Ponseti method compared with soft-tissue release for the management of clubfoot: A meta-analysis study

Table 1 Comparison of Laaveg-Ponseti score between patients treated with the Ponseti method and surgically managed patients

Studies	Level of evidence	Mean follow-up (yr)	Time period of procedure	Patients (n)	Feet (n)	Laaveg-Ponseti score mean (95%CI)	Excellent/good Laaveg-Ponseti rating rate (95%CI)
All Treatments				500	810	86.2 (84.2-88.2)	0.73 (0.67-0.78)
Ponseti method				147	224	86.3 (84.2-88.3)	0.76 (0.69-0.81)
Ippolito et al[1]	III	19	1979-1984	32	49	85.4 (83.9-86.9)	0.78 (0.64-0.87)
Laaveg et al[5]	III	18.8	1950-1967	70	104	87.5 (85.3-89.7)	0.74 (0.65-0.82)
Cooper et al[6]	IV	34	1950-1967	45	71	-	0.78 (0.63-0.88)
Soft-tissue release				353	586	82.0 (69.5-94.5)	0.62 (0.48-0.74)
Ippolito et al[1]	III	25	1973-1977	32	47	74.7 (71.4-78.0)	0.43 (0.29-0.57)
Dobbs et al[3]	III	31	1972-1979	45	73	65.3 (62.9-67.7)	0.33 (0.23-0.44)
Fridman et al[10]	IV	6.4	1986-2003	50	71	86.9 (84.1-89.6)	0.80 (0.69-0.88)
Schuh e et al[11]	IV	4.5	1986-2000	86	130	95.6 (94.0-97.2)	-
Singh et al[12]	IV	13.8	1980-1996	18	33	-	0.82 (0.65-0.92)
Prasad et al[13]	IV	-	-	30	50	-	0.58 (0.44-0.71)
Munshi et al[14]	III	3.5	-	-	50	87.3 (83.1-91.5)	0.78 (0.65-0.87)
Herbsthofer et al[15]	IV	6.7	1984-1994	38	62	-	0.47 (0.35-0.59)
Abulsaad et al[16]	IV	3.9	2000-2004	54	70	-	0.69 (0.57-0.78)
Difference between treatments						Q = 0.45, P = 0.50	Q = 3.73, P = 0.053

Table 2 Comparison of anteroposterior talocalcaneal angle, lateral talocalcaneal angle, and talocalcaneal index between patients treated with the Ponseti method and surgically managed patients

Studies	Patients	Feet	Talocalcaneal
			AP mean (95%CI)	Lateral mean (95%CI)	Index mean (95%CI)
All treatments	430	655	16.2 (14.9-17.5)	26.9 (23.9-29.9)	46.0 (41.4-50.7)
Ponseti method	147	224	15.8 (14.5-17.2)	29.9 (19.3-40.5)	45.7 (33.4-58.0)
Ippolito et al[1]	32	49	16.1 (14.6-17.6)	38.8 (37.1-40.4)	54.9 (51.7-58.0)
Laaveg et al[5]	70	104	14.5 (12.8-16.2)	20.9 (19.8-22.0)	35.5 (33.5-37.5)
Cooper et al[6]	45	71	17.0 (15.1-18.9)	30.0 (28.4-31.6)	47.0 (43.5-50.5)
Soft-tissue release	283	431	18.9 (15.0-22.8)	26.6 (23.5-29.8)	46.1 (41.0-51.1)
Ippolito et al[1]	32	47	14.1 (12.2-16.0)	33.2 (30.7-35.7)	47.3 (42.9-51.7)
Dobbs et al[3]	45	73	12.8 (11.1-14.4)	23.3 (21.8-24.8)	36.1 (32.9-39.3)
Fridman et al[10]	50	71	20.8 (19.3-22.3)	22.5 (20.9-24.0)	43.3 (40.9-45.6)
Singh et al[12]	18	33	28.4 (27.0-29.8)	30.9 (29.2-32.6)	59.3 (56.2-62.4)
Prasad et al[13]	30	50	18.5 (16.2-20.8)	27.4 (24.6-30.1)	45.8 (43.3-48.4)
Herbsthofer et al[15]	38	62	16.1 (14.6-17.6)	23.0 (21.3-24.7)	39.1 (36.0-42.2)
Abulsaad et al[16]	54	70	16.4 (15.1-17.6)	21.4 (19.9-23.0)	42.2 (39.7-44.7)
Docquier et al[17]	16	25	24.3 (21.5-27.1)	32.2 (29.6-34.8)	56.5 (51.1-61.9)
Difference between treatment			Q = 2.09, P = 0.15	Q = 0.33, P = 0.57	Q = 0.002, P = 0.96

