CORR Insights^®: Results of Clubfoot Management Using the Ponseti Method: Do the Details Matter? A Systematic Review

Where Are We Now?

The past decade has witnessed a paradigm shift in the management of clubfoot, and the minimally invasive Ponseti method has become the preferred treatment in many centers worldwide. As with any new treatment strategy or innovation, the challenge is how to effectively disseminate the knowledge and skills, scale up the delivery of services, and monitor the availability and quality of services, while simultaneously ensuring that the technical details are preserved.

The Ponseti method is based on a detailed knowledge of the pathoanatomy of clubfoot, and successful implementation requires a system for service delivery. Elements of this system include a mechanism for early screening and referral, trained providers to perform the casting, tenotomy to achieve initial correction, and the fabrication and regular use of a foot abduction orthosis to maintain correction. A mechanism for followup is required to ensure that adherence to bracing is maintained, and to identify and treat relapses. The ability to achieve and maintain correction of a clubfoot will necessarily be altered by deficiencies in one or more elements within the delivery system.

The outstanding results reported by Ponseti and colleagues at long-term followup come from a center with extensive experience, and we have subsequently seen encouraging results at short-term followup in numerous centers in economically developed and underdeveloped regions. When evaluating the results of treatment, it is essential to consider the degree to which investigators adhere to the treatment protocol recommended by Ponseti and colleagues. How can results be compared between different centers if the method of service delivery is not standardized? Additionally, if the technical details undergo multiple modifications in the future, it is possible, if not probable, that the ability to achieve or maintain correction may deteriorate.

This systematic review by Zhao and colleagues focuses on these important concerns. There were three goals for the present study: 1) determining the degree to which the details of the Ponseti method was followed in achieving the correction, 2) identifying variations in how the correction was maintained, and 3) establishing whether the same criteria were applied for the diagnosis and management of relapse.

Nineteen articles were reviewed, and patients’ ages ranged from 2 days to nearly 9 years of age. The technical details were described in detail in only 58% of studies, and were modified in 17%. The authors identified consistent criteria for adherence to the bracing program in only 42% of the studies, and alterations in wear schedule were identified in 16%. The same indications for the diagnosis and management of relapse were observed in only 53% of the studies. Most studies did not define the wear schedule for the orthosis, or when the device was to be discontinued. There also was substantial variation in the need for intra-articular surgery, which is generally accepted as indicating a failure of treatment.

Where Do We Need To Go?

While the variations in adherence to the technical details of the Ponseti method are concerning, some minor variations in methodology would seem acceptable. Assuming the feet are held in the recommended position, the fabrication details for the abduction orthosis would be a prime example. It has also become apparent that task shifting, or the use of nonsurgeon providers, has been effective in selected centers, such as physiotherapists in Nepal [1], Great Britain, UK [2], and Orthopaedic Clinical Officers in Malawi [3]. We must also recognize that the Ponseti method was developed and studied in infants and toddlers less than 2 years of age, and several of the studies included in this review focused on patients of walking age and as old as 10 years of age. Adaptations of the method are required in this older cohort of patients. Maximum abduction in an older patient may only be 30° to 50°, rather than the 60° to 70° expected in infants. It is impractical to attempt to keep a child of walking age in an abduction orthosis full time for 3 months after the initial correction is achieved. What orthotic recommendations should be made after initial correction in patients beyond the age when night time bracing is typically recommended? While such modifications are appropriate and necessary, all authors should acknowledge their specific protocol to facilitate comparison between studies.

How Do We Get There?

Is it difficult, if not impossible, to police the dissemination of knowledge or the adoption and utilization of the Ponseti method in centers in different regions of the world. Should journal editors and their reviewers be asked to judge whether authors are truly adhering to the technical details as professed by Dr. Ponseti and colleagues? Probably not. However, the journals can, as a minimum, require that authors provide a detailed description of the treatment protocol in their methods section. This will facilitate comparison between studies and allow readers to determine whether the treatment was delivered according to the details specified by Dr. Ponseti.