Meta-Analysis
Copyright ©2013 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Orthop. Jul 18, 2013; 4(3): 144-153
Published online Jul 18, 2013. doi: 10.5312/wjo.v4.i3.144
Ponseti method compared with soft-tissue release for the management of clubfoot: A meta-analysis study
Marios G Lykissas, Alvin H Crawford, Emily A Eismann, Junichi Tamai
Marios G Lykissas, Alvin H Crawford, Emily A Eismann, Junichi Tamai, Division of Pediatric Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, United States
Author contributions: All authors contributed equally to this paper.
Correspondence to: Marios G Lykissas, MD, PhD, Division of Pediatric Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 217, Cincinnati, OH 45229, United States. mariolyk@yahoo.com
Telephone: +1-513-6527207 Fax: +1-513-6527207
Received: January 9, 2013
Revised: March 27, 2013
Accepted: April 27, 2013
Published online: July 18, 2013

Abstract

AIM: To compare the functional outcomes of patients who underwent open surgery vs Ponseti method for the management of idiopathic clubfoot and to determine whether correlations exist between functional outcome and radiographic measurements.

METHODS: A meta-analysis of the literature was conducted for studies concerning primary treatment of patients with idiopathic clubfoot. We searched PubMed Medline, EMBASE, and the Cochrane Library databases from January 1950 to October 2011. Meta-analyses were performed on outcomes from 12 studies. Pooled means, SDs, and sample sizes were either identified in the results or calculated based on the results of each study.

RESULTS: Overall, 835 treated idiopathic clubfeet in 516 patients were reviewed. The average follow-up was 15.7 years. Patients managed with Ponseti method did have a higher rate of excellent or good outcome than patients treated with open surgery (0.76 and 0.62, respectively), but not quite to the point of statistical significance (Q = 3.73, P = 0.053). Age at surgery was not correlated with the functional outcome for the surgically treated patients (r = -0.32, P = 0.68). A larger anteroposterior talocalcaneal angle was correlated with a higher rate of excellent or good outcomes (r = 0.80, P = 0.006). There were no other significant correlations between the functional and radiographic outcomes.

CONCLUSION: The Ponseti method should be considered the initial treatment of idiopathic clubfeet, and open surgery should be reserved for clubfeet that cannot be completely corrected.

Key Words: Idiopathic clubfoot, Congenital talipes equinovarus, Ponseti method, Surgical release, Ponseti-Laaveg score

Core tip: This study analyzed a large cohort of patients with idiopathic clubfoot and presented differences in the functional and radiographic outcomes based on the management employed. Although no statistically significant difference was noted in the overall functional outcomes between patients managed with the Ponseti method or open surgery, patients treated with the Ponseti method had a higher rate of excellent or good outcomes. Serial manipulation and casting has been widely accepted as the initial treatment of idiopathic clubfeet, and soft-tissue release is reserved for clubfeet that cannot be completely corrected. A strict brace compliance remains the major challenge of the Ponseti method.



INTRODUCTION

During the second half of the twentieth century, the primary treatment of idiopathic clubfoot has ranged from gentle manipulations to aggressive surgical treatment. Surgical management predominated because it was considered as a method that could obtain full and lasting correction. Over time and based on long-term follow-up studies surgeons realized that the results of surgical intervention are unpredictable[1-3]. Extensive soft-tissue releases can result in scarring which may lead to stiffness, recurrent deformity, and pain[4]. It was this observation along with the promising results of the Ponseti method[5,6] that shifted treatment of idiopathic clubfoot towards a more conservative approach consisting of manipulations and serial casting, and frequently minimal invasive surgery. Open surgery is usually reserved for more severe cases that failed serial casting. However, even in these cases, current surgical procedures are less aggressive than procedures performed three decades ago.

Although there are a plethora of studies that have assessed the functional and radiographic outcomes following different treatment protocols, there are only a few studies that directly compare open surgery and Ponseti method for the management of idiopathic clubfoot[1,7-9]. This can be mainly attributed to variable and simplistic grading systems for scoring the severity of the deformity as well as the differing evaluation systems for assessing outcomes. Only one study in the current literature prospectively compares surgical management and Ponseti method, but there are no prospective randomize controlled trials[7].

The present meta-analysis aims to address two topics. The main purpose is to compare the functional outcomes between patients undergoing open surgery vs Ponseti method for the treatment of idiopathic clubfoot. A secondary aim is to determine if functional outcomes and radiographic measurements correlate.

MATERIALS AND METHODS
Literature search

A meta-analysis of the literature was conducted for studies concerning management of patients with idiopathic clubfoot with either soft-tissue release or Ponseti method. The search was performed with use of the following electronic bibliographic databases: Medical Literature Analysis and Retrieval System online (PubMed Medline), Excerpta Medica Database (EMBASE), and The Cochrane Library. The medical subject headings or text words utilized included: “clubfoot”, “congenital talipes equinovarus”, “soft-tissue release”, “surgery”, and “Ponseti method”. The bibliographies of the retrieved articles as well as the “related articles” option in PubMed Medline were also searched to assess for potentially inclusive papers that were missed by the initial search.

