Paradigm shift in clubfoot care strategies in Pakistan: A meta-analysis over three decades

Table 3 Bias assessment summary

Bias type	Key findings	Grade
Publication bias	Funnel plots (Figure 5) showed no obvious asymmetry for success, relapse, or age reduction despite high heterogeneity (I2 aproximately 82%-90%); quantitative tests were not applied due to unreliability	Grade: Moderate; no strong evidence of publication bias
Selective reporting	91% (114/125) reported pre-specified outcomes; 7.2% omitted relapse (pre-2010); 69.7% < 1-year follow-up = overestimates success	Grade: Moderate; overestimate Ponseti success, underestimate relapse
Other sources of bias	Language/citation bias minimal (PakMediNet mitigated; 41 added studies = no change)	Minimal impact; grade: High
Sensitivity analyses	Excluding short/high-risk studies: Success 88.1%, relapse 213% (stable)	Findings stable
Overall interpretation	Low-to-moderate bias. Mandate standardized scoring (Pirani ≥ 6.0 initial; relapse = recurrence requiring intervention) and minimum 4-year follow-up	Grade for key outcomes: Ponseti success: Moderate; relapse: Moderate; paradigm shift: High
Random-effects model (DerSimonian-Laird); analyses in R v4.3.2 (meta, metafor)