management. However, the leading cause of relapse and recurrence is nonadherence to the Denis Brown bracing protocol. This necessitates more extensive soft tissue surgeries. Based on a detailed up-to-date search, we have found that no other studies provide such a modified Ponseti technique. This study is unique, as it depends on using specific stretching exercises instead of bracing during management. Between August 2009 and June 2019, a consecutive series of 194 isolated idiopathic clubfoot patients (251 feet) were included in this study. The mean follow-up was 93 months (range 72 to 146), mean 91.8 months. All patients underwent a clinical and functional assessment using the Laaveg-Ponseti score and radiological assessments. There were 132 boys (68.1%) and 62 girls (31.9%), a male-to-female ratio of 2:1. The mean age at initiation of treatment was 14.9 days. According to the Laaveg-Ponseti score, 51.7% yielded excellent results, 35.3% yielded good results, 11.55% yielded fair results, and 1.59% yielded poor results. Bracing noncompliance has been identified as a major cause for treatment failure. This presented exercise protocol not only eliminates the need for bracing and reduces the cost for the affected individuals but also provides excellent clinical and radiographic end results, comparable to the original treatment protocol using the Denis Brown brace.