Criteria for eligibility

Since several methods and systems have been used to describe the functional and radiographic outcome of patients treated with open surgery or Ponseti method, we performed an initial search to identify the most commonly used functional scores and radiographic parameters. These included: Laaveg-Ponseti score (Figure 1)[5], anteroposterior talocalcaneal angle (TCA-AP), lateral talocalcaneal angle (TCA-LT), anteroposterior talus-first metatarsal angle (TMT-AP), lateral talus-first metatarsal angle (TMT-LT), anteroposterior calcaneus-fifth metatarsal angle (CMT-AP), lateral first-fifth metatarsal angle (MTT-LT), and talocalcaneal index (TCI) (Figure 2). The Laaveg-Ponseti score is a 100-point evaluation system with scores between 90 and 100 considered as excellent, 80 and 89 as good, 70 and 79 as moderate, and below 70 as poor. According to our initial search of the literature, this was the most commonly used functional score in patients who underwent soft-tissue release or Ponseti method from its description in 1980 until today. In contrast to other systems, it can be used to study the correlation between the functional outcome and radiographic measurements since it relies only on clinical aspects, not including any radiographic parameters[10].

Figure 1
Figure 1 Functional rating system for clubfoot. Reproduced from by Laaveg et al[5].
Figure 2
Figure 2 Radiographic parameters most commonly measured on plain films. Anteroposterior (A) and lateral (B) standing foot radiographs of a patient with clubfoot showing the anteroposterior talocalcaneal angle (a), anteroposterior calcaneus-fifth metatarsal angle (b), anteroposterior talus-first metatarsal angle (c), lateral talocalcaneal angle (d), lateral talus-first metatarsal angle (e), and lateral first-fifth metatarsal angle (f).

Based on the initial search findings, studies selected for the analyses were original studies fulfilling the following eligibility criteria: (1) assess idiopathic clubfoot; (2) assess primary treatment of idiopathic clubfoot; (3) use the functional evaluation score of Laaveg-Ponseti; (4) use of at least three of the radiographic outcome measures found to be the most commonly used in the literature and described above; (5) evaluate more than ten feet; (6) evaluate human subjects; and (7) was published from January 1950 through October 2011.

Potentially inclusive papers were manually reviewed and were discussed among the authors, and a decision was made regarding inclusion. If there was any disagreement among authors regarding the inclusion of an article, the senior author made the final decision.

Extraction of data

Data were carefully extracted and computerized on the following variables from those published articles that meet our inclusion criteria: (1) radiographic findings at final follow-up (main outcome variable); (2) Laaveg-Ponseti score at final follow-up (main outcome variable); (3) time period during which the procedure was performed; (4) duration of follow-up; (5) number of patients/feet; (6) unilateral or bilateral involvement; (7) sex of the patient; (8) age at treatment; (9) level of evidence; (10) publication year; and (11) authors’ names.

Statistical analysis

Due to the possibility of variation between studies, the more conservative, random-effects model was selected over a fixed-effects model. Random effects models account for both within-study and between-study variation and are more preferable when assessing observational studies. Pooled means, SDs, and sample sizes were either identified in the results of each study or calculated based on the results. Effect sizes with 95%CI were calculated using the mean and SE for each study. Subgroup analyses were performed in order to compare the Ponseti method and surgical treatment studies on all outcome measures. Variability between treatment types was assessed with Cochran’s Q statistic, which measures the presence or absence of heterogeneity between studies based on a χ2 distribution. It is calculated as the weighted sum of squared differences between individual study effects and pooled effects across studies. The I2 index was also calculated as a measure of the extent of heterogeneity between studies. Larger Q and I2 values indicate greater variability. The number of feet with good or excellent outcomes on the Laaveg-Ponseti scale was also compared to the number of feet with poor or fair outcomes using event rates of successful outcomes rather than effect sizes.

Meta-analyses were performed using the Comprehensive Meta-Analysis software (2.0, Bio-Stat, Englewood, NJ, United States). A P value of 0.05 or less was considered as statistical significant.

RESULTS
Literature search

Based on the title and the abstract, the initial electronic search yielded 512 articles as potentially eligible. After obtaining the full text of 364 articles, a total of fourteen articles were found to fulfill the inclusion criteria[1,3,5,6,9-18]. Two studies were excluded because the measures were in terms of medians and ranges, and thus, effect sizes could not be calculated[9,18]. A flow chart summary of the literature search is shown in Figure 3.

Figure 3
Figure 3 Flow chart summary of the literature.

Meta-analyses were performed on outcomes from 12 studies[1,3,5,6,10-17]. Nine studies evaluated functional and radiographic outcome following soft-tissue release, two studies after Ponseti method, and one study compared outcomes in patients who underwent Ponseti method or open surgery for the management of idiopathic clubfoot. Three studies were therapeutic level of evidence III studies[1,3,13]. The rest of the studies were observational level of evidence IV case series[5,6,10-12,14-17].

In summary, 835 treated idiopathic clubfeet in 516 patients were reviewed. Among these patients, 369 patients (611 feet) were treated with soft-tissue release and 147 patients (224 feet) were managed with the Ponseti method. The male-to-female ratio was 2.5:1. The unilateral-to-bilateral involvement ratio was 1.25:1. The mean age at initiation of treatment was 8.8 ± 4.8 mo. The average follow-up was 15.7 ± 10.8 years. The minimum follow-up was one year and the maximum 42 years.

Functional outcome

At the final follow-up, functional outcomes, as measured with the Laaveg-Ponseti score, did not differ between patients treated with Ponseti method and patients treated with soft-tissue release (86.3 and 82.0, respectively, Q = 0.45, P = 0.50) (Table 1). However, when compared categorically, patients managed with Ponseti method did have a higher rate of excellent or good outcome than patients treated with open surgery (0.76 and 0.62, respectively), but not quite to the point of statistical significance (Q = 3.73, P = 0.053) (Figure 4, Table 1).

