The Impact of Treatment Method and Timing on the Long Term Outcomes of Pediatric Clubfoot Management

CATEGORY: Other; Ankle; Hindfoot; Midfoot/Forefoot INTRODUCTION/PURPOSE: The Ponseti method of serial casting has been widely accepted as the new gold standard for management of idiopathic clubfoot, replacing joint invasive surgery, once the method-of-choice. While the short to midterm advantages of the method have been widely confirmed in the literature, there are limited comparative studies of the longer term outcomes. Dr. Ponseti's own definitive assessment of the long term result has not been decisively reevaluated by the literature. This systematic review compares the long-term functional outcomes of the two pediatric clubfoot management methods across different ages at treatment. METHODS: A comprehensive search was conducted of PubMed, CINAHL, Web of Science, and Cochrane from inception to December 2020 to identify literature on clubfoot. Using PRISMA guidelines, the search terms clubfoot OR clubfeet OR clubbed foot OR clubbed feet OR talipes equinovarus were used. Articles containing more than three human subjects, were included. The database was searched for longitudinal studies of pediatric, idiopathic clubfoot management with the Ponseti method or joint invasive surgery. Retrospective studies of primary Ponseti treatment with serial casting or invasive soft tissue release and joint surgery that was performed on newly born and children up to twenty four months old and with reported mean follow-up of two years or longer were included. Evaluation reported according to different scoring systems were dichotomized as success (good to satisfactory results) or failure (residual or relapse that requires corrective management). Probability of less than 0.05 is considered statistically significant. RESULTS: The initial search yielded 2907 articles, of which 29 articles reporting 2597 pediatric idiopathic clubfeet were included in this review, managed with either Ponseti casting, (group P = 1545 feet), or other surgical techniques, (group S = 1052 feet). The outcomes of 684 feet from group P with a mean long term follow up of 21+-13years were significantly superior to 1028 feet from group S with a mean follow up of 16+-5 years (p = 0.0002, odds ratio = 1.478). Multivariate analysis on 1310 feet from group P with mean age of 4.4 months (Range 1 - 8.9) against 794 feet from group S with mean age of 10.8 months (Range 1 - 22) detects no significant dependency on age (p = 0.128). CONCLUSION: The Ponseti method of serial casting resulted in significantly higher long term satisfaction outcomes compared with invasive surgical techniques in treatment of congenital clubfoot when performed within the first year of life. The findings supported Dr. Ponseti's own assessment regarding the high long term satisfaction rate (8+ years). Age was not found to be a significant contributor to the success of Ponseti casting over invasive surgery even though casting often started much earlier than surgery.