Comparison of two methods for idiopathic clubfoot treatment: A case-controlled study in Taiwan

Retrospective Case Analysis of 104 Cases of Talipes Equinus

A retrospective study of 104 patients (81 male and 23 females, the age range from 2 to 288days) with talipes equinus was conducted to explore the case factors associated with it. We analyzed and discussed the correlation of plaster correction times, age of first visit, gender, and birthplace of patients in the department and understood their correlation and causality. The data were analyzed using frequency analysis, normality test, chi-square goodness-of-fit test, chi-square test, and PLS regression. The findings are set out below. All the distributions of the number of plaster casts in the samples did not have normality. Therefore, we used the nonparametric test and partial least squares regression (PLS regression) and found that the number of plaster casts was more closely related to the age at first visit, gender, and birthplace and had a strong positive correlation. There was a negative correlation between the times of plaster correction and the compliance of braces. The lower the compliance of patients with braces, the more times the plaster correction will be conducted.

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 1^st January 2001 to 15^th 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.

The Ponseti Method Decreased the Surgical Incidence in Children with Congenital Clubfoot: A Population-Based, 8 Birth-Year Cohort Study

BACKGROUND

With the introduction of the Ponseti method for congenital clubfoot, the relapse rate and the surgical rate have been remarkably reduced. However, data from population studies for patients up to 10 years of age are still lacking. This study aimed to survey the relapse and surgery rates in the first 10 years of life in children with congenital clubfoot before and after introduction of the Ponseti method in Taiwan using the National Health Insurance Research Database (NHIRD).

METHODS

We retrieved clubfoot cases and related surgical procedures determined by International Classification of Diseases, Ninth Revision (ICD-9) 754.51 from the 1999-2016 NHIRD. Foot and ankle surgical procedures coded as ICD-9 754.51 for patients who were older than 6 months of age were regarded as surgical procedures for relapsed or residual deformities. The rate of clubfoot release when the patients were 0.5 to 1 year of age and extensive surgical procedures in the first 10 years of life were assessed among 8 birth-year cohorts (1999 to 2006) with a 10-year follow-up.

RESULTS

Among 622 children with idiopathic congenital clubfoot diagnosis, 301 underwent a total of 367 surgical procedures for clubfoot between 6 months and 10 years of age. Disease incidence of 0.32 per 1,000 live births remained stable in the 8 birth-year cohorts. After the Ponseti method was introduced in 2002, there was a decrease in the clubfoot release rate in the 0.5 to 1-year age group (25.8% in the 1999 to 2002 birth-year cohorts compared with 17.6% in the 2003 to 2006 birth-year cohorts) and the rate of extensive surgical procedures (41.5% in the 1999 to 2002 birth-year cohorts compared with 31.3% in the 2003 to 2006 birth-year cohorts), both determined to be significant at p < 0.05 using the chi-square test. A significant decreasing trend (p < 0.05) was revealed in the rate of clubfoot release in patients who were 0.5 to 1 year of age by polynomial correlation, with an increasing negative slope after a turning point around 2002. The Ponseti method increased the ratio of minor to extensive surgical procedures when a surgical procedure was required.

CONCLUSIONS

The Ponseti method decreased subsequent extensive surgical procedures for clubfoot, especially in the group that was 0.5 to 1 year of age.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.