Table 1 Comparison of Laaveg-Ponseti score between patients treated with the Ponseti method and surgically managed patients.
StudiesLevel of evidenceMean follow-up (yr)Time period of procedurePatients (n)Feet (n)Laaveg-Ponseti score mean (95%CI)Excellent/good Laaveg-Ponseti rating rate (95%CI)
All Treatments50081086.2 (84.2-88.2)0.73 (0.67-0.78)
Ponseti method14722486.3 (84.2-88.3)0.76 (0.69-0.81)
Ippolito et al[1]III191979-1984324985.4 (83.9-86.9)0.78 (0.64-0.87)
Laaveg et al[5]III18.81950-19677010487.5 (85.3-89.7)0.74 (0.65-0.82)
Cooper et al[6]IV341950-19674571-0.78 (0.63-0.88)
Soft-tissue release35358682.0 (69.5-94.5)0.62 (0.48-0.74)
Ippolito et al[1]III251973-1977324774.7 (71.4-78.0)0.43 (0.29-0.57)
Dobbs et al[3]III311972-1979457365.3 (62.9-67.7)0.33 (0.23-0.44)
Fridman et al[10]IV6.41986-2003507186.9 (84.1-89.6)0.80 (0.69-0.88)
Schuh e et al[11]IV4.51986-20008613095.6 (94.0-97.2)-
Singh et al[12]IV13.81980-19961833-0.82 (0.65-0.92)
Prasad et al[13]IV--3050-0.58 (0.44-0.71)
Munshi et al[14]III3.5--5087.3 (83.1-91.5)0.78 (0.65-0.87)
Herbsthofer et al[15]IV6.71984-19943862-0.47 (0.35-0.59)
Abulsaad et al[16]IV3.92000-20045470-0.69 (0.57-0.78)
Difference between treatmentsQ = 0.45, P = 0.50Q = 3.73, P = 0.053
Figure 4
Figure 4 Success rate of Ponseti method vs soft-tissue release for clubfoot management based on Laaveg-Ponseti score.

For all patients studied, a longer length of follow-up was correlated with worse functional outcomes (r = -0.82, P = 0.023). Age at surgery was not correlated with functional outcome for patients treated with open surgery (r = -0.32, P = 0.68).

Radiographic outcome

The radiographs taken at the time of the final follow-up did not show any significant differences between patients treated with manipulation and serial casting (Ponseti method) and patients treated with soft-tissue release regarding the TCA-AP (15.8° and 18.9°, respectively) (Q = 2.09, P = 0.15), TCA-LT (29.9° and 26.6°, respectively) (Q = 0.33, P = 0.57), TCI (45.7° and 46.1°, respectively) (Q = 0.002, P = 0.96), and the TMT-AP angles (0.96° and 6.04°, respectively) (Q = 0.55, P = 0.11) (Table 2).

Table 2 Comparison of anteroposterior talocalcaneal angle, lateral talocalcaneal angle, and talocalcaneal index between patients treated with the Ponseti method and surgically managed patients.
StudiesPatientsFeetTalocalcaneal
AP mean (95%CI)Lateral mean (95%CI)Index mean (95%CI)
All treatments43065516.2 (14.9-17.5)26.9 (23.9-29.9)46.0 (41.4-50.7)
Ponseti method14722415.8 (14.5-17.2)29.9 (19.3-40.5)45.7 (33.4-58.0)
Ippolito et al[1]324916.1 (14.6-17.6)38.8 (37.1-40.4)54.9 (51.7-58.0)
Laaveg et al[5]7010414.5 (12.8-16.2)20.9 (19.8-22.0)35.5 (33.5-37.5)
Cooper et al[6]457117.0 (15.1-18.9)30.0 (28.4-31.6)47.0 (43.5-50.5)
Soft-tissue release28343118.9 (15.0-22.8)26.6 (23.5-29.8)46.1 (41.0-51.1)
Ippolito et al[1]324714.1 (12.2-16.0)33.2 (30.7-35.7)47.3 (42.9-51.7)
Dobbs et al[3]457312.8 (11.1-14.4)23.3 (21.8-24.8)36.1 (32.9-39.3)
Fridman et al[10]507120.8 (19.3-22.3)22.5 (20.9-24.0)43.3 (40.9-45.6)
Singh et al[12]183328.4 (27.0-29.8)30.9 (29.2-32.6)59.3 (56.2-62.4)
Prasad et al[13]305018.5 (16.2-20.8)27.4 (24.6-30.1)45.8 (43.3-48.4)
Herbsthofer et al[15]386216.1 (14.6-17.6)23.0 (21.3-24.7)39.1 (36.0-42.2)
Abulsaad et al[16]547016.4 (15.1-17.6)21.4 (19.9-23.0)42.2 (39.7-44.7)
Docquier et al[17]162524.3 (21.5-27.1)32.2 (29.6-34.8)56.5 (51.1-61.9)
Difference between treatmentQ = 2.09, P = 0.15Q = 0.33, P = 0.57Q = 0.002, P = 0.96

Statistically significant differences were noted between patients managed with the Ponseti method and patients treated with open surgery in TMT-LT (5.51° and 12.08°, respectively) (Q = 10.74, P = 0.001), MTT-LT (15.4° and 25.2°, respectively) (Q = 10.48, P = 0.001), and CMT-AP angles (-6.49° and 3.86°, respectively) (Q = 16.12, P < 0.001) (Table 3).