Table 3 Comparison of talus-1^st metatarsal, 1^st-5^th metatarsal, and calcaneus-5^th metatarsal angles between patients treated with the Ponseti method and surgically managed patients

Studies	Patients	Feet	Talus-1st metatarsal		1st-5th metatarsal
			APmean (95%CI)	Lateralmean (95%CI)	Lateralmean (95%CI)	APmean (95%CI)
All treatments	516	655	1.27 (-0.23-2.77)	6.24 (5.00-7.48)	15.6 (16.7-17.9)	-5.11 (-6.83 - -3.40)
Ponseti method	147	224	0.96 (-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]	32	49	0.94 (-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]	70	104	-	-	14.7 (13.5-15.9)	-4.9 (-6.92 - -2.88)
Cooper et al[6]	45	71	1 (-1.56-3.56)	5 (3.60-6.40)	16 (14.8-17.2)	-8 (-10.33 - -5.67)
Soft-tissue release	283	431	6.04 (-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]	32	47	8.28 (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]	45	73	15.95 (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]	50	71	3.97 (1.27-6.67)	-	-	1.32 (-0.70 - 3.34)
Singh et al[12]	18	33	11.9 (9.89-13.91)	15.7 (13.14-18.26)	28.2 (25.9-30.5)	-
Prasad et al[13]	30	50	6.92 (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]	38	62	10.29 (7.68-12.90)	-	-	9.95 (7.90 - 12.00)
Abulsaad et al[16]	54	70	-5.43 (-6.85-4.02)	-	-	-
Docquier et al[17]	16	25	-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 treatment			Q = 2.50, P = 0.11	Q = 10.74, P = 0.001	Q = 10.48, P = 0.001	Q = 16.12, P < 0.001

Table 4 Between and within-study heterogeneity in outcomes of clubfoot treatment

	Overall		Ponseti method		Soft-Tissue release
	Q	I2	Q	I2	Q	I2
Laaveg-Ponseti score	468.8a	98.7	2.3	57.2	465.8a	99.1
Excellent/Good Laaveg-Ponseti ratings	72.5a	86.2	0.35	0	55.6a	87.4
TCA-AP	346.8a	97.1	4.1	50.9	312.5a	97.8
TCA-LT	496.3a	98.0	320.8a	99.4	158.1a	95.6
TCI	274.5a	96.4	114.3a	98.3	265.5a	95.4
TMT-AP	376.3a	97.6	0.001	0	365.2a	98.1
TMT-LT	67.3a	91.1	1.3	20.5	21.0a	80.9
MTT-LT	203.8a	96.6	2.3	12.0	89.0a	95.5
CMT-AP	328.7a	97.6	4.0	50.6	121.5a	95.9

^aP < 0.05 vs patients who underwent open surgery, significant variability. TCA-AP: Anteroposterior talocalcaneal angle; TCA-LT: Lateral talocalcaneal angle; TCI: Talocalcaneal index; TMT-AP: Anteroposterior talus-first metatarsal angle; TMT-LT: Lateral talus-first metatarsal angle; MTT-LT: Lateral first-fifth metatarsal angle; CMT-AP: Anteroposterior calcaneus-fifth metatarsal angle.

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-LT	0.43 (0.22)	-0.26 (0.46)
TCI	0.13 (0.73)	0.48 (0.16)
TMT-AP	0.27 (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-LT	0.11 (0.82)	-0.13 (0.79)

TCA-AP: Anteroposterior talocalcaneal angle; TCA-LT: Lateral talocalcaneal angle; TCI: Talocalcaneal index; TMT-AP: Anteroposterior talus-first metatarsal angle; TMT-LT: Lateral talus-first metatarsal angle; MTT-LT: Lateral first-fifth metatarsal angle.