Table 3 Comparison of talus-1st metatarsal, 1st-5th metatarsal, and calcaneus-5th metatarsal angles between patients treated with the Ponseti method and surgically managed patients.
StudiesPatientsFeetTalus-1st metatarsal
1st-5th metatarsal
APmean (95%CI)Lateralmean (95%CI)Lateralmean (95%CI)APmean (95%CI)
All treatments5166551.27 (-0.23-2.77)6.24 (5.00-7.48)15.6 (16.7-17.9)-5.11 (-6.83 - -3.40)
Ponseti method1472240.96 (-0.59-2.51)5.51 (4.20-6.82)15.4 (14.7-16.1)-6.49 (-8.33 - -4.65)
Ippolito et al[1]32490.94 (-1.01-2.89)6.39 (4.40-8.38)15.5 (14.2-16.7)-6.8 (-9.20 - -4.40)
Laaveg et al[5]70104--14.7 (13.5-15.9)-4.9 (-6.92 - -2.88)
Cooper et al[6]45711 (-1.56-3.56)5 (3.60-6.40)16 (14.8-17.2)-8 (-10.33 - -5.67)
Soft-tissue release2834316.04 (-0.06-12.13)12.08 (8.38-15.79)25.2 (19.3-31.0)3.86 (-0.84 - 8.57)
Ippolito et al[1]32478.28 (5.97-10.59)9.4 (6.69-12.11)22.1 (20.3-23.9)-0.62 (-3.04 - 1.80)
Dobbs et al[3]457315.95 (13.24-18.66)7.68 (4.06-11.30)18.1 (15.4-20.8)10.32 (8.55 - 12.09)
Fridman et al[10]50713.97 (1.27-6.67)--1.32 (-0.70 - 3.34)
Singh et al[12]183311.9 (9.89-13.91)15.7 (13.14-18.26)28.2 (25.9-30.5)-
Prasad et al[13]30506.92 (2.49-11.35)18.54 (11.90-25.18)46.2 (38.7-53.7)5.8 (2.22 - 9.38)
Herbsthofer et al[15]386210.29 (7.68-12.90)--9.95 (7.90 - 12.00)
Abulsaad et al[16]5470-5.43 (-6.85-4.02)---
Docquier et al[17]1625-3.5 (-6.52-0.48)10.9 (6.43-15.37)15.9 (12.7-19.1)-3.9 (-7.04 - -0.76)
Difference between treatmentQ = 2.50, P = 0.11Q = 10.74, P = 0.001Q = 10.48, P = 0.001Q = 16.12, P < 0.001
Heterogeneity in outcomes

For the Laaveg-Ponseti score and all radiographic measurements, except TCA-LT, greater variability was recorded in patients who underwent open surgery compared with patients managed with the Ponseti method, as indicated by the higher Q values and I2 values (Table 4).

Table 4 Between and within-study heterogeneity in outcomes of clubfoot treatment.
Overall
Ponseti method
Soft-Tissue release
QI2QI2QI2
Laaveg-Ponseti score468.8a98.72.357.2465.8a99.1
Excellent/Good Laaveg-Ponseti ratings72.5a86.20.35055.6a87.4
TCA-AP346.8a97.14.150.9312.5a97.8
TCA-LT496.3a98.0320.8a99.4158.1a95.6
TCI274.5a96.4114.3a98.3265.5a95.4
TMT-AP376.3a97.60.0010365.2a98.1
TMT-LT67.3a91.11.320.521.0a80.9
MTT-LT203.8a96.62.312.089.0a95.5
CMT-AP328.7a97.64.050.6121.5a95.9
Correlations between functional outcome and radiographic measurements

A larger TCA-AP angle was correlated with a higher rate of excellent or good outcomes (r = 0.80, P = 0.006). Functional outcomes were not significantly correlated with MTT-LT (r = -0.80, P = 0.20), TMT-AP (r = -0.80, P = 0.20), and TCA-AP (r = 0.70, P = 0.19) angles or the TCI (r = -0.30, P = 0.62) (Table 5).

Table 5 Correlations between functional and radiographic outcomes after clubfoot treatment.
Length of follow-upr (P value)Laaveg-Ponseti excellent/good outcomesr (P value)
TCA-AP-0.31 (0.39)0.80 (0.006)
TCA-LT0.43 (0.22)-0.26 (0.46)
TCI0.13 (0.73)0.48 (0.16)
TMT-AP0.27 (0.49)-0.36 (0.34)
TMT-LT-0.66 (0.16)-0.06 (0.91)
CMT-AP-0.26 (0.53)-0.64 (0.091)
MTT-LT0.11 (0.82)-0.13 (0.79)
DISCUSSION

Idiopathic clubfoot is a complex three dimensional deformity with an incidence of between 0.64 and 6.8 per 1000 live births[19]. Pathogenesis of idiopathic clubfoot remains obscure, but there is increased evidence for a multifactorial etiologic model. Both genetic and environmental factors have been implicated. Muscle growth impairment[20,21], primary germ plasm defect in the talus[22], vascular anomalies[23-25], medial retraction fibrosis[26], and intrauterine factors[19], such as oligohydramnios, placental insufficiency, drugs, infective pathogens, and amniocentesis prior to the eleventh week[27], have been proposed as potential etiologic factors in the pathogenesis of idiopathic clubfoot. Studies have shown that the deformity has a heritable factor, but is not inherited in a simple autosomal dominant or recessive mendelian fashion[28-32]. Although there is no evidence to support sex linkage, males are affected more commonly than females in all ethnic groups. The reported male-to-female ratio is 2.5:1[33]. This is in accordance to our findings. The male-to-female ratio in 516 patients with idiopathic clubfoot reviewed in our study was 2.5:1. We also recorded a unilateral-to-bilateral involvement ratio of 1.25:1.

The success rates in different series are difficult to compare because of variation in severity of the deformity between study groups and, more importantly, absence of common assessment protocols. In the present meta-analysis, in an effort to use a “common language” between patients treated with open surgery or Ponseti method, we used the subjective assessment method published by Laaveg et al[5]. It is based on functionality, presence of pain, foot and ankle range of motion, and patient’s satisfaction. In contrast to other systems, it can be used to study the correlation between the functional outcome and radiographic measurements since it relies only on clinical aspects, not including any radiographic parameters[15]. Although it may have been interesting to compare outcomes based on the degree of deformity prior to treatment, only five of the 12 studies included in this meta-analysis evaluated clubfeet at birth. Even in these few studies, the system used deferred, and a comparison in terms of severity of the deformity was not possible. It should also be noted that this study has the disadvantages adherent to low level of evidence studies analyzed and the relatively loose entry criteria.

Extensive soft-tissue release was the preferred method of treatment for many decades because it often provides definitive correction of the deformity. Full correction by addressing all components of the deformity was recommended. Surgical approaches most commonly used can be classified into three main categories: the Turco posteromedial incision[34], the Crawford’s circumferential Cincinnati incision[35], and the two-incision Carroll approach[36]. Ponseti et al[33] pioneered his manipulative and serial casting technique in the late 1940s and first published his method in 1963. He proposed simultaneous correction of all components of clubfoot by abducting the foot under the talus while a counter pressure is applied to the talar head. Based on long-term follow-up studies of patients who underwent extensive soft-tissue releases for the management of idiopathic clubfoot before 1980, it has been shown that aggressive surgical management results in poor long-term foot function due to pain, stiffness, and degenerative arthrosis[1-4]. Until today, there is a lack in the literature of studies evaluating adults with clubfeet treated with selective posteromedial release techniques, as these were described after 1983. The present meta-analysis, by including data of clubfeet treated with both aggressive and comprehensive release techniques, demonstrated that patients managed with the Ponseti method had a higher rate of excellent or good outcomes than patients treated with open surgery.

Noncompliance of the family to follow the brace protocol is associated with unexpected high recurrence rate ranging from 30% to 45%[7,37-49]. According to a recent study, there is no association between the poor bracing compliance and the families educational level, income or cultural origin[50]. Distance from the treatment centers and accessibility to the health care system are important parameters that may also adversely affect compliance, and secondarily the success rate. In addition, concurrent illnesses may affect management of clubfeet with the Ponseti method.

In an effort to objectively evaluate idiopathic clubfoot, assess treatment, and classify residual deformities, a large number of angular measurements have been proposed on the anteroposterior and lateral radiographic projections[51-53]. The TCA-AP and the TCA-LT, as well as the TCI (sum of TCA-AP and TCA-LT angles) are the most widely used parameters and reflect the anatomic relationship between the talus and the calcaneus. Among the other radiographic angles usually used in clinical practice, TMT-LT and MTT-LT angles measure midfoot cavus deformity, whereas TMT-AP and CMT-AP angles are expressions of forefoot adduction that characterize clubfoot. Our study did not reveal statistically significant difference in TCA-AP and TCA-LT angles between clubfeet treated with open surgery or the Ponseti method. The average TCI was measured above 40 in clubfeet managed with Ponseti method as well as in surgically treated clubfeet. A statistically significant difference was recorded in TMT-LT, MTT-LT, and CMT-AP angles.

Although radiographic evaluation has been extensively used as a measure of success of idiopathic clubfoot treatment, several authors have questioned the correlation between functional and radiographic outcomes as well as the prognostic value of radiographs[6,14,54,55]. Evaluation of radiographs is difficult to reproduce due to complexity of the deformity in various planes with multiple bone involvement, the small size or complete absence of ossific nuclei, particularly that of the navicular, the considerable overlap between radiographic values of normal feet and clubfeet, and difficulty in positioning the stiff and deformed foot[56]. Furthermore, the use of different functional systems does not allow direct comparison between studies in order to identify any association between these radiographic parameters and the functional outcome. In the present meta-analysis, the Laaveg-Ponseti score was used to study the correlation between the clinical scoring and angular measurements since it does not rely on any radiographic parameters. A higher TCA-AP angle was associated with a better functional outcome. This is in agreement with several previous studies[57,58], although many authors have found strong correlation between the functional rating and TCA-LT[5,18,34,59,60] or TCI[52,57,61]. Herbsthofer et al[15] demonstrated no correlation between angular measurements and functional outcome. It is our opinion, however, that several radiographic parameters representing each of the clubfoot deformities should be used to provide a comprehensive radiological assessment of the three dimensional clubfoot deformities. By measuring TCA-AP, MTT-LT, and TMT-AP angles, the heel varus, midfoot cavus, and forefoot adduction, can be radiologically assessed and correlated with the functional outcome. In contrast, using a severity evaluation system that is based exclusively on radiographic criteria may overestimate the value of radiographs.

Long-term follow-up studies of treated clubfeet evaluating function beyond skeletal maturity are rare[1-3,6,62]. The studies with the longer follow-up were those of Cooper et al[6] with an average of follow-up of 34 years, Ippolito et al[1] with an average duration of follow-up of 25 years, and Dobbs et al[3] with a mean of follow-up of 30 years. Cooper et al[6], evaluated 71 clubfeet in 45 patients treated with the Ponseti method. Seventy-eight percent of the patients had an excellent or good outcome. Mild arthrosis in the foot and ankle was found in 35% of the patients. Twenty-seven percent of the patients had an excellent or good outcome. Ippolito et al[1] compared the results of adult patients with idiopathic clubfoot treated during infancy either with the Ponseti method or extensive soft-tissue release. They recorded better long-term functional outcomes when the former technique was used. The mean Laaveg-Ponseti score was 85.4 and 74.7 for the Ponseti method and surgically treated group, respectively. Seventy-eight percent of the patients treated with the Ponseti method had an excellent or good outcome. In contrast, only 43% of the patients treated with extensive soft-tissue release had an excellent or good outcome. Thirty percent of the surgically treated patients and 38% of the patients treated with the Ponseti method were found to have recurrences requiring additional intervention. Among these recurrences, 86% in the surgical group and 27% in the Ponseti group were major. Dobbs et al[3] followed 73 clubfeet who had undergone either an extensive combined posterior, medial, and lateral release or a posterior release and plantar fasciotomy. They reported a correlation between the extent of soft-tissue release and the degree of functional impairment. Moderate to severe evidence of arthrosis in the foot and ankle was found in 56% of surgically treated patients. The mean Laaveg-Ponseti score was 65.3. Our study was in agreement with these findings, suggesting that foot function deteriorates over time in patients treated with open surgery. However, it should be noted that surgically treated patients in the last two long-term studies, as well as 20.87% of surgically treated clubfeet included in our study, were operated with extensive soft-tissue releases which does not represent the current surgical practice.

This study analyzed a large cohort of patients with idiopathic clubfoot and presented differences in the functional and radiographic outcomes based on the management employed. Although no statistically significant difference was noted in the overall functional outcomes between patients managed with the Ponseti method or open surgery, patients treated with the Ponseti method had a higher rate of excellent or good outcomes. Serial manipulation and casting has been widely accepted as the initial treatment of idiopathic clubfeet, and soft-tissue release is reserved for clubfeet that cannot be completely corrected. A strict brace compliance remains the major challenge of the Ponseti method.

COMMENTS
Background

During the second half of the twentieth century, the primary treatment of idiopathic clubfoot has ranged from gentle manipulations to aggressive surgical treatment. Although there are a plethora of studies that have assessed the functional and radiographic outcomes following different treatment protocols, there are only a few studies that directly compare open surgery and Ponseti method for the management of idiopathic clubfoot. This can be mainly attributed to variable and simplistic grading systems for scoring the severity of the deformity as well as the differing evaluation systems for assessing outcomes.

Research frontiers

The present study analyzed a large cohort of patients with idiopathic clubfoot and presented differences in the functional and radiographic outcomes based on the management employed. The findings suggest that foot function deteriorates over time in patients treated with open surgery.

Innovations and breakthroughs

In the present long-term study, although no statistically significant difference was noted in the overall functional outcomes between patients managed with the Ponseti method or open surgery, patients treated with the Ponseti method had a higher rate of excellent or good outcomes. Serial manipulation and casting has been widely accepted as the initial treatment of idiopathic clubfeet, and soft-tissue release is reserved for clubfeet that cannot be completely corrected. A strict brace compliance remains the major challenge of the Ponseti method.

Applications

The study results suggest that serial manipulation and casting is the accepted initial treatment of idiopathic clubfeet, and soft-tissue release is reserved for clubfeet that cannot be completely corrected.

Terminology

Ponseti method is the conservative treatment of idiopathic clubfoot consisting of manipulations and serial casting, and frequently minimal invasive surgery.

Peer review

This is an excellent meta-analysis in which authors analyze a large cohort of patients with idiopathic clubfoot and presented differences in the functional and radiographic outcomes based on the management employed. The results are interesting and suggest that Ponseti method has a higher rate of excellent or good outcomes.

Footnotes

P- Reviewers Erkan S, Gorgey AS, Malik H S- Editor Zhai HH L- Editor A E- Editor Zhang DN

References
1.  Ippolito E, Farsetti P, Caterini R, Tudisco C. Long-term comparative results in patients with congenital clubfoot treated with two different protocols. J Bone Joint Surg Am. 2003;85-A:1286-1294.  [PubMed]  [DOI]
2.  Hutchins PM, Foster BK, Paterson DC, Cole EA. Long-term results of early surgical release in club feet. J Bone Joint Surg Br. 1985;67:791-799.  [PubMed]  [DOI]
3.  Dobbs MB, Nunley R, Schoenecker PL. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am. 2006;88:986-996.  [PubMed]  [DOI]
4.  Carroll NC. Clubfoot in the twentieth century: where we were and where we may be going in the twenty-first century. J Pediatr Orthop B. 2012;21:1-6.  [PubMed]  [DOI]
5.  Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am. 1980;62:23-31.  [PubMed]  [DOI]
6.  Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up note. J Bone Joint Surg Am. 1995;77:1477-1489.  [PubMed]  [DOI]
7.  Halanski MA, Davison JE, Huang JC, Walker CG, Walsh SJ, Crawford HA. Ponseti method compared with surgical treatment of clubfoot: a prospective comparison. J Bone Joint Surg Am. 2010;92:270-278.  [PubMed]  [DOI]
8.  Karol LA, O’Brien SE, Wilson H, Johnston CE, Richards BS. Gait analysis in children with severe clubfeet: early results of physiotherapy versus surgical release. J Pediatr Orthop. 2005;25:236-240.  [PubMed]  [DOI]
9.  Zwick EB, Kraus T, Maizen C, Steinwender G, Linhart WE. Comparison of Ponseti versus surgical treatment for idiopathic clubfoot: a short-term preliminary report. Clin Orthop Relat Res. 2009;467:2668-2676.  [PubMed]  [DOI]
10.  Fridman MW, de Almeida Fialho HS. The role of radiographic measurements in the evaluation of congenital clubfoot surgical results. Skeletal Radiol. 2007;36:129-138.  [PubMed]  [DOI]
11.  Schuh A, Göske R, Salminen S, Zeiler G, Schraml A. [Results of operative therapy of idiopathic clubfoot using a dorsomedial approach with soft tissue preparation “à la carte”]. Zentralbl Chir. 2005;130:568-575.  [PubMed]  [DOI]
12.  Singh BI, Vaishnavi AJ. Modified Turco procedure for treatment of idiopathic clubfoot. Clin Orthop Relat Res. 2005;438:209-214.  [PubMed]  [DOI]
13.  Prasad P, Sen RK, Gill SS, Wardak E, Saini R. Clinico-radiological assessment and their correlation in clubfeet treated with postero-medial soft-tissue release. Int Orthop. 2009;33:225-229.  [PubMed]  [DOI]
14.  Munshi S, Varghese RA, Joseph B. Evaluation of outcome of treatment of congenital clubfoot. J Pediatr Orthop. 2006;26:664-672.  [PubMed]  [DOI]
15.  Herbsthofer B, Eckardt A, Rompe JD, Küllmer K. Significance of radiographic angle measurements in evaluation of congenital clubfoot. Arch Orthop Trauma Surg. 1998;117:324-329.  [PubMed]  [DOI]
16.  Abulsaad M, Abdelgaber N. Correlation between clinical outcome of surgically treated clubfeet and different radiological parameters. Acta Orthop Belg. 2008;74:489-495.  [PubMed]  [DOI]
17.  Docquier PL, Leemrijse T, Rombouts JJ. Clinical and radiographic features of operatively treated stiff clubfeet after skeletal maturity: etiology of the deformities and how to prevent them. Foot Ankle Int. 2006;27:29-37.  [PubMed]  [DOI]
18.  Haasbeek JF, Wright JG. A comparison of the long-term results of posterior and comprehensive release in the treatment of clubfoot. J Pediatr Orthop. 1997;17:29-35.  [PubMed]  [DOI]
19.  Barker S, Chesney D, Miedzybrodzka Z, Maffulli N. Genetics and epidemiology of idiopathic congenital talipes equinovarus. J Pediatr Orthop. 2003;23:265-272.  [PubMed]  [DOI]
20.  Isaacs H, Handelsman JE, Badenhorst M, Pickering A. The muscles in club foot--a histological histochemical and electron microscopic study. J Bone Joint Surg Br. 1977;59-B:465-472.  [PubMed]  [DOI]
21.  Handelsman JE, Badalamente MA. Neuromuscular studies in clubfoot. J Pediatr Orthop. 1981;1:23-32.  [PubMed]  [DOI]
22.  Irani RN, Sherman MS. The pathological anatomy of idiopathic clubfoot. J Bone Joint Surg Am. 1963;45:45-52.  [PubMed]  [DOI]
23.  Hootnick DR, Levinsohn EM, Crider RJ, Packard DS. Congenital arterial malformations associated with clubfoot. A report of two cases. Clin Orthop Relat Res. 1982;160-163.  [PubMed]  [DOI]
24.  Sodre H, Bruschini S, Mestriner LA, Miranda F, Levinsohn EM, Packard DS, Crider RJ, Schwartz R, Hootnick DR. Arterial abnormalities in talipes equinovarus as assessed by angiography and the Doppler technique. J Pediatr Orthop. 1990;10:101-104.  [PubMed]  [DOI]
25.  Muir L, Laliotis N, Kutty S, Klenerman L. Absence of the dorsalis pedis pulse in the parents of children with club foot. J Bone Joint Surg Br. 1995;77:114-116.  [PubMed]  [DOI]
26.  Ippolito E, Ponseti IV. Congenital club foot in the human fetus. A histological study. J Bone Joint Surg Am. 1980;62:8-22.  [PubMed]  [DOI]
27.  Farrell SA, Summers AM, Dallaire L, Singer J, Johnson JA, Wilson RD. Club foot, an adverse outcome of early amniocentesis: disruption or deformation CEMAT. Canadian Early and Mid-Trimester Amniocentesis Trial. J Med Genet. 1999;36:843-846.  [PubMed]  [DOI]
28.  Idelberger K. Die Ergebnisseder Zwillingsforschung beim angeborenen Klumpfuß. Verhandlungen der Deutschen Orthopädischen Gesellschaft. 1939;33:272–276.  [PubMed]  [DOI]
29.  Smith C. Heritability of liability and concordance in monozygous twins. Ann Hum Genet. 1970;34:85-91.  [PubMed]  [DOI]
30.  Strach EH. Club-foot through the centuries. Prog Pediatr Surg. 1986;20:215-237.  [PubMed]  [DOI]
31.  de Andrade M, Barnholtz JS, Amos CI, Lochmiller C, Scott A, Risman M, Hecht JT. Segregation analysis of idiopathic talipes equinovarus in a Texan population. Am J Med Genet. 1998;79:97-102.  [PubMed]  [DOI]
32.  Lochmiller C, Johnston D, Scott A, Risman M, Hecht JT. Genetic epidemiology study of idiopathic talipes equinovarus. Am J Med Genet. 1998;79:90-96.  [PubMed]  [DOI]
33.  Ponseti IV, Smoley EN. Congenital club foot: the results of treatment. J Bone Joint Surg Am. 1963;45:261-275.  [PubMed]  [DOI]
34.  Turco VJ. Resistant congenital club foot--one-stage posteromedial release with internal fixation. A follow-up report of a fifteen-year experience. J Bone Joint Surg Am. 1979;61:805-814.  [PubMed]  [DOI]
35.  Crawford AH, Marxen JL, Osterfeld DL. The Cincinnati incision: a comprehensive approach for surgical procedures of the foot and ankle in childhood. J Bone Joint Surg Am. 1982;64:1355-1358.  [PubMed]  [DOI]
36.  Carroll NC. Surgical technique for talipes equinovarus. Operative Technique in Orthop. 1993;3:1115-1120.  [PubMed]  [DOI]
37.  Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg Am. 2004;86-A:22-27.  [PubMed]  [DOI]
38.  Haft GF, Walker CG, Crawford HA. Early clubfoot recurrence after use of the Ponseti method in a New Zealand population. J Bone Joint Surg Am. 2007;89:487-493.  [PubMed]  [DOI]
39.  Dobbs MB, Gurnett CA. Update on clubfoot: etiology and treatment. Clin Orthop Relat Res. 2009;467:1146-1153.  [PubMed]  [DOI]
40.  Elshenawy EM, Hassanen EY, Ramadam AI, Ibrahim MM. The Mansoura experience in the treatment of idiopathic clubfoot deformity using the Ponseti technique. Acta Orthop Belg. 2008;74:659-666.  [PubMed]  [DOI]
41.  Kessler JI. A new flexible brace used in the Ponseti treatment of talipes equinovarus. J Pediatr Orthop B. 2008;17:247-250.  [PubMed]  [DOI]
42.  Boehm S, Sinclair M. Foot abduction brace in the Ponseti method for idiopathic clubfoot deformity: torsional deformities and compliance. J Pediatr Orthop. 2007;27:712-716.  [PubMed]  [DOI]
43.  Willis RB, Al-Hunaishel M, Guerra L, Kontio K. What proportion of patients need extensive surgery after failure of the Ponseti technique for clubfoot. Clin Orthop Relat Res. 2009;467:1294-1297.  [PubMed]  [DOI]
44.  Abdelgawad AA, Lehman WB, van Bosse HJ, Scher DM, Sala DA. Treatment of idiopathic clubfoot using the Ponseti method: minimum 2-year follow-up. J Pediatr Orthop B. 2007;16:98-105.  [PubMed]  [DOI]
45.  Thacker MM, Scher DM, Sala DA, van Bosse HJ, Feldman DS, Lehman WB. Use of the foot abduction orthosis following Ponseti casts: is it essential. J Pediatr Orthop. 2005;25:225-228.  [PubMed]  [DOI]
46.  Chen RC, Gordon JE, Luhmann SJ, Schoenecker PL, Dobbs MB. A new dynamic foot abduction orthosis for clubfoot treatment. J Pediatr Orthop. 2007;27:522-528.  [PubMed]  [DOI]
47.  George HL, Unnikrishnan PN, Garg NK, Sampath J, Bruce CE. Unilateral foot abduction orthosis: is it a substitute for Denis Browne boots following Ponseti technique. J Pediatr Orthop B. 2011;20:22-25.  [PubMed]  [DOI]
48.  Zionts LE, Dietz FR. Bracing following correction of idiopathic clubfoot using the Ponseti method. J Am Acad Orthop Surg. 2010;18:486-493.  [PubMed]  [DOI]
49.  Avilucea FR, Szalay EA, Bosch PP, Sweet KR, Schwend RM. Effect of cultural factors on outcome of Ponseti treatment of clubfeet in rural America. J Bone Joint Surg Am. 2009;91:530-540.  [PubMed]  [DOI]
50.  Ramírez N, Flynn JM, Fernández S, Seda W, Macchiavelli RE. Orthosis noncompliance after the Ponseti method for the treatment of idiopathic clubfeet: a relevant problem that needs reevaluation. J Pediatr Orthop. 2011;31:710-715.  [PubMed]  [DOI]
51.  Simons GW. Analytical radiography of club feet. J Bone Joint Surg Br. 1977;59-B:485-489.  [PubMed]  [DOI]
52.  Simons GW. A standardized method for the radiographic evaluation of clubfeet. Clin Orthop Relat Res. 1978;107-118.  [PubMed]  [DOI]
53.  Beatson TR, Pearson JR. A method of assessing correction in club feet. J Bone Joint Surg Br. 1966;48:40-50.  [PubMed]  [DOI]
54.  Günther KP, Uhl C, Puhl W. Ergebnisse operative Therapie beim idiopathischen Klumpfuß. Orthop Praxis. 1996;32:108-111.  [PubMed]  [DOI]
55.  Kausch T, Rütt J, Hackenbroch MH, Fünfgeld B. [Treatment results of Imhäuser’s method of treating neonatal clubfeet]. Z Orthop Ihre Grenzgeb. 1995;133:524-529.  [PubMed]  [DOI]
56.  Cummings RJ, Davidson RS, Armstrong PF, Lehman WB. Congenital clubfoot. J Bone Joint Surg Am. 2002;84-A:290-308.  [PubMed]  [DOI]
57.  Lau JH, Meyer LC, Lau HC. Results of surgical treatment of talipes equinovarus congenita. Clin Orthop Relat Res. 1989;219-226.  [PubMed]  [DOI]
58.  Yamamoto H, Furuya K. One-stage posteromedial release of congenital clubfoot. J Pediatr Orthop. 1988;8:590-595.  [PubMed]  [DOI]
59.  Ono K, Hayashi H. Residual deformity of treated congenital club foot. A clinical study employing frontal tomography of the hind part of the foot. J Bone Joint Surg Am. 1974;56:1577-1585.  [PubMed]  [DOI]
60.  Thompson GH, Richardson AB, Westin GW. Surgical management of resistant congenital talipes equinovarus deformities. J Bone Joint Surg Am. 1982;64:652-665.  [PubMed]  [DOI]
61.  Porat S, Kaplan L. Critical analysis of results in club feet treated surgically along the Norris Carroll approach: seven years of experience. J Pediatr Orthop. 1989;9:137-143.  [PubMed]  [DOI]
62.  Aronson J, Puskarich CL. Deformity and disability from treated clubfoot. J Pediatr Orthop. 1990;10:109-119.  [PubMed]  [DOI]